DEPT.

OF ORTHODONTICS
AND
DENTOFACIAL ORTHOPAEDICS
SRI AUROBINDO COLLEGE OF DENTISTRY

JOURNALCLUB-6
PREVENTING ADVERSE EFFECTS ON TEMPOROMANDIBULAR JOINT
THROUGH ORTHODONTIC TREATMENT
(AJODO JUNE 1987)

BY : CHAITREE DE
P.G. 1ST YEAR

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 INTRODUCTION
The temporo-mandibular joint is one of the most
complicated working assemblies in the human body.

The effect of orthodontic treatment on TMJ has

forever been a topic of controversy in the dental
community.

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Arguments against the orthodontic treatment are usually
based on the deleterious effects on stomatognathic
function such as occlusal interferences, consequences of
the use of intermaxillary elastics, extraoral forces or
functional appliances.

On the other hand, several studies demonstrate no relation

between orthodontics and TMD .

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 Temporo-mandibular disorders

Temporo-mandibular Joint Disorders (TMD) encompass a

group of musculoskeletal and neuromuscular conditions
that involve the temporomandibular joints, the masticatory
muscles, and all associated tissues. (AADR)

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Continuous monitoring of TMJ is essential to detect the
onset of a TMD as early as possible.

In these cases it is recommended to temporarily stop

orthodontic treatment in order to avoid possible aggravating
factors until signs and symptoms, especially pain, improve.

Otherwise, if TMD is diagnosed in the first evaluation of the

patient, the orthodontic treatment should not be initiated.

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 Diagnosis and Treatment

DIAGNOSIS

• A set of transcranial x-ray films should be taken of both right

and left joints , including the jaw in clenched, relaxed, and fully
opened postures and should be used to determine

(1) shape and surface of the fossa,

(2) shape and surface of the head of the condyle,
(3) posterior, anterior, and superior joint spaces,
(4) the forward movement of the condyle on maximum
extension of the joint.

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• Muscles in the area are palpated for soreness, tenderness,
contracture, and spasm.

• A careful audiovisual examination is done to clinically

determine the vertical and horizontal ranges of movement
of the mandible.

• The paths of opening and closure are examined for lateral

deviations. A jaw will deviate toward the side in which
there is an anteriorly dislocated disk.

• The occlusion is checked for premature occlusal

contacts , anterior guidance, freeway space and
parafunctional habits. Particular stress, tensions, and
strains peculiar to the patient are also included in his
records.
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• The orthodontist should be on the alert for signs of TMJ
problems, like-

(1) Head, neck, and shoulder pain, including general

headaches. Tender and sore muscles, and trismus are
related problems of patients with TMD.

(2) Hearing impairment, frequently accompanied by

tinnitus.

(3) Joint sounds including crepitus (a crackling sound

indicating a rough condyle, disk, or eminence surface)
and “Clicking” or “popping” sounds, which can occur
at any point in jaw opening, indicate TMJ distress.
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TMD Symptoms

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(4) “Closed-lock” condition or an inability to fully open the
jaw could be a major problem. This is a sign of acute
TMJ distress and indicates that the disk is dislocated
anteriorly or anteromedially and will not reposition itself
on the condyle while mandibular depression.

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• Dentists, through many accepted dental procedures,
may inadvertently exert distal pressure on the mandibular
complex, which can be tbe etiology or aggravating factor
for TMJ disorder.

• Some of these procedures are:

1. Extractions
2. Crowns, bridges, or fillings
3. Equilibration (eg, adjusting the occlusal surface of the
teeth so that cusps and fossae meet properly).
4. Orthodontic treatment

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 ALLEGATIONS ON ORTHODONTICS

Some examples of how orthodontic treatment may be

detrimental to the TMJ and how this can be prevented
are-

1. In Class II malocclusions with deep interlocking cusps,

headgear and/or Class II elastics are used in an effort to
get the patient into Class I cuspal relationship.

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• As the maxilla is moved backward, the muscles of
mastication will attempt to retract the mandible when the
patient closes in to maximum intercuspation.

• This compensating movement by the mandible can put

distal pressure on the condyles and conceivably cause an
anterior dislocation of the disk .

• To correct this problem in orthodontic treatment, a flat

plane of acrylic, which can be bonded on the occlusal
surfaces of the lower molars and premolars after the fixed
appliance has been placed.

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• There should be a reverse curve in both arch wires to
prevent overeruption of the anterior segments

• When cusps get past a “point-to-point” contact, the flat

occlusal acrylic plate is removed. Now the cuspal inclines
tend to move the mandible forward and the maxilla
backward on maximum closure.

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2. Midline switch or cross elastics have a more subtle effect.
As the jaw is pulled to one side, distal pressure is put on
one condyle only. If this creates a TMJ problem, midline
elastics should be worn only during waking hours so that
muscles can help to hold the mandible forward.

3 . Lower headgears or reverse headgears that exert distal

pressure on the chin and Class III elastics. If there is a
developing problem, it is better to have the patient wear
lower or reverse headgear and Class III elastics only
during waking hours.

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4. Lower expansion and upper contraction, with crowded lower
anterior teeth (in deep bite cases with no tooth size discrepancy)
that are in contact with the lingual of the upper anterior teeth
should not be expanded unless the bite is first opened.

5. The retentive phase of orthodontic treatment may have caused

more TMJ problems than any other orthodontic procedure.

• The majority of orthodontically treated cases may have dental

deep bites at the beginning and some also have skeletal deep
bites.

• The orthodontically corrected deep bite will lead to increase in

the height of lower third of face equal to the extrusion
observed in the molar-premolar region.

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• In the majority of cases, the vertical dimension of the lower
third of the face revert to its original height , due to constant
muscle force winning out over bone and tooth structure.

• As the bite closes, the lower anterior teeth are forced into
premature contact with the lingual surfaces of the upper
anterior teeth which thus constitutes a steep inclined plane.
It may have 4 different effects:

(1) It separates the upper anterior teeth.

(2) It may crowd lower anterior teeth.
(3) It tends to move the maxilla forward
(4) drive the mandible distally.
There can be a combination of any of these also.
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• canine-to-canine (3 to 3) fixed retainer on the lower
anterior teeth prevents them from collapsing lingually as
the bite closes.
• A Hawley-type retainer with a labial bow is usually
placed on the upper arch to prevent the upper anterior
teeth from rotating, separating, or moving forward

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6. Preventing forward movement of maxilla and distal
movement of mandible during retention.

• Initially, all deep bite cases should be leveled early in

treatment and held at a level occlusal plane throughout.

• At the end of active treatment, the use of an upper

hawleys-type retainer with an occlusal biteplate in the
anterior portion is recommended.

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 Conclusion
No orthodontic procedure can be performed in isolation without
considering its possible effect on the temporomandibular joint.
Therefore, the following recommendations are made for
diagnosis and treatment planning -

1.Etiologic factors that might cause upward and backward pressures

on the mandible should be reduced as much as possible.

2.Mechanotherapy that may cause upward and backward pressures

on the condyles is not recommended. Final detailed correction of
dental abnormalities should always consider optimal
temporomandibular health and function.

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3. Retention procedures should be planned to provide a proper
path of closure to minimize or prevent possible retrogressive
post-treatment changes.

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 Take Home Message

With the ongoing controversy, keeping patients welfare in

mind and to avoid any future medicolegal issues, proper
diagnosis and treatment planning should be achieved.

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 References

• Influence of orthodontic treatment on

temporomandibular disorders. A systematic review
(Felipe J. Fernández-González)

• Management of temporomandibular disorders and

occlusion (Okeson)

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