The challenge of ecological validity in temporomandibular disorders research.

OBJECTIVE: To review the ecological validity of outcomes from current research involving temporomandibular disorders (TMDs), with an emphasis on chronic myofascial pain and the precocious development of degenerative disease of the temporomandibular joint (TMJ). MATERIALS AND METHODS: Current approaches used to study TMDs in terms of neuromechanics, masticatory muscle behaviours, and the dynamics of the autonomic nervous system (ANS) were assessed for ecological validity in this review. In particular, the available literature was scrutinized regarding the effects of sampling, environmental and psychophysiological constraints and averaging data across biological rhythms. RESULTS: Validated computer-assisted numerical modelling of the neuromechanics used biological objective functions to accurately predict muscle activation patterns for jaw-loading tasks that were individual-specific. With respect to masticatory muscle behaviour, current findings refute the premise that sustained bruxing and clenching at high jaw-loading magnitudes were associated with painful TMDs such as myofascial pain. Concerning the role of the ANS in TMDs, there remains the need for personalized assessments based on biorhythms, and where the detection of dysregulated physiologic oscillators may inform interventions to relieve pain and restore normal function. CONCLUSIONS: Future human research which focuses on TMD myofascial pain or the precocious development and progression of TMJ degenerative joint disease requires experimental designs with ecological validity that capture objectively measured data which meaningfully reflect circadian and ultradian states.

Orthognathic surgery effects on temporomandibular joint compressive stresses.

INTRODUCTION: This study tested orthognathic surgery effects on temporomandibular joint (TMJ) compressive stresses. METHODS: Pre- (T1) and post-surgery (T2) cone-beam computed tomography images were collected from consenting subjects aged ≥15 years. Anatomical data were used to measure surgical changes in anteroposterior mandibular position and occlusal plane angle (FH-OP), estimate condylar loading areas (mm2 ) and calculate T1 and T2 TMJ and jaw muscle forces (N) during canine biting via numerical modelling. Analysis of covariance tested for sex and biting angle differences in T2 - T1 TMJ compressive stresses (TMJ force/loading area, MPa). Principal component analyses identified jaw muscle forces that accounted for changes in T2 - T1 TMJ loads. Regression analyses tested the correlations between surgical changes in mandibular position, FH-OP, TMJ loads and muscle forces. RESULTS: Of 148 cases screened, 28 females and 16 males provided complete records. Condylar loading areas were significantly smaller (P = .024) for females vs males (124 ± 5 vs 144 ± 7 mm2 ). T2 - T1 differences in TMJ compressive stresses varied by surgical change, biting angle and sex. Overall, the largest increases in TMJ compressive stresses post-surgery were for females with mandibular setbacks where FH-OP angle decreased. T2 - T1 changes in jaw muscle forces had moderate (ipsilateral, λ = 4.59; η2 = 0.071) to large (contralateral, λ = 1.49; η2 = 0.31) effects on TMJ loads. CONCLUSIONS: T2 - T1 differences in TMJ compressive stresses during canine biting were affected by surgical changes in mandibular position and occlusal plane angle, biting angle and sex. Surgical changes altered jaw muscle forces for the same biting conditions and, thus, affected TMJ loads and compressive stresses.

Opinions, plans, and demographics of orthodontic residents: A follow-up study.

INTRODUCTION: This study aimed to explore current orthodontic residents' demographics, their opinions on their residency and plans for the future and highlight secular changes since past surveys. METHODS: An anonymous 39-item institutional review board-approved survey was implemented at the 2018 Graduate Orthodontic Resident Program using an online survey tool and portable devices. Questions fit 3 categories: program, future goals, and demographics. Responses were analyzed to determine frequencies, means, and cross tabulations. Analyses of variance and chi-square were applied with significance defined as P <0.05. RESULTS: Of the 489 attendees, 76% completed the survey; most were female (51%), white (60%), U.S. citizens (85%), single (63%), and very satisfied with their programs (54%). Tuition costs varied, but 18% of respondents paid >$80,000 annually. Orthodontic and total educational debts were significantly correlated (r = 0.704) and averaged $137,706 ± $127,380 and $323,071 ± $266,510, respectively. These debts were significantly lower (P <0.0001) for respondents with stipends. Debts influenced the decision of where to work in the future for 62% of respondents and were a source of anxiety for 72% of respondents. Educational debts were significantly positively associated with anxiety levels (P <0.0001). CONCLUSIONS: This survey provided current information on orthodontic residents' opinions, plans, and demographics. Comparisons with previous surveys showed increases in the number of female respondents, tuition costs, and educational debts and decreases in stipends. Orthodontics may be approaching a "bubble market" where the financial benefits do not outweigh specialty education costs.

Night-time autonomic nervous system ultradian cycling and masticatory muscle activity.

OBJECTIVES: To test if there was a correlation between night-time masticatory muscle activity, as measured by duty factors, and ultradian cycling of autonomic nervous system (ANS) spectral powers in subjects without temporomandibular disorder (TMD)-related pain. SETTING AND SAMPLE POPULATION: The University of Missouri-Kansas City School of Dentistry. Three women and four men of average ages 38 ±8 and 56 ± 17 years, respectively, gave informed consent to participate. MATERIAL AND METHODS: Investigators taught subjects to record heart (electrocardiography, ECG) and masticatory muscle activities (electromyography, EMG). ECG recordings were analysed for ANS ultradian cycling by a polynomial fit to the ratio of sympathetic and parasympathetic spectral powers (ms2 ). Masseter and temporalis EMG recordings were analysed over 20-minute epochs around peaks and valleys in the ANS ultradian cycles. Duty factors (% time of masticatory muscle activity/20-minute epoch) were determined relative to average threshold EMG (TEMG ) required to produce a given bite force (N). Regression analyses quantified relationships between normalized muscle duty factors and ANS spectral powers. RESULTS: Subjects made a total of 27 sets of night-time ECG and EMG recordings that averaged 6.6 ± 1.1 hours per recording. Highest average duty factors were associated with TEMG of 1-2 N and showed cumulative masseter and temporalis activities of 9.2 and 8.8 seconds/20-minute epoch, respectively. Normalized masticatory muscle duty factors showed non-linear relationships with normalized sympathetic (R2  = +0.82), parasympathetic (R2  = -0.70) and sympathetic/parasympathetic spectral powers (R2  = +0.75). CONCLUSIONS: Night-time ANS spectral powers showed ultradian cycling and were correlated with masseter and temporalis muscle activities in adult subjects without TMD.

Preface to COAST 2018 Innovators' Workshop: Bridging the biology and technology gap in orthodontics and craniofacial care.

OBJECTIVE: A third focused workshop explored how to transfer novel findings into clinical orthodontic practice. SETTING AND SAMPLE POPULATION: Participants met at the Scottsdale Plaza Resort, 12-16 September 2018 for the Consortium for Orthodontic Advances in Science and Technology 2018 Innovators' Workshop. Thirty speakers and four lunch-hour focus group leaders shared and exchanged information with approximately 45 registered attendees. MATERIAL AND METHODS: This Innovators' Workshop was organized according to five themed sessions which covered: (a) The relevance of genetics, biology and environment to therapeutic outcomes; (b) Application of bioinformatics in craniofacial research; (c) Regeneration with and for orthodontic treatment; (d) Technology in precision orthodontics; and (e) Muscle, joint, and airway: Growth, function and pain. RESULTS: The papers that comprise this supplemental issue exemplify the important outcomes of the 2018 COAST Workshop. In addition, matters identified as important needs include improved understanding of neural, skeletal and muscle tissue crosstalk in early craniofacial growth; standardized methods for three-dimensional radiographic and surface landmark and reference plane identification, measurements and serial superimpositioning techniques for use in the clinic; sharing and making available existing data sets (eg, cone beam computed tomography images, genotype-phenotype data); evidence of the usefulness and effectiveness of new devices; guidelines of what to measure to characterize the airway; more information about the influences of the soft tissues on craniofacial morphology; and information about effective digital work flows applied to clinical and educational settings. CONCLUSIONS: Progress in bridging the biology-technology gap has identified new needs for improvements in orthodontics and craniofacial care.

Effects of mechanical stress and growth on the velocity of tooth movement.

INTRODUCTION: In this study, we investigated the effects of the magnitudes of applied stress and growth status on the speed of tooth movement. METHODS: Eighty-two maxillary canines in 41 subjects were retracted for 84 days by estimated stresses of 4, 13, 26, 52, or 78 kPa applied continuously via segmental mechanics. Dental impressions made at intervals of 1 to 14 days resulted in 9 or 10 dental casts per subject. Three-dimensional tooth movements were quantified using these casts, custom reference templates, and a measuring microscope. Serial height and cephalometric measurements determined growth status. RESULTS: Distal tooth movement was linear with no lag phase in 96% of the teeth. Speeds averaged 0.028, 0.040, 0.050, 0.054, and 0.061 mm per day (standard errors, ± 0.004) for 4, 13, 26, 52, and 78 kPa, respectively. The maximum difference in speed between teeth was 9:1. Teeth moved significantly faster (P <0.0001) in growing compared with nongrowing subjects, on average by 1.6-fold. Stress and speed of tooth movement were logarithmically related in growing (R(2) = 0.47) and nongrowing (R(2) = 0.34) subjects. Other tooth movements were relatively small, except for the distopalatal rotation of teeth moved by 78 kPa that averaged more than 19°. CONCLUSIONS: The speed of retraction was logarithmically related to the applied stress and was significantly faster in actively growing subjects compared with those who were not growing.

Outcome assessment of orthodontic clear aligner vs fixed appliance treatment in adolescents with moderate to severe malocclusions.

OBJECTIVE: To compare the efficacy and efficiency of treatment with clear aligners (CAT) vs fixed appliances (FAT) in adolescents with Class I and II moderate to severe malocclusions. MATERIALS AND METHODS: One operator's (Garfinkle) cases from 2014 to 2019, started at age 12-18 years, with pre- and posttreatment records were identified and used according to an institutional review board-approved protocol. Records were measured by two calibrated, blinded investigators, aided by software (OrthoCAD [Cadent, Fairview, N.J.], Dolphin Imaging & Management Solutions [Chatsworth, Calif]). Discrepancy index (DI) and cast radiograph evaluation (CRE) scores, treatment duration, number of scheduled and emergency visits, and reported appliance and interarch elastic wear compliance were compared between groups using Wilcoxon rank sum and Fisher's exact tests. Cephalometric superimpositions were completed to evaluate craniofacial growth and dental changes. RESULTS: Records from 72 cases met the criteria and were included. For the 47 CAT and 25 FAT cases, mean DI (21 ± 5 and 24 ± 8, respectively; P = .20) and CRE (35 ± 10 and 34 ± 9, respectively; P = .90) scores were not significantly different. Other case attributes and reported appliance and interarch elastic wear compliance were also not significantly different. CAT vs FAT cases had significantly smaller treatment durations (24 ± 6 vs 27 ± 5 months; P = .01) and visit numbers (16 ± 5 vs 24 ± 4; P < .01), but emergency visit numbers were not significantly different (2 ± 2 vs 3 ± 2; P = .08). CONCLUSIONS: In adolescents with Class I and II malocclusions and moderate to severe DI scores, on average, CAT vs FAT cases were completed 3 months faster with eight fewer visits, but treatment efficacy was not significantly different.

An augmented Lagrangian method for sliding contact of soft tissue.

Despite the importance of sliding contact in diarthrodial joints, only a limited number of studies have addressed this type of problem, with the result that the mechanical behavior of articular cartilage in daily life remains poorly understood. In this paper, a finite element formulation is developed for the sliding contact of biphasic soft tissues. The augmented Lagrangian method is used to enforce the continuity of contact traction and fluid pressure across the contact interface. The resulting method is implemented in the commercial software COMSOL Multiphysics. The accuracy of the new implementation is verified using an example problem of sliding contact between a rigid, impermeable indenter and a cartilage layer for which analytical solutions have been obtained. The new implementation's capability to handle a complex loading regime is verified by modeling plowing tests of the temporomandibular joint (TMJ) disc.

Archwire vibration and stick-slip behavior at the bracket-archwire interface.

INTRODUCTION: It is unknown whether or not intraoral vibrations affect stick-slip behavior at orthodontic bracket-archwire interfaces. In this study, we evaluated bracket-archwire stick-slip behavior as a function of ligation method and archwire vibration. METHODS: In-vivo archwire vibrations were measured to obtain frequencies and amplitudes for ex-vivo testing. A piezoresistive accelerometer ligated to the maxillary right canines of 6 subjects transduced the intraoral vibrations. All subjects gave informed consent to participate. Amplitude and frequency of the vibrations were quantified and used in a bench-top friction testing apparatus. Active and passive ligation methods were compared for 9 vibration scenarios. The amount of time to move the bracket along a stainless steel wire was recorded in 90 trials. Analysis of variance and post-hoc tests were used for statistical analyses of the data. RESULTS: During carrot biting, orthodontic wire vibrations had a mean frequency of 98 Hz and a peak-to-peak mean amplitude of 151 mV. The bench-top stick-slip measurement trials containing medium (150 mV) and high (190 mV) amplitude vibrations had significantly less friction (ln, s), 4.81 ± 2.08 and 4.67 ± 2.00, respectively, than those subjected to low (110 mV) amplitudes, 5.80 ± 1.39 (P = 0.04). There were no significant differences between passive and active ligation methods. CONCLUSIONS: Amplitudes of archwire vibrations affect stick-slip behavior at the bracket-archwire interfaces.

A theoretical analysis of longitudinal temporomandibular joint compressive stresses and mandibular growth.

OBJECTIVES: To determine if temporomandibular joint (TMJ) compressive stresses during incisor biting (1) differed between growing children over time, and (2) were correlated with Frankfort Horizontal-mandibular plane angle (FHMPA, °) and ramus length (Condylion-Gonion (Co-Go), mm). MATERIALS AND METHODS: Three-dimensional anatomical geometries, FHMPA and Co-Go, were measured longitudinally from lateral and posteroanterior cephalographs1 of children aged 6 (T1), 12 (T2), and 18 (T3) years. Geometries were used in numerical models to estimate subject-specific TMJ eminence shape and forces for incisor bite-forces of 3, 5, and 8 Newtons at T1, T2, and T3, respectively. TMJ compressive stresses were estimated via two steps: First, TMJ force divided by age-dependent mandibular condylar dimensions, and second, modified by loading surfaces' congruency. Analysis of variance and Tukey honest significant difference post-hoc tests, plus repeated measures and mixed effects model analyses were used to evaluate differences in variables between facial groups. Regression analyses tested for correlation between age-dependent compressive stresses, FHMPA, and Co-Go. RESULTS: Sixty-five of 842 potential subjects had T1-T3 cephalographs and were grouped by FHMPA at T3. Dolichofacial (FHMPA ≥ 27°, n = 36) compared to meso-brachyfacial (FHMPA< 27°, n = 29) subjects had significantly larger FHMPA at T1-T3, shorter Co-Go at T2 and T3 (all P < .01), and larger increases in TMJ compressive stresses with age (P < .0001). Higher compressive stresses were correlated with larger FHMPA (all R2 ≥ 0.41) and shorter Co-Go (all R2 ≥ 0.49). CONCLUSIONS: Estimated TMJ compressive stress increases from ages 6 to 18 years were significantly larger in dolichofacial compared to meso-brachyfacial subjects and correlated to FHMPA and Co-Go.