Orthodontic Therapy and : An Update Orthodontic Therapy and : An Update by Jeffrey P Okeson, DMD Professor and Chief, Division of Orofacial Pain Director, Orofacial Pain Program University of Kentucky College of Dentistry Lexington, Kentucky 40536-0297 okeson@uky.edu www.jeffokeson.net? The American Association of Orthodontists Orlando, Florida May 3, 2016 Temporomandibular Disorders Some important questions for us to consider. Musculoskeletal pain disorders of the. Temporomandibular Disorder symptoms? 2. What causes Temporomandibular Disorder? 3. What are the functional treatment goals of orthodontic therapy? 4. When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder? 5. Can orthodontic therapy prevent? Orthodontic therapy and - a data based review - - let s ask some specific questions - symptoms? Signs and Symptoms: Post-Ortho vs Controls Authors # pat # controls years results Sadowsky & BeGole, 1980 75 75 10 years no significant differences Sadowsky & Polson, 1984 96 103 10 years no significant differences Larsson & Ronnerman, 1981 23 HI 10 years no significant differences Dahl et al, 1988 51 47 5 years no sign differences (- pat) Smith & Freer, 1989 87 28 4 years no sign differences (+ pat) Rendell et al, 1992 462 HI 18 mons no significant differences Hirata et al, 1992 102 41 2 years no significant differences Kremenak et al, 1992 109 HI 1-6 years no significant differences Wadhwa et al, 1993 31 71 4 years no significant differences Henrikson et al, 2000 65 60 2 years no significant differences 1
Orthodontic therapy and - a data based review - - let s ask some specific questions - symptoms? 2. Does premolar extraction increase the incidence of symptoms? Extraction vs. Non Extraction and Various Symptoms Authors # ex pat # non ex years results Janson & Hasund, 1981 30 30 5 years no significant differences Sadowsky et al., 1991 87 68 3 years no significant differences Luppanapornlarp, 1993 33 29 15 years no significant differences Kremenak et al, 1992 39 26 1-2 years no significant differences Dibbets et al, 1992 73 38 20 years no significant differences Orthodontic therapy and - a data based review - - let s ask some specific questions - symptoms? 2. Does premolar extraction increase the incidence of symptoms? 3. Does premolar extraction resulting in posterior displacement of condyles? Extraction vs. Non Extraction and Posterior Displacement of the Condyle Authors # ex pat # non ex results Gianelly et al, 1988 30 37 no significant differences Luecke et al,1992 42 --- 70 % more forward after tx Beattie et al, 1994 33 30 no significant differences Artun et al, 1992 29 34 Mixed: Right mid & lat all other areas no sign diff O Reilly et al, 1993 60 60 no significant differences Orthodontic therapy and - a data based review - - let s ask some specific questions - symptoms? 2. Does premolar extraction increase the incidence of symptoms? 3. Does premolar extraction resulting in posterior displacement of condyles? 4. Does orthodontic therapy prevent? Does Orthodontic Therapy Prevent Symptoms Authors # pat # controls years results Sadowsky & BeGole, 1980 75 75 10 years no significant differences Sadowsky & Polson, 1984 96 103 10 years no significant differences Larsson & Ronnerman, 1981 23 HI 10 years no significant differences Dahl et al, 1988 51 47 5 years no sign differences (- pat) Smith & Freer, 1989 87 28 4 years no sign differences (+ pat) Rendell et al, 1992 462 HI 18 mons no significant differences Hirata et al, 1992 102 41 2 years no significant differences Kremenak et al, 1992 109 HI 1-6 years no significant differences Wadhwa et al, 1993 31 71 4 years no significant differences Henrikson et al, 2000 65 60 2 years no significant differences 2
These studies suggest that orthodontic therapy is not a risk factor for. Some considerations regarding the conclusions of these studies Is that true?..or are there other factors that may need to be considered regarding the results of these studies? 1. The studies are true, there is no relationship between orthodontic therapy and. 2. The studies have only looked at well controlled orthodontic therapy. 3. The studies looked at young, growing, adaptive patients. 4. Orthodontic therapy does affect occlusion but.. the relationship between occlusion and is unclear. Some important questions for us to consider. Temporomandibular Disorder symptoms? 2. What causes Temporomandibular Disorder? 3. What are the functional treatment goals of orthodontic therapy? 4. When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder? 5. Can orthodontic therapy prevent? The Role of Occlusion in Temporomandibular Disorders Occlusion Our history? = =? Evidence based Dentistry TM Disorders Opinion? or Data? I reviewed the findings of 78 epidemiologic studies that investigated the relationship between occlusal factors and symptoms. Pub Med search from 1979-2008 3
Studies that investigate the relationship between occlusion and Williamson and Simmons, 1979 DeBoever and Adriaens, 1983 Egermark-Eriksson et al., 1983 Gazit et al., 1984 Brandt, 1985 Nesbitt et al., 1985 Thilander, 1985 Budtz-Jorgenson et al., 1985 Bernal and Tsamtsouris, 1986 Nilner, 1986 Stringert and Worms, 1986 Riolo et al., 1987 Kampe et al., 1987 Kampe and Hannerz, 1987 Gunn et al., 1988 Pullinger, et al., 1988 Seligman and Pullinger, 1989 Linde and Isacsson, 1990 Dworkin et al., 1990 Kampe et al., 1991 Steele et al., 1991 Takenoshita et al., 1991 Pullinger and Seligman, 1991 Wänman and Agerberg, 1991 Cacchiotti et al., 1991 Kampe et al., 1991 Steele et al., 1991 Total = 78 Studies Takenoshita et al., 1991 Pullinger and Seligman, 1991 Wänman and Agerberg, 1991 Cacchiotti et al., 1991 Egermark and Thilander, 1992 Shiau and Chang, 1992 Glaros et al., 1992 Huggare and Raustia, 1992 Kirveskari et al., 1992 Könönen, 1992 Könönen et al., 1992 List and Helkimo, 1992 Shian and Chang, 1992 Al Hadi, 1993 Pullinger and Seligman, 1993 Pullinger et al., 1993 Scholte et al.,1993 Tanne et al., 1993 Wadhwa et al., 1993 Keeling et al., 1994 Magnusson et al., 1994 Tsolka et al., 1994 Vanderas, 1994 Bibb et al., 1995 Castro, 1995 Hochman et al., 1995 Lebbezzo-Scholte et al., 1995 Olsson and Lindqvist, 1995 Mauro et al., 1995 Tsolka et al., 1995 Westling, 1995 Raustia et al., 1995 Conti et al., 1996 Sato et al.,1996 Seligman and Pullinger, 1996 Henrikson et al., 1997 Watanabe et al., 1998 Ciancaglini et al, 1999 Kahn et al., 1999 Seligman and Pullinger, 2000 Pullinger and Seligman, 2000 Rauhala et al., 2000 Thilander et al., 2002 Carlsson et al., 2002 Egermark et al., 2003 Gesch et al., 2004 Taskaya-Yilmaz et al., 2004 Landi et al., 2004 Pahkala et al., 2004 Magnusson et al., 2005 Gesch et al., 2005 Williamson and Simmons, 1979 DeBoever and Adriaens, 1983 Egermark-Eriksson et al., 1983 Gazit et al., 1984 Brandt, 1985 Nesbitt et al., 1985 Thilander, 1985 Budtz-Jorgenson et al., 1985 Bernal and Tsamtsouris, 1986 Nilner, 1986 Stringert and Worms, 1986 Riolo et al., 1987 Kampe et al., 1987 Kampe and Hannerz, 1987 Gunn et al., 1988 Pullinger, et al., 1988 Seligman and Pullinger, 1989 Linde and Isacsson, 1990 Dworkin et al., 1990 Kampe et al., 1991 Steele et al., 1991 Takenoshita et al., 1991 Pullinger and Seligman, 1991 Wänman and Agerberg, 1991 Cacchiotti et al., 1991 Kampe et al., 1991 Steele et al., 1991 No Studies that found no relationship between occlusion and No Total = 25 Studies Takenoshita et al., 1991 Pullinger and Seligman, 1991 Wänman and Agerberg, 1991 Cacchiotti et al., 1991 Egermark and Thilander, 1992 Shiau and Chang, 1992 Glaros et al., 1992 Huggare and Raustia, 1992 Kirveskari et al., 1992 Könönen, 1992 Könönen et al., 1992 List and Helkimo, 1992 Shian and Chang, 1992 Al Hadi, 1993 Pullinger and Seligman, 1993 Pullinger et al., 1993 Scholte et al.,1993 Tanne et al., 1993 Wadhwa et al., 1993 Keeling et al., 1994 Magnusson et al., 1994 Tsolka et al., 1994 Vanderas, 1994 Bibb et al., 1995 Castro, 1995 Hochman et al., 1995 Lebbezzo-Scholte et al., 1995 Olsson and Lindqvist, 1995 Mauro et al., 1995 Tsolka et al., 1995 Westling, 1995 Raustia et al., 1995 Conti et al., 1996 Sato et al.,1996 Seligman and Pullinger, 1996 Henrikson et al., 1997 Watanabe et al., 1998 Ciancaglini et al, 1999 Kahn et al., 1999 Seligman and Pullinger, 2000 Pullinger and Seligman, 2000 Rauhala et al., 2000 Thilander et al., 2002 Carlsson et al., 2002 Egermark et al., 2003 Gesch et al., 2004 Taskaya-Yilmaz et al., 2004 Landi et al., 2004 Pahkala et al., 2004 Magnusson et al., 2005 Gesch et al., 2005 Yes Studies that found a relationship between occlusion and Williamson and Simmons, 1979 DeBoever and Adriaens, 1983 Egermark-Eriksson et al., 1983 Gazit et al., 1984 Brandt, 1985 Nesbitt et al., 1985 Thilander, 1985 Budtz-Jorgenson et al., 1985 Bernal and Tsamtsouris, 1986 Nilner, 1986 Stringert and Worms, 1986 Riolo et al., 1987 Kampe et al., 1987 Kampe and Hannerz, 1987 Gunn et al., 1988 Pullinger, et al., 1988 Seligman and Pullinger, 1989 Linde and Isacsson, 1990 Dworkin et al., 1990 Kampe et al., 1991 Steele et al., 1991 Takenoshita et al., 1991 Pullinger and Seligman, 1991 Wänman and Agerberg, 1991 Cacchiotti et al., 1991 Kampe et al., 1991 Steele et al., 1991 Total = 53 Studies Takenoshita et al., 1991 Pullinger and Seligman, 1991 Wänman and Agerberg, 1991 Cacchiotti et al., 1991 Egermark and Thilander, 1992 Shiau and Chang, 1992 Glaros et al., 1992 Huggare and Raustia, 1992 Kirveskari et al., 1992 Könönen, 1992 Könönen et al., 1992 List and Helkimo, 1992 Shian and Chang, 1992 Al Hadi, 1993 Pullinger and Seligman, 1993 Pullinger et al., 1993 Scholte et al.,1993 Tanne et al., 1993 Wadhwa et al., 1993 Keeling et al., 1994 Magnusson et al., 1994 Tsolka et al., 1994 Vanderas, 1994 Bibb et al., 1995 Castro, 1995 Yes Hochman et al., 1995 Lebbezzo-Scholte et al., 1995 Olsson and Lindqvist, 1995 Mauro et al., 1995 Tsolka et al., 1995 Westling, 1995 Raustia et al., 1995 Conti et al., 1996 Sato et al.,1996 Seligman and Pullinger, 1996 Henrikson et al., 1997 Watanabe et al., 1998 Ciancaglini et al, 1999 Kahn et al., 1999 Seligman and Pullinger, 2000 Pullinger and Seligman, 2000 Rauhala et al., 2000 Thilander et al., 2002 Carlsson et al., 2002 Egermark et al., 2003 Gesch et al., 2004 Taskaya-Yilmaz et al., 2004 Landi et al., 2004 Pahkala et al., 2004 Magnusson et al., 2005 Gesch et al., 2005 What was the occlusal relationship found to be related to? The following occlusal conditions were reported as related to :..but all of these conditions were not reported in every study. anterior openbite increased overjet increased overbite centric slide >2 mm asymmetrical slide unilateral contact in CR Angle class II Angle class II, division 1 Angle class II, division 2 Angle class III posterior crossbite anterior crossbite non working contacts midline discrepancy loss of teeth loss of molar support presence of restoration reduced tooth contacts in CO crowding occlusal interferences attrition laterotrusive attrition anterior attrition no slide What was the occlusal relationship found to be related to? What was the occlusal relationship found to be related to? How common were these conditions reported? 16 studies = anterior openbite (20%)* 3 studies = loss of teeth (4%) 13 studies = increased overjet (17%) 3 studies = loss of molar support (4%) 10 studies = centric slide >2 mm (13%) 3 studies = posterior crossbite (4%) 9 studies = asymmetrical slide (12%) 3 studies = reduced CO tooth contacts (4%) 8 studies = non working contacts (10%) 2 studies = attrition (4%) 7 studies = occlusal interferences (9%) 2 studies = presence of restoration (4%) 6 studies = unilateral contact in CR (8%) 1 study = Angle class II, division 2 (1%) 5 studies = anterior crossbite (6%) 1 study = laterotrusive attrition (1%) 4 studies = Angle class II (5%) 1 study = anterior attrition (1%) 4 studies = Angle class II division 1 (5%) 1 study = crowding (1%) 4 studies = Angle class III (5%) 1 study = midline discrepancy (1%) 4 studies = increased overbite (5%) 1 study = no slide (1%) * % of the 78 studies reporting this finding How common were these conditions reported? 16 studies = anterior openbite (20%)* 13 studies = increased overjet (17%) 10 studies = centric slide >2 mm (13%) 9 studies = asymmetrical slide (12%) 8 studies = non working contacts (10%) 7 studies = occlusal interferences (9%) 6 studies = unilateral contact in CR (8%) 5 studies = anterior crossbite (6%) 4 studies = Angle class II (5%) 4 studies = Angle class II division 1 (5%) 4 studies = Angle class III (5%) 4 studies = increased overbite (5%) 3 studies = loss of teeth (4%) 3 studies = loss of molar support (4%) 3 studies = posterior crossbite (4%) An 3 studies anterior = reduced openbite CO tooth may contacts be(4%) 2 studies the = results attrition of (4%) a, 2 studies = presence of restoration (4%) and not the cause a. 1 study = Angle class II, division 2 (1%) 1 study = laterotrusive attrition (1%) 1 study = anterior attrition (1%) 1 study = crowding (1%) 1 study = midline discrepancy (1%) 1 study = no slide (1%) * % of the 78 studies reporting this finding 4
What was the occlusal relationship - Important found - to be related to? These occlusal conditions do not always lead to! How common were these conditions reported? 16 studies = anterior openbite (20%)* 3 studies = loss of teeth (4%) 13 studies = increased overjet (17%) 3 studies = loss of molar support (4%) 10 studies = centric slide >2 mm (13%) 3 studies = posterior crossbite (4%) 9 studies = asymmetrical slide (12%) 3 studies = reduced CO tooth contacts (4%) 8 studies = non working contacts (10%) 2 studies = attrition (4%) 7 studies = occlusal interferences (9%) 2 studies = presence of restoration (4%) 6 studies = unilateral contact in CR (8%) 1 study = Angle class II, division 2 (1%) 5 studies = anterior crossbite (6%) 1 study = laterotrusive attrition (1%) 4 studies = Angle class II (5%) 1 study = anterior attrition (1%) 4 studies = Angle class II division 1 (5%) 1 study = crowding (1%) 4 studies = Angle class III (5%) 1 study = midline discrepancy (1%) 4 studies = increased overbite (5%) 1 study = no slide (1%) * % of the 78 studies reporting this finding 5
of the of the The is unaffected The develops symptoms Correct the occlusal condition of the Slade, Ohrbach and Maixner: Orthodontic Treatment, Genetic Factors, and Risk of Seminars in Orthodontics Vol14, No 2, 2008, pp 146-156 The Three asymptomatic common COMT Etiologic haplotypes Factors low pain sensitivity (LPS) average pain sensitivity (APS) high pain sensitivity (HPS) of the How do you treat the symptoms? The is unaffected Some important questions for us to consider. Temporomandibular Disorder symptoms? 2. What causes Temporomandibular Disorder? 3. What are the functional treatment goals of orthodontic therapy? 4. When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder? 5. Can orthodontic therapy prevent? These are the treatment goals for orthodontic therapy - Condylar Stability - The condyles are in their most superior anterior position in the fossae resting against the posterior slopes of the articular eminentiae. (musculoskeletally stable) The discs are properly interposed between the condyles and the fossae. - Occlusal Stability - Even and simultaneous contact of all teeth with posterior teeth contacting slightly heavier than anterior teeth. Adequate tooth-guided contacts on the laterotrusive side. In the normal upright position, posterior teeth contact heavier than anterior teeth (envelop of function). 6
Orthodontic therapy can produce orthopedic stability Some believe the best position for the condyle is in a forward, protrusive position in the fossa. Joint Stability = Occlusal Stability This is a muscle braced position not a musculoskeletally stabilized position. MSS Position Some believe the best position for the condyle is in a forward, protrusive position in the fossa. Does placing the condyle in a forward position cause any anatomical problems? No, this is a functional position: protrusion This is a muscle braced position not a musculoskeletally stabilized position. However, the muscles must actively brace the condyle to maintain it in this position. What would be the purpose of moving the mandibular forward in a protrusive position? 1. Functional Orthodontics Bring the mandibular forward (in a growing patient) Insert a functional appliance Allow the condyle to grow into the musculoskeletally stable position. 7
With time the muscle develops a myostatic contracture. A painless shortening of the functional length of the muscle. But what if the mandible does not grow? And the occlusion is established in this forward position. But what if the mandible does not grow? MSS Position Now the condyles are braced forward and the occlusion is stabilized in this position. What if at a later time the condyles become seated into their musculoskeletally stable positions? And the occlusion is established in this forward position. MSS Position Now the condyles are braced forward and the occlusion is stabilized in this position. What if at a later time the condyles become seated into their musculoskeletally stable positions? An anterior open bite (significant orthopedic instability) The orthodontist should assess for condylar stability before finishing the occlusion. - some considerations - 1. Try a bilateral mandibular manipulation. 2. Consider an anterior bite plane for a short time (2-7 days). 3. Consider imaging. - Conclusion - Radiographs are not an accurate method of assessing joint position. 8
Okeson AAO May 3, 2016 Joint stability Does a lack of orthopedic stability lead to? Occlusal instability Joint instability Orthopedic instability plus loading An intracapsular disorder Occlusal stability - Important This orthopedic instability must be of clinical significance. - another important concept - A stable malocclusion A dental malocclusion that is orthopedically stable. MSS ICP > 3-4 mm 9
A stable dental malocclusion Find the musculoskeletally stable position. Orthopedic stability (not a risk factor) Find the musculoskeletally stable position. Find the musculoskeletally stable position. Orthopedic Instability (a potential risk factor) (loading) Orthodontic therapy only affects one factors. Some important questions for us to consider. Temporomandibular Disorder symptoms? 2. What causes Temporomandibular Disorder? 3. What are the functional treatment goals of orthodontic therapy? 4. When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder? 5. Can orthodontic therapy prevent? How does orthodontic therapy affect? of the 10
Orthodontic therapy only affects one factors. Orthodontic therapy will fail to affect the symptoms. of the Some important questions for us to consider. Temporomandibular Disorder symptoms? 2. What causes Temporomandibular Disorder? 3. What are the functional treatment goals of orthodontic therapy? 4. When should you consider orthodontic therapy for the treatment of a Temporomandibular Disorder? 5. Can orthodontic therapy prevent? Orthodontic therapy only affects one factors. of the Some additional thoughts to consider. Goal of orthodontic therapy: Establish orthopedic stability Orthodontic therapy may reduce only one risk factor associated with. So why does the literature report very little relationship between orthodontic and? So why does the literature report very little relationship between orthodontic and? If the occlusion is finalized before final maturation of the condyles. Perhaps it is the patient that makes us look so good. then the TMJs will adapt/develop to the musculoskeletally stable positions. - form follows function - 11
of the of the The adult patient may not have the same adaptability. Orthodontic therapy only affects one factors. Maintaining a Healthy Functioning Masticatory System through Orthodontic Therapy - Conclusions - of the The orthodontist should appreciate: 1. The importance of orthopedic stability in the. 2. The importance of patient adaptability. 3. Occlusal factors are only one of many factors that may be associated with. Not likely. Can orthodontic therapy prevent? In order to prevent you must control all the factors. This greatly concerns me. Thank you for your kind attention. - Jeffrey P Okeson, DMD 12
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