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Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint
Int. J. Oral Maxillofac. Surg. 2012; 41: 1046–1050 http://dx.doi.org/10.1016/j.ijom.2012.02.024, available online at http://www.sciencedirect.com
Clinical Paper TMJ Disorders
Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint
¨ gren, C. Fa¨ltmars, B. Lund, M. O A. Holmlund Department of Oral and Maxillofacial Surgery, Institution of Dental Medicine, Karolinska Institutet/Karolinska University Hospital, Huddinge, Sweden
¨ gren, C. Fa¨ltmars, B. Lund, A. Holmlund: Hypermobility and trauma as M. O etiologic factors in patients with disc derangements of the temporomandibular joint. Int. J. Oral Maxillofac. Surg. 2012; 41: 1046–1050. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of the study was to investigate patients with temporomandibular joint (TMJ) disc derangement with its two clinical variants reciprocal clicking (RC) and chronic closed lock (CCL) with regard to the etiologic factors, previous jaw trauma and general (GJH) and local joint hypermobility (LJH). 42 patients (21 with RC and 21 with CCL) and 20 control individuals were studied. The patients and controls were asked whether they had sustained any jaw trauma in the past and were then examined for the presence of GJH and LJH, using defined criteria. Patient and control groups were compared. Statistical evaluation included x2 test and paired Student’s t test. Odds ratio was calculated in order to assess the relative risk of developing RC and CCL when the etiological factor was present. The results showed a significant association between RC and GJH (OR = 9.6, p = 0.0010) as well as LJH (OR = 38, p = 0.0001). CCL was clearly associated with GJH (OR = 7.5, p = 0.0030) while its association with LJH was not significant (OR = 9.5, p = 0.0582). No significant association with previous trauma was found. The results indicate that GJH is an important etiologic factor for the development of RC and CCL of the TMJ.
Temporomandibular joint (TMJ) disc derangement (DD) is the most common TMJ disorder leading to surgery. About 19% of the adult population in Sweden show symptoms of TMJ DD.1 There are two distinct clinical variants of TMJ DD, which differ from a tissue point of view, clinical characteristics and by the way they are treated,2 namely reciprocal clicking (RC) and chronic closed lock (CCL). 0901-5027/0901046 + 05 $36.00/0
RC has a prevalence of 7% in the population.1 In patients, the condition usually runs with a varying degree of pain. TMJs with RC, typically show no degenerative changes and inflammation is minor or absent. The disc has a callous formation in the posterior part, formed by tightly packed, thick collagen bundles.3 Clinically the condition is recognized as a reproducible RC caused by the disc with
Key words: TMJ; disc derangement; hypermobility; trauma. Accepted for publication 20 February 2012 Available online 31 May 2012
its callous displacing back and forth over the condyle. If the clicking becomes more pronounced a catch develops, which may be painful. This more severe subgroup may be treated surgically by discectomy.4 RC also progresses to CCL in many patients.2 CCL has a prevalence of about 12% in the population.1 In patients, the condition usually has an acute onset and rapidly
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint develops into a degenerative joint disease where inflammation and adhesions are frequently found. The translation of the disc-condyle is typically reduced. Clinical signs and symptoms are painful reduced vertical and horizontal mandibular movements. About 40% of CCL patients seem to recover spontaneously within a 2.5 year period while in the remaining 60% symptoms persist.5 The first choice of treatment is arthroscopic lysis and lavage.6 If this treatment is unsuccessful discectomy may be performed.4 Both treatments have about the same effectiveness, but arthroscopy is less invasive.6 It has been indicated that disc derangements and previous trauma to the jaw may be associated.7 Other suggested etiologic factors for DD are general (GJH) and localized joint hypermobility (LJH).8–10 Westling and Mattiasson studied adolescents and found that signs and symptoms of TMJ DD were more common in adolescents with a GJH.10 In a systematic review, Dijkstra et al. found that very few studies investigating GJH and temporomandibular joint dysfunction (TMD) were of good quality considering methodology and selection criteria.11 Since then a few other studies have appeared,8,9,12 indicating an association between TMJ DD and GJH. To the authors’ knowledge, patients with more severe TMJ DD requiring surgical treatment have not been investigated. The authors’ hypothesis is that trauma and joint hypermobility (general and local) are etiological factors for the development of advanced RC and CCL and that differences exist between the two patient groups. The aim of this study is to investigate the two clinical variants of TMJ DD, RC and CCL requiring TMJ surgery, with regard to previous trauma to the jaws and existing GJH and LJH. Material and methods
Consecutive patients with TMJ DD, referred to the division of Oral and Maxillofacial Surgery, Department of Dental Medicine, Karolinska Institutet Huddinge, as well as a control group (C) comprising consecutive patients receiving dental care at the dental school of the Karolinska Institutet from March 2010 to March 2011, were asked to participate in the study. Inclusion criteria for RC were reproducible reciprocal clicks with catching, with or without pain. Inclusion criteria for CCL were painful impaired vertical and horizontal
mandibular movements with or without previous clicking. Exclusion criteria were all other TMJ diseases. The control group were age and gender matched with the patients. Informed consent was received from all patients and control individuals prior to inclusion in the study. The study was approved by the regional research ethics committee (3 February 2010). The following etiologic factors were investigated by interviewing and examining the patients. The participants were interviewed and specifically asked whether they had sustained any previous trauma to the mandible. General hypermobility was determined using the Carter and Wilkinson criteria (3 positive tests out of 5).13 The 5 tests were: passive apposition of the thumb to the flexor aspect of the forearm; passive hyperextension of the fingers so that they lie parallel with the extensor aspect of the forearm; ability to hyperextend the elbow more than 10 degrees; ability to hyperextend the knee more than 10 degrees; an excess range of passive dorsiflexion of the ankle and eversion of the foot. Local hypermobility of the TMJ was determined by interviewing and examining the participants for episodes for mandibular luxation or subluxations. All patients and controls were also evaluated with regard to functional impairment and pain. Impaired mandibular function was assessed using a modified mandibular function impairment questionnaire (MFIQ)2,14 (minimum value 0, maximum value 21). Pain in the TMJ when performing mandibular movements was registered on a visual analogue scale (VAS), where 0 denotes no pain and 10 worst pain imaginable. The x2 test was performed in order to determine whether the differences between patient groups and control were significant or not. A p-level <0.05 was regarded as significant. If the p-level was between 0.01 and 0.05, Yate’s correction was performed. If the resulting new plevel was below 0.05 the difference was considered significant. The odds ratio (OR) was calculated in order to assess the relative risk of developing RC or CCL when the etiologic factor was present. An increased risk was considered if OR was above 1. A paired Student’s t test was performed to analyse if the frequencies of MFIQ and VAS values between RC, CCL and controls were significant. A p-value <0.05 was regarded as significant.
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Results
Tables 1–3 show the data for patients with RC or CCL and the controls. The mean values of MFIQ and VAS for the CCL patients were 11.38 (SD = 4.09) and 5.43 (SD = 2.38), respectively. For RC patients the corresponding values were 10.00 (SD = 3.26) and 4.24 (SD = 2.19). The corresponding values for the control patients were 0.45 (SD = 0.83) and 0.20 (SD = 0.52). The differences regarding MFIQ and VAS between the patient groups (RC and CCL) and the control group were significant (p < 0.0001). The frequencies of a previous trauma were 7/21 33% (RC), 5/21 24% (CCL) and 9/20 45% (C). GJH was diagnosed in 16/ 21 76% of the RC, 15/21 71% of the CCL and 5/20 25% of the C patients. Corresponding frequencies for LJH were 14/21 67% (RC), 7/21 33% (CCL) and 1/20 5% (C). In the RC group, all 7 patients with previous trauma also had GJH and 5 had LJH as well. The frequencies for the CCL group were 4 of 5 (GJH) and 1 of 5 (LJH). In the C group the frequencies were 3 of 5 (GJH) and 1 of 1 (LJH). Both LJH (p < 0.0001) and GJH (p < 0.0010) were significantly associated with RC. Regarding CCL, GJH (p < 0.001) showed a significance association. LJH was not significant after Yate’s correction (p = 0.0580). No significance association was found between previous trauma and the patient groups. The risk (OR) for GJH and LJH patients to develop RC and CCL was clearly increased (GJH-RC 9.6; GJH-CCL 7.5; LJH-RC 38.0; LJH-CCL 9.5). Previous trauma was not linked to an increased risk of developing RC (OR = 0.61) or CCL (OR = 0.18). Discussion
Dijkstra, in a systematic review of previous studies on GJH and TMD pointed out that many studies showed imperfect design.11 In many studies the individuals were symptom free or it was unclear whether they had TMJ symptoms of such magnitude that they sought advice or treatment. It was the aim of the current study to investigate only patients with a high degree of symptoms. Other criteria proposed by Dijkstra et al. were fulfilled.11 The results of the present investigation indicate that GJH is an important etiologic factor for the development of RC of the TMJ. The frequency of GJH and LJH were both high and correlated significantly with RC. CCL was also clearly associated with GJH, but the correlation with LJH must be
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Table 1. Reciprocal clicking. Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 P Mean value (M) Total women Total men Percent (%) SD Max Min
Gender: men (1), woman (0) 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 5 0.24 16 5 24 0.4364 1 0
Age (years)
Trauma
24 64 56 19 27 26 25 31 61 40 21 58 18 19 53 25 22 18 35 38 38 718 34.19
0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 1 1 1 0 0 1 7 0.33
15.4552 64 18
33 0.4830 1 0
General hypermobility
Local hypermobility
MFIQ (max: 21)
VAS (max: 10)
1 0 0 1 1 1 1 0 1 1 1 1 1 1 0 1 1 1 1 0 1 16 0.76
1 0 0 1 1 0 0 1 1 0 1 1 1 1 0 1 1 1 1 0 1 14 0.67
10 5 10 4 9 12 12 15 8 11 7 9 11 6 8 11 15 9 9 17 12 210 10.00
4 1 4 3 0 4 6 8 8 3 3 4 7 3 2 4 7 6 3 3 6 89 4.24
76 0.4364 1 0
67 0.4830 1 0
3.2558 17 4
General hypermobility
Local hypermobility
MFIQ (max: 21)
1 0 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 15 0.71
0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 1 1 0 0 7 0.33
9 9 13 6 12 9 6 12 19 15 13 11 12 13 3 13 19 16 13 7 9 239 11.38
7 6 0 7 6 2 4 8 8 7 5 2 7 4 8 8 8 3 3 5 114 5.43
33 0.4830 1 0
4.0924 19 3
2.3785 8 0
2.1887 8 0
Table 2. Chronic closed lock. Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 P Mean value (M) Total woman Total men Percent (%) SD Max Min
Gender: men (1), woman (0) 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 3 0.14 18 3 14 0.3586 1 0
Age (years)
Trauma
76 63 39 43 27 47 31 27 25 20 44 38 35 25 30 20 33 34 24 49 30 760 36.19
0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 1 0 5 0.24
13.9915 76 20
24 0.4364 1 0
71 0.4629 1 0
VAS (max: 10) 6
Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint
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Table 3. Control group. Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 P Mean value (M) Total women Total men Percent (%) SD Max Min
Gender: men (1), woman (0) 0 1 0 1 1 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 6 0.30 14 6 30 0.4702 1 0
interpreted with caution because the association was weak. A feasible explanation for this is that LJH patients had impaired joint mobility per se and thus the diagnosis had to rely more on reported subluxations or luxations by the patient. The present results agree with what has been found for adolescents9,10 and adults8 in population based material. Kavuncu et al., in patient based material, found a strong association between TMD and both GJH and LJH.12 Using TMD as an inclusion criterion is questionable since this denotation includes other TMJ conditions such as muscular dysfunction. Instead, the authors have used well-accepted tissue-based clinical criteria for RC and CCL.2 The frequencies of reported trauma to the jaws were low regarding RC and CCL in the present study and contradict the results in a previous study by Pullinger et al.7 The data were based on interviewing patients, which is a weakness, but Pullinger did the same and longitudinal studies are for obvious reasons difficult to undertake. Nevertheless, it seems that trauma is not a major etiologic factor for the development of RC and CCL. The frequency of previous trauma was higher than expected in the controls. A slight selection bias may explain this as patients seeking treatment at a dental school
Age (years)
Trauma
General hypermobility
Local hypermobility
76 31 68 75 62 34 25 18 18 36 60 45 25 32 28 59 23 31 19 20 785 39.25
0 1 0 1 0 0 0 1 0 1 1 1 1 0 0 0 1 1 0 0 9 0.45
0 1 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 1 5 0.25
0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0.05
0 1 0 0 2 0 0 0 2 0 2 2 0 0 0 0 0 0 0 0 9 0.45
0 0 0 0 1 0 0 0 0 0 0 2 0 0 0 0 1 0 0 0 4 0.20
45 0.5104 1 0
25 0.4443 1 0
5 0.2236 1 0
0.8256 2 0
0.5231 2 0
19.9126 76 18
may deviate from normal control material regarding socioeconomic factors and may have a higher incidence of trauma. All 7 patients with previous trauma in the RC group also had GJH and 5 had LJH as well. This further strengthens the authors’ conclusion that previous trauma is not a major cause of RC. The mean values for VAS and MFIQ did not differ significantly between RC and CCL patients but were, as expected, clearly significantly different from the controls. The mean age and male/female ratio for RC and CCL patients were in agreement with previous studies on patients intended for TMJ surgery.4,6 The mean age and male/female ratio differed slightly between the groups but were not of such magnitude that they should affect the conclusions of the study It has been suggested that GJH may have a hereditary origin.15,16 Westling et al.16 studied the collagen and proteoglycan content in skin biopsies from GJH patients with TMD. Compared to controls, the patients had a lower collagen and higher proteoglycan content, but the study material was small and it was not possible to draw any definite conclusions. Studies are needed to investigate the different types of collagen, elastin and relevant proteoglycans in patients with RC, CCL and GJH.
MFIQ (max: 21)
VAS (max: 10)
In conclusion, GJH seems to be an important etiologic factor for the development of TMJ DD while the role of a jaw trauma is more uncertain. Funding
None. Competing interests
None declared. Ethical approval
The study was approved by the regional research ethics committee (3 February 2010). References 1. Lundh H, Westesson P-L. Clinical signs of temporomandibular joint internal derangements in adults. An epidemiologic study. Oral Surg Oral Med Oral Pathol 1991;72: 637–41. 2. Holmlund A. Disc derangements of the temporomandibular joint. A tissue-based characterization and implications for surgical treatment. Int J Oral Maxillofac Surg 2007;36:571–6. 3. Paegle D, Holmlund A, Hjerpe A. Matrix glycosaminoglycans in temporomandibular
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5.
6.
7.
8.
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joint in patients with painful clicking and chronic closed lock. Int J Oral Maxillofac Surg 2003;32:397–400. Eriksson L, Westesson P-L. Discectomy as an effective treatment for painful temporomandibular joint internal derangement: a 5year clinical and radiographic follow-up. J Oral Maxillofac Surg 2001;59:750–8. Kurita K, Westesson P-L, Yuasa H, Toyama M, Machida J, Ogi N. Natural course of untreated symptomatic temporomandibular joint disc displacement without reduction. J Dent Res 1998;77:361–5. Holmlund AB, Axelsson S, Gynther GW. A comparison of discectomy and arthroscopic lysis and lavage for treatment of chronic closed lock of the temporomandibular joint: a randomized outcome study. J Oral Maxillofac Surg 2001;59:972–7. Pullinger AG, Seligman DA. Trauma history in diagnostic groups of temporomandibular diorders. Oral Surg Oral Med Oral Pathol 1991;71:529–34. Hirsch C, John MT, Stang A. Association between generalized joint hypermobility and signs and diagnoses of temporomandibular
disorders. Eur J Oral Sci 2008;116(6): 525–30. [9] Huddlestone Slater JJR, Lobbezoo F, Onland-Moret VN, Naeije M. Anterior disc displacement with reduction and symptomatic hypermobility in the human temporomandibular joint: prevalence rates and risk factors in children and teenagers. J Orofacial Pain 2007;21(1):55–62. 10. Westling L, Mattiasson A. General joint hypermobility and temporomandibular joint derangement in adolescents. Ann Rheum Dis 1992;51:87–90. 11. Dijkstra PU, Kropmans TJB, Stegenga B. The association between generalized joint hypermobility and temporomandibular joint disorders: a systematic review. J Dent Res 2002;81(3):158–63. 12. Kavuncu V, Sahin S, Kamanli A, Karan A, Aksoy C. The role of systemic hypermobility and condylar hypermobility in the temporomandibular joint dysfunction syndrome. Reumatol Int 2006;26:257–60. 13. Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip. J Bone Joint Surg Am 1964;46B(1):40–5.
[14] Stegenga B. Temporomandibular joint osteoarthrosis and internal disc derangement. Diagnostic and therapeutic outcome assessment. Dotoral Thesis. Groningen, Drukkerij van Denderen BV; 1991, p. 147. 15. Child A. Joint hypermobility syndrome: inherited disorders of collagen synthesis. J Reumatol 1986;13(2):239–43. 16. Westling L, Holm S, Wallentin I. Temporomandibular joint dysfunction. Connective tissue variations in skin biopsies and mitral valve function. Oral Surg Oral Med Oral Pathol 1992;74(6):709–18.
Address: Anders Holmlund Department of Oral and Maxillofacial Surgery (B61) Institution of Dental Medicine Box 4064 141 04 Huddinge Sweden Tel: +46 8 58583950 Fax: +46 8 7743875 E-mail: [email protected]
Clinical Paper TMJ Disorders
Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint
¨ gren, C. Fa¨ltmars, B. Lund, M. O A. Holmlund Department of Oral and Maxillofacial Surgery, Institution of Dental Medicine, Karolinska Institutet/Karolinska University Hospital, Huddinge, Sweden
¨ gren, C. Fa¨ltmars, B. Lund, A. Holmlund: Hypermobility and trauma as M. O etiologic factors in patients with disc derangements of the temporomandibular joint. Int. J. Oral Maxillofac. Surg. 2012; 41: 1046–1050. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of the study was to investigate patients with temporomandibular joint (TMJ) disc derangement with its two clinical variants reciprocal clicking (RC) and chronic closed lock (CCL) with regard to the etiologic factors, previous jaw trauma and general (GJH) and local joint hypermobility (LJH). 42 patients (21 with RC and 21 with CCL) and 20 control individuals were studied. The patients and controls were asked whether they had sustained any jaw trauma in the past and were then examined for the presence of GJH and LJH, using defined criteria. Patient and control groups were compared. Statistical evaluation included x2 test and paired Student’s t test. Odds ratio was calculated in order to assess the relative risk of developing RC and CCL when the etiological factor was present. The results showed a significant association between RC and GJH (OR = 9.6, p = 0.0010) as well as LJH (OR = 38, p = 0.0001). CCL was clearly associated with GJH (OR = 7.5, p = 0.0030) while its association with LJH was not significant (OR = 9.5, p = 0.0582). No significant association with previous trauma was found. The results indicate that GJH is an important etiologic factor for the development of RC and CCL of the TMJ.
Temporomandibular joint (TMJ) disc derangement (DD) is the most common TMJ disorder leading to surgery. About 19% of the adult population in Sweden show symptoms of TMJ DD.1 There are two distinct clinical variants of TMJ DD, which differ from a tissue point of view, clinical characteristics and by the way they are treated,2 namely reciprocal clicking (RC) and chronic closed lock (CCL). 0901-5027/0901046 + 05 $36.00/0
RC has a prevalence of 7% in the population.1 In patients, the condition usually runs with a varying degree of pain. TMJs with RC, typically show no degenerative changes and inflammation is minor or absent. The disc has a callous formation in the posterior part, formed by tightly packed, thick collagen bundles.3 Clinically the condition is recognized as a reproducible RC caused by the disc with
Key words: TMJ; disc derangement; hypermobility; trauma. Accepted for publication 20 February 2012 Available online 31 May 2012
its callous displacing back and forth over the condyle. If the clicking becomes more pronounced a catch develops, which may be painful. This more severe subgroup may be treated surgically by discectomy.4 RC also progresses to CCL in many patients.2 CCL has a prevalence of about 12% in the population.1 In patients, the condition usually has an acute onset and rapidly
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint develops into a degenerative joint disease where inflammation and adhesions are frequently found. The translation of the disc-condyle is typically reduced. Clinical signs and symptoms are painful reduced vertical and horizontal mandibular movements. About 40% of CCL patients seem to recover spontaneously within a 2.5 year period while in the remaining 60% symptoms persist.5 The first choice of treatment is arthroscopic lysis and lavage.6 If this treatment is unsuccessful discectomy may be performed.4 Both treatments have about the same effectiveness, but arthroscopy is less invasive.6 It has been indicated that disc derangements and previous trauma to the jaw may be associated.7 Other suggested etiologic factors for DD are general (GJH) and localized joint hypermobility (LJH).8–10 Westling and Mattiasson studied adolescents and found that signs and symptoms of TMJ DD were more common in adolescents with a GJH.10 In a systematic review, Dijkstra et al. found that very few studies investigating GJH and temporomandibular joint dysfunction (TMD) were of good quality considering methodology and selection criteria.11 Since then a few other studies have appeared,8,9,12 indicating an association between TMJ DD and GJH. To the authors’ knowledge, patients with more severe TMJ DD requiring surgical treatment have not been investigated. The authors’ hypothesis is that trauma and joint hypermobility (general and local) are etiological factors for the development of advanced RC and CCL and that differences exist between the two patient groups. The aim of this study is to investigate the two clinical variants of TMJ DD, RC and CCL requiring TMJ surgery, with regard to previous trauma to the jaws and existing GJH and LJH. Material and methods
Consecutive patients with TMJ DD, referred to the division of Oral and Maxillofacial Surgery, Department of Dental Medicine, Karolinska Institutet Huddinge, as well as a control group (C) comprising consecutive patients receiving dental care at the dental school of the Karolinska Institutet from March 2010 to March 2011, were asked to participate in the study. Inclusion criteria for RC were reproducible reciprocal clicks with catching, with or without pain. Inclusion criteria for CCL were painful impaired vertical and horizontal
mandibular movements with or without previous clicking. Exclusion criteria were all other TMJ diseases. The control group were age and gender matched with the patients. Informed consent was received from all patients and control individuals prior to inclusion in the study. The study was approved by the regional research ethics committee (3 February 2010). The following etiologic factors were investigated by interviewing and examining the patients. The participants were interviewed and specifically asked whether they had sustained any previous trauma to the mandible. General hypermobility was determined using the Carter and Wilkinson criteria (3 positive tests out of 5).13 The 5 tests were: passive apposition of the thumb to the flexor aspect of the forearm; passive hyperextension of the fingers so that they lie parallel with the extensor aspect of the forearm; ability to hyperextend the elbow more than 10 degrees; ability to hyperextend the knee more than 10 degrees; an excess range of passive dorsiflexion of the ankle and eversion of the foot. Local hypermobility of the TMJ was determined by interviewing and examining the participants for episodes for mandibular luxation or subluxations. All patients and controls were also evaluated with regard to functional impairment and pain. Impaired mandibular function was assessed using a modified mandibular function impairment questionnaire (MFIQ)2,14 (minimum value 0, maximum value 21). Pain in the TMJ when performing mandibular movements was registered on a visual analogue scale (VAS), where 0 denotes no pain and 10 worst pain imaginable. The x2 test was performed in order to determine whether the differences between patient groups and control were significant or not. A p-level <0.05 was regarded as significant. If the p-level was between 0.01 and 0.05, Yate’s correction was performed. If the resulting new plevel was below 0.05 the difference was considered significant. The odds ratio (OR) was calculated in order to assess the relative risk of developing RC or CCL when the etiologic factor was present. An increased risk was considered if OR was above 1. A paired Student’s t test was performed to analyse if the frequencies of MFIQ and VAS values between RC, CCL and controls were significant. A p-value <0.05 was regarded as significant.
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Results
Tables 1–3 show the data for patients with RC or CCL and the controls. The mean values of MFIQ and VAS for the CCL patients were 11.38 (SD = 4.09) and 5.43 (SD = 2.38), respectively. For RC patients the corresponding values were 10.00 (SD = 3.26) and 4.24 (SD = 2.19). The corresponding values for the control patients were 0.45 (SD = 0.83) and 0.20 (SD = 0.52). The differences regarding MFIQ and VAS between the patient groups (RC and CCL) and the control group were significant (p < 0.0001). The frequencies of a previous trauma were 7/21 33% (RC), 5/21 24% (CCL) and 9/20 45% (C). GJH was diagnosed in 16/ 21 76% of the RC, 15/21 71% of the CCL and 5/20 25% of the C patients. Corresponding frequencies for LJH were 14/21 67% (RC), 7/21 33% (CCL) and 1/20 5% (C). In the RC group, all 7 patients with previous trauma also had GJH and 5 had LJH as well. The frequencies for the CCL group were 4 of 5 (GJH) and 1 of 5 (LJH). In the C group the frequencies were 3 of 5 (GJH) and 1 of 1 (LJH). Both LJH (p < 0.0001) and GJH (p < 0.0010) were significantly associated with RC. Regarding CCL, GJH (p < 0.001) showed a significance association. LJH was not significant after Yate’s correction (p = 0.0580). No significance association was found between previous trauma and the patient groups. The risk (OR) for GJH and LJH patients to develop RC and CCL was clearly increased (GJH-RC 9.6; GJH-CCL 7.5; LJH-RC 38.0; LJH-CCL 9.5). Previous trauma was not linked to an increased risk of developing RC (OR = 0.61) or CCL (OR = 0.18). Discussion
Dijkstra, in a systematic review of previous studies on GJH and TMD pointed out that many studies showed imperfect design.11 In many studies the individuals were symptom free or it was unclear whether they had TMJ symptoms of such magnitude that they sought advice or treatment. It was the aim of the current study to investigate only patients with a high degree of symptoms. Other criteria proposed by Dijkstra et al. were fulfilled.11 The results of the present investigation indicate that GJH is an important etiologic factor for the development of RC of the TMJ. The frequency of GJH and LJH were both high and correlated significantly with RC. CCL was also clearly associated with GJH, but the correlation with LJH must be
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Table 1. Reciprocal clicking. Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 P Mean value (M) Total women Total men Percent (%) SD Max Min
Gender: men (1), woman (0) 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 5 0.24 16 5 24 0.4364 1 0
Age (years)
Trauma
24 64 56 19 27 26 25 31 61 40 21 58 18 19 53 25 22 18 35 38 38 718 34.19
0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 1 1 1 0 0 1 7 0.33
15.4552 64 18
33 0.4830 1 0
General hypermobility
Local hypermobility
MFIQ (max: 21)
VAS (max: 10)
1 0 0 1 1 1 1 0 1 1 1 1 1 1 0 1 1 1 1 0 1 16 0.76
1 0 0 1 1 0 0 1 1 0 1 1 1 1 0 1 1 1 1 0 1 14 0.67
10 5 10 4 9 12 12 15 8 11 7 9 11 6 8 11 15 9 9 17 12 210 10.00
4 1 4 3 0 4 6 8 8 3 3 4 7 3 2 4 7 6 3 3 6 89 4.24
76 0.4364 1 0
67 0.4830 1 0
3.2558 17 4
General hypermobility
Local hypermobility
MFIQ (max: 21)
1 0 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 15 0.71
0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 1 1 0 0 7 0.33
9 9 13 6 12 9 6 12 19 15 13 11 12 13 3 13 19 16 13 7 9 239 11.38
7 6 0 7 6 2 4 8 8 7 5 2 7 4 8 8 8 3 3 5 114 5.43
33 0.4830 1 0
4.0924 19 3
2.3785 8 0
2.1887 8 0
Table 2. Chronic closed lock. Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 P Mean value (M) Total woman Total men Percent (%) SD Max Min
Gender: men (1), woman (0) 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 3 0.14 18 3 14 0.3586 1 0
Age (years)
Trauma
76 63 39 43 27 47 31 27 25 20 44 38 35 25 30 20 33 34 24 49 30 760 36.19
0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 1 0 5 0.24
13.9915 76 20
24 0.4364 1 0
71 0.4629 1 0
VAS (max: 10) 6
Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint
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Table 3. Control group. Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 P Mean value (M) Total women Total men Percent (%) SD Max Min
Gender: men (1), woman (0) 0 1 0 1 1 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 6 0.30 14 6 30 0.4702 1 0
interpreted with caution because the association was weak. A feasible explanation for this is that LJH patients had impaired joint mobility per se and thus the diagnosis had to rely more on reported subluxations or luxations by the patient. The present results agree with what has been found for adolescents9,10 and adults8 in population based material. Kavuncu et al., in patient based material, found a strong association between TMD and both GJH and LJH.12 Using TMD as an inclusion criterion is questionable since this denotation includes other TMJ conditions such as muscular dysfunction. Instead, the authors have used well-accepted tissue-based clinical criteria for RC and CCL.2 The frequencies of reported trauma to the jaws were low regarding RC and CCL in the present study and contradict the results in a previous study by Pullinger et al.7 The data were based on interviewing patients, which is a weakness, but Pullinger did the same and longitudinal studies are for obvious reasons difficult to undertake. Nevertheless, it seems that trauma is not a major etiologic factor for the development of RC and CCL. The frequency of previous trauma was higher than expected in the controls. A slight selection bias may explain this as patients seeking treatment at a dental school
Age (years)
Trauma
General hypermobility
Local hypermobility
76 31 68 75 62 34 25 18 18 36 60 45 25 32 28 59 23 31 19 20 785 39.25
0 1 0 1 0 0 0 1 0 1 1 1 1 0 0 0 1 1 0 0 9 0.45
0 1 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 1 5 0.25
0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0.05
0 1 0 0 2 0 0 0 2 0 2 2 0 0 0 0 0 0 0 0 9 0.45
0 0 0 0 1 0 0 0 0 0 0 2 0 0 0 0 1 0 0 0 4 0.20
45 0.5104 1 0
25 0.4443 1 0
5 0.2236 1 0
0.8256 2 0
0.5231 2 0
19.9126 76 18
may deviate from normal control material regarding socioeconomic factors and may have a higher incidence of trauma. All 7 patients with previous trauma in the RC group also had GJH and 5 had LJH as well. This further strengthens the authors’ conclusion that previous trauma is not a major cause of RC. The mean values for VAS and MFIQ did not differ significantly between RC and CCL patients but were, as expected, clearly significantly different from the controls. The mean age and male/female ratio for RC and CCL patients were in agreement with previous studies on patients intended for TMJ surgery.4,6 The mean age and male/female ratio differed slightly between the groups but were not of such magnitude that they should affect the conclusions of the study It has been suggested that GJH may have a hereditary origin.15,16 Westling et al.16 studied the collagen and proteoglycan content in skin biopsies from GJH patients with TMD. Compared to controls, the patients had a lower collagen and higher proteoglycan content, but the study material was small and it was not possible to draw any definite conclusions. Studies are needed to investigate the different types of collagen, elastin and relevant proteoglycans in patients with RC, CCL and GJH.
MFIQ (max: 21)
VAS (max: 10)
In conclusion, GJH seems to be an important etiologic factor for the development of TMJ DD while the role of a jaw trauma is more uncertain. Funding
None. Competing interests
None declared. Ethical approval
The study was approved by the regional research ethics committee (3 February 2010). References 1. Lundh H, Westesson P-L. Clinical signs of temporomandibular joint internal derangements in adults. An epidemiologic study. Oral Surg Oral Med Oral Pathol 1991;72: 637–41. 2. Holmlund A. Disc derangements of the temporomandibular joint. A tissue-based characterization and implications for surgical treatment. Int J Oral Maxillofac Surg 2007;36:571–6. 3. Paegle D, Holmlund A, Hjerpe A. Matrix glycosaminoglycans in temporomandibular
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[14] Stegenga B. Temporomandibular joint osteoarthrosis and internal disc derangement. Diagnostic and therapeutic outcome assessment. Dotoral Thesis. Groningen, Drukkerij van Denderen BV; 1991, p. 147. 15. Child A. Joint hypermobility syndrome: inherited disorders of collagen synthesis. J Reumatol 1986;13(2):239–43. 16. Westling L, Holm S, Wallentin I. Temporomandibular joint dysfunction. Connective tissue variations in skin biopsies and mitral valve function. Oral Surg Oral Med Oral Pathol 1992;74(6):709–18.
Address: Anders Holmlund Department of Oral and Maxillofacial Surgery (B61) Institution of Dental Medicine Box 4064 141 04 Huddinge Sweden Tel: +46 8 58583950 Fax: +46 8 7743875 E-mail: [email protected]