253 J INDIAN SOC PEDOD PREVENT DENT | Oct - Dec 2009 | Issue 4 | Vol 27 |

CASE REPORT
Management of temporomandibular disorder
associated with bruxism
Bedi S, Sharma A
Department of Pedodontics, Seema Dental College and
Hospital, Rishikesh - 249 203, Uttarakhand, India.
Correspondence:
Dr. Sumit Bedi, Senior Lecturer, Department of Pedodontics,
Seema Dental College and Hospital, Rishikesh - 249 203,
Uttarakhand, India. E-mail: sumitbedi2007@gmail.com
Abstract
Bruxism is the non-functional clenching or grinding of the
teeth that may occur during sleep or, less commonly in
the daytime in 5-20%of adults and about 30%of 56 year
old children. Although research on bruxism is extensive, its
etiology remains debatable. There is some literature to suggest
that bruxism is correlated with temporomandibular disorders
(TMDs) and malocclusion. The aim of this article is to present
the course of this condition in a case of bruxism coupled with
TMD with special emphasis on the importance of accurate
diagnosis of maxillofacial pain. We also report an association
between supernumerary teeth and TMDs that has not been
reported earlier in the literature.
Key words
Bruxism, supernumerary teeth, temporomandibular disorder
DOI: ********** PMID: ***********
Introduction
The diagnosis and treatment of bruxism and associated
temporomandibular disorders (TMDs) in children and
young adults has received increased attention in the past
20 years. The most prevalent clinical signs of TMD are
temporomandibular joint (TMJ) sounds, limitation of
mandibular movements, TMJ and muscle tenderness,
headache, TMJ sounds and bruxism. The prevalence
of TMD in children varies widely in the literature,
from 16% to 90% in children. The etiology of TMD is
considered to be multifactorial and is still considered
controversial. Possible causal factors include different
structural parameters, psychosocial variables, acute
trauma, occlusal interferences, stress and functional
mandibular overload variables (e.g., parafunctional
habits, grinding or bruxism, etc.).
[1]
The term bruxism is defined as an involuntary rhythmic
or spasmodic non-functional gnashing, grinding or
clenching of teeth. Reported prevalence for bruxism
in children ranges from 5% to 100%. Various theories
regarding its etiology fall into the following categories:
occlusion related and psychological and originating
within the central nervous system.
[2]
Myofacial pain and muscular hypertrophy, TMJ
structural damage and non-restorative sleep are serious
consequences of bruxism. Trauma to dentition and
supporting tissues include thermal hypersensitivity,
tooth hypermobility, injury to the periodontal ligament
and periodontium, etc.
[2,3]
The aim of this article
is to present the course of the condition in a child
with bruxism associated with TMD attributable to
supernumerary teeth and malocclusion.
Case Report
History
A 7 year old boy was brought to the Department of
Pediatric and Preventive Dentistry by his parents
with the chief complaint of pain in the lower left back
tooth region and history of grinding sounds during
sleep often heard by his parents since 4 years of age.
Parents further revealed that the child suffered from
early morning pain in the right ear region for the last
3 weeks and was being treated for it by his pediatrician
with analgesics but without much success. His medical
history was uneventful and, during consultation, the
patient was very pleasant and interactive.
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254 J INDIAN SOC PEDOD PREVENT DENT | Oct - Dec 2009 | Issue 4 | Vol 27 |
Clinical examination
Intraoral clinical examination showed that two
supernumerary teeth (mesiodentes) were observed on
the ridge causing abnormal spacing and premature
contact interfering with occlusion [Figure 1]. Further
examination revealed numerous carious lesions in the
primary dentition. Pronounced attrition was observed
in most of the primary teeth. Neither mouth-opening
limitation or deviation nor clicking was detected during
the examination of the TMJ.
Radiographic examination
Radiographic examination confirmed pronounced wear
on primary teeth and the presence of two well-formed
mesiodentes [Figure 2] between the upper central
incisors.
Course of condition
The following four stage treatment plan was developed:
1. Surgery: Surgical extraction of the supernumerary
and the grossly decayed teeth
2. Restorative treatment: Pulp therapy with full-
coverage stainless steel crowns over the remaining
primary teeth
3. Orthodontic correction [Figure 3]: Treatment
for malocclusion, i.e. protruded upper incisors and
midline diastema (spacing)
4. Referral for psychological evaluation: Followup
visits were scheduled every second month and
the patient was followed-up for 9 months in order
to verify tooth wear and monitor eruption of
permanent teeth. Psychological evaluation by the
specialist showed the child as normal. Two weeks
after the surgical and restorative phase, the patient
reported that the morning right side TMJ area
pain had stopped completely and 7 months post-
operatively the parents reported a reduction of sleep
grinding sounds in their child.
Discussion
Bruxism is believed, by most researchers, to be one of
the leading causes of TMD. Besides bruxism, TMDs
may also be caused by malocclusion, like a premature
contact or due to supernumerary teeth as in the present
case. Sonnesen et al.
[4]
concluded in their study that
errors of tooth formation in the form of agenesis
or peg-shaped lateral teeth showed a significant
association with signs and symptoms of TMD. But, in
the present case, the presence of supernumerary teeth
was related to symptoms of TMD and this association
has not been reported earlier in the literature. Ramjford
et al.
[5]
suggested that occlusal abnormalities that
prevent stable occlusion of the mandible may be a
cause of bruxism and the mechanism is believed to be
an alteration of definite afferent impulses originating
in the periodontium or a lower threshold of initiation.
Therefore, surgical extraction of supernumerary teeth
was indicated to correct the malocclusion in the present
case. This case report highlights the presentation of a
case of bruxism with TMJ symptoms that was found
to be related to supernumerary teeth and malocclusion.
Figure 1: Two supernumerary teeth (mesiodentes) between the upper
central incisors
Figure 2: Intra oral periapical radiograph illustrating the mesiodentes
between maxillary central incisors
Figure 3: Orthodontic correction for closure of space after extraction
of mesiodentes
Bedi, et al.: Management of temporomandibular disorder
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255 J INDIAN SOC PEDOD PREVENT DENT | Oct - Dec 2009 | Issue 4 | Vol 27 |
This was further corroborated as the symptoms
resolved significantly after the surgical extraction
of the supernumerary teeth and with orthodontic
treatment for malocclusion.
What this case report adds
This case report highlights the presentation of a case
of bruxism with TMJ symptoms that were found to
be related to supernumerary teeth and malocclusion.
The above-mentioned association has not been
reported earlier in the literature.
The importance of multidisciplinary treatment
is highlighted taking into consideration the
multifactorial etiology of bruxism and TMDs.
Why this paper is important to pediatric
dentists
Diagnosis of TMDs is particularly challenging for
the pediatric dentist. This paper emphasizes on the
work-up necessary for evaluation of each case of
bruxism or TMD.
References
1. Barbosa Tde S, Miyakoda LS, Pocztaruk Rde L, Rocha CP,
Gavio MB. Temporomandibular disorders and bruxism in
childhood and adolescence: Review of the literature. Int J Pediatr
Otorhinolaryngol 2008;72:299-314.
2. Nissani M. A bibliographical survey of bruxism with special
emphasis on non traditional treatment modalities. J Oral Sci
2001;43:73-83.
3. Okeson JP. Management of temporomandibular disorders and
occlusion.4th ed. St.Louis: Mosby, Inc.; 1998. p. 166-72.
4. Sonnesen L, Bakke M, Solow B. Malocclusion traits and
symptoms and signs of temporomandibular disorders in children
with severe malocclusion. Eur J Orthod 1998;20:543-59.
5. Cash RC. Bruxism in children: Review of the literature. J Pedod
1988;12:107-27.
Bedi, et al.: Management of temporomandibular disorder
Source of Support: Nil, Conict of Interest: Nil
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