OrIgINAL PAPErS - Advances in Clinical and Experimental Medicine

OrIgINAL PAPErS - Advances in Clinical and Experimental Medicine

original papers
Adv Clin Exp Med 2011, 20, 5, 635–639
ISSN 1230-025X
© Copyright by Wroclaw Medical University
Beata Kawala, Liwia Minch, Joanna Antoszewska
Temporomandibular Dysfunction and Malocclusion
in Young Adult Males – A Clinical Examination
in a Medical Experiment
Dysfunkcje stawu skroniowo-żuchwowego a wady zgryzu
u młodych dorosłych mężczyzn
– badanie kliniczne w eksperymencie medycznym
Department of Maxillofacial Orthopedics and Orthodontics, Wroclaw Medical University, Poland
Abstract
Background. The prevalence of symptoms of temporomandibular dysfunction (TMD) has increased considerably
in the past decades. Many theories related to the etiology of TMD have been presented in the past, but a specific
and unique etiologic factor has not yet been diagnosed.
Objectives. The main goal of this study was to investigate the prevalence of malocclusion in young adult males and
to estimate the association between malocclusion and the prevalence and severity of TMD signs and symptoms.
Material and Methods. The material comprised healthy male volunteers, army recruits (n = 300, age of 19–26 years).
The clinicians established the prevalence of malocclusion and performed the registration of a Helkimo Anamnestic
Index and Dysfunction Index.
Results. The Anamnestic Index – AI = 0 occurred in 239 (79.7%) recruits, AI = 1 in 61 soldiers (20.3%), no one
presented with advanced symptoms – AI = 2. No clinical symptoms (DI = 0) were found in 184 soldiers (61.3%),
recruit numbers with DI = I and DI = II were comparable and reached 59 (19.7%) and 57 (19.0%), respectively.
None of the subjects displayed symptoms of severe dysfunction (DI = III). There were no statistically significant
differences between the prevalence of malocclusion and signs of anamnestic and clinical TMJ dysfunction according to the Helkimo indices.
Conclusions. The results of this study show an evidently minor association of malocclusion and TMD signs in
young, adult males. However other homogenous groups of individuals should be examined to enhance the evidence, preferably after unification of TMD classification (Adv Clin Exp Med 2011, 20, 5, 635–639).
Key words: temporomandibular disorders, Helkimo Index, malocclusion, young adults.
Streszczenie
Wprowadzenie. Częstość występowania objawów dysfunkcji stawów skroniowo-żuchwowych (d.s.ż.) zwiększyły
się w ciągu ostatnich lat. W przeszłości przedstawiono wiele teorii tłumaczących etiologię d.s.ż., lecz nie zdiagnozowano jednego swoistego czynnika.
Cel pracy. Zbadanie częstości występowania wad zgryzu wśród młodych dorosłych mężczyzn oraz ocena korelacji
między występowaniem wad zgryzu a objawami d.s.ż.
Materiał i metody. Materiał obejmował zdrowych ochotników, poborowych (liczba = 300, wiek 19–26 lat).
Badający oceniali występowanie wad zgryzu i przeprowadzali rejestrację wskaźnika klinicznego i anamnestycznego
według Helkimo.
Wyniki. Wskaźnik anamnestyczny – AI = 0 wystąpił u 239 (79,7%) poborowych, AI = 1 u 61 żołnierzy (20,3%),
nikt nie miał poważnych objawów – AI = 2. Brak klinicznych objawów (DI = 0) stwierdzono u 184 poborowych
(61,3%), liczba żołnierzy z DI = I i DII = II była podobna i wyniosła odpowiednio 59 (19,7%) i 57 (19,0%,). U nikogo
z badanych nie stwierdzono poważnej dysfunkcji (DI = III). Nie stwierdzono statystycznie istotnej korelacji między
występowaniem wady zgryzu a objawami anamnestycznego i klinicznego wskaźnika dysfunkcji według Helkimo.
Wnioski. Wyniki tego badania wykazały słabe powiązania okluzji z objawami d.s.ż. u młodych dorosłych mężczyzn.
Niemniej jednak o istotnych dowodach można będzie mówić dopiero po zbadaniu innych grup homogennych
i najlepiej po ujednoliceniu klasyfikacji objawów d.s.ż. (Adv Clin Exp Med 2011, 20, 5, 635–639).
Słowa kluczowe: dysfunkcje stawu skroniowo-żuchwowego, wskaźnik Helkimo, wady zgryzu, młodzi dorośli.
636
The importance of experimental research in
the development of efficient, evidence-based treatment is irrefutable. Discussing this problem only in
regard to orthodontics, it is necessary to cite Cattaneo et al. [1, 2], the researchers who evidently –
applying nonclinical experiments – contributed to
the implementation of sophisticated biomechanical approaches in the improvement of malocclusion.
However, the clinical aim of modern orthodontics is not only to develop a perfect occlusion,
but also to restore/maintain the normal function
of the temporomandibular joint (TMJ), whose
dysfunction (TMD) is the scope of the clinicians’
interest. TMD is a generic term for a number of
clinical signs and symptoms involving the masticatory muscles, the temporomandibular joints
and associated structures [3]. The prevalence of
the signs and symptoms of TMD have increased
considerably in the past decades. Many theories related to the etiology of TMD have been presented,
but a specific and unique etiologic factor has not
been detected [4]. In the last decade, much effort
has been made to clarify the supposed relationship
of malocclusion and TMD prevalence [5]; even
modern and sophisticated diagnostic tools such
as magnetic resonance imaging, and long-term
follow-up studies did not contribute [6].
Since the reasons of frequently occurring functional disorders of the masticatory system are still
controversial [7–13], the question remains: is there
any significant correlation of TMD and malocclusion? Therefore, applying a simple clinical experiment to answer this question was the aim of the
presented study, possibly helping in TMD prevention, and thus protecting one of the most complicated joints in the human body.
Material and Methods
The material comprised healthy male volunteers, army recruits (n = 300; aged 19–26 years;
mean age x = 21.2; standard deviation S = 1.6)
previously treated or untreated orthodontically,
reporting regular dental appointments. They came
from different regions of Poland and displayed different socio-economic backgrounds.
The methodology required extra-oral and intra-oral evaluation: palpation and eye inspection,
with the dental probe and the dental mirror, under
the light of a dental unit. The next step covered alginate impressions of upper and lower dental arches, followed by casting of plaster models. Based on
study models, thus providing conditions similar to
chair-time in general dental practice, the severity
of malocclusion and treatment needs were evalu-
B. Kawala, L. Minch, J. Antoszewska
ated separately by two orthodontists (L.M., B.K.).
In order to avoid bias, repetitive assessment of 50
randomly selected casts was performed 6 weeks after the initial evaluation.
A Helkimo Anamnestic Index and Dysfunction
Index [14] were registered in each individual. Registration of subjective symptoms applying the Anamnestic Index (AI) required a questionnaire-based
survey. The anamnestic examination was based on
the symptoms reported by the individuals and was
ranked on the AI scale as: 0 – no symptoms, 1 –
mild symptoms: sensation of the jaw-fatigue, jaw
stiffness and TMJ sounds, and 2 – severe symptoms: one or more of the following: a) difficulty
in the mouth opening, b) jaw locking, c) mandible
dislocation and its painful movement, and d) painful TMJ region and/or masticatory muscles.
The registrations of the symptoms of TMD
began with the assessment of mandibular mobility –
deviation exceeding 2 mm during the mouth opening, with a deviation > 5 mm registered as severe.
Subsequently, the following factors were evaluated:
a) TMJ function – joint clicking was recorded
for the right and the left sides separately, as palpable or evidently audible, no stethoscope. Locking
and luxation were recorded during mandibular
movements,
b)TMJ pain – occurring during palpation both
from aside and via external acoustic holes. The tenderness was recorded as palpable or as a palpebral
reflex (pain causing eyelid reaction),
c) muscle tenderness – revealed during palpation of the temporal and masseter muscles of either
facial side, recorded using the same assessments as
for TMJ pain,
d)clinical dysfunction index.
To accomplish the examination of the latter
subclass, a modified version of Helkimo’s Dysfunction Index (DI) was calculated. The clinical
symptoms were ranked as follows:
1. Opening range: 0 – if > 40 mm, 1 – if 30–39
mm, 2 – if < 30 mm.
2. Mandibular deviation during lowering: 0 –
if < 2 mm, 1 – if 2–5 mm, 2 – if > 5 mm.
3. TMJ dysfunction (clicking, locking, luxation): 0 – no impairment, 1 – palpable clicking,
2 – evident clicking, locking, luxation.
4. TMJ pain: 0 – no pain, 1 – palpable pain,
2 – palpebral reflex.
5. Muscle pain: 0 – no pain, 1 – palpable pain,
2 – palpebral reflex.
The sum of scores allowed the establishment
of the following dysfunction severity grades: 0 – no
dysfunction; I – mild dysfunction (1–4 points); II
– moderate dysfunction (5–9 points); III – severe
dysfunction (> 9 points).
637
Malocclusion in Young Adult Males
Statistical Analysis
The prevalence of TMD signs and symptoms
were analyzed considering all subjects as the sample. The t-test and c2 test were used to determine
associations between TMD and malocclusion. The
level of significance was established at p < 0.05.
Results
The analysis of the Anamnestic Index of the
TMJ scores showed that in most army recruits, 239
(79.7%), no subjective dysfunction symptoms were
observed (AI = 0). Slight disorders (AI = 1) were
found in 61 soldiers (20.3%) however no one presented with advanced symptoms (AI = 2) (Fig. 1).
The scores of the clinical TMJ Helkimo Dysfunction Index were different, as a lack of clinical symptoms (DI = 0) was found in 184 soldiers
(61.3%). Recruit numbers with a slight dysfunction
(DI = I) and with a medium one (DI = II) were
comparable and reached 59 (19.7%) and 57 (19.0%)
respectively. None of the subjects had symptoms of
severe dysfunction (DI = III), (Fig. 2).
There was no statistically significant difference (p
> 0.05) between the prevalence of malocclusion and
signs and symptoms assessed either with AI or DI
(Fig. 3). However, there was a statistically significant
correlation (p < 0.05) of AI and DI scores (Fig. 4).
Discussion
The present study revealed a lack of signs of
TMD (AI = 0) in 79.7% of recruits and at least
one of the symptoms of TMD (DI = I and II) diagnosed in 38.7% of the subjects. These results
are similar to those reported by Jenni et al. [15],
who obtained AI = 0 in 79.5% and DI = I and II
134
150
Al 1; 20.33%
Al 2; 0.00%
0
61 subject
105
100
40
50
21
0
yes
239 subject
Fig. 1. Sings of TMD, anamnestic index according to
Helkimo
Ryc. 1. Objawy dysfunkcji stawu skroniowo-żuchwowego, wskaźnik anamnestyczny wg Helkimo
DI II;
19.00%
present
no
malocclusion
…
absent
signs of
anamnesc
dysfuncon
index
Fig. 3. Lack of statistically significant differences
(p > 0.05) between prevalence of malocclusion and
signs and symptoms of anamnestic and clinical TMJ
dysfunction index according to Helkimo
Ryc. 3. Brak statystycznie istotnej różnicy (p > 0,05)
między obecnością wady zgryzu a objawami anamnestycznego i klinicznego wskaźnika dysfunkcji
wg Helkimo
DI III; 0.00%
0 subjects
57 subjects
59 subjects
184
subjects
no
minor moderate
dysfunc- dysfunc- dysfunc�on
�on
�on
symptoms of dysfunc�on
…
…
Fig. 2. Symptoms of TM, dysfunction index according
to Helkimo
Ryc. 2. Objawy dysfunkcji stawu skrioniowo-żuchwowego, wskaźnik kliniczny wg Helkimo
anamnes�c
dysfunc�on
index
Fig. 4. Statistically significant correlation (p < 0.05)
between values of anamnestic and clinical TMJ dysfunction index according to Helkimo
Ryc. 4. Statystycznie istotna korelacja (p < 0,05)
między anamnestycznym a klinicznym wskaźnikiem
dysfunkcji wg Helkimo
638
B. Kawala, L. Minch, J. Antoszewska
in 39.6% of the examined Swiss army recruits. According to other studies, by Ćelić et al. [16] and
Nawrocka-Furmanek et al. [17], evaluating males
at the age between 20 and 25 years, no dysfunction was found in 62.0% and 81.0% of subjects respectively. The wide range of affected subjects reported in various studies may however result from
multiplicity of the applied indices. The relatively
rare TMD prevalence in the current report possibly suggests that young, generally healthy males
demonstrate highly efficient adaptive systems,
therefore the presence of many factors predisposing them to the dysfunctions, such as malocclusions, oral habits, stress due to change of living
or work conditions and individual predisposition,
have little influence on the stomatognathic system.
In the studies assessing heterogeneous groups in
regard to gender and age, different results are obtained – from 21.2% to 70.6% of subjects with no
dysfunctions [18–23]. The conclusion of Kim et al.
[24], that there is a problem during the attempt of
comparing the results of different studies due to
lack of uniformed TMD classification, seems to be
relevant. Thus a homogeneous diagnostic system
with the study of homogeneous groups is crucial
for evidence-based comparisons.
Many authors [19, 23, 25] report a statistically
insignificant correlation between the frequency of
clinical TMD symptoms and occlusal relationships.
On the contrary, Ćelić et al. [16] and Nawrocka-
Furmanek et al. [17] found class II malocclusion
and crossbite correlated with TMD. However, they
refrained from the evident conclusion stipulating
that a low correlation ratio proves a rather weak
association, thus confirming a highly complex
TMD etiology.
In 1995, McNamara et al., based on a vast literature review, established occlusal risk factors for
TMD such as: 1) skeletal open bite, 2) overjet greater than 6–7 mm, 3) discrepancies between centric
relation (CR) and centric occlusion (CO) greater
than 4 mm, 4) unilateral crossbite, 5) the absence of
five or more posterior teeth [26]. Nonetheless since
the etiology of TMD is complex, its development is
hard to attribute to one factor only. Therefore, permanent research is required in order to confirm or
disapprove weak contributions of malocclusion in
TMD development if an orthodontic treatment protocol based on further experimental studies is not to
compromise the TMJ.
The results of the presented study indeed
proved no correlation of malocclusion and TMD
symptoms, but only in young, adult males. Nevertheless the role of easily accessible clinical evaluation in a possible evidence-based medical experiment aimed at excellent orthodontic results must
not be neglected. On the contrary, other homogenous groups of individuals should be examined to
enhance the evidence, preferably after the unification of TMD classification.
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Address for correspondence:
Liwia Minch
Department of Maxillofacial Orthopedics and Orthodontics
Wroclaw Medical University
Krakowska 26
50-425 Wrocław
Poland
Tel./fax +48 71 784 02 99
E-mail: [email protected]
Conflict of interest: None declared
Received: 22.07.2011
Revised: 27.09.2011
Accepted: 5.10.2011