European Journal of Orthodontics 13 (1991) 27-34 © 1991 European Orthodontic Society

Comparison of 'normal' TMJ-function in

Class I, II, and III individuals
Bernd Zimmer, Andreas Jager, and Dietmar Kubein-Meesenburg
Department of Orthodontics, Gottingen, West-Germany

SUMMARY Fifty-seven non-orthodontically treated young adults, judged as either clinically

healthy or with only mild symptoms of TMJ-dysfunction, were divided into groups according to
their sagittal molar relationship (Class I-, Class II-, and Class Ill-group). All underwent a
standardized clinical and axiographic examination with an axiographic recording device (SAS-
SYSTEM).
The comparison of the lengths of the axiographical protrusive curves showed significantly
highervaluesintheClassll group than in the Class I (/3<0.01) and in the Class I group than in the
Class III group (P<0.001). Analogous differences could be found in clinical protrusive
measurements at the incisal point and in lateral excursions. It was concluded that the protrusive
condylar movement capacity coincides with the dental sagittal relationship.
In opening, significant differences were seen axiographically (Class I v. Class III: P<0.001;

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Class II v. Class III: P<0.01), but not clinically. Since axiographic measurements show only
condyle translation, but not rotation in contrast to measurements at the incisal point, it can be
concluded that the differences in opening are also translatory and not rotational.
Measurements of the average change of curvature of axiographic tracings showed significantly
less curved protrusive tracings in Class III than in Class I (P<0.001) and Class II individuals
(P<0.01), supporting the concept that in the Class 111 group condyle movement is restricted to the
straight posterior slope of the tubercle.
Moreover, the inclinations of the pro- and mediotrusive tracings were significantly flatter in the
Class III group than in the Class I and Class II groups, demonstrating differences in the inclination
of the functional protrusive and mediotrusive paths between the groups.

Introduction that correlations exist between the range of

The mechanism of craniomandibular function is
thought to be based on the same principle in all
humans (Steinhardt, 1959; Lindblom, 1960).
However, a number of functional parameters,
such as maximum mouth opening capacity
(Rieder, 1978), chewing patterns (Ahlgren, 1967;
Proschel, 1987), border movements (Schrems,
1977) and maximum bite force (Ingervall and
Thilander, 1974; Ingervall et al., 1979; Johnston
et al., 1984) show a broad range of differing
values. These differences are considered to be
signs of either a physiological or pathological
inter-individual variation. Some studies indicate
functional differences between groups of patients
with different skeletal and occlusal morphologi-
cal patterns (Moyers, 1961; Ahlgren et al., 1973;
Graber, 1973). Ingervall (1970, 1971) showed
mandibular movement and certain parameters of
facial morphology, overbite, and overjet in
groups of children and young women.
Frequently studies were aimed at answering
the question of whether a specific morphologic
pattern represents a disposition towards TMJ-
diseases (Janson, 1982; Egermark-Eriksson et
al., 1983; Mohlin and Thilander, 1984; Riolo et
al., 1987). Other studies showed that skeletal and
dental relationships are associated with typical
physiological functional parameters (Ringquist,
1973; O'Ryan and Epker, 1984; Bolt. and
Orchardson, 1986; Zimmer et al., 1989). As an
extension of these findings, the aim of this study
was to look for physiological differences in
mandibular mobility and corresponding func-
tional parameters between groups of patients
with a Class I, II, or III relationship.
•2S
Subjects and methods
Fifty-seven non-orthodontically treated young-
adults, who showed Helkimo anamnestic and
dysfunction indexes (1974) of 0 (no symptoms)
or 1 (mild symptoms) were divided into three
groups according to their dental relationship.
The Class I-group comprised 18 individuals (11
women, 7 men, mean age 24.6 years ±4.8) with a
Class I molar and canine relationship; and an
overbite and overjet of 2-4 mm. The Class II
group consisted of 20 Class II division 1 patients
with a full Class II molar relationship (13
women, 7 men, mean age 23.1 years ±5.0) with
an overbite of — 2 to 8 mm and an overjet of 6-14
mm, respectively. The Class III group consisted
of 19 patients with a full Class III molar
relationship (11 women, 8 men, 25.3 years ± 7.8)
an overbite of — 3 to 4 mm and an overjet of — 8
to —2 mm. In addition, the ANB-angle and the
ML/NL-angle were calculated for each subject.
Statistical testing showed significant differences
between all groups for the ANB-angle, but not
for the ML/NL-angle. All patients underwent a
standardized clinical examination consisting of
three measurements of maximum opening (inter-
incisal distance corrected by adding the amount
of vertical overlap), maximum protrusive and
Figure 1 Axiographic registration device connected to the patient. A modified SAM upper face-bow
bears the foil to measure the change in resistance caused by the translocation of a scanner which is
connected to an ALMORE-lowcr face-bow.
B. ZIMMER, A. JAGER AND D. KUBEIN-MEESENBURG
maximum lateral movement with teeth in con-
tact. All three started in CO and were measured
between the incisal points by use of a Dentaurum
gauge (No. 042-751). Movements were repeated
three times with the longest one used for statisti-
cal evaluation. The same movements were mea-
sured a second time close to the lateral pole of the
condyle with an electronic-axiographic device
(SAS-SYSTEM, Munich; Meyer, 1982, Fig. 1)
which shows translation, but not rotation of the
hinge-axis points. After the individual hinge-axis
had been determined at a 10-fold magnification
the above-mentioned movements were moni-
tored in the sagittal-vertical plane. Every move-
ment was performed three times in the same
manner as the measurements at the incisal point.
Thus, nine tracings representing the movement
of the hinge-axis point during three mandibular
movements were monitored on an x-y plotter
(PHILLIPS 8134) again magnified 10-fold. The
longest curve of each movement was digitized
(Houston Instruments Digitizer). The length (L),
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initial inclination (/j) and average change of
curvature (C) were calculated. The average
change of curvature (C) was defined as the
difference between initial and terminal inclina-
tion (/, — /,) divided by the length of the curve (L).
In this report, only the measurements of the
VARIATIONS IN TMJ-FUNCTION 29

right joints were tested. Statistical evaluation was Results

performed by use of the Wilcoxon-test in order to
detect differences between the three groups.
Although a normal-distribution could not be
shown, covariance-analysis was applied for de-
scriptive reasons to detect effects of the skeletal
vertical pattern. Correlations of either overjet or
ANB-angle with the amount of clinical protru-
sion and length of axiographic protrusive curva-
ture were examined by use of linear correlation
analysis.
Clinical measurements showed that Class II
patients were able to move their mandibles
significantly further forward and sideward than
Class III patients (Tables 1 and 2). Class II
patients could also protrude further than Class I
patients (Table 1). In protrusion the median of
the Class II group was 12 mm, the highest level,
followed by 10 mm in the Class I group, and 8
mm in the Class III group. The greatest differ-

Table 1 Differences between the Class I, II, and III group in

clinical protrusion, length, initial inclination, and average
change of curvature of the axiographic protrusive curve.
Twenty-fifth percentile—median value—75th percentile for each
group and actual probabilities of errors between groups are
indicated.

Length
Protrusion Clinical axiograph. Inclination Curvature

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I 7.5-10-11 9-9.5-10.3 50-59-65.5 3.4-4.2-4.7
V. *• n.s. *
II 10-12-15 11-12.5-15 49-61-66.8 2.6-3.1-3.9
I 7.5-10-11 9-9.5-10.3 50-59-65.5 3.4-4.2-4.7
n.s. +••
V. *••
Ill 6-7-8.5 5-6-8 36-47-62 0-0.1-2.3
II 10-12-15 11-12.5-15 49-61-66.8 2.6-3.1-3.9
V. ••• •*
Ill 6-7-8.5 5-6-8 36-47-62 0-0.1-2.3

•/"<0.05; •*/»<0.01; "»/ ) <0.001; n.s., not significant.

Table 2 Differences between the Class I, II, and III group in

clinical mediotrusion, length, initial inclination, and average change
of curvature of the axiographic mediotrusive curve. Twenty-fifth
percentile—median value—75th percentile for each group and
actual probabilities of errors between groups are indicated.

Length
Mediotrusion Clinical axiograph. Inclination Curvature
I 8.5-10-12 13.8-15-18 47-52-65.8 2-2.5-3.1
V. n.s. n.s. n.s. n.s.
II 7-10-13 13-16.5-21 53-61.5-66 1.8-2.4-3.2
1 8.5-10-12 13.8-15-18 47-52-65.8 2-2.5-3.1
V. n.s. • ••
Ill 6.3-7.5-10 7-9-11 33-47-56 0-0.3-1.6
II 7-10-13 13-16.5-21 53-61.5-66 1.8-2.4-3.2
V. * **•
Ill 6.3-7.5-10 7-9-11 33-47-56 0-0.3-1.6

*P<0.05; **P<Q.0l; ***P<0.001; n.s. not significant.

30 B. ZIMMER, A. JAGER AND D. KUBEIN-MEESENBURG

ence was detected between the Class II and the
Class III group, since no overlap of the 50th
percentile of the Class II and the Class III group
occurred (Table 1). No significant differences in
maximum mouth opening capacity were detected
between the groups (Table 3).
Axiographically, it was found that Class I and
Class II patients had significantly longer, steeper,
and more curved tracings in protrusion and
mediotrusion than Class III patients (Tables 1
and 2). The median values for length of axio-
graphic protrusive curves were 12 mm in the
Class II group, 9.5 mm in the Class I group and
only 6 mm in the Class III group (Figs 2 and 3).
Fiftieth percentiles between all groups showed
missing overlaps, demonstrating clear group
differences (Table 1).
The comparison of initial inclination of axio-
graphic protrusive curves showed median values
of 61 degrees for the Class II group, 58 degrees
for the Class I group, and 47 degrees for the Class
curved tracings in Class I and Class II patients
than in Class III patients and to almost straight
protrusive tracings in Class III patients. While
the 50th percentile of the Class III group was
clearly separated from those of the Class I and
Class II group, basically indicating a high reliabi-
lity of the group differences, widely-spread mini-
mum and maximum values in all groups showed
that widely variable values within each group can
also be expected. Statistical values for the
reported differences are demonstrated in Table 1.
Similar differences were found in mediotrusion
(Table 2).
As to group differences in maximal opening,
significant effects could be detected only in the
length of the axiographic curvature (Table 3). As
with the pro- and mediotrusion, the opening-
tracings in Class III patients were shorter than in
Class I and in Class II patients.
Comparisons between different types of move-
ment indicated that significant differences were

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III group (Fig. 4). Significant differences were
present between Class I and Class III, and
between Class II and Class III, but not between
Class I and Class II (Table 1). Similar statistical
findings are demonstrated for mediotrusion in
Table 2.
For protrusion, the median values of the
average change of curvature were 4.2 degrees/
mm in the Class I group, 3.1 degrees/mm in the
Class II group and 0.1 degree/mm in the Class III
group (Fig. 5). These results point to more
most frequent and distinct in protrusion (Table
1), followed by mediotrusion (Table 2). Effects in
opening were rare (Table 3). Comparing the four
tested parameters to each other, the most pro-
nounced effects could be detected in the axio-
graphic length of tracings. However, differences
between the Class I and the Class III group, and
between the Class II and the Class III group were
more obvious than between the Class I and the
Class II group.
In order to obtain an idea of how much the

Table 3 Differences between the Class I, II, and IN group in

clinical opening, length, initial inclination, and average change of
curvature of the axiographic opening curve. Twenty-fifth percen-
tile—median value—75th percentile for each group and actual
probabilities of errors between groups are indicated.

Length
Opening Clinical axiograph. Inclination Curvature

I 43.8-48-53 14-15.5-18 47.5-62.5-68 2.2-3.8-5.8

V. n.s. n.s. n.s. n.s.
II 48-51-55 14-16-16 47.3-63-68.5 1.8-3.6-4.9
I 43.8-48-53 14-15.5-18 47.5-62.5-68 2.2-3.8-5.8
V. n.s. n.s. n.s.
Ill 43-49-55 6-11-16 40-56-62 0.2-2.9-5.2
II 48-51-55 14-16-16 47.3-63-68.5 1.8-3.6-4.9
V. n.s. *• n.s. n.s.
in 43-49-55 6-11-16 40-56-62 0.2-2.9-5.2

*** P^0.00\; "P^O.01; */ > i0.05; n.s. not significant.

VARIATIONS IN TMJ-FUNCTION 31

[ml
26'
U
ir
n
18
16
14
17
IB
I
6
Class I Class II Class III
4
7 Figure 5 One typical protrusive curve for each group.
Median values in average change of curvature are presented.
Class I Class II Class III C = average change of curvature, I, = initial inclination,
I, = terminal inclination, L = length.
Figure 2 Distribution of values for the axiographical length
of the protrusive curve in the Class I, II, and III g r o u p
|mm]
20-

18-
Srmbol • b Cl*m I
16- Symbol £ h am**
14-

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5 12-
A A

C
6-
4-

-8 -8 -4 -2 0 24 6 8 101214
OVEBJET |mm|

Class I Class II Class III Figure 6 Correlation of the overjet with the amount of
maximum clinical protrusion in the Qass II and the Class III
Figure 3 One typical protrusive curve for each group. group (n = 39, seven observations hidden).
Median values in length are presented. L = length.

20-

Oiinbnl • Is ( t a i l
16- Symbol A it CbMl

14-

-XI -10 - 8 -6 -4 -2 0 2 4 6 8 10
Class I Class I I Class I I I AN* I'l

Figure 4 One typical protrusive curve for each group. Figure 7 Correlation of the ANB-angle with the amount of
Median values in initial inclination are presented. I| = initial maximum clinical protrusion in the Qass II and the Qass III
inclination. group (n = 39, five observations hidden).
32 B. ZIMMER, A. JAGER AND D. KUBEIN-MEESENBURG
vertical skeletal pattern influenced the four tested
parameters, a covariance-analysis was per-
formed. The ML/NL-angle was tested as an
influencing factor for the reported group differ-
ences. However, no evidence was obtained to
show that the ML/NL-angle might influence any
of the tested parameters significantly.
In order to determine whether skeletal mor-
phology or the occlusal relationship is related to
the clinical protrusion measurements or to axio-
graphic length, a linear correlation analysis was
performed. The distribution of values is graphi-
cally presented in Figs 6 and 7. Linear correlation
coefficients of r = 0.19 for the Class II group and
of r = 0.42 for the Class III group could be
detected between maximum clinical protrusion
and the overjet (Fig. 6). In Fig. 7 a widely
analogous distribution to Fig. 6 exists, demon-
strating also only a moderate correlation
between maximum clinical protrusion and the
ANB-angle (Class II: r = 0.39; Class III: r = 0.52).
Although the correlation coefficients in both
groups were slightly higher for the ANB-angle
than for the overjet, this difference was insignifi-
cant and did not give strong evidence whether
specific functional findings are mainly correlated
to skeletal or dental parameters.
Discussion
In this study axiography was used instead of an
X-ray method (Ingervall, 1972) to obtain non-
invasive measurements close to the lateral pole of
the condyle. For their interpretation one must
remember that axiographic tracings actually
represent the movement of an individual hinge-
axis point, and do not coincide with the move-
ment of a specific anatomical point on or within
the condyle. However, if the registrations are
made at the hinge-axis points close to the lateral
poles of the condyles (as done in this investiga-
tion), a close relationship between the writing-
points of the registering instrument and relevant
anatomical structures should exist. Therefore,
valid assessments of actual condylar movement
can be made, thus, avoiding severe projection
errors from the opposite temporomandibular
joint. One special advantage of axiography is
that it monitors only translation and not rotation
of the hinge-axis points. This, of course, requires
a precise determination of the hinge-axis points
before beginning the measurements. Because
incisal measurements actually represent the
result of condyle translation and rotation, they
do not necessarily coincide with axiographic
measurements. In comparing the two measure-
ments, conclusions can be drawn about the
degree of condyle translation and rotation in
different movements.
In accordance with former clinical, roentgeno-
logical, and electromyographical investigations,
and bite force measurements our findings show
that differences in skeletal morphology and in
dentition may coincide with typical functional
findings. Because all individuals participating in
our study could be judged as either clinically
healthy or showed only mild symptoms of dys-
function, the detected differences cannot be
interpreted as signs of pathology, but rather
seem to represent a spectrum of normalcy.
Our clinical measurements and axiographic
tracings show that in pro- and mediotrusion a
strong tendency exists for the mandibular move-
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ment capacity in the Class II group to be higher
than in the Class I group and for the Class I
group to be higher than in the Class III group.
Most obvious, however, were differences
between the Class II and the Class III group. This
is in accordance with a study by Ingervall (1970),
who found correlations between mandibular
movement capacity and the sagittal skeletal
relationship in children. However, no correla-
tions were found in adults (Ingervall, 1971). The
contrast to our results might be explained by the
fact that in Ingervall's study a randomized
sample of patients was used, which might not
have included Class III patients.
The fact that the median value of Class III
individuals in protrusion is considerably smaller
than that of Class II individuals is of clinical
importance, because restricted mandibular
movements are often considered diagnostic of an
articular or muscular limitation, commonly
thought to be pathological. On the other hand,
an ability to carry out large mandibular move-
ments has often been erroneously denoted as
'hypermobility' or chronic subluxation (Nevak-
ari, 1960; Agerberg, 1974; Rieder, 1978). How-
ever, this mobility seems to be a 'normal' finding
in many clinically healthy Class II patients.
It was striking that significant differences in
length of clinical and axiographical protrusion
were more frequent and distinct than in opening.
In this respect it is of importance to consider that
protrusion is mainly caused by a bodily trans-
VARIATIONS IN TMJ-FUNCTION
lation of the condyles along the posterior slope of
the eminentia articularis (Ingervall, 1972) while
opening is a combined rotational-translatory
condyle movement (Posselt, 1952, 1957). Con-
dyle rotation, however, is not recorded by the
SAS-system. This means that the reported differ-
ences are actually differences mainly in the
translatory (protrusive) capacity between differ-
ent groups of patients.
This assumption is supported by the finding
that only the axiographic measurements, which
show translation of the hinge-axis point, but not
rotation, revealed differences in opening. Thus,
an enhanced rotational capacity may compen-
sate for the protrusive deficiency in Class III
patients compared to Class II patients. Alterna-
tively, geometrical effects such as different
lengths of the mandibular rami on mouth open-
ing (Ingervall, 1970, 1971) must be taken into
account in order to explain the complex relation-
ships in mouth-opening (Epker and O'Ryan,
1982; Kubein-Meesenburg et ai, 1988).
Although an extensive geometrical analysis,
including measurements of mandibular length,
intercondylar distance, and vertical incisor
movement, is necessary in order to explain the
differences in movement capacity between axio-
graphic and clinical mediotrusive measurements,
the results of the latter basically support the
assumption of group-differences in protrusive
capacity.
As Lundberg (1963) found, the translation of
the condyle follows the contour of the tubercle.
Accordingly, a difference in the steepness of the
functional protrusive path might also point to a
difference in the steepness of the posterior slope
of the eminentia articularis, which according to
our findings seems to be flatter in Class Ill-
individuals than in Class I and Class II indi-
viduals.
Our finding that Class III tracings were less
curved than Class I and Class II tracings is
similar to data presented by Schrems (1977) and
Ott (1982). Surprisingly, the typical change of
curvature per millimeter in the Class III group
was close to zero for pro- and mediotrusion,
indicated by almost straight tracings. Because
the same observation could be made in the initial
part of Class I and Class II tracings, it can be
hypothesized that in humans with a Class III
morphology, the protrusive and mediotrusive
33
condylar movement chiefly takes place at the
straight posterior part of the eminentia articular-
is lying in the sagittal plane. On the other hand,
condyles of Class I and Class II patients seem to
advance more anteriorly towards the severely
curved 'highest point' of the eminentia articular-
is, as was the case on opening in all humans
according to Ingervall in 1972.
In order to find the fundamental cause for the
reported differences, it is of interest to note
parameters to which specific functional findings
are primarily correlated. Both covariance analy-
sis and the fact that significant functional differ-
ences were present between groups of patients
that did not significantly differ in their vertical
morphologic pattern, indicated that vertical
morphology is not a major factor. This is in
contrast to findings by Ingervall (1970, 1971)
who demonstrated significant correlations for
the length of mandibular ramus and mandibular
movements. Again, differences in sample selec-
tion might explain these variations. According to
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our findings, the sagittal relationship seems to
exert a much greater influence. However, it still
could not be decided whether the reported
findings are primarily correlated to the sagittal
dental (Angle classification) or skeletal relation-
ship (ANB-angle), because the groups were
significantly different in both respects. The
attempt to gain additional information by apply-
ing linear correlation analysis revealed that the
ANB-angle was only slightly more correlated to
clinical protrusive capacity than the overjet. This
result indicates that it is neither a single dental
parameter such as overjet nor a skeletal one such
as the ANB-angle that is correlated to or even
responsible for the typical functional findings.
More probably, an unknown number of factors
may modify TMJ-protrusive capacity. Several
causes must be examined in order to find possible
explanations (differences in TMJ morphology, in
muscle length and activation, ligamentary limi-
tations, respiratory variations and their effect on
head posture, etc.). Possibly, the reported find-
ings are related to heredity, being connected with
a specific anomaly or possibly acquired by an
unconscious training-effect, aimed to force the
prominent mandible backwards or to hold the
underdeveloped mandible forward. A multivar-
iate approach in a future study should provide
more information on this question.
34
Address for correspondence
Dr Bernd Zimmer
Zahnarzt fur Kieferorthopadie
TeichstraBe 24
D-3500 Kassel
West Germany
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