Orthodontic Therapy and TMD: An Update - AAO

Okeson AAO May 3, 2016 1 by Jeffrey P Okeson, DMD Professor and Chief, Division of Orofacial Pain Director, Orofacial Pain Program University of Kentucky College of Dentistry Lexington, Kentucky 40536-0297 [email protected] www.jeffokeson.net Orthodontic Therapy and TMD: An Update The American Association of Orthodontists Orlando, Florida May 3, 2016


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Okeson AAO May 3, 2016
Jeffrey P Okeson, DMDProfessor and Chief, Division of OrofacialPainDirector, Orofacial Pain ProgramUniversity of Kentucky College of DentistryLexington, Kentucky [email protected]
www.jeffokeson.netOrthodontic Therapy and TMD: An UpdateThe American Association of OrthodontistsOrlando, Florida
Orthodontic Therapy and TMD: An Update
?
Temporomandibular Disorders
1.Does orthodontic therapy lead to an increase in Temporomandibular Disordersymptoms?2.What causes Temporomandibular Disorder?3.What are the functional treatment goals of orthodontic therapy?4.When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder?5.Can orthodontic therapy prevent TMD?Some important questions for us to consider.
-let’s ask some specific questions -1.Does orthodontic therapy lead to an increase in TMD symptoms?Orthodontic therapy and TMD-a data based review -
Sadowsky& BeGole, 1980 75
Authors # pat # controls years results
Okeson AAO May 3, 2016
-let’s ask some specific questions -1.Does orthodontic therapy lead to an increase in TMD symptoms?2.Does premolar extraction increase the incidence of TMD symptoms?Orthodontic therapy and TMD-a data based review -
Janson & Hasund, 1981 30 30 5 years no significant differencesSadowsky et al., 1991 87 68 3 years no significant differencesLuppanapornlarp, 1993 33 29 15 years no significant differencesKremenak et al, 1992 39 26 1-2 years no significant differencesDibbets et al, 1992 73 38 20 years no significant differencesExtraction vs. Non Extraction and Various TMD Symptoms
Authors # ex pat # non ex years results
-let’s ask some specific questions -1.Does orthodontic therapy lead to an increase in TMD symptoms?2.Does premolar extraction increase the incidence of TMD symptoms?3.Does premolar extraction resulting in posterior displacement of condyles?Orthodontic therapy and TMD-a data based review -
Gianelly et al, 1988 30 37 no significant differencesLuecke et al,1992 42 ---70 % more forward after txBeattieet al, 1994 33 30 no significant differencesArtun et al, 1992 29 34 Mixed: Right mid & lat all other areas no sign diffO’Reilly et al, 1993 60 60 no significant differencesExtraction vs. Non Extraction and Posterior Displacement of the Condyle
Authors # ex pat # non ex results
-let’s ask some specific questions -1.Does orthodontic therapy lead to an increase in TMD symptoms?2.Does premolar extraction increase the incidence of TMD symptoms?3.Does premolar extraction resulting in posterior displacement of condyles?4.Does orthodontic therapy prevent TMD?Orthodontic therapy and TMD-a data based review -
Sadowsky & BeGole, 1980 75 75 10 years no significant differencesSadowsky & Polson, 1984 96 103 10 years no significant differencesLarsson & Ronnerman, 1981 23 HI 10 years no significant differencesDahl et al, 1988 51 47 5 years no sign differences (-pat)Smith & Freer, 1989 87 28 4 years no sign differences (+ pat)Rendell et al, 1992 462 HI 18 mons no significant differencesHirata et al, 1992 102 41 2 years no significant differencesKremenak et al, 1992 109 HI 1-6 years no significant differencesWadhwa et al, 1993 31 71 4 years no significant differencesHenrikson et al, 200065602 years no significant differences
Authors # pat # controls years results
Does Orthodontic Therapy Prevent TMD Symptoms
Okeson AAO May 3, 2016
These studies suggest that orthodontic therapy is not a risk factor for TMD.Is that true?…..or are there other factors that may need to be considered regarding the results of these studies?
Some considerations regarding the conclusions of these studies1. The studies are true, there is no relationship between orthodontic therapy and TMD.2. The studies have only looked at well controlled orthodontic therapy.3. The studies looked at young, growing, adaptive patients. 4. Orthodontic therapy does affect occlusion but….…. the relationship between occlusion and TMD is unclear.
1.Does orthodontic therapy lead to an increase in Temporomandibular Disordersymptoms?2.What causes Temporomandibular Disorder?3.What are the functional treatment goals of orthodontic therapy?4.When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder?5.Can orthodontic therapy prevent TMD?Some important questions for us to consider.
Normal functioning masticatory system
TMD
Occlusal FactorsThe asymptomatic individual
The Role of Occlusion in Temporomandibular Disorders
Occlusion
TM Disorders
Evidence based Dentistry
I reviewed the findings of78 epidemiologic studies that investigated the occlusal factors and TMD symptoms.
Pub Med search from 1979 -2008
Opinion ? or Data ?
Okeson AAO May 3, 2016
Williamson and Simmons, DeBoeverand Adriaens, 1983Egermark-Eriksson et al.,Gazitet al., Brandt, 1985Nesbitt et al., 1985Thilander, 1985Budtz-Jorgenson et al., 1985Bernal and Tsamtsouris, 1986Nilner, 1986Stringertand Worms, 1986Rioloet al.,Kampeet al., 1987Kampeand Hannerz, 1987et al.,Pullinger, et al., Seligman and Pullinger, Linde and Isacsson, 1990 Dworkinet al.,Kampeet al., 1991et al., 1991Takenoshitaet al., 1991Pullingerand Seligman, Wänmanand Agerberg, 1991Cacchiottiet al.,Kampeet al., 1991et al., 1991Takenoshita et al., 1991Pullinger and Seligman, Wänman and Agerberg, 1991Cacchiottiet al.,Egermark and Thilander, 1992Shiau and Chang, 1992Glaros et al., 1992Huggare and Raustia, 1992Kirveskari et al., 1992Könönen, 1992Könönen et al., 1992List and Helkimo, 1992Shian and Chang, 1992Al Hadi, 1993Pullinger and Seligman, Pullinger et al., 1993Scholte et al.,Tanne et al., 1993Wadhwa et al., 1993Keeling et al., 1994Magnusson et al., 1994Tsolka et al., 1994 Vanderas, 1994Bibb et al., Castro, 1995Hochman et al., 1995Lebbezzo-Scholte et al., 1995Olsson and Lindqvist, 1995Mauro et al., 1995Tsolka et al., 1995Westling, Raustia et al., 1995 Conti et al., 1996Sato et al.,Seligman and Pullinger, Henrikson et al., 1997Watanabe et al., 1998Ciancaglini et al, 1999Kahn et al., 1999Seligman and Pullinger, Pullinger and Seligman, Rauhala et al., 2000Thilander et al., 2002Carlsson et al., 2002Egermark et al., 2003Gesch et al., 2004Taskaya-Yilmaz et al., 2004Landi et al., 2004Pahkala et al., 2004Magnusson et al., 2005Gesch et al., 2005
Studies that investigate the relationship between occlusion and TMD
Total = 78 Studies
Williamson and Simmons, DeBoeverand Adriaens, 1983Egermark-Eriksson et al.,Gazitet al., Brandt, 1985Nesbitt et al., 1985Thilander, 1985Budtz-Jorgenson et al., 1985Bernal and Tsamtsouris, 1986Nilner, 1986Stringertand Worms, 1986Rioloet al.,Kampeet al., 1987Kampeand Hannerz, 1987et al.,Pullinger, et al., Seligman and Pullinger, Linde and Isacsson, 1990 Dworkinet al.,Kampeet al., 1991et al., 1991Takenoshitaet al., 1991Pullingerand Seligman, Wänmanand Agerberg, 1991Cacchiottiet al.,Kampeet al., 1991et al., 1991Takenoshita et al., 1991Pullinger and Seligman, Wänman and Agerberg, 1991Cacchiottiet al.,Egermark and Thilander, 1992Shiau and Chang, 1992Glaros et al., 1992Huggare and Raustia, 1992Kirveskari et al., 1992Könönen, 1992Könönen et al., 1992List and Helkimo, 1992Shian and Chang, 1992Al Hadi, 1993Pullinger and Seligman, Pullinger et al., 1993Scholte et al.,Tanne et al., 1993Wadhwa et al., 1993Keeling et al., 1994Magnusson et al., 1994Tsolka et al., 1994 Vanderas, 1994Bibb et al., Castro, 1995Hochman et al., 1995Lebbezzo-Scholte et al., 1995 Olsson and Lindqvist, 1995Mauro et al., 1995Tsolka et al., 1995Westling, Raustia et al., 1995 Conti et al., 1996Sato et al.,Seligman and Pullinger, Henrikson et al., 1997Watanabe et al., 1998Ciancaglini et al, 1999Kahn et al., 1999Seligman and Pullinger, Pullinger and Seligman, Rauhala et al., 2000Thilander et al., 2002Carlsson et al., 2002Egermark et al., 2003Gesch et al., 2004Taskaya-Yilmaz et al., 2004Landi et al., 2004Pahkala et al., 2004Magnusson et al., 2005Gesch et al., 2005
Total = 25 StudiesStudies that found no relationship between occlusion and TMD
NoNo
Williamson and Simmons, DeBoeverand Adriaens, 1983Egermark-Eriksson et al.,Gazitet al., Brandt, 1985Nesbitt et al., 1985Thilander, 1985Budtz-Jorgenson et al., 1985Bernal and Tsamtsouris, 1986Nilner, 1986Stringertand Worms, 1986Rioloet al.,Kampeet al., 1987Kampeand Hannerz, 1987et al.,Pullinger, et al., Seligman and Pullinger, Linde and Isacsson, 1990 Dworkinet al.,Kampeet al., 1991et al., 1991Takenoshitaet al., 1991Pullingerand Seligman, Wänmanand Agerberg, 1991Cacchiottiet al.,Kampeet al., 1991et al., 1991Takenoshita et al., 1991Pullinger and Seligman, Wänman and Agerberg, 1991Cacchiottiet al.,Egermark and Thilander, 1992Shiau and Chang, 1992Glaros et al., 1992Huggare and Raustia, 1992Kirveskari et al., 1992Könönen, 1992Könönen et al., 1992List and Helkimo, 1992Shian and Chang, 1992Al Hadi, 1993Pullinger and Seligman, Pullinger et al., 1993Scholte et al.,Tanne et al., 1993Wadhwa et al., 1993Keeling et al., 1994Magnusson et al., 1994Tsolka et al., 1994 Vanderas, 1994Bibb et al., Castro, 1995Hochman et al., 1995Lebbezzo-Scholte et al., 1995 Olsson and Lindqvist, 1995Mauro et al., 1995Tsolka et al., 1995Westling, Raustia et al., 1995Conti et al., 1996Sato et al.,Seligman and Pullinger, Henrikson et al., 1997Watanabe et al., 1998Ciancaglini et al, 1999Kahn et al., 1999Seligman and Pullinger, Pullinger and Seligman, Rauhala et al., 2000Thilander et al., 2002Carlsson et al., 2002Egermark et al., 2003Gesch et al., 2004Taskaya-Yilmaz et al., 2004Landi et al., 2004Pahkala et al., 2004Magnusson et al., 2005Gesch et al., 2005
Total = 53 StudiesStudies that found a relationship between occlusion and TMD
YesYes
anterior openbiteincreased overjetincreased overbitecentric slide� 2 mmasymmetrical slideunilateral contact in CRAngle class IIAngle class II, division 1Angle class II, division 2Angle class IIIposterior crossbiteanterior crossbitenon working contactsmidline discrepancyloss of teethloss of molar supportpresence of restorationreduced tooth contacts in COcrowding“occlusal interferences”attritionlaterotrusive attritionanterior attritionno slideThe following occlusal conditions were reported as related to TMD:..but all of these conditions were not reported in every study.
What was the occlusal relationship found to be related to TMD?
16 studies = anterior openbite (20%)*13 studies = increased overjet (17%)10 studies = centric s�lide 2 mm (13%)9 studies = asymmetrical slide (12%)8 studies = non working contacts(10%)7 studies = occlusal interferences(9%)6 studies = unilateral contact in CR (8%)5 studies = anterior crossbite (6%)4 studies = Angle class II (5%)4 studies = Angle class II division 1 (5%)4 studies = Angle class III (5%)4 studies = increased overbite (5%)3 studies = loss of teeth (4%)3 studies = loss of molar support (4%)3 studies = posterior crossbite (4%)3 studies = reduced CO tooth contacts (4%)2 studies = attrition (4%)2 studies = presence of restoration (4%)1 study = Angle class II, division 2(1%)1 study = laterotrusive attrition(1%)1 study = anterior attrition(1%)1 study = crowding(1%)1 study = midline discrepancy(1%)1 study = no slide(1%)* % of the 78 studies reporting this findingHow common were these conditions reported?
What was the occlusal relationship found to be related to TMD?
16 studies = anterior openbite (20%)*13 studies = increased overjet (17%)10 studies = centric s�lide 2 mm (13%)9 studies = asymmetrical slide (12%)8 studies = non working contacts(10%)7 studies = occlusal interferences(9%)6 studies = unilateral contact in CR (8%)5 studies = anterior crossbite (6%)4 studies = Angle class II (5%)4 studies = Angle class II division 1 (5%)4 studies = Angle class III (5%)4 studies = increased overbite (5%)3 studies = loss of teeth (4%)3 studies = loss of molar support (4%)3 studies = posterior crossbite (4%)3 studies = reduced CO tooth contacts (4%)2 studies = attrition (4%)2 studies = presence of restoration (4%)1 study = Angle class II, division 2(1%)1 study = laterotrusive attrition(1%)1 study = anterior attrition(1%)1 study = crowding(1%)1 study = midline discrepancy(1%)1 study = no slide(1%)* % of the 78 studies reporting this findingHow common were these conditions reported?
What was the occlusal relationship found to be related to TMD?
An anterior openbitemay bethe results of a TMD,and not the cause a TMD.
Okeson AAO May 3, 2016
16 studies = anterior openbite (20%)*13 studies = increased overjet (17%)10 studies = centric s�lide 2 mm (13%)9 studies = asymmetrical slide (12%)8 studies = non working contacts(10%)7 studies = occlusal interferences(9%)6 studies = unilateral contact in CR (8%)5 studies = anterior crossbite (6%)4 studies = Angle class II (5%)4 studies = Angle class II division 1 (5%)4 studies = Angle class III (5%)4 studies = increased overbite (5%)3 studies = loss of teeth (4%)3 studies = loss of molar support (4%)3 studies = posterior crossbite (4%)3 studies = reduced CO tooth contacts (4%)2 studies = attrition (4%)2 studies = presence of restoration (4%)1 study = Angle class II, division 2(1%)1 study = laterotrusive attrition(1%)1 study = anterior attrition(1%)1 study = crowding(1%)1 study = midline discrepancy(1%)1 study = no slide(1%)* % of the 78 studies reporting this findingHow common were these conditions reported?
What was the occlusal relationship found to be related to TMD?
-Important -These occlusal conditions do not always lead to TMD!
Normal functioning masticatory system
TMD
Occlusal FactorsThe asymptomatic individual
Normal functioning masticatory system
TMD
Occlusal Factors
TraumaThe asymptomatic individual
Normal functioning masticatory system
TMD
Occlusal Factors
Trauma
Emotional StressThe asymptomatic individual
Normal functioning masticatory system
TMD
Occlusal Factors
Trauma
Emotional Stress
Deep Pain InputThe asymptomatic individual
Normal functioning masticatory system
TMD
Occlusal Factors
Trauma
Emotional Stress
Deep Pain Input
ParafunctionThe asymptomatic individual
Okeson AAO May 3, 2016
Normal functioning masticatory system
TMD
Occlusal Factors
Trauma
Emotional Stress
Deep Pain Input
ParafunctionThe asymptomatic individualThe individual is unaffected
Adaptability of the individual
AdaptabilityGenetic factorsBiologic factorsHormonal factorsPsychosocial factorsOthers ?
Normal functioning masticatory system
Adaptability
The asymptomatic individualThe individual develops TMD symptoms
Adaptability of the individual
Occlusal Factors
Trauma
Emotional Stress
Deep Pain Input
ParafunctionGenetic factorsBiologic factorsHormonal factorsPsychosocial factorsOthers ?
Etiologic Factors
TMD
The asymptomatic individualHow do you treat the TMD symptoms?
Normal functioning masticatory system
Correct the occlusal condition
Trauma
Emotional Stress
Deep Pain Input
Parafunction
AdaptabilityAdaptability of the individualGenetic factorsBiologic factorsHormonal factorsPsychosocial factorsOthers ?
Normal functioning masticatory system
TMD
Occlusal Factors
Trauma
Emotional Stress
Deep Pain Input
ParafunctionThe asymptomatic individualThe individual is unaffected
Adaptability of the individual
Adaptability
Slade, Ohrbachand Maixner: Orthodontic Treatment, GeRisk of TMD Vol14, No 2, 2008, pp 146-156Three common COMT haplotypeslow pain sensitivity (LPS)average pain sensitivity (APS)high pain sensitivity (HPS)
Genetic factorsBiologic factorsHormonal factorsPsychosocial factorsOthers ?
1.Does orthodontic therapy lead to an increase in Temporomandibular Disordersymptoms?2.What causes Temporomandibular Disorder?3.What are the functional treatment goals of orthodontic therapy?4.When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder?5.Can orthodontic therapy prevent TMD?Some important questions for us to consider.
-Condylar Stability -•The condyles are in their most superior anterior positionin the fossae resting against the posterior slopes of thearticular eminentiae. (musculoskeletally stable)•The discs are properly interposed between thecondyles and the fossae.-Occlusal Stability -These are the treatment goals for orthodontic therapy•Even and simultaneous contact of all teeth with posteriorteeth contacting slightly heavier than anterior teeth.•Adequate tooth-guided contacts on the laterotrusive side.•In the normal upright position, posterior teeth contact heavier than anterior teeth (envelop of function).
Okeson AAO May 3, 2016
Orthodontic therapy can
Joint Stability = Occlusal Stability
The Anterior Protrusive Position
This is a muscle bracedposition not a musculoskeletally stabilized position.Some believe the best position for the condyle is in a forward, protrusive position in the fossa.
The Anterior Protrusive Position
This is a muscle bracedposition not a musculoskeletally stabilized position.Some believe the best position for the condyle is in a forward, protrusive position in the fossa.
MSS Position
MSS Position
The Anterior Protrusive PositionDoes placing the condyle in a forward position cause any anatomical problems?No, this is a functional position: protrusionHowever, the muscles must actively brace the condyle to maintain it in this position.
The Anterior Protrusive Position1.Functional Orthodontics
What would be the purpose of moving the mandibular forward in a protrusive position?
The Anterior Protrusive Position
Bring the mandibular forward (in a growing patient)…
Insert a functional appliance…Allow the condyle to grow into the musculoskeletally stable position.
Okeson AAO May 3, 2016
The Anterior Protrusive Position
But what if the mandible does not grow?And the occlusion is established in this forward position.
With time the muscle developsa myostatic contracture.A painless shorteningof the functional lengthof the muscle.
The Anterior Protrusive Position
But what if the mandible does not grow?And the occlusion is established in this forward position.
The Anterior Protrusive Position
MSS Position
Now the condyles are braced forward and the occlusion is stabilized in this position.What if at a later time the condyles become seated into their musculoskeletally stable positions?
The Anterior Protrusive Position
Now the condyles are braced forward and the occlusion is stabilized in this position.What if at a later time the condyles become seated into their musculoskeletally stable positions?
MSS Position
MSS Position
An anterior open bite(significant orthopedic instability)
The Anterior Protrusive PositionThe orthodontist should assess for condylar stability before finishing the occlusion.1.Try a bilateral mandibular manipulation.2.Consider an anterior bite plane for a short time (2-7 days).3.Consider imaging.-some considerations --Conclusion -Radiographs are not an accurate method of assessing joint position.

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