REVIEW ARTICLE

Orthodontics and temporomandibular disorders: A review of the literature (1966-1988) Reint M. Reynders, DDS, MSc.* Milan, Italy

The orthodontist has been both accused of causing and complimented for curing temporomandibular dysfunction. To better understand the origins of these conflicting opinions, a review of the orthodontic and temporomandibular joint journals was performed for articles published since 1966. A total of 91 publications that discussed the relationship between orthodontics and temporomandibular disorders was found, and these articles were divided in three categories: viewpoint publications, case reports, and sample studies. Among the areas scrutinized in each category was the method that has led to the diversity of viewpoints. From this analysis, the following conclusions were drawn: (1) viewpoint publications and case reports were excessively represented in comparison with the number of sample studies; (2) viewpoint publications and case reports described a wide variety of conflicting opinions on th e relationship between orthodontics and temporomandibular disorders; (3) unlike sample Studies, viewpoint publications and case reports have little or no value in assessment of the relationship between orthodontics and temporomandibular disorders; (4) sample studies indicate that orthodontic treatment is not responsible for creating temporomandibular disorders, regardless of the orthodontic technique; and (5) sample studies indicate that orthodontic treatment is not specific or necessary to cure signs and symptoms of temporomandibular dysfunction. (AM J ORTHOD DENTOFACORTHOP 1990;97:463-71.)

T h e specialists in orthodontics have long been interested in the problems associated with the diagnosis and management of tempor0mandibular disorders. TM In the last decade, a more comprehensive understanding of the temporomandibular joint (TMJ) and its associated structures has failed to diminish the controversy surrounding this subject. An important aspect.of today's confusion results from conflicting information in the literature. 5~7 The interpretation of numerous published reports is hampered by inadequate design, biased case sampling, inappropriate or nonexistent control groups, incomplete or inaccurate data collection, unjustified assumptions, and faulty interpretation. ~82' Indeed, orthodontic treatment has been characterized in diverse publications as both causing and curing temporomandibular dysfunction.5"8"'2z2s To better understand the origins of these conflicting opinions,it has been necessary to comprehensively review the orthodontic literature from the standpoint of methods used. MATERIALS AND METHODS

A MEDLINE search was requested to list the articles published on the topic of orthodontics and tem*Former Research Associate and Clinical Instructor, Department of Orthodontics, Northwestern University, Chicago, Illinois, 811114548

poromandibular disorders in the orthodontic and TMJ journals. MEDLINE provides a computerized index of the dental literature that includes all dental articles published since 1966. With this system, the following journals were screened: Angle Orthodontist, AMERICANJOURNAL OF ORTHODONTICSAND DENTOFACIAL ORTHOPEDICS, Australian Orthodontic Journal, British Journal of Orthodontics, European Journal of Orthodontics, Facial Orthopedics and Temporomandibular Arthrology, Functional Orthodontist, htternational Journal of Adult Orthodontics and Orthognathic Surgery, hzternational Journal of Orofacial Myology, International Journal of Orthodontics, Journal of Clhdcal Orthodontics, Journal of Craniomandibular Practice, Orthodontist, and Journal of Craniomandibular Disorders Facial and Oral Pahz. The initial MEDLINE search provided a total of 285 publications. All were retrieved; however, only 91 publications discussed the relationship between orthodontics and temporomandibular disorders. These were submitted for detailed review and divided into three categories: viewpoint publications, case reports, and sample studies. Editorials were excluded from consideration. Viewpoint publications state the authors' specific opinions on the relationship between orthodontics and temporomandibular disorders. The origin of these opinions was analyzed in each article and tabulated under 463

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Table I. Relationship between orthodontics and temporomandibular disorders in orthodontic and temporomandibular joint journals since 1966 (Summary tables II-IV) Relationship between orthodontics and temporomandibular disorders Total No. of publications

Type of publication Viewpoint publications

8

Case reports Sample studies TOTAL

10

4

23 8

2 35

4 8

33

55

7

30

40

6 9--1

TERM[NOLtX]Y: - - , Orthodontics causes temporomandibular disorders; + , orthodontics cures temporomandibular disorders; 0, orthodontics does not influence temporomandibular disorders; _ , orthodontics can both cause and cure temporomandibular disorders.

tionship between orthodontics and temporomandibular disorders. The cumulated findings of these publications are summarized in Table I.

Viewpoint publications (Table I1) The viewpoint type of article was the most common in the total sample (Table I). Of the 55 viewpoint publications, 10 articles indicated a curative effect, 8 articles indicated a causal effect, and 4 articles claimed no effect of orthodontics on the signs and symptoms of temporomandibular dysfunction. Thirty-three viewpoint articles claimed that orthodontics can both cause and cure temporomandibular disorders. Of the 55 viewpoint publications, 49 were based on the personal viewpoint of the author (PVA) and 219'29 originated from the data of controlled sample studies (CSSO) (Table II). Twenty-three viewpoint publications were published in one journal (Table II).

Case reports (Table III)

the following headings: the personal viewpoint of the author (PVA); !he personal viewpoint of other author(s) ¢PVO); case reports of the author (eRA), case reports of other author(s) (CRO); controlled sample study, author (CSSA); controlled sample study, other author(s) (CSSO); uncontrolled sample study, author (USSA); uncontrolled sample study, other author(s) (USSO). The category of "case reports" included publications describing the influence of certain orthodontic treatment modalities in one or more cases on the signs and symptoms of temporomandibular dysfunction. Sample studies reported data on this relationship as found after a study of large sample groups. The following characteristics of these studies were tabulated: the character of the design, the size of the samples, controlled versus uncontrolled study, and the type of orthodontic appliances used. The putative relationship between orthodontics and temporomandibular disorders was designated by one of three characters: - , + , or 0. The minus symbol indicated that orthodontics caused temporomandibular dysfunction, a plus symbol indicated that orthodontics cured such disorders, either directly or as an essential part of a multiple-phase TMJ therapy, and finally the zero symbol indicated that orthodontics has no influence on temporomandibular dysfunction. If the author claimed that orthodontics can both cause and cure temporomandibular disorders, the viewpoints were characterized by a --- symbol.

RESULTS Between 1966 and 1988 the orthodontic and TMJ journals published 91 articles that discussed the rela-

Thirty case reports were available (Table I). A curative effect was shown in 23 articles, whereas 7 articles defined a combined causal/curative effect of orthodontics on the signs and symptoms of temporomandibular dysfunction. Of the 30 case reports, 15 were published by one author !n one journal and all presented a curative effect (Table III).

Sample studies (Table IV) Only 6 sample studies were found (Table I). Two showed a curative effect and 4 showed no effect of orthodontics on temporomandibular disorders. Five sample studies had a controlled design, and one did not (Table IV).

DISCUSSION Viewpoint publications Viewpoint publications serve an important purpose because they generate new ideas and hypoiheses. However, once these propositions are introduced, they should be tested for validity in a controlled experimental environment. As shown in Table I, such attempts have been rare (55 viewpoint publications versus 6 sample studies). Moreover, 49 of these 55 viewpoint articles were based on the personal biases of the authors without cross-referencing studies of others (Table II). This is not surprising because scientific data supporting these convictions are not available. Only 2 of the 55 viewpoint publications presented opinions based on findings in controlled sample studies. ~9"29Furthermore, Table I illustrates the wide diversity of opinions on the relationship between orthodontics and temporomandibular disorders. These viewpoints can be roughly classified into three groups. The first group claims that orthodontics jeopardizes the temporomandibular complex.

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Table II. Viewpoint publications on the relationship between orthodontics and temporomandibular disorders Author(s) Ricketts 79 M a t h e w s a7 S i l v e r m a n 8° W i l s o n 3t M a r b a c h 36 Perry HT. ~' Perry HT. s: Freer ~3 S p y r o p o u l o s et al. 3-" W i l l i a m s o n ~5 Lewis~ Timm and Ash ~ B e n c h et al. ~ Aubre~ 7 L e v y 35 R o t h 6° R o t h et al. 62 Roth ~ R o t h et al. 6~ Williamson ~ W i l l i a m s o n s9 Libin 87 Greene 29 Haden ~ Williamson ~ Bellavia 9° Bell 9~ B e a n 49 M e h t a 53 W i t z i g ~° Stack u K u s s i c k 9" B o w b e e r 43 B e a n '~3 Grummons~ B o w b e e ru P e r r y SS. 4g Broadbent~ B r o a d b e n t 5~ B r o a d b e n t ~2 B r o a d b e n t 4-" G e r b e r ~s B o w b e e t 33 T h o m p s o n ~° G e l b 3s G e l b S° Wyatt~ R i n c h u s e ~9 B o w b e e r 39 Bowbeer~ M c L a u g h l i n~ A l p e r n et al. 97 SpahP ~ Bowbeer~ Livingston ~7

Journal AM J ORTHOD

Angle Orthod AM J ORTttOD

Orthodontist AM J ORTtIOD AM J OR'ntOD AM J ORTHOD Aast Orthod J AM J ORTHOD

Angle Orthod AM J ORTHOD

J Clin Orthod J Clin Orthod AM J ORTHOD

hzt J Orthod J Clin Orthod J Clin Orthod J Clin Orthod J Clin Orthod J Clbz Orthod J Clin Orthod hzt J Orthod Angle Orthod J Craniomandibular Pract J Clin Orthod J Craniomandibular Pract J Clin Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Funct Orthod Angle Orthod Funct Orthod Funct Orthod A~.! J ORTHOD DENIOFAC ORTHOP AM J ORTItOD DEmOFAC ORTHOP

Funct Orthod Funct Orthod Angle Orthod Angle Orthod Funct Orthod Funct Orthod Funct Orthod

Year

Relatiot,ship orthodontics and TM disorders

1966 1967 1968 1971 1972 1973 1975 1975 1976 1976 1976 1977 1978 1978 1979 1981 1981 1981 1981 1981 1981 1982 1982 1982 1982 1983 1984 1984 1984 1984 1985 1985 1985 1985 1985 1986 1986 1986 1986 1986 1986 1986 1986 1986 1987 1987 1987 1987 1987 1987 1988 1988 1988 1988 1988

± + ± -± -0 -± ----± ± ± -+ ~ ± ± ± ± ± 0 + + + 0 ± + ± + ± ± ± + ± ± + + ± + +-± ± 0 ± ± ± ± ± ±

I Origin viewpoint PVA PVA PVA PVA PVA PVA PVA PVA CRO PVA/CRA CRO PVA PVA PVA/PVO/CRA/CRO PVA PVA PVA PVA PVA PVA PVA PVA CSSO PVA PVA PVA PVA PVA PVA PVA PVA PVA PVA/CRA PVA PVA PVA PVAICRA PVA PVA PVA PVA PVA PVA PVA PVA PVA PVA CSSO PVA/PVOICRA PVA PVO PVA PVA PVA/CRA PVO

TERMINOLOGY; - - , O r t h o d o n t i c s causes t e m p o r o m a n d i b u l a r disorders; + , orthodontics cures t e m p o r o m a n d i b u l a r disorders; 0, orthodontics does not influence t e m p o r o m a n d i b u l a r disorders; ± , orthodontics c a n both cause and cure t e m p o r o m a n d i b u l a r disorders. PVA, Personal viewpoint, author(s); PVO, personal viewpoint, other author(s); CRA, case report, author(s); CRO, case report, other author(s); CSSA, controlled sample study, author(s); CSSO, controlled sample study, other author(s); USSA, uncontrolled sample study, author(s); USSO uncontrolled sample study, o t h e r author(s).

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Table ill. Case reports on the relationship between orthodontics and temporomandibular disorders

J Authors

Journal

Year

Roths lngervall"-s Parker98 Owen'~ Callender1°° Bronson1°1 Owenl°2 Bandeenm Bronson1°4 Williamson~°s Williamson1°~ Williamson1°7 WilliamsonI°s Wiltiamson1°9 Williamsonu° Williamsonm Williamsonm Williamsonm Williamsonli~ Williamsonm WilliamsonH6 Thompson9 Williamsonm WilliamsonIlg WilIiamsonm Bledsoe~z° Davidm Lynnm Mintzm Owenm

Angle Orthod AMJ OR'roOD AMJ ORTHOD J Craniomandibular Pract J Clin Orthod Funct Orthod J Craniomandibular Pract AMJ OORTIIOD Funct Orthod Facial Orthop TemporomandibularArthrol Facial Orthop Temporomandibular Arthrol Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Facial Orthop Temporomandibular Arthrol Facial Orthop TemporomatutibularArthrol Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Angle Orthod Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Facial Orthop TemporomandibularArthrol Funct Orthod Funct Orthod Funct Orthod Angle Or(hod AMJ ORTHoD DENTOFACORTHOP

1973 1978 1978 1984 1984 1984 1984 1985 1985 1985 1985 1985 1985 1985 1985 1986 1986 1986 1986 1986 1986 1986 1987 1987 1987 1987 1988 1988 1988 1988

Relationship orthodontics and TM disorders

No. of cases

__. + ----+ + + ± --___ + + + + + + + + + + + + ___ + + + + + + + ___

TERMINOLOGY:--, Orthodonticscauses temporomandibulardisorders; +, orthodonticscures temporomandibulardisorders; 0, orthodonticsdoes not influencetemporomandibulardisorders; -4-,orthodonticscan both cause and cure temporomandibulardisorders.

Supporters of this position generally declare that premolar extractions and certain mechanics used in fixedappliance therapy cause temporomandibular disorders. I°'zs'3°47 The second group proposes that nonextraction treatment, functional appliances, face masks, an d second molar extractions can cure or prevent signs and symptoms of temporomandibular dysfunction. 3°'33'34'39"42"45"~The third group claims that temporomandibular disorders result from orthodontic treatment that was not finished according to the gnathologic standards) 5~2 All three viewpoints are repeated continually in the literature. However, these ideas cannot be supported by data in controlled sample studies, as will be discussed later. 6365 Finally, 23 of the 55 viewpoint publications were published in one journal, of which the first edition appeared in 1984 (Table II). All 23 articles represented similar opinions of the relationship between orthodontics and temporomandibular disorders.

Case reports Case reports play a dual role in clinical science. They can be beneficial and lead to new insights into clinical problems. However, case reports can also be quite harmful, since they can, by virtue of their initial convincing appearance, easily mislead the reader. Case reports particularly obscure the issue when they are used as evidence to prove certain viewpoints of an author and can, thereby, lead to misinterpretations of causeand-effect relationships. This damaging effect is fortified even more when identical case reports are published in large numbers, as seen on the topic of orthodontics and temporomandibular disorders (Table III). When properly used, one single case report should be presented first, leading to a hypothesis, which then later should be tested in an experimental design. Such tests are extremely important, especially in light of the capricious nature of temporomandibular disorders.

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Table IV. Sample studies on the relationship between orthodontics and temporomandibular disorders

Author(s)

Journal

Relationship [ orthodonicsand Year ] TM disorders Number of cases I Appliance}Control

Design

Larsson and Ronnerman73

Eur J Ortkod

1981

+

23 Experimental

Fixed No Functional

Retrospective

Janson and Hasund72

Eur J Orthod

1981

+

60 Experimental 30 Control

Fixed Yes Functional

Retrospective

Sadowsky and Begole u

AM J ORTnOD

1980

0

75 Experimental 75 Control

Fixed

Yes

Cross sectional

Sadowsky and Poison~

AM J ORI-HOD

1984

0

207 Experimental Fixed 214 Control

Yes

Cross sectional

Pancherz ~25

AM J OR'I'ttOD

1985

0

20 Experimental

Herbst

Yes

Before-after

Dibbetts and van der Weele63

AM J ORTHOD DENTOFACORTHOP 1987

0

63 Functional 72 Fixed

Fixed Yes Functional

Longitudinal

"tERML'~OLOCY:- - , Orthodontics causes temporomandibular disorders; + , orthodontics cures temporomandibular disorders; O, orthodontics does not influence temporomandibular disorders; --+, orthodontics can both cause and cure temporomandibular disorders.

Table I shows the majority of case reports (23 of 30) conclude that orthodontic treatment had a curing effect on temporomandibular disorders. This almost unanimous claim stands in sharp contrast to the wide diversity of opinions presented in the viewpoint publications. One possible explanation for the high percentage of case reports claiming a curative response to orthodontic treatment is that 15 of the 23 articles were published by one author (Table III). Moreover, all the articles were published in the same journal, of which this author is the sole editor. (It should be noted that this journal was published for only 4 years before being withdrawn from circulation.) In these 15 case reports, orthodontic treatment was considered an essential component of the multiple-phase therapy for temporomandibular disorders. Another possible explanation for the large number of single case reports claiming orthodontics has a curative effect on temporomandibular disorders was presented in longitudinal epidemiologic surveys. Such studies have pointed out that signs and symptoms of temporomandibular dysfunction are not constant and may come and g o . 66"67 Further, controlled placebo studies and reports of no treatment have coincided with remission of temporomandibular disorders. 6s7° It is therefore not difficult to understand how the promising results achieved in single case reports could easily lead to false interpretation of clinical success.

Sample studies Because of the wide variety and large number of factors influencing the signs and symptoms of temporomandibular dysfunction, delicate methods are re-

quired to evaluate the effects of orthodontic treatment on these disorders. In the designing of such studies, several essential factors should be controlled: ethnic background, socioeconomic status, sex, interobserver variability, types of orthodontic appliances, psychoemotional status, placebo effects, and age. Controlling for age is extremely important as demonstrated in several recent epidemi010gic surveys. These studies document the generally increasing incidence of temporomandibular disorders during the age when orthodontic treatment is usually performed. 66m Egermark-Eriksson et al. 7~ showed, for example, that the prevalence of such symptoms increased from 30% to 60% between the ages of 7 and 15 years. Table I shows that of the total of 91 publications that discussed the relationship between orthodontics and temporomandibular disorders, only 6 were designed to investigate this putative association. Four sample studies described no relationship between orthodontics and temporomandibular dysfunction, whereas 2 sample studies 23,72showed orthodontic treatment can, in certain patient groups, slightly lower the prevalence of functional disorders of temporomandibular complex. However, both of these latter studies contained some flaws in their designs. The first study z3 was not controlled, but the findings were compared with the results of the epidemiologic surveys by Helkimo. 73 Comparisons of data with those obtained in other investigations must be made with extreme caution because dissimilarity in sample characteristics may lead to different results. In the second study, 72 age was not adequately controlled, and this defect may have skewed the data.

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468 Reynders

As noted previously, numerous viewpoint publications cite specific treatment mechanics used in fixed orthodontic appliance therapy as the cause of temporomandibular dysfunction. These mechanics include Class II and crossbite elastics, headgear, chincups, first premolar extractions, and palatal tipping of maxillary incisors. 1°'zs'3°-47Onthe other hand, the same category of literature suggests that second molar extractions, face mask therapy, nonextraction treatment, and functional appliances can actually cure or prevent temporomand i b u l a r d i s o r d e r s . 30,33,34'39.42,45"54 A third category of viewpoint literature presents the opinions of the gnathologists. These authors claim that nonfunctional occlusal contacts, when introduced by orthodontic treatment, can cause signs and symptoms of temporomandibular dysfunction. 5s62 The validity of these diverse viewpoints was addressed in 3 carefully designed sample studies .63455 In 1977 the National Institutes of Health awarded research contracts to the University of Illinois and the Eastman Dental Center to study the prevalence of temporomandibular disorders and the status of functional occlusion in a large group of 207 subjects who had received fixed orthodontic appliance treatment at least 10 years previously as adolescents. ~'65 In both investigations, special precautions were taken to compare the orthodontic groups with suitable control samples. The findings of both investigations were similar and showed that orthodontic treatment performed during adolescence does not generally increase or decrease the risk of developing temporomandibular disorders in later life. These results have some important implications. First, the assumption made by some authors that orthodontic treatment can prevent symptoms of mandibular dysfunction is disproven. Second, it is shown that orthodontic treatment does not induce temporomandibular disorders. Interestingly, a trend toward a lower incidence of symptoms of temporomandibular dysfunction in the orthodontic group was present but not significant. Many of the orthodontic mechanics, described as potential initiators of temporomandibular disorders in several viewpoint publications, are widely applied in the edgewise technique. It seems appropriate, therefore, to assume that such mechanics were also applied in treatment of the patients surveyed in the Illinois and Eastman investigations. On the basis of the findings in those studies, we probably can conclude that such techniques are not detrimental to the TMJ.19 Another important finding in the Illinois and Eastman studies was the high incidence of nonfunctional occlusal contacts found in both orthodontic and control groups. 64"65Similar observations were also documented

in 4 other carefully controlled surveys. 7477 However, the Illinois study could not show a relationship between signs or symptoms of temporomandibular dysfunction and the presence of nonfunctional contacts or mandibular shifts. 6~ This finding therefore challenges the assumption the gnathologists presented in the viewpoint literature. The effects of functional appliance treatment on the incidence of signs and symptoms of temporomandibular dysfunction were addressed in a recent thoroughly designed longitudinal study at the University of Groningen in the Netherlands. 63 In the Groningen survey, activator treatment was compared with fixed-appliance treatment. Of the latter group, 86%* underwent 4 premolar extractions, whereas the activator patients were treated without extractions. Ten years after the start of orthodontic therapy there were no differences in symptoms of TMJ dysfunction between the activator patients and those treated with fixed appliances. It should be noted that the latter group was treated according to the Begg philosophy. This technique generally uses Class II elastics and also induces excessive retroclination of incisors in the early stages of treatment. 7s Further, it must be emphasized that the Groningen survey was longitudinally designed. Longitudinal designs are particularly powerful because they provide information on prevalence as well as incidence. Finally, contrary to the observations made in the Groningen study, several case reports and viewpoint publications have labeled fixed appliances as the cause of temporomandibular dysfunction and functional appliances as the means of curing such disorders. An explanation for these reports could be related to the age variable. Functional-appliance treatment is generally started at an earlier age than fixed-appliance therapy. As described, longitudinal studies have indicated that the incidence of temporomandibular disorders is lower in the younger age range. ~m These data, combined with the observations made in the Groningen study, indicate once more how dangerous it is to extrapolate findings from single case reports to simple cause-andeffect relationships. In conclusion, it is surprising that, although some of these carefully designed sample studies were published in the early 1980s, the authors of viewpoint publications and case reports have largely ignored these findings and have continued to saturate the literature with their biased data. CONCLUSIONS

The orthodontic and TMJ literature published since 1966 was reviewed in an effort to determine whether *Personal communication with the authors.

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orthodontic treatment causes, cures, or does not influence temporomandibular dysfunction. A total o f 91 publications was found, and these articles were tabulated in three categories: viewpoint publications, case reports, and sample studies. The method o f the different types of publications was analyzed and discussed. F r o m this analysis, the following conclusions were drawn: 1. Viewpoint publications and case reports were excessively represented in comparison with the number of sample studies. 2. Viewpoint publications and case reports failed to reach a consensus on the relationship between orthodontics and the signs and symptoms o f temporomandibular dysfunction but, instead, described a wide variety o f conflicting opinions on this subject. 3. Unlike sample studies, viewpoint publications and case reports have little or no value in the assessment of the relationship between orthodontics and temporomandibular disorders. 4. Sample studies demonstrated that orthodontic treatment mechanics with fixed appliances used during adolescence does not influence the risk o f the development o f temporomandibular disorders in later life.64'rs 5. Longitudinal sample research has shown no differences in the incidence o f temporomandibular joint dysfunction among the patients treated with functional appliances (activators) without extractions as compared with patients treated with fixed orthodontic appliances and four premolar extractions. 63 6. The findings presented in 4 and 5 indicate that orthodontic treatment should not be considered responsible for creating temporomandibular disorders, regardless o f the orthodontic technique. These data also reject the assumption that orthodontic treatment is specific or necessary to cure signs and symptoms o f temporomandibular dysfunction. 7. Nonfunctional occlusal contacts were distributed equally among orthodontically treated patients and nontreated patients. These types o f occlusal contact showed no relationship with the presence o f signs and symptoms of temporomandibular dysfunction. I wish to extend special thanks to the following persons at Northwestern University for reviewing this manuscript: Dr. Louis Keith, Department of Obstetrics and Gynecology, and Drs. David P. Forbes, Charles S. Greene, and Harold T. Perry, Department of Orthodontics.

Review article

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29. 30.

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47. 48. 49. 50. 51. 52. 53. 54. 55.

Reynders

mandibular dysfunction symptoms. AM J ORTHOD 1978;73: 551-9. Greene CS. Orthodontics and the temporomandibularjoint. Angle Orthod 1982;52:166-72. Witzig JW, AAFO's man of the year 1984 Dr. John Witzig [interview by Dr. Craig C. Stoner]. Funct Orthod 1984;!(4):910,12-13,15 passim. Wilson HE. Extraction of second permanent molars in orthodontic treatment. Orthodontist 1971;3:18-24. Spyropoulos MN, Askarieh M. Vertical control: a multifactorial problem and its clinical implications. AMJ ORTtIOD 1976;70:7080. Bowbeer GR. Saving the face and the TMJ. Part 3. Funct Orthod 1986;3(5):6-18, 20-1. Bowbeer GR. Saving the face and the TMJ. Part 2. Funct Orthod 1986;3(2):9-13,15,17 passim. Levy PH. Clinical implications of mandibular repositioning and the concept of an alterable centric relation, lnt J Orthod 1979;17(3):6-25. Marbach JJ. Therapy for mandibular dysfunction in adolescents and adults. AM J ORTHOD 1972;62:601-5. Mathews JR. Functional considerations of the temporomandibular articulation and orthodontic implications. Angle Orthod 1967 ;37:81-93. Gelb H. An interview with Dr. Harold Gelb by Jimi Mehta. Part I. Funct Orthod 1987;4(2): i 9-20,22-3,26-7,47-8. Bowbeer GRN. The 6th key to facial beauty and TMJ health. Funct Orthod 1987;4(4):!0-11,13-16,18,20,21,24-31. Bowbeer GRN. An interview with AAFO's man of the year, 1987, Gran R.N. Bowbeer, DDS, MS, with Craig C. Stoner. Funct Orthod 1987;4(6):12-6. Br°adbent JM" Sec°nd m°lar rem°val' third m°lar replacement" Funct Orthod 1986;3(2):37-9. Broadbent JM. How you can achieve superior results for your patients. Funct Orthod 1986;3(6):19-20. Bowbeer GRN. Saving the face and the TMJ. Funct Orthod 1985;2(5):32-44. Williamson EH. Occlusal concepts in orthodontic diagnosis and treatment. Part III. Clinical significance. Facial Orthop Temporomandibular Arthrol 1987;4(3):13-6. Spahl TJ. Problems faced by fixed and functional schools of thought in pursuit of orthodontic excellence. Funct Orthod 1988;5(2):28-31,33-34. Bowbeer GRN. The seventh key to facial beauty and TMJ health: proper condylar position. Funct Orthod 1988;5(5):418,20. Livingston N. Moving teeth and raising eyebrows. Funct Orthod 1988;5(6):21,24. Perry SS. Treatment of Class II, Division 2 TMJ patients. Funct Orthod 1986;3(6):35-43. Bean MD. How to use the sagittal appliance effectively. Funct Orthod 1984;1(2):12-3,15-6. Gelb H. An interview with Dr. Harold Gelb by Jimi Mehta. Part II. Funct Orthod 1987;4(3):18,20,24,27,28,30,32. Broadbent JM. The orthopedic corrector. Funct Orthod 1986; 3(4):7-11. Broadbent JM. The sagittal appliance. Funct Orthod 1986; 3(5):36-38-9. Mehta J. Incorporating functional appliances in a traditional fixed appliance practice. Funct Orthod 1984;1(1):30-2. Stack B. Orthopedic/orthodontic case finishing techniques on TMJ patients. Funct Orthod 1985;2(2):28-35,43-4. Williamson EH. Occlusion: understanding or misunderstanding. Angle Orthod 1976;46:86-93.

Am. J. Orthod. Dentofac. Orthop. June 1990

56. Roth RH. Functional occlusion for the orthodontist. Part IlL J Clin Orthod 1981;15:174-9,182-98. 57. Aubrey RB. Occlusal objectives in orthodontic treatment. AM J Oa~OD 1978;74:162-75. 58. Williamson EH. Dr. Eugene It. Williamson on occlusion and TMJ dysfunction [interview by S. Brandt]. J Clin Orthod 1981; 15:333-59. 59. Williamson EH. Dr. Eugene H. Williamson on occlusion and TMJ dysfunction. Part 2 [interview by S. Bran&]. J Clin Orthod ! 981; ! 5:393-404,409-10. 60. Roth RH. Functional occlusion for the orthodontist. Part I. J Clin Orthod 1981;15:32-41,44-51. 61. Roth RH, Gordon WW. Functional occlusion for the orthodontist. Part IV. J Clin Orthod 1981;15:246-54,259-65. 62. Roth RH, Rofs DA. Functional occlusion for the orthodontist. Part I1. J Clin Orthod 1981;15:100-9,112-23. 63. Dibbets JMH, van der Weele LT. Orthodontic treatment in relation to symptoms attributed to dysfunction of the temporomandibular joint: a 10-year report of the University of Groningen study. A.',I J ORTHOD DENTOFACORTHOP 1987;91:193205. 64. Sadowsky C, BeGole EA. Long-term status of temporomandibular joint function and functional occlusion after orthodontic treatment. AM J ORTHOD 1980;78:201-12. 65. Sadowsky C, Poison AM. Temporomandibular disorders and functional occlusion after orthodontic treatment: results of two long-term studies. AM J ORTHOD 1984;86:386-90. 66. Egermark-Eriksson I, Carlsson GE, Magnusson T. A long-term epidemiologic study of the relationship between occlusal factors and mandibular dysfunction in children and adolescents. J Dent Res 1987;66:67-71. 67. Magnusson T, Egermark-Eriksson I, Carlsson GE. Five-year longitudinal study of signs and symptoms of mandibular dysfunction in adolescents. Cranio 1986;4:338-44. 68. Goodman P, Greene CS. Laskin DM. Response of patients with myofascial pain-dysfunction syndrome to mock equilibration. J Am Dent Assoc 1976;92:755-8. 69. Forssell H. Mandibular dysfunction and headache. Proc Finn Dent Soc 1985;81(Suppl 1-2):1-91. 70. Greene CS, Laskin DM. Long-term evaluation of conservative treatment for myofascial pain-dysfunction syndrome. J Am Dent Assoc 1974;89:1365-8. 71. Egermark-Eriksson I, Carlsson GE, Ingervall B. Prevalence of mandibular dysfunction and orofacial parafunction in 7-, 11-, and 15-year-old Swedish children. Eur J Orthod 1981 ;3:163-72. 72. Janson M, Hasund A. Functional problems in orthodontic patients out of retention. Eur J Orthod 1981;3:173-9. 73. Helkimo M. Studies on function and dysfunction of the masticatory system. 1I. Index for anamnestic and clinical dysfunction and occlusal state. Sven Tandlak Tidskr 1974;67:101-21. 74. Rinchuse DJ, Sassouni V. An evaluation of functional occlusal interferences in orthodontically treated and untreated subjects. Angle Orthod 1983;53:122-30. 75. Ahlgren J, Posselt U. Need of functional analysis and selective grinding in orthodontics: a clinical and electromyographic study. Acta Odontol Scand 1963;21:187-226. 76. Cohen WE. A study of occlusal interference in orthodontically treated occlusions and untreated normal occlusions. AM J ORaatOD 1965;51:647-89. 77. Gazit E. Liberman MA. The intercuspal surface contact area registration: an additional tool for evaluation of normal occlusion. Angle Orthod 1973;43:96-106. 78. Begg PR, Kesling PC. Begg orthodontic theory and technique. 3rd ed. Philadelphia: WB Saunders, 1977.

Volume 97 Number 6

79. Ricketts RM. Clinical implications of the temporomandibular joint. AM J OR'roOD 1966;52:416-39. 80. Silverman MM. Equilibration of the natural dentition following orthodontic treatment to prevent movement of teeth and other problems. AM J OR'naOD 1968;54:831-51. 81. Perry HT. Adolescent tempornmandibular dysfunction. AM J ORa'HOD 1973;63:517-25. 82. Perry HT. Mandibular function: an orthodontic responsibility. AM J OR'roOD 1975;67:316-23. 83. Freer TJ. Who says that child needs orthodontic treatment? Aust Orthod J 1975;4(2):64-70. 84. Lewis PD. Class II treatment in orthodontics. AM J OR~IOD 1976;70:529-42. 85. Timm TA, Ash MM. The occlusal bite plane splint: an adjunct to orthodontic treatment. J Clin Orthod 1977;I 1:383-90. 86. Bench RW, Gugino CF, Hilgers JJ. Bioprogressive therapy. Part 8. J Clin Orthod 1978;12:279-98. 87. Libin BM. Cranial-mandibular-cervical therapy, lnt J Orthod 1982;20(1):13-9. 88. Haden JL. Occlusion finalization following TMJ therapy. J Craniomandibular Pract 1982-1983;1:14-9. 89. Williamson EH. The masticatory silent period: its use in diagnosis and treatment of dysfunctions. J Clin Orthod 1982; 16:686-91. 90. Bellavia WD. Functional jaw device to aid in treating anterior displaced discs. J Craniomandibular Pract 1983;1:53-60. 91. Bell WE. JCO interviews Dr. Weldon E. Bell on TMJ function and dysfunction. J Clin Orthod 1984;18:877-81. 92. Kussick L. Bone remodeling: the next generation of orthodontists. A total, early, nonextraction approach. Funct Orthod 1985;2(2)i I 1-7,19-21,24. 93. Bean M. An interview with AAFO's man of the year, Dr. Merle Bean. Funct Orthod 1985;2(6):14-6,18-21. 94. Grummons DC. Grumzat intermediary appliance. Funct Orthod 1985;2(3):36-42,44. 95. GerberJW. F i x e d + removable = total orthodonticcaretreatment. Part II. Funct Orthod 1986;3(5):24-6,28-31. 96. McLanghlin RP. Malocclsuion and the temporomandibular joint--an historical perspective. Angle Orthod 1988;58:18591. 97. Alpem MC, Nuelle DG, Wharton MC. TMJ diagnosis and treatment in a multidisciplinary environment--a follow-up study. Angle Orthod 1988;58:101-26. 98. Parker WS. Centric relation and centric occlusion--an orthodontic responsibility. Ar,t J ORrHOD 1978;74:481-500. 99. Owen AH. Orthodontic/orthopedic treatment of craniomandibular pain dysfunction. Part 3. Anterior condylar displacement. JCraniomandibular Pract 1984-1985;3:31-45. 100. Callender JM. Orthodontic application of the mandibular kinesiograph. Part 2. J Clin Orthod 1984;18:791-805. 101. Bronson JR. Diagnosis and treatment narrative for Christy S: a case report. Funct Onhod 1984;1(I):35-7. 102. Owen AH. 11I. Orthodontic/orthopedic treatment of craniomandibular pain dysfunction. Part 2: posterior condylar displacement. J Craniomandibular Pract 1984;2:333-49. 103. Bandeen RL, TimmiTA. Temporomandibularjoint dysfunction. Report of a ease. AM J ORTHOO 1985;87:275-9. 104. Bronson JR. Elizabeth Williams: a narrative case report. Funct Orthod 1985;2(1)il 1-5. 105. Williamson EH. Treatment of temporomandibular disc dislocations with a function regulator II. Facial Orthop Temporomandibular Arthrol 1985;2(2):4-6. 106. Williamson EH. Correction of anterior disc displacement. Facial Orthop Temporomandibular Arthrol 1985;2(1):4-7.

Review article

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107. Williamson EH. Treatment of anterior disk displacement with the removable Herbst appliance. Facial Orthop Temporomandibular Arthrol 1985;2(12):4-6. 108. Williamson EH. Treatment of temporomandibular dysfunction and anterior open bite. Facial Orthop Temporomandibular Arthrol 1985;2(10):4-7. 109. Williamson EH. Treatment of temporomandibular joint dysfunction and bilateral posterior open bite. Facial Orthop Temporomandibular Arthrol 1985;2(9):4-7. 110. Williamson EH. Treatment of temporomandibular disc dislocation with a modified orthopedic corrector. Facial Orthop Temporomandibular Arthrol 1985;2(4):4-6. 111. Williamson Ett. Temporomandibular pain dysfunction and mandibular asymmetry: a compromise case. Facial Orthop Temporomandibular Arthrol 1986;3(9):3-8. 112. Wiltiamson EH. Mandibular orthopedic change and closure of anterior open b~te following reduction of disk dislocation. Facial Orthop Temporomandibular Anhrol 1986;3(7):3-7. 113. Williamson EH. staged intracapsular and orthognathic surgical procedures in the treatment of internal derangement. Facial Orthop Temporomandibular Arthrol 1986;3(3):3-6. 114. Williamson EH. Treatment of internal derangement and closure of posterior Open bite in the adult. Facial Orth0p Temporomandibular Arthrol 1986;3(2):3-5. 115. Williamson EH. Treatment of acute anterior dislocation without reduction followed by functional orthopedics and Class II correction. Facial Orthop Temporomandibular Arthrol 1986; 3(6):3-7. 116. Williamson EH. Treatment of internal derangement in an adult with resulting mandibular orthopedic change. Facial Orthop Temporomandibular Arthrol 1986;3(5):3-7. 117. Williamson EH. Adult orthopedic mandibular change in the treatment of internal derangement. Facial Orthop Temporomandibular Arthrol 1987;4(8):3-6. 118. Williamson EH. Lars treatment in the meso-to dolichofacial patient in the presence of internal derangement. Facial Orthop Temporomandibular Arthrol 1987;4(7):3-7. 119. Williamson EH. Orthopedic mandibular change and distalization of buccal segments in the treatment of internal derangement. Facial Orthop Temporomandibular Arthrol 1987;4(11): 3-7. 120. Bledsoe WS Jr. Making phase 1 appliances "diagnose" and phase 2 appliances "function" in your TMJ/functional orthopedic practice. Funct Orthod 1987;4(6): 17,18,20,21,24-6 passim. 121. David JA. Functional appliance does job of oral surgeon. Funct Orthod 1988;5(1):29-33. 122. Lynn JM. Adult: TMJ, severe headaches, 12 year molar extraction, class II, crowding, open bite. Funct Orthod 1988; 5(3)i7-8,10,13-6. 123. Mintz AH. Buccal separators for relief of TMJ pain and symptoms. Angle Orthod 1988;58:351-6. 124. Owen AH III. Unexpected TMJ responses to functional jaw orthopedic therapy. AM J ORTHOD DEN'rOFACORTHOP 1988; 94:338-49. 125. Pancherz H. The Herbst appliance--its biologic effects and clinical use. AM J ORTHOD 1985;87(1):1-20. Reprint requests to: Dr. Reint M. Reynders Via Dezza 27 20144 Milan Italy