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EVOLUTION OF OCCLUSION AND TEMPOROMANDIBULAR

DISORDER IN ORTHODONTICS: Past, Present & Future
-Jeffery P. Okeson

• American Journal Of Orthodontics and Dentofacial

Orthopedics 2015;147:S216-23
INTRODUCTION
• Occlusion → Functional disorders of masticatory system continues
to be a resounding issue in Orthodontics.
• Orthodontist : change pateint's occlusal conditions.
• Over the years, role of Occlusion on TMDs has been extensively
debated.

Purpose: to review history of occlusion and TMD as it relates to

orthodontics.
• Article:

1. History of Occlusion and TMD

2. Role of Orthodontic Therapy in TMD

3. Current Functional Treatment goals of Orthodontic Therapy

4. Future considerations of occlusion for the orthodontist

5. Conclusions
HISTORY OF OCCLUSION & TMD IN
ORTHODONTICS
• Dr. Edward H. Angle ( father of orthodontics)
- founded Angle's school of Orthodontia in 1900.
MALOCCLUSION: abnormality in dental configuration

- classification of malocclusion
-Angle's Class I
-Angle's Class II
-Angle's Class III
-During that era, Occlusion was associated with esthetics.
-Andrew gave his 6 keys of normal occlusion but had no reference to TMJ.
• Later in mid 1970s and early 1980s....
-some orthodontist proposed sound occlusal position and condyles in a
stable joint position.

• Dr. Ronald Roth began to write about joint positions in orthodontic

therapy.
- He suggested 5 treatment goals:
Facial esthetics
Dental esthetics
Functional Occlusion
Peridontal Health &
Stability.
-use of articulators to evaluate occlusal position to joint position.
-concept was debated!
But to everybody's concern, this became true in 1987 when a lawsuit
was filed by a lady that her orthodontist caused her TMD.
-and she received a sizable compensation and then, needed research
was started to understand this relationship.
Role of Orthodontic Therapy in
TMD
• Interest in TMD & Orthodontic therapy grew......
Speculations Grew!
Claims like: orthodontic therapy always causes TMD or never causes TMD.
extraction always causes TMD or never causes TMD.
↓↓
clinical Impressions
• By mid 1990s, studies done by Sadoski et al., Henrikson et al., Dibbets JM et al.,
and others
-orthodontic therapy was not a significant risk factor for development of TMD.
• so we could say that orthodontic therapy does not lead to TMD but these were
the results of well designed, well controlled orthodontic therapies, done in
universities... in young patients.
• 5 etiologic factors associated with TMD are:
02
OCCLUSION 01 TRAUMA

03
PARAFUNCTION 05 EMOTIONAL STRESS

04
DEEP PAIN INPUT

-Patients adaptability
•genetic makeup impacts pain perception.
•Gene coding for - Catechol o methyl transferase → pain responsiveness.
•3 cluster of persons: more sensitive to pain & some are less sensitive.
•pain sensitive cluster → developed more symptoms of TMD.
↓
not the orthodontic therapy itself but performing the same in pain sensitive
haplotype could be a significant risk factor.

Moreover,
assumption- orthodontic treatment completly unrelated to TMD is relatively
unjustifiable.
• How does the orthodontic therapy can help minimise risk factor for TMD?
orthodontic therapy → patients occlusion → occlusal factors are etiologic for
tmd → minimising these → minimized risk for TMD
CURRENT FUNCTIONAL TREATMENT
GOALS FOR ORTHODONTIC
THERAPY
• Esthetic and inter cuspal stability.
• Stable masticatory system includes stable occlusal position & stable
joint position.
↓
risk factor
• ANATOMY OF TMJ
TMJ : condyles resting in articular fossa with articular disk interposed
between them.
-Articular disk: avascular, dense fibrous connective tissue( bear heavy
forces)
separates, protects and stabilize the mandible during functional
movements.

Positional stability of the joint → muscles- Musculo skeletally stable

position.
• Major muscles : Elevators viz Temporalis,
Masseter & Medial pterygoid.

Temporalis: pulls mandible in superiorly.

Masseter & Medial pterygoid: superoanterior
direction thus guiding the mandible against
posterior slopes of articular eminence.

Besides these,
Lateral pterygoid: also helps in guiding the
mandible against the posterior slopes of
articular eminence.
• Orthopedially stable joint position
-condyles in superoanterior position
-resting against the slopes of articular eminence
-with articular disks properly interposed
• However,
-does not consider the teeth.

When condyles are in stable position, the teeth should be in maximum intercuspation.
hence, maximum stability and minimum forces on teeth during function.

So, , the criteria for optimum orthopedic stability in the masticatory system,
simultaneous contact of all possible teeth when
the mandibular condyles are in their most superoanterior
position,
resting against the posterior slopes of the articular eminences, with the discs properly
interposed.
• Besides this,
Lateral excursive movements of the mandible → horizontal forces on teeth
Anterior teeth (especially Canine): accepts more horizontal force than on posterior
teeth ding lateral excursive movements of mandible.

Furthermore, during protusive movement of mandible

anterior teeth should provide proper guidance to disocclude posterior teeth
 lateral excursions,
condyles in most adequate tooth guided
superoanterior contact on working
position with even side to disocclude non
contact of all posterior working side.
teeth
-canine guidance

when posterior teeth

protusive movements, are in contact,
tooth guided contact
on anterior teeth and posterior tooth
dissoclusion of contact should be
posterior teeth. heavier than anterior
tooth contacts
• Treatment planning...
-musculo skeletally stable position
-maximum inter cuspal position should be developed
-treatment should complete before complete maturation of condyle fossa
relationship.
and which is within patient's physiologic adaptability

Articulators: adult patients

FUTURE CONSIDERATIONS OF
OCCLUSION FOR
ORTHODONTISTS
• How the occlusal contact pattern of teeth affect dynamic function of masticatory
system?
Need: to understand how orthopedic stability affect the dynamic function of
masticatory system....chewing, swallowing, speech....

And,
investigation should be done to investigate patient's ability to adapt to change.
↓
better selection of treatment methods
 CONCLUSION
• Since the inception, occlusion is an important consideration to orthodontist.
Earlier there were emphasis on alignment of teeth, proper intercuspation, and
esthetics. But recently, more emphasis has been laid on ORTHOPEDIC PRINCIPLES
with Masticatory functions.

Orthodontic therapy does not cause TMD but Orthodontist can be the one who can
provide orthopedically stable positions which s most likely to reduce risk factors for
TMDs.