European Journal of Orthodontics 14 (1992) 16-20 I 1992 European Orthodontic Society

Long-term effects of orthodontic treatment, including

extraction, on signs and symptoms attributed to CMD
J. M. H. Dibbets and L Th van der Weele
Delleweg 9, 9921 TG Stedum, The Netherlands

SUMMARY The prevalence of signs and symptoms attributed to craniomandibular disorders

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(CMD) was established in an orthodontically treated sample. The effect of orthodontic therapy
upon this prevalence was studied by monitoring three groups of patients whose treatment
procedures were different. The first group was treated with functional appliances, the second
with Begg light wire, and the third with chin cups. In addition, the effect of extraction upon the
prevalence was studied by monitoring three groups in which different extraction decisions had
been made: four first premolars extracted, all other types of extraction, and no extraction. Based
upon the finding of similar prevalences after 20 years of observation, it appears that neither
orthodontic treatment nor extraction has a causal relationship with the signs and symptoms of
CMD recorded during this study.

Introduction monitor, and analyse the relationship between

Orthodontic treatment has been linked by case
reports to the onset of craniomandibular dis-
orders (CMD). Surprising, in retrospect, is the
fact that case reports were accepted as evidence
(Rinchuse, 1987; Reynders, 1990). This is all
the more startling since no single case report
will ever form sufficient evidence for an ortho-
dontist to question his therapeutic regime. Why,
then, take a defensive attitude with regard to
CMD solely on the basis of case reports? In
addition, a discouraging legal case (Brimm v.
Dr X, 1987) and conscientiously conducted
research disputing the claimed negative effects
of orthodontic treatment have confounded the
profession even more (Pancherz, 1976; Dibbets,
1977; Sadowsky and BeGole, 1980; Janson and
Hasund, 1981; Larsson and Ronnerman, 1984;
Madone and Ingervall, 1984; Sadowsky and
Poison, 1984; Janson, 1985; Dibbets et ai,
1985a,b; Gianelly et ai, 1988; Greene, 1988).
One of the long-term studies designed to
respond to the question of orthodontic treat-
ment and CMD is the Groningen study. It
originated in 1970 and was intended to docu-
ment the development of osteoarthritis in chil-
dren over a period of 5 years. However, because
all of the children involved in the study received
orthodontic treatment, this study was rede-
signed later in the seventies, to document,
CMD and orthodontic treatment.
In order to assure a prospective character,
the original protocol was maintained although
new goals were defined. In addition, new data
had considerably expanded the body of know-
ledge on CMD. Thus, the achievable results
have been limited in favour of providing con-
tinuity in collecting the data. As a reward true
prospective longitudinal data gathered over a
period of 20 years are available.
The early recognition of an age dependence
of CMD signs and symptoms frustrated the
initial attempt of a straightforward comparison
of frequency of occurrence registered before and
after orthodontic treatment. The solution, age-
matching between treated and yet-to-be treated
individuals, could be accomplished only at the
expense of small sample sizes (Dibbets and van
der Weele, 1987). Meanwhile, the collection of
data progressed to the 15-year follow-up and
more data was collected (van der Weele and
Dibbets, 1986,1987; Dibbets and van der Weele,
1989). The influence of age had diminished
because the individuals had grown older and
now a desired control group could successfully
be established by comparing groups of subjects
who had undergone different orthodontic treat-
ment procedures (Dibbets and van der Weele,
1990). However, considerable time was spent
before an adverse sampling factor could be
 ORTHODONTIC TREATMENT, EXTRACTIONS, AND CMD
traced that was to blame for the confusing
results obtained by the analysis of the extraction
procedures (Dibbets and van der Weele, 1991).
For the present paper, sub-groups that reflect
the conflicting opinions regarding CMD were
created. This approach is founded upon the
expectation that different treatment procedures
will disclose different prevalences of CMD in
the long run. This expectation reflects, after all,
the evil message the case reports had brought
us.
Subjects and methods
The data
One-hundred-and-seventy-two children (45 per
cent boys, 55 per cent girls) who were to be
treated orthodontically were documented lon-
gitudinally (Dibbets, 1977). No selection criteria
based on CMD symptomology were included.
Their mean age at the onset of the study was
12.5 years, with 88 per cent of the children
ranging between 8 and 15 years of age. The
1980 follow-up examination included 103 parti-
cipants, the 1985 follow-up included 109
participants and the 1990 follow-up included
92 participants.
The follow-up protocol was approved by the
Medical Ethical Authority of the University of
Groningen. Both subjectively reported clicking,
pain, and/or locking upon questioning, and
objectively registered clicking and/or crepitation
detected through palpating the joint were
recorded. Because it sometimes is difficult to
clinically segregate clicking and crepitation, one
cumulative variable, 'objective signs', was cre-
ated. To reduce the number of graphs, the low
-percentages of pain-and locking were likewise
combined with clicking to one variable, 'subject-
ive symptoms'.
Orthodontic treatment procedures
Thirty-eight per cent of the cases were treated
with removable appliances (REM in the figures);
all were functional appliance hybrids and most
were sturdy activators. Forty-three per cent of
the cases were treated with Begg light wire
technique (B 1,11 in the figures) using Class II
elastics. The remaining cases (19 per cent)
required either Class III Begg mechanics or chin
cups, 500 g each side and minimal 14 hours/day
(Cl III in the figures).
17
Extractions
Four first premolars were extracted in 29 per
cent of the individuals. Other extractions includ-
ing two upper premolars, four second pre-
molars, and first or second molars were
performed in 37 per cent of the cases, while in
34 per cent of the cases no teeth were extracted.
The findings
In the results depicted in the graphs, the group
frequencies were tested at the separate time-
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points for differences with the chi-square test
and considered significant at a level of alpha =
0.05. This is indicated by an asterisk underneath
the time-point scale.
Results
The prevalence of CMD signs and symptoms
in the three different orthodontic treatment
procedure groups over a period of 20 years is
depicted in Figs 1 and 2. Ten years after the
beginning of the study, there were no statistic-
ally significant differences between the three
groups.
The prevalence of CMD signs and symptoms
in the three different extraction groups over a
period of 20 years is depicted in Figs 3 and 4.
The subjectively reported symptoms manifested
a significantly higher frequency in the first pre-
molar extraction group in 1985, 15 years after
the beginning of the study, but this difference
essentially disappeared at 20 years, in 1990.
Discussion
Functional appliances are supposed to distract
the condyle from its superior posterior position
in a forward and downward direction: Begg
light wire technique is supposed to restrain
condylar growth when end-to-end incisor con-
tact is achieved during stage I of treatment.
Class III treatment, more specifically high chin-
cup force, is supposed to drive the condyle up
into its fossa. Each of these procedures separ-
ately have been claimed to cause CMD. An
excellent overview on the emergence of these
thoughts and the men behind them has been
presented by Greene (1988). Thus, our expecta-
tion was that this study would show that each
orthodontic treatment procedure induced CMD
to a different extent. Consequently, different
prevalences of CMD were to be expected in
18 J. M. H. DIBBETS AND L. TH VAN DER WEELE

Sub

60

50

40

30

20

10

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Figure 1 Prevalence of subjectively reported symptoms (Sub) over a 20-year period in three groups of essentially different
treatment procedures. Bold solid line: -REM-, removable activator type functional appliances; thin solid line: -B I, II-,
Begg multiband technique with class II elastics; broken line: -Cl III-, either Begg Class III mechanics and class III elastics
or chin-cup 500 g each side. An asterisk underneath the time-point indicates a chi-square test significant at alpha = 0.05.

Ob
60
50
40
30
20
10
o-i
t - o 1 1960 1985 1990

Figure 2 Prevalence of objectively palpated signs (Ob) over a 20-year period in three groups of essentially different
treatment procedures. Bold solid line: -REM-, removable activator type functional appliances; thin solid line: -B I, II-,
Begg multiband technique with class II elastics; broken line: -Cl III-, either Begg Class III mechanics and class III elastics
or chin-cup 500 g each side. An asterisk underneath the time-point indicates a chi-square test significant at alpha = 0.05.

Sub

90
80
70
60
50
40
30
20
10
0
t =0 1 3 4 1980 1985 1990

Figure 3 Prevalence of subjectively reported symptoms (Sub) over a 20-year period in three groups of essentially different
extractions performed. Bold solid line: -non-, no extractions performed; thin solid line: -other-, any other choice of
extractions; broken line: -4 + 4-, four first premolar extractions. The asterisk underneath 1985 indicates a chi-square test
significant at alpha = 0.05.
ORTHODONTIC TREATMENT, EXTRACTIONS, AND CMD
60
50
40
30
20
10
0
t - 0 1 3 4
Figure 4 Prevalence of objectively palpated signs (Ob) over a 20-year period in three groups in which essentially different
extractions were performed. Bold solid line: -non-, no extractions performed; thin solid line: -other-, any other choice of
extractions; broken line: -4 + 4-, four first premolar extractions.
these treatment groups. However, Figs 1 and 2
sufficiently demonstrate that this is not the case.
The initial and statistically significant differ-
ences are, for the most part, accounted for by
age: younger individuals (Class III) display
fewer CMD signs and symptoms than do older
individuals (in 1970 selected to be treated with
fixed appliances). However, none of the treat-
ment procedures over the long-term differed
significantly from others. Since the biomechan-
ics of the procedures evoke antagonistic reac-
tions in the joint, as explained, the conclusion
may be drawn that none of these three treatment
procedures has a causative relationship to the
symptoms registered.
An analog method has been used to study
the influence of extraction, since extraction,
specifically of first premolars, is linked to the
onset of CMD. Individuals who underwent
extraction were divided into two groups: a 'four
first premolar' extraction group and an 'any-
thing other' extraction group. A third group
was formed by individuals who had undergone
~no extractions. The statistically- significant
record for 1985 in Fig. 3 of subjectively reported
symptoms in thefirstpremolar extraction group
levelled dramatically by 1990. Considering this
observation as an exception, the results of Figs 3
and 4 indicate that there is no real difference in
CMD symptom frequencies in groups in which
different extraction decisions were made 20
years previously.
Conclusions
1. Treatment procedures as different as func-
tional appliances, Begg's multiband tech-
nique, and chin cups resulted in equal CMD
19
Ob
,4±4
1980 1985 1990
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prevalences 20 years after the beginning of
the study.
2. Since the reacting forces on the condyle-disc-
fossa structures is widely divergent, conclu-
sion 1 may be expanded to say that no
relationship exists between treatment proced-
ures and signs and symptoms of CMD.
3. Neither extraction nor non-extraction pro-
cedures resulted in a difference of CMD
prevalences 20 years after the beginning of
the study.
4. Since treatment varied considerably because
of the different extraction procedures, con-
clusion 3 may be expanded to say that extrac-
tion is not related to signs and symptoms of
CMD.
References
Brimm v. Dr X 1987 Oakland County Circuit Court,
Detroit, Michigan, USA. Case No. 852 987 50 NM
Dibbets J M H 1977 Juvenile temporomandibular joint dys-
function and craniofacial growth. A statistical analysis.
Stafle_u & Thplen, Leiden
Dibbets J M H, Weele LTh van der 1987 Orthodontic
treatment in relation to symptoms attributed to dysfunc-
tion of the temporomandibular joint. American Journal
of Orthodontics 91: 193-199
Dibbets J M H , Weele LTh van der 1989 Prevalence of
TMJ symptoms and X-ray findings. European Journal
of Orthodontics 11: 31-36
Dibbets J M H , Weele LTh 1990 Orthodontic treatment
modalities and TMJ dysfunction. In: Carlson D S (ed.)
Craniofacial growth theory and orthodontic treatment.
Concordance and conflict. Center for Human Growth
and Development, University of Michigan, Ann Arbor,
pp.153-170
Dibbets J M H , Weele L Th van der 1991 Extraction, ortho-
dontic treatment and craniomandibular dysfunction.
American Journal of Orthodontics and Dentofacial
Orthopedics 99: 210-219
20
Dibbets J M H, Weele L Th van der, Uildriks A K J 1985a
Symptoms of temporomandibular joint dysfunction:
indicators of growth patterns? Journal of Pedodontics 9:
265-284
Dibbets J M H , Weele LTh van der, BoeringG 1985b
Craniofacial morphology and temporomandibular joint
dysfunction in children. In: Carlson D S, McNamara J A,
Ribbens K A (eds) Developmental aspects of temporom-
andibular joint disorders. Center for Human Growth and
Development, University of Michigan, Ann Arbor,
151-182
Gianelly A A, Hughes H M, Wohlgemuth P, Gildea G 1988
Condylar position and extraction treatment. American
Journal of Orthodontics and Dentofacial Orthopedics 93:
201-205
Greene CS 1988 Orthodontics and temporomandibular
disorders. Dental Clinics of North America 32: 529-538
Janson M 1985 Die kieferorthopadische Behandelung—ein
Risikofaktdr fur funktionelle und okklusale Storungen?
Deutsch Zahnarztliches Zeitschrift 40: 432-440
Janson M, Hasund A 1981 Functional problems in ortho-
dontic patients out of retention. European Journal of
Orthodontics 3: 173-179
Larsson E, RonnermanA 1981 Mandibular dysfunction
symptoms in orthodontically treated patients ten years
after the completion of treatment. European Journal of
Orthodontics 3: 89-94
J. M. H. DIBBETS AND L. TH VAN DER WEELE
Madone G, Ingervall B 1984 Stability of results and func-
tion of the masticatory system in patients treated with
the Herren type of activator. European Journal of Ortho-
dontics 6: 92-106
PancherzH 1976 Long-term effects of activator (Andresen
appliance) treatment. Odontologisk Revy Suppl. 35
Reynders R M 1990 Orthodontics and temporomandibular
disorders: a review of the literature (1966-1988). Amer-
ican Journal of Orthodontics and Dentofacial Orthoped-
ics 97: 463-471
Rinchuse D J 1987 Counterpoint: Preventing adverse effects
on the temporomandibular joint through orthodontic
treatment. American Journal of Orthodontics and Dento-
Downloaded from http://ejo.oxfordjournals.org/ at Columbia University Libraries on September 28, 2014
facial Orthopedics 91: 500-506
Sadowsky C, BeGole E A 1980 Long-term status of tempo-
romandibular joint function and functional occlusion
after orthodontic treatment. American Journal of Ortho-
dontics 78: 201-212
Sadowsky C, Poison A M 1984 Temporomandibular dis-
orders and functional occlusion after orthodontic treat-
ment: results of two long term studies. American Journal
of Orthodontics 86: 386-390
Weele LTh van der, Dibbets J M H 1986 Conceptual
models for analyzing symptoms of temporomandibular
joint dysfunction. Journal of Craniomandibular Praxis 4:
357-366
Weele L Th van der, Dibbets J M H 1987 Helkimo's index:
a scale or just a set of symptoms? Journal of Oral
Rehabilitation 14: 229-237