Acta Clin Croat 2012; 51:419-424 Review

Temporomandibular disorders and occlusion

Tomislav Badel1, Miljenko Marotti 2, Ivana Savić Pavičin3 and Vanja Bašić-Kes4

Department of Removable Prosthodontics, School of Dental Medicine, University of Zagreb; 2Department of

1

Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center; 3Department of Dental
Anthropology, School of Dental Medicine, University of Zagreb; 4University Department of Neurology, Sestre
milosrdnice University Hospital Center, Zagreb, Croatia

SUMMARY – Occlusion has an important place within the multifactorial concept of the tem-
poromandibular disorder (TMD) etiopathogenesis as well as in every form of dental treatment. The
modern concept of treatment of these disorders differentiates initial and definitive forms of trea-
tment. The aim of this paper is to analyze recent viewpoints on the role of occlusion in the etiopat-
hogenesis and treatment of TMDs. Masticatory muscles and temporomandibular joints are directly
connected with occlusal relations and TMDs are traditionally linked with occlusal disorders. The
initial occlusal treatment can be applied to all TMD patients, regardless of their having intact teeth
with respect to physiological occlusal relations and in patients in need of orthodontic or prostho-
dontic treatment or an oral surgical procedure. On managing TMD patients, there are doubts about
the indications for definitive treatment and whether there has been a possibility of treating a painful
TMD by reversible treatment modalities, that is, by initial treatment. Other types of orofacial pain
such as trigeminal neuralgia can be comorbid with TMDs but also result in unnecessary procedures
on the teeth and prosthodontic work if they are not recognized. Although dental profession mainly
recognizes the importance of occlusal treatment of TMD problems, their relationship is contro-
versial because it is not strictly demonstrated in numerous scientific studies. Occlusion is not the
dominant cause of TMD problems.
Key words: Dental occlusion; Temporomandibular disorders; Splint; Prosthodontic treatment; Orofa-
cial pain

Introduction to TMDs, however, without confirmed causal rela-

tionship. The aim of this paper is to review recent con-
Musculoskeletal disorders in the area of stomatog- cepts on the role of occlusion in the etiopathogenesis
nathic system comprise the articular and/or muscular and treatment of TMDs.
component of temporomandibular disorders (TMDs). A number of described theories have been system-
The masticatory muscles (myogenic subgroup) and/or atically grouped based on a single factor. The theory
articular component (disc displacement (DD) and de- of mechanical displacement is based on otorhinolar-
generative bone changes or osteoarthritis (OA)) are yngology (Costen’s syndrome). Loss of teeth in the
the most common cause of orofacial somatic nono- supporting zone causes condylar movement with re-
dontogenic pain1,2. There are numerous factors related spect to the cranium, which leads to orofacial pain.
Clinical significance of otologic symptoms in the
Correspondence to: Assist. Prof. Tomislav Badel, PhD, Department clinical picture of TMDs is undeniable due to embry-
of Removable Prosthodontics, School of Dental Medicine, Uni-
versity of Zagreb, Gundulićeva 5, HR-10000 Zagreb, Croatia onic and topographic reasons. However, even clearly
E-mail: badel@sfzg.hr pronounced TMD symptoms can be confused with
Received November 12, 2011, accepted April 24, 2012 otologic pathology in the course of diagnosis3.

Acta Clin Croat, Vol. 51, No. 2, 2012 419

T. Badel et al. TMD and occlusion

According to the neuromuscular theory, parafunc- poromandibular pain has a low prevalence, mostly less
tion (bruxism) is a result of occlusal interferences, than 10% of the general population, and most often
which cause muscular spasm and muscular hyperac- only 5%10. Another issue in the TMD epidemiology
tivity. A trigger point which causes pain and muscle is dependence on the patient age and gender. Manfre-
spasm upon stimulation can be identified. Any other dini et al.11 differentiated two age peaks (two peaks of
occlusal interference should be excluded. The psycho- greatest incidence) in TMD patients (30-35 and 50-
logical theory considers TMD a psychosomatic disor- 55 years) with the female:male ratio 5:1, which partly
der. Psychological disorders (anxiety, depression) ini- coincides with previous knowledge that the greatest
tiate muscle hyperactivity (parafunctions), which leads prevalence is in women of reproductive age (that is
to occlusal disorders. According to the psychophysio- age 18-45)10,12,13. In the elderly population, there is a
logical theory, the main cause is muscle spasm, which discrepancy of the high incidence (70%) of OA signs
is a result of muscle fatigue, excessive muscle flexion accompanied by the low incidence of clinical signs of
or extension. In this way, parafunction and occlusal TMD14. Female predominance in TMD patients is
disorders occur. Each theory is controversial in its ap- explained by the effects of female hormones, biologi-
plication because they are mutually exclusive with re- cal and physiological differences, behavioral charac-
gard to the etiology explained by them4,5. teristics, and genetic factors15.
The American Academy of Orofacial Pain de- The occurrence of TMD signs and symptoms was
fined the following factors: traumatic, anatomical, followed during 20 years, with the first examination
pathophysiological and psychosocial6. In other words, at the age of three. It was determined that TMD
the multifactorial etiology includes a large number of symptoms had a higher incidence on later examina-
factors, which can have different relative significance tions (incidence 5%-9%), while at the youngest age,
in individual cases. there was almost none. However, the need for treat-
The biomedical approach to TMD diagnosis and ment was 1%-2%16.
treatment stresses the importance of development Magnetic resonance imaging (MRI) diagnostics
of chronic pain, which is a common feature of other of a 12-year-old female patient with clinical signs and
musculoskeletal disorders of the human body7. How- symptoms of clicking in both TMJs was performed
ever, TMD symptoms are not easily recognized in a as part of the pre-orthodontic treatment. The MRI
clinical picture, that is, they are not pathognomonic finding confirmed bilateral DD. The MRI follow-up
with other pathological conditions in the region of finding remained unchanged after treatment of uni-
the face and mandible: traumas, tumors, rheumatic lateral cross bite17.
diseases, muscle and temporomandibular joint (TMJ)
pain after extraction, etc.8.
Occlusion and Temporomandibular Disorders
Occlusion was considered as a possible etiopatho-
genic factor of TMD but their relationship is com- The importance of occlusion in the etiopathogen-
plex and still remains partially unexplained. Occlusal esis has been redefined by refuting the mechanistic
treatment is important not only to patients but also concept, which has been present since the beginning
to dentists – nearly half of the interviewed Swedish of scientific research of TMD. Loss of teeth and/or
dentists consider that the replacement of molars is disorders of occlusion are certainly illnesses by nature
necessary due to the development of TMD and com- but any type of irreversible occlusal treatment cannot
promising of masticatory function9. be associated with causal treatment of TMD18,19.
In an epidemiological study, a low incidence of
The Epidemiology of Temporomandibular certain variables of malocclusion was found (unilateral
Disorders open bite, negative overjet and unilateral cross-bite in
men, and edge-to-edge bite in women) with signs or
Although there are some methodological dis- symptoms of TMD. In both genders, anatomically
crepancies that can hinder direct comparison of epi- correct occlusion was not significantly associated with
demiological results of TMD, it is certain that tem- TMD compared with malocclusions. By including

420 Acta Clin Croat, Vol. 51, No. 3, 2012

T. Badel et al. TMD and occlusion

static and dynamic factors of occlusion, a significant occlusal stimulus depends on the current state of agi-
correlation with TMD incidence was statistically de- tation of those centers. In patients, even the slightest
termined but with a low correlation coefficient 20. interference can produce the state of high stimulation
Anterior open bite, deep overjet 6 mm or more, and muscle hyperactivity, which can cause TMD at a
unilateral cross-bite and difference between centric lower level of adaptation. In other individuals with low
relation and maximal intercuspidation amounting to level of activity of those centers, an increase of mus-
more than 2 mm with more than six posterior teeth cle tonus due to occlusal interference does not occur.
to be replaced can be considered increased risk factors Only in cases of hypervigilance, the occlusal changes
for TMD21. Conversely, Rammelsberg22 offered a re- will lead to TMD, due to increased awareness of one’s
view of the etiopathogenic model of DD development own body and intensified activity of emotional motor
wherein high abrasion and insufficient restorative pro- system such as stress, pain or psychosocially caused
cedure on posterior teeth are risk factors causing oc- parafunction. Hypervigilance is a changed form of
clusal instability. observation wherein the harmful nociceptive stimuli
In a population of children, Pereira et al.23 did not are intensified13,28,29.
find any correlation between malocclusion and TMD Malocclusions, as well as different occlusal varia-
but they identified bruxism and posterior cross bite tions are secondary to TMD etiopathogenesis. Or-
as risk factors for TMD. Tecco et al.24 and Tecco and thopedic instability only worsens the symptoms which
Festa 25 found a correlation between TMD with pain- develop due to some other reason. Contrary to such a
ful symptoms in children (5-15 years of age) and uni- viewpoint, wherein occlusal pathology is seen only as
lateral cross bite, but not with TMJ sounds. Myofas- a secondary factor of etiopathogenesis30, continuing
cial pain was more prevalent in females. In their study, reviews of the subject can be found in the literature,
Badel et al.26 found a significantly higher prevalence but based only on morphological variables of occlu-
of hyperbalance and interference contacts in asymp- sion related to TMD31.
tomatic patients compared to TMD patients. No dif-
ference was found between Angle’s classes in patients
Trigeminal Neuralgia
with DD and asymptomatic individuals. There was a
statistically significant difference in teeth contact be- Neuropathic trigeminal pain is a significant form
tween the maximal intercuspidation and centric posi- of other orofacial pains manifested with various symp-
tion in patients and asymptomatic subjects. toms as an extremely disabling illness. Trigeminal neu-
The importance of occlusal interferences was per- ralgia commonly afflicts the second or third division
ceived differently regarding the etiopathogenesis of and therefore a primarily dental component can be ex-
TMDs. Le Bell et al.27 found that artificial interfer- pected when the strong and sudden neuralgic pain ap-
ences did not stimulate development of dysfunctional pears in both jaws. The nature of the initial complaint
symptoms in healthy subjects, instead they adapted can be difficult to distinguish – occlusion and occlusal
successfully to them. In patients whose medical his- contacts, prosthetic works or individual teeth can have
tories show TMD interferences stimulate the recur- a false-positive finding because some patients have ex-
rence of stronger symptoms. tremely focal sites of neuralgic pain32,33.
Trigeminal neuralgia can have comorbidity with
Hypervigilance TMDs, wherein the strong, paroxysmal attacks cre-
ate difficulties in making the correct diagnosis. Den-
Reflex response to peripheral stimulus, that is, oc- tal and medical clinicians should recognize symptoms
clusal interference via periodontal receptors, can be of neuropathic trigeminal pain, especially within the
modulated in the central nervous system in such a way general group of patients with orofacial non-dental
that the stimulus causing normal opening in that case pains, since the share of patients with trigeminal neu-
causes mouth closing. The hypothalamus and the lim- ralgia can be 11.2%34.
bic system mediate tonus increase in affective condi- Regarding the prevailing view of occlusion as an
tions and under stress, whereas the reflex response to etiologic factor of TMDs, the discrepancy between

Acta Clin Croat, Vol. 51, No. 3, 2012 421

T. Badel et al. TMD and occlusion

unrecognized strong neuralgic pain and the mild clin- control and alleviating temporomandibular pain. In
ical picture of the teeth and TMJs can lead to wrong its essence, palliative medicine comprises symptom-
treatment, unnecessary endodontic procedures, as atic methods of treatment, which in musculoskeletal
well as tooth extractions or removal of correct prost- pain does not necessarily mean poor outcome of treat-
hodontic appliances35. ment. However, the principle of noninvasive and re-
versible methods of treatment is preferred before de-
Discussion finitive complex prosthodontic treatment in patients
with TMDs39. These methods encompass occlusal
Taking into account the great number of static and splints and physical therapy, which are mostly used
dynamic occlusal variables, it is difficult to compre- by dentists as well as cognitive-behavioral methods,
hend the overall correlation with the development acupuncture and psychological therapy in cases of
of TMDs due to the often non-standardized studies chronic pain40.
based on occlusal analysis. According to John et al.36 By recognizing the signs and symptoms of TMDs
‘complex interaction’ is the only but scientifically non- and by choosing initial methods of treatment as the
defined link between occlusion and TMDs. Occlusion methods of choice, the excessive use of diagnostics
ensures orthopedic stability of TMJ, whereas occlusal (for example, MRI) as well partial or complete over-
stability is ensured by mutually antagonistic contacts treatment modalities are avoided41,42. It has become
in the position of maximal intercuspidation. When the the dominant radiologic technique in the diagnostics
relationship between the two factors is compromised, of TMDs enabling imaging of cartilaginous articular
it could lead to an overload of articular structures and surfaces and it can successfully show the position of the
consequently pose a risk of TMD development. The articular disc43. Therefore, MRI has become the gold
changes in occlusal relations are pronounced in the standard of diagnostics which is used simultaneously
etiopathogenesis, causing co-contraction of antago- with clinical diagnosis and as a means of evaluation of
nist muscles the purpose of which is to protect the validity of other clinical diagnostic methods12,44. Ex-
agonists and remove pain. The influence of possible cessive, unnecessary and incorrect treatment methods
adverse chronic effects can be avoided by the adapta- in TMDs patients can have legal repercussions45.
tion of muscular activity37. Complex prosthodontically rehabilitated patients
There is a dichotomy between scientific and clini- are satisfied irrespective of the occlusion of their re-
cal concepts of occlusion, which can be explained by movable or fixed dentures – chewing efficiency appears
the concept of integrated neurobiological system38. to be more important to the patients19. The patient has
Occlusion is a basic component of dental restorative an input in the planning of own treatment and the
procedures, which changes or supplements the com- dentist should consider the patient’s wishes, and the
promised or lost occlusal relations in each segment of current trend is to collaborate with other dental and
planning the procedure. The pathogenetic and thera- medical specialists, which is a multidisciplinary ap-
peutic effects of myofascial pain can be explained proach regarding TMD problems. Cuspid guidance
only as a mutual relationship between occlusion and in prosthodontic treatment is more functional and
neuromusculature. The results of La Bell et al.27 are more acceptable than balanced or group function46.
explained by the neurobiological hypothesis based on In conclusion, permanent occlusal treatment is
the differentiated activity of the part of the muscle acceptable in functionally uncompromised patients,
in which increased tension and pain can occur. The which opposes the traditional opinion that there is a
changes in occlusal relations cause mild unloading more or less direct causal relationship between TMDs
in painful muscles or within the structures of TMJ, and occlusion. However, occlusion has not been deter-
which means that different condyle positions during mined as the dominant cause of TMD problems. Tem-
treatment can have the same effect. However, the mu- porary and reversible treatments by occlusal splints
tual relationship between occlusal interferences and are the primary means of TMD treatment, whereas
microtrauma has not been completely explained19. prosthodontic and orthodontic treatment should be
Generally, in TMD treatment the principle of pal- carried out in patients who are without functional
liative medicine is preferred, which means treatment, disorders of the stomatognathic system.

422 Acta Clin Croat, Vol. 51, No. 3, 2012

T. Badel et al. TMD and occlusion

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Sažetak

TemporomandibularNI POREMEĆAJI I OKLUZIJA

T. Badel, M. Marotti, I. Savić Pavičin i V. Bašić-Kes

Okluzija ima istaknuto mjesto unutar multifaktorijalnog koncepta etiopatogeneze temporomandibularnih poremećaja
kao i svakog oblika stomatološkog liječanja. Suvremena koncepcija liječenja tih poremećaja razlikuje inicijalne od defini-
tivnih oblika terapije. Svrha rada je dati pregled suvremenog shvaćanja uloge okluzije u etiopatogenezi i liječenju tempo-
romandibularnih poremećaja. Žvačni mišići i temporomandibularni zglobovi su izravno povezani s okluzijskim odnosima
pa su temporomandibularni poremećaji tradicionalno povezani s okluzijskim poremećajima. Inicijalna okluzijska terapija
može biti provedena kod svih pacijenata s temporomandibularnim poremećajima bez obzira na to imaju li intaktne zube
u okviru fizioloških okluzijskih odnosa, pacijenata kojima je potrebna ortodontska, protetska terapija ili operacijski oralno
kirurški zahvat. U liječenju pacijenata s temporomandibularnim poremećajima postoji nedoumica je li postojala indika-
cija za definitivnu terapiju, ako se bolni temporomandibularni poremećaj mogao izliječiti oblicima reverzibilne terapije,
odnosno inicijalnom terapijom. Druge vrste orofacijalnih bolova, npr. trigeminalna neuralgija, mogu biti u komorbiditetu
s temporomandibularnim poremećajima, ali i kao neprepoznata bolest imati za posljedicu nepotrebne intervencije na
zubima i protetskim radovima. Iako u struci postoji prevladavajuće shvaćanje važnosti okluzijske terapije temporomandi-
bularnih poremećaja, taj međuodnos je kontroverzan, jer to nije strogo dokazano u brojnim znanstvenim istraživanjima.
Okluzija se nije pokazala dominatnim uzročnikom temporomandibularnih poremećaja.
Ključne riječi: Dentalna okluzija; Temporomandibularni poremećaji; Udlaga; Protetsko liječenje; Orofacijalna bol

424 Acta Clin Croat, Vol. 51, No. 3, 2012