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Comparison of internal derangements of the TMJ with occlusal findings
Comparison of internal derangements of the TMJ with occlusal findings Christopher A. Roberts, D.D.S., * Ross H. Tallents, D.D.S.,** Richard W. Katzberg, M.D., *** Roberto E. Sanchez-Woodworth. D.D.S.,**** and Stanley L. Handelman, D.D.S.,****** Mark A. Espeland, Ph.D.,***** Rochester. N. Y. EASTMAN
DENTAL
CENTER
.AND UNIVERSITY
OF ROCHESTER
SCHOOL
OF MEDICINE
AND
DENTlSTR\
Two hundred five patients were examined because of temporomandibular joint pain and dysfunction. Arthrograms were performed on 222 joints (188 unilateral and 17 bilateral). No significant differences were found between arthrographic groups with respect to Angle classification, horizontal and vertical overlap, posterior tooth wear, missing posterior teeth, cuspid-protected occlusion, balancing-side contacts, deflective occlusion, and clenching of the teeth. Tilted teeth on the contralateral side were more common in cases of reducing meniscal dislocation than in cases of normal meniscus position or of nonreducing meniscal dislocation. (ORAL SCIRC. ORAL MED. ORAL PATHOL. 1987:63:645-50)
0 cclusion is thought to be a major factor in the
etiology of temporomandibular joint (TMJ) pain and dysfunction. Though malocclusion may play a role in mandibular dysfunction, there is no common agreement as to which specific factors are important; there is even less certainty with respect to the relationship between elimination of the occlusal disharmonies and relief of TMJ symptoms. Occlusions are classified according to Angle as Class I, Class II, or Class III, with the associated skeletal relationships postulated as predisposing factors for TMJ dysfunction. The purpose of this study is to compare occlusal factors with the arthrographic depiction of the presence or absence of TMJ internal derangements. MATERIALS
AND METHODS
Two hundred five patients with TMJ symptoms (222 joints, 188 unilateral and 17 bilateral) were *Resident in Orthodontics, Eastman Dental Center. **Clinical and Research Associate, Department of Orthodontics and Senior Clinical Associate, Department of Prosthodontics, Eastman Dental Center; Assistant Professor of Clinical Dentistry, University of Rochester School of Medicine and Dentistry. ***Associate Professor, Diagnostic Radiology, University of Rochester; Clinical and Research Associate, Department of Orthodontics, Eastman Dental Center. ****Temporomandibular Joint Fellow, Eastman Dental Center. *****Coordinator of Biostatistics, Eastman Dental Center. ******Chairman, Department of General Dentistry, Eastman Dental Center.
prospectively examined both clinically and by arthrography for TMJ internal derangements. Arthrograms were categorized as “normal,” as showing “meniscus displacement with reduction,” or as showing “meniscus displacement without reduction.“’ Only the parameters with respect to unilateral joint involvement are reported in this article in order to permit consistent interpretation of the relationships between arthrographic joint findings and ipsilateral/ contralateral occlusal findings. The horizontal and vertical overlap was measured with the teeth at the centric occlusal position.2 A millimeter ruler was placed horizontally against the labial surface of the mandibular incisors. The amount of horizontal overlap was measured from the labial surface of the mandibular incisors to the labial surface of the maxillary incisors at the midline. The amount of vertical overlap was marked with a pencil and was measured to the mandibular incisor edge at the midline. The patient’s occlusion was classified according to the system proposed by Angle.) If first molar teeth were missing or had drifted, no classification was given. Anterior and posterior teeth were classified as being in crossbite in accordance with the “Glossary of Prosthodontics Terms.“4 Tipped teeth were defined as having an abnormal angulation of the long axis relative to the occlusal plane. The amount of anterior and posterior tooth wear was scaled as described by Hansson and Nilner.’ 645
646 Roberts et al
Oral Surg. .lune. I 9X7
I. Occlusion
Table
Angie class
Afeniscus displacement n’ith reduction
Normal
Class I Class II, Division 1 Class 11. Division 2 Class III Edentulous/unclassifed Total
30 (73%,) 8 (20%) O( 0%) O( 0%) 3( 7%) 41
45 18 2 0 I 66
Meniscus displacement LrYthout reduction
(68%) (27%) ( 39) ( 0%) ( 27)
1-~-
58 (72%) 19 (23%,) 3 ( 4%) I ( 17,) O( 0%) 81
-Total I33 (70%) 45 (24%) 5 ( 3%) I ( I %) 4( 2%) 188
p > 0.05
Table
II. Horizontal and vertical overlaps
Table Ill.
Arthrographic diagnosis
._.I-
Normal Meniscus displacement with reduction Meniscus displacement without reduction Vertical. Horizontal.
Vertical
Horizontal
2.90 k 0.53 3.75 t 0.41
2.67 t 0.38 2.63 t 0.30
3.34 + 0.42
2.21 + 0.31
Posterior tooth wear
O-l*
p > 0.05. /I > 0.05.
60 (91%) 6 ( 9%) 66
32 (79%) 9 (21%) 41
2-3 Total
71 (88%) IO (12%) 81
p > 0.05. *Scale
proposed
by Hnnsson
and
Nilner’
0 = no wear I = enamel
Laterotrusive and mediotrusive occlusal contacts were evaluated by having the patient perform right and left lateral excursions. Mediotrusive contacts were evaluated with articulating paper, visually, and by observation of any wear facets. Laterotrusive contacts were evaluated with articulating paper and visually. Cuspid guidance was defined as no multiple tooth contacts in lateral excursions.6Group function was defined as two or more working contacts. The amount and direction of any deflective malocclusion (mandibular shift) from the retruded contact position (centric relation) to the maximum intercuspal position (centric occlusion) were recorded. The centric relation was located by means of the technique described by Ramfjord and Ash.’ Mandibular shifts were recorded as none, less than 1 mm, or greater than 1 mm. The direction of the deflection malocclusion was recorded as none, straight, opposite, or to the same side as the side of the arthrogram. The patients’ subjective opinions-whether they clenched their teeth while asleep or while experiencing tension, or both-were also recorded. These factors were collected on a tabulation form and subjected to statistical analysis. Differences among the diagnostic groups for discrete variables were evaluated with the aid of x’ tests. For continuous variables, one-way analyses of variance were performed. Any significant findings from the analy-
2 = near
only into
3 = one-third
dentin of crown
worn
ses of variance were subsequently assessedwith the Newman-Keuls multiple comparisons test. RESULTS
Table I shows the relationships between the Angle classifications and meniscal abnormalities as depicted by arthrography. Seventy percent of the patients had Class I malocclusions, 24% had Class II, Division 1 malocclusion, 3% had Class II, Division 2 malocclusion, 1% had Class III malocclusion, and 2% were unclassified. The distribution of Angle’s classification among the three arthrographic diagnosesdid not differ significantly (p > 0.05). The mean ventrical overlap of the anterior teeth for the three diagnostic categories (Table II) ranged from 2.90 f. 0.53 to 3.75 -t 0.41, and the mean horizontal overlap ranged from 2.67 + 0.38 to 2.21 + 0.31 (JJ> 0.05 and p > 0.05, respectively). Posterior tooth wear (Table III) was most prevalent among the “normal” group, but the differences were not statistically significant (p > 0.05). The prevalence of tilted teeth on the contralateral side (Table IV) was significantly higher among reducing menisci than among nonreducing and normal menisci (p < 0.05). The prevalence of missing posterior teeth on the affected (Table V) and nonaf-
Comparison of TMJ internal derangements with occlusal jindings
Volume 63 Number 6
Tilted teeth (opposite side)
Table IV.
Table VI.
647
Missing teeth (opposite side)
,_.,
No
38 (93%) 3 ( 7%) 41
Yes Total
51 (77%) I.5 (23’S)* 66
72 (88%) 9 (I 2%) 81
p < 0.05. Tilted teeth-same side, p > 0.05 (not shown). *“Meniscus displacement with reduction” group is signilicantly direrent than ‘*normal” group and “displacement without reduction” group.
Table V.
None
32 (78%) 6 ( IS%,) 3 ( 7%,)
I to 3 4 or more
43 (65c”t) 20 (31%) 3( 47)
49 (60%‘) 28 (32%) 4 ( 87,)
p > 0.05.
Table VII.
Lateral occlusion (same side)
Missing teeth, same side
~ None I to 3
4 or more Total
29 (70%) 8 (20%) 4 (IO%) 41
44 (67%) 20 (30%) 2( 3%) 66
53 (65%) 23 (28%) 5 ( 7%) 81
p > 0.0.
fected (Table VI) sides did not differ significantly among the arthrographic groups (p > 0.05 and p > 0.05, respectively). The prevalence of cuspid-protected occlusion or group function was essentially equally distributed among the arthrographic groupings both for the same side and for the opposite side (Tables VII and VIII) (p > 0.05 and p > 0.05, respectively). Balancing side contacts on the same side (p > 0.05) and on the opposite side @ > 0.05) did not correlate to specific meniscal abnormalities (Tables IX and X). The direction and amount of deflection malocclusion (Table XI) were not significantly related to the specific abnormality (p > 0.05). Clenching of the teeth while sleeping or experiencing tension or both (as recorded from the patient’s history) did not correlate with specific meniscal abnormalities (p > 0.05) (Table XII). DISCUSSION
It is generally assumed that malocclusion plays a major role in the development of TMJ dysfunction. Perry* and Loiselle9 have suggested that there is a predominance of Class II jaw relationships among patients with dysfunctional TMJs. Our investigation (Table I) suggests that there is a predominance of Class I malocclusions in this study, which occur at an
Cuspid
I9 (46%)
Group
22 (54%)
Total
41
33 (50%) 33 (50%)
38 (47%) 43 (53%)
p > 0.05.
Table VIII.
Cuspid Group Total
Lateral occlusion (opposite side)
I8 (44%) 23 (56%)
41
32 (48%) 34 (52%,) 66
38 (47%) 43 (53%) 81
p > 0.05.
even greater percentage than in a normal population.‘O Consideration must be given to the low numbers of Class II, Division 2 and Class III malocclusions in the present study. Loss of posterior teeth with bite collapse has been implicated as a specific cause of TMJ pain and dysfunction. Agerberg and Carlsson” in a retrospective study, showed that mandibular mobility was inversely correlated with the number of residual teeth. They also found no greater frequency of dysfunction in patients with TMJ pain than in the general population. Helkimo” demonstrated a lower prevalence of headache and of muscle and joint symptoms in the youngest persons with the most residual teeth. Kopp13found no significant correlation among molar loss, crepitation, and tendernessto palpation. If loss of molar support causesTMJ pain and dysfunction, then restoration might be expected to eliminate or lessen symptoms. However, Leder-
Roberts et al
648
Table IX. No. of balancing contacts 0 l-3 4-5 Total
Oral Surg. June. 1987
Balancing contacts (same side)
Table X.
Normal
Meniscus displacement with reduction
Meniscus displacement without reduction
20 (49%) 18 (44%) 3 ( 7%) 41
38 (58%) 28 (42?6) 0 ( 0%) 66
38 (47%) 40 (49%) 3( 4%) 81
0 l-3 4-5 Total
Balancing contacts (opposite side)
19 (46%) 19 (46%) 3 ( 8%) 41
44 (67%) 21 (31%) I ( 2%) 66
16 (579) 33 (414) 2 ( 27&j 81
p > 0.05
p > 0.05
Table Xl.
Direction of deflective malocclusion Normal
Direction None Straight Same side Opposite side Total
6 24 9 2 41
Meniscus displacement with reduction
(15%) (58%) (22%) ( 5%)
II 31 13 II 66
(17%) (47%) (19%) (17%)
Meniscus displacement without reduction 10 47 7 17 81
(12%) (58%) ( 8%) (22%)
Total 27 102 29 30 188
(14%) (54%) (16%) (16%)
p > 0.05.
Table XII.
Incidence of clenching or grinding
None While asleep While experiencing tension Both Total
r
Normal
Meniscus displacement with reduction
23 (56%) 9 (22%) 3 ( 7%)
30 (46%) 12 (18%) 14 (21%)
41 (50%) 17 (22%) 6 ( 7%)
6 (15%) 41
IO (15%) 66
17 (21%) 81
/J > 0.05
man and ClaytonI found a frequency of dysfunction of 68% among 50 subjects with fixed partial dentures in all posterior quadrants. The concept that occlusal interferences trigger abnormal masticatory function has received much attention through clinical studies. Interferences in habitual and hinge closure, laterotrusion, mediotrusion, and bruxism all have been implicated in the production of mandibular dysfunction. Zarb and Thompsonts found that 50% of 106 patients demonstrated a slide from centric relation to centric occlusion. Sadowsky and Beyale16found no difference in signs or symptoms of TMJ dysfunction in 75 patients treated orthodontically as compared with a matched control group of 75 patients with untreated malocclusions.
Contacts on the mediotrusive (balancing) side have been related to TMJ dysfunction in some did not studies”, I8but not in others. 12.14. 16, 19 Bushl9.20 find an association in 298 dental students who were examined for laterotrusive, protrusive, and retrusive contacts or for canine disclusion and muscle tenderness.Ingerval’* found that single tooth contact on the laterotrusive side was negatively correlated with parafunction. The wear of the posterior and the anterior teeth was assessedas proposed by Hansson and Nilner,’ with the greater percentage of patients having no wear or very slight wear. However, differences among the arthrographic groups were not statistically significant (Table III). Problems in evaluation of molar relationships do exist.z’*22Class I or II molar relationships may occur with or without a deep curve of Spee or abnormal horizontal and vertical overlap. To help assessthis further, the horizontal and vertical overlaps were measured (Table II). With the three arthrographic diagnostic groups, there were no statistical differences between patients with horizontal and vertical overlap. Helije and coworkers23,Williamson,24 and Berry and Watkinson have all considered the deepness of the bite to be a predisposing factor to TMJ dysfunction and pain. Bush’9,20found no significant differences in muscle palpation among Class I, Class II, and Class III malocclusions in 298 dental students. Kopp13found
Volume 63 Number 6
Comparison of TMJ internal derangements with occlusal jindings
no significant correlation between loss of molar support and crepitation or tenderness to palpation of the TMJ. Heliie and Heliiez6 found no correlation among 406 Swedish patients who experienced TMJ pain and dysfunction. Agerberg and Carlsson” found no differences in the patients with dysfunction when they were compared with the general population. Our study suggests that there is little difference (Tables V and VI) in molar loss on the sameside and on the opposite side (p > 0.05 and p > 0.05, respectively), although tilting of the teeth on the opposite side appears to be more prevalent in patients with meniscal displacement with reduction than in patients with displacement without reduction or normal arthrographic findings. Occlusal schemes (group function versus cuspid disclusion) have been evaluated to determine whether abnormal stress on teeth*’ or periodontal problemsz8may be correlated with dysfunction. Suggestions have also been made that the occlusion may progress from canine protection to group function through normal or abnormal wear.29Tables VII and VIII show that the distribution of the two occlusions was equal, suggesting that the anterior guidance alone, which interacts with horizontal and vertical overlap of the anterior teeth, may not be considered to represent multiple causes. Balancing and mediotrusive interferences have been shown to be related in some studies’7.‘8 and shown to be unrelated in others.‘2,‘“,‘6.‘9 This study demonstrates that balancing contacts on the same side or on the opposite side (p > 0.05 and p > 0.05, respectively) were not related to specific meniscal abnormalities (Tables IX and X). The presence of an interference from centric relation to centric occlusion has been reported. The asymmetry of the slide has been correlated to pain and tenderness.30In contrast, neither asymmetry nor the amount of shift was related to symptoms.‘2,“3 “. I8 This study demonstrates that the presenceor absence of deflective malocclusion or the direction of the skid does not relate to the type of meniscal abnormality 0, > 0.05, Table XI). Krogh-Poulsen and Olsson3’ and GraP2 have suggested that bruxism or rubbing the teeth together may precipitate dysfunction. Table XII shows no relationship between these factors and either the presenceof or the severity of the meniscal abnormality. Although we found no significance in many occlusal findings, we cannot exclude the possibility that, in any individual patient, certain occlusal factors are important. Findings such as a gross deflective malocclusion or an extreme deep bite may, in individual
649
cases, predispose the patient to TMJ problems. However, occlusal findings in themselves are not a good indicator of the severity of TMJ internal derangements. REFERENCES I. Katzberg RW, Dolwick MF, Bales DJ, Helms CA. Arthrotomography of the TMJ: New techniques and preliminary observations. AJR 1979;132:949-55. Agerberg G. Maximal mandibular movements in young men and women. Sven Tandlak Tidskr 1974;67:81-100. Angle EH. Classification of malocclusion. Dental Cosmos 1899:4 I :248-64. Glossary of prosthodontic terms. J Prosthet Dent 1977; 38:77. Hansson T, Nilner M. A study of the occurrences of symptoms of diseases of the temporomandibular joint masticatory muscles and related structures. J Oral Rehabil 1975:2:31324. 6. O’Leary TJ, Shanley DB, Drake RB. Tooth mobility in cuspid-protected and group-function occlusions. J Prosthet Dent 1972;27:21-5. 7. Ramfjord SP. Ash MM. Occlusion. 3rd ed. Philadelphia: WB Saunders Co, 1983:301-4. 8. Perry HT. Relation of occlusion to the temporomandibular joint dysfunction: the orthodontic viewpoint. J Am Dent Assoc 1969:79:137-41. 9. Loiselle RJ. Relation of occlusion to the temporomandibular joint dysfunction: the prosthodontic viewpoint. J Am Dent ASSOC1969;79: 145-6. 10. Kelly JE. An assessment of the occlusion of the teeth of youths 12-17 years, United States. Rockville, Maryland: National Center for Health Statistics, 1977; DHEW publication No. (HRA)77-1644. (Vital and health statistics: series 11, data for the National Health Survey, No. 162.) 11. Agerberg G, Carlsson GE. Symptoms of functional disturbances of the masticatory system 11. Symptoms in relation to impaired mobility of the mandible as judged from investigation by questionnaire. Acta Odontol Stand 1975;33:183-90. 12. Helkimd M. Studies on function and dysfunction of the masticatory system. Swed Dent J 1974;67:1-18. 13. Kopp S. Clinical findings in temporomandibular joint osteoarthrosis. Acta Odontol Stand 1977;85:434-43. 14. Lederman KH, Clayton JA. Restored occlusions, Part II: the relationship of clinical and subject symptoms to varying degrees of TMJ dysfunction. J Prosthet Dent 1982;47:3039. 15. Zarb GA, Thompson GW. The treatment of patients with temporomandibular joint pain and dysfunction syndrome. Can Dent Assoc J 1975;41:410-7. 16. Sadowsky C, Beyole EA. Long-term status of temporomandibular joint function and functional occlusion after orthodontic treatment. Am J Orthod 1980;78:201-12. 17. Geering AH. Occlusal interferences and functional disturbances of the masticatory system. J Clin Periodontol 1974;l:l 12-9. 18. lngerval B. Prevalence of symptoms of functional disturbances of the masticatory system of Swedish men. J Oral Rehabil 1980;7: I 12-9. 19. Bush FM. Occlusal parameters and TMJ facial pain in dental students. J Dent Res 1981:60 (special issue) A: Abstract No 878. 20. Bush FM. Malocclusion, masticatory muscle, and temporomandibular joint tenderness. J Dent Res 1985;64:129-33. 21. Gravely JF, Johnson DB. Angle’s classification of malocclusion: an assessment of reliability. Br J Orthod 1974;1:79-86. 22. Helm S. Intraexaminer reliability of epidemiologic registrations of malocclusion. Acta Odontol Stand 1977;35:161-5. 23. Heloe B, Heiberg AN, Krogstad BS. A multiprofessional
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24. 25.
26.
27. 28. 29.
Roberts et al
Oral Surg. June. 1987
study of patients with myofacial pain dysfunction syndrome 1. Acta Odontol Stand 1980;38: 109. Williamson EH. Temporomandibular dysfunction in pretreatment adolescent patients. Am J Orthod 1977;72:429-33. Berry DC, Watkinson AC. Mandibular dysfunction and incisor relationship. A theoretical explanation for the clicking joint. Br Dent J 1978;144:74-7. Heloe B. Heliie LA. Characteristics of a group of patients with temporomandibular joint disorders. Community Dent Oral Epidemiol 1975;3:72-9. Alexander P. The periodontium and the canine theory. J Prosthet Dent 1967;18:571. Goldstein GR. The relationship of canine-protected occlusion to be a periodontal index. J Prosthet Dent 1979;41:277-83. Beyron H. Optimal occlusion. Dent Clin North Am 1969:
30. Solberg KW, Woo MW. Houston JB. Prevalence of mandibular dysfunction in young adults. J Am Dent Assoc 1979; 98:25-34. 3 I. Krogh-Poulsen
WC, Olsson A. Management of the occlusion of the teeth. Background, definitions, rationale. In: Schwartz L, Chayes CM, eds. Facial pain and mandibular dysfunction. Philadelphia: WB Saunders Co, 1968:236-80. 32. Graf H. Bruxism. Dent Clin North Am 1969:13:659. Reprint
requests
to:
Dr. Richard W. Katzberg University of Rochester Medical Center Department of Radiology, P.O. Box 648 Rochester, NY 14642
13:537.
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DENTAL
CENTER
.AND UNIVERSITY
OF ROCHESTER
SCHOOL
OF MEDICINE
AND
DENTlSTR\
Two hundred five patients were examined because of temporomandibular joint pain and dysfunction. Arthrograms were performed on 222 joints (188 unilateral and 17 bilateral). No significant differences were found between arthrographic groups with respect to Angle classification, horizontal and vertical overlap, posterior tooth wear, missing posterior teeth, cuspid-protected occlusion, balancing-side contacts, deflective occlusion, and clenching of the teeth. Tilted teeth on the contralateral side were more common in cases of reducing meniscal dislocation than in cases of normal meniscus position or of nonreducing meniscal dislocation. (ORAL SCIRC. ORAL MED. ORAL PATHOL. 1987:63:645-50)
0 cclusion is thought to be a major factor in the
etiology of temporomandibular joint (TMJ) pain and dysfunction. Though malocclusion may play a role in mandibular dysfunction, there is no common agreement as to which specific factors are important; there is even less certainty with respect to the relationship between elimination of the occlusal disharmonies and relief of TMJ symptoms. Occlusions are classified according to Angle as Class I, Class II, or Class III, with the associated skeletal relationships postulated as predisposing factors for TMJ dysfunction. The purpose of this study is to compare occlusal factors with the arthrographic depiction of the presence or absence of TMJ internal derangements. MATERIALS
AND METHODS
Two hundred five patients with TMJ symptoms (222 joints, 188 unilateral and 17 bilateral) were *Resident in Orthodontics, Eastman Dental Center. **Clinical and Research Associate, Department of Orthodontics and Senior Clinical Associate, Department of Prosthodontics, Eastman Dental Center; Assistant Professor of Clinical Dentistry, University of Rochester School of Medicine and Dentistry. ***Associate Professor, Diagnostic Radiology, University of Rochester; Clinical and Research Associate, Department of Orthodontics, Eastman Dental Center. ****Temporomandibular Joint Fellow, Eastman Dental Center. *****Coordinator of Biostatistics, Eastman Dental Center. ******Chairman, Department of General Dentistry, Eastman Dental Center.
prospectively examined both clinically and by arthrography for TMJ internal derangements. Arthrograms were categorized as “normal,” as showing “meniscus displacement with reduction,” or as showing “meniscus displacement without reduction.“’ Only the parameters with respect to unilateral joint involvement are reported in this article in order to permit consistent interpretation of the relationships between arthrographic joint findings and ipsilateral/ contralateral occlusal findings. The horizontal and vertical overlap was measured with the teeth at the centric occlusal position.2 A millimeter ruler was placed horizontally against the labial surface of the mandibular incisors. The amount of horizontal overlap was measured from the labial surface of the mandibular incisors to the labial surface of the maxillary incisors at the midline. The amount of vertical overlap was marked with a pencil and was measured to the mandibular incisor edge at the midline. The patient’s occlusion was classified according to the system proposed by Angle.) If first molar teeth were missing or had drifted, no classification was given. Anterior and posterior teeth were classified as being in crossbite in accordance with the “Glossary of Prosthodontics Terms.“4 Tipped teeth were defined as having an abnormal angulation of the long axis relative to the occlusal plane. The amount of anterior and posterior tooth wear was scaled as described by Hansson and Nilner.’ 645
646 Roberts et al
Oral Surg. .lune. I 9X7
I. Occlusion
Table
Angie class
Afeniscus displacement n’ith reduction
Normal
Class I Class II, Division 1 Class 11. Division 2 Class III Edentulous/unclassifed Total
30 (73%,) 8 (20%) O( 0%) O( 0%) 3( 7%) 41
45 18 2 0 I 66
Meniscus displacement LrYthout reduction
(68%) (27%) ( 39) ( 0%) ( 27)
1-~-
58 (72%) 19 (23%,) 3 ( 4%) I ( 17,) O( 0%) 81
-Total I33 (70%) 45 (24%) 5 ( 3%) I ( I %) 4( 2%) 188
p > 0.05
Table
II. Horizontal and vertical overlaps
Table Ill.
Arthrographic diagnosis
._.I-
Normal Meniscus displacement with reduction Meniscus displacement without reduction Vertical. Horizontal.
Vertical
Horizontal
2.90 k 0.53 3.75 t 0.41
2.67 t 0.38 2.63 t 0.30
3.34 + 0.42
2.21 + 0.31
Posterior tooth wear
O-l*
p > 0.05. /I > 0.05.
60 (91%) 6 ( 9%) 66
32 (79%) 9 (21%) 41
2-3 Total
71 (88%) IO (12%) 81
p > 0.05. *Scale
proposed
by Hnnsson
and
Nilner’
0 = no wear I = enamel
Laterotrusive and mediotrusive occlusal contacts were evaluated by having the patient perform right and left lateral excursions. Mediotrusive contacts were evaluated with articulating paper, visually, and by observation of any wear facets. Laterotrusive contacts were evaluated with articulating paper and visually. Cuspid guidance was defined as no multiple tooth contacts in lateral excursions.6Group function was defined as two or more working contacts. The amount and direction of any deflective malocclusion (mandibular shift) from the retruded contact position (centric relation) to the maximum intercuspal position (centric occlusion) were recorded. The centric relation was located by means of the technique described by Ramfjord and Ash.’ Mandibular shifts were recorded as none, less than 1 mm, or greater than 1 mm. The direction of the deflection malocclusion was recorded as none, straight, opposite, or to the same side as the side of the arthrogram. The patients’ subjective opinions-whether they clenched their teeth while asleep or while experiencing tension, or both-were also recorded. These factors were collected on a tabulation form and subjected to statistical analysis. Differences among the diagnostic groups for discrete variables were evaluated with the aid of x’ tests. For continuous variables, one-way analyses of variance were performed. Any significant findings from the analy-
2 = near
only into
3 = one-third
dentin of crown
worn
ses of variance were subsequently assessedwith the Newman-Keuls multiple comparisons test. RESULTS
Table I shows the relationships between the Angle classifications and meniscal abnormalities as depicted by arthrography. Seventy percent of the patients had Class I malocclusions, 24% had Class II, Division 1 malocclusion, 3% had Class II, Division 2 malocclusion, 1% had Class III malocclusion, and 2% were unclassified. The distribution of Angle’s classification among the three arthrographic diagnosesdid not differ significantly (p > 0.05). The mean ventrical overlap of the anterior teeth for the three diagnostic categories (Table II) ranged from 2.90 f. 0.53 to 3.75 -t 0.41, and the mean horizontal overlap ranged from 2.67 + 0.38 to 2.21 + 0.31 (JJ> 0.05 and p > 0.05, respectively). Posterior tooth wear (Table III) was most prevalent among the “normal” group, but the differences were not statistically significant (p > 0.05). The prevalence of tilted teeth on the contralateral side (Table IV) was significantly higher among reducing menisci than among nonreducing and normal menisci (p < 0.05). The prevalence of missing posterior teeth on the affected (Table V) and nonaf-
Comparison of TMJ internal derangements with occlusal jindings
Volume 63 Number 6
Tilted teeth (opposite side)
Table IV.
Table VI.
647
Missing teeth (opposite side)
,_.,
No
38 (93%) 3 ( 7%) 41
Yes Total
51 (77%) I.5 (23’S)* 66
72 (88%) 9 (I 2%) 81
p < 0.05. Tilted teeth-same side, p > 0.05 (not shown). *“Meniscus displacement with reduction” group is signilicantly direrent than ‘*normal” group and “displacement without reduction” group.
Table V.
None
32 (78%) 6 ( IS%,) 3 ( 7%,)
I to 3 4 or more
43 (65c”t) 20 (31%) 3( 47)
49 (60%‘) 28 (32%) 4 ( 87,)
p > 0.05.
Table VII.
Lateral occlusion (same side)
Missing teeth, same side
~ None I to 3
4 or more Total
29 (70%) 8 (20%) 4 (IO%) 41
44 (67%) 20 (30%) 2( 3%) 66
53 (65%) 23 (28%) 5 ( 7%) 81
p > 0.0.
fected (Table VI) sides did not differ significantly among the arthrographic groups (p > 0.05 and p > 0.05, respectively). The prevalence of cuspid-protected occlusion or group function was essentially equally distributed among the arthrographic groupings both for the same side and for the opposite side (Tables VII and VIII) (p > 0.05 and p > 0.05, respectively). Balancing side contacts on the same side (p > 0.05) and on the opposite side @ > 0.05) did not correlate to specific meniscal abnormalities (Tables IX and X). The direction and amount of deflection malocclusion (Table XI) were not significantly related to the specific abnormality (p > 0.05). Clenching of the teeth while sleeping or experiencing tension or both (as recorded from the patient’s history) did not correlate with specific meniscal abnormalities (p > 0.05) (Table XII). DISCUSSION
It is generally assumed that malocclusion plays a major role in the development of TMJ dysfunction. Perry* and Loiselle9 have suggested that there is a predominance of Class II jaw relationships among patients with dysfunctional TMJs. Our investigation (Table I) suggests that there is a predominance of Class I malocclusions in this study, which occur at an
Cuspid
I9 (46%)
Group
22 (54%)
Total
41
33 (50%) 33 (50%)
38 (47%) 43 (53%)
p > 0.05.
Table VIII.
Cuspid Group Total
Lateral occlusion (opposite side)
I8 (44%) 23 (56%)
41
32 (48%) 34 (52%,) 66
38 (47%) 43 (53%) 81
p > 0.05.
even greater percentage than in a normal population.‘O Consideration must be given to the low numbers of Class II, Division 2 and Class III malocclusions in the present study. Loss of posterior teeth with bite collapse has been implicated as a specific cause of TMJ pain and dysfunction. Agerberg and Carlsson” in a retrospective study, showed that mandibular mobility was inversely correlated with the number of residual teeth. They also found no greater frequency of dysfunction in patients with TMJ pain than in the general population. Helkimo” demonstrated a lower prevalence of headache and of muscle and joint symptoms in the youngest persons with the most residual teeth. Kopp13found no significant correlation among molar loss, crepitation, and tendernessto palpation. If loss of molar support causesTMJ pain and dysfunction, then restoration might be expected to eliminate or lessen symptoms. However, Leder-
Roberts et al
648
Table IX. No. of balancing contacts 0 l-3 4-5 Total
Oral Surg. June. 1987
Balancing contacts (same side)
Table X.
Normal
Meniscus displacement with reduction
Meniscus displacement without reduction
20 (49%) 18 (44%) 3 ( 7%) 41
38 (58%) 28 (42?6) 0 ( 0%) 66
38 (47%) 40 (49%) 3( 4%) 81
0 l-3 4-5 Total
Balancing contacts (opposite side)
19 (46%) 19 (46%) 3 ( 8%) 41
44 (67%) 21 (31%) I ( 2%) 66
16 (579) 33 (414) 2 ( 27&j 81
p > 0.05
p > 0.05
Table Xl.
Direction of deflective malocclusion Normal
Direction None Straight Same side Opposite side Total
6 24 9 2 41
Meniscus displacement with reduction
(15%) (58%) (22%) ( 5%)
II 31 13 II 66
(17%) (47%) (19%) (17%)
Meniscus displacement without reduction 10 47 7 17 81
(12%) (58%) ( 8%) (22%)
Total 27 102 29 30 188
(14%) (54%) (16%) (16%)
p > 0.05.
Table XII.
Incidence of clenching or grinding
None While asleep While experiencing tension Both Total
r
Normal
Meniscus displacement with reduction
23 (56%) 9 (22%) 3 ( 7%)
30 (46%) 12 (18%) 14 (21%)
41 (50%) 17 (22%) 6 ( 7%)
6 (15%) 41
IO (15%) 66
17 (21%) 81
/J > 0.05
man and ClaytonI found a frequency of dysfunction of 68% among 50 subjects with fixed partial dentures in all posterior quadrants. The concept that occlusal interferences trigger abnormal masticatory function has received much attention through clinical studies. Interferences in habitual and hinge closure, laterotrusion, mediotrusion, and bruxism all have been implicated in the production of mandibular dysfunction. Zarb and Thompsonts found that 50% of 106 patients demonstrated a slide from centric relation to centric occlusion. Sadowsky and Beyale16found no difference in signs or symptoms of TMJ dysfunction in 75 patients treated orthodontically as compared with a matched control group of 75 patients with untreated malocclusions.
Contacts on the mediotrusive (balancing) side have been related to TMJ dysfunction in some did not studies”, I8but not in others. 12.14. 16, 19 Bushl9.20 find an association in 298 dental students who were examined for laterotrusive, protrusive, and retrusive contacts or for canine disclusion and muscle tenderness.Ingerval’* found that single tooth contact on the laterotrusive side was negatively correlated with parafunction. The wear of the posterior and the anterior teeth was assessedas proposed by Hansson and Nilner,’ with the greater percentage of patients having no wear or very slight wear. However, differences among the arthrographic groups were not statistically significant (Table III). Problems in evaluation of molar relationships do exist.z’*22Class I or II molar relationships may occur with or without a deep curve of Spee or abnormal horizontal and vertical overlap. To help assessthis further, the horizontal and vertical overlaps were measured (Table II). With the three arthrographic diagnostic groups, there were no statistical differences between patients with horizontal and vertical overlap. Helije and coworkers23,Williamson,24 and Berry and Watkinson have all considered the deepness of the bite to be a predisposing factor to TMJ dysfunction and pain. Bush’9,20found no significant differences in muscle palpation among Class I, Class II, and Class III malocclusions in 298 dental students. Kopp13found
Volume 63 Number 6
Comparison of TMJ internal derangements with occlusal jindings
no significant correlation between loss of molar support and crepitation or tenderness to palpation of the TMJ. Heliie and Heliiez6 found no correlation among 406 Swedish patients who experienced TMJ pain and dysfunction. Agerberg and Carlsson” found no differences in the patients with dysfunction when they were compared with the general population. Our study suggests that there is little difference (Tables V and VI) in molar loss on the sameside and on the opposite side (p > 0.05 and p > 0.05, respectively), although tilting of the teeth on the opposite side appears to be more prevalent in patients with meniscal displacement with reduction than in patients with displacement without reduction or normal arthrographic findings. Occlusal schemes (group function versus cuspid disclusion) have been evaluated to determine whether abnormal stress on teeth*’ or periodontal problemsz8may be correlated with dysfunction. Suggestions have also been made that the occlusion may progress from canine protection to group function through normal or abnormal wear.29Tables VII and VIII show that the distribution of the two occlusions was equal, suggesting that the anterior guidance alone, which interacts with horizontal and vertical overlap of the anterior teeth, may not be considered to represent multiple causes. Balancing and mediotrusive interferences have been shown to be related in some studies’7.‘8 and shown to be unrelated in others.‘2,‘“,‘6.‘9 This study demonstrates that balancing contacts on the same side or on the opposite side (p > 0.05 and p > 0.05, respectively) were not related to specific meniscal abnormalities (Tables IX and X). The presence of an interference from centric relation to centric occlusion has been reported. The asymmetry of the slide has been correlated to pain and tenderness.30In contrast, neither asymmetry nor the amount of shift was related to symptoms.‘2,“3 “. I8 This study demonstrates that the presenceor absence of deflective malocclusion or the direction of the skid does not relate to the type of meniscal abnormality 0, > 0.05, Table XI). Krogh-Poulsen and Olsson3’ and GraP2 have suggested that bruxism or rubbing the teeth together may precipitate dysfunction. Table XII shows no relationship between these factors and either the presenceof or the severity of the meniscal abnormality. Although we found no significance in many occlusal findings, we cannot exclude the possibility that, in any individual patient, certain occlusal factors are important. Findings such as a gross deflective malocclusion or an extreme deep bite may, in individual
649
cases, predispose the patient to TMJ problems. However, occlusal findings in themselves are not a good indicator of the severity of TMJ internal derangements. REFERENCES I. Katzberg RW, Dolwick MF, Bales DJ, Helms CA. Arthrotomography of the TMJ: New techniques and preliminary observations. AJR 1979;132:949-55. Agerberg G. Maximal mandibular movements in young men and women. Sven Tandlak Tidskr 1974;67:81-100. Angle EH. Classification of malocclusion. Dental Cosmos 1899:4 I :248-64. Glossary of prosthodontic terms. J Prosthet Dent 1977; 38:77. Hansson T, Nilner M. A study of the occurrences of symptoms of diseases of the temporomandibular joint masticatory muscles and related structures. J Oral Rehabil 1975:2:31324. 6. O’Leary TJ, Shanley DB, Drake RB. Tooth mobility in cuspid-protected and group-function occlusions. J Prosthet Dent 1972;27:21-5. 7. Ramfjord SP. Ash MM. Occlusion. 3rd ed. Philadelphia: WB Saunders Co, 1983:301-4. 8. Perry HT. Relation of occlusion to the temporomandibular joint dysfunction: the orthodontic viewpoint. J Am Dent Assoc 1969:79:137-41. 9. Loiselle RJ. Relation of occlusion to the temporomandibular joint dysfunction: the prosthodontic viewpoint. J Am Dent ASSOC1969;79: 145-6. 10. Kelly JE. An assessment of the occlusion of the teeth of youths 12-17 years, United States. Rockville, Maryland: National Center for Health Statistics, 1977; DHEW publication No. (HRA)77-1644. (Vital and health statistics: series 11, data for the National Health Survey, No. 162.) 11. Agerberg G, Carlsson GE. Symptoms of functional disturbances of the masticatory system 11. Symptoms in relation to impaired mobility of the mandible as judged from investigation by questionnaire. Acta Odontol Stand 1975;33:183-90. 12. Helkimd M. Studies on function and dysfunction of the masticatory system. Swed Dent J 1974;67:1-18. 13. Kopp S. Clinical findings in temporomandibular joint osteoarthrosis. Acta Odontol Stand 1977;85:434-43. 14. Lederman KH, Clayton JA. Restored occlusions, Part II: the relationship of clinical and subject symptoms to varying degrees of TMJ dysfunction. J Prosthet Dent 1982;47:3039. 15. Zarb GA, Thompson GW. The treatment of patients with temporomandibular joint pain and dysfunction syndrome. Can Dent Assoc J 1975;41:410-7. 16. Sadowsky C, Beyole EA. Long-term status of temporomandibular joint function and functional occlusion after orthodontic treatment. Am J Orthod 1980;78:201-12. 17. Geering AH. Occlusal interferences and functional disturbances of the masticatory system. J Clin Periodontol 1974;l:l 12-9. 18. lngerval B. Prevalence of symptoms of functional disturbances of the masticatory system of Swedish men. J Oral Rehabil 1980;7: I 12-9. 19. Bush FM. Occlusal parameters and TMJ facial pain in dental students. J Dent Res 1981:60 (special issue) A: Abstract No 878. 20. Bush FM. Malocclusion, masticatory muscle, and temporomandibular joint tenderness. J Dent Res 1985;64:129-33. 21. Gravely JF, Johnson DB. Angle’s classification of malocclusion: an assessment of reliability. Br J Orthod 1974;1:79-86. 22. Helm S. Intraexaminer reliability of epidemiologic registrations of malocclusion. Acta Odontol Stand 1977;35:161-5. 23. Heloe B, Heiberg AN, Krogstad BS. A multiprofessional
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study of patients with myofacial pain dysfunction syndrome 1. Acta Odontol Stand 1980;38: 109. Williamson EH. Temporomandibular dysfunction in pretreatment adolescent patients. Am J Orthod 1977;72:429-33. Berry DC, Watkinson AC. Mandibular dysfunction and incisor relationship. A theoretical explanation for the clicking joint. Br Dent J 1978;144:74-7. Heloe B. Heliie LA. Characteristics of a group of patients with temporomandibular joint disorders. Community Dent Oral Epidemiol 1975;3:72-9. Alexander P. The periodontium and the canine theory. J Prosthet Dent 1967;18:571. Goldstein GR. The relationship of canine-protected occlusion to be a periodontal index. J Prosthet Dent 1979;41:277-83. Beyron H. Optimal occlusion. Dent Clin North Am 1969:
30. Solberg KW, Woo MW. Houston JB. Prevalence of mandibular dysfunction in young adults. J Am Dent Assoc 1979; 98:25-34. 3 I. Krogh-Poulsen
WC, Olsson A. Management of the occlusion of the teeth. Background, definitions, rationale. In: Schwartz L, Chayes CM, eds. Facial pain and mandibular dysfunction. Philadelphia: WB Saunders Co, 1968:236-80. 32. Graf H. Bruxism. Dent Clin North Am 1969:13:659. Reprint
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