The importance ofthe relationship between malocclusion and ...

European Journal of Orthodontics 6 (1984) 192-204© 1984 European Orthodontic Society

The importance of the relationship betweenmalocclusion and mandibular dysfunction andsome clinical applications in adults

Bengt Mohlin and Birgit ThilanderG6teborg, Sweden

Summary. Studies on the relationship between malocclusion and mandibulardysfunction have been performed in adult subjects. Three samples have beenexamined: 56 patients with mandibular dysfunction, 389 men aged 21-54 years and272 women aged 20-46 years.

Approximately 25% of the men and the women had moderate or severedysfunction according to the clinical dysfunction index. Fifteen per cent of the men and34% of the women had subjective symptoms of dysfunction.

Rotation of teeth was correlated with subjective symptoms of mandibulardysfunction in the men and the women. Angle class III malocclusion in the men andneed for orthodontic treatment in the women showed the strongest correlation with theseverity of clinical symptoms of dysfunction. Crossbite and frontal open bite were moreprevalent in the patients with mandibular dysfunction than has been found in otherstudies. Most of these crossbites were associated with lateral displacements of themandible between RP and IP. Bilateral crossbite showed a strong correlation tonon-working side interference in the patients. The results also indicated that theaetiology of mandibular dysfunction is multifactorial.

The implications of these results on" orthodontic treatment indications and someaspects on when the treatment should be performed are discussed.

Five case presentations are given to illustrate the possibilities of orthodontictreatment of adult patients with mandibular dysfunction.

A good knowledge of the relationship between different malocclusions and mandibular dysfunction enables the orthodontist: a.to determine the functional objectives of theorthodontic treatment and hence evaluatethe results of the treatment, b. to judgewhen. orthodontic treatment of mandibulardysfunction may be expected to give a goodresult, and c. to assess the objective need fororthodontic treatment in the growing child.

This assessment has to be made inrelation to the prevalence of dysfunctionand general aetiological factors as well asour knowledge of the indications for orthodontic treatment.

Prevalence of mandibular dysfunction

A number of studies have shown a highprevalence of mandibular dysfunction (forreview, see Mohlin 1982). The figures varywithin fairly wide limits, however. Theprevalence of subjective symptoms of dysfunction ranges from 12 to 57 per cent andthe prevalence of clinically recorded symptoms from 28 to 88 per cent. One of themain reasons for this disagreement is probably imprecise description of the symptomsof mandibular dysfunction. It thereforeseems important to use similar and welldefined criteria when different studies of

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MALOCCLUSION AND MANDIBULAR DYSFUNCTION

dysfunction are compared. One way ofachieving this is to use an index for clinicaldysfunction, such as the one devised byHelkimo (1974), and to use these definitionswhen formulating questions on subjectivesymptoms. In this index, the symptoms ofreduced movement capacity: deviation onopening, locking or luxation of the mandible, pain on movement, TMJ sounds,muscle- and TMJ tenderness are scored.Each symptom is judged according to athree-grade scale. 'No symptom' is given 0,a mild symptom, 1 and a severe symptom, 5points. The sum of the scores can be used toform the basis of grouping into grades ofdysfunction (O=no dysfunction, I=mild dysfunction, II=moderate dysfunction andIII = severe dysfunction).

Aetiology of mandibular dysfunction

Even with a strict definition of dysfunction,there will still be considerable disagreementabout the importance of different aetiological factors. A number of studies haveindicated an influence of local factors e.g.interferences and malocclusion:

The role of occlusal intereferences hasbeen stressed in some electromyographicstudies (Ramfjord 1961, Schaerer et al.,1967, Randow et al., 1976).

Some malocclusions have been shown toinfluence the mandibular movement pattern (Ahlgren 1967, Ingervall and Thilander 1974). A relationship between posterior crossbite and hyperactivity in thetemporal muscle in the rest position hasbeen found (Haralabakis and Loufty1964, Troelstrup and M01ler 1970,Ingervall and Thilander 1975).

Pain in connection with dual bite wherethere is an open bite in the retrudedcontact position has been reported (Harvold and Poyton 1962).

A correlation between facial morphologyand the activity in the masticatory muscleshas been demonstrated (Ahlgren et al.,

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1973, Ingervall and Thilander 1974). Individuals with large angles between themaxilla and the mandible generally showa lower than average muscle activity.Ingervall et al., (1979) found that themuscular activity in individuals for whomsurgical treatment of mandibular prognathism was planned was clearly lowerthan in those with normal occlusion. Themuscle activity rose to an almost normallevel within 8 months of surgery. Goodresults of orthodontic treatment for dysfunction have been reported (EgermarkEriksson et al., 1975, Ingervall 1978).Some examples of this will be given laterin this paper.

Factors within the central nervous system have also been strongly emphasized asbeing responsible for development of mandibular dysfunction (Moulton 1955, Laskin1969, Lupton 1969, Molin 1973, Yemm1979, Rugh and Solberg 1979, Olsson 1979).

The influence of emotional and stressfactors acting via the limbic system,hypothalamus and reticular system maycreate an increased level of musculartension (Ericsson and Riise 1974, Solbergand Rugh 1972, Rugh and Solberg 1975).Direct stimulation of the hypothalamus inthe cat has been shown to increase the jawclosing reflex by 10 times (Olsson 1979).

Patients with dysfunction are undergreater emotional stress than others(Evaskus and Laskin 1972). TMJ patientshave a tendency to maintain a high levelof muscle tension in stress situations,contrary to persons without such symptoms (Yemm 1979).

Psychological studies, on the other hand,have failed to describe a specific personality trait for TMJ patients (Dahlstrom1977, Rugh and Solberg 1979).

Together with these two groups ofaetiological factors, social conditions andgeneral health have also been claimed tohave an influence on the development ofmandibular dysfunction (Franks 1964,


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Figure 1 Factors claimed to have an influence on thedevelopment of dysfunction.

He16e and Heide 1975, Agerberg et al.,1977, Agerberg and Carlsson 1975).

All the aetiological factors that havebeen mentioned are clearly interrelated(Fig. 1). Social conditions have an influenceupon dental health as well as on generalhealth. Poor health probably often createsan increased level of anxiety, which maylead to increased muscle tension. Impulsesfrom occlusal interferences may add toimpulses from other spheres. It thereforeseems to be very difficult to determine therelative importance of different aetiologicalfactors.

194

(GENERAL ~HEALTH V""

L

CNS

V

INTERFERENCESMALOCCLUSION

~ SOCIAL~ FACTORS

~

BENGT MOHLIN AND BIRGIT THILANDER

patients with mandibular dysfunction(Mohlin and Kopp 1978) it was found thatthe number of tipped and rotated teethincreased with age. Furthermore, the prevalence of tooth loss, especially loss ofmolars, has been found to be high in a groupof young and middle-aged Swedish men(Mohlin et al., 1979). Some types of occlusalrelation probably have a greater ability tomaintain stability than others. In.connectionwith periodontitis, for example, there maybe relatively small changes in the occlusionin a case with a good number of teeth incontact, while in a case with severe postnormal occlusion a vertical collapse of theocclusion occurs more easily.

To cover the aspect of occlusal changesin adult ages, and also to cover the longterm functional consequences of untreatedmalocclusions, our studies have dealt onlywith adults.

Present studies in adults on the relationshipbetween malocclusion and mandibular dysfunction

Indications for orthodontic treatment

A morphological malocclusion by itself cannever justify orthodontic treatment exceptwhen it causes, or may cause, aesthetic orfunctional problems. When considering theindications for orthodontic treatment, weseem in some instances to have a fairly poorbasis for decision. This is particularly truefor the correlation between chewing function and malocclusion and also for thecorrelation between malocclusion and mandibular dysfunction. We do not know withcertainty which malocclusions should betreated in order to reduce the risk ofdeveloping symptoms of dysfunction.

A difficulty in this context is that we notonly have to deal with malocclusions presentin children but also have to make a prognosis for the long-term development of theocclusion. It is easy to show that majorchanges in the occlusion may occur following, for example, tooth loss. In a group of

Subjects examined. Three different groupsof individuals have been studied (Table 1),with regard to malocclusion, dysfunctionand also social and health conditions. Forfurther details, see Mohlin (1982).

Results. The clinical dysfunction index (Helkimo 1974) showed that 40% of the men and34% of the women were free from clinicalsymptoms (Di 0), while approximately 25%in both groups had moderate or severedysfunction (Division II and III).

Fifteen per cent of the men and 34% ofthe women stated that they had subjectivesymptoms, including headache, TMJ ormuscle pain or difficulty in opening theirmouths. If headache was excluded, as it maynot have any connection with dysfunction,the prevalence was 12% and 28%, respectively. In the group of men, muscle tenderness was the clinically recorded symptomthat showed the closest correlation withsubjective symptoms. Numerous factors


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Table 1 Number of individuals studied and the rate of participation in different examinations.

Method

Age Clinical Dental TotalGroup (years) examination casts Questionnaire number

Patients 16-22 56 56 56Men 21-54 385 357 389 389Women 2~46 205 205 272 272

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were found to be correlated with subjectivedysfunction symptoms. Many of those factors have no connection with occlusion. Thecorrelation between dysfunction and chestpain may reflect an increased level oftension. Symptoms also seemed to be morecommon in people born in cities than inthose born in the countryside and were alsomore common in people with a low educational level. (Table 2)

The prevalence of malocclusion in nonpatients was found to be at the same level ashas been found in children, in spite of thefact that 9% of the 'men and 25% of thewomen had had orthodontic treatment during their childhood (Table 3). Some malocclusions, especially tipping and rotation ofteeth and deep bite, were more prevalentthan has been found in most studies inchildren. Interventions like tooth extractionhave probably created some of these malocclusions in the adult subjects.

To study the correlations further, regression analyses were performed (Table 4).Owing to the fairly large number of itemstested, only variables with a level of statistical significance of the regression coefficient of p<O.OOl are given. The variablesthat best explained the variation of thedependent variable 'subjective symptoms'were educational level and maxillary crowding, with a negative association, and rotation of teeth, with a positive association.The presence of maxillary crowding probably does not by itself reduce the risk ofdysfunction. Maxillary crowding probablyreflects the dental status. With an increasednumber of missing teeth, the prevalence ofcrowding may be reduced.

The dental status was also found to becorrelated with social conditions and educational level as well as with tipping androtation of teeth in these subjects (Mohlin etal., 1979).

Table 2 Significant rank correlation coefficients between subjectivesymptoms and malocclusion traits, dental status and general variablesin the group of men.

Subjective symptoms(headache included)

Subjectivedysfunction symptoms(headache excluded)

Maxillary crowdingEducational levelChest painMaxillary crowdingNeed for prosthetic

treatment forocclusionrehabilitation

Educational levelPlace of birthWeightTriceps skinfold

-0.18**-0.11 *

0.11*-0.17**

0.12*

-0.18**-0.13*-0.10*-0.10*

*=O.OI<p<O.05, **=p<O.OI


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Table 3 Prevalence of different malocclusions in themale (n=357) and female (n=205) groups studied.Percentage distribution by men and women given.

Dentitional anomalies d Cj?Rotated teeth 68.9 83.9

lateral teeth 51.3 48.8Tipped teeth 30.5 37.1

lateral teeth 24.4 34.1Inversion of incisors 3.1 3.9

Space anomaliesCrowding 42.9 51.2

maxillary 21.0 23.4mandibular 34.5 42.9

Spacing 17.7 14.2maxillary 13.2 7.3mandibular 7.6 5.3

Maxillary medial diastema 2.0 2.0

Occlusal anomaliesExtreme maxillary overjet 10.6 9.8Mandibular overjet 3.1 1.0Deep bite 16.2 11.2Frontal open bite 4.2 3.4Lateral open bite 2.2 1.5Angle class I 80.4 71.2

II:l 8.1 14.6II:2 5.3 10.7III 6.2 2.4

Crossbite 19.3 26.8Scissors bite 3.1 3.4


Variation in the severity of clinicallyrecorded dysfunction according to the indexwas best explained by the independentvariable Angle class III malocclusion in thegroup of men. Using a partial correlationanalysis with age, number of teeth, educational level and place of birth as confounding variables, we found a correlation between clinical symptoms and Angle class IIImalocclusion and also crossbite and need fororthodontic treatment (according to theindex proposed by the National Board ofHealth and Welfare).

Regarding the dependent variable'muscle tenderness', no variables in theregression analyses reached the requiredlevel of significance. Age and Angle class IImalocclusion were the variables that wereclosest to that level. This symptom tendedto decrease in prevalence with increasingage.

In the women, we found the samecorrelation between subjective dysfunctionsymptoms and rotation of teeth as wasfound in the men.

Need for orthodontic treatment was the

Table 4 Independent variables for explaining the variation of the dependent variables Subjective dysfunctionsymptoms, Helkimo's dysfunction index and muscle tenderness in the men and the women examined (n=357 and 205respectively) .

Dependentvariable

Subjective dysfunctionsymptoms

Helkimo's dysfunctionindex

Independentvariable

IMaxillary crowding

d Educational levelRotated teeth

Number of rotated teeth

Angle class IIImalocclusion

Need for orthodontictreatment

Significance ofregression coefficient

-p<0.002-p<0.OO7+p<O.OI

+p<0.0002

+p<0.0003

+p<O.OOOI

Muscle tenderness No variable reached the required level of significance

INeed for orthodontic +p<0.0005Cj? treatment

OR index +p<0.002(need for prosthetic treatment for occlusion rehabilitation)


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variable that best explained the variation inseverity of clinical symptoms. Very fewwomen had Angle class III malocclusionand only one woman showed a mandibularoverjet.

Women with class III malocclusionshowed on average higher dysfunction indexvalues, but the differences were not statistically significant. Need for orthodontic treatment was also correlated with muscletenderness, as was the need for prosthetictreatment for occlusion rehabilitation.

In the group of patients with mandibular dysfunction, two types of malocclusionwere more prevalent than usually found:crossbite (32%) and frontal open bite(160/0). We also found some correlationsbetween occlusal interferences and malocclusion. Unilateral as well as bilateral crossbite were correlated with interferences between the retruded contact position (RP)and the intercuspal position (IP) causing alateral slide (p<0.01). Bilateral crossbiteshowed a correlation with non-working sideinterferences (p<O.Ol). Most of the bilateral crossbites in this group were associatedwith this type of interference. The numberof tipped teeth also showed a correlationwith non-working side interferences(p<0.05).

Conclusions and clinical applications

There seems to be a correlation betweensome malocclusions and mandibular dysfunction. Angle class III malocclusionsshowed the strongest correlation with theseverity of clinical symptoms. Crossbite alsoseemed to be correlated with dysfunction, aconclusion that can be drawn from previousas well as from these studies. Uni- andbilateral crossbite in connection with interferences between RP and IP and bilateralcrossbite in connection with non-workingside interferences seem to have the greatestinfluence on dysfunction. It therefore seemsavisable to check bilateral crossbite withregard to non-working side interferences.

Frontal open bite was found to be very

197

prevalent in patients with dysfunction and itwas also the malocclusion that showed thestrongest correlation with non-working sideinterferences in the men and women. Openbite and Angle class III malocclusion oftenrepresent a facial morphology characterizedby lower than average muscle activity. Theinfluence of tipping and rotation of teethseems to be more difficult to determine asthese malocclusions often reflect a poordental status which, in turn, is related tosocial conditions and other factors whichmay contribute to development of dysfunction. Similar results have been obtained instudies on the relationship between malocclusion and mandibular dysfunction in children (Egermark-Eriksson 1982).

As the cause of mandibular dysfunctionis obviously multifactorial, prevention ofsuch disorders alone seldom warrants adecision to start orthodontic treatment butthe correlations found should be consideredin the treatment planning.

The question of the most suitable agefor orthodontic treatment also has to beconsidered in this conext. In some instances,orthodontic treatment of malocclusions thathave caused dysfunction can be successfullyperformed in adults. Patients with crossbitecausing a lateral displacement are besttreated at younger ages. The muscularhyperactivity in the rest position on thecrossbite side in such cases (Haralabakis &Loufty 1964, Troelstrup & M011er 1970,Ingervall and Thilander 1975) indicates thatthe growth pattern may be unfavourablyinfluenced. Early treatment of such casestherefore seems preferable. The nature ofthe relationship between facial morphologyand muscular activity in cases with Angleclass III malocclusion or skeletal open bitedoes not seem to be fully understood. It thusseems difficult to predict whether earlyorthodontic treatment of such malocclusionswill normalize the activity of the masticatorymuscles and result in a more harmoniousfacial development. Longitudinal studies ofskeletal and occlusal development withreference to dysfunction in orthodonticallytreated and untreated children are needed.


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Another interesting field of study is thecorrelation between malocclusion, dysfunction and perception of mandibularposition (Thilander 1961).

Case presentations

On the following pages are some examplesof orthodontic treatment of adult subjectswith mandibular dysfunction.


Address for correspondence

Bengt Mohlin,Department of Orthodontics,Faculty of Odontology,University of Goteborg,Box 33070,S-400 33 Goteborg, Sweden.


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References

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