major maxillomandibular malrelations and temporomandibular joint pain-dysfunction

5
Major msrxilfomandibular malrela+ians and temporomandibular joint pain-dysfunction L. George Upton, D.D.S., M.S.,* Richard F. Scott, D.D.S., M.S.,** and James R, Hayward, D.D.S., M.S.*** University of Michigan, School of Dentistry and School of Medicine, Ann Arbor, M,ich. T he distinction between dentoalveolar malocclusion and malocclusion that results from maxillomandibular skeletal discrepancies is well known, and its recognition forms the basis of the orthodontic-surgical (ortho- surgery) approach to correction of dentofacial discrep- ancies. Many publications have been concerned with the association of dental occlusion, muscles of mastica- tion, and psychologic status to temporomandibular joint (TM J) pain-dysfunction.‘-’ However, the associa- tion between major maxillomandibular malrelations and TMJ pain-dysfunction has received little atten- tion. Consequently, the effect of surgical correction of such disharmonies on patients with TMJ pain- dysfunction is not well documented. The purpose of the present investigation was to explore this subject by obtaining data from patients with both significant maxillomandibular skeletal dis- harmonies and concomitant TM J pain-dysfunction. Two specific questions were asked: 1. Do patients with skeletal Class II, Class III, or open-bite malocclusions have a greater incidence of TMJ pain-dysfunction than Class I patients? 2. Does correction of dental-skeletal disharmonies in patients with existing TMJ symptoms result in improvement or resolution of the symptoms? MATERIAL AND METHODS A retrospective study of all major orthognathic surgical patients treated between July 1, 1978, and June 30, 1981, was completed. This was carried out in relation to the incidence of TMJ pain-dysfunction in both pretreatment and posttreatment phases and was accomplished by use of a questionnaire. Of the 213 patients contacted, 102 responded. The group consisted *Profrssor. Oral and blaxillofacial Surgery, School of Dentistry; Assrxinte Professor in Surgery, School of Medicine. **:\ssisian~ (Xinical Professor, Oral and Maxillofacial Surgery, School of Dentistry; Assistant Clinical Professor in Surgery, School of hledicine. ***Professor and former Chairman, Oral and Maxillofacial Surgery, School of Dentist-y; Professor in Surgery, School of Medicine. 686 Table I. TMJ symptoms prior to orthodontic or surgical treatment -.~___ Present Not present -___ Total No. % NO. w No. Women 40 57 30 43 70 Men &? 47 17 53 32 55 53 47 47 102 - ___-..-___ of 70 women (68.6%) and 32 men (31.4%) with the following preoperative diagnoses: 46 patients with skeletal Class II malocclusions (45%); 39 patients with skeletal Class III malocclusions (38.2%); 14 patients with skeletal open-bite malocclusions (13.7%); and three patients with other forms of skeletal malocclu- sions such as asymmetry or segmental incoordination (3%). Seventy-six patients were treated by an ortho- surgery approach, and 26 patients were treated with surgery alone. RESULTS Of the 102 patients who completed the question- naire, 55 (53%) reported pretreatment TMJ pain- dysfunction symptoms. In the female subpopulation, 40 (57%) reported pretreatment symptoms, while 15 (47%) of the male respondents reported similar symp- toms (Table I). The five pretreatment symptoms described included TM J pain, soreness, clicking, popping, and limited jaw opening. The distribution of the symptoms is illu- strated in Table II. Associations between types of skeletal relationships prior to treatment and their incidence of symptomatol- ogy were: (1) patients with skeletal Class II malocclu- sions reported a 59% preoperative incidence of TMJ pain-dysfunction symptoms; (2) patients with Class III skeletal malocclusions reported a 51% incidence of preoperative TM J pain-dysfunction symptoms; (3) patients with skeletal open-bite reported a 50% inci- dence of preoperative TMJ pain-dysfunction symp- MAY 1984 VOLUME 51 NUMBER 5

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Major msrxilfomandibular malrela+ians and temporomandibular joint pain-dysfunction

L. George Upton, D.D.S., M.S.,* Richard F. Scott, D.D.S., M.S.,** and James R, Hayward, D.D.S., M.S.*** University of Michigan, School of Dentistry and School of Medicine, Ann Arbor, M,ich.

T he distinction between dentoalveolar malocclusion and malocclusion that results from maxillomandibular skeletal discrepancies is well known, and its recognition forms the basis of the orthodontic-surgical (ortho- surgery) approach to correction of dentofacial discrep- ancies. Many publications have been concerned with the association of dental occlusion, muscles of mastica- tion, and psychologic status to temporomandibular joint (TM J) pain-dysfunction.‘-’ However, the associa- tion between major maxillomandibular malrelations and TMJ pain-dysfunction has received little atten- tion. Consequently, the effect of surgical correction of such disharmonies on patients with TMJ pain- dysfunction is not well documented.

The purpose of the present investigation was to explore this subject by obtaining data from patients with both significant maxillomandibular skeletal dis- harmonies and concomitant TM J pain-dysfunction. Two specific questions were asked:

1. Do patients with skeletal Class II, Class III, or open-bite malocclusions have a greater incidence of TMJ pain-dysfunction than Class I patients?

2. Does correction of dental-skeletal disharmonies in patients with existing TMJ symptoms result in improvement or resolution of the symptoms?

MATERIAL AND METHODS

A retrospective study of all major orthognathic surgical patients treated between July 1, 1978, and June 30, 1981, was completed. This was carried out in relation to the incidence of TMJ pain-dysfunction in both pretreatment and posttreatment phases and was accomplished by use of a questionnaire. Of the 213 patients contacted, 102 responded. The group consisted

*Profrssor. Oral and blaxillofacial Surgery, School of Dentistry; Assrxinte Professor in Surgery, School of Medicine.

**:\ssisian~ (Xinical Professor, Oral and Maxillofacial Surgery, School of Dentistry; Assistant Clinical Professor in Surgery, School of hledicine.

***Professor and former Chairman, Oral and Maxillofacial Surgery, School of Dentist-y; Professor in Surgery, School of Medicine.

686

Table I. TMJ symptoms prior to orthodontic or surgical treatment

-.~___ Present Not present

-___ Total No. % NO. w No.

Women 40 57 30 43 70 Men &? 47 17 53 32

55 53 47 47 102 - ___-..-___

of 70 women (68.6%) and 32 men (31.4%) with the following preoperative diagnoses: 46 patients with skeletal Class II malocclusions (45%); 39 patients with skeletal Class III malocclusions (38.2%); 14 patients with skeletal open-bite malocclusions (13.7%); and three patients with other forms of skeletal malocclu- sions such as asymmetry or segmental incoordination (3%). Seventy-six patients were treated by an ortho- surgery approach, and 26 patients were treated with surgery alone.

RESULTS

Of the 102 patients who completed the question- naire, 55 (53%) reported pretreatment TMJ pain- dysfunction symptoms. In the female subpopulation, 40 (57%) reported pretreatment symptoms, while 15 (47%) of the male respondents reported similar symp- toms (Table I).

The five pretreatment symptoms described included TM J pain, soreness, clicking, popping, and limited jaw opening. The distribution of the symptoms is illu- strated in Table II.

Associations between types of skeletal relationships prior to treatment and their incidence of symptomatol- ogy were: (1) patients with skeletal Class II malocclu- sions reported a 59% preoperative incidence of TMJ pain-dysfunction symptoms; (2) patients with Class III skeletal malocclusions reported a 51% incidence of preoperative TM J pain-dysfunction symptoms; (3) patients with skeletal open-bite reported a 50% inci- dence of preoperative TMJ pain-dysfunction symp-

MAY 1984 VOLUME 51 NUMBER 5

MALOCCLUSION AND TMJ PAIN-DYSFUNCTION

Table II. Frequency of TMJ pain-dysfunction symptoms prior to orthognathic surgery

Symptom

No. of patients

TMJ pain Soreness Clicking Popping

Limited opening

Women 40 17 20 21 20 20

Men lj 9 4 9 2 -z Total 55 19 26 27 22 27 Percent 34 47 49 40 49

Table III. Association between types of jaw relationships and incidence of TMJ pain-dysfunction (PD) symptoms

Class II (N = 46)

___~- TMJ PD Normal

Class III Open bite Other (N = 39) (N = 14) (N = 3)

~~ -~- TMJ TMJ TMJ PD Normal PD Normal PD Normal

Women 21 15 13 9 5 4 1 1

Men 4 3 2 lo 2 2 -!2 .-I Total 27 19 20 19 7 7 1 2 Percent 59 41 51 49 56 44 33 66

_~

toms; and (4) patients in the category termed “other” Table IV. Incidence of pretreatment TMJ reported a 33% incidence of preoperative TMJ pain- pain-dysfunction (PD) in patients with dysfunction symptoms (Table III). ortho-surgery vs. surgery alone

Seventy-six patients underwent a combination of orthodontic and surgical treatment, while 26 patients were treated by surgery alone. Of the former group, 55% reported pretreatment TM J pain-dysfunction symptoms, while in the latter group this was recorded in 50% (Table IV). Seven patients (9%) in the ortho- surgery category described an increase in TMJ pain- dysfunction during the presurgical orthodontic phase of treatment. All these patients stated that completion of treatment resulted in improvement in their symp toms.

Women Men

Total Percent

Ortho-surgery Surgery alone

TMJ TMJ PD Normal PD Normal

31 22 9 8 1_! r2 f s 42 34 13 13 55 46 50 50

Of the 55 patients who experienced pretreatment TM J pain-dysfunction symptoms, 43 (78%) stated the symptoms improved after completion of treatment for their skeletal malocclusion. In the same group, 31 of 41 patients (76%) receiving a combined ortho-surgery approach reported improvement in symptoms. Also in this group, 12 of 14 patients (86%) receiving surgery alone reported improvement in symptoms.

Of the 55 patients who experienced pretreatment TMJ pain-dysfunction symptoms, three (5%) stated that the symptoms had grown worse after completion of treatment. In this same group, two of 41 patients (5%) receiving a combined or&o-surgery approach reported an increase in symptoms, while one of 14 patients (7%) receiving surgery alone reported an increase in symp- toms.

Of the 55 patients who experienced pretreatment TM J pain-dysfunction symptoms, nine (16%) reported no change in their symptoms after treatment. In this same group, eight of 41 patients (20%) receiving an ortho-surgery approach reported no change, while one of 14 patients (7%) receiving surgery alone reported no change.

Table V summarizes the effect of treatment on the symptomatology of the ortho-surgery group and the surgery alone group.

Of the 40 women who reported pretreatment TMJ pain-dysfunction symptoms, 30 (75%) reported improvement, Seven (17.5%) reported no change, and three (7.5%) reported an increase after completion of treatment (Table V).

THE JOURNAL OF PROSTHETIC DENTISTRY 687

UPTON, SCOTT, AND HAYWARD

Table V. Comparison of effects of ortho-surgery and surgery alone on pretreatment TMJ symptoms ___--_ .-- __-.----..--

Ortho-surgery (N = 41) Surgery alone (N = 14) ---_ .-I___

Improved No change Worse Improved No change W0l-W

Women 22 6 2 8 1 1

Men 2 1 0 a 0 0 Total 31 8 2 12 1 1 Percent 75 20 5 86 7 7

___-I .----. .____.---

Table VI. Patients experiencing increased TMJ pain-dysfunction symptoms at completion of treatment

Pretreatment symptoms

NO

No

Yes

NO NO

Yes Yes

_. --___ Time

Sex Occlusion Ortho-surgery (yr) Symptom

M Class II Yes 3 Pop on wide opening F Open bite No - Decreased opening, click,

locking F Class III Yes 5 Soreness after chewing

tough food M Class III No - Popping on wide opening F Segment No - Jaw muscle pan

malalignment F Asymmetry Yes 3 Clicking of TMJ F Class III No l Not identified’

-. --.-~ *Patient lost to follo\v-up.

Of the 15 men who reported pretreatment TMJ pain-dysfunction symptoms, 13 (86.7%) reported improvement, two (13.3%) reported no change, and none reported increase in symptoms after completion of treatment (Table V).

Of the 46 patients who stated they had no pretreat- ment TMJ pain-dysfunction symptoms, four (8.5%) stated they developed symptoms after completion of treatment. Of these four patients, one had undergone combined ortho-surgery treatment and three received surgery alone. Thus, in the population of 102 patients, seven (6.9%) either developed postoperative TMJ pain-dysfunction symptoms where none had been reported preoperatively or had an increase in preoper- ative symptoms. Table VI summarizes the data on patients whose symptoms became worse or who stated they developed symptoms after treatment.

Of 102 patients, 95 (93%) reported either no change in their TM J apparatus or improvement in preexisting symptoms after completion of treatment.

DISCUSSION

The diagnosis of TM J dysfunction is based primar- ily on patients’ symptoms. It has become generally accepted that TMJ dysfunction may have a variety of

causes, and the concept of “one disease-one treatment” has largely been abandoned.’ Emphasis placed on one or more etiologic factors as opposed to others has led to some confusion in terminology. Myofasciai pain-

dysfunction (MPD) as used by Laskin3 and TMJ pain-dysfunction as used by Schwartz’ are not entirely synonymous. MPD refers to patients with (1) pain of unilateral origin, (2) muscle tenderness, (3) clicking or popping noise in the TMJ, and (4) limitation of jaw function. In addition, there must be absence of clinical, radiographic, or biochemical evidence of organic changes in the TMJ, plus a lack of tenderness in the TMJ when it is palpated via the external auditory meatus. However, Laskin3 points out that as the syndrome persists, it can lead to organic changes within the TM J so that these negative diagnostic criteria may no longer apply. The negative criteria do not pertain to TMJ pain-dysfunction. MPD by definition does not involve the TMJ itself,‘O whereas TMJ pain-dysfunc- tion is a broader term that also includes joint pain.

Green et al.” reported the most frequent symptoms in a study of 277 patients as pain (87%), clicking or other joint sounds (66%), and limitation of jaw move- ments (63%). Perry” listed the three cardinal symp- toms as joint sounds-articular crepitus, articular

688 MAY 1984 VOLUME 5’1 NUMBER 5

MALOCCLUSION AND TMJ PAIN-DYSFUNCTION

cracking; immobility of the mandible-stiffness in opening, deviation in opening; and pain-articular, muscular, ligamentous. PerryI also noted that “vertical problems related to occlusion . . . seemingly create the dysfunction pattern.” He has noted a predominance of this disturbance in patients with Angle Class II, division 2, malocclusion, patients with cross-bite or tipped teeth, patients with a unilateral dentition, and patients with an excessive curve of Spee.12 In our study the three most common symptoms noted are in close agreement with those noted in previous reports.13 The frequency of recorded pain symptoms is in good agreement with the observation of Green et al.,” as is the frequency of joint sounds. Our study recorded limited opening in fewer patients with preoperative symptoms than the study by Green et al.” reported.

The overall incidence of TMJ pain-dysfunction history in this group was 53%, which coincides with at least two epidemiologic studies that show an incidence of 57%.14*15 Of this group, 57% were women and 43% were men. The ratio of women to men in our study is comparable with figures obtained in other studies.‘6z’7

These comparisons suggest that the incidence of TM J pain-dysfunction symptoms present in patients who require orthognathic surgery for correction of skeletal maxillomandibular relations is essentially the same as the incidence of those symptoms encountered in the general population. However, it should be noted that the subjective incidence of TM J pain-dysfunction in Agerberg and Carlsson’s’4 study and Helkimo’s’5 study involves an older mean population (15 to 74 and 15 to 65 years, respectively). The current study involves a younger population (15 to 39 years of age). Since some published reports indicate that the symp- toms increase with age,18 it appears that the current population studied reveals a higher incidence than the general population when evaluated for subjective symptoms alone. It should also be noted that studies including a clinical examination reveal uniformly high- er figures.18

Numerous studies have explored the relation between muscle function and the shape of the jaws in animals.‘9-24 In general, these studies have shown that a change in muscle function results in a change in skeletal morphology.

Nickerson and M$ystadz5 suggested that “a clinician should be very skeptical about the status of the TM J’s on orthognathic patients, even though the patient may not complain about his or her joints.” Van Sickels and Ivey26 described a patient with concomitant short-face syndrome and TMJ dysfunction. The short-face syn- drome is characterized by vertical maxillary deficiency,

a short square-shaped face, deep labiomental fold, well-developed masseter muscles, and often a distinct chin button.27 The authors suggest that patients who exhibit the short-face syndrome may be .predisposed to developing TM J dysfunction. Piecuch et a1.28 report a similar patient treated by splint therapy for 6 months followed by maxillary disimpaction. Rotskoff 9 describes an incidence of TMJ dysfunction symptoms of 43% in a population of 141 patients prior to orthognathic surgery. Twenty-nine percent had post- surgical symptoms.

We could not account for the four previously asymp- tomatic patients who developed postsurgical symptoms or the three patients whose symptoms became worse (Table VI), and no correlations could be found. Gline- burg et a1.30 and others have noted that intermaxillary fixation can produce significant histologic changes on articular surfaces and the articular disk. The Class II patients who undergo sagittal advancement may addi- tionally experience TM J alteration secondary to over- zealous “seating of the condyle” with resultant anterior disk displacement or adhesions. The effects of mallet and osteotome on the joint while the proximal and distal segments are being separated may also be of significance.

Certainly the three patients with preexisting symp- toms may have experienced increasing symptoms because of the normal progression of their condition.

Our conclusions support the contention that skeletal maxillomandibular disharmonies may be an additional etiologic factor in the development of TMJ pain- dysfunction. Furthermore, surgical repositioning of the maxillomandibular skeleton may lead to resolution or improvement of TM J pain-dysfunction symptoms in an unpredictable number of patients.

SUMMARY

A retrospective questionnaire survey of 102 patients who underwent orthognathic surgery for maxilloman- dibular disharmonies assessed the incidence of TMJ pain-dysfunction in both pretreatment and posttreat- ment phases. While retrospective questionnaire studies have obvious limitations, the following conclusions deserve consideration.

1. The incidence of TMJ pain-dysfunction symp- toms found in this patient population appears to be higher than the incidence of those symptoms reported in previous epidemiologic studies of general popula- tions which involved subjective symptoms alone.

2. Maxillomandibular disharmonies may be an important etiologic factor in the development of TMJ pain-dysfunction. Surgical correction of the disharmo-

THE JOURNAL OF PROSTHETIC DENTISTRY 689

ny in a significant percent of patients with maxillo- mandibular disharmonies and concomitant TM J pain- dysfunction may alleviate or improve the TMJ pain- dysfunction symptoms.

3. There is a possibility that patients may develop TM J pain-dysfunction symptoms after orthognathic surgery.

REFERENCES

I.

2.

3.

4.

5

6.

7

8.

9.

10.

I I.

12.

13.

14.

IS.

16

Costen, J. B.: Syndrome of ear and sinus symptoms dependent upon disturbed function of temporomandibular joint. Ann Otol Rhino1 Laryngol 43:55, 1934. S&w,xtz, L.: Pain associated with the temporomandibular joint. ,J Am Dent Assoc 51:394, 1955. I.askin, D M.: Etiology of the pain-dysfunction syndrome. J )Zm Dem Assoc 79:147, 1969. Bell, W. E.: Clinical diagnosis of the pain-dysfunction syn- drome. J .4m Dent Assoc 79:154, 1969. hlolin, C.: Studies in mandibular pain-dysfunction syndrome. Swed Dent ,J 66(Suppl 4), 1973. Ingervall. B., and Thilander. B.: Activity of temporal and masscter muscles in children with a lateral forced bite. Angle Orthod 45.249 1975. . _ E;gertnark-Eriksson, I.. Ingervall, B., and Carlsson, G. E.: Tandreglering som behandling av patienter med kikledsbesvsr. ‘l‘iindlaka~~rdningen 67:404, 1975. hlongini, 1:. .\natomic and clinical evaluation of the rela- tionship between the temporomandibular joint and occlusion. J PIUJS 1‘111:~ DENT 38539, 1977.

Zarb, G. .A., and Speck, J. E.: The treatment of mandibular dyslunclirm In Zarb, G. .I., and Carlsson, G. E., editors: Temporomandibular Joint-Function and Dysfunction. C:openhagen, 19?9, Munksgaard. Weinberg, I,. A.: Role of condylar posirion in TMJ dysfunc- tion-pain syndrome. J PROSTHET DENT 41:636, 1979.

C;reen, C. S., Lerman, M. D., Sutcher, H. D., and Laskin, 1). hi.. Thr TMJ pain-dysfunction syndrome: Heterogeneity of the patient population. J Am Dent Assoc 79:1169, 1969. Perry, H. ‘I‘.: Relation of the occlusion to temporomandibular joint dysfunction: The orthodontic viewpoint. J Am Dent Assoc 79:13, 1969 Zarb, (; A. and Speck, J. E.: The treatment of temporoman- dibular joint dysfunction: .4 retrospective study. J PR~STHET

DENT 39:420, 1977.

i\gerberg, G., and Car&on, G. D.: Functional disorders of the masticatory system. Symptoms in relation to impaired mobility of the mandible as .judged from investigation by questionnaire. Acta Odontol Stand 31:335, 1973. Helkimo, M.: Studies on function and dysfunction of the masticatory system. Sven Tgndlak Tidskr 67:101, 1974. Agrrberg, G.. and osterberg, T.: Maximal mandibular move-

17.

18.

19.

20.

21.

22.

2.3.

34.

25.

26.

2:.

3

39.

30

UPTON, SCOT-I, AND HAYWARD

merits and symptoms of mandibular dysfunction in 7i)-xear-old men and women. Swed Dent J 67: I. 1974. Dibbets, J.: Juvenile Temporomandibular ]omt Dysfunction and Cranofxial Growth. Dissertation, Rljkcunivemiirit ‘I’e Groningen. 1977. Helkimo, M.: Epidemiological aurvcy of tlbsfunrtion of the masticatory Isystem. III Zarb, G. .\ , ant: C;rrisson, G. E., editors: Temporomandibular Joint ---Functicrn .md Dvsfunc- tion. St. LOWS, 1979, The C. V. Mosb! (:I). p I”i. Wart. D. G.. and Williams, C ii. ;21.: ‘l’l~r effects of the physical consistency of food on the growth .md dr\elopment of the mandible and maxilla of the rat. \m ,J ( frchodont 37:X95. I 9 -3 1 Barber. (;. C;., Green, L. J., and (:ox. (, ,I : Effecta of the physical consistency of diet on the cond\lar r:ruwth of ihe rat mandible. J Dent Res 42:848. 1963 blcPhee, C. I~., and Kronman, J. H.: Cephalometric studv of craniofacial development in rabbit, wnh imp:jired masticator) function. J Dent Res 48~1268, 1969. Horowirz, S. IL., and Shapiro, H. H: hltrdit;c,ttion of qkull and jaw architecture following removal of the rnahsrter muscle in ihe rat. :\m .J Phys .Anthropol 13:X I, 19% Simpson. C D.: Experimental mandibular dysplasia. r2nglr Orthod 36:X+ 196(>. Nanda, S. K.. Xterow. W. L%‘., and Sassoumi \‘.: Reposirioning of the massetcr muscle and its rflcct on ik&ral form and wuuure. An$e Orthod 37:304, 1067. Nickerson. J. M;.: rind MBystad, A.. Otrservau~)ns on Individu- al\ with radiographic hilateral condvlar rrnu)drlin~g. ,J (Zrani- omandib Pratt 1:21. 1982. Van Sickels, J. E.. and Ivey, D. W.. Myofacz~l pain dysfunt- tion: A manifestation of the short-furc syndrome. J PROSTHET

DEW 42:547, 1979. Bell, I\‘. H.. (iorrecrion of the short-face syndrome- L’ertical maxillary dellciency: A prrliminarv rcpor; J Oral SW% 35: I IO. 1977.

Piecuch, ,J., ‘l‘ideman, H, and DcKoomen H.. Short-face syndrome: Treatment of myofacial pain dysfurtrtion by maxil- lar) disimpact~on. Oral Surg 49: 1 12. 19)iO. Rotskoll, K. S.: Evaluation of temp~~ro~nantiiOuI,~r ,joint dys- func~on. Presented at AAO-AAOhlS 1983 (:iinicsl (Ioi~gress on Suryical-Orthodontic Challenges \ .\latu* inq Persptactivr. Januar! 29-X. 1983. New Orleans. Glineburg. R. W., Laskin, D. M.. and Blatlstein. D. 1.. The rl‘l‘ects of ,mmnbilization on the primate ternporomandibular joint: .I histologic and histochemical stud). ,J Oral Maxillofac Surg 41:3, 1982.

690 MAY 1984 VOLLJME 51 NUMBER 5