Complex Orthodontic Problems:

The Orthognathic Patient With

Temporomandibular Disorders
Paul M. Thomas and Myron R. Tucker

The diagnosis and treatment of temporomandibular disorders (TMD) remain

controversial despite considerable research and publication in this area. The
relationship of these problems to dental and skeletal malocclusion is equally
debatable. Recent studies suggest that although malocclusion may have a
role, it is a small one. Accordingly, treatment of TMD with occlusion-altering
therapy, such as orthodontics and orthognathic surgery, should be limited to
specific situations. This report discusses the management of patients with
coexisting TMD and skeletal malocclusion. Current concepts in clinical and
radiographic diagnosis are discussed, as well as an overview of noninvasive
therapy. A case report is used to illustrate an approach to diagnosis and
treatment planning in an individual with active T M D and a skeletal malocclu-
sion requiring orthognathic surgery for correction. (Semin Orthod 1999;5:244-
256.) Copyright © 1999 by W.B. Saunders Company

A lthough the pathophysiological characteris-

tics of t e m p o r o m a n d i b u l a r (TM) joint and
masticatory muscle dysfunction (TMD) have be-
come better u n d e r s t o o d over the past decade, 1,2
considerable controversy remains regarding the
cause, diagnosis, and appropriate treatment.
Given the controversy associated with TMD, the
p r u d e n t clinician might consider some of the
following questions when treating an orthog-
nathic patient:
1. Are individuals with a skeletal malocclusion at
greater risk for developing TM disorders?
2. If they are, do certain morphological classifica-
tions place one at greater risk than others?
3. Is the severity of symptoms related to the
severity of the skeletal malocclusion?
4. What diagnostic evaluation is appropriate for
these patients?
From the Departments of Orthodontics and Oral and Maxillofa-
cial Surgery, University of North Carolina School of Dentistry,
Chapel Hill, NC.
Address correspondence to Paul Thomas, DMD, MS, Private
Practice, 5501 Fortunes Ridge Dr, Suite H, Wooderoft Professional
Cent~ Durham, NC 27713.
Copyright © 1999 by W.B. Saunders Company
107348746/99/0504-0006510. 00/0
5. When should patients with skeletal malocclu-
sion receive TMD therapy?
6. What TMD therapy is indicated, and how
should it be integrated with the orthognathic
phase of treatment?
7. Are TMD problems likely to be improved,
exacerbated, or left u n c h a n g e d by orthog-
nathic treatment?
8. What is the likelihood that a previously asymp-
tomatic patient will develop TMD symptoms
after orthognathic treatment?
Epidemiological Data of TMD
Undoubtedly, some of the contradiction and
controversy surrounding TMD can be attributed
to the shortage of good epidemiological data.
Dworkin et aP addressed these shortcomings
with a TMD epidemiological study that used
uniform methods to compare symptomatic indi-
viduals seeking treatment with both painfree
controls and randomly selected persons from the
same community who reported pain. T h e r e were
no statistically significant demographic differ-
ences among the subsamples, with the exception
of the woman to man ratio, which was 5:1 in the
treated-TMD group and 3:1 in the untreated-
TMD group. Range of motion, j o i n t noise, and

244 Seminars in Orthodontics, Vol 5, No 4 (December), 1999: pp 244-256

 The Orthognathic Patient With T M D
pain on function or to palpation were compared.
W h e n separated by gender, treated w o m e n h a d
the greatest reduction in vertical jaw motion,
followed by untreated-TMD w o m e n a n d painfree
controls. Interestingly, there was no significant
difference a m o n g the groups when c o m p a r i n g
eccentric m a n d i b u l a r excursions. Discrete pop-
ping or clicking was palpated in 43% of the
treated group, 33% of the untreated symptom-
atic group, and 24% of the controls. Crepitus was
observed equally (8%) in all groups, and grating
was detected in a like percentage of those having
pain, but rarely was seen in controls. Significant
differences existed a m o n g all three groups in
response to j o i n t and muscle palpation. As m i g h t
be expected, the treatment-seeking group h a d
the greatest prevalence of pain on palpation, six
to seven times greater than the control group. In
c o m p a r i n g the variance in subjective or r e p o r t e d
symptoms, the treatment-seeking sample consis-
tently o v e r r e p o r t e d symptoms c o m p a r e d with
the c o r r o b o r a t i n g signs f o u n d during examina-
tion. By contrast, the control g r o u p r e p o r t e d
lower percentages of positive findings c o m p a r e d
with the signs actually found.
Some p r i m a r y impressions e m e r g e regarding
the majority of patients experiencing signs or
symptoms consistent with TMD. Patients actively
seeking care will be predominently women, whose
most c o m m o n complaints are likely to be pain
on palpation and pain on function, especially in
vertical opening. T h e muscular c o m p o n e n t of
the clinical findings is the major contributing
factor in the origin of pain. 4 W h e n there are
coexisting joint pathological states, muscle splint-
ing is a contributing factor. Isolated clicking,
which has traditionally b e e n considered indica-
tive of TMD, can be f o u n d in b o t h non-TMD
controls and those having occasional discomfort
but not seeking care. T h e r e is increasing evi-
dence to suggest t e m p o r o m a n d i b u l a r j o i n t (TMJ)
clicking in itself is a benign finding. 5 Although
the research of Von Korff et al is not yet suffi-
ciently longitudinal to be conclusive, these re-
searchers r e p o r t e d TMD seems less prevalent in
older individuals. 6 T h e signs do not c o m m o n l y
increase in severity or progress toward deteriora-
tion and disability. Although TMD pain is the
principal symptom of treatment-seeking individu-
als, it generally tends to recur in cyclic fashion
and is eventually self-limiting.
945
T h e R o l e o f Malocclusion in TMD
Careful research during the last decade has
c o n t i n u e d to build the case that malocclusion is
a potential but not a principal factor in TMD.
G r e e n e and Laskin 7 were a m o n g the earliest to
suggest occlusion may only have a m i n o r role.
B u s h 8'9 offered further evidence that malocclu-
sion was not a m a j o r factor in patients with TMD
who had muscle pain as a p r i m a r y finding.
Gianelly et aP °,la d e b u n k e d the c o n c e p t that
d e e p bites and extraction orthodontics com-
monly resulted in distalized condyles and disc
interference disorders. Using corrected tomo-
grams to measure j o i n t space, Pullinger et aP e
f o u n d no correlation between condyle position
a n d occlusal factors. An arthrographic study
f r o m the Eastman Dental Center further under-
scored the lack of correlation between internal
d e r a n g e m e n t s and various malocclusions. 13With
c o n t i n u e d research, even previous advocates of
the occlusat i n t e r f e r e n c e / n e u r o m u s c u l a r theory
acknowledged the lack of correlation with the
d e v e l o p m e n t and m a i n t e n a n c e of m a n d i b u l a r
dysfunction. 14 Alterations in condylar m o r p h o -
logical characteristics were f o u n d to be adaptive
changes to varying occlusal schemes, rather than
a sign of pathological states.15
After an emotional and well-publicized mal-
practice case, 16the American Association of Orth-
odontics funded research to examine the relation-
ship between malocclusion, its treatment, and
TMD. In the synopsis of conclusions, the very
first finding m e n t i o n e d is the lack of association
between structure (dental and osseous) and
TMD. 17 Perhaps the role of malocclusion is best
stated by Parker is in his article discussing a
dynamic m o d e l of cause in TMD:
Dentists should be alert to a danger in having occlusion
as a factor in the model. Our profession knows occlusion
better than any other factor. We will find some degree of
occlusal discrepancy in nearly every patient with TMD. The
temptation is for us to give occlusion more etiologic and
therapeutic emphasis than it deserves. The danger is that the
dentist may fail to look beyond a malocclusion for the other
etiologic possibilities that are almost certain to exist, is
The R o l e o f Dentofacial Skeletal D e f o r m i t i e s
in TMD
Litde published information exists regarding
possible relationships between various classifica-
tions of skeletal malocclusion and TMD, and the
246 Thomas and Tucker
criteria for b o t h malocclusion and TMD vary
a m o n g the investigators. In one of the earlier
reports, U p t o n et alm r e p o r t e d a retrospective
study of 102 patients with severe malocclusion
who responded to a questionnaire. The malocclu-
sions were broadly classified as I, II, III, or o p e n
bite, and TMD criteria were similar to those
previously described. Fifty-three percent of the
responding patients r e p o r t e d one or m o r e find-
ings compatible with TMD. Patients with Class II
malocclusions r e p o r t e d a slightly greater preva-
lence of TMD symptoms (59%) c o m p a r e d with
Class III patients (53%), but no statistical infer-
ence was calculated. T h e n u m b e r of skeletal
o p e n bites was too small for meaningful interpre-
tation. W h e n separated by gender, w o m e n had a
greater prevalence of TMD symptoms than their
male counterparts.
In a similar study, White and Dolwick 2° re-
ported 49% of their 75-member sample pre-
sented with signs and symptoms of TMD. Head-
ache was included as a factor, along with the
c o m m o n l y included criteria of muscle and j o i n t
pain, altered function, and j o i n t noise. In addi-
tion to using the m o r e traditional Angle classifi-
cation, the sample was f u r t h e r subdivided by sex
and descriptive anatomic relationships. Chi-
square testing failed to show a significant differ-
ence in prevalence by sex, although there was a
trend toward greater female involvement. W h e n
segregated by classification, patients described as
Class II h a d a statistically greater prevalence of
TMD symptoms. The malocclusion with the great-
est preoperative prevalence was the asymmetry
group, with 85.7% showing TMD symptoms.
In one of the largest studies to date, Kerstens
et alm used the criteria o f j o i n t noise, m a n d i b u l a r
deviation, limited range of motion, and j o i n t or
muscle pain to prospectively identify TMD in
orthognathic surgical patients. In addition to the
usual sagittal m o r p h o l o g i c a l descriptors, pa-
tients were categorized by vertical facial type and
whether m a n d i b u l a r deformity was relative or
absolute. C o m p a r e d with the US literature, the
prevalence of TMD was relatively low. T h e low-
angle Class II patients had the greatest preva-
lence, with 22%. Either the E u r o p e a n popula-
tion seeking orthognathic t r e a t m e n t is healthier
or, m o r e likely, the US selection criteria are m o r e
stringent.
More recently, Rodrigues-Garcia et a122 r e -
ported the results of a multi-institutional study
on the effects of sagittal split osteotomy for the
correction of m a j o r Class II malocclusions. T h e
Craniomandibular Index, Peer Assessment Rat-
ing Index, and symptoms questionnaires were
used to evaluate 124 patients before and 2 years
after surgical-orthodontic correction of their
malocclusion. Although the results showed a
significant i m p r o v e m e n t in occlusion, the im-
p r o v e m e n t in muscle symptoms was small but
statistically significant. The n u m b e r of patients
with o p e n i n g clicks decreased significantly f r o m
33 to 13, although there was no m e n t i o n of how
the examiners d e t e r m i n e the discs were reduced
versus displaced without reduction. T h a t the
incidence of crepitus increased fi'om 5 to 16
patients may be an indication that at least a
portion of the discs were displaced with subse-
q u e n t perforation. Interestingly, the reduction
in subjective pain and discomfort was not related
to the severity of the p r e t r e a t m e n t malocclusion.
T h e investigators concluded the results did n o t
support the theory that TMD is related to Class II
malocclusion.
Risk Factors A s s o c i a t e d With T M D
A somewhat different a p p r o a c h was taken by
Susan Allen-Hime 2~ in an unpublished thesis
examining relationships between skeletal maloc-
clusion and TMD. Two p r i m a r y questions were
posed. Are there specific risk indicators associ-
ated with TMD in dentofacial patients? What are
the odds for each of the significant indicators?
T h e intent was to develop information that
would be helpful in counseling patients regard-
ing the chances their malocclusion or other risk
factors would contribute to TMD. Stepwise regres-
sion was used to separate suspected factors, and
the Mantel-Haenszel analysis tested whether the
p r o p o r t i o n of TMD was different for each condi-
tion. Selection criteria comprised the c o m m o n l y
accepted triad of pain, altered m a n d i b u l a r func-
tion, and j o i n t noise. Patients with previous j o i n t
surgery, syndromes, or systemic j o i n t disease
were excluded. T h e risk indicators included sex,
age, previous orthodontic treatment, previous
facial injury, missing teeth, crossbite, and skel-
etal and dental discrepancies in the antero-
posterior and vertical dimensions. O n e exam-
iner reviewed all preoperative p a n o r a m i c films
for subjective evidence of condylar dymorphology.
Patient age b e c a m e a risk factor when the age
 The Ortho~aathic Patient With TMD
of 25 years was used as a defining point. As in
other studies, w o m e n were at greater risk than
men. W h e n controlled for age and sex, the
classification of skeletal malocclusion was not a
significant risk factor. The presence of condylar
dysmorphology in terms of size, shape, and
articulating surface a p p e a r a n c e tested as signifi-
cant. W h e n the odds were tested for each risk
factor, female dentofacial patients, regardless of
skeletal morphological characteristics, were ap-
proximately three times m o r e likely to develop
TMD signs and symptoms. W h e n considered as a
group, patients aged older than 25 years are
likewise at 3 times greater risk. The presence of
positive condylar findings on a p a n o r a m i c screen-
ing film indicated a 2½ times greater chance of
having problems. Interestingly, and in keeping
with the trends in o t h e r studies, patients with
reverse overjet, regardless of the skeletal contri-
bution, were half as likely to develop findings
consistent with TMD as were those with in-
creased overjet.
Evaluation of Patients With Coexisting
TMD and Dentofacial Problems
T h e evaluation of the patient with TMD, facial
pain, or b o t h should include a history; physical
evaluation, including supplemental diagnostic
techniques; radiographic evaluation; and psycho-
logical assessments. L a b o r a t o r y studies and o t h e r
diagnostic techniques, although advocated by
some clinicians, are less well established. These
also are discussed briefly next.
History
The i m p o r t a n c e of detailed history taking can-
not be overemphasized. The process of diagnos-
ing a p r o b l e m is m a d e m u c h easier by obtaining
as m u c h information as possible regarding the
complaint, its onset, and progression. This can
be extremely complicated in patients with TMD.
Frequently, these patients have a p r o l o n g e d his-
tory of symptoms and clinical signs, and some
patients had n u m e r o u s previous evaluations and
treatments. T h e interview required to uncover
the entire history can be extremely time consum-
ing. A detailed questionnaire given to the patient
before the initial a p p o i n t m e n t may be helpful in
assembling this information in a m o r e effective
fashion. The classic symptom descriptors of on-
set, character, intensity, duration, location(s),
247
radiation, frequency, associated p h e n o m e n a , and
relieving and aggrevating factors serve as a basic
framework for eliciting the detailed history. Pain
and dysfunction associated with vascular or neu-
rological p h e n o m e n a , neoplastic disease, or infec-
tious processes may have a myofascial compo-
nent. A distinction must be made, however,
because m a n a g e m e n t is different.
The interview and history taking should care-
fully evaluate the p r i m a r y and associated reasons
that led the individual to seek care. A clear
statement in language similar to the patient's
own words should describe the concerns of the
patient in detail. This statement should include
the p r i m a r y and associated complaints. The
evaluation process should establish the patient's
priority for correction of these problems. T h a t is,
a patient with TMJ pain, muscle p a i n , j o i n t noise,
limited opening, and difficulty eating should list
in priority the seriousness of each complaint or
which of these concerns requires the most ur-
gent attention. This is of p a r a m o u n t i m p o r t a n c e
in the patient with a coexisting skeletal malocclu-
sion. A review of p r i m a r y complaints voiced by
patients presenting to a university-based dentofa-
cial p r o g r a m indicated 22% had the correction
of TMD as their principal goal in seeking treat-
m e n t (unpublished data, DentoFacial Program,
University of N o r t h Carolina at Chapel Hill
School of Dentistry).
Habits of bruxing and clinching may contrib-
ute to muscular symptoms, j o i n t symptoms, or
both. The timing of these habits and relationship
to pain or dysfunction should be noted. In m a n y
cases, a diagnosis can be facilitated by obtaining
information regarding the success or failure of
previous t r e a t m e n t techniques. For example, a
patient who presents with muscular as well as
j o i n t pain may have received t r e a t m e n t (physical
therapy, splint therapy) designed specifically for
muscular rehabilitation. T h e resolution of mus-
cular problems with continued j o i n t pain may
increase the suspicion of an internal j o i n t patho-
logical condition.
Radiographic Evaluation
Radiographic evaluation can be one of the most
useful adjuncts in TMD diagnosis, but the increas-
ing sophistication of e q u i p m e n t and techniques
can be confusing at times. Recognizing this
problem, the American Academy of Oral and
248 Thomas and Tucker

Maxillofacial Radiology published a position pa- O t h e r Adjuncts

per and table as an aid to decision making that
summarizes the relative value of various tech-
niques 24 (Table 1). T h e investigators state the
n e e d for imaging should be based on selection
criteria that r e p r e s e n t clinical signs and symp-
toms, indicating the study would have some
value in the diagnosis and care of the patient.
The study should provide new information that
may influence patient care. Decision-making
factors include cost, radiation dosage, and the
results of prior studies, in addition to the pro-
posed t r e a t m e n t plan and expected outcome.
Laboratory Evaluation
W h e n TMJ symptoms are c o m b i n e d with physi-
cal findings that cause the practitioner to suspect
systemic involvement, laboratory testing may be
appropriate. Individual laboratory tests can rarely,
if ever, be used in isolation to make a diagnosis;
however, some basic laboratory information, com-
b i n e d with a set of symptoms and clinical find-
ings, may help d o c u m e n t or rule out suspected
problems, such as one of the a u t o i m m u n e disor-
ders. This is particularly i m p o r t a n t if orthog-
nathic treatment is anticipated because the stabil-
ity of the surgical correction may be affected by
occult systemic disease. Because the details of a
clinical laboratory workup are beyond the scope
of this report, the reader is referred to a standard
text in internal medicine.
Thermography. Thermography, the assessment
and recording of t e m p e r a t u r e alterations, has
b e e n used to evaluate TMD, typically when the
symptoms include muscular disorders. 25,26 Infra-
red t h e r m o g r a p h y requires no surface contact
and is relatively accurate but extremely expen-
sive. Liquid-crystal t h e r m o g r a p h y requires sur-
face contact but also provides information at a
decreased cost. Both techniques have b e e n shown
to detect increased t e m p e r a t u r e in areas of
increased inflammation. 26 However, these find-
ings are somewhat inconsistent. T h e use of this
technique in routine evaluation requires further
investigation.
Condylar movement recordings. Condylar move-
m e n t recordings have b e e n advocated as a way to
evaluate and d o c u m e n t internal derangements.
Mauderli and L u n d e e n 27 described a simplified
condylar tracing technique that produces a pan-
tographic type of tracing in the sagittal plane.
This type of recording is p r o d u c e d by placing a
clutch on the lower teeth, with g r a p h p a p e r
recorders over the TMJ area. Markings are then
p r o d u c e d that theoretically simulate the condy-
lar path during m o v e m e n t . Different intracapsu-
lar pathological states may p r o d u c e different
types of condylar path recordings. In addition to
d o c u m e n t a t i o n of a specific abnormality, this
recording supposedly can be used to follow the
effectiveness of treatment. Unfortunately, abnor-

Table 1. Relative Value of Imaging

Pano- Skull Nuclear
Diagnostic ram@ Transcranial Series Tomgraphy Arthrography CT MRI SPECT Medicine Ultrasound Thermography
Task ($) ($) ($) ($) ($) ($$) ($$$) ($$) ($$) ($) ($-$$)
Bony ankylosis 0 0 0 ++ 0 +++ + 0 0 0 0
Fibrous ankylosis 0 0 0 0 0 ++ +++ 0 0 0 0
Arthritides + + 0 ++ 0 ++ +++ ++ ++ 0 +
Anomaly + + + ++ 0 +++ ++ 0 0 0 0
Disk position 0 0 0 0 +++ + +++ 0 0 0 0
Fractures ++ + ++ ++ 0 +++ ++ + + 0 0
Implants + 0 + ++ 0 +++ +++ ++ ++ 0 0
Inflammation 0 0 0 + ++* + +++ +++ +++ 0 ++t
Neoplasia + + + ++ 0 +++ +++ ++ ++ 0 0

Abbreviations: $, less than $300; $$, $300 to $800; $$$, more than $800; 0, no value for the diagnostic task; +, occasionally
useful; + +, often useful; + + +, almost always useful.
*When including arthrocentesis with arthrography.
tAlthough thermograpfiy shows promise, it is a new technique with limited research; CT, computed tomography; MRI,
magnetic resonance imaging; SPECT, single p h o t o n emission c o m p u t e d tomography.
Modified and reprinted with permission from Brooks SL, BrandJW, Gibbs SJ, et al: Imaging of the temporomandibularjoint: A
position paper of the American Academy of Oral and Maxillofacial Radiology. Oral Surg, Oral Med, Oral Radiol Endod
83:609-618, 1997. 24
 The Orthocnathic Patient With TMD
mal-appearing condylar path recordings may
reflect normal variation, rather than a pathologi-
cal state.
Controversial adjuncts to diagnosis. T h e r e has
been a proliferation of new procedures and
devices advocated as useful in diagnosing TMD.
Before the routine use of new devices and
procedures, research reports should d o c u m e n t
efficacy, safety, and reliability. Unfortunately, some
of the devices and methods have not proven
their worth through double-blind studies and
clinical trials before marketing. T h e techniques
in question include sonography (analysis of j o i n t
sounds), surface electrode electromyographic
(EMG) evaluation, and kinesiography. The reader
is referred to McCall's 2s overview of the Ameri-
can Dental Association's position on alternative
diagnostic methods. Gay et a129,31and Heffez and
Blaustine 31 have shown the limitations of sonog-
raphy.
EMG analysis has been used by a variety of
investigators with variable results? 2,~3 T h e r e are
several shortcomings to the use of EMG silent
period recording for the evaluation of patients
with facial pain. These include variable indi-
vidual responses, difficulty defining the silent
period, operator bias, the influence of variable
bite force, and the possibility that EMG abnor-
malities are not always specific for muscle pain or
dysfunctional problems. EMG evaluation has
been used outside the clinical setting for the
long-term evaluation of muscle activity during
daily life events. 34 Portable devices have re-
c o r d e d the relationship between increased
muscle activity and pain to stressful episodes in
daily life. ~5 This technology has also proven
useful in monitoring muscle activity during treat-
ment with medications or splint therapy. 32
Kinesiography, a m e t h o d for recording man-
dibular movement in three dimensions, has been
suggested as a useful technique for evaluating
TMD. 36 Recording is accomplished by computer-
assisted tracking of a magnet secured to the
mandibular teeth. The premise b e h i n d jaw track-
ing is that mandibular dysfunction can be distin-
guished by alterations in the pattern, velocity,
and anteroposterior displacement of the man-
dible during function. 37,3s Unfortunately, the
premises have not been substantiated by indepen-
dent investigators. Dao et aP 9 f o u n d the instru-
m e n t directly stimulated the distal axons of the
masticatory muscle m o t o r neurons rather than
249
causing relex closure, as claimed. Feine et al 4°
evaluated symptomatic and healthy patients and
f o u n d significant dysfunctional abnormalities in
both groups, defined by kinesiograph standard
criteria. Using the methods suggested by the
manufacturer, they could not differentiate be-
tween patients in the healthy and dysfunctional
populations. Although the instrumentation is
expensive and appears sophisticated, kinesiogra-
phy has no controlled research to support its
efficacy in the evaluation of TMD.
Reversible Treatment
After completion of the workups of the dentofa-
cial deformity, as well as the TMD, the initial
phase of treatment can begin. The guiding
principle is that pathological problems, includ-
ing TMD, should be brought u n d e r control
before dentofacial deformity is treated. This
initial treatment phase may consist of patient
education, medication, physical therapy, and
splint therapy. This obviously would be initiated
only after a complete discussion with the patient
describing the diagnosis, potential treatment
options, and anticipated range of outcomes.
Patient Education
As with any clinical problem, the first step in
treating TMD is to provide patients with ad-
equate knowledge to help them understand the
causative factors producing the pain and dysfunc-
tion. In some cases, clinical problems may be of
short duration and self-limiting and may not
require aggressive treatment. Simply educating
the patient about the problem and likely out-
come may be the only required treatment. Most
problems involving TMD and dentofacial defor-
mity are more complex and require long-term
treatment and a clear understanding on the part
of the patient of the likely outcome of each step.
Part of patient education includes providing
information regarding the role of diet, perni-
cious habits, and other jaw functional activities
that may be producing or exacerbating TMD
symptoms. T h e role of stress, particularly as it
relates to muscle hyperactivity and myofascial
pain, is extremely important for these patients.
Medication. Patients experiencing significant
j o i n t and muscle pain a n d / o r dysfunction can
frequently benefit from medication, including
anti-inflammatory drugs, muscle relaxants, and,
250 Thomas and Tucker
on rare occasion, narcotic analgesics. In addi-
tion, many patients with chronic pain can benefit
from antidepressant drugs.
Nonsteroidal anti-inflammatory drugs
(NSAIDs) are used primarily to control discom-
fort and reduce inflannnation in both muscles
and joints. Although there are several categories
of NSAIDs, all these drugs work by inhibiting
cyclo-oxygenase, with subsequent inhibition of
prostaglandin synthesis. 41,42Although these drugs
usually do not totally eliminate intercapsular or
intramuscular inflammation, the significant re-
duction generally produces decreased pain and
improvement in function. Mild gastric irritation
is a relatively c o m m o n complication, although
severe side effects resulting from NSAIDs use are
relatively rare.
Muscle relaxants are frequently prescribed for
patients with TMD to reduce pain and dysfunc-
tion resulting from muscle hyperactivity or obvi-
ous muscle spasm. However, the results are
widely variable, and the potential for addiction
must always be considered. Muscle relaxants may
also function by reducing anxiety and producing
some degree of sedation. 43
Analgesic medicines other than NSAIDs may
range from mild analgesics, such as acetamino-
phen, to potent narcotics. Narcotics should not
be considered for chronic long-term manage-
merit of discomfort.
Chronic pain and dysfunction are frequently
associated with depression, and antidepressant
drugs are frequently beneficial for patients with
chronic facial pain. 44,45 The tricyclics frequently
produce an analgesic effect shortly after begin-
ning drug therapy, whereas the actual antidepres-
sant effects may not be evident for 1 to 2 weeks.
Some improvement in sleep pattern may also be
noted, even when drugs are used in very low
doses, such as 10 to 25 mg of amitriptylene at
bedtime.
Physical therapy. The primary goal of physical
therapy is to maximize the functional range of
motion that can be achieved with relative com-
fort. Whereas a variety of sophisticated physical
therapy modalities and techniques can be used, a
simple progressive h o m e exercise program is a
vital part of improvement for rehabilitation of
muscular, as well as joint, problems. This gener-
ally begins with gentle stretching exercises, with
either passive jaw opening or progressive active
stretching. H o m e therapy coupled with a soft
diet and anti-inflammatory medication is often
sufficient to produce the desired effect.
Referral to a physical therapist may be indi-
cated in patients with persistent problems. They
offer such modalities as ultrasound to help re-
lieve pain and improve function during stretch-
ing exercises by increasing tissue temperature,
altering blood flow, and relieving muscle spasm.
Ultrasound can elevate tissue temperature at a
level much d e e p e r than that provided by simple
surface heat application. 46 The theoretical ben-
efits of increasing tissue temperature include
increased circulation, increase in uptake of pain-
producing metabolic byproducts, and disruption
of collagen cross-linking, as in the case of early
adhesion formation.
EMG biofeedback is also frequently used by
physical therapists to d o c u m e n t muscle hyperac-
tivity and educate the patient about the relation-
ship of stress to muscle hyperactivity and pain.
EMG monitoring of the patient's muscle activity
is often used as a teaching tool in relaxation
training therapy, providing an instant feedback
of muscle activity.47 Transcutaneous electronic
nerve stimulation (TENS) is accomplished by
applying a low-dose electrical current to the skin.
In theory, this would stimulate cutaneous sen-
sory nerves, which then override input from
smaller pain fibers innervating muscles and
joints. 4s A c o m m o n use of TENS therapy is to
provide pain relief to patients with chronic pain
when other more routine methods of pain man-
agement have not been successful. Despite the
application of TENS for relatively short periods
of time (minutes to hours), pain relief often
extends beyond the time period of TENS applica-
tion. Possible explanations for this clinical find-
ing include the release of such substances as
serotonin and dopamine from TENS applica-
tion, which then produce the extended period of
pain relief. 49,5°
Splint therapy. Splint therapy includes a wide
variety of appliance-based therapies frequently
used in the treatment of TMD. A wide variety of
success rates have b e e n reported for improve-
m e n t in both muscle and j o i n t symptoms. 52-55
The mechanism for the effectiveness of the splint
is highly controversial. Explanations range from
a simple placebo effect56 to alterations in muscle
orientation, as well as changes in condyle and
disc position. Splint therapy includes partial to
complete coverage of the occlusion, bite-open-
 The Orthognathic Patient With TMD 251

ing appliances, those that p r o d u c e protrusion or Although there are a limited n u m b e r of sur-
some o t h e r m a n i p u l a t e d jaw position, or those geons still advocating open-joint surgery for
that simply a t t e m p t to remove occlusion interfer- internal d e r a n g e m e n t or disk interference disor-
ences. Despite the controversy regarding splint ders, most clinicians have recognized the out-
design and explanation of efficacy, clinical im- come is rarely better than that achieved with
p r o v e m e n t in patients' symptoms is frequently noninvasive treatment. Surgery is still and always
attributed to the use of splint therapy. has b e e n an option for gross pathological states
The use of any or all of the previously men- and reconstruction of osseous structural integ-
tioned nonsurgical reversible techniques is cer- rity. T h e n u m b e r of patients requiring surgical
tainly not m a n d a t o r y in the m a n a g e m e n t of the intervention, however, is relatively small com-
patient with dentofacial TMD. However, m a n y of p a r e d with the prevalence of TMD signs and
these t r e a t m e n t modalities used either in isola- symptoms.
tion or in combination may result in significant
short-term and long-term i m p r o v e m e n t in clini- Case Report
cal symptoms. In m a n y patients, the TMD symp-
toms may improve significantly or resolve com-
History
pletely; thus, the p r i m a r y emphasis can then be Wendy P. first developed signs and symptoms of
focused on the dentofacial deformity. Continued TMD at the age of 15 years. Initially, her left j o i n t
m o n i t o r i n g of clinical signs a n d symptoms of was clicking and locking intermittently, but she
TMD, of course, is necessary. had no discomfort. She b e g a n to experience
TMJ surgery. The rediscovery of disk displace- left-sided muscle and j o i n t pain a m o n t h later
m e n t in the mid-1970s led to a decade and a half and was referred to an orthodontist by her family
of open-joint surgery. Disks were repositioned dentist. By the time she was seen, she was
with bilaminar zone plication or r e a t t a c h m e n t to experiencing clicking, popping, and left j o i n t
either the condylar h e a d or glenoid fossa. Disks and muscle pain, a n d h e r range of o p e n i n g had
d e e m e d beyond salvage were r e m o v e d and re- decreased to 15 m m because of muscle splinting.
placed with dermis, facia lata, fiber-reinforced The symptoms b e c a m e worse with wide o p e n i n g
silicone sheeting, muscle flaps, a variety of man- or increased function. She was treated with
m a d e substances, and, in some cases, n o t h i n g at NSAIDs, diazepam, a soft diet, a flat-plane splint,
all. Joints with severe b o n e regeneration were and physical therapy (Fig 1).
replaced with costochondral grafts or total j o i n t
prostheses.
By the mid-1980s, surgeons recognized the
futility of attempts at disk repositioning and the
disastrous results associated with the p l a c e m e n t
of m a n m a d e materials. In m a n y cases, the vari-
ous alloplastic implants resulted in an insidious
giant-cell granulomatous reaction that led to
progressive erosion and resorption of surround-
ing bone. Following the lead of orthopedic
surgeons, arthroscopy b e c a m e p o p u l a r as a less
invasive intervention. Surgeons soon discovered,
however, that operative arthroscopy h a d a long
and steep learning curve. Given the anatomic
limitations and the size of the arthroscopic
equipment, the majority of t r e a t m e n t was limited
to finite visualization, followed by lysis of adhe-
sions and lavage of the capsule. Arthrocentesis
Figure 1. When first seen by the authors, after 5 years
b e c a m e recognized as a means of achieving the
of treatment, the patient was 15 years old and had
same objectives using simple instrumentation been experiencing left-sided joint and muscle pain.
and with less potential morbidity. She also had a limited range of motion.
252 Thomas and Tucker
T h e r e was little i m p r o v e m e n t in the clicking
and locking, and she was referred to an oral and
maxillofacial surgeon the following month. At
that time, h e r range of m o t i o n without pain was
35 m m , and she o p e n e d with initial deviation to
her left. T h e r e was an o p e n i n g p o p on the left
side, a palpable click on the right, and reciprocal
clicks bilaterally. T h e r e was no j o i n t pain at this
time, but Wendy had a difficult time finding a
comfortable occlusion after wearing the splint.
With the condyles centered in the glenoid fossa,
Wendy showed a Class II o p e n bite malocclusion.
An increase in pain p r o m p t e d a second opin-
ion f r o m a n o t h e r oral and maxillofacial surgeon.
Corrected linear t o m o g r a p h y suggested mild
surface erosion of the left condyle and a possible
subcondylar cyst. A magnetic resonance imaging
(MRI) study was read as left disc displacement
without reduction and right disc displacement
with reduction. A b o n e scan showed increased
left TMJ uptake at 2 hours after injection, which
was indicative of degenerative or reparative
changes.
Based on the diagnostic studies and contin-
ued symptoms, a left meniscoplasty and emi-
n e n c e reduction was p e r f o r m e d . A 2-mm perfo-
ration in the retrodiscal tissue was resected, and
the disk was sutured to the lateral pole of the
condyle. T h e symptoms associated with the left
TMJ i m p r o v e d after surgery but worsened in the
right joint. Lysis of adhesions and lavage was
p e r f o r m e d t h r o u g h artlaroscopy of the right
j o i n t several m o n t h s later. After an i m p r o v e m e n t
in symptoms, evaluation was b e g u n before orth-
odontic therapy and possible orthognathic sur-
gery. Wendy's p r i m a r y concerns included dental
esthetics and function, in addition to t r e a t m e n t
of the TM disorder.
O r t h o d o n t i c appliances were placed, a n d
Wendy was c o n t i n u e d on reversible therapy,
including the flat-plane occlusal splint. Treat-
m e n t goals included leveling and alignment and
arch coordination in preparation for mandibu-
lar surgery. Although she was ready for surgery
after a year of orthodontic preparation, it was
delayed until school vacation. A bilateral sagittal
split osteotomy with wire osteosynthesis and
maxillomandibular fixation was completed. Af-
ter 6 weeks of maxillomandibular fixation, orth-
odontic finishing was initiated. T h e r e was almost
immediate relapse of the Class II o p e n bite
malocclusion and the beginning of right TMJ
pain (Fig 2). W h e n symptoms continued to
increase, right TMJ arthrocentesis was per-
f o r m e d several m o n t h s later. C o m p u t e d tomo-
graphic and MRI studies were p e r f o r m e d that
were positive for bilateral j o i n t disease. T h e MRI
was read as a n o n r e d u c i n g right displaced disk
and partial displacement and reduction of the
left disc.
T h e reconstructed c o m p u t e d t o m o g r a p h i c
scans showed bilateral flattening and foreshorten-
ing of the condyles. T h e r e was bilateral cortical
erosion and anterior osteophytes on the right
condyle. Both glenoid fossas showed signs of
sclerosis and chronic degenerative changes.
Symptoms included constant right j o i n t discom-
fort and left j o i n t and muscle pain a b o u t every 7
days.
After 5 years of treatment, Wendy was referred
to the authors at the age of 20 years for evalua-
tion of her malocclusion and TM disorder. She
was experiencing increasing pain. T h e extraoral
clinical examination showed no gross asymmetry
or misproportion. T h e maxillary and mandibu-
lar midlines were coincident but deviated to the
right of the midsagittal plane by 1 to 2 ram.
Wendy showed 5 m m of overjet and 2 m m of
o p e n bite without evidence of occlusal slide or
19y am ~mmeo-oostop
Igy 6m IMF RELEASE
©
% •
+ +- /
Figure 2. The relapse of the mandibular advance-
ment is illustrated by this superimposition of the
immediate postoperative and follow-up cephalometric
tracings.
 The Orthognathic Patient With TMD
skid (Fig 3). T h e r e was 4 m m of u p p e r incisor
exposed with the u p p e r lip at rest and 8 m m
during a n i m a t e d smile. The TM j o i n t capsules
were mildly to moderately tender to palpation,
with the right showing m o r e discomfort than the
left. T h e r e was no muscle pain, although Wendy
r e p o r t e d this was cyclic. Range of m o t i o n was
n e a r normal, with a comfortable interincisal
o p e n i n g of 43 m m . T h e left lateral excursions
were slightly r e d u c e d at 6 m m . Surprisingly,
there were no palpable clicks or crepitus at this
visit.
T h e most recent imaging studies were consis-
tent with bony changes, but it was impossible to
d e t e r m i n e what m i g h t be pathological versus the
r e m o d e l i n g e x p e c t e d after previous orthog-
nathic and o p e n j o i n t surgery (Fig 4). T h e r e was
no indication of condylar neck shortening, as
seen with avascular necrosis. T r e a t m e n t se-
quence and alternatives were discussed with
Wendy and her family, which included 3 orthog-
nathic options and possible arthroplasty, depend-
ing on her response to continued reversible
TMD therapy. T h e orthognathic alternatives with
associated advantages a n d disadvantages in-
cluded:
1. Repeat sagittal split osteotomy with rigid inter-
nal fixation: This option had the advantages
of potentially better esthetics and limiting
t r e a t m e n t to the mandible. Disadvantages
included the potential liability of closing an
o p e n bite with m a n d i b u l a r surgery u n d e r the
best of circumstances. In this case, TMJ health
and the previous invasive procedures were a
p r i m a r y consideration. T h e surgical move-
m e n t would place increased force on the
condyles and result in reorientation, which
could lead to undesirable remodeling.
Figure 3. Immediately before the second orthog-
nathic procedure, occlusal contact was limited to the
first and second molars bilaterally.
953
Figure 4. A radionucleide single photon emission
computed tomographic scan indicated increased up-
take in the right joint. Although not specific for
disease, this study shows an asymmetric metabolic
state that could lead to relapse after surgical correc-
tion.
2. LeFort surgery with maxillary retraction and
posterior impaction: Isolated maxillary sur-
gery offers g o o d stability in o p e n bite treat-
m e n t and would avoid the possibility of fur-
ther c o m p r o m i s i n g j o i n t integrity. Clinical
experience has shown, however, that maxil-
lary retraction can result in an undesirable
esthetic o u t c o m e because of decreased sup-
p o r t for the soft tissue drape and the appear-
ance of p r e m a t u r e aging.
3. Double-jaw surgery with maxillary impaction
and m a n d i b u l a r advancement: Mobilization
of b o t h jaws would avoid maxillary retraction,
but relapse potential generally increases and
predictability decreases with double-jaw sur-
gery. In addition, there was the p r o b l e m of
repeat surgery on a previously o p e r a t e d man-
dible with questionable TMJ integrity.
Treatment
Based on several discussions with Wendy and her
parents and a review of c o m p u t e r - g e n e r a t e d
t r e a t m e n t simulations (Fig 5), the decision was
m a d e to use the LeFort I option. T h e o r t h o d o n -
tist r e s u m e d the wire sequence leading to heavy
surgical stabilizing wires. Wendy was to u n d e r g o
a 3-month regimen of long-acting NSAID therapy
and continue o t h e r reversible measures for TMD
m a n a g e m e n t . T h e b o n e scan was to be repeated
254 Thomas and Tucker
6 weeks after cessation of NSAID therapy. If there
was no evidence of active disease, the surgery
would be completed. In the event the reversible
TMD measures were unsuccessful, the right joint
would be operated with possible disk removal
and replacement with ear cartilage.
Wendy became asymptomatic with the longer
regimen of NSAIDs. She continued to be rela-
tively asymptomatic after their cessation. The
bone scan showed increased uptake by the right
condyle, but given the lack of symptoms, these
changes were believed to be reparative or remod-
eling rather than pathological (Fig 4). A LeFort I
osteotomy with bone plate fixation was used to
retract the maxilla 3 m m and intrude it 3 m m
posteriorly. Wendy was seen for follow-up 1
m o n t h after surgery and was referred to begin
postoperative orthodontic finishing. H e r braces
were removed and retention b e g u n 5 years after
first developing symptoms. She was seen the
following spring and f o u n d to have mild intermit-
tent temporalis tenderness. The cyclic nature of
TMD and its relationship to life-event stress was
reviewed with Wendy. She recognized her symp-
toms coincided with stressful periods at school.
She was seen again several months later and was
asymptomatic, with excellent stability of her
orthognathic and orthodontic result (Fig 6). A
letter from her 2 years later confirmed contin-
Figure6. Final occlusion 2 years after tile completion
of treatment. The outcome has remained stable.
Figure 5. Pre- and posttreat-
ment profile photograph. In
addition to the functional
improvement, the change
in Wendy P's demeanor was
dramatic with the comple-
tion of a protracted and
complicated treatment.
ued lack of symptoms and stability of the occlusal
correction (Fig 7).
Summary
There is ilo strict regimen or sequence for the
m a n a g e m e n t of patients with coexisting TM
disorders and skeletal malocclusion. However,
there are certain principles that help guide the
treatment decision-making process. First and
foremost are the patient's primary concerns. If
the primary c o n c e r n is the relief of TMD signs
and symptoms, it is appropriate to pursue the
least invasive therapy that will achieve that end.
Irreversible treatment should only be enter-
tained after less invasive alternatives have been
unsuccessful. O n average, orthognathic correc-
tion of the skeletal malocclusion is no more
likely than reversible therapy to improve symp-
toms. Furthermore, there is approximately a
Figure 7. Posttreatment frontal photograph.
 The Orthognathic Patient With TMD
10% to 12% chance the symptoms may escalate
after orthognathic s u r g e r y . ~9,21
If the TMD is a secondary consideration, and
the patient has significant concerns a b o u t facial
a p p e a r a n c e a n d dental function and esthetics,
orthognathic surgery becomes a m o r e reason-
able alternative. T h e presurgical evaluation
should include studies to verify the relative
morphological and metabolic stability of the
j o i n t structures. Without this information, clini-
cians have no means of d e t e r m i n i n g whether
postoperative instability is caused by orthodontic
relapse, m o v e m e n t of the mobilized segments,
or continued change in the j o i n t architecture. It
is not m a n d a t o r y that all patients be treated " o n
the disk." Adaptive metaplasia of the retrodiscal
tissue has b e e n shown to occur in patients with
n o n r e d u c i n g disc displacement. T h e absence of
pain may be considered an indication they can
function in this relationship.
The status of an individual's TMD should be
carefully monitored after orthognathic
ment. Orthodontic appliances should be left in
p l a c e u n t i l t h e r e is s o m e r e a s o n a b l e a s s u r a n c e o f
stability. I f t h e r e a r e m i n o r o c c l u s a l d i s c r e p a n -
cies r e l a t e d t o c h a n g i n g j o i n t a r c h i t e c t u r e , f i n i s h -
ing orthodontics may be adequate compensa-
tion. Likewise, orthodontic detailing may be
needed if open-joint surgery becomes necessary
in the postoperative period. Management
c o m b i n e d p r o b l e m s c a n b e r e w a r d i n g o r ex-
tremely frustrating depending on patient selec-
tion and the approach to treatment. Results vary
from excellent in terms of esthetics and function
to long-term complications beyond comprehen-
sion. Careful attention to patient concerns,
coupled with a prudently prepared treatment
p l a n , will h e l p e n s u r e t h e d e s i r e d o u t c o m e .
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