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Examination of temporomandibular disorders in the orthodontic patient: A

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EXAMINATION OF TEMPOROMANDIBULAR DISORDERS

IN THE ORTHODONTIC PATIENT: A CLINICAL GUIDE

Ana Claúdia de Castro Ferreira CONTI1, Paula Vanessa Pedron OLTRAMARI1,

Ricardo de Lima NAVARRO1,2 , Márcio Rodrigues de ALMEIDA1

1- DDS, MSc, PhD, Assistant Professor of Orthodontics, UNINGÁ Dental School, Maringá, PR, Brazil.
2- DDs, MSc, PhD, Assistant Professor of Oral and Maxillofacial Surgery, UNINGÁ Dental School, Maringá, PR, Brazil.

Corresponding address: Ana Cláudia de Castro Ferreira Conti - Rua Renato Tâmbara, 2-147 - Res. Samambaia, Cep.: 17018-100, Bauru-SP
- phone/fax: +55 14 3223-5217 - e-mail: accfconti@uol.com.br

Received: November 17, 2006 - Accepted: February 12, 2007

ABSTRACT
T he possible association between orthodontic treatment and temporomandibular disorders (TMD) is a topic of great interest
in the current literature. The true role of orthodontic therapy on the etiology of TMD, however, is still uncertain. From the
clinical prospective, a thorough examination of the stomatognathic system is always necessary in order to detect possible
TMD signs and symptoms prior to the beginning of the orthodontic therapy. Caution should be exercised when planning,
performing and finalizing orthodontics, especially in patients who with history of signs and symptoms of TMD. The clinician
must always eliminate patient’s pain and dysfunction before initiating any type of orthodontic mechanics. Muscle incoordination,
unstable disc-condyle relationship and bone alterations are usual TMD conditions that can interfere with the presenting
occlusal relationship. This article reviews these aspects and presents a detailed clinical guide for the examination of the
orthodontic patient, considering aspects related to facial pain and dysfunction.

Uniterms: Temporomandibular joint disorders; Orthodontics; Orthopedics; Dental occlusion.

INTRODUCTION would be due to occlusal interferences or even to a new

occlusal design, achieved after orthodontic therapy.
The possible relationship between orthodontic treatment Premolar extractions and incisor retraction, causing posterior
and temporomandibular disorders (TMD) is frequently displacement of the condyle and consequent overload to
subject of discussion between clinicians and issue of pain-sensitive areas used to be considered TMD-
different studies in the last decades1,3,5,10,14,16,20-23. Despite contributing factors as well9,25,28,42. This alteration in the
these studies, many doubts concerning the real participation condyle position would cause intra-capsular problems and
of orthodontic treatment in the etiology of TMD still remain joint pain. These statements, however, have been based
unsolved. A thorough clinical interview and physical merely on clinical experience and reports of personal points
examination to detect TMD signs and symptoms prior to of view. Most scientific, evidence-based studies do not
the establishment of the orthodontic therapy is mandatory. confirm these assumptions5,13,19.
Even considering that orthodontic treatment does not cause
TMD signs and symptoms27, caution should be exercised Orthodontics and TMD
when planning, performing and finalizing orthodontics, The role of functional and morphological malocclusion
especially in patients with a past history of signs and as a TMD-contributing factor has been widely discussed.
symptoms of TMD. The first report correlating occlusal factors and TMD
symptoms is attributed to Costen7 in the 1930’s. Since that
ORTHODONTIC TREATMENT AND TMD time, different types of therapies involving orthodontic/
Orthodontic therapy as a possible TMD etiologic factor orthopedic treatment as well as occlusal adjustment have
has been a subject of discussion, especially after a lawsuit, been proposed to correct malocclusion and improve TMD
in which orthodontic treatment was considered the main signs and symptoms8.
cause of pain35. Thereafter, many studies in this field have According to these theories, functional and
been developed based on scientific data1,14,18. morphological malocclusions cause TMD, and the
Some authors have speculated that the deleterious effects achievement of an ideal occlusion through orthodontics or
of orthodontic mechanics in the stomatognathic system occlusal adjustment must eliminate pain and dysfunction.

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 EXAMINATION OF TEMPOROMANDIBULAR DISORDERS IN THE ORTHODONTIC PATIENT: A CLINICAL GUIDE

However, available longitudinal studies and well-designed have demonstrated a tendency of condyle to return to its
statistical tests have shown that patients submitted to original position after the treatment is completed. It is worth
irreversible treatment frequently present relapse of TMD mentioning that those reports do not consider the absence
problems. Based on that, investigations concerning the role of condyle concentricity as a condition for joint health.
of occlusal and skeletal factors as contributors to TMD Even though anterior condyle position was partially
onset have been carried out. maintained after orthopedic treatment with Herbst or
Sadowsky and Begole 38 (1980) reported that no Bionator appliances, this advanced mandibular position
relationship should be expected from orthodontic treatment could improve joint pain in symptomatic subjects. This fact
and risks to develop TMD signs and symptoms. In a similar is due to the partial time repositioning appliances for these
study, Conti, et al.5 (2003), evaluated the influence of patients, which induce a retrodiscal adaptation, and an
orthodontic treatment on TMD etiology, comparing treated improvement of TMJ pain6.
and untreated patients with malocclusion. Severe TMD was To effectively deal with orthodontic patients, the
not found in the surveyed population, and no association professional should have a comprehensive knowledge of
between TMD severity and the type of orthodontic therapy TMD, which would improve the quality of the treatment.
was detected. The authors concluded that occlusion is Even considering that orthodontic treatment does not
considered a secondary factor in TMD etiology, which has represent a great risk to develop TMD signs and symptoms,
a multifactorial aspect. Yet, TMD incidence was very similar there is also no evidence that orthodontic treatment prevents
in treated and untreated patients. It was also reported that TMD. Based on this, it is mandatory that the clinician
orthodontic treatment has no relationship with TMD signs performs a thorough examination before initiating any sort
and symptoms when considering a successful orthodontic of rehabilitation treatment, such as orthodontic therapy.
treatment. As orthodontics cannot cause TMD it also cannot
be indicated to treat TMD. Patient examination
According to McNamara26 (1997), the relationship For most patients, the examination process includes a
between orthodontic treatment and TMD can be summarized detailed clinical interview and a comprehensive physical
in few topics: inspection. Temporomandibular joint (TMJ) imaging and
1) TMD signs and symptoms may exist in healthy additional tests (as serology and electromyography) are
individuals; necessary only for very few specific cases. It has been
2) TMD may develop during orthodontic treatment, but stated that approximately 70% of the diagnostic process is
it does not cause TMD; based on the history review3. Physical examination must
3) Orthodontic treatment performed during adolescence include investigation of the mandibular active range of
does not alter TMD risks; motion (AROM), standardized TMJ and masticatory and
4) There is no evidence that orthodontic mechanics can cervical muscle palpation, as well as inspection of articular
predispose the subject to a higher risk for TMD; joint sounds. In case of any abnormality, the orthodontist
5) Even though the accomplishment of a stable should refer the patient to a TMD specialist to perform TMD
occlusion is one of the orthodontic goals, TMD cannot be management prior to the starting the orthodontic therapy.
attributed to the failure in achieving this aim; The clinical interview of the TMD patient should be well
6) There is little evidence that orthodontic treatment documented and must contain questions regarding the onset
can prevent TMD. of the problem, previous diagnosis and performed
treatment2,24,29.
Orthopedics and TMD
Orthopedic treatment was first considered an etiologic Anamnesis
factor of TMD because condyle position can be affected The following information should be part of a
when mandibular protrusion is assumed with the use of comprehensive history: chief complaints, history of present
orthopedic appliances. This type of therapy is worldwide illness, past medical and dental history, review of the systems
used for correction of Class II in patients with mandibular (systemic conditions that can enhance or cause the pain
deficiency. sensation) and psychosocial history.
Several studies30,31,41 have been conducted to evaluate History review is the most important part of the
TMD risks caused by the alterations in condyle position. examination process. The first question to be done is about
Pancherz 32 (1985) reported an increase in muscular the chief complaint, which is the main reason that made the
sensitivity in patients treated with mandibular repositioning patient seek help. This information is of great importance
appliances in the first 3 months. After 12 months these because even if the patient has many complaints, the
symptoms disappeared, which was explained based on the attenuation or resolution of the main problem may improve
great level of TMJ adaptation. This finding is corroborated the general status and quality of life2,24,29.
by Sfondrini, et al.39 (1996), who found an increase in muscle Each complaint should be listed separately in order of
fibers resistant to fatigue and a decrease in muscle fibers importance to the patient, and shall contain information
sensitive to fatigue. about:
When considering condyle position, studies based on - Onset: it relates to when the patient first noticed the
MRI findings before and after orthopedic treatment33,34,36,37 symptoms and is important in order to define for how long

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CONTI A C de C F, OLTRAMARI P V P, NAVARRO R de L, ALMEIDA M R de

the patient has been sick. This information is useful to and dysfunction.
determine whether the patient has an acute or chronic - Family history: The patient should report if some
condition, which is crucial for the establishment of a proper relative presents the same conditions because some
therapy. disorders are genetically predisposed. Migraine, for
- Location: the patient should be oriented to indicate instance, is a primary headache related to family inheritance.
with only one finger the exact site of his/her pain. The intra- - Dental history: many patients associate the onset of
capsular pain is well pointed by the patient, but muscle pain the painful sensation with a procedure performed by a
is diffuse and difficult to be localized. The detection of the dentist. Patients very often report the onset of pain after
pain source is decisive for the success of the treatment. It is long dental treatment appointments, such as root canal
important to note that the site of pain can be different from therapy and third molar extractions.
the source of pain (ectopic pain), as in the myofascial pain - Presence of parafunctional habits: The patient should
syndromes. be asked about the presence of any parafunctional activity.
- Intensity: Intensity of pain is a difficult parameter to The habits most frequently found in TMD patients are
quantify. The visual analogue scale (VAS) is a simple and clenching and grinding. Nail biting and poor posture due to
reliable method that is extensively used in clinical practice occupational activities should also be recorded.
and research to measure pain intensity. It is a visual
representation of relative pain intensity consisting of a 10- Physical examination
cm horizontal line with “no pain” at one end and “worst At this point, the clinician should have a reasonable
pain ever” at the opposite end. By simply placing a mark idea of the nature of patient’s problem. A comprehensive
along this line, the patient is able to display his/her relative physical examination will help to determine the source of
pain intensity. pain as well as the severity of the dysfunction. This part of
- Frequency: it is known as its temporal behavior. The assessment includes TMJ evaluation (joint range of motion,
patient is asked whether the pain is constant or paroxysmal, inspection of joint sounds and pain on palpation), and muscle
which means that it comes in periods of attacks. Constant palpation. Additional diagnostic tests can be necessary for
pain will obviously require an immediate care. When pain is some patients. Dental and occlusal evaluations are also
of musculoskeletal origin and manifests only during performed2,4,29.
activities such as chewing and speaking, the treatment
normally assumes a non-invasive approach. Pain that comes I- TMJ evaluation
in quick attacks and lasts for seconds is usually related to TMJ clinical inspection is often based on joint range of
either trigeminal or glossopharyngeal neuralgia. motion, pain on palpation and presence of joint sounds
- Quality: Patients are often not able to determine exactly during mandibular and opening movement.
the quality of pain they are suffering. TMD pain is normally TMJ range of motion: some chief complaints include
described as deep, dull and sometimes aching (throbbing), limitation of opening and difficulties in mandibular
like in the inflammatory acute processes of the joints. Burning movement. The patient is requested to fully open the mouth
or shock-like pain is probably from neuropathic origin. and the sum of interincisal distance and overbite, measured
Headache reports are associated with migraine or other with a millimeter rule is documented (Figure 1). The normal
primary headache disorders. values to maximum opening range from 45 to 55 mm11,
- History of the chief complaints: it is valuable to detect although smaller figures are frequently found in
possible aggravating factors to the pain and to obtain more asymptomatic individuals. The mandibular opening and
information about the patient’s chief complaints. closing movements may be accomplished in a straight line,
Musculoskeletal pain is aggravated when using masticatory to assess deviation or deflection. Measurements of
system structures and also by emotional stress. Avoiding protrusion, lateral right and left movements must also be
these activities or using antiinflammatory or analgesic performed. For these measurements it is recommended the
medications may alleviate patient symptoms. Vascular or demarcation of two reference points, on the maxilla and
neurogenic pain is usually not affected by masticatory mandible, close to the midline. These reference points will
function. The orthodontist should also ask patients about assist the measurements of the range of motion during
previous treatment modalities, traumatic events and mode mandibular excursion (Figure 1).
of pain onset. - Detection of joint sounds: The presence of joint sounds
- Current and past medications: If the patient is taking during mouth opening and mandibular excursion can be
any medication, it must be reported because some useful in the diagnosis of disc-condyle incoordination. It is
conditions can be associated with drug side effects. believed that the clinical registration by means of manual
Additionally, drugs that will be possibly prescribed can inspection or by using a stethoscope is very reliable in the
interact with those that the patient is already taking. detection of articular sounds 11 (Figure 2). Clicking,
Questions regarding allergies are also very important. crepitation and terminal thud (related to hypertranslation)
- Medical and surgical history: Questions related to are the most common sounds in TMD patients.
general health conditions must be answered by the patient. - TMJ palpation: Tenderness to palpation is considered
Some systemic pathologies, such as fibromyalgia and one of the most important signs in the detection of
osteoarthritis, among others, can cause generalized pain intracapsular pathologies. During repeated opening and

79
 EXAMINATION OF TEMPOROMANDIBULAR DISORDERS IN THE ORTHODONTIC PATIENT: A CLINICAL GUIDE

closing movements the clinician should locate the lateral Occlusal examination
polo of mandibular condyle. After that, with the patient The presence or absence of lateral and anterior guides
maintaining the mouth in a relaxed position, TMJ bilateral (Figure 6) is recorded as the overbite and overjet. In this
and simultaneous palpation of the lateral aspect of the joint evaluation, the patient is asked to perform lateral mandibular
should be done. This palpation should be performed with movements in order to detected occlusal interferences in
pressure of 1 kgf in the lateral and posterior aspects of the the non-working side, using a cellophane paper. The
joints (Figure 3). Reports of pain can lead to diagnosis of discrepancies between centric relation and intercuspal
capsulitis and/or sinovitis. In order to graduate the patient’s position are also registered by means of the mental pressure
response to palpation, score ranging from 0 to 3 can be technique. When large discrepancies are detected or the
used: 0 - absence of pain on palpation; 1 - mild pain; 2 - results are uncertain, an articulator mounting can be
moderate pain; 3 - severe pain, palpebral reflex or “jump indicated2.
sign”2,12.
IV – Additional Diagnostic Tests2
II- Muscle palpation In case some doubt still persists, additional tests can
Muscle palpation is a very important step in the help defining a diagnostic impression. Functional muscle
diagnosis of TMD and myofascial pain syndromes. By manipulation, TMJ overloading, cryotherapy and diagnostic
means of mechanical stimuli caused by digital pressure, nerve blockage are useful for this purpose.
nociceptive neurons located in the muscular and myofascial
structures are stimulated to detect and transmit pain V- TMJ imaging assessment
messages to the central nerve system. The graduation of The real need and validity of TMJ images in the diagnosis
patient’s response to palpation allows evaluating the of TMD is controversial, despite all technological apparatus
severity of pain and is used to measure the efficacy of a available in present days. Joint imaging should be indicated
given treatment modality in follow-up visits. Palpation should based on the dentist’s good sense, but diagnosis and
be performed with a pressure of 1.5 Kg, which is strong treatment techniques are still mainly elaborated based on
enough to elicit pain message in symptomatic patients, and clinical examination24.
mild enough to not cause pain in asymptomatic control The general rule is that imaging exams are necessary
subjects2,15,40. when they might, somehow, change an initially established
Palpation should be done bilaterally, in a relaxed position, management strategy. The overestimation of image findings,
with the tip of the finger or by pincer palpation, when no followed by unnecessary irreversible treatment is a potential
underline bone support is present. Yet, during the problem, especially for non-experienced clinicians.
examination, the patient should be seated facing the Panorex is helpful only to rule out dental and bone
orthodontist in such a way that the clinician can observe pathologies, with no validity on the diagnosis of TMJ
the patient’s reactions. position or anatomical form. Transcranial, lateral images and
The three portions of the temporalis (posterior, medial computed tomography can detect bone changes, condyle
and anterior) (Figure 4), superficial and deep masseter (Figure degeneration, mobility and fractures. Magnetic resonance
5), as well as the insertion of the medial pterygoid muscle image (MRI), on the other hand, is able to detect TMJ disc
should be examined. The sternocleidomastoid, supeior position and the presence of inflammatory processes.
trapezius and subocciptal are important cervical muscles to Again, the detection of small abnormalities in TMJ
be also considered in this evaluation. images is highly prevalent in asymptomatic individuals and
Muscle palpation is also scored 0 to 3, according to the does not mean that a treatment is mandatory. Flattening of
patient’s response34. The detection of trigger points in the the condyle in older subjects is an example of this statement.
myofascial structures is done during the examination. When
the patient presents severe pain, this spot is continuously
pressed from 8 to 10 seconds in order to stimulate referred CONCLUSION
pain. When referred pain zones are reproduced, a diagnosis
of myofascial pain is done, which requires specific The available evidence-based data demonstrate that
management modalities. orthodontic treatment has little to do with TMD signs and
symptoms. Some conditions, such as muscle incoordination,
III– Dental and occlusal evaluation unstable disc-condyle relationship and bone alterations can
Dental examination interfere with the occlusal relationship and interfere with
Dental and periodontal conditions, such as defective orthodontic analysis. A non-invasive approach and
restorations, missing teeth or periodontal problems that reversible treatment of the TMD conditions are mandatory
could contribute to pain onset should be detected at this for all patients before the orthodontic therapy starts. In case
moment. Most orofacial pain conditions has a dental origin17. of relapse of symptoms during the course of orthodontics,
The presence of incisal or occlusal dental attrition is also an the patient should be reexamined and, if necessary,
indicator of possible parafunctional habits. mechanics should be discontinued until the improvement
of TMD signs and symptoms.

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CONTI A C de C F, OLTRAMARI P V P, NAVARRO R de L, ALMEIDA M R de

FIGURE 1- Measurement of maximum active opening and FIGURE 4- Palpation of anterior and posterior temporalis
maximum lateral movement muscle

FIGURE 5- Palpation of the superficial and deep masseter

muscle

FIGURE 2- Joint sound inspection with a stethoscope

FIGURE 6- Anterior and lateral guide assessment

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