Orthodontic Therapy and TMD: An Update - AAO Jeffrey... · Okeson AAO May 3, 2016 2 - let’s ask some specific questions - 1. Does orthodontic therapy lead to an increase in TMD

Okeson AAO May 3, 2016

1

byJeffrey P Okeson, DMD

Professor and Chief, Division of Orofacial PainDirector, Orofacial Pain Program

University of Kentucky College of DentistryLexington, Kentucky 40536-0297

[email protected]

Orthodontic Therapy and TMD: An Update

The American Association of OrthodontistsOrlando, Florida

May 3, 2016

Orthodontic Therapy and TMD: An Update

?

Temporomandibular Disorders

Musculoskeletal pain disorders

of the masticatory system. 1. Does orthodontic therapy lead to an increase in Temporomandibular Disorder symptoms?

2. What causes Temporomandibular Disorder?3. What are the functional treatment goals of

orthodontic therapy?4. When should you consider orthodontic therapy for

the treatment of a Temporomandibular Disorder?5. Can orthodontic therapy prevent TMD?

Some important questions for us to consider.

- let’s ask some specific questions -

1. Does orthodontic therapy lead to an increase in TMD symptoms?

Orthodontic therapy and TMD- a data based review -

Sadowsky & BeGole, 1980 75 75 10 years no significant differences

Sadowsky & Polson, 1984 96 103 10 years no significant differences

Larsson & Ronnerman, 1981 23 HI 10 years no significant differences

Dahl et al, 1988 51 47 5 years no sign differences (- pat)

Smith & Freer, 1989 87 28 4 years no sign differences (+ pat)

Rendell et al, 1992 462 HI 18 mons no significant differences

Hirata et al, 1992 102 41 2 years no significant differences

Kremenak et al, 1992 109 HI 1-6 years no significant differences

Wadhwa et al, 1993 31 71 4 years no significant differences

Henrikson et al, 2000 65 60 2 years no significant differences

TMD Signs and Symptoms: Post-Ortho vs Controls

Authors # pat # controls years results


2



2. Does premolar extraction increase the incidence of TMD symptoms?


Janson & Hasund, 1981 30 30 5 years no significant differences

Sadowsky et al., 1991 87 68 3 years no significant differences

Luppanapornlarp, 1993 33 29 15 years no significant differences

Kremenak et al, 1992 39 26 1-2 years no significant differences

Dibbets et al, 1992 73 38 20 years no significant differences

Extraction vs. Non Extraction and Various TMD Symptoms

Authors # ex pat # non ex years results




3. Does premolar extraction resulting in posterior displacement of condyles?


Gianelly et al, 1988 30 37 no significant differences

Luecke et al,1992 42 --- 70 % more forward after tx

Beattie et al, 1994 33 30 no significant differences

Artun et al, 1992 29 34 Mixed: Right mid & lat all other areas no sign diff

O’Reilly et al, 1993 60 60 no significant differences

Extraction vs. Non Extraction and Posterior Displacement of the Condyle

Authors # ex pat # non ex results




3. Does premolar extraction resulting in posterior displacement of condyles?

4. Does orthodontic therapy prevent TMD?


Sadowsky & BeGole, 1980 75 75 10 years no significant differences

Sadowsky & Polson, 1984 96 103 10 years no significant differences

Larsson & Ronnerman, 1981 23 HI 10 years no significant differences

Dahl et al, 1988 51 47 5 years no sign differences (- pat)

Smith & Freer, 1989 87 28 4 years no sign differences (+ pat)

Rendell et al, 1992 462 HI 18 mons no significant differences

Hirata et al, 1992 102 41 2 years no significant differences

Kremenak et al, 1992 109 HI 1-6 years no significant differences

Wadhwa et al, 1993 31 71 4 years no significant differences

Henrikson et al, 2000 65 60 2 years no significant differences

Authors # pat # controls years results

Does Orthodontic Therapy Prevent TMD Symptoms


3

These studies suggest that orthodontic therapy is not a risk factor for TMD.

Is that true?

…..or are there other factors that may need to be considered regarding the

results of these studies?

Some considerations regarding the conclusions of these studies

1. The studies are true, there is no relationship between orthodontic therapy and TMD.

2. The studies have only looked at well controlled orthodontic therapy.

3. The studies looked at young, growing, adaptive patients.

4. Orthodontic therapy does affect occlusion but….…. the relationship between occlusion and TMD is unclear.

1. Does orthodontic therapy lead to an increase in Temporomandibular Disorder symptoms?





Normal functioning masticatory system

Etiologic Factors

TMD

Occlusal Factors

The asymptomatic individual

The Role of Occlusion in Temporomandibular Disorders

Occlusion

TM Disorders

=

?

?

=

Our history

Evidence based Dentistry

I reviewed the findings of78 epidemiologic studies that investigated the

relationship betweenocclusal factors and TMD symptoms.

Pub Med search from 1979 - 2008

Opinion ? or Data ?


4

Williamson and Simmons, 1979DeBoever and Adriaens, 1983Egermark-Eriksson et al., 1983

Gazit et al., 1984Brandt, 1985

Nesbitt et al., 1985Thilander, 1985

Budtz-Jorgenson et al., 1985Bernal and Tsamtsouris, 1986

Nilner, 1986Stringert and Worms, 1986

Riolo et al., 1987Kampe et al., 1987

Kampe and Hannerz, 1987Gunn et al., 1988

Pullinger, et al., 1988Seligman and Pullinger, 1989

Linde and Isacsson, 1990 Dworkin et al., 1990Kampe et al., 1991Steele et al., 1991

Takenoshita et al., 1991Pullinger and Seligman, 1991Wänman and Agerberg, 1991

Cacchiotti et al., 1991Kampe et al., 1991Steele et al., 1991


Cacchiotti et al., 1991Egermark and Thilander, 1992

Shiau and Chang, 1992Glaros et al., 1992

Huggare and Raustia, 1992Kirveskari et al., 1992

Könönen, 1992Könönen et al., 1992

List and Helkimo, 1992Shian and Chang, 1992

Al Hadi, 1993Pullinger and Seligman, 1993

Pullinger et al., 1993Scholte et al.,1993Tanne et al., 1993

Wadhwa et al., 1993Keeling et al., 1994

Magnusson et al., 1994Tsolka et al., 1994

Vanderas, 1994Bibb et al., 1995

Castro, 1995

Hochman et al., 1995Lebbezzo-Scholte et al., 1995

Olsson and Lindqvist, 1995Mauro et al., 1995Tsolka et al., 1995

Westling, 1995Raustia et al., 1995 Conti et al., 1996Sato et al.,1996

Seligman and Pullinger, 1996Henrikson et al., 1997Watanabe et al., 1998Ciancaglini et al, 1999

Kahn et al., 1999Seligman and Pullinger, 2000Pullinger and Seligman, 2000

Rauhala et al., 2000Thilander et al., 2002Carlsson et al., 2002Egermark et al., 2003

Gesch et al., 2004Taskaya-Yilmaz et al., 2004

Landi et al., 2004Pahkala et al., 2004

Magnusson et al., 2005Gesch et al., 2005

Studies that investigate the relationship between occlusion and TMD

Total = 78 Studies Williamson and Simmons, 1979DeBoever and Adriaens, 1983Egermark-Eriksson et al., 1983






















Castro, 1995



Westling, 1995Raustia et al., 1995 Conti et al., 1996Sato et al.,1996







Total = 25 Studies

Studies that found no relationship between occlusion and TMDNo No

Williamson and Simmons, 1979DeBoever and Adriaens, 1983Egermark-Eriksson et al., 1983






















Castro, 1995



Westling, 1995Raustia et al., 1995Conti et al., 1996Sato et al.,1996







Total = 53 Studies

Studies that found a relationship between occlusion and TMDYes Yes

anterior openbite

increased overjet

increased overbite

centric slide >2 mm

asymmetrical slide

unilateral contact in CR

Angle class II

Angle class II, division 1

Angle class II, division 2

Angle class III

posterior crossbite

anterior crossbite

non working contacts

midline discrepancy

loss of teeth

loss of molar support

presence of restoration

reduced tooth contacts in CO

crowding

“occlusal interferences”

attrition

laterotrusive attrition

anterior attrition

no slide

The following occlusal conditions were reported as related to TMD:

..but all of these conditions were not reported in every study.

What was the occlusal relationship found to be related to TMD?

16 studies = anterior openbite (20%)*

13 studies = increased overjet (17%)

10 studies = centric slide >2 mm (13%)

9 studies = asymmetrical slide (12%)

8 studies = non working contacts (10%)

7 studies = occlusal interferences (9%)

6 studies = unilateral contact in CR (8%)

5 studies = anterior crossbite (6%)

4 studies = Angle class II (5%)

4 studies = Angle class II division 1 (5%)

4 studies = Angle class III (5%)

4 studies = increased overbite (5%)

3 studies = loss of teeth (4%)

3 studies = loss of molar support (4%)

3 studies = posterior crossbite (4%)

3 studies = reduced CO tooth contacts (4%)

2 studies = attrition (4%)

2 studies = presence of restoration (4%)

1 study = Angle class II, division 2 (1%)

1 study = laterotrusive attrition (1%)

1 study = anterior attrition (1%)

1 study = crowding (1%)

1 study = midline discrepancy (1%)

1 study = no slide (1%)

* % of the 78 studies reporting this finding

How common were these conditions reported?





























An anterior openbite may bethe results of a TMD,

and not the cause a TMD.


5



























What was the occlusal relationship found to be related to TMD?- Important -These occlusal conditions do not always lead to TMD!


Etiologic Factors

TMD

Occlusal Factors



Etiologic Factors

TMD

Occlusal Factors

Trauma



Etiologic Factors

TMD

Occlusal Factors

Trauma

Emotional Stress



Etiologic Factors

TMD

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input



Etiologic Factors

TMD

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction



6


Etiologic Factors

TMD

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction


The individual is unaffected

Adaptability of the individual

Adaptability

Genetic factorsBiologic factors

Hormonal factorsPsychosocial factors

Others ?


Etiologic Factors

TMD

Adaptability


The individual develops TMD

symptoms


Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction



Others ?

Etiologic Factors

TMD


How do you treat the TMD

symptoms?


Correct the occlusal condition

Trauma

Emotional Stress

Deep Pain Input

Parafunction

Adaptability

Adaptability of the individualGenetic factorsBiologic factors


Others ?


Etiologic Factors

TMD

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction


The individual is unaffected


Adaptability

Slade, Ohrbach and Maixner: Orthodontic Treatment, Genetic Factors, and Risk of TMD Seminars in Orthodontics Vol14, No 2, 2008, pp 146-156

Three common COMT haplotypeslow pain sensitivity (LPS)

average pain sensitivity (APS)high pain sensitivity (HPS)



Others ?






- Condylar Stability -

• The condyles are in their most superior anterior positionin the fossae resting against the posterior slopes of thearticular eminentiae. (musculoskeletally stable)

• The discs are properly interposed between thecondyles and the fossae.

- Occlusal Stability -

These are the treatment goals for orthodontic therapy

• Even and simultaneous contact of all teeth with posteriorteeth contacting slightly heavier than anterior teeth.

• Adequate tooth-guided contacts on the laterotrusive side.• In the normal upright position, posterior teeth contact

heavier than anterior teeth (envelop of function).


7

Orthodontic therapy can produce orthopedic stability

Joint Stability = Occlusal Stability

The Anterior Protrusive Position

This is a muscle bracedposition not a musculoskeletally

stabilized position.

Some believe the best position for the condyle

is in a forward, protrusive position in

the fossa.


This is a muscle bracedposition not a musculoskeletally

stabilized position.

Some believe the best position for the condyle

is in a forward, protrusive position in

the fossa.MSS PositionMSS Position


Does placing the condyle in a forward position cause any anatomical problems?

No, this is a functional position: protrusion

However, the muscles must actively brace the condyle to maintain it in this position.


1. Functional Orthodontics

What would be the purpose of moving the mandibular forward in a protrusive position?


Bring the mandibular forward (in a growing patient)…

Insert a functional appliance…

Allow the condyle to grow into the musculoskeletally stable position.


8


But what if the mandible does not grow?

And the occlusion is established in this forward position.

With time the muscle develops

a myostatic contracture.

A painless shorteningof the functional length

of the muscle.


But what if the mandible does not grow?

And the occlusion is established in this forward position.


MSS Position

Now the condyles are braced forward and the occlusion is

stabilized in this position.

What if at a later time the condyles become seated into their

musculoskeletally stable positions?


Now the condyles are braced forward and the occlusion is

stabilized in this position.

What if at a later time the condyles become seated into their

musculoskeletally stable positions?MSS PositionMSS Position An anterior open bite

(significant orthopedic instability)


The orthodontist should assess for condylar stability before finishing the occlusion.

1. Try a bilateral mandibular manipulation.

2. Consider an anterior bite plane for a short time (2-7 days).

3. Consider imaging.

- some considerations -

- Conclusion -Radiographs are not an accurate method

of assessing joint position.


9

Does a lack of orthopedic stabilitylead to TMD?

Joint stability

Occlusal instability

Occlusal stability

Joint instability Orthopedic instability

plus loading

An intracapsular disorder

- Important -This orthopedic instability must be of clinical significance.

MSS ICP > 3-4 mm

A “stable malocclusion”

- another important concept -

A dental malocclusionthat is orthopedically stable.


10

A stable dental malocclusion

Orthopedic stability

(not a risk factor)

Find themusculoskeletally

stable position.


stable position.


stable position.

Orthopedic Instability(a potential risk factor)

(loading)







Etiologic Factors

TMD

Adaptability



Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction

Orthodontic therapy only affects one factors.



Others ?

How does orthodontic therapyaffect TMD?


11


Etiologic Factors

TMD

Adaptability



Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction

Orthodontic therapy will failto affect the TMD symptoms.




Others ? 1. Does orthodontic therapy lead to an increase in Temporomandibular Disorder symptoms?






Etiologic Factors

TMD

Adaptability



Hormonal factorsOthers ?

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction


Goal of orthodontic therapy:Establish orthopedic stability

Orthodontic therapy may reduce only one risk factor associated with TMD.

Occlusal Factors

Some additional thoughts to consider.

So why does the literature report very little relationship between orthodontic and TMD?

Perhaps it isthe patient that makes

us look so good.

So why does the literature report very little relationship between orthodontic and TMD?

- form follows function -

If the occlusion is finalized before final

maturation of the condyles….

…then the TMJs will adapt/develop to the musculoskeletally stable positions.


12


Etiologic Factors

TMD

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction


Adaptability



Others ?


Etiologic Factors

TMD

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction


Adaptability


The adult patient may not have the same

adaptability.



Others ?

- Conclusions -

The orthodontist should appreciate:

1. The importance of orthopedic stability in the masticatory system.

2. The importance of patient adaptability.3. Occlusal factors are only one of many factors that

may be associated with TMD.

Maintaining a Healthy Functioning Masticatory System through Orthodontic Therapy


Etiologic Factors

TMD

Adaptability



Hormonal factorsOthers ?

Occlusal Factors

Trauma

Emotional Stress

Deep Pain Input

Parafunction


Can orthodontic therapyprevent TMD?

Not likely. In order to prevent TMD you must control all the factors.

This greatly concerns me. Thank you for your kind attention.

- Jeffrey P Okeson, DMD


13

Seventh Edition546 pages

February 2014

Quintessence Publishers1-800-621-0387

Seventh Edition488 pages

2013

Elsevier/Mosby Company1-800-325-4177

Newly Updated Lecture Series- DVDs or streaming -www.jeffokeson.net

Okeson TextsOkeson Home Page

University of KentuckyMini-Residency Program

June 6-10, 2016Shadowing Program

1 week (40 hr)

[email protected]

Documents

Orthodontic Therapy and TMD: An Update - AAO Jeffrey... · Okeson AAO May 3, 2016 2 - let’s ask some specific questions - 1. Does orthodontic therapy lead to an increase in TMD