Class 11 elastics and extractions and
temporomandibular disorders: A longitudinal
prospective study
Maria T. O'Reilly, DMD, MDS, PhD, ~ Donald J. Rinchuse, DMD, MDS, PhD, b and
John Close, MA c
Pittsburgh, Pa.
C l a s s II elastics and maxillary premolar ex-
tractions have been implicated as causes of temporo-
mandibular disorders (TMD). Only anecdotal evidence
has been offered supporting this claim. This study was
designed to assess the effects of these variables on the
following signs and symptoms of TMD: joint sounds,
muscle tenderness, and range of mandibular motion.
One hundred and twenty subjects were used in this
study. Sixty were patients who were treated with
"straight wire" orthodontic mechanotherapy that in-
cluded Class II elastics. In the treated group, 34 subjects
had only maxillary first premolar extractions, whereas
12 subjects had extractions of maxillary and mandibular
first premolar teeth. The 60 orthodontically untreated
control subjects consisted of the experimental group
subjects' nearest age siblings. The subject inclusion
criteria used in this investigation were: no reported past
history of TMD or trauma and the absences of signs or
symptoms of TMD. Muscle tenderness was assessed
by palpation of selected sites; joints sounds assessed
by auscultation, palpation and patient self-report; and
range of mandibular movement was measured in mil-
limeters during active opening, maximum protrusion,
and lateral movements. Measurements were made be-
fore start of treatment and at 6-month intervals to com-
pletion of treatment. The results indicated a significant
time by treatment group interaction on only one of the
criteria measures, pain on palpation "lateral to capsule"
(p < 0.005). Only 40% of patients in the experimental
group reported mild pain; 60% remaining reported no
pain. We conclude that Class I1 elastics and extractions
have little or no effect on general TMD signs and
symptoms.
Farrar and McCarty I believed that a posteriorly po-
i"
From the University of Pittsburgh.
'Associate Professor of Orthodontics; Diplomate ABO.
bAssociate Professor of Orthodontics; Diplomate ABO.
'Assistant Professor.
Ast J Oa'rltoo DL,,-rof,sc ORrHOP 1993;103:459-63.
Copyright 9 1993 by the American Association of Orthodontists.
0589-5406/93/51.00 + 0.10 8/1/389.14
sitioned condyle is a frequent predisposing factor in
anterior TMJ disk displacement. AsWyatt'- explained,
"distal pressure exerted on the mandible and ultimately
on the condyle induces a temporomandibular joint dis-
order (TMD). When the mandible is forced posteriorly,
distal pressure is exerted on the condyles; the disks
above them may be "popped" (protracted) anteriorly
and.medially. The condyles are pressed against the vas-
cular, innervated retrodiscal tissue causing pain."
Witzig 3~ supported the notion of Farrar and
McCarty t and further added that patients with Class II,
Division 2 deep bite malocclusions, or patients with
retroclined and overretracted maxillary incisors, as a
result of orthodontics with premolar extractions, have
a high incidence of TMD. Furthermore, Grummons 6
alleged that orthodontic mechanotherapies such as Class
II and III elastics, mandibular headgears, facial masks,
chin cups, and balancing side occlusal interferences,
can cause TMD. Finally, Solberg and Seligman, 7
Thompson, g~~ and Ricketts 't't3 expressed similar view-
points.
Contrary to the aforementioned anecdotal clinical
reports are the experimental studies by Gianelly et al.,~4
Dibbets and Vander Weele, '5 Hirata et al.,t6 and Rendeli
et al., t7 which support the proposition that orthodontic
treatment is not causative of TMD.
The purpose of this study was to address the issue
as to whether orthodontically treated patients having
had extractions and Class II elastics possess a greater
incidence of signs and symptoms of TMD than non-
orthodontically treated subjects. The independent vari-
ables, extractions, and Class I1 elastics were studied
together and not isolated in this investigation.
METHODS AND MATERIALS
Subjects
Two groups of subjects were used in this study. The
experimental group comprised 60 subjects, 30 girls and 30
boys,.svith a mean age at the start of treatment of 15.3 years
(range 14.3 to 16.1 years). These subjects received ortho-
dontic treatment with edgewise straight wire appliances, ex-
tractions, and retraction of the anterior maxillary teeth with
459
460 O'Reilly, Rinchuse, and Close
Table I. S a m p l e characteristics
Angle's
Classification Overjet
Class H Class ! Class H (1) Class I
E 48 12 7.0 (4.0-10.0) 3.0 (2.0-4.0)
U 38 22 6.0 (2.5-7.0) 3.0 (2.0-5.0)
E. Treated; U, untreated.
Class II elastics from eafiines to mandibular second molars.
The teeth extracted were the maxillary first premolars in 48
patients and the maxillary and mandibular first premolars in
12 subjects. There were 48 subjects with Class 11, Division
I malocclusions and 12 subjects with Class I malocclusions
w h o had a mean overjet of 7 mm (4 to I0 mm) and 3 mill
9(2 to 4 mm), respectively. The overbite was deep (>50%) in
142 subjects and normal in 18 subjects. The mean treatment
;duration was 24 months.
The control group consisted of 60 orthodontically u n - .
itreated subjects. The 60 subjects who comprised this group
were the experimental subjects' nearest age siblings. There
:were 25 boys and 35 girls and their age was within.16 months
iof that of the sibling in the experimental grou p. The overbite
was deep (>50%) in 25 subjects and normal in 35 subjects.
There were 38 subjects with Class II, Division 1 malocclu-
sions who had a mean ovcrjet of 6 mm and a range of 2.5
to 7 mm, and 22 subjects with Class 1 malocclusion who had
a mean overjet of 3 mm and a range of 2 to 5 mm (Table I).
No determination of the facial skeletal pattern was performed
for either control or experimental group. The subjects who
met the criteria for inclusion for both experimental and control
groups were selected from a larger population comprised of
600 subjects.
The subjects' inclusion criteria in this study were no re-
ported past history of TMD or trauma and the absence of
signs and symptoms of TMD at the time of the examination.
Procedure
Clinical measures of TMD signs and symptoms were
collected for both groups before the initiation of treatment
(TI); 8 to I0 months in treatment (T2); 12 to 16 months in
treatment (T~); and at the end of treatment, no later than 2
months after appliance removal (3",). Before the clinical ex-
amination the subjects completed a questionnaire concerning
their general health, medications taken, past history of trauma
or habits, and personal assessment of signs and symptoms of
TMD.
Clinical examination
All measurements were made by two examiners who were
calibrated before initiation of the study and who were unaware
of the purpose of the study. 18~ All measurements were made
in a dental chair with the subject in an upright position. :~
Range of mandibular movements was measured in millimeters
during active opening, maximum protrusion, and lateral
movements.
American Journal of Orthodontics and Dentofacial Orthopedics
May 1993
Overbite Gender Extractions
414
>50% Normal Male Female 4~ 4~I
42 18 30 30 48 12
25 35 25 35
Active opening was measured with a plastic millimeter
ruler. Subjects were instructed to open the mouth as wide as
possible and asked as to whether pain was present. Pain was
recorded on a categorical scale, with 1 for no pain and 2 for
pain present.
For maximum protrusion, the subjects were instructed to
bring the mandible as far forward as it would go. Any pain
during this movement was also recorded. Measurements were
taken with a millimeter ruler as the distance from the labial
surface of the most labially placed mandibular central incisor
to the most labially placed maxillary central incisor.
Lateral nmvements: The midline of the maxillary and
mandibular incisors coincident with the facial (anatomic)
maxillary midl~ne (reference line) was marked with a pencil.
Measurements were taken between the pencil marks on the
maxillary and mandibular incisors as the patient was in-
structed to move the mandible maximally to the right and to
the left.
Overjet was measured from the facial labial surface of
the most labially placed mandibular central incisor to the
incisal edge of the most labially placed maxillmy central
incisor. Overbite was measured as the degree of overlap from
the incisal edge of the mandibular central incisor to the point
of maximal overlap of tlae maxillary central incisor and re-
corded as the percent of the lower covered by the upper
incisor.
Joint soltnds: While positioned behind the subject, the
examiner instructed the subjects to open and to close several
times, palpating both condyles laterally and posteriorly with
finger pressure. Audible or palpable joint sounds were re-
corded as either present or absent.
Muscle tenderness was assessed by using a pressure al-
gometer with a constant pressure of 2 Kg/cm2/scc. ~s Ten-
derness to palpation was determined through patient self-
report of no pain, mild, moderate or severe pain (Fig. 1).
Method of analysis
A 2 • 4 multivariate analysis of variance (MANOVA)
was used to test for mean differences on the temporoman-
dibular joint (TMJ) signs and symptoms between control and
experimental groups across the four times. Because some of
the variables were "categorical" in nature but were dichoto-
mous in their response, they were included in the MANOVA.
To determine interrater reliability of the TMJ measure-
ments, 18 randomly selected subjects were remeasured by a
clinician blind to the purpose of the study I week later for
the categorical variables (muscle and joint tenderness, sounds,
American Journal of Orthodontics and Dentofacial Orthopedics O'Reilly, Rinchuse, and Close 461
Volume 103, No. 5

FR TIME X GROUP INTERACTION

M.T. A.T.
C MEAN
2.0

1.5 ,.d,-- . . . . . .-L

-" , EXP
9"
"
I
~. CTL
1.0 i j," ]

D.C.
0.5

0.0 I I I I
T1 T2 T3 T4
D.M. TIME
Fig. 1. Muscle palpation sites: AT, anterior temporal; MT, Middle Fig. 2. Time by treatment interaction for pain on palpation at
temporal; SM, Superficial masseter; DM, Deep masseter; LC,
LC (lateral to capsule).
Lateral to capsule; DC, Dorsal to capsule; FR, Frontal.

Table II. Muscle palpation . -

I
Time 1 Time 2 , Time 3 Time 4
Pretreatment (8-10 months) (12-16 months) (2 months after treatment)

Sites E
I u E
I U . "E
I U
" E
I U

AT 1.0 1.0 1.11 - 0.06 1.03 - 0.02 1.06 +-- 0.03 1.06 --- 0.03 1.06 m 0.04 l.ll -'- 0 . 0 4
MT 1.0 !.0 1.21 m 0.06 1.13 _ 0.04 1.25 _ 0.05 1.21 • 0.05 1.23 ~ 0.06 1.30 ")- 0 . 0 6
SM !.0 1.0 1.26 __. 0.05 1.35 - 0.06 1.26 -+ 0.05 1.38 - 0.06 1.38 - 0.08 1.20 +-- 0 . 0 5
DM 1.0 1.0 1.28 • 0.05 1.20 - 0.05 1.31 • 0.06 1.23 • 0.05 1.41 • 0.08 1.21 --- 0 . 0 5
LC* 1.0 1.0 1.40 • 0.05 1.01 +-. 0.01 1.35 • 0.06 1.06 • 0.03 1.28 • 0.07 1.10 m 0.03
DC !.0 1.0 1.11 • 0.05 1.01 _.-z- 0.01 1.18 m 0.05 1.03 • 0.02 1.18 • 0.05 1.10 • 0.03
FR 1.0 1.0 1.0 - 0.06 1.01 • 0.01 1.01 • 0.0l 1.05 • 0.02 l.ll • 0.04 1.08 • 0.03

1. N o pain.
2. Mild.
3. Moderate.
4. Severe.
*p < 0.005.

and pain during mandibular movement). There was 100%
interrater reliability.
For the quantitative variables, the interrater reliability
coefficient (Pearson's r) ranged between 0.65 for lateral right
movements to 0.86 for opening. There were no significant
mean differences as tested by the t test for paired samples
between raters for any of the mandibular movements.
Intrarater measurements were made on the same visit day
in the morning and again in the afternoon in a different group
of 18 randomly selected subjects. The results for the cate-
gorical variables were 100% agreement and for the quanti-
tative variables the reliability coefficient ranged from 0.63
for lateral movement to 0.94 for opening. No significant dif-
ferences were observed between two measurements time with
the t test for paired comparisons.
RESULTS
Only one of the tests for main effects or interactions
in the analysis was statistically significant. A significant
time by treatment interaction was observed for pain on
palpation "lateral to capsule" (P < 0.005). The control
subjects did not change over the four time measures.
The experimental group changed from no pain (1.00)
at the initial measurement to a mean pain of 1.40 at T~
(8 to 10 months in treatment). The experimental group
dropped to a mean pain at T~ (12 to 16 months) and T4
(20 to 24 months) of 1.35 and 1.28, respectively. Only
40% of patients in the experimental group reported mild
pain; the 60% remaining patients reported no pain
(Table II and Fig. 2).
DISCUSSION
The results of this prospective study support the
'"geii~ral" hypothesis that orthodontic treatment is not
causative of TMD. The variables specifically addressed
in this study were Class II elastics and extractions. The
data from this study are consistent with previous in-
469 O'Reilly, Rinchuse, and Close
vestigations, ~4"~s'2~'31 and provide additional evidence,
demonstrating a "passive" relationship between ortho-
dontics and TMD. As stated by Rendell et al. t7 the
small number of subjects with TMJ symptoms does not
suggest that orthodontic patients in general have a lower
incidence of TMJ symptoms, but rather patients with
significant TMJ complaints were excluded from their
study.
The claim that orthodontic treatment causes TMD
is based on scientifically unfounded notions and is con-
trary to the results o f the many experimentally designed
studies. Biased reports Of an association between ortho-
dontics and TMD have been offered by Farrar and
McCarty, ! Witzig, 35 Wyatt, 2 and Grummons. 6 Even
studies reporting a causal relationship between ortho-
dontics and TMD are "flawed" by the investigator's
designs, i.e., cross-sectional, retrospective, inappro-
priate controls, and no "base line" data regarding TMJ
s)atus. Further, because TMJ signs symptoms are cyclic
and many times disappear, one does not know whether
the TMD subjects in these studies are chronic sufferers
Or those who have a single, or occasional, TMD
episode.
: The only significant finding in this study was pain
(i.e., mild) on palpation "lateral to the TMJ capsule"
at the 8- to 10-month period during orthodontic treat-
ment; this was present for 40% of the orthodontically
treated subjects. There is no logical explanation for this
finding. Perhaps, however, the perception of pain by
the experimental group was different than the control
group at this particular time period. At the 8- to 10-
month period, the orthodontically treated subjects were
beginning to have the extraction spaces closed and their
teeth and jaws may have been sore because of the tooth
movement and changing proprioception. Possibly, their
awareness of their TMJs was more pronounced. Maybe
when they experience pain in one area (i.e., their
mouth), it is generalized to closely related anatomic
areas, i.e., TMJ muscles.
There are several "strengths" of this study. First,
the experimental and control groups were comparable
regarding ages, gender, and genetics. Second, all
subjects used in this study had no past or present his-
tory/record of TMD before the initiation o f the inves-
tigation. Next, all the experimental subjects underwent
similar orthodontic treatments and treatment lengths.
Finally, the "end of treatment" evaluation was obtained
immediately after appliance removal and thus the in-
fluence of nonorthodontic factors on the TMJ, over
time, was controlled.
The results of this study are applicable to the ortho-
dontic treatment variables, consisting o f Class II ela-sti~g"
and extractions. Therefore conclusion from this study
American Journal of Orthodontics and Dentofacial Orthopedics
May 1993
can only be made relative to the actual variables tested
(i.e., extractions and Class II elastics) and can not be
generalized to all orthodontic treatment mechanother-
apies. Also, Class II elastics and extractions were con-
sidered together as a single variable in this study and
not each isolated as separate variables. However, this
was not of considerable importance in this study. If
positive results would have occurred, it would not have
been known if only one of these variables was caus-
ative. In addition, the results of this study are applicable
to TMD signs/symptoms immediately after orthodontic
treatment and do not address the long-term effect o f
orthodontics and TMD. In conclusion, this study dem-
onstrates that edgewise straight wire orthodontic treat-
ment involving extractions and Class II elastics have
no effect, or little effect (i.e., mild pain "lateral to TMJ
capsule"), on TMJ signs and symptoms.
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Reprint requests to:
Dr. Maria T. O'Reilly
University of Pittsburgh
School of Dental Medicine
3501 Terrace St.
Pittsburgh, PA 15261

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