CRANIO® The Journal of Craniomandibular & Sleep Practice
ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20
Eminence-Posterior Occlusal Plane Angle in Patients with Temporomandibular Disorders Duane C. Keller & Aldo Carano To cite this article: Duane C. Keller & Aldo Carano (1991) Eminence-Posterior Occlusal Plane Angle in Patients with Temporomandibular Disorders, CRANIO®, 9:2, 159-164, DOI: 10.1080/08869634.1991.11678362 To link to this article: http://dx.doi.org/10.1080/08869634.1991.11678362
Published online: 18 Feb 2016.
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Date: 16 August 2017, At: 10:14
Eminence-Posterior Occlusal Plane Angle in Patients with Temporomandibular Disorders Duane C. Keller, D.M.D., Aldo Carano, D.D.S The causes of temporomandibular disorder are not clearly understood. The controversy regarding the role of the features, either dental or skeletal, still exists after nearly a half century of debate. The present study demonstrates an interesting correlation, expressed as an angular value, between the posterior surface of the articular eminence and the posterior occlusal plane. The group with dysfunction had a mean value significantly lower (133 ± 4) than the group without symptoms ( 144 ± 5). In light of this data, it is suggested to interpret a small eminence-posterior occlusal plane as an anatomical predisposing pattern for dysfunction.
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Abstract
Dr. Duane Keller received his D.M.D. degree from the Washington University School of Dental Medicine. St. Louis. Missouri. He is presently on staff at St. Louis University in the Chronic Pain Center. He is a member of the American Equilibration Society. the Society of Occlusal Studies, and the International Orthodontic Association.
Dr. Aldo Carano received his D.D.S. degree from the University of Bari in Bari, Italy, and is obtaining his M.S. degree in Orthodontics from Washington University School of Dental Medicine in St. Louis, Missouri. Presently, he is an associate researcher in the Department of Pathology at Jewish Hospital at Washington University Medical Center.
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Orthodontics he causes of temporomandibular disorder (TMD) are not clearly understood. A multifactorial etiology is indicated and controversy concerning possible etiologic factors exist within the dental profession.1-9 A range of condylar positions within the fossa can be seen in the normal joint. 10- 12 The functional relationship between the anatomic structures of the temporomandibular joint (TMJ) is dictated by the status of the musculature, the occlusion, the relationship of the head to the cervical spine, and the morphology of the joint. Each of these factors, individually or in combination with the others, controls either the static or dynamic function of the articular components. There is a growing consensus that, in nonoccluding movements, the joint and neuromuscular proprioceptors determine postural relationships of the mandible to the maxilla. Once the teeth occlude, the mandibular movement shows the proprioceptive dominance of the occlusion over the musculature. No matter what the occlusal pattern, the muscles will accommodate to pull the mandible into that position. 13 Theoretically, the amount of torquing and twisting required to close the mandible into a malocclusion is correlated with the degree of dysfunctional movement of the condyle within the fossa. 14· 15 Yet, no specific condyle-fossa relationships have been associated with abnormal temporomandibular joint function. 10 • I6. 17 Occlusal factors such as centric relation interferences, tipped molars, loss of molar support, functional crossbites, angle class II division 2 malocclusion, and especially deep incisal overbite may yield a negative orthopedic effect at the joint. However, the association between these types of malocclusion and TMD are not consistently reported. 10 •12 ·18- 20 The wide range of variability when characterizing orthofunction of the basis of selected occlusal factors led to the concept of resistance and susceptibility being introduced to explain the presence of temporomandibular disorders in some patients and not in others. Despite the increasing interest for this subject in the literature, cause and effect relationships have not been established regarding TMD etiology. 3-9.18,20.21 The importance of the occlusal plane in oral function is well documented, but its relationship to the TMJ anatomy and facial morphology is not well defined in the literature. 11 •22- 25 Furthermore, the role of the occlusal plane in TMD has not been investigated. A study by Nickel et al. 26 gave quantitative evidence of early eminence development and the continuum of its development from birth to early adulthood. This study showed a small amount of intersubject variability
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in eminence slope development, when measured to the posterior occlusal plane rather than to more traditional anthropometric planes. The mean of the eminenceposterior occlusal plane angle determined by this author was of 142 degrees at 12 years and of 137 degrees at 18 years of age. The small sample (three skulls for each measurement) and the inability to distinguish asymptomatic from symptomatic skulls could explain the slight difference with the present findings. Other authors such as Angel, 22 Ricketts, 24 Taylor, 11 and Ingervali23 reported inconclusive results concerning the relationship between craniofacial form and eminence development. The present study was conducted to analyze the inclination of the TMJ eminence in relation to the posterior occlusal plane in symptomatic and asymptomatic subjects. Material and Methods Fifty subjects, ranging from 14 to 40 years of age, were evaluated in the present study. Twenty-five were defined as being symptomatic (TMD), exhibiting positive signs of TMD. All of the symptomatic subjects reported pain in the orofacial region with frequency ranging from continuous to weekly intervals between episodes. Primary elevator muscle pain upon palpation was consistently observed. Other signs commonly recorded were: 1. Restricted range of motion, measured clinically. 2. Deviation or deflection of the mandible upon opening or closing. 3. Pain in the TMJ to lateral or posterior pressure. 4. Noise in the TMJ using Doppler auscultation, or stethoscope. The asymptomatic (ORT) subjects were free of these signs and symptoms. A further requirement for both groups was the existence of a lateral cephalometric film that clearly showed the articular eminence. Eighteen subjects had class I; 24 had class II, division 1; and eight had class II, division 2 malocclusions according to the traditionally accepted clinical and cephalometric criteria (Table 1). All of the subjects were selected from the private practice of Dr. Duane Keller and none had undergone prior orthodontic treatment or TMJ surgery.
Clinical Examination The patients had been examined utilizing a standard procedure including a comprehensive medical and dental history. Structural relationships were evaluated and
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Table 1 Distribution of Dental Malocclusions in 25 Patients without Symptoms of Temporomandibular Disorders and in 25 Patients with Symptoms of Temporomandibular Disorders Class I
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10
8
Class II Division I
Class II Division 2
10 14
5 3
radiographs were completed, consisting of: (I) corrected transcranial or tomographic radiographs, (2) cephalometric radiographs, and (3) panora) radiographs. This examination was used to assign patients to the symptomatic and asymptomatic subject groups.
Cephalometric Evaluation A single radiograph of the lateral profile was used for each subject with the mandible in the maximum intercuspal position and the lips at rest. Tracings of the middle and lower thirds of the face were constructed from the 50 lateral headfilms. A cephalometric analysis was performed according to the technique described by Cervera. 27 This analysis was preferred to others because it is based on angles and measurements of the functional area of the masticatory apparatus rather than aesthetic considerations (Figure 1).
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palatal plane and posterior occlusal plane-palatal plane were measured. Reliability of the Eminence-Occlusal Plane Angle in Cephalometric Analysis The lateral cephalometric radiograph is a two-dimensional image of the three-dimensional head. Discernible problems exist because the fossa and the
The principle points include: A point, 8 point, Pogonion osseo (Po), Menton osseo (Me), Gnathion (Gn), Gonion (Go), Occlusal point Cervera (OpC, the point of intersection between the occlusal plane and A-Po), Anterior nasal spine (ANS), and Posterior nasal spine (PNS) The principle planes include: Palatal plane (SpP), Occlusal plane (Oc, defined by Jacobson, 28 intersected the mesiobuccal cusp tip of the first molar and the cusp tips of the premolar), Mandibular plane (GoGn), Upper incisor axis, Lower incisor axis, Vertical (V, the constructed perpendicular to SpP from OpC), and Eminence plane (the posterior surface of the articular eminence determined by the linear segment between the concavity and the convexity of the anterior portion of the fossa). The eminence-occlusal plane angle was constructed by drawing a straight line through the posterior slope of the eminence, intersecting the posterior occlusal plane (Figure 2). The eminence plane and the posterior occlusal plane were separately evaluated relative to the palatal plane. The angles eminence-
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Figure 2 Angle formed by the anterior slope of the eminence intersecting the posterior occlusal plane.
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condylar head are obscured by superimposed anatomical features. In this study, the fossa could not be determined in 30% of the cases and these were excluded on this basis. The remaining 70% constitute the 50 subjects of this study. The reliability of the eminence-occlusal plane angle was demonstrated by a study of dried skulls. Ten skulls were each radiographed with two different methods using a standard cephalometric head holder. One of the cephalograms was taken with a 1-mm lead foil between the occlusal surfaces of the posterior teeth and another along the posterior portion of the articular eminence. The lead foil was clearly visible and measurable of the radiograph. A second radiograph was taken without the lead foil trips. The eminence-occlusal plane angle was drawn and measured on the two different cephalograms of the same skull. The differences in the angular values were analyzed and an index of possible interpretive error was derived. Another source of error that was considered was reproducibility when drawing the eminence-posterior occlusal plane angle. Analysis of this revealed a maximum variability of 2 degrees.
A.
DECREES
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Mil limiters
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DOll
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.TMD
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SpP· GoGn-
Oc
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A-Po
Oc
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DECREES
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130
().SpP
Eminence-Post. Dcclusel Plene
Figure 3
Statistical Analysis Where an error range is given, it represents standard deviation. All comparisons of data where a difference is concluded were significant (p less than 0.01 ).
Results General cephalometric evaluations were completed on the symptomatic (TMD) and asymptomatic (ORT) groups, without yielding a statistical divergence between the two groups. Furthermore, the study subject groups were compared with reference normal values without revealing a statistically significant difference (Figure 3A). Evaluation of the angle formed by the slope of the glenoid fossa and the posterior occlusal plane did result in a significant difference between the TMD and asymptomatic groups. The angle formed by these two planes in the TMD group was found to be significantly smaller than in the asymptomatic group. In the symptomatic group (TMD) the mean of the angle was found to be 133 ± 4, in the asymptomatic group (ORT) the mean of the angle was 144 ± 5. When taken individually and related to the palatal plane, the angle formed by the eminence plane or the posterior occlusal plane in the TMD group also yielded smaller angular measurements that were statistically less sig-
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A. Cephalometric values and SD of the nonnal population (NORM). group requiring orthodontic without symptoms (ORT) and the symptomatic population (TMD). None of the measurements shows a significant difference in the three groups. B. A statistically significant difference between the eminence-occlusal plane angle of the asymptomatic group (ORT) and the symptomatic group (TMD) is illustrated in the figure. The occlusal plane (0) and the plane of the eminence (E) as they relate to the palate (SpP) also show a difference between the symptomatic and the asymptomatic group. These differences are of less statistical importance than the previous one.
nificant when compared with the asymptomatic group
(Figure 38). Discussion Clinical dysfunctions of the human TMJ are often due to a lack of coordination between the rotational and translatory movements of the articular disk and the condylar head. 2•29 During functional mandibular movements, the mandibular condyles rotate in relationship to the disk and translate relative to the glenoid fossa of the temporal bone. Even though the mandible may translate 18 to 20 mm, the masticatory translation range is often limited to 3 to 4 mm. 30 The dental interdigitation and functional rest position appear pivotal in determining the relationship of TMJ relationships, then it would seem plausible that tooth alignment
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should also be related to TMJ function or dysfunction. Yet the majority of patients requiring orthodontic correction, where a malocclusion could be thought to create a lack of TMJ disk and condyle coordination, do not show increased symptoms of TMD.10.16.2o Some authors have postulated that there is a correlation between the depth of the fossa and the inclined plane of the cusps of the teeth. 31 - 34 Others did not find a statistically significant correlation between occlusal configuration of cusps and fossa configuration. 10· 11 ·24 This study found no differences in terms of dental and skeletal pattern between the symptomatic and asymptomatic groups when compared by standard cephalometric technique. Thus, it appeared that the dental and facial skeletal features were not directly related to the health of the TMJ apparatus, considering that no particular malocclusion was found prevailing in one of the two groups. An optimal TMJ image depicts the hard tissue anatomy and the soft tissue elements of the joint. The cephalometric radiograph is not considered a valid technique for TMJ imaging because of the superimposition of bony structures and the absence of soft tissue depiction. The purpose of this study was to evaluate the angle formed by the intersection of the slope of the articular eminence with the posterior occlusal plane, and to determine the feasibility of its use as a diagnostic tool. The widespread use of the cephalometric radiograph, improved imaging, its low cost and its illustrative capability to show all of the hard tissue masticatory structures, are the main reasons for the choice of this radiographic technique. In the last 10 years, techniques have been developed which yield clearer TMJ images (e.g., transcranials, tomographs, and MRI), 10·16·24 ·35 but as the image was concentrated on the joint, other dentoalveolar and skeletal features were excluded. Thus, in allowing the clinician to see greater detail in the articular anatomy, possible relationships with other components of the stomatognathic system may have been overlooked. The present study illustrated an interesting comparison, expressed as an angular value, between the posterior surface of the articular eminence and the posterior occlusal plane. The group with dysfunction had a mean value significantly lower (133 ± 4) than the group without symptoms (144 ± 5). The reason for this difference could be interpreted as a deflective orientation of both planes in space. This is supported by referring the tridimensional position of the two planes to another bony structure, the palatal plane. Upon analysis, the angle of the eminence to the palatal plane and the angle of the posterior occlusal plane to
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the palatal plane are lower in the dysfunctional group when compared with the asymptomatic group. Evidence that eminence steepness is a cause of dysfunction has been discussed by others, 9·31>-- 39 but in these studies the posterior occlusal plane was not considered. In other studies, the anatomical remodeling of articular bony surfaces in the TMD subject is represented by a reduction in the deepness of the fossa and a flattening of the articular eminence of the temporal bone. 11 •12 Thus, the increased steepness of the eminence could not be demonstrated as an effect of TMD. In light of this data, it is more reasonable to interpret a small eminence-occlusal plane angle as an anatomical predisposing pattern for dysfunction. The interaction of these two variables (eminence steepness and steepness of the posterior occlusal plane), when unfavorable, may produce an aggravated response resulting in a greater likelihood of TMD. Acknowledgment The authors wish to thank Dr. Robert B. Pickard for his overall support of this manuscript. Reprint requests to: Duane C. Keller, D.M.D 3929 Bav/ess Avenue St. Louis. Missouri 63125
References I. Carlsson GE, Droukas CB: Dental occlusion and the health of the masticatory system. J Craniomandib Pract 1984; 2:141-147 2. Dolmick MF. Katzberg RW. Helms CA: Internal derangements of the temporomandibular joint: Fact or fiction? J Prosthet Dent 1983; 49:415-418 3. Meug HP. Dibbets JMH, van der Weele LT. Boering G: Symptoms of the temporomandibular joint dysfunction and predisposing factors. J Prosthet Dent 1987; 57:215-222 4. Marbach JJ, Raphael KG. Dohrenwend BP. Lennon MC: The validity of tooth grinding measures: Etiology of pain dysfunction syndrome revisited. JADA 1990; 3:327-333 5. Ramer E: Controversies in temporomandibular joint disorder. Dent Clin North Am 1990; 34:125-133 6. Roberts D: The etiology of the temporomandibular joint dysfunction syndrome. Am J Orthod 1974; 66:498-515 7. Gage JP: Mechanisms of disc displacement in the temporomandibular joint. Aust Dent J 1989; 34:427-436 8. Stockstill JW: The placebo effect in the management of chronic myofascial pain: A review. JAm Col/ Dent 1989; 56:14-18 9. Bell WE: Temporomandibular Disorders (3rd ed. ). Chicago: Year Book Medical Publishers. Inc, 1990 10. Pullinger AG. Solberg WK. Hollender L. Guichet D: Tomographic analysis of mandibular condylar position to the dental occlusion factors in an asymptomatic population. Am J Orthod Dentofacial Orthop 1987; 91:200-206 II. Taylor RC. Ware WH. Fowler D. Kobayashi J: A study of the temporomandibular joint morphology and its relationship to the dentition. Oral Surg Oral Med Oral Path 1972; 33:1002-1013 12. Solberg WK. Bibb CA. Nordstrom BB. Hansson TL: Malocclusion associated with temporomandibular joint changes in young adults at autopsy. Am J Orthod 1986; 89:326-330 13. Jankelson B: Three-dimensional orthodontic diagnosis and treatment. A neuromuscolar approach. J Clin Orthod 1984; 18:9
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KELLER AND CARANO 14. Solberg WK. Hansson TL. Nordstrom 88: The temporomandibular joint in young adults at autopsy: A morphologic classification and evaluation. J Oral Rehabil 1985; 12:303-321 15. Solberg WK: Neuromuscular problems in the orofacial region: Diagnosis-classification. signs and symptoms. lm Dent J 198 I; 31:206215 16. Pullinger AG. Solberg WK. Hollender L. Guichet D: Tomographic analysis of mandibular condyle position in diagnostic subgroups of temporomandibular disorders. J Prosrhet Dent 1986; 55:723729 17. Girardot RA: Condylar displacement in patients with TMJ dysfunction. CDS Rev 1989; 89:49-55 I 8. Weinberg LA. Lager L: Clinical report on the etiology and diagnosis ofTMJ dysfunction-pain syndrome. J Prosther Dent 1980; 44:642653 19. Stringert HG. Worms FW: Variations in skeletal and dental patterns in patients with structural and functional alterations of the temporomandibular joint: A preliminary report. Am J Orthod 1986; 89:285297 20. Helm S. Petersen PE: Mandibular dysfunction in adulthood in relation to morphologic malocclusion at adolescence. Acta Odmrtol Scand 1989; 57:307-314 21. Weinberg LA: A conceptual overview of the TMJ dysfunction pain. NY State Dent J 1987; Oct: I 8-24 22. Angel JL: Factors in temporomandibular joint form. Am J Anat 1948; 83:223-246 23. lngervall 8: Relation between height of the articular tubercle of the temporomandibular joint and the facial morphology. Angle Ortlwd 1974; 44:15-24 24. Ricketts RM: Variations of the temporomandibular joint as revealed by cephalometric laminography. Am J Orthod 1950; 36:877-898 25. DiPaolo RJ: An individualized approach to locating the occlusal plane. Am J Orrhod Dentofacial Orthop 1987; 92:41-45 26. Nickel JC. McSachlan KR. Smith DM: Eminence development of the postnatal human temporomandibular joint. J Dent Res 1988; 67:896902 27. Cervera A: Trallato di Ortodon:ia Clinica. Madrid: CEOSA. 1974 28. Jacobson A: Application of the "Wits" appraisal. Am J Orthod 1976; 70:179-189 29. Farrar WB: Characteristics of the condylar path in internal derangements of the TMJ. J Prosrhet Dent 1978; 39Z:319-323
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30. Smith RJ: Functions of condylar translation in human mandibular movement. Am J Orthod 1988; 88:191-201 31. D'Amico A: Functional occlusion applicable to restorative dentistry. J Prosthet Dent 1953; 3:772-782 32. Shillingburg HT. Hobo S. Whitsett LD: Fundamentals of Fixed Prosthodontics (2nd ed.). Lombard: Quintessence Publishing Co. Inc. 1981 33. Stallard H. Stuart CE: Eliminating tooth guidance in natural teeth of man. J Prosthet Dent 1961; II :474-479 34. Stuart CE: Good occlusion for natural teeth. J Prosthet Dent 1964; 14:716-724 35. Katzberg RW: Temporomandibular joint imaging. State of the an. Radiology 1989; 170:297-307 36. Hinton RJ: Form and function in the temporomandibular joint. Craniofacial biology. In Carlson DS (ed). Center of Human Growth and Development. Ann Arbor: University of Michigan. 1981; 3760 37. Seward FS: Tooth attrition principles as applied to dentistry. Angle Orthod 1966; 46: 162-170 38. Atkinson WB. Bates RE: The effect of the angle of the articular eminence on articular disk displacement. J Prosthet Dent 1983; 49:554555 39. Kersten HCJ. Tuinzing DB. Golding RP. Vander Kwast WAM: Inclination of the temporomandibular joint eminence and anterior disk displacement. lnt J Oral Maxillofac Surg 1989; I 8:228-232
For Additional Reading Burlon BM: Anatomy and biomechanics of the TMJ. In Kraus SL (ed). TMJ Disorders. Management of the Craniomandibular Complex. Clinics in Physical Therapy. volume 18 Gibbs CH. Lundeen HC: Jaw movements and forces during chewing and swallowing and their clinical significance. In Lundeen HC. Gibbs Ch (eds). Advances in Occlusion. Boston: John Wright-PSG. Inc. 1982; 2-32 Kraus BS. Jordan RE. Abraus L: Dental Anatom\·andOcclusion. Baltimore: The Williams & Wilkins Co. 1969 . Shuyler CH: Factors of occlusion of the natural teeth of man. J Prosthet Dent 1953; 3:772-782
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ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20
Eminence-Posterior Occlusal Plane Angle in Patients with Temporomandibular Disorders Duane C. Keller & Aldo Carano To cite this article: Duane C. Keller & Aldo Carano (1991) Eminence-Posterior Occlusal Plane Angle in Patients with Temporomandibular Disorders, CRANIO®, 9:2, 159-164, DOI: 10.1080/08869634.1991.11678362 To link to this article: http://dx.doi.org/10.1080/08869634.1991.11678362
Published online: 18 Feb 2016.
Submit your article to this journal
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ycra20 Download by: [Australian Catholic University]
Date: 16 August 2017, At: 10:14
Eminence-Posterior Occlusal Plane Angle in Patients with Temporomandibular Disorders Duane C. Keller, D.M.D., Aldo Carano, D.D.S The causes of temporomandibular disorder are not clearly understood. The controversy regarding the role of the features, either dental or skeletal, still exists after nearly a half century of debate. The present study demonstrates an interesting correlation, expressed as an angular value, between the posterior surface of the articular eminence and the posterior occlusal plane. The group with dysfunction had a mean value significantly lower (133 ± 4) than the group without symptoms ( 144 ± 5). In light of this data, it is suggested to interpret a small eminence-posterior occlusal plane as an anatomical predisposing pattern for dysfunction.
Downloaded by [Australian Catholic University] at 10:14 16 August 2017
Abstract
Dr. Duane Keller received his D.M.D. degree from the Washington University School of Dental Medicine. St. Louis. Missouri. He is presently on staff at St. Louis University in the Chronic Pain Center. He is a member of the American Equilibration Society. the Society of Occlusal Studies, and the International Orthodontic Association.
Dr. Aldo Carano received his D.D.S. degree from the University of Bari in Bari, Italy, and is obtaining his M.S. degree in Orthodontics from Washington University School of Dental Medicine in St. Louis, Missouri. Presently, he is an associate researcher in the Department of Pathology at Jewish Hospital at Washington University Medical Center.
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Orthodontics he causes of temporomandibular disorder (TMD) are not clearly understood. A multifactorial etiology is indicated and controversy concerning possible etiologic factors exist within the dental profession.1-9 A range of condylar positions within the fossa can be seen in the normal joint. 10- 12 The functional relationship between the anatomic structures of the temporomandibular joint (TMJ) is dictated by the status of the musculature, the occlusion, the relationship of the head to the cervical spine, and the morphology of the joint. Each of these factors, individually or in combination with the others, controls either the static or dynamic function of the articular components. There is a growing consensus that, in nonoccluding movements, the joint and neuromuscular proprioceptors determine postural relationships of the mandible to the maxilla. Once the teeth occlude, the mandibular movement shows the proprioceptive dominance of the occlusion over the musculature. No matter what the occlusal pattern, the muscles will accommodate to pull the mandible into that position. 13 Theoretically, the amount of torquing and twisting required to close the mandible into a malocclusion is correlated with the degree of dysfunctional movement of the condyle within the fossa. 14· 15 Yet, no specific condyle-fossa relationships have been associated with abnormal temporomandibular joint function. 10 • I6. 17 Occlusal factors such as centric relation interferences, tipped molars, loss of molar support, functional crossbites, angle class II division 2 malocclusion, and especially deep incisal overbite may yield a negative orthopedic effect at the joint. However, the association between these types of malocclusion and TMD are not consistently reported. 10 •12 ·18- 20 The wide range of variability when characterizing orthofunction of the basis of selected occlusal factors led to the concept of resistance and susceptibility being introduced to explain the presence of temporomandibular disorders in some patients and not in others. Despite the increasing interest for this subject in the literature, cause and effect relationships have not been established regarding TMD etiology. 3-9.18,20.21 The importance of the occlusal plane in oral function is well documented, but its relationship to the TMJ anatomy and facial morphology is not well defined in the literature. 11 •22- 25 Furthermore, the role of the occlusal plane in TMD has not been investigated. A study by Nickel et al. 26 gave quantitative evidence of early eminence development and the continuum of its development from birth to early adulthood. This study showed a small amount of intersubject variability
Downloaded by [Australian Catholic University] at 10:14 16 August 2017
T
160 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
0886-9634/91/0902-0159$03.00/0 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE Copyright© 1991 by Williams & Wilkins
in eminence slope development, when measured to the posterior occlusal plane rather than to more traditional anthropometric planes. The mean of the eminenceposterior occlusal plane angle determined by this author was of 142 degrees at 12 years and of 137 degrees at 18 years of age. The small sample (three skulls for each measurement) and the inability to distinguish asymptomatic from symptomatic skulls could explain the slight difference with the present findings. Other authors such as Angel, 22 Ricketts, 24 Taylor, 11 and Ingervali23 reported inconclusive results concerning the relationship between craniofacial form and eminence development. The present study was conducted to analyze the inclination of the TMJ eminence in relation to the posterior occlusal plane in symptomatic and asymptomatic subjects. Material and Methods Fifty subjects, ranging from 14 to 40 years of age, were evaluated in the present study. Twenty-five were defined as being symptomatic (TMD), exhibiting positive signs of TMD. All of the symptomatic subjects reported pain in the orofacial region with frequency ranging from continuous to weekly intervals between episodes. Primary elevator muscle pain upon palpation was consistently observed. Other signs commonly recorded were: 1. Restricted range of motion, measured clinically. 2. Deviation or deflection of the mandible upon opening or closing. 3. Pain in the TMJ to lateral or posterior pressure. 4. Noise in the TMJ using Doppler auscultation, or stethoscope. The asymptomatic (ORT) subjects were free of these signs and symptoms. A further requirement for both groups was the existence of a lateral cephalometric film that clearly showed the articular eminence. Eighteen subjects had class I; 24 had class II, division 1; and eight had class II, division 2 malocclusions according to the traditionally accepted clinical and cephalometric criteria (Table 1). All of the subjects were selected from the private practice of Dr. Duane Keller and none had undergone prior orthodontic treatment or TMJ surgery.
Clinical Examination The patients had been examined utilizing a standard procedure including a comprehensive medical and dental history. Structural relationships were evaluated and
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Table 1 Distribution of Dental Malocclusions in 25 Patients without Symptoms of Temporomandibular Disorders and in 25 Patients with Symptoms of Temporomandibular Disorders Class I
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TMD Symptomatic Asymptomatic
10
8
Class II Division I
Class II Division 2
10 14
5 3
radiographs were completed, consisting of: (I) corrected transcranial or tomographic radiographs, (2) cephalometric radiographs, and (3) panora) radiographs. This examination was used to assign patients to the symptomatic and asymptomatic subject groups.
Cephalometric Evaluation A single radiograph of the lateral profile was used for each subject with the mandible in the maximum intercuspal position and the lips at rest. Tracings of the middle and lower thirds of the face were constructed from the 50 lateral headfilms. A cephalometric analysis was performed according to the technique described by Cervera. 27 This analysis was preferred to others because it is based on angles and measurements of the functional area of the masticatory apparatus rather than aesthetic considerations (Figure 1).
1991.
VOL.
9,
NO.
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Principle points and planes of Cervera cephalometric analysis.
palatal plane and posterior occlusal plane-palatal plane were measured. Reliability of the Eminence-Occlusal Plane Angle in Cephalometric Analysis The lateral cephalometric radiograph is a two-dimensional image of the three-dimensional head. Discernible problems exist because the fossa and the
The principle points include: A point, 8 point, Pogonion osseo (Po), Menton osseo (Me), Gnathion (Gn), Gonion (Go), Occlusal point Cervera (OpC, the point of intersection between the occlusal plane and A-Po), Anterior nasal spine (ANS), and Posterior nasal spine (PNS) The principle planes include: Palatal plane (SpP), Occlusal plane (Oc, defined by Jacobson, 28 intersected the mesiobuccal cusp tip of the first molar and the cusp tips of the premolar), Mandibular plane (GoGn), Upper incisor axis, Lower incisor axis, Vertical (V, the constructed perpendicular to SpP from OpC), and Eminence plane (the posterior surface of the articular eminence determined by the linear segment between the concavity and the convexity of the anterior portion of the fossa). The eminence-occlusal plane angle was constructed by drawing a straight line through the posterior slope of the eminence, intersecting the posterior occlusal plane (Figure 2). The eminence plane and the posterior occlusal plane were separately evaluated relative to the palatal plane. The angles eminence-
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Figure 2 Angle formed by the anterior slope of the eminence intersecting the posterior occlusal plane.
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condylar head are obscured by superimposed anatomical features. In this study, the fossa could not be determined in 30% of the cases and these were excluded on this basis. The remaining 70% constitute the 50 subjects of this study. The reliability of the eminence-occlusal plane angle was demonstrated by a study of dried skulls. Ten skulls were each radiographed with two different methods using a standard cephalometric head holder. One of the cephalograms was taken with a 1-mm lead foil between the occlusal surfaces of the posterior teeth and another along the posterior portion of the articular eminence. The lead foil was clearly visible and measurable of the radiograph. A second radiograph was taken without the lead foil trips. The eminence-occlusal plane angle was drawn and measured on the two different cephalograms of the same skull. The differences in the angular values were analyzed and an index of possible interpretive error was derived. Another source of error that was considered was reproducibility when drawing the eminence-posterior occlusal plane angle. Analysis of this revealed a maximum variability of 2 degrees.
A.
DECREES
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130
().SpP
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Statistical Analysis Where an error range is given, it represents standard deviation. All comparisons of data where a difference is concluded were significant (p less than 0.01 ).
Results General cephalometric evaluations were completed on the symptomatic (TMD) and asymptomatic (ORT) groups, without yielding a statistical divergence between the two groups. Furthermore, the study subject groups were compared with reference normal values without revealing a statistically significant difference (Figure 3A). Evaluation of the angle formed by the slope of the glenoid fossa and the posterior occlusal plane did result in a significant difference between the TMD and asymptomatic groups. The angle formed by these two planes in the TMD group was found to be significantly smaller than in the asymptomatic group. In the symptomatic group (TMD) the mean of the angle was found to be 133 ± 4, in the asymptomatic group (ORT) the mean of the angle was 144 ± 5. When taken individually and related to the palatal plane, the angle formed by the eminence plane or the posterior occlusal plane in the TMD group also yielded smaller angular measurements that were statistically less sig-
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A. Cephalometric values and SD of the nonnal population (NORM). group requiring orthodontic without symptoms (ORT) and the symptomatic population (TMD). None of the measurements shows a significant difference in the three groups. B. A statistically significant difference between the eminence-occlusal plane angle of the asymptomatic group (ORT) and the symptomatic group (TMD) is illustrated in the figure. The occlusal plane (0) and the plane of the eminence (E) as they relate to the palate (SpP) also show a difference between the symptomatic and the asymptomatic group. These differences are of less statistical importance than the previous one.
nificant when compared with the asymptomatic group
(Figure 38). Discussion Clinical dysfunctions of the human TMJ are often due to a lack of coordination between the rotational and translatory movements of the articular disk and the condylar head. 2•29 During functional mandibular movements, the mandibular condyles rotate in relationship to the disk and translate relative to the glenoid fossa of the temporal bone. Even though the mandible may translate 18 to 20 mm, the masticatory translation range is often limited to 3 to 4 mm. 30 The dental interdigitation and functional rest position appear pivotal in determining the relationship of TMJ relationships, then it would seem plausible that tooth alignment
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should also be related to TMJ function or dysfunction. Yet the majority of patients requiring orthodontic correction, where a malocclusion could be thought to create a lack of TMJ disk and condyle coordination, do not show increased symptoms of TMD.10.16.2o Some authors have postulated that there is a correlation between the depth of the fossa and the inclined plane of the cusps of the teeth. 31 - 34 Others did not find a statistically significant correlation between occlusal configuration of cusps and fossa configuration. 10· 11 ·24 This study found no differences in terms of dental and skeletal pattern between the symptomatic and asymptomatic groups when compared by standard cephalometric technique. Thus, it appeared that the dental and facial skeletal features were not directly related to the health of the TMJ apparatus, considering that no particular malocclusion was found prevailing in one of the two groups. An optimal TMJ image depicts the hard tissue anatomy and the soft tissue elements of the joint. The cephalometric radiograph is not considered a valid technique for TMJ imaging because of the superimposition of bony structures and the absence of soft tissue depiction. The purpose of this study was to evaluate the angle formed by the intersection of the slope of the articular eminence with the posterior occlusal plane, and to determine the feasibility of its use as a diagnostic tool. The widespread use of the cephalometric radiograph, improved imaging, its low cost and its illustrative capability to show all of the hard tissue masticatory structures, are the main reasons for the choice of this radiographic technique. In the last 10 years, techniques have been developed which yield clearer TMJ images (e.g., transcranials, tomographs, and MRI), 10·16·24 ·35 but as the image was concentrated on the joint, other dentoalveolar and skeletal features were excluded. Thus, in allowing the clinician to see greater detail in the articular anatomy, possible relationships with other components of the stomatognathic system may have been overlooked. The present study illustrated an interesting comparison, expressed as an angular value, between the posterior surface of the articular eminence and the posterior occlusal plane. The group with dysfunction had a mean value significantly lower (133 ± 4) than the group without symptoms (144 ± 5). The reason for this difference could be interpreted as a deflective orientation of both planes in space. This is supported by referring the tridimensional position of the two planes to another bony structure, the palatal plane. Upon analysis, the angle of the eminence to the palatal plane and the angle of the posterior occlusal plane to
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the palatal plane are lower in the dysfunctional group when compared with the asymptomatic group. Evidence that eminence steepness is a cause of dysfunction has been discussed by others, 9·31>-- 39 but in these studies the posterior occlusal plane was not considered. In other studies, the anatomical remodeling of articular bony surfaces in the TMD subject is represented by a reduction in the deepness of the fossa and a flattening of the articular eminence of the temporal bone. 11 •12 Thus, the increased steepness of the eminence could not be demonstrated as an effect of TMD. In light of this data, it is more reasonable to interpret a small eminence-occlusal plane angle as an anatomical predisposing pattern for dysfunction. The interaction of these two variables (eminence steepness and steepness of the posterior occlusal plane), when unfavorable, may produce an aggravated response resulting in a greater likelihood of TMD. Acknowledgment The authors wish to thank Dr. Robert B. Pickard for his overall support of this manuscript. Reprint requests to: Duane C. Keller, D.M.D 3929 Bav/ess Avenue St. Louis. Missouri 63125
References I. Carlsson GE, Droukas CB: Dental occlusion and the health of the masticatory system. J Craniomandib Pract 1984; 2:141-147 2. Dolmick MF. Katzberg RW. Helms CA: Internal derangements of the temporomandibular joint: Fact or fiction? J Prosthet Dent 1983; 49:415-418 3. Meug HP. Dibbets JMH, van der Weele LT. Boering G: Symptoms of the temporomandibular joint dysfunction and predisposing factors. J Prosthet Dent 1987; 57:215-222 4. Marbach JJ, Raphael KG. Dohrenwend BP. Lennon MC: The validity of tooth grinding measures: Etiology of pain dysfunction syndrome revisited. JADA 1990; 3:327-333 5. Ramer E: Controversies in temporomandibular joint disorder. Dent Clin North Am 1990; 34:125-133 6. Roberts D: The etiology of the temporomandibular joint dysfunction syndrome. Am J Orthod 1974; 66:498-515 7. Gage JP: Mechanisms of disc displacement in the temporomandibular joint. Aust Dent J 1989; 34:427-436 8. Stockstill JW: The placebo effect in the management of chronic myofascial pain: A review. JAm Col/ Dent 1989; 56:14-18 9. Bell WE: Temporomandibular Disorders (3rd ed. ). Chicago: Year Book Medical Publishers. Inc, 1990 10. Pullinger AG. Solberg WK. Hollender L. Guichet D: Tomographic analysis of mandibular condylar position to the dental occlusion factors in an asymptomatic population. Am J Orthod Dentofacial Orthop 1987; 91:200-206 II. Taylor RC. Ware WH. Fowler D. Kobayashi J: A study of the temporomandibular joint morphology and its relationship to the dentition. Oral Surg Oral Med Oral Path 1972; 33:1002-1013 12. Solberg WK. Bibb CA. Nordstrom BB. Hansson TL: Malocclusion associated with temporomandibular joint changes in young adults at autopsy. Am J Orthod 1986; 89:326-330 13. Jankelson B: Three-dimensional orthodontic diagnosis and treatment. A neuromuscolar approach. J Clin Orthod 1984; 18:9
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KELLER AND CARANO 14. Solberg WK. Hansson TL. Nordstrom 88: The temporomandibular joint in young adults at autopsy: A morphologic classification and evaluation. J Oral Rehabil 1985; 12:303-321 15. Solberg WK: Neuromuscular problems in the orofacial region: Diagnosis-classification. signs and symptoms. lm Dent J 198 I; 31:206215 16. Pullinger AG. Solberg WK. Hollender L. Guichet D: Tomographic analysis of mandibular condyle position in diagnostic subgroups of temporomandibular disorders. J Prosrhet Dent 1986; 55:723729 17. Girardot RA: Condylar displacement in patients with TMJ dysfunction. CDS Rev 1989; 89:49-55 I 8. Weinberg LA. Lager L: Clinical report on the etiology and diagnosis ofTMJ dysfunction-pain syndrome. J Prosther Dent 1980; 44:642653 19. Stringert HG. Worms FW: Variations in skeletal and dental patterns in patients with structural and functional alterations of the temporomandibular joint: A preliminary report. Am J Orthod 1986; 89:285297 20. Helm S. Petersen PE: Mandibular dysfunction in adulthood in relation to morphologic malocclusion at adolescence. Acta Odmrtol Scand 1989; 57:307-314 21. Weinberg LA: A conceptual overview of the TMJ dysfunction pain. NY State Dent J 1987; Oct: I 8-24 22. Angel JL: Factors in temporomandibular joint form. Am J Anat 1948; 83:223-246 23. lngervall 8: Relation between height of the articular tubercle of the temporomandibular joint and the facial morphology. Angle Ortlwd 1974; 44:15-24 24. Ricketts RM: Variations of the temporomandibular joint as revealed by cephalometric laminography. Am J Orthod 1950; 36:877-898 25. DiPaolo RJ: An individualized approach to locating the occlusal plane. Am J Orrhod Dentofacial Orthop 1987; 92:41-45 26. Nickel JC. McSachlan KR. Smith DM: Eminence development of the postnatal human temporomandibular joint. J Dent Res 1988; 67:896902 27. Cervera A: Trallato di Ortodon:ia Clinica. Madrid: CEOSA. 1974 28. Jacobson A: Application of the "Wits" appraisal. Am J Orthod 1976; 70:179-189 29. Farrar WB: Characteristics of the condylar path in internal derangements of the TMJ. J Prosrhet Dent 1978; 39Z:319-323
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30. Smith RJ: Functions of condylar translation in human mandibular movement. Am J Orthod 1988; 88:191-201 31. D'Amico A: Functional occlusion applicable to restorative dentistry. J Prosthet Dent 1953; 3:772-782 32. Shillingburg HT. Hobo S. Whitsett LD: Fundamentals of Fixed Prosthodontics (2nd ed.). Lombard: Quintessence Publishing Co. Inc. 1981 33. Stallard H. Stuart CE: Eliminating tooth guidance in natural teeth of man. J Prosthet Dent 1961; II :474-479 34. Stuart CE: Good occlusion for natural teeth. J Prosthet Dent 1964; 14:716-724 35. Katzberg RW: Temporomandibular joint imaging. State of the an. Radiology 1989; 170:297-307 36. Hinton RJ: Form and function in the temporomandibular joint. Craniofacial biology. In Carlson DS (ed). Center of Human Growth and Development. Ann Arbor: University of Michigan. 1981; 3760 37. Seward FS: Tooth attrition principles as applied to dentistry. Angle Orthod 1966; 46: 162-170 38. Atkinson WB. Bates RE: The effect of the angle of the articular eminence on articular disk displacement. J Prosthet Dent 1983; 49:554555 39. Kersten HCJ. Tuinzing DB. Golding RP. Vander Kwast WAM: Inclination of the temporomandibular joint eminence and anterior disk displacement. lnt J Oral Maxillofac Surg 1989; I 8:228-232
For Additional Reading Burlon BM: Anatomy and biomechanics of the TMJ. In Kraus SL (ed). TMJ Disorders. Management of the Craniomandibular Complex. Clinics in Physical Therapy. volume 18 Gibbs CH. Lundeen HC: Jaw movements and forces during chewing and swallowing and their clinical significance. In Lundeen HC. Gibbs Ch (eds). Advances in Occlusion. Boston: John Wright-PSG. Inc. 1982; 2-32 Kraus BS. Jordan RE. Abraus L: Dental Anatom\·andOcclusion. Baltimore: The Williams & Wilkins Co. 1969 . Shuyler CH: Factors of occlusion of the natural teeth of man. J Prosthet Dent 1953; 3:772-782
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