Orthodontics and the temporomandibular joint: Where are we now? Part 1. Orthodontic treatment and temporomandibular disorders F. Luther, BDS (Hons), MSc, MOrth, FDS RCS (Eng) T: question of whether a relationship exists between orthodontic treatment, abnormal condyle and dise position, and. temporomandibular disorders (TMD) has been investigated for many years. Despite the abun- dance of studies, the question continues to ‘trouble orthodontists Before discussing this issue in any detail, itis important to define the terms, and then to set ‘matters in context by examining the prevalence ‘of TMD in nonpatient populations. In this paper, the abbreviation TMD (temporo- mandibular disorders) will be used to signify the variety of symptoms, signs, and combinations thereof that have often been assigned to the TMJ (temporomandibular joint) and its related struc tures. This is intended to encompass all symp- tomes associated with the muscle, bone, and facial structures. Okeson’ stated that the term, sug- gested by Bell, has gained wide acceptance and popularity Table 1 gives an averview of epidemiological studies undertaken in various parts of the world. TMD is a common condition, although the prevalence of symptoms and signs varies accord- ing to the criteria used and the methods of data collection. This subject will be discussed later. Longitudinal studies are probably the most use- ful. They tend to show that the prevalence of signs and symptoms increases with age and that the prevalence of signs is greater than the preva- Tence of symptoms. Where signs rather than symptoms are investigated, sex differences tend to vanish, although this is not supported by all studies Golberg etal?) Regarding condyle and disc position, it would. again be useful to set things in context. Dise dis- placement has been recognized for many years, and the condition was described at least as early as 1919 by Pringle. In relation to orthodontic treatment, Ricketts in a viewpoint article, de- scribed four types of “improper occlusion,” two Cf which are said to result in posterior displace ment of the condyle (termed "posterior disloca- Review Article Abstract, Key words ‘Submitted: July 1995 Orthodontists are concerned about the possibilty ofa link between the treatment they provide and temporomandibular disorders (TMD). The purpose of this article was to review the literature relating malocclusion and orthodontic treatment to problems of the temporomandibular joint (TMJ) and surrounding anatomy. in Part 1, the relationship of orthodontic treatment to TMD is discussed. In Part 2, the relationship of TMD to malocclusion will be addressed. Orthodontic treatment + Malocclusion * Temporomandibular disorder * Review Revised and accepted: August 1997 Angle Orthod 1998;68(4):295-904, The Angle Orthodontist Vol. 68 No. 4 1998 295Luther Koy: M = males, nals; ques. = questionnale; ? = not stated unknown; 1, = occlusal inter ‘etnaded postiontetrded contact poston; IPNCP = intacuspal postion; MT = maditusion intererance: fciduous dentton; Mx dh = med denon; Eaty perm» eat perma same = ame subjects asin the 12 y exam, new = now subjects compared wth 12 y exam rece: NWSI Jt dention: Pet ‘pemanent settion; yr) Tablet Prevalence of some symptoms/signs of TMD in various epidemiological studies ‘Swayand Typeot Samples Agevange Sample “wihOls Panen amine %eample county study o wit symptoms rmuseo palpation agreementtest— ortho orsign (Geol sample) undertaken? treated Sober Clnicaloxam 739 19.25 yrs Atleast 66 26.aM:42.2F Yes > tale + quest. (969M: 370F}. ‘symptom, (FCP-ICP liters ony) (1979) Solocted trom fotalsamplen25.8 nat Usa students ‘Alleast 1 sign, coincident, entering UCLA -60.5,F=B42 lal No symptoms, sample) 133 M=269 Clinical exam 440 random — 7-14 ys 36 79 ot Yes 15 ‘interview selection (symptoms, (in RP, (otal sample) {inter-only) (22am, 218) ‘otal sample) total sample) Ninec?—Clnicalexam 300, 15418 yes a 83 55 Yes 25 (1981) interview random (symptoms, (in RP, (total Ginter ony Sweden selection total sample) total sample) sample) (474; 3626) Hoikinnoimo Quest + 1. seyrsand 70% = MTEM, 12y18=12 Temporal Not expt: 168 otal clncalexam (84; 83M) 1S yrs_hadsigns/ MTF, 12yrs=1.2 muscle: 2 authors (1990) (longiucinal symptoms TIM, 15yes=72 MT2yr5-0 attended Finland ‘tudy) (otal sample) MTLF, Syrsa2_4_ Fi2yrs=8 training stage 12yrsSO% with MT MISyrssame-0 session ‘al t5yis did FiSyresame=12 both rothave MT! WiSyrsnew=18.2 present altayis Fibysnew=7.1_ ateach clinical exam. Monin Clricalexam 1018 1298 46 Unistoral a Yes (intra) 7 etal Sauest. selected by (signs) contact in (1991) Longitudinal. o5mm=03 (total sample) Deng nical exam 3105 a9 98 Nosex Notexamined Notexamined Statos hat 7 etal (? selection age groups _aiferences ‘alioation (1905) methed) according fo foundin signs. took place China stageot Combined but results dental sexmeans nel given development given Decid dr: 14.3, Mix dn: 20.2 Early perm: 21.9 Perm: 15.9 non-working side itrironce vs) 296 The Angle Orthodontist Vol. 68 No. 4 1998Orthodontics and the TMJ: Part 1. Orthodontic treatment and TMD tion,” or "jamming" of the condyle into the fossa, ‘when associated with loss of posterior support However, Blaschke and Blaschke’ investigated condylar position in 25 asymptomatic patients ‘using corrected lateral tomograms. They did not state what type of occlusion the patients had, but they found that “..mandibular condyles as- sumed widely varying positions within their re- spective joints when the teeth were in centric occlusion..Some of the normal subjects pre- sented joints in which the condyles could sub- jectively be classified as severely retruded or protruded.” What, then, is the concern? Gianelly* summa- rized the problems said to arise following cer- tain forms of orthodontic treatment: "...an iatrogenic cause of posterior condylar position is premolar extraction in orthodontic treatment (presumably because over retraction of the inci- sor segment can occur during space closure forc- ing the mandible posteriorly).” And "posterior condylar position within the fossa is associated with an anteriorly displaced disk. Presumably space constraints would require that the condyle bbe positioned posteriorly ifthe disk were ante- rior.” He pointed out that itis not clear whether posterior positioning of the mandible leads to internal derangement or vice versa. Debate concerning the relationship between ‘TMD and orthodontic treatment came to a head in 1987 following a lawsuit. The case (cited by Luecke and Johnston’) of Brimm vs. Malloy (Witzig, JW, Deposition, Oakland County (Ml) ireuit Court, Case No. 852 987 50, July 13) re- volved around whether orthodontic treatment hhad caused TMD in a patient, The case went against the orthodontist, but since then many investigations have been carried out in attempts to clarify the situation, Some of these studies and. other work will be presented to see if any kind of conclusion can be reached, A number of questions need to be addressed, but initially, if the above statements regarding the effects of orthodontic treatment on condyle position are true, it should be possible to test them in a number of ways. For example, by: 1, Measurement of joint space (before and af- ter treatment) 2, Assessment of dise position 3. Comparison of symptoms/signs of patients before and after orthodontic treatment using dif- ferent treatment modalities In addition, in order to test these aspects, itis necessary to make atleast the following assump- tions: 1. A satisfactory method for measuring joint space exists. 2. We know what a normal joint space is, 3. We know what an abnormal joint space is, 4. We can assess disc position with respect to condylar position, 5, We know what TMD is, 6. A suitable method for measuring and rating ‘TMD exists 7. Patients can be assessed pretreatment as well as posttreatment, 8, Patients undergoing orthodontic treatment are no different from untreated controls or, al- ternatively, if treatment comparisons are to be ‘made, then patients undergoing different forms of treatment should be no different from each other. Before going further, one needs to ask what evidence supports these assumptions, as they are central to many other questions. Can we measure joint space and determine whether itis normal or abnormal? Can we assess disc position? Gianelly® cited the work of Farrar and McCarty (1983), who proposed that a space of less than 24 mm posterior to the condyle on a transcranial X-ray suggested an internal derangement. Weinberg’ concluded that “Bilateral asymmetric temporomandibular joint spaces are considered to be radiographic evidence of dysfunction, with rare exceptions,” and “Unilateral or bilateral condylar retrusion is usually associated with dise derangement and/or palpable muscle spasts.” In his sample of 67 patients, only 10 were asymp- tomatic, and these had concentrically positioned condyles. However, he did not investigate the normal range of condylar position. Pullinger et al? investigated 44 young adults (with a variety of malocclusions) with no history (or signs or symptoms) of TMD and no orthodontic or other occlusal therapy. Using corrected lateral tomograms, they found that 25% of the adults with Class I malocelusions had posteriorly posi- tioned condyles, 18% had anteriorly positioned condyles, and 57% had concentrically placed condyles, However, although many similar studies could bbe quoted, the value of such radiographic exami- nations must be seriously questioned when one considers the dangers of using 2-dimensional views to gain information about 3-dimensional structures. For example, Juniper" reported severe changes in condylar shape and size in the joints (of 105 patients whose treatment involved arthro- tomy for the surgical treatment of their TMD. ‘The Angle Orthodontist Vol. 68 No. 4 1998 297Luther specs of Hektmo dystuncon index, roma ex extraction: melee, = maoccksion eg cs) =satitall rican ieroncos nomi tu; pram = prokminary, max = maximum; oe index w accel inde; nanex = nonetaction Table2 ‘Summary of various studies comparing orthodontically treated and untreated cases for TMD. ‘Rutorsand Sample Agovango Contras, Testol___Typeot __Postieaiment __Typeof Findings country sizo(o) (Years) ——smatcheg—=——oxaminer_ treatment time assessment wits? agreement? Sadowsky, 75918 2555 “Carelaly No Edgewise; «10-35 ys Pain jont —Nosig. dts Begole" — 29M46F (ono) ———_matehod” ‘0s wih utat sounds, max. (1980) . 10-35 yrs for agolsen! exactions retontion opening, Usa TScontis before) atnicy! functional 2aM7F ental aware occlusal nessidental assessment, health state! paratuncsonal ‘education able Sadowsty, 207 p18 Meanages “Caroll No Edges; Aloast ——_Pain,jint_ No sip. cits Polsor® 268M por matched? 36% with Tyr out sounds, max. (1984) ve only given: for agelsexd euractions retention "opening, USA 2idcontols 29-987 ethicy! ‘unetonal 130F'84M ental aware noseidontal heals @ paratunctonal statusieducaton habits Larsson, 23988 2628 Ptscompared No vasous: Atleast Helkimo Nog. dis onnerman'© 11M12F wih Heme data ‘aclvatr (ones); 10yrs——_ystnetion (2961) UFR ony index Sweden UFA. LFA (ecgowise) Hepmex + HG sanson, sons 1436 Notstated No SO ptsedgowiso Average, Hokimo _Treatod Hasund® — (roatodor 1) $4pmex—Syrsout Indices cases tower (981) BORNSORE ‘S0nonex —afretenton (+A) functional Noway vs. 30.contols sctvator + HG probloms than SNM then edgewse contals Danletal® 54 pts 19 Botngroupe No Notstaed Average, Hokimo. No sig. if, (1988) 20F-2aM scored Syrsout indices Noway vs. 4? contols simiary on ofretenion D+ A+0 19F 20M ‘an 206 index KeBetal® stpevs. 20-90 No ‘Caretul 41:functonal “Finished for Creal, Functional + (1981) S2contole caliyaton’ applarcetren many years’ —_ooclusel+ _oocusal status Gemany _? sax FAIS Insrumertal of ex-rtno dstibution ‘unetional only methods of pts more ‘assessment + harmonious Holkima indices than conals Egermark, 298 17.25 Longludinal study Notexpict —_34%had arable Hekimoindex Onho pishad “Thlander" 1350 160F olteated + some form of (O)+ quest. hadsig. (1982) ‘untreated ‘othodonte lower cintcal ‘Swedon individuals veatment