Comparison of nonsurgical treatment options in pediatric condylar fractures: rigid intermaxillary fixation versus using guiding elastic therapy.

A prospective study was done to compare rigid intermaxillary fixation and guiding elastic for treatment of condylar fractures in pediatric patients. Sixty-one children younger than 12 years with condylar fractures were studied in 2 groups. Group 1 consisted of 31 patients who were treated with arch bar and intermaxillary fixation for 7 to 12 days, and group 2 consisted of 30 patients who were treated with arch bar and elastics without rigid intermaxillary fixation. Patients had minimal function during treatment time, which lasted 7 to 12 days. Evaluation of deviation on opening between both groups (groups 1 and 2) with a χ test did not show any relationship between them. Incidence of temporomandibular dysfunction signs was 25.8% in group 1 patients and 23.3% in group 2 patients. Comparison of temporomandibular dysfunction signs in both treatment groups did not show a statistically significant relationship. Our study showed the same results using guiding elastics as using rigid intermaxillary fixation in pediatric condylar fractures. Guiding elastic is more tolerable, and children have function during treatment.

Correlation of RDC/TMD axis I diagnoses and axis II pain-related disability. A multicenter study.

As part of an ongoing multicenter investigation involving four highly specialized tertiary clinics for temporomandibular disorders (TMD) treatment, retrospective analysis of Research Diagnostic Criteria for TMD (RDC/TMD) axis I and axis II data gathered on clinic and community cases were assessed with a twofold aim: (1) to search for a correlation between axis I diagnoses and axis II pain-related disability, and (2) to identify clinical (axis I) and psychosocial (axis II) predictors of high pain-related disability. Two samples of patients seeking treatment for TMD (clinic cases, N = 1,312) and a sample of general population subjects (community cases, N = 211) underwent a thorough assessment in accordance with the RDC/TMD version 1.0 [1] guidelines to receive both axis I and axis II diagnoses. Spearman's test was performed to assess the level of correlation between axis I diagnoses and Graded Chronic Pain Scale (GCPS) pain-related disability. A stepwise multiple logistic regression model was used to identify the significant associations between 12 clinical and psychosocial predictors and the presence of high pain-related disability. Axis I findings were related with pain-related impairment (GCPS scores) in the overall study sample including both clinic community cases (Spearman correlation = 0.129, p = 0.000), but the results of the correlation analyses performed on the clinic sample alone were not significant (Spearman correlation = -0.018, p = 0.618). Predictors for high disability were related to axis II findings (severe depression and somatization) or psychosocial aspects related to the pain experience (pain lasting from more than 6 months; treatment-seeking behavior), while none of the axis I diagnoses remained in the final logistic regression model. The final model predicted the level of pain-related impairment at a fair level (R(2) = 26.7%). The correlation between axis I diagnoses and pain-related impairment is not significant in the patients populations. Treatment-seeking behavior and other factors related with the pain experience are likely to be more important than the physical findings to determine the degree of psychosocial impairment.

Do malocclusion and Helkimo Index ≥ 5 correlate with body posture?

Whether there are correlations between the stomatognathic system and body posture remains controversial. Here, we have investigated whether malocclusal traits and having a Helkimo Index ≥ 5 show detectable correlations with body-posture alterations in children and young adults. A total of 1178 11- to 19-year-old subjects were divided into four groups: (i) controls; (ii) malocclusion; (iii) Helkimo Index ≥ 5 and (iv) malocclusion + Helkimo Index ≥ 5. Dental occlusion assessment included the following: overbite, overjet, posterior crossbite, scissorbite, mandibular crowding and dental class. Subsequently, body-posture assessments were performed through static analyses of body inclination and trunk asymmetry, and according to the dynamic Fukuda stepping test. Univariate and multivariate statistical analyses were performed. Although at the univariate level both the trunk asymmetry and Fukuda stepping test showed significant differences among the groups, the multivariate level revealed that age and gender were mostly responsible for this. The only significant correlation that was seen was for the malocclusion + Helkimo Index ≥ 5 group: these subjects had a positive (worse) trunk asymmetry and a negative (better) Fukuda stepping test performance. At the further multivariate analyses of each single malocclusal trait /Helkimo Index ≥ 5 (irrespective of the groups), only an increased overbite showed a statistically significant association with a slightly better Fukuda stepping test performance. Given the small number of significant associations seen and their limited entities, this study does not support the existence of clinically relevant correlations for malocclusal traits and Helkimo Index ≥ 5 with body posture in children and young adults.

Classifying degenerative joint disease by the RDC/TMD and by panoramic imaging: a retrospective analysis.

The purposes of the study were to evaluate the utility of diagnosing degenerative joint disease (DJD) by the clinical finding of coarse crepitus alone, without supporting imaging studies, as defined by the RDC/TMD, and to evaluate the contribution of panoramic radiography as an aid in the diagnosis of DJD. A retrospective analysis of 372 consecutive patients with TMD was conducted. Their panoramic radiographs were evaluated for the extent of their contribution to the final diagnosis. Panoramic radiography was of no diagnostic value in 94.4% of the cases when the group was considered as a whole. When patients diagnosed with DJD were considered separately, panoramic radiography was completely sufficient for reaching the final diagnosis in 20.0% of the cases. In almost 90% of these patients, however, the clinical examination did not support the diagnosis of DJD (no coarse crepitus was found). This raises some doubts about the effectiveness of the clinical examination according to the RDC/TMD and about the utility of panoramic radiography in the definitive diagnosis of DJD, because both techniques have low accuracy (11.1% and 20%, respectively). The present study supports the current recommendations that panoramic radiography should not be ordered routinely to assess DJD, but still it is first choice when any dental problem is suspected. Further additional imaging (computerized tomography, magnetic resonance imaging) should be considered only if there is reason to expect that the findings might affect diagnosis and management. This study adds to recent criticisms of the clinical validity of the RDC/TMD, with regard to DJD.

Correlation of the temporomandibular dysfunction classification index with cephalometric indicators of facial structure: a study on adult female subjects.

AIM: The aim of this study was to determine whether associations exist between temporomandibular dysfunction index (TMI) and craniofacial morphology. METHODS: The sample consisted of 30 symptomatic (mean age 28.3+/-6.7; range 24-39 years, TMI 0.48+/-0.21) and 30 asymptomatic women (mean age 27.4+/-9.2; range 22-42 years, TMI 0.1+/-0.05) seeking orthodontic treatment at Department of Dental Sciences ''G. Messina'', University of Palermo, who had routine lateral cephalograms. Symptoms and signs of temporomandibular joint dysfunction (TMD) were assessed by a standardized clinical examination and the TMI (a clinical measure of dysfunction used to evaluate the severity of TMD). Linear and angular cephalometric measurements were taken to evaluate skeletal and dental characteristics of the two groups. Unpaired t test was used to compare the symptomatic subjects with the control subjects. RESULTS: The sella-nasion-supramentale (SNB) angle (P<0.038, indicating mandibular retrognathism relative to cranial base), the lower facial height and the palatal plane-mandibular plane angle (P<0.025 and P<0.037 respectively, indicating hypodivergent facial profile) were significantly smaller in the symptomatic than in the asymptomatic women. The occlusal plane was steeper (P<0.033) and the cranial flexion was higher (P<0.035) in the symptomatic group than in the asymptomatic group. In addition the overjet (P<0.008) and the overbite (P<0.005) were significantly greater in symptomatic group than in the asymptomatic group. CONCLUSION: This study showed a significant correlation between dentofacial characteristics and TMD.

Classification, causation and treatment of masticatory myogenous pain and dysfunction.

This article focuses on chronic myogenous pains affecting the masticatory muscles, including focal myalgia, regional myalgia, myofascial pain, and fibromyalgia. The probable mechanisms are discussed and treatment options, including self-directed treatment, physical medicine modalities, and several types of pharmacologic agents, are presented.

Inflammatory Cytokines and Sleep Disturbance in Patients with Temporomandibular Disorders.

AIMS: To assess the degree and interrelationship of sleep disturbance and plasma cytokine levels in temporomandibular disorder (TMD) pain patients. METHODS: Forty female TMD patients and 20 age-, sex-, and body mass index (BMI)-matched healthy subjects were enrolled. TMD was diagnosed using the Research Diagnostic Criteria for TMD. The TMD patients were classified as having low or high disability according to Graded Chronic Pain Scale findings. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to measure sleep quality. Plasma concentrations of interleukin (IL)-1ß, IL-6, IL-10, tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) were measured from blood samples collected between 9 am and noon. Statistical analyses included Kruskal-Wallis and one-way analysis of variance tests to compare results between different groups and multivariate general linear models to evaluate the effect of sleep status on cytokine levels. RESULTS: The high-disability group had the highest PSQI and ESS scores (P < .001). Plasma levels of IL-1ß, IL-6, IL-10, and TNF-α were significantly higher in the patient groups, with the high-disability group exhibiting the highest values (P ≤ .001). The plasma cytokine levels were significantly correlated with PSQI scores (P < .05). Plasma levels of IL-10 and TNF-α were significantly associated with the disability level after adjusting for both sleep indices (both P < .05). CONCLUSION: Patients with TMD, especially those with high disability, had elevated plasma cytokine levels and increased ESS and PSQI scores suggestive of sleep disturbance.

Searching for an assessment instrument to determine temporomandibular disorder pain profiles for the purposes of primary health care.

The objective was to study the utility of the graded chronic pain (GCP) scale of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) for the purpose of recognizing TMD pain profiles in primary health care. The GCP scale was used to gather data from 93 consecutive TMD patients seeking treatment in a primary health care setting. The GCP data were compared with pain profiles assessed by scales similar to the more complicated multidimensional pain inventory (MPI). The scales used were able to produce the similar 'dysfunctional profiles' in the TMD patients as the original MPI scale in the sample of chronic pain patients. Also, the original MPI profiles of 'adaptive copers' and 'interpersonally distressed' were produced with distinctive features. The GCP grades distributed almost identically among the subgroups produced by the pain profiles. Most grade I patients were classified as adaptive copers (82--86%), most grade II patients were interpersonally distressed (59%) and all except one of the grade III patients were classified as dysfunctional (83%). The results seem to support the main assumption of our study that the GCP scale is a simple screening tool suitable for identifying primary care TMD patients with various types of pain profiles.

Association between mandibular condylar position and clinical dysfunction index.

OBJECTIVES: Condylar position in the glenoid fossa has been associated with temporomandibular disorders. The purpose of the present study was to investigate the correlation between clinical dysfunction index (Di) and mandibular condylar position in patients with temporomandibular joint dysfunction (TMD) using cone beam computed tomography (CBCT). METHODS: In this cross-sectional study, participants were recruited from the Department of Maxillofacial Radiology at Shiraz Dental University in Iran. The condylar position was assessed on the CBCT images of 120 temporomandibular joints in 60 patients with TMD. Patients were divided into 3 groups based on Helkimo's clinical Di. The chi-square test was used to correlate degree of the Helkimo's Di with the mandibular condylar position. The p value was set at 0.05. RESULTS: A total of 60 patients (42 women and 18 men; mean age, 33.4 years) participated in this study. Significant differences in condylar position were found among the 3 groups (Di I, II, and III) (p < 0.05). Patients with mild to moderate TMD were found to have anteriorly and concentric seated condyles. Posteriorly seated condyles were found in patients with severe TMD. CONCLUSION: Condylar position is associated with different severity of TMD.

Temporomandibular joint dysfunction and facial pain in children: an approach to diagnosis and treatment.

A model for the diagnosis and treatment of temporomandibular joint dysfunction and facial pain in children is presented. Emphasis is placed on systematic assessment of physical, psychologic, and behavioral factors when conservative medical therapy is inadequate for symptom relief. The model represents a multidisciplinary approach to patient care which is described through case presentations. The results of research on the incidence of primary psychopathology in 53 children and 322 adults evaluated during a 3-year period for temporomandibular joint dysfunction and facial pain are also presented. It was found that children were more likely to be psychiatrically impaired (25%) than adults (7%). Children had a variety of psychiatric diagnoses including depression, conversion and adjustment disorders, overanxious behavior, and anorexia nervosa. The benefits of a multidisciplinary approach are discussed in terms of the efficacy of this coordinated treatment effort in ameliorating symptoms.

Psychophysical subtypes of temporomandibular disorders.

This study presents an approach to the classification of temporomandibular disorders (TMD) based on acknowledgement of the interaction of physical, psychologic, and social factors using a multidimensional instrument that has been previously validated. The psychometric properties of this instrument were reevaluated in 140 women with TMD. Multidimensional clustering identified three subgroups of patients with TMD, including a highly distressed, psychosocially maladaptive group; a moderately distressed, behaviorally functional group; and a predominantly physical disorder group with an unremarkable psychosocial profile. These groups were termed maladaptive, adaptive, and uncomplicated, respectively, according to the constellation of predominant symptoms and psychosocial profiles of each cluster. The groups showed no consistent differences in pain frequency, use of medication, or duration of pain. This finding supports earlier work that suggested the prominence of three subtypes of this disorder according to both physical illness and psychosocial illness impact parameters.

Prevalence of temporomandibular disorder subtypes, psychologic distress, and psychosocial dysfunction in Asian patients.

AIMS: To use the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to investigate the physical diagnoses, psychologic distress, and psychosocial dysfunction in Asian TMD patients. The RDC/TMD Axis I and II findings were compared to those of Swedish and American TMD patients. METHODS: One hundred ninety-one patients (53 male and 138 female) referred to 2 institutionalized TMD clinics in Singapore were enrolled in the study. The mean age of the predominantly Chinese population (83.2%) was 33.6 +/- 9.3 years. Data from a RDC/TMD history questionnaire and clinical examination were fed directly by patients and clinicians into a computerized diagnostic system (NUS TMDv1.1). Axis I and II findings were generated on-line, based on RDC/TMD rule engines. Data were automatically exported to SPSS for statistical analysis. RESULTS: Group I (muscle) disorders were found in 31.4% of the patients; Group II (disc displacement) disorders were found in 15.1% and 15.7% of the patients in the left and right temporomandibular joints, respectively; and Group III (arthralgia, arthritis, and arthrosis) disorders were found in 12.6% and 13.0% of the patients in the left and right joints, respectively. Axis II assessment of psychologic status showed that 39.8% of patients experienced moderate to severe depression and 47.6% had moderate to severe nonspecific physical symptom scores. Psychosocial dysfunction was observed in only 4.2% of patients based on graded chronic pain scores. CONCLUSION: Axis I and II findings of Asian TMD patients were generally similar to their Swedish and American cohorts. In all 3 populations, women of child-bearing age represented the majority of patients. Muscle disorders were the most prevalent type of TMD. A substantial portion of TMD patients were depressed and experienced moderate to severe somatization.

Prognostic stratification for the mandibular pain dysfunction syndrome.

Combinations of the symptoms and signs of the mandibular pain dysfunction syndrome (MDS) provoked by movements of the mandible are complex and patients are treated as a homogeneous group. The process of prognostic stratification applied to an inception cohort of 169 MDS patients, separated groups of patients according to affected movements of the mandible associated with similar outcomes of treatments. From the data, two staging systems for the dysfunction were derived and evaluated. It is suggested that further analyses of more data would distinguish groups of patients with comparable prognoses enabling universal and valid comparisons of treatment of the dysfunction to be made.

Clinical classification of 14-16-year-old Danish children according to functional status of the masticatory system.

The high prevalence of functional disturbances in the masticatory system and the tendency to increasing severity with duration stresses the necessity for a reproducible index. Clinical examination of the masticatory system was performed in 14-16-yr-old children. The sequence of examination, TMJ-muscles-opening capacity was chosen in order to minimize the bias. For the same reason, information on symptoms and occlusal conditions was not available for the examiner. According to the amount and character of the signs of dysfunction, the children were classified into three groups. Both single traits of dysfunction and the classification of the subjects were tested for reproducibility. The reproducibility of the compound clinical index was high. The ability to differentiate between children with moderate/severe signs and without signs was higher but the highest value was reached when differentiation was made between children with no/moderate signs and children with severe signs.

Prevalence, interrelation, and severity of signs of dysfunction from masticatory system in 14-16-year-old Danish children.

A clinical evaluation of the functional status of the masticatory system was performed on 706 14-16-yr-old children who had received a minimum of 9 yr regular dental care and had only natural teeth. Applying a classification system developed for this specific age group, 19% were assigned to the group with moderate and 11% to the group with severe disturbances. An analysis of the association between the signs of dysfunction revealed that TMJ clicking was always associated with some but not necessarily numerous palpatory findings. The localizations of the TMJ clickings were related to specific signs of dysfunction from the masticatory system. Restriction of movement capacity of 2 standard deviations was frequently found as an isolated phenomenon, whereas restriction of 3 standard deviations was always associated with either palpatory findings or sounds from the joints.

The functional status of the masticatory system of 11-16-year-old adolescents: classification and validity.

Epidemiological studies to assess the prevalence and course of functional disturbances of the masticatory system should be based on a valid and reliable measure of the functional status of the masticatory system. NIELSEN et al. (2, 3) proposed a classification method that included three different classes of dysfunction. This classification was used to compare the results of a sample of 447 11-16-year-old Swiss adolescents with those of the Danish study and to test the validity of this classification method. The two studies showed similar prevalences in two of the three dysfunction classes and a similar pattern of dysfunction categories. Concurrent and construct validity analyses showed significant correlations between the assessment from clinical examination and the subjective judgments of the adolescents. The results demonstrated cross- and concurrent validation of the "Nielsen index" but also stressed the necessity of a careful re-evaluation of the "severe" class criterion. The limitations of the Nielsen index led to the construction of a "Zurich-MAP index". The potential applications of both indices are discussed.

Current terminology and diagnostic classification schemes.

This article reviews the current terminology and classification schemes available for temporomandibular disorders. The origin of each term is presented, and the classification schemes that have been offered for temporomandibular disorders are briefly reviewed. Several important classifications are presented in more detail, with mention of advantages and disadvantages. Final recommendations are provided for future direction in the area of classification schemes.

The correlation between occlusal characteristics and temporomandibular dysfunction in Saudi Arabian children.

The aim of the present study was to investigate the association between the different occlusal characteristics and signs and symptoms of temporomandibular dysfunction (TMD) in children with primary dentition in the western region of Saudi Arabia. A total of group of 502 children 4-6 years old residing in the city of Jeddah, Saudi Arabia provided the data for analysis. The result of this study showed significant correlation between signs and symptoms of TMD and some of the occlusal characteristics including posterior crossbite (P < 0.05), edge to edge (P < 0.013), anterior openbite (P < .036) and class III canine relationship and as well as asymmetrical canine relationship (P < .048 and P < .046 respectively). On the other hand, no correlation was reported between signs and symptoms of TMD and the remaining occlusal characteristics. The lack of significant correlation between TMD and some of the occlusal variants could be attributed to sampling and methodology differences. However, the present study supported the previous conclusion that temporomandibular dysfunction is multifactorial and highlights the importance of early intervention to prevent further consequences to the TMD and permanent occlusion.

[Comparison of treatment options for myogenous temporomandibular dysfunction]. / Vergelijking tussen behandelingsvormen bij myogene temporomandibulaire dysfunctie.

A randomized clinical trial which included a follow-up of one year was applied to 118 myogenous TMD-patients. The therapies investigated were: physiotherapy of the masticatory system or splint therapy for patients without occlusal interferences, and occlusal adjustment therapy or the combination of splint and occlusal adjustment therapy for patients with pronounced occlusal interferences. Counseling, which yielded a reduction of 27% of the scored pain intensity, will most likely eliminate any further need for treatment of patients with a low level of myogenous TMD signs and symptoms. Otherwise, physiotherapy might be preferred as a starting option with respect to splint therapy because of 1. A similar efficacy; 2. A shorter treatment duration so that either chronic facial pain is earlier relieved or a patient can undergo a second type of therapy earlier; and 3. Lower costs. One third of the patients selected had pronounced occlusal interferences. Using stringent criteria it might be possible to apply occlusal adjustment therapy without involvement of splint therapy yielding a similar therapy efficacy and with advantages of a shorter treatment duration and lower costs. All types of therapy diminished not only facial pain but also pain of neck and shoulder areas.