Etiology of Temporomandibular Disorders

Charles S. Greene

This article discusses the subject of causation (etiology) as it has been ap-
plied to the field of temporomandibular disorders (TMD). These disorders
have been the focus of considerable disagreement about what constitutes
proper diagnosis and treatment, and it is clear that the main basis for these
controversies has been conflicting views about the etiology of the various
disorders. Many earlier theories emphasized dental morphological factors of
malocclusion, occlusal dysharmony, and bad mandibular alignment as being
primarily responsible for the development of TMD symptoms. Certain ver-
sions of these dental/skeletal concepts have long been a part of the belief
system of the orthodontic specialty, leading to some special orthodontic
protocols for managing TM disorders. Today, it is generally agreed that the
etiology of TM disorders includes a multifactorial combination of physical
and psychosocial factors, with some of them being either poorly understood
or difficult to assess. In most cases, there are no special occlusa[ or orth-
odontic factors to be considered, and therefore occlusion-changing proce-
dures are not generally required for successful treatment. This means that
contemporary orthodontists must face the same challenge as all their other
dental colleagues: to learn about modern concepts of diagnosis and treat-
ment for all types of orofacial pain patients, and then to use currently rec-
ommended protocols for pain management and musculoskeletal therapy for
those patients who have temporomandibular disorders. (Semin Orthod
1995; 1:222-228.)
Copyright ~) 1995 by W.B. Saunders Company

m etiology o f t e m p o r o m a n d i b u l a r (TM) occur. 1 This obvious truism (:an hardly be dis-

T tisorders is a c o m p l e x subject at best, but it
m u s t be discussed to f u r t h e r o u r u n d e r s t a n d -
ing o f these p r o b l e m s . A h h o u g h the field is
only 60 years old, we already have observed a
n u m b e r o f m a j o r and m i n o r shifts in ttfinking
a b o u t this subject. As m i g h t be expected, these
conceptual shifts have had an e n o r m o u s im-
pact on the t r e a t m e n t o f patients, while also
being a source o f significant controversy a m o n g
clinicians. Before p r o c e e d i n g with this discus-
sion o f past a n d p r e s e n t o r t h o d o n t i c concepts
o f T M D etiology, it is first necessary to con-
sider some general issues in the study o f etio-
logic relationships.
T h e key to p r o p e r t r e a t m e n t of any disor-
der is an u n d e r s t a n d i n g o f what caused it to
From the TMD Clinic, Northwestern University Dental
School, Department of Orthodontics.
Address corresponde'nce to Charles S. Greene, DDS, 4709
Golf Road, Suite I005, Shokie, IL 60076.
Copyright © 1995 by W.B. Saunders Company
1073-8746/95/0104-000455.00/0
puted, hut in the real world we have to deter-
mine when it can or cannot be applied to the
p r o b l e m s o f each patient. T h e r e are m a n y
medk:al conditions that are poorly u n d e r s t o o d
in terms of etiology; yet, clinicians can a n d do
treat t h e m at some level below the ideal one o f
fully u n d e r s t a n d i n g the cause. In addition,
there are some conditions in which the etiology
may be k n o w n but u n c h a n g e a b l e . For e x a m -
pie, t r a u m a often is a clear etiologic factor in
specific injury cases, but it c a n n o t simply be
undone. I n ot her situations, the etiology seems
t<) be muhifactorial, but these types o f disor-
ders generally are characterized by disagree-
m e n t between e x p e r t s as to what weight each
f a c t o r s h o u l d be given. 2 I n d e e d , the t e r m
"multifactorial" often seems to be m e r e l y an
intellectual c o v e r - u p for the t e r m "idiopathic"
(etiology unknown).
Discussions a b o u t e t i o l o g y h a v e b e c o m e
complicated in recent years by the i n t r o d u c t i o n
o f new terminologies, often b a s e d on statistical

7_22 Seminars in Orthodontics, Vol 1, No 4 (December), 1995.'pp 222-228

 Charles S. Greene
concepts. Although it is beyond the scope of
this article to discuss all of these, many readers
will recognize the most c o m m o n terms: corre-
lations, associations, risk factors, and odds ra-
tios. Despite the warnings that most investiga-
tors provide when writing about these issues,
there is a tendency for some readers to over-
interpret certain data that infer an etiologic re-
lationship, but are far from proving it. Even
the well-known relationship between smoking
and lung cancer had to travel a long road from
being a positive correlation to becoming estab-
lished as a major causative (etiologic) factor in
that disease; it was necessary to determine how
the ingredients of tobacco smoke could actu-
ally cause lung cells to become cancerous,
which is a level of science that is much more
complex than the assessment of risk.
Some i n t e r e s t i n g ethical questions arise
from the study of so-called risk factors for var-
ious diseases. For example, if it is determined
that a certain morphological factor appears
more often in an affected population (this is
properly described as an association), how far
should we go with that knowledge? Is this fac-
tor actually contributing to causation of the
problem, or is it merely a predictor of greater
likelihood of" getting the problem? Do we know
for sure that changing this morphology is ther-
apeutic, or is it too late to reverse the condition
by that approach because the damage is al-
ready done? Is there a risk-benefit ratio asso-
ciated with changing morphology? Should we
change it in children to prevent them from de-
veloping the condition later in life? Should
a s y m p t o m a t i c adults routinely be screened
and/or treated for the potential risk attributed
to this factor? If these questions sound familiar
to orthodontic readers, it should not be sur-
prising.
One approach to the complexity of causal
relationships is to subdivide possible etiological
factors into three categories:
1. P r e d i s p o s i n g factors. These include a mix-
ture of morphological, physiological, psy-
chological, a n d e n v i r o n m e n t a l variables
that heighten an individual's susceptibility
to develop a certain problem.
2. Precipitating factors. These include vari-
ous combinations of trauma, stress, hyper-
function, and possibly failure of natural in-
223
hibiting factors, all of which lead to the on-
set of symptoms.
3. P e r p e t u a t i n g factors. These include poor
healing capacity, failure to control etiologic
factors, secondary gains from staying sick,
and negative effects f r o m i n a p p r o p r i a t e
treatments.
Although this approach is both reasonable
and practical, its limitations must be recog-
nized; at any given point in time, only some
of these etiologic factors can be identified,
whereas others may remain quite elusive. Of-
ten such factors can be analvzed in groups o f
patients (by comparing them with normal pop-
ulations), but they are difficult to identify in
individual patients.
For clinicians who wish to provide the best
care possible, despite the lack of clear etiologic
findings, some i m p o r t a n t decisions must be
made. Should one wait for a more perfect eti-
ologic picture to emerge from research, mean-
while providing only symptomatic care, or is it
possible to do better than that? Although we
have an imperfect u n d e r s t a n d i n g of the etiol-
ogy of most TM disorders at this time, we have
been able to develop some rational systems of
treatment based on other data; namely, the
large body of" data that has been p r o d u c e d
f r o m controlled studies of the clinical out-
comes of many treatment approaches for the
various TM disorders. 3-6 Other authors in this
issue have p r e s e n t e d the c u r r e n t l y recom-
m e n d e d nonsurgical treatment protocols for
these disorders, based on the extensive litera-
ture dealing with this subject.
Any a t t e m p t to clarify the etiology a n d
treatment issues in regard to T M disorders
also must incIude a critical review of past ther-
apeutic concepts in this field, many of which
were based on faulty etiologic theories. 7 In the
next section, several orthodontic versions of
causation and cure for TMD that have had a
significant impact on the behavior of specialists
in this discipline will be considered.
Special Orthodontic Concepts of
TMD Etiology
T h e origins of orthodontic thinking about T M
disorders can be traced to the writings o f
T h o m p s o n . 8 His concept of posterior and su-
perior displacement of the condyle greatly in-
224 Etiolo~, ~[ TM Disorders
fluenced orthodontists when it first was pub-
lished 40 years ago, and even today he and
others are still p r o m o t i n g this concept. :~'m Al-
t h o u g h p r o s t h o d o n t i s t s , in g e n e r a l , h a v e
claimed that most condyles in patients with
T M D are anterior to their p r o p e r centric rela-
tion (and t h e r e f o r e need to be pushed hack-
ward and upward), T h o m p s o n believed that
most condyles n e e d e d to be b r o u g h t down-
ward and forward. Tiffs viewpoint was based
on his analysis of tracings taken f r o m cephalo-
metric radiographs in which the condyle could
not be observed in the closed position, so it had
to be traced on o p e n - m o u t h views and trans-
posed to the first radiograph. T h e t r e a t m e n t
concept that followed f r o m this line of think-
ing often was r e f e r r e d to as "freeing up a dis-
talized (trapped) mandible," requiring a m o n g
other things anterior positioning o f the u p p e r
incisors.
Subsequent d e v e l o p m e n t s in the o r t h o d o n -
tic view of T M disorders came f r o m the radio-
graphic studies p e r f o r m e d by Ricketts, 11 as
well as f r o m a n u m b e r o f electromyographic
studies p e r f o r m e d by Perry, TM Jarabak, l:~ and
Moyers. 14 T h e s e studies initially s e e m e d to
show significant differences hetween normal
subjects and T M D patients, hut f u r t h e r re-
search over the years has tailed to s u p p o r t
these early findings. 15 Even with the improved
sophistication o f m o d e r n imaging and EMG
procedures, it has been f o u n d that neither ap-
proach can be reliably used to separate T M D
patients f r o m n o r m a l populations.n~'17
A m o r e insidious d e v e l o p m e n t for orth-
odontists came when some o f their own col-
leagues began attributing "I'M disorders to im-
p r o p e r finishing o f orthodontic cases TM and a
lack o f appreciation for "correct" concepts o f
functional occlusion (eg, CO and CR must co-
incide; no balancing interferences should he
present; anterior guidance must disclude the
posterior teeth; and st) forth). Despite consid-
erable debate about this subject, it never was
shown scientifically that any "wrong" concepts
o f occlusion or " i m p r o p e r " finishing by orth-
odontists using diverse m e t h o d s had p r o d u c e d
any significant n u m b e r o f p o s t o r t h o d o n t i c
T M D sufferers. Even today there still is no
a g r e e m e n t a m o n g orthodontists about any su-
perior m e t h o d s o f finishing cases.
More recent ideas about the p r e s u m e d link-
age between orthodontics arid T M disorders
have come both f r o m traditional o r t h o d o n -
tists l'J and f r o m various nonspecialist dentists
who provide o r t h o d o n t i c treatment. 'm T h e s e
practitioners often discuss matters in terms o f
so-called functional .jaw orthopedics (FJO), a
concept that in m a n y ways resembles the early
concepts of posterior .jaw displacement. With
the a d v e n t o f f u n c t i o n a l o r t h o p e d i c appli-
ances, many o f these practitioners have m a d e
o r t h o p e d i c inandibular a d v a n c e m e n t the cen-
terpiece o f their entire treatment philosophy,
claiming that they are p r o d u c i n g superior re-
suhs both orthodontically and in terms o f TMJ
health. 2°'~ At the same time, they are criticiz-
ing conventional orthodontists for continuing
to do such traditional p r o c e d u r e s as p r e m o l a r
extractions, incisor retraction, and using vari-
()us headgear. None o f this rhetoric has been
supt)orted by findings fi-om the scientitic liter-
ature, but the debate has heen a source o f con-
siderable bitterness hoth within the o r t h o d o n -
tic profession and outside o f it.
Its 1988, a review and analysis o f this topic
entitled "Orthodontics and T e m p o r o m a n d i h -
ular Disorders" was published, 22 and a list o f
10 myths in tiffs field was presented:
1. People with certain types o f u n t r e a t e d
malocclusion (fi)r example, Class II Divi-
sion 2, deep overbite, crossbite) are m o r e
likely m develop T M disorders.
2. People with excessive incisal guidance, or
p e o p l e totally lacking incisal g u i d a n c e
(open bite), are m o r e likely to develop T M
disorders.
3. People with gross nlaxi[lomandihular dis-
harmonies are m o r e likely to develop T M
disorders.
4. P r e t r e a t m e n t radiographs o f both TMJs
should be taken before starting o r t h o d o n -
tic treatment. T h e position o f each condyle
in its fossa should be assessed as good or
bad, and o r t h o d o n t i c t r e a t m e n t should be
directed at p r o d u c i n g a good relationship
at the end. ("Good" position usually was
defined as being a concentric placement o f
the condyle in the fossa).
5. O r t h o d o n t i c t r e a t m e n t , w h e n p r o p e r l y
d o n e , r e d u c e s the l i k e l i h o o d o f subse-
quently developing T M disorders.
6. Finishing o r t h o d o n t i c cases according to
 Charles S. Greene
specific functional occlusion guidelines
(eg, gnathologic principles) reduces the
likelihood of subsequently developing TM
disorders.
7. The use of certain traditional orthodontic
procedures and/or appliances may in-
crease the likelihood of subsequently de-
veloping TM disorders.
8. Adult patients who have some type of oc-
clusal "disharmony" along with the pres-
ence of TMD symptoms will probably re-
quire some form of occlusal correction to
get well and stay well.
9. Retrusion of the mandible because of nat-
ural causes or after treatment procedures
is a major factor in the etiology of TM dis-
orders.
10. When the mandible is distalized, the artic-
ular disc may slip off the front of the
condyle.
None of these statements is correct accord-
ing to the current scientific literature. Most of
them simply represent the accumulated myth-
ology of the orthodontic profession, handed
down from one generation to another. In an
excellent review of this topic that was pre-
sented to an international conference spon-
sored by the National Institute of Dental Re-
search (NIDR), McNamara, Seligman, and
Okeson 23 listed eight conclusions that essen-
tially refute all of the previous statements:
i. Signs and symptoms of TMD occur in
healthy individuals
2. Signs and symptoms of TMD increase with
age, particularly during adolescence. Thus,
TMD that originates during [orthodontic]
treatment may not be related to the treat-
ment.
3. Orthodontic treatment performed during
adolescence generally does not increase or
decrease the chances of developing TMD
later in life.
4. The extraction of teeth as part of an orth-
odontic treatment plan does not increase
the risk of developing TMD.
5. There is no elevated risk for TMD associ-
ated with any particular type of orthodontic
mechanics.
6. Although a stable occlusion is a reasonable
orthodontic treatment goal, not achieving a
225
specific gnathologically ideal occlusion does
not result in TMD signs and symptoms.
7. No method of TM disorder prevention has
been demonstrated.
8. When more severe TMD signs and symp-
toms are present, simple treatments can al-
leviate them in most patients.
In reaching these conclusions, the authors
d e p e n d e d heavily on the large n u m b e r of
long-term prospective and retrospective stud-
ies performed by orthodontic and occlusion re-
searchers throughout the world. 24-26 In addi-
tion, they incorporated the fine literature re-
views and analyses performed by both Swedish
and American investigators 2''9s that assessed
the relationships between all types of occlusal
variables and nearly all forms of TMD. Alto-
gether, McNamara et a123 cited over 100 ref-
erences in their article.
What Should Contemporary
Orthodontists Be Doing in Relation to
TM Disorders?
If orthodontists can accept the fact that there is
no special orthodontic viewpoint required for
dealing with TMD patients, they can join their
other dentaI colleagues in providing the best of
modern diagnosis and treatment for these pa-
tients. Intellectually, this process must begin by
shedding the beliefs of the past, especially
those etiologic concepts that have been either
disproved or unsupported by scientific evi-
dence. 7'22'2:~ For many orthodontists, the big-
gest barrier to taking this step is that so many
patients have apparentIy done well following
orthodontic treatment for TMD, but the same
can be said for prosthodontic treatment, oc-
clusal equilibration, bite opening, condylar re-
positioning, and many other irreversible den-
tal procedures that have not withstood the ret-
rospective scrutiny of scientific analysis. Most
authorities today agree that the high level of
positive response in TMD patients treated by
these aggressive methods is due to the combi-
nation of a natural tendency to recover, pla-
cebo effects, and ingredients from therapies
that work successfully.3'4'29
In many cases, TMD patients have under-
gone a two-stage treatment protocol in which
Phase I provides symptom relief (with conser-
226 Etiology oJ TM Disorders
vative and reversible modalities), a n d Phase II
requires s o m e p e r m a n e n t a h e r a t i o n o f den-
toskeletal relationships. 3° As is true o f most
t r e a t m e n t concepts, this a p p r o a c h is based on
s o m e type o f etiologic t h e o r y ; in this con-
cept, e i t h e r t h e m a n d i b l e is d e s c r i b e d as
being malpositioned, malaligned, or displaced,
or the c o n d y l e is d e s c r i b e d as b e i n g in a
w r o n g centric position or not c e n t e r e d in the
fossa. ~°'1s'31 All o f this is said to be caused by
some m a l r e l a t i o n s h i p of the u p p e r arid lower
teeth, e i t h e r c o n g e n i t a l or acquired. ~2 T h e
o r t h o d o n t i c version o f this t r e a t m e n t concept
for TM disorders often includes both an
o r t h o d o n t i c c o m p o n e n t and an o r t h o g n a t h i c
surgery c o m p o n e n t . Frequently, the Phase II
p r o c e d u r e s a r e b a s e d o n a p a r t i c u l a r type
of oral appliance (splint) that has been used
in Phase i to establish a "correct".jaw position,
a n d i n d e e d t h e s e t y p e s o f a p p l i a n c e s can
produce permanent dental and skeletal
changes. :~1':~:<:~4 H o w e v e r , it has b e e n t b u n d
through both retrospective and prospective
studies that the Phase I t r e a t m e n t s are what
really help T M D patients to i m p r o v e , whereas
Phase II generally r e p r e s e n t s a mechanistic
"stabilization" o f the m a n d i h l e for patients who
would not have n e e d e d it if their original.jaw
position h a d b e e n m a i n t a i n e d . 4'3"~':~ T h e r e -
fore, the m e r e a c c u m u l a t i o n o f "successfully
treated" T M D cases is far f r o m being sufficient
p r o o f of the c o n c e p t u a l validity o f any partic-
ular etiologic theory or t r e a t m e n t philosophy.
A n o t h e r step t h a t m o s t p r a c t i c i n g o r t h -
odontists will n e e d to consider is rejection o f
the false p r o p h e t s a n d g u r u s within t h e i r
own specialty. Many well-known o r t h o d o n t i c
a u t h o r i t i e s c o n t i n u e to detkend t h e T M D /
o r t h o d o n t i c positions of the past, a viewpoint
that was clearly e x p r e s s e d in a recent editorial
in their m a j o r . j o u r n a l . :37 It is soinewhat ironic
that an entire issue o f that same j o u r n a l was
devoted to scientific studies a n d review articles
a b o u t T M disorders and orthodontics which,
in g e n e r a l , r e j e c t e d m o s t o f that o u t d a t e d
thinking. :~s
Even o r t h o d o n t i s t s who p r e f e r not to treat
patients with T M d i s o r d e r s will find t h e m -
selves caught u p in certain clinical dilemmas.
H o w should you deal with a patient who is re-
f e r r e d by a n o t h e r dentist for t r e a t m e n t o f oro-
facial pain, if that dentist already has attrib-
uted the pain to s o m e type o f malocclusion?
W h a t should you do if o n e o f y o u r own pa-
tients develops s y m p t o m s o f t e m p o r o m a n d i b -
ular d i s c o m f o r t d u r i n g y o u r o r t h o d o n t i c treat-
ment? W h a t kind o f T M D screening should
you do b e f o r e starting t r e a t m e n t , especially in
this age o f medicolegal concerns? W h a t if a
f o r m e r patient c o m e s back s o m e time later
with a T M d i s o r d e r that a n o t h e r dentist has
b l a m e d on y o u r t r e a t m e n t ? T o deal with any o f
these situations, a c o n t e m p o r a r y o r t h o d o n t i s t
nlust have a r e a s o n a b l e level o f k n o w l e d g e
a b o u t m o d e r n concepts o f T M D etiology, di-
agnosis, a n d t r e a t m e n t .
A l t h o u g h it is b e y o n d the scope o f this arti-
cle to discuss all aspects o f w h a t s h o u l d be
learned in this field, the following short list
may serve as a guideline to those who are in-
terested:
1. I,earn a b o u t the complexities o f differential
diagnosis of orofacial pain. Because t h e r e
are m o r e than 150 varieties o f h e a d a c h e s
classilied by tile I n t e r n a t i o n a l ! l e a d a c h e So-
ciety, ~9 a diagnosis o f a T M d i s o r d e r m u s t
be segregated fronl a large n u m b e r o f o t h e r
possibilities.
2. l~earn a b o u t the differences between acute
a n d c h r o n i c pain. T h e s e distinctions be-
c o m e crucial in the m a n a g e m e n t o f T M D
patients, especially w h e n they do not re-
s p o n d to initial therapy. I n chronic pain sit-
uations, p s y c h o l o g i c a l v a r i a b l e s b e c o m e
even m o r e i m p o r t a n t , a n d this is a n o t h e r
subject that m u s t be u n d e r s t o o d by all clini-
cians.
3. Learn a b o u t the musculoskeletal n a t u r e o f
T M disorders. T h e s e disorders are similar
to most o t h e r joint, muscle, a n d disc disor-
ders t h r o u g h o u t the body, a n d an appreci-
ation o f o r t h o p e d i c principles is f u n d a m e n -
tal to p r o p e r u n d e r s t a n d i n g o f these prob-
[enls.
4. l,earn how to treat patients with conserva-
tive a n d reversible modalities. Again, the in-
f o r m a t i o n gained f r o m the general ortho-
pedic literature has b e e n the f o u n d a t i o n for
d e v e l o p m e n t o f m o d e r n t r e a t m e n t proto-
cols for T M D . 7 As in o t h e r areas o f the
body, t h e r e has b e e n a clear t r e n d toward
m o r e conservative m a n a g e m e n t techniques,
 Charles S. Greene
usually involving a considerable a m o u n t of
patient self-help participation.
T h e sources for all of this infi)rmation are
many and varied, but a g o o d place to start is by
reading several overview articles that summa-
rize the major diagnostic categories and the
r e c o m m e n d e d treatment protocols fi)r T M dis-
orders/a0 43 In addition, the guidelines pub-
lished by the American Academy of Orofacial
Pain 36 have become recognized as the most
c o m p r e h e n s i v e and up-to-date summary o f
current diagnostic classifications and treat-
ment protocols for the m a n a g e m e n t of T M D
patients. Some recent textbooks also provide a
great deal of information about contemporary
c o n c e p t s of t e m p o r o m a n d i b u l a r a n a t o m y ,
physiology, normal function, and dysfunc-
tio n. 44-46
In conclusion, the subject of etiology in the
field of temporomandibular disorders remains
both controversial and incoinplete, but this has
not prevented our profession from making sig-
nificant advances in the care o f T M D patients.
As more work is being performed on the study
of etiologic factors, concerned dentists must
continue to provide the best possible care with
the lowest possible risk 1o relieve the pain and
suffering of these patients 3:5'41'42 and enable
them to return to a more normal and comlort-
able life.
References
1. Laskin DM. Etiology of the pain-dysfunctiun syn
drome. ,] Arn Dent Assoc 1969;79:147-153.
2. Clark GT. Etiologic theory and prevention of tempo-
romandibular disorders. Adv Dent Res 1991 ;5:60-66.
3. Mjersjo C, Carlsson GE. Long-term results o1 treat-
ment for temt)oron3andibular pain dysfunction. J
Prosthet Dent 1983;49:809 815.
4. (,reene CS, Laskin DM. Long-term evaluation of
treatment for myofascial pain-dysfunction syndrome:
A comparative analysis. J Am I)ent Assoc 1983;107:
235-238.
5. Greene CS, Laskin DM. lxmg-term status o f ' I ' M [
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