Condylar displacement between centric relation and maximum intercuspation in symptomatic and asymptomatic individuals

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1 Originl Article Condylr displcement between centric reltion nd mximum intercusption in symptomtic nd symptomtic individuls Soo Young Kim Weffort ; Solnge Mongelli de Fntini b ABSTRACT Objective: To mesure condylr displcement between centric reltion (CR) nd mximum intercusption (MIC) in symptomtic nd symptomtic subjects. Mterils nd Methods: The smple comprised 70 non-deprogrmmed individuls, divided eqully into two groups, one symptomtic nd the other symptomtic, grouped ccording to the reserch dignostic criteri for temporomndibulr disorders (RDC/TMD). Condylr displcement ws mesured in three dimensions with the condylr position indictor (CPI) device. Dhlberg s index, intrclss correltion coefficient, repeted mesures nlysis of vrince, nlysis of vrince, nd generlized estimting equtions were used for sttisticl nlysis. Results: A greter mgnitude of difference ws observed on the verticl plne on the left side in both symptomtic nd symptomtic individuls (P 5.033). The symptomtic group presented higher mesurements on the trnsverse plne (P 5.015). The percentge of displcement in the mesil direction ws significntly higher in the symptomtic group thn in the symptomtic one (P 5.049). Both groups presented significntly higher percentge of mesil direction on the right side thn on the left (P 5.036). The presence of bilterl condylr displcement (left nd right sides) in n inferior nd distl direction ws significntly greter in symptomtic individuls (P 5.012). However, no sttisticl difference ws noted between genders. Conclusion: Sttisticlly significnt differences between CR nd MIC were quntifible t the condylr level in symptomtic nd symptomtic individuls. (Angle Orthod. 2010;80: ) KEY WORDS: Condylr displcement; Centric reltion; Mximum intercusption INTRODUCTION Regrding dentl procedures, the mndible cn ssume two well-known positions s reference for tretment: centric reltion (CR) nd mximum intercusption (MIC). 1 These usully re not coincident in the generl popultion The MIC position refers to the occlusl reltionship in which the teeth of both rches re mostly interposed. In this cse, the mndible genertes joint position dictted by the teeth. On the other side, CR is defined s the most nterior-superior position the condyles cn chieve in PhD Grdute Student, Deprtment of Orthodontics nd Dentl Peditrics, Fculty of Dentistry, University of São Pulo, Brzil. b Professor of Deprtment of Orthodontics nd Dentl Peditrics, Fculty of Dentistry, University of São Pulo, Brzil. Corresponding uthor: Dr Soo Young Kim Weffort, Deprtment of Orthodontics nd Dentl Peditrics, Fculty of Dentistry, Av Prof Lineu Prestes, 2227, University of São Pulo, Brzil (e-mil: sookim@usp.br) Accepted: December Submitted: September G 2010 by The EH Angle Eduction nd Reserch Foundtion, Inc. the foss, seted ginst the rticulr disc t the posterior slope of the eminence, centered trnsversely by coordinted mstictory muscles. 7,20 It hs lso been described s the most stble nd comfortble position of the mndible in which the joints cn be loded without discomfort. 20 Controversy continues bout wht is considered n idel condyle-foss reltionship when the teeth estblish MIC. 1 4 If ny premture occlusl contct chnges the jw closing rc, the condyles might be displced to chieve mxillomndibulr reltionship in MIC, thus voiding premture contct. It is not cler how occlusl chnges (nturl dentition development, occlusl tretments, or restortion procedures) ffect the function of the temporomndibulr joint. 21,22 Severl studies hve shown tht in most cses the neuromusculture plces the mndible in such position tht the highest number of occlusl contcts is estblished without tking into ccount the finl condylr position. 1 4,13,23 26 However, the role of condylr displcement in the context of morphologic nd functionl occlusion s risk fctor in temporomndibulr disorder (TMD) development hs not been clerly elucidted. For this DOI: /

2 836 WEFFORT, DE FANTINI Figure 1. Mximl intercusption (MIC) wx bite registrtion ws tken with one sheet only of Beuty Pink Wx (Moyco Inc, Phildelphi, P). reson, ssessment of rticulted models in CR should not be ignored becuse the mlocclusion could be different, depending on the mndibulr position dopted during the orthodontic dignosis. 1 3,25 27 Previous studies 1,2,4,24 26,28 30 hve shown tht CR-MIC discrepncies re frequently present in the generl popultion, in symptomtic s often s in symptomtic subjects, whether they re of distinct fcil pttern or not, nd whether deprogrmmed or not. Differences between CR nd MIC re observed on three sptil plnes, eqully t the condylr level, by mens of condylr position indictor (CPI), nd t the dentl level, vi n interdentl reltion exmintion. CR-MIC discrepncies observed t the level of the occlusion frequently hve been shown not to correspond to those mesured t the condylr level. 1,2,4,24 26,28 31 The purpose of this cross-sectionl study ws to mesure condylr displcement between CR nd MIC in symptomtic nd symptomtic individuls with TMD. The objectives were s follows: N Mesure the CR-MIC discrepncy in the three dimensions of spce N Sttisticlly compre the mgnitude, direction, nd frequency of CPI mesurements in both study groups N Compre condylr displcement mong mles nd femles MATERIALS AND METHODS The smple comprised 70 non-deprogrmmed individuls, divided eqully into two groups: symptomtic group (men ge, 22.8 yers) nd n symptomtic group (men ge, 23.6 yers). Ech group contined 20 femles nd 15 mles, ged 18 to 30 yers. Prticipnts were selected from the students Figure 2. For the centric reltion (CR) bite record, Blue Bite Registrtion Delr Wx (Delr Corp, Lke Oswego, Ore) ws used in two sections ccording to Roth s power centric technique. nd ptients of the Orthodontic Deprtment t São Pulo Dentl School, University of São Pulo, Brzil. All individuls signed n informed consent indicting their greement with the reserch procedures. Approvl for the procedures of this reserch ws obtined from the Ethics Committee of the University of São Pulo (Project Number 82/05). All subjects completed questionnire to identify fcil pin, joint nd muscle complints, problems of mstiction, hedche, prfunction, nd clenching, grinding, nd bite hbits. Subsequent clinicl muscle nd joint exmintions were performed on ech ptient. On the bsis of dt collected during nmnesis nd clinicl exmintion, subjects were divided into two groups symptomtic group nd n symptomtic group in ccordnce with the Reserch Dignostic Criteri (RDC) for TMD (Axis I group I). 32 The temporomndibulr joint (TMJ) physicl exmintion included mesurements of mouth opening, right nd left excursion of the mndible, nd protrusion. All these mesurements were mde on mximum unssisted extension. The joint noise level ws verified by digitl plption during mndibulr movements such s opening-closing, protrusion-retrusion, nd lterl excursion. In the TMJ exmintion, possible restriction or devition of jw movement ws observed. Following the previous exmintion, plption for the reference point of muscle pin nd tenderness ws nlyzed. As pressure ws pplied, the ptient ws sked if the plption ws pinful, nd if the reference point of the pin ws locted wy from the plption site. A numeric rting scle (0 to 10) ws used to quntify pin levels experienced by ptients. The symptomtic group hd no history of ny type of TMD (ie, bsence of the following signs nd symptoms: fcil muscle pin/ftigue, tenderness

3 CONDYLAR DISPLACEMENT BETWEEN CR AND MIC 837 Figure 3. Centric reltion (CR) position in condylr position indictor (CPI) instrumenttion determined by CR bite record. upon plption, limited rnge of motion, pin upon movement, clicking or locking joint, or TMJ pin). The symptomtic group ws identified s prticipnts who presented with myofscil pin, in whom click sound could be present or bsent. Pin upon plption t three or more musculr sites hd to be present (pin level $5 on numeric scle) on mstictory muscles. The muscle sites included the origin, body, nd insertion of the msseter; the deep msseter; the nterior, medium, nd posterior temporlis; the ttchment of the temporlis on the coronoid process; nd the medil nd lterl pterygoid. Musculr spsm, musculr contrcture, nd myositis were considered to be exclusion criteri. None of the subjects hd history of hed, jw, or neck trum, extensive restortion or rehbilittion, periodontl disese, or ny condition cusing pin of dentl origin. Figure 5. Centric reltion (CR) position ws mrked in blck, nd mximl intercusption (MIC) in red. On the verticl plne, negtive sign represents tht MIC is dislocted in the superior direction, nd on the horizontl plne, in the posterior direction. A positive sign on the verticl plne indictes inferior direction, nd on the horizontl plne, nterior direction. A wx bite registrtion in MIC ws tken for ech ptient (Figure 1). The CR bite registrtion (Figure 2) ws tken ccording to Roth s power centric technique 1,10 modified by Fntini, 33 with the ptient in supine position nd bimnul mndibulr mnipultion pplied to chieve the best CR vilble tht dy. No other deprogrmming method ws used. Mxillry nd mndibulr models of ll prticipnts were mounted on n rticultor (Pndent, Pndent Corp, Grnd Terrce, Clif). For the mounting of ech subject, condylr displcement between CR (Figure 3) nd MIC (Figure 4) ws ssessed with CPI (Pndent) nd ws evluted for frequency, direction, nd mgnitude on three plnes of spce (Figure 5). All Figure 4. Mximl intercusption (MIC) position in condylr position indictor (CPI) instrumenttion determined by MIC bite record. Tble 1. Study Error for Repetbility nd Reproductibility of CR- MIC Displcement Mesurements Opertor CPI Intrclss Correltion IC (95%) Min Mx Dhlberg s Index Intr- Ver R Ver L Hor R Hor L Trns Inter- Ver R Ver L Hor R Hor L Trns CPI indictes condylr position indictor; CR, centric reltion; IC, intrclss correltion; mx, mximum; MIC, mximl intercusption; nd min, minimum.

4 838 WEFFORT, DE FANTINI Tble 2. Men Vlues (SD), Minimum nd Mximum (mm), of Condylr Displcement on Verticl, Horizontl, nd Trnsversl Plnes in Symptomtic nd Asymptomtic Groups Asymptomtic CPI Men (SD) Min-Mx Men (SD) Min-Mx Ver R 1.22 (0.74) (0.69) Ver L 1.30 (0.73) (0.92) Hor R 0.63 (0.50) (0.49) Hor L 0.63 (0.61) (0.40) Trns 0.23 (0.28) (0.32) mounting models, records, nd exmintions were performed by one opertor, except interopertor error nlysis, in which second opertor prticipted. One rticultor ws used for ll mountings. Sttisticl Anlysis Symptomtic CPI, condylr position indictor; mx, mximum; nd min, minimum. Intropertor error for reproducibility of CR records ws determined by collecting new CR records of 30 rndomly selected subjects performed by the sme opertor. Interopertor error for repetbility ws determined by hving new CR records for 10% of the smple (rndomly selected) performed by second opertor. Both were evluted by intrclss correltion nd Dhlberg s index. Repeted mesures nlysis of vrince ws used to compre the sttisticl significnce of CPI mens on verticl nd horizontl plnes in symptomtic nd symptomtic groups ccording to side nd gender. The two-wy nlysis of vrince (ANOVA) ws used for comprison on the trnsverse plne. The possible ssocition between the direction of condylr displcement nd the symptoms ws tested by mens of generlized estimting equtions (GEE). Person s chi-squre test ws undertken to compre the frequency distribution of inferior nd distl direction condylr displcement on both sides (left nd right) nd TMD symptoms. All tests were run t 95% confidence level. RESULTS Results of study error nlysis vi intrclss correltion coefficient (ICC) nd Dhlberg s index in ll interopertor nd intropertor mesurements showed high repetbility nd reproducibility of the described technique (Tble 1). For the symptomtic group, the bsolute men vlue of condylr displcement ws 1.22 mm (right side) nd 1.30 mm (left side) on the verticl plne; 0.63 mm (right nd left sides) on the horizontl plne; nd 0.23 mm on the trnsverse plne. In the symptomtic group, the vlues were 1.48 mm (right side) nd 1.72 mm (left side) on the verticl plne; 0.63 mm on the horizontl plne on the right side nd 0.64 mm on the left; nd 0.41 mm on the trnsverse plne. The symptomtic group presented lrger vlues in comprison with the symptomtic group. Vlues of greter mgnitude were observed on the verticl plne in both symptomtic nd symptomtic individuls (Tble 2). Becuse the prmeters nlyzed re not independent (ie, the condylr movement in the right joint is dependent on tht on the left side), interctions between fctors, side, symptom, nd gender hd to be clculted. For verticl nd horizontl mesures, no sttisticlly significnt effects of interctions were Tble 3. Repeted Mesures Anlysis of Vrince with the Repeted Fctor Side nd the Fixed Fctors Symptom nd Gender for Mens (SD) of Condylr Displcement on Verticl nd Horizontl Plnes in Symptomtic nd Asymptomtic Groups According to Side nd Gender Interction Effects (P) Fctor Effects (P) CPI Femle Mle Side 3 Symptom 3 Gender Side 3 Symptom Side 3 Gender Symptom 3 Gender Side Symptom Gender Verticl * Asymptomtic Right 1.25 (0.65) 1.18 (0.86) Left 1.42 (0.69) 1.15 (0.78) Symptomtic Right 1.64 (0.76) 1.26 (0.53) Left 1.92 (1.01) 1.46 (0.75) Horizontl Asymptomtic Right 0.69 (0.58) 0.55 (0.38) Left 0.56 (0.45) 0.74 (0.78) Symptomtic Right 0.63 (0.55) 0.65 (0.40) Left 0.61 (0.36) 0.69 (0.47) CPI, condylr position indictor. * P # 0.05.

5 CONDYLAR DISPLACEMENT BETWEEN CR AND MIC 839 Tble 4. Anlysis of Vrince of Condylr Displcement on Trnsversl Plne in Symptomtic Group Compring Symptoms nd Gender CPI Fctor Sum of Squres Squre Men Trns Symptom * Gender Symptom 3 Gender CPI, condylr position indictor. * P #.05. observed between side nd gender (P..05). A sttisticlly significnt effect ws present on the fctor side on the verticl plne (P 5.033), nd the mens on the left side were significntly higher thn on the right in both groups (Tble 3). A sttisticlly significnt difference ws found in the comprison of condylr displcement between symptomtic nd symptomtic groups on the trnsverse plne (P 5.015) (Tble 4), where greter vlues were observed in the symptomtic group. No ssocition ws seen between displcement directions ccording to symptoms nd side, nd no sttisticlly significnt effect of interctions ws observed between fctors (P..05). A sttisticlly significnt effect ws noted on the fctor side (Tble 5) (P 5.036), where the percentge of mesil direction on the right side ws significntly higher thn on the left side in both groups. Condylr displcement in the mesil direction ws more prevlent in symptomtic individuls (Tble 5) (P 5.049) thn in the symptomtic group. Anlysis of the direction of condylr displcement showed tht in the symptomtic group, 55.7% of the condyles were displced in the posterior-inferior direction, 41.3% nterior-inferior, nd 2.8% stright inferior. In the symptomtic group, displcement ws nterior-inferior in 55.7%, 35.7% followed posteriorinferior direction, nd 8.5% were stright inferior. The Tble 5. Condylr Displcement Direction Distribution (Number of Cses nd %) on Horizontl Plne According to Symptom Presence nd Side Asymptomtic Symptomtic CPI Right Left Right Left Horizontl direction Mesil 26 (74.3) 19 (54.3) 16 (45.7) 15 (42.9) Distl 9 (25.7) 16 (45.7) 19 (54.3) 20 (57.1) Interction effects P Fctor P effects Side 3 Symptom.116 Side.036* Symptom.049* CPI, condylr position indictor. * P #.05. P Tble 6. Chi-Squre Test for Comprison of Presence of Bilterl Condylr Displcement (Inferior nd Distl Direction on Left nd Right Sides) Bilterl Condylr Displcement Asymptomtic Symptomtic Presence 7 (20.0%) 17 (51.4%) Absence 28 (80.0%) 18 (48.6%) Totl 35 (100%) 35 (100%) * P presence of bilterl condylr displcement (left nd right sides) in n inferior nd distl direction ws significntly greter in symptomtic individuls (Tble 6) (P 5.012). DISCUSSION Condylr displcement between CR nd MIC mndibulr positions ws nlyzed in comprisons of symptomtic nd symptomtic groups. Results of study error nlysis in this study confirmed those of previous studies. 1,10,29 The men vlues of the symptomtic group were consistent with those of Utt et l., 26 Crwford, 2 Fntini, 24 nd the hyperdivergent smple of Girrdot, 25 lso grouped symptomticlly. The men vlues of displcements found in the symptomtic group re higher thn those found, by other uthors, in symptomtic groups. 28,29 Becuse difficulty in mndibulr mnipultion is firly frequent in symptomtic individuls, it ws expected tht symptoms could hmper condylr seting nd consequently CR registrtion. However, this ws not observed, indicting tht mndibulr bimnul mnipultion ws effective. Vlues of greter mgnitude on the verticl plne, observed in both groups, re in greement with those of other studies, 1,24 26,28,30,31,34 being sttisticlly different on the right nd left sides (.033). Before mjor clinicl conclusions re reched on the importnce of results when the sides re compred, new studies re recommended, becuse these symmetries hve lso been witnessed in the literture on subjects with distinct chrcteristics. 26,31 Wood nd Korne 34 registered mjor displcements on the horizontl plne on the left side. On the other hnd, Fntini 24 found symmetry on the verticl plne, fter neuromusculr deprogrmming with bite splints, nd the displcements were greter on the right side. Upon studying symptomtic individuls, Rosner nd Goldberg 28 found no difference between the two sides. Diverse uthors 2,3,20,35 gree tht symptomtic ptients with TMD my present significnt discrepncies between CR nd MIC, especilly on the trnsverse plne observed t the occlusl nd rticulr levels. 4,26 The results of this study lso demonstrte greter condylr displcement on the trnsverse plne in the symptomtic

6 840 WEFFORT, DE FANTINI Figure 6. (A) Right lterl view of models mounted in mximl intercusption (MIC). (B) Right lterl view of models mounted in centric reltion (CR) from the sme ptient. group. On evlution of possible correltion between condylr displcement direction nd occurrence of signs nd symptoms of TMD, symptomtic individuls presented mjor prevlence of displcement in the mesil direction when compred with symptomtic individuls. The prevlence of directions of displcement posteroinferior, nterior-inferior, nd stright inferior is in close greement with tht of others who used nlogous methods. 1,2,4 The posteriorinferior direction of displcement in symptomtic individuls hs lredy been seen by Weinberg 36,37 nd Mikhil nd Rosen 38 on tomogrphs, nd ltely by Crwford, 2 utilizing similr methods to those used in this study. In comprisons between men nd women in both studied groups, no sttisticl differences were identified. This finding confirms the sme conclusions reched by Cordry, 1 Fntini et l., 24 Utt et l., 26 nd Tursi. 4 The mgnitude of the CR-MIC discrepncy t the condylr level hs n influence on occlusl reltionships (Figures 6A,B nd 7A,B), chnging the type or severity of mlocclusion, depending on the mndibulr position dopted during the nlysis. It cnnot be quntified directly in the mouth becuse of some structurl fetures, such s fcil type, gonil ngle, nd occlusl plne inclintion, ll of which will lso influence the resulting mlocclusion. This mens tht ptients with distinct fcil chrcteristics will demon- Figure 7. (A) Left lterl view of models mounted in mximl intercusption (MIC). (B) Left lterl view of models mounted in centric reltion (CR) from the sme ptient.

7 CONDYLAR DISPLACEMENT BETWEEN CR AND MIC 841 strte lrger or smller differences between rch reltionships, even in the presence of the sme mount of condylr displcement. The dignosis for orthodontic tretment with mounted models in CR is recommended by vrious uthors, 3,10,13,24 26,30,31 by llowing identifiction of discrepncies tht my be msked when nlyzed on trditionl orthodontic models rticulted by hnd. Becuse condylr displcement ws observed in both study groups, orthodontic models mounted in CR re recommended for dignosis s routine procedure. 1,3,24 Clinicl conditions of TMJ lso should be checked t the beginning of, during, nd t the end of orthodontic tretment. CONCLUSIONS N When the plne nd the direction of the displcement were considered, sttisticlly significnt differences between CR nd MIC were quntifible t the condylr level in symptomtic nd symptomtic individuls. N No sttisticl differences were noted between genders. ACKNOWLEDGMENTS The uthors would like to grtefully cknowledge Dr Frnk Cordry, Assistnt Clinicl Professor in the Deprtment of Orthodontics, Ohio Stte University, for his precious help in reviewing this mnuscript, nd lso Lur K. Frnklin for her ssistnce in editing nd grmmr correction. We would like to thnk the Fundção de Ampro à Pesquis do Estdo de São Pulo (FAPESP) for the finncil support provided for the development of this study (Grnt 05/ ). Bsed on disserttion submitted to the Fculty of Dentistry, University of São Pulo, Brzil, in prtil fulfillment of requirements for the mster s degree. REFERENCES 1. Cordry FE. Three-dimensionl nlysis of models rticulted in the seted condylr position from deprogrmmed symptomtic popultion: prospective study. Prt 1. Am J Orthod Dentofcil Orthop. 2006;129: Crwford SD. Condylr xis position, s determined by occlusion nd mesured by the CPI instrument, nd signs nd symptoms of temporomndibulr dysfunction. Angle Orthod. 1999;69: Roth RH. 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