REVIEW ARTICLE

Orthodontics and temporomandibular disorders:

A review of the literature (1966-1988)
Reint M. Reynders, DDS, MSc.*
Milan, Italy

The orthodontist has been both accused of causing and complimented for curing temporomandibular
dysfunction. To better understand the origins of these conflicting opinions, a review of the
orthodontic and temporomandibular joint journals was performed for articles published since 1966. A
total of 91 publications that discussed the relationship between orthodontics and temporomandibular
disorders was found, and these articles were divided in three categories: viewpoint publications,
case reports, and sample studies. Among the areas scrutinized in each category was the method
that has led to the diversity of viewpoints. From this analysis, the following conclusions were drawn:
(1) viewpoint publications and case reports were excessively represented in comparison with the
number of sample studies; (2) viewpoint publications and case reports described a wide variety of
conflicting opinions on th e relationship between orthodontics and temporomandibular disorders; (3)
unlike sample Studies, viewpoint publications and case reports have little or no value in assessment
of the relationship between orthodontics and temporomandibular disorders; (4) sample studies
indicate that orthodontic treatment is not responsible for creating temporomandibular disorders,
regardless of the orthodontic technique; and (5) sample studies indicate that orthodontic treatment is
not specific or necessary to cure signs and symptoms of temporomandibular dysfunction. (AM J
ORTHOD DENTOFACORTHOP 1990;97:463-71.)

T h e specialists in orthodontics have long
been interested in the problems associated with the di-
agnosis and management of tempor0mandibular dis-
orders. TM In the last decade, a more comprehensive
understanding of the temporomandibular joint (TMJ)
and its associated structures has failed to diminish the
controversy surrounding this subject. An important as-
pect.of today's confusion results from conflicting in-
formation in the literature. 5~7 The interpretation of nu-
merous published reports is hampered by inadequate
design, biased case sampling, inappropriate or non-
existent control groups, incomplete or inaccurate data
collection, unjustified assumptions, and faulty inter-
pretation. ~82' Indeed, orthodontic treatment has been
characterized in diverse publications as both causing
and curing temporomandibular dysfunction.5"8"'2z2s
To better understand the origins of these conflicting
opinions,it has been necessary to comprehensively re-
view the orthodontic literature from the standpoint of
methods used.
MATERIALS AND METHODS
A MEDLINE search was requested to list the ar-
ticles published on the topic of orthodontics and tem-
*Former Research Associate and Clinical Instructor, Department of Orthodon-
tics, Northwestern University, Chicago, Illinois,
811114548
poromandibular disorders in the orthodontic and TMJ
journals. MEDLINE provides a computerized index of
the dental literature that includes all dental articles pub-
lished since 1966. With this system, the following jour-
nals were screened: Angle Orthodontist, AMERICANJOUR-
NAL OF ORTHODONTICSAND DENTOFACIAL ORTHOPEDICS,
Australian Orthodontic Journal, British Journal of
Orthodontics, European Journal of Orthodontics, Fa-
cial Orthopedics and Temporomandibular Arthrology,
Functional Orthodontist, htternational Journal of Adult
Orthodontics and Orthognathic Surgery, hzternational
Journal of Orofacial Myology, International Journal of
Orthodontics, Journal of Clhdcal Orthodontics, Jour-
nal of Craniomandibular Practice, Orthodontist, and
Journal of Craniomandibular Disorders Facial and
Oral Pahz.
The initial MEDLINE search provided a total of
285 publications. All were retrieved; however, only 91
publications discussed the relationship between ortho-
dontics and temporomandibular disorders. These were
submitted for detailed review and divided into three
categories: viewpoint publications, case reports, and
sample studies. Editorials were excluded from consid-
eration.
Viewpoint publications state the authors' specific
opinions on the relationship between orthodontics and
temporomandibular disorders. The origin of these opin-
ions was analyzed in each article and tabulated under
463
464 Reynders
Table I. Relationship between orthodontics and
temporomandibular disorders in orthodontic and
temporomandibular joint journals since 1966
(Summary tables II-IV)
Relationship
between
orthodontics and
temporomandibular
disorders
Total No. of
Type of publication publications
Viewpoint publications 8 10 4 33 55
Case reports 23 7 30
Sample studies 2 4 6 point publications, 49 were based on the personal view-
TOTAL 8 35 8 40 9--1
TERM[NOLtX]Y: - - , Orthodontics causes temporomandibular disorders;
+ , orthodontics cures temporomandibular disorders; 0, orthodontics
does not influence temporomandibular disorders; _ , orthodontics can
both cause and cure temporomandibular disorders.
the following headings: the personal viewpoint of the
author (PVA); !he personal viewpoint of other author(s)
¢PVO); case reports of the author (eRA), case reports
of other author(s) (CRO); controlled sample study, au-
thor (CSSA); controlled sample study, other author(s)
(CSSO); uncontrolled sample study, author (USSA);
uncontrolled sample study, other author(s) (USSO).
The category of "case reports" included publications
describing the influence of certain orthodontic treatment
modalities in one or more cases on the signs and symp-
toms of temporomandibular dysfunction. Sample stud-
ies reported data on this relationship as found after a
study of large sample groups. The following charac-
teristics of these studies were tabulated: the character
of the design, the size of the samples, controlled versus
uncontrolled study, and the type of orthodontic appli-
ances used.
The putative relationship between orthodontics and
temporomandibular disorders was designated by one of
three characters: - , + , or 0. The minus symbol in-
dicated that orthodontics caused temporomandibular
dysfunction, a plus symbol indicated that orthodontics
cured such disorders, either directly or as an essential
part of a multiple-phase TMJ therapy, and finally the
zero symbol indicated that orthodontics has no influence
on temporomandibular dysfunction. If the author
claimed that orthodontics can both cause and cure tem-
poromandibular disorders, the viewpoints were char-
acterized by a --- symbol.
RESULTS
Between 1966 and 1988 the orthodontic and TMJ
journals published 91 articles that discussed the rela-
Am. J. Orthod. Dentofac. Orthop.
June 1990
tionship between orthodontics and temporomandibular
disorders. The cumulated findings of these publications
are summarized in Table I.
Viewpoint publications (Table I1)
The viewpoint type of article was the most common
in the total sample (Table I). Of the 55 viewpoint pub-
lications, 10 articles indicated a curative effect, 8 ar-
ticles indicated a causal effect, and 4 articles claimed
no effect of orthodontics on the signs and symptoms of
temporomandibular dysfunction. Thirty-three view-
point articles claimed that orthodontics can both cause
and cure temporomandibular disorders. Of the 55 view-
point of the author (PVA) and 219'29 originated from the
data of controlled sample studies (CSSO) (Table II).
Twenty-three viewpoint publications were published in
one journal (Table II).
Case reports (Table III)
Thirty case reports were available (Table I). A cu-
rative effect was shown in 23 articles, whereas 7 articles
defined a combined causal/curative effect of orthodon-
tics on the signs and symptoms of temporomandibular
dysfunction. Of the 30 case reports, 15 were published
by one author !n one journal and all presented a curative
effect (Table III).
Sample studies (Table IV)
Only 6 sample studies were found (Table I). Two
showed a curative effect and 4 showed no effect of
orthodontics on temporomandibular disorders. Five
sample studies had a controlled design, and one did not
(Table IV).
DISCUSSION
Viewpoint publications
Viewpoint publications serve an important purpose
because they generate new ideas and hypoiheses. How-
ever, once these propositions are introduced, they
should be tested for validity in a controlled experimental
environment. As shown in Table I, such attempts have
been rare (55 viewpoint publications versus 6 sample
studies). Moreover, 49 of these 55 viewpoint articles
were based on the personal biases of the authors without
cross-referencing studies of others (Table II). This is
not surprising because scientific data supporting these
convictions are not available. Only 2 of the 55 view-
point publications presented opinions based on findings
in controlled sample studies. ~9"29Furthermore, Table I
illustrates the wide diversity of opinions on the rela-
tionship between orthodontics and temporomandibular
disorders. These viewpoints can be roughly classified
into three groups. The first group claims that ortho-
dontics jeopardizes the temporomandibular complex.
Voh,me 97 Review article 465
Number 6

Table II. Viewpoint publications on the relationship between orthodontics and temporomandibular disorders
Relatiot,ship orthodontics I
Author(s) Journal Year and TM disorders Origin viewpoint

Ricketts 79 AM J ORTHOD 1966 ± PVA

M a t h e w s a7 Angle Orthod 1967 + PVA
S i l v e r m a n 8° AM J ORTttOD 1968 ± PVA
W i l s o n 3t Orthodontist 1971 - PVA
M a r b a c h 36 AM J ORTtIOD 1972 -- PVA
Perry HT. ~' AM J OR'ntOD 1973 ± PVA
Perry HT. s: AM J ORTHOD 1975 -- PVA
Freer ~3 Aast Orthod J 1975 0 PVA
S p y r o p o u l o s et al. 3-" AM J ORTHOD 1976 -- CRO
W i l l i a m s o n ~5 Angle Orthod 1976 ± PVA/CRA
Lewis~ AM J ORTHOD 1976 ----- CRO
Timm and Ash ~ J Clin Orthod 1977 ± PVA
B e n c h et al. ~ J Clin Orthod 1978 ± PVA
Aubre~ 7 AM J ORTHOD 1978 ± PVA/PVO/CRA/CRO
L e v y 35 hzt J Orthod 1979 -+ PVA
R o t h 6° J Clin Orthod 1981 ~ PVA
R o t h et al. 62 J Clin Orthod 1981 ± PVA
Roth ~ J Clin Orthod 1981 ± PVA
R o t h et al. 6~ J Clin Orthod 1981 ± PVA
Williamson ~ J Clbz Orthod 1981 ± PVA
W i l l i a m s o n s9 J Clin Orthod 1981 ± PVA
Libin 87 hzt J Orthod 1982 - PVA
Greene 29 Angle Orthod 1982 0 CSSO
Haden ~ J Craniomandibular Pract 1982 + PVA
Williamson ~ J Clin Orthod 1982 + PVA
Bellavia 9° J Craniomandibular Pract 1983 + PVA
Bell 9~ J Clin Orthod 1984 0 PVA
B e a n 49 Funct Orthod 1984 ± PVA
M e h t a 53 Funct Orthod 1984 + PVA
W i t z i g ~° Funct Orthod 1984 ± PVA
Stack u Funct Orthod 1985 + PVA
K u s s i c k 9" Funct Orthod 1985 ± PVA
B o w b e e r 43 Funct Orthod 1985 ± PVA/CRA
B e a n '~3 Funct Orthod 1985 ± PVA
Grummons~ Funct Orthod 1985 + PVA
B o w b e e ru Funct Orthod 1986 ± PVA
P e r r y SS. 4g Funct Orthod 1986 ± PVAICRA
Broadbent~ Funct Orthod 1986 - PVA
B r o a d b e n t 5~ Funct Orthod 1986 + PVA
B r o a d b e n t ~2 Funct Orthod 1986 + PVA
B r o a d b e n t 4-" Funct Orthod 1986 ± PVA
G e r b e r ~s Funct Orthod 1986 + PVA
B o w b e e t 33 Funct Orthod 1986 - PVA
T h o m p s o n ~° Angle Orthod 1986 +-- PVA
G e l b 3s Funct Orthod 1987 - PVA
G e l b S° Funct Orthod 1987 ± PVA
Wyatt~ A~.! J ORTHOD DENIOFAC ORTHOP 1987 ± PVA
R i n c h u s e ~9 AM J ORTItOD DEmOFAC ORTHOP 1987 0 CSSO
B o w b e e r 39 Funct Orthod 1987 ± PVA/PVOICRA
Bowbeer~ Funct Orthod 1987 ± PVA
M c L a u g h l i n~ Angle Orthod 1988 - PVO
A l p e r n et al. 97 Angle Orthod 1988 ± PVA
SpahP ~ Funct Orthod 1988 ± PVA
Bowbeer~ Funct Orthod 1988 ± PVA/CRA
Livingston ~7 Funct Orthod 1988 ± PVO

TERMINOLOGY; - - , O r t h o d o n t i c s causes t e m p o r o m a n d i b u l a r disorders; + , orthodontics cures t e m p o r o m a n d i b u l a r disorders; 0, orthodontics does

not influence t e m p o r o m a n d i b u l a r disorders; ± , orthodontics c a n both cause and cure t e m p o r o m a n d i b u l a r disorders. PVA, Personal viewpoint,
author(s); PVO, personal viewpoint, other author(s); CRA, case report, author(s); CRO, case report, other author(s); CSSA, controlled sample
study, author(s); CSSO, controlled sample study, other author(s); USSA, uncontrolled sample study, author(s); USSO uncontrolled sample study,
o t h e r author(s).
 466 Reynders Am. J. Orthod. Dentofac. Orthop.
June 1990

Table ill. Case reports on the relationship between orthodontics and temporomandibular disorders
J Relationship orthodontics No. of
Authors Journal Year and TM disorders cases

Roths Angle Orthod 1973 __.

lngervall"-s AMJ OR'roOD 1978 +
Parker98 AMJ ORTHOD 1978 -----
Owen'~ J Craniomandibular Pract 1984 +
Callender1°° J Clin Orthod 1984 +
Bronson1°1 Funct Orthod 1984 +
Owenl°2 J Craniomandibular Pract 1984 ±
Bandeenm AMJ OORTIIOD 1985 ---
Bronson1°4 Funct Orthod 1985 ___
Williamson~°s Facial Orthop TemporomandibularArthrol 1985 +
Williamson1°~ Facial Orthop Temporomandibular Arthrol 1985 +
Williamson1°7 Facial Orthop TemporomandibularArthrol 1985 +
WilliamsonI°s Facial Orthop TemporomandibularArthrol 1985 +
Wiltiamson1°9 Facial Orthop TemporomandibularArthrol 1985 +
Williamsonu° Facial Orthop TemporomandibularArthrol 1985 +
Williamsonm Facial Orthop TemporomandibularArthrol 1986 +
Williamsonm Facial Orthop TemporomandibularArthrol 1986 +
Williamsonm Facial Orthop Temporomandibular Arthrol 1986 +
Williamsonli~ Facial Orthop TemporomatutibularArthrol 1986 +
Williamsonm Facial Orthop TemporomandibularArthrol 1986 +
WilliamsonH6 Facial Orthop TemporomandibularArthrol 1986 +
Thompson9 Angle Orthod 1986 ___
Williamsonm Facial Orthop TemporomandibularArthrol 1987 +
WilliamsonIlg Facial Orthop TemporomandibularArthrol 1987 +
WilIiamsonm Facial Orthop TemporomandibularArthrol 1987 +
Bledsoe~z° Funct Orthod 1987 +
Davidm Funct Orthod 1988 +
Lynnm Funct Orthod 1988 +
Mintzm Angle Or(hod 1988 +
Owenm AMJ ORTHoD DENTOFACORTHOP 1988 ___

TERMINOLOGY:--, Orthodonticscauses temporomandibulardisorders; +, orthodonticscures temporomandibulardisorders; 0, orthodonticsdoes

not influencetemporomandibulardisorders; -4-,orthodonticscan both cause and cure temporomandibulardisorders.

Supporters of this position generally declare that pre- Case reports

molar extractions and certain mechanics used in fixed-
appliance therapy cause temporomandibular disor-
ders. I°'zs'3°47 The second group proposes that nonex-
traction treatment, functional appliances, face masks,
an d second molar extractions can cure or prevent signs
and symptoms of temporomandibular dysfunc-
tion. 3°'33'34'39"42"45"~The third group claims that tempo-
romandibular disorders result from orthodontic treat-
ment that was not finished according to the gnathologic
standards) 5~2 All three viewpoints are repeated contin-
ually in the literature. However, these ideas cannot be
supported by data in controlled sample studies, as will
be discussed later. 6365 Finally, 23 of the 55 viewpoint
publications were published in one journal, of which
the first edition appeared in 1984 (Table II). All 23
articles represented similar opinions of the relationship
between orthodontics and temporomandibular dis-
orders.
Case reports play a dual role in clinical science.
They can be beneficial and lead to new insights into
clinical problems. However, case reports can also be
quite harmful, since they can, by virtue of their initial
convincing appearance, easily mislead the reader. Case
reports particularly obscure the issue when they are used
as evidence to prove certain viewpoints of an author
and can, thereby, lead to misinterpretations of cause-
and-effect relationships. This damaging effect is for-
tified even more when identical case reports are pub-
lished in large numbers, as seen on the topic of ortho-
dontics and temporomandibular disorders (Table III).
When properly used, one single case report should be
presented first, leading to a hypothesis, which then
later should be tested in an experimental design. Such
tests are extremely important, especially in light
of the capricious nature of temporomandibular dis-
orders.
Volume97 Review article 467
Number6

Table IV. Sample studies on the relationship between orthodontics and temporomandibular disorders
Relationship
[ orthodonicsand
Author(s) Journal Year ] TM disorders Number of cases I Appliance}Control Design
Larsson and Ronnerman73 Eur J Ortkod 1981 + 23 Experimental Fixed No Retrospective
Functional
Janson and Hasund72 Eur J Orthod 1981 + 60 Experimental Fixed Yes Retrospective
30 Control Functional
Sadowsky and Begole u AM J ORTnOD 1980 0 75 Experimental Fixed Yes Cross sectional
75 Control
Sadowsky and Poison~ AM J ORI-HOD 1984 0 207 Experimental Fixed Yes Cross sectional
214 Control
Pancherz ~25 AM J OR'I'ttOD 1985 0 20 Experimental Herbst Yes Before-after
Dibbetts and AM J ORTHOD DENTOFACORTHOP 1987 0 63 Functional Fixed Yes Longitudinal
van der Weele63 72 Fixed Functional

"tERML'~OLOCY:- - , Orthodontics causes temporomandibular disorders; + , orthodontics cures temporomandibular disorders; O, orthodontics does
not influence temporomandibular disorders; --+, orthodontics can both cause and cure temporomandibular disorders.

Table I shows the majority of case reports (23 of 30)
conclude that orthodontic treatment had a curing effect
on temporomandibular disorders. This almost unani-
mous claim stands in sharp contrast to the wide diversity
of opinions presented in the viewpoint publications. One
possible explanation for the high percentage of case re-
ports claiming a curative response to orthodontic treat-
ment is that 15 of the 23 articles were published by one
author (Table III). Moreover, all the articles were pub-
lished in the same journal, of which this author is the
sole editor. (It should be noted that this journal was
published for only 4 years before being withdrawn from
circulation.) In these 15 case reports, orthodontic treat-
ment was considered an essential component of the
multiple-phase therapy for temporomandibular disor-
ders. Another possible explanation for the large number
of single case reports claiming orthodontics has a cu-
rative effect on temporomandibular disorders was pre-
sented in longitudinal epidemiologic surveys. Such
studies have pointed out that signs and symptoms of
temporomandibular dysfunction are not constant and
may come and g o . 66"67 Further, controlled placebo stud-
ies and reports of no treatment have coincided with re-
mission of temporomandibular disorders. 6s7° It is there-
fore not difficult to understand how the promising results
achieved in single case reports could easily lead to false
interpretation of clinical success.
Sample studies
Because of the wide variety and large number of
factors influencing the signs and symptoms of tempo-
romandibular dysfunction, delicate methods are re-
quired to evaluate the effects of orthodontic treatment
on these disorders. In the designing of such studies,
several essential factors should be controlled: ethnic
background, socioeconomic status, sex, interobserver
variability, types of orthodontic appliances, psycho-
emotional status, placebo effects, and age. Controlling
for age is extremely important as demonstrated in sev-
eral recent epidemi010gic surveys. These studies doc-
ument the generally increasing incidence of temporo-
mandibular disorders during the age when orthodontic
treatment is usually performed. 66m Egermark-Eriksson
et al. 7~ showed, for example, that the prevalence of
such symptoms increased from 30% to 60% between
the ages of 7 and 15 years.
Table I shows that of the total of 91 publications
that discussed the relationship between orthodontics and
temporomandibular disorders, only 6 were designed to
investigate this putative association. Four sample stud-
ies described no relationship between orthodontics and
temporomandibular dysfunction, whereas 2 sample
studies 23,72showed orthodontic treatment can, in certain
patient groups, slightly lower the prevalence of func-
tional disorders of temporomandibular complex. How-
ever, both of these latter studies contained some flaws
in their designs. The first study z3 was not controlled,
but the findings were compared with the results of the
epidemiologic surveys by Helkimo. 73 Comparisons of
data with those obtained in other investigations must
be made with extreme caution because dissimilarity in
sample characteristics may lead to different results. In
the second study, 72 age was not adequately controlled,
and this defect may have skewed the data.

468 Reynders
As noted previously, numerous viewpoint publica-
tions cite specific treatment mechanics used in fixed
orthodontic appliance therapy as the cause of tempo-
romandibular dysfunction. These mechanics include
Class II and crossbite elastics, headgear, chincups, first
premolar extractions, and palatal tipping of maxillary
incisors. 1°'zs'3°-47Onthe other hand, the same category
of literature suggests that second molar extractions, face
mask therapy, nonextraction treatment, and functional
appliances can actually cure or prevent temporoman-
d i b u l a r d i s o r d e r s . 30,33,34'39.42,45"54 A third category of
viewpoint literature presents the opinions of the gnath-
ologists. These authors claim that nonfunctional occlu-
sal contacts, when introduced by orthodontic treatment,
can cause signs and symptoms of temporomandibular
dysfunction. 5s62 The validity of these diverse view-
points was addressed in 3 carefully designed sample
studies .63455
In 1977 the National Institutes of Health awarded
research contracts to the University of Illinois and the
Eastman Dental Center to study the prevalence of tem-
poromandibular disorders and the status of functional
occlusion in a large group of 207 subjects who had
received fixed orthodontic appliance treatment at least
10 years previously as adolescents. ~'65 In both inves-
tigations, special precautions were taken to compare
the orthodontic groups with suitable control samples.
The findings of both investigations were similar and
showed that orthodontic treatment performed during
adolescence does not generally increase or decrease the
risk of developing temporomandibular disorders in later
life.
These results have some important implications.
First, the assumption made by some authors that ortho-
dontic treatment can prevent symptoms of mandibular
dysfunction is disproven. Second, it is shown that
orthodontic treatment does not induce temporomandib-
ular disorders. Interestingly, a trend toward a lower
incidence of symptoms of temporomandibular dys-
function in the orthodontic group was present but not
significant.
Many of the orthodontic mechanics, described as
potential initiators of temporomandibular disorders in
several viewpoint publications, are widely applied in
the edgewise technique. It seems appropriate, therefore,
to assume that such mechanics were also applied in
treatment of the patients surveyed in the Illinois and
Eastman investigations. On the basis of the findings in
those studies, we probably can conclude that such tech-
niques are not detrimental to the TMJ.19
Another important finding in the Illinois and East-
man studies was the high incidence of nonfunctional
occlusal contacts found in both orthodontic and control
groups. 64"65Similar observations were also documented
Am. J. Orthod. Dentofac. Orthop.
June 1990
in 4 other carefully controlled surveys. 7477 However,
the Illinois study could not show a relationship between
signs or symptoms of temporomandibular dysfunction
and the presence of nonfunctional contacts or mandib-
ular shifts. 6~ This finding therefore challenges the as-
sumption the gnathologists presented in the viewpoint
literature.
The effects of functional appliance treatment on the
incidence of signs and symptoms of temporomandibular
dysfunction were addressed in a recent thoroughly de-
signed longitudinal study at the University of Groningen
in the Netherlands. 63 In the Groningen survey, activator
treatment was compared with fixed-appliance treat-
ment. Of the latter group, 86%* underwent 4 premolar
extractions, whereas the activator patients were treated
without extractions. Ten years after the start of ortho-
dontic therapy there were no differences in symptoms
of TMJ dysfunction between the activator patients and
those treated with fixed appliances. It should be noted
that the latter group was treated according to the Begg
philosophy. This technique generally uses Class II elas-
tics and also induces excessive retroclination of incisors
in the early stages of treatment. 7s Further, it must be
emphasized that the Groningen survey was longitudi-
nally designed. Longitudinal designs are particularly
powerful because they provide information on preva-
lence as well as incidence.
Finally, contrary to the observations made in the
Groningen study, several case reports and viewpoint
publications have labeled fixed appliances as the cause
of temporomandibular dysfunction and functional ap-
pliances as the means of curing such disorders. An
explanation for these reports could be related to the age
variable. Functional-appliance treatment is generally
started at an earlier age than fixed-appliance therapy.
As described, longitudinal studies have indicated that
the incidence of temporomandibular disorders is lower
in the younger age range. ~m These data, combined
with the observations made in the Groningen study,
indicate once more how dangerous it is to extrapolate
findings from single case reports to simple cause-and-
effect relationships.
In conclusion, it is surprising that, although some
of these carefully designed sample studies were pub-
lished in the early 1980s, the authors of viewpoint pub-
lications and case reports have largely ignored these
findings and have continued to saturate the literature
with their biased data.
CONCLUSIONS
The orthodontic and TMJ literature published since
1966 was reviewed in an effort to determine whether
*Personal communication with the authors.
Volume 97
Number 6
orthodontic treatment causes, cures, or does not influ-
ence temporomandibular dysfunction. A total o f 91
publications was found, and these articles were tabu-
lated in three categories: viewpoint publications, case
reports, and sample studies. The method o f the different
types of publications was analyzed and discussed. F r o m
this analysis, the following conclusions were drawn:
1. Viewpoint publications and case reports were
excessively represented in comparison with the number
of sample studies.
2. Viewpoint publications and case reports failed
to reach a consensus on the relationship between ortho-
dontics and the signs and symptoms o f temporoman-
dibular dysfunction but, instead, described a wide va-
riety o f conflicting opinions on this subject.
3. Unlike sample studies, viewpoint publications
and case reports have little or no value in the assessment
of the relationship between orthodontics and tempo-
romandibular disorders.
4. Sample studies demonstrated that orthodontic
treatment mechanics with fixed appliances used during
adolescence does not influence the risk o f the devel-
opment o f temporomandibular disorders in later life.64'rs
5. Longitudinal sample research has shown no dif-
ferences in the incidence o f temporomandibular joint
dysfunction among the patients treated with functional
appliances (activators) without extractions as compared
with patients treated with fixed orthodontic appliances
and four premolar extractions. 63
6. The findings presented in 4 and 5 indicate that
orthodontic treatment should not be considered respon-
sible for creating temporomandibular disorders, re-
gardless o f the orthodontic technique. These data also
reject the assumption that orthodontic treatment is spe-
cific or necessary to cure signs and symptoms o f tem-
poromandibular dysfunction.
7. Nonfunctional occlusal contacts were distributed
equally among orthodontically treated patients and non-
treated patients. These types o f occlusal contact showed
no relationship with the presence o f signs and symptoms
of temporomandibular dysfunction.
I wish to extend special thanks to the following persons
at Northwestern University for reviewing this manuscript: Dr.
Louis Keith, Department of Obstetrics and Gynecology, and
Drs. David P. Forbes, Charles S. Greene, and Harold T. Perry,
Department of Orthodontics.
REFERENCES
1. Brodie AG. Differential diagnosis of joint conditions in ortho-
dontia. Angle Orthod 1934;4:160-70.
2. Brodie AG. The temporomandibularjoint. I11Dent J 1939;8:2-
12.
3. Thompson JR, Brodie AG. Factors in the position of the man-
dible. J Am Dent Assoe 1942;29:925-41.
4. Ricketts RM. Variations of the temporomandibularjoint as re-
Review article 469
vealed by cephalometric laminagraphy. AM J ORTHOD 1950;
36:877-98.
5. Roth RH. Temporomandibular pain-dysfunction and occlusal
relationships. Angle Orthod 1973;43:136-52.
6. Upton LG, Scott RF, Hayward JR. Major maxillomandibular
malrelations and temporomandibular joint pain-dysfunction.
J Prosthet Dent 1984;51:686-90.
7. Thompson JR. Function--the neglectod phase of orthodontics.
Angle Orthod 1956;26:129-43.
8. Thompson JR. Function and growth. Angle Orthod 1961;
31:132-9.
9. Thompson JR. Abnormal function of the temporomandibular
joints and related musculature: orthodontic implications. Part
I. Angle Orthod 1986;56:143-63.
10. Thompson JR. Abnormal function of the temporomandibular
joints and related musculature: orthodontic implications. Part
II. Angle Orthod 1986;56:181-95.
1I. Ricketts RM. Laminagraphy in the diagnosis of temporoman-
dibular joint disorders. J Am Dent Assoc 1953;46:620-48.
12. Ricketts RM. Abnormal function of the temporomandibular
joint. AM J ORTttOD 1955;41:435-41.
13. Costen JB. A syndrome of ear and sinus symptoms dependent
upon disturbed function of the temporomandibular joint. Ann
Otol Rhinol Laryngol 1934;43:1-15.
14. Ramfjord SP. Dysfunctionaltemporomandibularjoint and mus-
cle pain. J Prosthet Dent 1961;11:353-37.
15. Witzig JW, Spahl TJ. Volume I: mechanics. In: The clinical
management of basic maxillofacial orthopedic appliances. Lit-
tleton, Massachusetts: PSG Publishing, 1987.
16. Wilson HE. Early recognition of some etiological factors in
temporomahdibularjoint disorders. Trans Br Soc Study Orthod
1956:88-98.
17. Williamson EH. Temporomandibular dysfunction in pretreat-
ment adolescent patients. AM J ORTHOD1977;72:429-33.
18. Greene CS. The fallacies of clinical success in dentistry. J Oral
Med 1976;31:52-5.
19. Rinchuse DJ. Counterpoint: preventing adverse effects on the
temporomandibularjoint through orthodontic treatment. AM J
ORTHODDEN'rOFACORTHOP1987;91:500-6.
20. Kuttas G. The wonderful world of studies. J Acad Gen Dent
1974;22:17-8.
21. Shell ER. The risk of risk studies. Atlantic Magazine 1987
November: 114-5.
22. Witzig JW, Yerkes IM. Functionaljaw orthodontics: mastering
more than technique. In: Gelb H, ed. Clinical management of
head, neck, and TMJ pain and dysfunction: a multidisciplinary
approach to diagnosis and treatment. 2rid ed. Philadelphia: WB
Saunders, 1985:598-618.
23. Larsson E, Ronnerman A. Mandibular dysfunction symptoms
in orthodontically treated patients ten years after the completion
of treatment. Eur J Orthod 1981;3:89-94.
24. Solberg WK, Seligman DA. Temporomandibular orthopedics:
a new vista in orthodontics. In: Johnston LE, ed. New
vistas in orthodontics. Philadelphia: Lea & Febiger, 1985:
148-83.
25. Wyatt WE. Preventing adverse effects on the temporomandib-
ular joint through orthodontic treatment. AM J ORTHODDEN-
TOFACORTHOP1987;91:493-9.
26. Thomson JR. Abnormal function of the stomatognathicsystem
and its orthodontic implications. AM J ORTHOD1962;48:758-
65.
27. Perry HT. Temporomandibularjoint and occlusion. Angle Or-
thod 1976;46:284-93.
28. Ingervall B. Orthodontic treatment in adults with temporo-
 Am. J. Orthod. Dentofac. Orthop.
470 Reynders
June 1990

mandibular dysfunction symptoms. AM J ORTHOD 1978;73:
551-9.
29. Greene CS. Orthodontics and the temporomandibularjoint. An-
gle Orthod 1982;52:166-72.
30. Witzig JW, AAFO's man of the year 1984 Dr. John Witzig
[interview by Dr. Craig C. Stoner]. Funct Orthod 1984;!(4):9-
10,12-13,15 passim.
31. Wilson HE. Extraction of second permanent molars in ortho-
dontic treatment. Orthodontist 1971;3:18-24.
32. Spyropoulos MN, Askarieh M. Vertical control: a multifactorial
problem and its clinical implications. AMJ ORTtIOD 1976;70:70-
80.
33. Bowbeer GR. Saving the face and the TMJ. Part 3. Funct
Orthod 1986;3(5):6-18, 20-1.
34. Bowbeer GR. Saving the face and the TMJ. Part 2. Funct
Orthod 1986;3(2):9-13,15,17 passim.
35. Levy PH. Clinical implications of mandibular repositioning and
the concept of an alterable centric relation, lnt J Orthod
1979;17(3):6-25.
36. Marbach JJ. Therapy for mandibular dysfunction in adolescents
and adults. AM J ORTHOD 1972;62:601-5.
37. Mathews JR. Functional considerations of the temporomandib-
ular articulation and orthodontic implications. Angle Orthod
1967 ;37:81-93.
38. Gelb H. An interview with Dr. Harold Gelb by Jimi Mehta.
Part I. Funct Orthod 1987;4(2): i 9-20,22-3,26-7,47-8.
39. Bowbeer GRN. The 6th key to facial beauty and TMJ health.
Funct Orthod 1987;4(4):!0-11,13-16,18,20,21,24-31.
40. Bowbeer GRN. An interview with AAFO's man of the year,
1987, Gran R.N. Bowbeer, DDS, MS, with Craig C. Stoner.
Funct Orthod 1987;4(6):12-6.
41. Br°adbent JM" Sec°nd m°lar rem°val' third m°lar replacement"
Funct Orthod 1986;3(2):37-9.
42. Broadbent JM. How you can achieve superior results for your
patients. Funct Orthod 1986;3(6):19-20.
43. Bowbeer GRN. Saving the face and the TMJ. Funct Orthod
1985;2(5):32-44.
44. Williamson EH. Occlusal concepts in orthodontic diagnosis and
treatment. Part III. Clinical significance. Facial Orthop Tem-
poromandibular Arthrol 1987;4(3):13-6.
45. Spahl TJ. Problems faced by fixed and functional schools of
thought in pursuit of orthodontic excellence. Funct Orthod
1988;5(2):28-31,33-34.
46. Bowbeer GRN. The seventh key to facial beauty and TMJ
health: proper condylar position. Funct Orthod 1988;5(5):4-
18,20.
47. Livingston N. Moving teeth and raising eyebrows. Funct Or-
thod 1988;5(6):21,24.
48. Perry SS. Treatment of Class II, Division 2 TMJ patients. Funct
Orthod 1986;3(6):35-43.
49. Bean MD. How to use the sagittal appliance effectively. Funct
Orthod 1984;1(2):12-3,15-6.
50. Gelb H. An interview with Dr. Harold Gelb by Jimi Mehta.
Part II. Funct Orthod 1987;4(3):18,20,24,27,28,30,32.
51. Broadbent JM. The orthopedic corrector. Funct Orthod 1986;
3(4):7-11.
52. Broadbent JM. The sagittal appliance. Funct Orthod 1986;
3(5):36-38-9.
53. Mehta J. Incorporating functional appliances in a traditional
fixed appliance practice. Funct Orthod 1984;1(1):30-2.
54. Stack B. Orthopedic/orthodontic case finishing techniques on
TMJ patients. Funct Orthod 1985;2(2):28-35,43-4.
55. Williamson EH. Occlusion: understanding or misunderstand-
ing. Angle Orthod 1976;46:86-93.
56. Roth RH. Functional occlusion for the orthodontist. Part IlL
J Clin Orthod 1981;15:174-9,182-98.
57. Aubrey RB. Occlusal objectives in orthodontic treatment. AM
J Oa~OD 1978;74:162-75.
58. Williamson EH. Dr. Eugene It. Williamson on occlusion and
TMJ dysfunction [interview by S. Brandt]. J Clin Orthod
1981; 15:333-59.
59. Williamson EH. Dr. Eugene H. Williamson on occlusion and
TMJ dysfunction. Part 2 [interview by S. Bran&]. J Clin Orthod
! 981; ! 5:393-404,409-10.
60. Roth RH. Functional occlusion for the orthodontist. Part I.
J Clin Orthod 1981;15:32-41,44-51.
61. Roth RH, Gordon WW. Functional occlusion for the ortho-
dontist. Part IV. J Clin Orthod 1981;15:246-54,259-65.
62. Roth RH, Rofs DA. Functional occlusion for the orthodontist.
Part I1. J Clin Orthod 1981;15:100-9,112-23.
63. Dibbets JMH, van der Weele LT. Orthodontic treatment in
relation to symptoms attributed to dysfunction of the tempo-
romandibular joint: a 10-year report of the University of Gron-
ingen study. A.',I J ORTHOD DENTOFACORTHOP 1987;91:193-
205.
64. Sadowsky C, BeGole EA. Long-term status of temporoman-
dibular joint function and functional occlusion after orthodontic
treatment. AM J ORTHOD 1980;78:201-12.
65. Sadowsky C, Poison AM. Temporomandibular disorders and
functional occlusion after orthodontic treatment: results of two
long-term studies. AM J ORTHOD 1984;86:386-90.
66. Egermark-Eriksson I, Carlsson GE, Magnusson T. A long-term
epidemiologic study of the relationship between occlusal factors
and mandibular dysfunction in children and adolescents. J Dent
Res 1987;66:67-71.
67. Magnusson T, Egermark-Eriksson I, Carlsson GE. Five-year
longitudinal study of signs and symptoms of mandibular dys-
function in adolescents. Cranio 1986;4:338-44.
68. Goodman P, Greene CS. Laskin DM. Response of patients with
myofascial pain-dysfunction syndrome to mock equilibration.
J Am Dent Assoc 1976;92:755-8.
69. Forssell H. Mandibular dysfunction and headache. Proc Finn
Dent Soc 1985;81(Suppl 1-2):1-91.
70. Greene CS, Laskin DM. Long-term evaluation of conservative
treatment for myofascial pain-dysfunction syndrome. J Am
Dent Assoc 1974;89:1365-8.
71. Egermark-Eriksson I, Carlsson GE, Ingervall B. Prevalence of
mandibular dysfunction and orofacial parafunction in 7-, 11-,
and 15-year-old Swedish children. Eur J Orthod 1981 ;3:163-72.
72. Janson M, Hasund A. Functional problems in orthodontic pa-
tients out of retention. Eur J Orthod 1981;3:173-9.
73. Helkimo M. Studies on function and dysfunction of the mas-
ticatory system. 1I. Index for anamnestic and clinical dysfunc-
tion and occlusal state. Sven Tandlak Tidskr 1974;67:101-21.
74. Rinchuse DJ, Sassouni V. An evaluation of functional occlusal
interferences in orthodontically treated and untreated subjects.
Angle Orthod 1983;53:122-30.
75. Ahlgren J, Posselt U. Need of functional analysis and selective
grinding in orthodontics: a clinical and electromyographic
study. Acta Odontol Scand 1963;21:187-226.
76. Cohen WE. A study of occlusal interference in orthodontically
treated occlusions and untreated normal occlusions. AM J OR-
aatOD 1965;51:647-89.
77. Gazit E. Liberman MA. The intercuspal surface contact area
registration: an additional tool for evaluation of normal occlu-
sion. Angle Orthod 1973;43:96-106.
78. Begg PR, Kesling PC. Begg orthodontic theory and technique.
3rd ed. Philadelphia: WB Saunders, 1977.
Volume 97
Number 6
79. Ricketts RM. Clinical implications of the temporomandibular
joint. AM J OR'roOD 1966;52:416-39.
80. Silverman MM. Equilibration of the natural dentition following
orthodontic treatment to prevent movement of teeth and other
problems. AM J OR'naOD 1968;54:831-51.
81. Perry HT. Adolescent tempornmandibular dysfunction. AM J
ORa'HOD 1973;63:517-25.
82. Perry HT. Mandibular function: an orthodontic responsibility.
AM J OR'roOD 1975;67:316-23.
83. Freer TJ. Who says that child needs orthodontic treatment?
Aust Orthod J 1975;4(2):64-70.
84. Lewis PD. Class II treatment in orthodontics. AM J OR~IOD
1976;70:529-42.
85. Timm TA, Ash MM. The occlusal bite plane splint: an adjunct
to orthodontic treatment. J Clin Orthod 1977;I 1:383-90.
86. Bench RW, Gugino CF, Hilgers JJ. Bioprogressive therapy.
Part 8. J Clin Orthod 1978;12:279-98.
87. Libin BM. Cranial-mandibular-cervical therapy, lnt J Orthod
1982;20(1):13-9.
88. Haden JL. Occlusion finalization following TMJ therapy.
J Craniomandibular Pract 1982-1983;1:14-9.
89. Williamson EH. The masticatory silent period: its use in di-
agnosis and treatment of dysfunctions. J Clin Orthod 1982;
16:686-91.
90. Bellavia WD. Functional jaw device to aid in treating anterior
displaced discs. J Craniomandibular Pract 1983;1:53-60.
91. Bell WE. JCO interviews Dr. Weldon E. Bell on TMJ function
and dysfunction. J Clin Orthod 1984;18:877-81.
92. Kussick L. Bone remodeling: the next generation of orthodon-
tists. A total, early, nonextraction approach. Funct Orthod
1985;2(2)i I 1-7,19-21,24.
93. Bean M. An interview with AAFO's man of the year, Dr. Merle
Bean. Funct Orthod 1985;2(6):14-6,18-21.
94. Grummons DC. Grumzat intermediary appliance. Funct Orthod
1985;2(3):36-42,44.
95. GerberJW. F i x e d + removable = total orthodonticcaretreat-
ment. Part II. Funct Orthod 1986;3(5):24-6,28-31.
96. McLanghlin RP. Malocclsuion and the temporomandibular
joint--an historical perspective. Angle Orthod 1988;58:185-
91.
97. Alpem MC, Nuelle DG, Wharton MC. TMJ diagnosis and
treatment in a multidisciplinary environment--a follow-up
study. Angle Orthod 1988;58:101-26.
98. Parker WS. Centric relation and centric occlusion--an ortho-
dontic responsibility. Ar,t J ORrHOD 1978;74:481-500.
99. Owen AH. Orthodontic/orthopedic treatment of craniomandi-
bular pain dysfunction. Part 3. Anterior condylar displacement.
JCraniomandibular Pract 1984-1985;3:31-45.
100. Callender JM. Orthodontic application of the mandibular ki-
nesiograph. Part 2. J Clin Orthod 1984;18:791-805.
101. Bronson JR. Diagnosis and treatment narrative for Christy S:
a case report. Funct Onhod 1984;1(I):35-7.
102. Owen AH. 11I. Orthodontic/orthopedic treatment of cranio-
mandibular pain dysfunction. Part 2: posterior condylar dis-
placement. J Craniomandibular Pract 1984;2:333-49.
103. Bandeen RL, TimmiTA. Temporomandibularjoint dysfunction.
Report of a ease. AM J ORTHOO 1985;87:275-9.
104. Bronson JR. Elizabeth Williams: a narrative case report. Funct
Orthod 1985;2(1)il 1-5.
105. Williamson EH. Treatment of temporomandibular disc dislo-
cations with a function regulator II. Facial Orthop Temporo-
mandibular Arthrol 1985;2(2):4-6.
106. Williamson EH. Correction of anterior disc displacement. Fa-
cial Orthop Temporomandibular Arthrol 1985;2(1):4-7.
Review article 471
107. Williamson EH. Treatment of anterior disk displacement with
the removable Herbst appliance. Facial Orthop Temporoman-
dibular Arthrol 1985;2(12):4-6.
108. Williamson EH. Treatment of temporomandibular dysfunction
and anterior open bite. Facial Orthop Temporomandibular Ar-
throl 1985;2(10):4-7.
109. Williamson EH. Treatment of temporomandibular joint dys-
function and bilateral posterior open bite. Facial Orthop Tem-
poromandibular Arthrol 1985;2(9):4-7.
110. Williamson EH. Treatment of temporomandibular disc dislo-
cation with a modified orthopedic corrector. Facial Orthop Tem-
poromandibular Arthrol 1985;2(4):4-6.
111. Williamson Ett. Temporomandibular pain dysfunction and
mandibular asymmetry: a compromise case. Facial Orthop Tem-
poromandibular Arthrol 1986;3(9):3-8.
112. Wiltiamson EH. Mandibular orthopedic change and closure of
anterior open b~te following reduction of disk dislocation. Facial
Orthop Temporomandibular Anhrol 1986;3(7):3-7.
113. Williamson EH. staged intracapsular and orthognathic surgical
procedures in the treatment of internal derangement. Facial
Orthop Temporomandibular Arthrol 1986;3(3):3-6.
114. Williamson EH. Treatment of internal derangement and closure
of posterior Open bite in the adult. Facial Orth0p Temporo-
mandibular Arthrol 1986;3(2):3-5.
115. Williamson EH. Treatment of acute anterior dislocation without
reduction followed by functional orthopedics and Class II
correction. Facial Orthop Temporomandibular Arthrol 1986;
3(6):3-7.
116. Williamson EH. Treatment of internal derangement in an adult
with resulting mandibular orthopedic change. Facial Orthop
Temporomandibular Arthrol 1986;3(5):3-7.
117. Williamson EH. Adult orthopedic mandibular change in the
treatment of internal derangement. Facial Orthop Temporo-
mandibular Arthrol 1987;4(8):3-6.
118. Williamson EH. Lars treatment in the meso-to dolichofacial
patient in the presence of internal derangement. Facial Orthop
Temporomandibular Arthrol 1987;4(7):3-7.
119. Williamson EH. Orthopedic mandibular change and distaliza-
tion of buccal segments in the treatment of internal derange-
ment. Facial Orthop Temporomandibular Arthrol 1987;4(11):
3-7.
120. Bledsoe WS Jr. Making phase 1 appliances "diagnose"
and phase 2 appliances "function" in your TMJ/functional
orthopedic practice. Funct Orthod 1987;4(6): 17,18,20,21,24-6
passim.
121. David JA. Functional appliance does job of oral surgeon. Funct
Orthod 1988;5(1):29-33.
122. Lynn JM. Adult: TMJ, severe headaches, 12 year molar ex-
traction, class II, crowding, open bite. Funct Orthod 1988;
5(3)i7-8,10,13-6.
123. Mintz AH. Buccal separators for relief of TMJ pain and symp-
toms. Angle Orthod 1988;58:351-6.
124. Owen AH III. Unexpected TMJ responses to functional jaw
orthopedic therapy. AM J ORTHOD DEN'rOFACORTHOP 1988;
94:338-49.
125. Pancherz H. The Herbst appliance--its biologic effects and
clinical use. AM J ORTHOD 1985;87(1):1-20.
Reprint requests to:
Dr. Reint M. Reynders
Via Dezza 27
20144 Milan
Italy