Malfunction of the masticatory system … · DOI: 10.1051/odfen/2011206 J Dentofacial Anom Orthod 2011;14:207 RODF / EDP Sciences 1 Malfunction of the masticatory system (Temperomandibular

DOI: 10.1051/odfen/2011206 J Dentofacial Anom Orthod 2011;14:207� RODF / EDP Sciences

1

Malfunction of the masticatorysystem (Temperomandibulardisorders TMD)and malocclusion:is there a relationship?A systematic revue of the literaturefrom 2000 to 2009

Lorraine BELOTTE-LAUPIE, Millewa SAYAGH,

Armelle MANIERE-EZVAN

ABSTRACT

Many hypotheses concerning the relationships that might exist between thedisorders of masticatory system or temperomandibular disorders (TMD) andmalocclusions have been advanced. But, in terms of evidence-based medicine,can we say that any of them have scientific merit?

The objective of our project was to analyze the existing international literatureof the years 2000 to 2009 on the relationship between malocclusion andmalfunction of the masticatory system.

Materials and method: we used MEDLINE to find all papers written inFrench or English that had an abstract referring to ‘‘Malocclusion’’ and‘‘Temperomandibular joint disorders.’’ We subjected them to a critical analysisusing a reading record program that sorted the papers into types of study,descriptive or analytical, and the intensity of their methodology. Two of ourauthors calibrated this analysis and we compared their results.

Results: We examined 17 studies out of a panel of 171 articles. Nine out ofthe seventeen were transverse studies, six were longitudinal studies, oneevaluated cases and a control group, and one was a cohort study. An ethicalcommittee had approved of 9 of the studies and 9 out of the group had beenrandomized. From all seventeen we collected calibrations from observers andmade statistical analyses of the data.

Address for correspondence:

L. BELOTTE-LAUPIE,Le Saint Jacques,7 boulevard [email protected]

Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2011206

http://www.jdao-journal.org

http://dx.doi.org/10.1051/odfen/2011206

Our conclusion was that there is a relationship betweenmalocclusion and TMD but that it is a weak one.

The results of the different studies varied considerably as a factorof the type of malocclusion incriminated and the type oftemperomandibular disorder reported. Our work indicated that arelationship between TMD and malocclusion cannot be establishedand the studies we reviewed had little scientific value primarilybecause of the heterogeneity of the samples and of the lack ofclearly established definitions of the terms ‘‘malocclusion’’ and‘‘disorder’’ of the masticatory system.

KEYWORDS

Malocclusions,

Malfunction of the masticatory system,

Systematic review of the literature,

TMD (Temperomandibular disorder).

1 – INTRODUCTION

In spite of many attempts to eluci-date the supposed role that occlusionplays in the development of disordersof the masticatory system over the pastthirty years, no one has yet producedany significant or clinical evidence thatit is, in fact, an etiological factor eventhough for many years dentists ac-cepted pronouncements that it was aprincipal agent in the disorder. There istoday no consensus that malocclu-sions play a major, a minor, or any roleat all in the development of disorders ofthe masticatory system (TMD), whichare said to have a multifactorial etiol-ogy. For the supposed contribution ofmalocclusion, Mackie and Lyons

16

citedthe stress and psychological difficultiesassociated with it, noxious habits,

systemic factors, and trauma. DeBoever (cited by Landi

13

), in a systema-tic 2000 review of the literature re-ported that many occlusal factors wereassociated with disorders of themasticatory system, but that this asso-ciation was not ‘‘strong.’’ The goal ofour work is to focus on studies carriedout since 2000, to assess their proto-cols, to analyze their scientific value,and to determine if it is possible to drawany significant conclusions on therelationship that might exist betweenmalocclusion and disorders of themasticatory system, in order to reduceuncertainty about the issue and helporthodontists gain a better understand-ing about our functioning in our dailypractices.

Received: 12-2010.Accepted: 03-2011.

LORRAINE BELOTTE-LAUPIE, MILLEWA SAYAGH, ARMELLE MANIERE-EZVAN

2 Belotte-Laupie L, Sayagh M, Maniere-Ezvan A. Malfunction of the masticatory system(Temperomandibular disorders TMD) and malocclusion

2 – PROTOCOL OF THIS STUDY

We propose to employ the fouraxes proposed by ANAES1 :

Identification of information,Selection of articles to study,Analysis of articles,Synthesis.

2 – 1 – Title

Malocclusions and disorders of themasticatory system: is there a rela-tionship?

2 – 2 – Objective of the study

In this work we propose to evaluatethe quality of the methodology ofpublished studies on the relationshipbetween malocclusion and disorders ofthe masticatory system. In a secondsection, we examine these studies

with respect to their methodologicaland/or ethical criteria.

2 – 3 – Methods and materials(or ‘‘identificationof information)6,12,15

2 – 3 – 1 – Concept of the database

• Definition of data base: a stock orbank of data that is a collection ofdigital information related to definedarea of knowledge, organized andstructured to facilitate location of de-tails and access to them by means ofdevices that are usually electronic.

• Criteria for the selection

of articles

We decided to choose journal arti-cles published in English or Frenchbetween 2000 and 2009 that included

Figure 1Number of studies published per year.

Figure 2Number of studies per country.

MALFUNCTION OF THE MASTICATORY SYSTEM (TEMPEROMANDIBULAR DISORDERS TMD) AND MALOCCLUSION: IS THERE A RELATIONSHIP?

J Dentofacial Anom Orthod 2011;14:207 3

the key words ‘‘malocclusion’’ and‘‘TMD’’ that had an abstract, and werenot case reports or literature reviews.

• Sources of information

– T h e m e d i c a l d a t a b a n k ,MED-LINE, for English languagemedical literature, Analysis andretrieved Systems Online, themost important digitalized, analy-tical bibliographical data base pro-duced by United States NationalInstitute of Health’s NationalLibrary of Medicine. It referencesworldwide biomedical literatureand is updated daily. But it doesnot actually provide completeworld coverage because no data-base could possibly contain every-thing. So if Medline fails toproduceresults, researchers must lookelsewhere.We decided to choose journalarticles published in English orFrench between 2000 and 2009to evaluate the methodologicalquality of studies using databases like Aidsline, Embase, Tox-line and others to which wegained access through Pubmed(http: //wwwpubmed.org).

– The ‘‘grey’’ literatureIn ANAES (which has becomeHAS), ‘‘there are non-indexedofficial catalogues, conventionalinformation circuits, abstractsfrom conventions, governmentaldocuments, unpublished studies,reports and other unconventionaldocuments, all of which make itan important source of informa-tion.

• Accessing the database

– We searched through PUBMEDwithout using the MeSh the-

saurus for the subject ‘‘Malocclu-sions and TMD, is there arelationship?’’ Accordingly wehad to conduct our search witha combination of key words,‘‘malocclusions’’ and ‘‘TMD’’ ina time frame of 2000 to 2009. Sowe harvested two groups ofarticles, reflecting two sets ofcriteria applied in the same timeperiod. Then we applied addi-tional criteria, the first beingpresence of an abstract, inclu-sion of a tag which helped us toeliminate review articles, casereports, interviews, letters, andeditorials. After having win-nowed our crop by type, we thenlimited the harvest by language,English or French only.

– Results of the searchOur initial yield was consisted of3,244 TMD articles and 6,350malocclusion articles for the timesegment of 2000 to 2009. Thenwe reduced the groups to articlesthat had an intersection of TMDand malocclusion, leaving a finallist of 171 articles.

– List of articles obtained fromMEDLINE:

In order to be certain our listcontained only articles dealing withmalocclusion and TMD we reviewedour list manually to remove thosefocused on orthognathic surgery,treatment with oral splints, and kine-sitherapy, subjects we did not evalu-ate in our analysis.

– Two readers performed the triagein order to reduce the risk ofindividual error. After the first selec-tion, 51 articles remained in our list.

– In a third weeding out process,we eliminated articles that:



* were long-term studies with norecent results;

* articles that viewed malocclusionin terms of ‘‘occlusodontics’’ notorthodontics;

* articles whose sole goal was toestablish a relationship betweenorthodontics and TMD;

* were literature reviews, not stu-dies;

This left us with our group of 17articles whose authors were:

– L. SONNESSEN, et al. (3 articles)22,23,24,

– E. CARLSON, et al. (1 article)3,– R. CELIC, et al. (2 articles)4,5,

– B. THILANDER, et al. (1 article)25,

– B. MOHLIN, et al. (1 article)18,

– CM. SELAIMEN, et al. (1 article)21,

– T. MAGNUSSON, et al. (1 article)17,

– C. HIRSCH (1 article)11,

– D. GESCH, et al. (1 article)8,

– R. PAHKALA, et al. (1 article)19,

– V. TUERLINGS, et al. (1 article)26,

– A. CONTI, et al. (1 article)7,

– T . H E N R I K S O N a n d N I L N E R

(1 article)10,

– F. GODOY, A. ROSENBLATT, J. BEZERRA

(1 article)9.

2 – 3 – 2 – Critical analysisof the articles (our‘‘methodology’’)14,15

• General terms

After the first two identification andselection phases of article selectionwe analyzed the articles in order toharvest information we could use inour synthetic document. This literatureanalysis constituted the initial stage ofour preparation of medical and profes-sional recommendations and refer-ences that would guarantee quality.

For this work we used a reading gridthat we adapted from the ‘‘CriticalAppraisal Worksheet’’ of the Centrefor Clinical Epidemiology and Biosta-tistics of the University of Newcastle,New South Wales, Australia, whichconsists of eight evaluation criteria:the objective of the study, the type ofprotocol employed, the factors stu-died, the judgment criteria, the popu-lation source and subjects examined,the statistical analyses, the possiblebiases, the statistical analyses, andthe author’s conclusions (Guide ofanalysis of the literature and gradationof recommendations, ANAES 2001).

• Evaluation of criteria

Readers need landmarks that helpthem decode and sort information inan effective and standardized fashionso that they can more easily identifythe strengths and the weaknesses ofan article as well the inclusion ofpoints that weaken an article’s validity.

– The objective of our studyA critical reading gives us the

necessary information to place anarticle in an appropriate rubric in orderto clarify its objective that may be toelucidate: the history of the malady,the prognosis and development of themalady, the mode of utilization, per-formance, the benefits of a diagnostictest, the impact of therapy, and thedetermination of an etiology and caus-ality, in terms of our study, malocclu-sion and TMD.

– The type of study and the qualityof proofs it presents are etiologi-cal. According ANAES the mostsatisfactory protocols for judgingcausality are, in ranking order ofthe level of proof: random trials,cohort studies, and case studieswith control groups.



– The factors studied (here thecriteria for evaluation of the mal-occlusion). The factor we studiedwas the intervention that wasdesigned to cause favorablechanges in the health problem,a malady or clinical condition.

The questions the reader shouldformulate:

– how were the factor, or factors,measured?

– were all the possibly pertinentfactors taken into account?

– were the measurement methodsapplied equivalently to all sub-jects and all groups?

– what is the resultant factor orjudgment criterion (here for eval-uating TMD)?

– The judgment criterion is theevent or situation supposed tohave resulted from the influenceof the factor being studied, suchas death, disease, handicap, dis-comfort, and dissatisfaction. Thereader should also be attentive tothe precision with the definitionof the resultant factor is framedas well as the measurementmethod so that a final synthesisof the results can be made.

– Population and sample studiedThe reference population or the

population being studied is the groupfor which the results of the study canbe applied if they are valid. Thesample is a sub-group of the popula-tion studied, sometimes selected ran-domly, sometimes not, that reflectsthe characteristics of the population asa whole when it is not possible, forpractical reasons, to evaluate thatentire population. The subjects in thesample may be segregated intogroups.

Questions to ask:– was the selection correct?– was it randomized? (dividing the

sample or the population intotwo or more comparable groupswith a method that is based onchance);

– were the groups differentiated bycharacteristics other than thefactors being studied?

– what proportion of the subjectswas available to follow-ups? Ac-cording to ANAES1, the charac-teristics of populations exposedand not exposed, sick and con-trol, that determined the criteriafor inclusion or exclusion, mustbe known, especially if the riskfactors and malady being studiedcan be related to these charac-teristics.

– Possible biasBias occurs in subject selections

that are not randomized.– The resultsThe reader must know if the results

derive from chance or statisticallyrepresent an action of the factor underexamination. Variables help to answerthis question. The value p stands forthe probability, calculated by the teststatistic constructed from the col-lected data, of chance having causeddifferences equal to or greater than thedifference that was observed. A resultis called statistically significant if it isunlikely to have occurred by chance.Statisticians usually employ signifi-cance levels of 1% or 5%, which, inmeans that there are one chance orfive chances out of 100 that thedifference observed was due tochance and not the factor observed.If, then, the significance level chosenis 5%, which is usually the case; that



means that p < 0,05% signifying thatthe effect is statistically significant,that is, due to something other thanchance.

– Conception of the analysis gridThe conception of our reader’s

analysis grid is based on the Land-rivon14 grid, which an adaptation ofthe ‘‘Critical Appraisal Worksheet.’’

The reading grid of an article oncausality helps the reader answerthese questions: is there an associa-tion between the risk factor and themalady, is this relationship strong, canthe risk factor have caused the effect?

We prepared a record sheet foreach article in our study.

3 – RESULTS OF THE CRITICAL READING

The 17 studies that survived ourweeding out process constituted oursample.

– Type of study: nine of theseventeen were transverse stu-dies, six were longitudinal, onewas a case study with a controlgroup, and one was a cohortstudy.

– Ethical committee: An ethicalcommittee approved nine out ofthe seventeen studies in oursample.

– Randomization: Nine studieswere randomized.

– Calibration: Observers cali-brated fourteen of the studies.

– Statistics: All seventeen of thearticles in our group were statis-tical studies.

– Synthesis of the results: God-oy, et al.9 concluded that pa-t ients whose teeth weremaloccluded were at no greaterrisk for developing TMD thanpersons who did not have mal-occlusions. Tuerling26 came tothe same conclusion that therewas no correlation betweenTMD and malocclusion in infants,who have a great capacity foradaptation.

According to Sonnessen, et al.24,overbite, and especially lingual inclina-tion of the maxillary incisors, are riskfactors for TMD and Pahkala19 as-serted that pronounced overjet andanterior open bite in children bothincreased the risk for developingmuscular sensitivity. But Hirsch11 con-cluded that there was no relationshipbetween overbite, even in extremecases, and the objective TMD symp-toms. On the other hand Conti’sstudy

7

came to the conclusion thatthere was a statistically significantrelationship between the absence ofanterior guidance and the presence ofas well as the severity of TMD.

Selaimen21 found that Class II mal-occlusions and lack of canine gui-dance increase the prevalence ofTMD. Celic4 work concluded thatpeople with Class I malocclusionswith an overjet greater 5 mm, ClassII division 2 malocclusions, anteriorcross bites, midline deviations, andnon-working contacts in working man-dibular movements have increasedrisk of TMD but that the relationshipis weak. Thilander’s study reported asignificant association between TMDand posterior cross bites, Class IIImalocclusions, and severe overjets.



Magnusson, et al.17 found a signifi-cant correlation between TMD and aforced lateral occlusion, a vertical orsagittal differential between centricrelation occlusion and maximal inter-cuspation occlusion, and unilateralcross bite, but no relationship be-tween over bite and occlusal interfer-ences with TMD. Landi13 found thatonly a differential greater than 2 mmbetween centric and maximum inter-cuspation occlusion increased the riskof facial muscular pain.

Sonnesen23 found the most fre-quently occurring sign of TMD in crossbite cases, associated with a severetransverse discrepancy and an acutegonial angle, was sensitivity of thesuperficial masseter and anterior tem-poral muscles. And Gesch8 describeda relationship between TMD problemsand diastemas. Finally, Calrson3 as-serted that tooth abrasion and over-bite during childhood were significantpredictors of an increase in clinicalmalfunction.

4 – DISCUSSION

Having collected such a large de-scriptive panoply of factors studiedand results presented, we decided toconcentrate exclusively on malocclu-sions and TMD problems and theprecise manner in which the authorshad defined and measured them. Thatis why we searched in each study forconclusions that reported the exis-tence or absence of a relationshipbetween malocclusion and TMD.

Our sample, derived exclusivelyfrom a sector of the literature delim-ited by the years 2000 to 2009, wascomprised of studies whose resultswere totally divergent!

This could be explained by the lack ofharmony in the form and parameters ofthe studies, both of which contributedto the bias we found in them.

4 – 1 – The form of the studies

– The sample population: therewas a lack of harmony in the

selection of the study samples insize, some working with dozensof cases, others with thousands.The age groups varied widely,ranging from children to adoles-cents, adults, and seniors. Theorigins of the groups were differ-ent, some were school children,some came from the frameworkof a previous study. Some werepredetermined, grouping malesand females separately; otherswere random from the beginningof the study. So we cannot besure that the results we exam-ined were representative of thegeneral population.

– The follow-up: the signs andsymptoms of TMD fluctuate overtime so some of the studieswere too limited in length ofobservation. Moreover, in trans-verse studies, delays in theappearance of problems wereinconsistent or non-existent.



4 – 2 – The parameters(or factors studied)

– The malocclusions: the authorsof the papers in our study did notagree in their definition of mal-occlusion. Some focused theirresearch on ‘‘functional maloc-clusions’’, or interferences, whileothers included ‘‘morphologicalmalocclusions. Different authorsassessed malocclusions in differ-ent ways making it impossiblefor an eventual correlation be-tween malocclusion and TMD toemerge from their work. Further-more, words have differentmeanings in different countries,

for example an ‘‘occlusal inter-ference’’ in the Nordic countriescorresponds in French to ‘‘uneprematurite occlusale’’ or occlu-sal prematurity. Furthermore,some authors are imprecise, fail-ing to mention whether a ‘‘ClassII malocclusion’’ was dental orskeletal or whether a cross bitewas unilateral or bilateral.

– TMD: the method of assessingTMD in clinical examinationsvaries as well. Some clinicianslisten for audible clicks in thetempero-mandibular joint whileothers use a stethoscope todetect them. Others palpate thejoint searching for irregularities.

Figure 3Malocclusions and TMD in the sample studied.



And assessing muscular sensitiv-ity by means of a Helkimo orMcNeill index remains subjec-

tive, all of which make calibrationof TMD difficult.

5 – CONCLUSION

Our study affirms that there is noconsensus about the relationship be-tween TMD and malocclusion. Stu-dies published on the subject havelittle scientific value, partly because ofthe bias in sample selection and partlybecause of the disparity in the defini-tion of the basic terms, malocclusionand Tempero-Mandibular Disorders orTMD.

In order for researchers to undertakeTMD projects that have real scientificmerit they must join in an internationalagreement on the definition of TMDand devise an accepted diagnosticallyreliable classification for it. It seems tous indispensable for future researchthat we have a uniform conception ofthe nature of the problem.

In 2010 Cairns, List, Michelotti,Ohrbach and Svensson2 proposed inthe Journal of Oral Rehabilitation anumber of recommendations:

– The necessity of defining TMD.– The necessity of defining accep-

table occlusion. Today, in effect,any occlusion that is not ideal isconsidered to be a malocclusion.It would be useful to create sub-groups of malocclusion and ofTMD.

– The necessity of incorporatingthe principles of evidence basedmedicine into rigorous protocolsfor future studies. We cannotyet, it is true, demonstrate andlink between TMD and malocclu-

sion but there is no scientificproof that demonstrates the ab-sence of such a link. Accordingly,we must keep the multi-factorialetiology of TMD carefully in mindand remember that the appear-ance of temperomandibular jointsymptoms also depends on theindividual patient’s capacity toadapt. In this view, orthodonticsdoes not appear to be, in itselfthe prime factor in the preventionor the treatment of TMD. Never-theless, orthodontists shouldstrive to achieve treatment re-sults whose occlusions respondto rigorous occluso-functional cri-teria. Successful orthodontictreatment does not consist solelyof well-aligned teeth and a Class Iocclusion. In order to assure thatthe teeth of our patients are ableto withstand the extra con-straints imposed open them bymodern life, they must be as wellorganized as possible to adaptsuccessfully to the demands ofthe 21st century.

NdlR – the tables relating to theresearch that was used for the pre-paration of this study: Table I- file ofpublication analysis; Table II – list ofpublications of the sample, classifiedin decreasing chronological order; Ta-ble III – synthesis of the results bypublication that can be consulted formore detail at the Revue d’ODF site :www.revue-odf.org.



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Documents

Malfunction of the masticatory system … · DOI: 10.1051/odfen/2011206 J Dentofacial Anom Orthod 2011;14:207 RODF / EDP Sciences 1 Malfunction of the masticatory system (Temperomandibular