Orthodontics, Malocclusion, and TMD

Malocclusion and TMD

unilateral posterior crossbite is modestly correlated with symptoms of TMD at 5 year follow-up [EgermarkEriksson et al., 1990], and is more prevalent in populations with both TMD [Pullinger et al., 1993] and
headaches [Lambourne et al., 2007]
anterior openbite is modestly correlated with symptoms of TMD at 5 year follow-up [Egermark-Eriksson et al.,
1990], and is more prevalent in populations with TMD [Pullinger et al., 1993]
overjet >5-6mm is modestly correlated with symptoms of TMD at 5 year follow-up [Egermark-Eriksson et al.,
1990], and is more prevalent in populations with both TMD [Pullinger et al., 1993] and headaches [Lambourne
et al., 2007]
5+ missing posterior teeth is more prevalent in populations with TMD [Pullinger et al., 1993]
CR-MI slide >2mm is more prevalent in populations with TMD; neither smaller midline shifts, nor the
direction of the shift appear to be of significance [Pullinger et al., 1993]

deep bite is unrelated to TMD [Pullinger et al., 1993] but is more common in patients reporting
headaches [Lambourne et al., 2007]

orthodontic treatment need (ICON) at age 11-12 was not correlated with TMD at 20 year follow-up
[Macfarlane et al., 2009], but malocclusion severity (PAR) was correlated [Mohlin et al., 2004]
Angles classification is unrelated to TMD [Pullinger et al., 1993]
midline discrepancy is unrelated to TMD [Pullinger et al., 1993]

Orthodontic Treatment and TMD

Short Term
active orthodontic treatment decreases self-reported parafunctional grinding activity [Hirsch et al., 2009]
orthodontic treatment did not eect the incidence of new TMD signs/symptoms at 3 year followup [Macfarlane et al., 2009]
history of orthodontic treatment did not eect the prevalence TMD signs/symptoms in children aged 1018 [Hirsch et al., 2009]
Long Term
orthodontic treatment did not eect the incidence of new TMD signs/symptoms at 8 or 20 year follow-up
[Mohlin et al., 2004] [Macfarlane et al., 2009]
patients who had orthodontic treatment 10+ years previously were no more likely to have an RDC/TMD
diagnosis than those who had never had orthodontic treatment [Manfredini et al., 2015]
extraction did not increased signs of symptoms of TMD at 10+ years post-treatment [Luppanapornlarp &
Johnston, 1993] [Mohlin et al., 2004]

Treatment Quality
orthodontically treated patients demonstrating residual/relapsed malocclusion (crossbite, deep bite, open
bite, overjet, CR-CO slide) at 10+ years post-treatment are no more likely to have RDC/TMD diagnosis than
those who have retained an ideal result [Manfredini et al., 2015]

Resolution of TMD

orthodontic treatment did not make TMD symptoms more or less likely to resolve over 20 year followup [Macfarlane et al., 2009]

Patient Factors
Age
overall TMD prevalence increased from the childhood (3.2%) to age 19 to 20 (17.6%), and decreased by age
30 to 31 (9.9%) [Macfarlane et al., 2009]
Gender
females are more likely to develop TMD symptoms [Macfarlane et al., 2009]
females are less likely to have resolution of TMD symptoms [Macfarlane et al., 2009]

Psychological
psychometric testing indicating poor health, psychological distress, neuroticism, and low self-esteem all
associated with TMD [Mohlin et al., 2004]
Genetics
catechol-O-methyltransferase variants may contribute to pain resistance [Slade et al., 2008]
pain resistant COMT haplotypes have a low TMD incidence
orthodontic treatment did not influence this incidence
pain sensitive COMT haplotypes have a TMD incidence of
this appears to interact with orthodontic treatment, leading to a TMD incidence of >20% after
orthodontic treatment in pain-sensitive individuals

Key References
Egermark-Eriksson, I., Carlsson, G. E., Magnusson, T., & Thilander, B. (1990). A longitudinal study on malocclusion in
relation to signs and symptoms of cranio-mandibular disorders in children and adolescents. European Journal of
Orthodontics, 12(4), 399407.
Methodology: prospective cohort / cross-sectional
Population: 7, 11, and 15 year olds
Sample: 238 subjects
Data: clinical exam of occlusal characteristics, questionnaire and exam for TMD signs/symptoms (mobility, pain on
palpation, pain on excursions) 5 years later
Results
unilateral crossbite, anterior open bite, and overjet >6mm were associated with signs/symptoms of TMD;
however, correlation was weak (Corr. coeff. 0.20-0.30)
Limitations: not controlled for patients who recevied corrective orthodontic treatment during study period
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Hirsch, C. (2009). No Increased risk of temporomandibular disorders and bruxism in children and adolescents during
orthodontic therapy. Journal of Orofacial Orthopedics, 70(1), 3950.
Study Type: Epidemiology, Cross-Sectional

Population: adolescents between ages 10-18 years (total eligible population: 24,129)
Sample: 1,011/1,190 children randomly selected from general public (85% consented to participate)
Inclusion: age 10-18, attending public school
Exclusion: special needs, private school (samples taken from public schools)
Data:
self-reported: facial pain, tooth grinding, history of orthodontic treatment
clinical exam: RDC category (pain, joint sounds, range of motion) & Helkimo index (range of motion & pain), and
to assess for chronic bruxism (defined as presence of wear facets)
Results :
no statistically significant difference between orthodontically treated and non-orthodontically treated sub-groups
in: facial pain , muscle pain , joint pain , joint sounds , limited jaw opening , Helkimo index score , RDC
diagnosis
statistically significant difference: self-reported current grinding (decreased during active orthodontic treatment),
wear facets on front teeth (decreased in orthodontic treatment )
Conclusion :
no increased risk of TMD in children and adolescents during orthodontic therapy
possible decrease in parafunctional habits during orthodontic therapy
Limitations: there is no logical explanation for how wear the presence of facets could decrease during orthodontic
treatment, and not thereafter; this is likely a spurious correlation
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Kandasamy, S., Boeddinghaus, R., & Kruger, E. (2013). Condylar position assessed by magnetic resonance imaging
after various bite position registrations. American Journal of Orthodontics and Dentofacial Orthopedics, 144(4), 512
517.
Population: young adults (20-39 years) without TMD
Sample: 19 patients
Data: MRI assessment of condylar position anteroposteriorly and superoinferiorly in CO, CR, and Roth CR; blinded
examiner
Results:
differences condylar position between the different bite averaged ~0 mm, with wide individual variation in the
subjects (ie: no consistent change in condylar position/seating was obtained by any method)
Limitations:
repeat MRI using the same bite registration would be beneficial in determining if the large variation seen was
due to experimental setup and measurement, or due to the bite registrations
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Kim, M.-R., Graber, T. M., & Viana, M. A. (2002). Orthodontics and temporomandibular disorder: A meta-analysis.
American Journal of Orthodontics and Dentofacial Orthopedics, 121(5), 438446.
Methodology: systematic review, no meta-analysis
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Lambourne, C., Lampasso, J., Buchanan, W. C., Dunford, R., & McCall, W. (2007). Malocclusion as a risk factor in the

etiology of headaches in children and adolescents. American Journal of Orthodontics and Dentofacial Orthopedics,
132(6), 754761.
Methodology: retrospective, case control
Population: adolescents aged 8-16 years
Population: 50 patients who reported headaches in orthodontic records
Control: 50 age and sex matched patients
Data: models to assess malocclusion features
Results:
overbite >5mm, overjet >5mm and posterior crossbite were stat. sig. more common in the headache group (OR
~2.5)
presence of multiple features increased risk exponentially
Limitations: sample depends on recording of headaches in medical history of orthodontic records
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Luppanapornlarp, S., & Johnston, L. E. (1993). The effects of premolar-extraction: a long-term comparison of outcomes
in clear-cut extraction and nonextraction Class II patients. The Angle Orthodontist, 63(4), 257272.
Methodology: retrospective cohort, discriminant analysis
Population: 2500 consecutively treated Class II patients, treated 1969-1980
Sample: 57 patients designated clear-cut extraction or non-extraction cases, based on discriminant analysis
Data: signs and symptoms of TMD by craniomandibular index (assesses pain, joint sounds, limited range of motion)
Results: no difference in signs and symptoms of TMD between extraction and non-extraction group
Limitations: craniomandibular index scores are not reported in the companion borderline article, which would be more
useful in assessing the effect of extractions between better matched groups
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Macfarlane, T. V., Kenealy, P., Kingdon, H. A., Mohlin, B. O., Pilley, J. R., Richmond, S., & Shaw, W. C. (2009). Twentyyear cohort study of health gain from orthodontic treatment: temporomandibular disorders. American Journal of
Orthodontics and Dentofacial Orthopedics, 135(6), 692.e18.
Methodology: prospective cohort
Population: children aged 11-12 years, UK
Sample: 1018 patients initial, 337 by end of study
Data: TMJ exam (mobility, joint sounds, pain, functional occlusion), malocclusion (ICON score) @ 0, 3, 8, and 20 years
follow-up
Analysis: prevalence and incidence of TMD
Results:
orthodontic treatment did not effect incidence or persistence of existing TMD at each follow-up (OR range
included 1)
females were more likely to have TMD incidence, and more likely to have persistence of TMD symptoms in
subsequent follow-ups
initial malocclusion severity/treatment need (ICON >44) did not effect likelihood of having TMD at age 30
Limitations: ~70% attrition; same sample is reported in two different studies
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Manfredini, D., Stellini, E., Gracco, A., Lombardo, L., Nardini, L. G., & Siciliani, G. (2015). Orthodontics is
temporomandibular disorderneutral. The Angle Orthodontist, 051015318.16.
Methodology: retrospective case control
Population: adults, Italy

TMD Sample: 505 patients seeking TMD treatment

Control: 97 age and sex matched
Inclusion: 30-40 yo; 24+ teeth present; no orthodontic treatment in previous 10 years; no significant prosthetic work
Data: history of orthodontic treatment, RDC Dx, malocclusion (crossbite, deep bite, open bite, overjet, CR-CO slide)
Results:
orthodontic no OR increase for TMD or any RDC category Dx
ideal vs non-ideal outcome (by presence of malocclusion features) no OR increase for TMD
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McNamara, J. A. (1997). Orthodontic treatment and temporomandibular disorders. Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology, and Endodontics, 83(1), 107117.
Methodology: literature review
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Mohlin, B. O., Derweduwen, K., Pilley, R., Kingdon, A., Shaw, W. C., & Kenealy, P. (2004). Malocclusion and
temporomandibular disorder: a comparison of adolescents with moderate to severe dysfunction with those without signs
and symptoms of temporomandibular disorder and their further development to 30 years of age. Angle Orthodontist,
74(3), 319327.
Methodology: prospective cohort
Population: children aged 11-12 years, UK
Sample: 1018 patients initial, 337 by end of study
Data: TMJ exam (mobility, joint sounds, pain, functional occlusion), malocclusion (PAR), psychometric tests (stress,
general health, neuroticism, self-esteem); followed at @ 3, 8, and 20 years
Analysis: compared sub-groups with no symptoms and moderate-severe symptoms
Results:
high PAR scores associated with TMD
poor health, psychological distress, neuroticism, and low self-esteem all associated with TMD
neither orthodontic treatment nor extractions associated with TMD
Limitations: ~70% attrition; same sample is reported in two different studies
Mohlin, B., Axelsson, S., Paulin, G., Pietil, T., Bondemark, L., Brattstrm, V., et al. (2007). TMD in relation to
malocclusion and orthodontic treatment. Angle Orthodontist, 77(3), 542548.
Methodology: systematic review
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Okeson, J. P. (2015). Evolution of occlusion and temporomandibular disorder in orthodontics: Past, present, and future.
American Journal of Orthodontics and Dentofacial Orthopedics, 147(5 Suppl), S21623.
Methodology: opinion
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Pullinger, A. G., Seligman, D. A., & Gornbein, J. A. (1993). A multiple logistic regression analysis of the risk and relative
odds of temporomandibular disorders as a function of common occlusal features. Journal of Dental Research, 72(6),
968979.
Methodology: case control
Population: consecutive patients from UCLA Pain Management clinic

Control: asymptomatic dental and hygeine students (147)

Sample:
disc displacement with reduction (81)
disc displacement without reduction (48)
osteoarthrosis with previous disc displacement (75) and without (85)
myalgia (124)
Data: malocclusion features by clinical exam and casts
Analysis: regressional
Results: (see paper for occlusal contributions to specific TMD sub-categories)
anterior open bite, unilateral crossbite, overjet >6 mm, >5 missing posterior teeth, and RCP-ICP slides >2 mm
were more prevalent in the TMD groups
anterior open bite was the most significant risk factor (OR ~7)
Limitations: odds ratios for positive risk factors were typically only marginally above 1, with the exception of anterior
open bite
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Rinchuse, D. J., & McMinn, J. T. (2006). Summary of evidence-based systematic reviews of temporomandibular
disorders. American Journal of Orthodontics and Dentofacial Orthopedics, 130(6), 715720.
Methodology: systematic review, no meta-analysis
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Slade, G. D., Diatchenko, L., Ohrbach, R., & Maixner, W. (2008). Orthodontic Treatment, Genetic Factors and Risk of
Temporomandibular Disorder. Seminars in Orthodontics, 14(2), 146156.
Methodology: prospective cohort
Population: female, 18-34 years
Sample: 254 at baseline, 186 by end of follow-up
Exclusion: history of TMD, active orthodontic treatment, significant medical illness
Data: clinical TMJ exam, catechol-O-methyltransferase SNPs, psychosocial questionnaire at baseline; TMD
questionnaire at 3 month intervals, clinical TMJ exam at 1 year intervals for 3 year follow-up
Results:
pain resistant COMT haplotypes had a TMD incidence of ~6% over the study period; orthodontic treatment did
not influence this incidence
pain sensitive COMT haplotypes had a TMD incidence of 22.9% after orthodontic treatment
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