European Journal of Orthodontics 12 (1990) 399-407
© 1990 European Orthodontic Society
A longitudinal study on malocclusion in relation to signs and symptoms of cranio-mandibular disorders in children and adolescents I. Egermark-Eriksson, G. E. Carlsson, T. Magnusson, and B. Thilander Departments of Orthodontics, Prosthetics and Stomatognathic Physiology, University of Joteborg and the Institute for Postgraduate Dental Education, Jonkoping, Sweden
Introduction
Several investigations during the last two decades concerning the prevalence of malocclusion in children have been published (Ingervall et al., 1972; Thilander and Myrberg, 1973; Egermark-Eriksson, 1982; Nilner, 1983; Gazit et al., 1984; Jamsa et al., 1988). In most of the studies about half of the children were judged to have had some sort of morphological malocclusion. The prevalences of different functional malocclusions (occlusal interferences) as well as signs and symptoms of craniomandibular disorders (CMD) have also been found to be high in children and adolescents (Grosfeld and Czarnecka, 1977; Egermark-Eriksson, 1982; Nilner, 1983; Gazit et al., 1984; Magnusson et al., 1985, 1986; Egermark-Eriksson et al., 1987; Wanman, 1987; Riolo et al., 1988). The occurrence of signs and symptoms of CMD in children was judged to be nearly as great as in adults but they were milder in character and less frequent (EgermarkEriksson, 1982). Many epidemiological studies of CMD have been published and efforts have been made to
elucidate their aetiology (Carlsson, 1984; Wanman, 1987). It is well accepted that the development of functional disturbances of the masticatory system is multifactorial. Epidemiological studies in both children and adults have shown high prevalences of mandibular dysfunction but no predominant aetiology has been documented. One of the factors discussed is functional malocclusion which is considered to be of great aetiological importance (Ramfjord and Ash, 1971; Dawson, 1974), while other authors stress central and/or psychological factors (Rugh and Solberg, 1979; Yemm, 1979). Correlations between morphological and functional malocclusion and CMD have been analysed in some epidemiological studies in both children and adults (Egermark-Eriksson et al., 1983, 1987; Mohlin, 1982; Gazit et al., 1984; Jamsa et al., 1988). The results of these studies indicate, in general, that occlusal factors to a minor degree influence and cause functional disorders of the masticatory system. It would be of interest to study whether those associations differ with age or in the single subjects. That some patients with TMJ problems can be
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SUMMARY Two-hundred-and-thirty-eight subjects in three different age-groups (7, 11, and 15 years) were followed over a period of 4-5 years in respect of morphological malocclusions, and signs and symptoms of functional disturbances. About half of the 7-year-olds had at least one of the morphological malocclusions registered while the corresponding figure was 38 per cent at the age of 20. Some subjects had received corrective orthodontic treatment. When compared with subjects without such treatment, there were no differences in prevalences of occlusal interferences, nor in signs or symptoms of craniomandibular disorders (CMD). The associations between CMD and different morphological malocclusions were low. Nevertheless, some malocclusions were found to be more important than others. In a long-term perspective cross-bite, both uni- and bilateral, anterior open bite, post-, and prenormal occlusion had some association with the development of CMD.
400
I. EGERMARK-ERIKSSON ET AL.
Subjects Four-hundred-and-two children in three agegroups, 7, 11, and 15 years old (EgermarkEriksson, 1982), were selected for the follow-up
study. From the two youngest age-groups, 120 children were randomly selected and invited to a new examination 4 years later; all but one participated. From the oldest age-group, all 135 subjects were invited and 119 came to a new examination 5 years later. Sixteen subjects could not participate in the clinical examination because of moving from the district, unknown addresses or other reasons, but two of them returned the completed questionnaire. The total number of individuals participating in the longitudinal study was thus 238 and the age and sex distribution is shown in Fig. 1. Methods Clinical examination Occlusal conditions such as morphological and functional malocclusions (occlusal interference) and dental wear (according to a 5-point scale) were registered. Different signs of CMD such as mandibular mobility, TMJ function, pain on palpation of TMJs and muscles, as well as pain on movement of the mandible were also registered, and from these recordings a clinical dysfunction index according to Helkimo (1974) was constructed. Exam II
11 yr n=54
yr «=66 (?36,cT30)
15yrn=135
15 yr /r=53 (925,cf28)
20yrn=119($55,Cf64) Figure 1 A random sample of 255 out of 402 children in the original study (Exam I) were called for a follow-up 4-5 years later. 238 (93%) took part in the second examination (Exam II). , same individuals.
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cured by occlusal adjustment has been demonstrated by several authors (Magnusson and Carlsson, 1983; Forsell, 1985; Wenneberg et ai, 1988). Furthermore, orthodontically treated individuals show lower prevalences of signs and symptoms of CMD than those reported from epidemiological studies (Larsson and Ronnerman, 1981; Carlsson, 1984). However, it is difficult to draw any clear conclusions about the role of occlusal factors. One way to determine whether occlusal factors are of importance or not would be to follow individuals from childhood through adolescence to adulthood. The purpose of this study was, thus, to reexamine a group of children and adolescents after an interval of 4-5 years with respect to some occlusal factors as well as signs and symptoms of CMD. Furthermore, in a group of 20-year-olds, we studied whether any differences in these respects could be found between those who had received orthodontic treatment at earlier ages and those who had not.
401
CRANIO-MANDIBULAR DISORDERS
background for this paper are presented in Figs 2-4.
Questionnaire The participants were asked to answer a questionnaire concerning different symptoms of CMD. Details of the methods used have been given elsewhere (Egermark-Eriksson, 1982; Magnusson et al., 1985, 1986; Egermark-Eriksson et al., 1987). Some results relevant as a
Orthodontic treatment Information on interceptive and corrective orthodontic treatment was obtained from the clinical
100
80
I
60
I
II
I
II
I
II
I
II
II
40
20
11
11 15
15 20
7 11 11 15 15 20 AGE (YEARS) UNILATERAL CONTACT IN RCP
•
-FUNCTIONAL INTERF. WITHIN 3 MM EXCURSION
L J = I N EXTREME EXCURSIONS >3 MM Figure 2 Prevalence of functional malocclusions in the different age groups (n = 238). I = first examination, 11 = second examination.
I
II
I
II
I
I
II
7
11
I
II
II
l~ln fin fin 7 11
11 15
15 20
GREAT SAGITTAL DEVIATION RCP-IP ( 21.5 MM)
11 15
15 20
AGE (YEARS)
LATERAL DEVIATION RCP-IP
• •
•0.5 MM •>1.0 MM
Figure 3 Prevalence of functional malocclusions in the different age groups (n = 238). I = first examination, 11 = second examination.
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7
NON-WORKING SIDE INTERFERENCE
402
I. EGERMARK-ERIKSSON ET AL.
I
II
7
11
I
II
11 15
I II
15 20
SUBJECTIVE SYMPTOMS OF CMD
I
7 11
II
11 15
15 20
AGE (YEARS)
CLINICAL SIGNS OF CMD
L J - OCCASIONAL
L J - Dl I
•
E S J - D i 11—Iff
• FREQUENT
I
record cards of those 20-year-olds who had earlier received orthodontic treatment.
except a few subjects that still had a deep bite (overbite > 5 mm). Furthermore, some of the 20year-olds had received interceptive treatment Statistics during a short period in order to guide the eruption of the teeth or to prevent oral parafuncWilcoxon's matched-pairs signed rank test was tions. In these subjects, morphological maloccluused for analysis of differences between the two sion often persisted, but to a minor degree examinations. Correlations (rs) between varicompared to the pretreatment status. Those of ables were calculated by means of Spearman's the 20-year-olds that had received orthodontic rank correlation test (Siegel, 1956). A regression treatment showed no higher prevalences of analysis has also been performed and the results occlusal interferences or subjective or clinical were checked with non-parametric methods signs of CMD than those who had not received (Bradley, 1968; Egermark-Eriksson, 1982). The such treatment. following levels of significance have been used: *** = p
© 1990 European Orthodontic Society
A longitudinal study on malocclusion in relation to signs and symptoms of cranio-mandibular disorders in children and adolescents I. Egermark-Eriksson, G. E. Carlsson, T. Magnusson, and B. Thilander Departments of Orthodontics, Prosthetics and Stomatognathic Physiology, University of Joteborg and the Institute for Postgraduate Dental Education, Jonkoping, Sweden
Introduction
Several investigations during the last two decades concerning the prevalence of malocclusion in children have been published (Ingervall et al., 1972; Thilander and Myrberg, 1973; Egermark-Eriksson, 1982; Nilner, 1983; Gazit et al., 1984; Jamsa et al., 1988). In most of the studies about half of the children were judged to have had some sort of morphological malocclusion. The prevalences of different functional malocclusions (occlusal interferences) as well as signs and symptoms of craniomandibular disorders (CMD) have also been found to be high in children and adolescents (Grosfeld and Czarnecka, 1977; Egermark-Eriksson, 1982; Nilner, 1983; Gazit et al., 1984; Magnusson et al., 1985, 1986; Egermark-Eriksson et al., 1987; Wanman, 1987; Riolo et al., 1988). The occurrence of signs and symptoms of CMD in children was judged to be nearly as great as in adults but they were milder in character and less frequent (EgermarkEriksson, 1982). Many epidemiological studies of CMD have been published and efforts have been made to
elucidate their aetiology (Carlsson, 1984; Wanman, 1987). It is well accepted that the development of functional disturbances of the masticatory system is multifactorial. Epidemiological studies in both children and adults have shown high prevalences of mandibular dysfunction but no predominant aetiology has been documented. One of the factors discussed is functional malocclusion which is considered to be of great aetiological importance (Ramfjord and Ash, 1971; Dawson, 1974), while other authors stress central and/or psychological factors (Rugh and Solberg, 1979; Yemm, 1979). Correlations between morphological and functional malocclusion and CMD have been analysed in some epidemiological studies in both children and adults (Egermark-Eriksson et al., 1983, 1987; Mohlin, 1982; Gazit et al., 1984; Jamsa et al., 1988). The results of these studies indicate, in general, that occlusal factors to a minor degree influence and cause functional disorders of the masticatory system. It would be of interest to study whether those associations differ with age or in the single subjects. That some patients with TMJ problems can be
Downloaded from by guest on October 29, 2014
SUMMARY Two-hundred-and-thirty-eight subjects in three different age-groups (7, 11, and 15 years) were followed over a period of 4-5 years in respect of morphological malocclusions, and signs and symptoms of functional disturbances. About half of the 7-year-olds had at least one of the morphological malocclusions registered while the corresponding figure was 38 per cent at the age of 20. Some subjects had received corrective orthodontic treatment. When compared with subjects without such treatment, there were no differences in prevalences of occlusal interferences, nor in signs or symptoms of craniomandibular disorders (CMD). The associations between CMD and different morphological malocclusions were low. Nevertheless, some malocclusions were found to be more important than others. In a long-term perspective cross-bite, both uni- and bilateral, anterior open bite, post-, and prenormal occlusion had some association with the development of CMD.
400
I. EGERMARK-ERIKSSON ET AL.
Subjects Four-hundred-and-two children in three agegroups, 7, 11, and 15 years old (EgermarkEriksson, 1982), were selected for the follow-up
study. From the two youngest age-groups, 120 children were randomly selected and invited to a new examination 4 years later; all but one participated. From the oldest age-group, all 135 subjects were invited and 119 came to a new examination 5 years later. Sixteen subjects could not participate in the clinical examination because of moving from the district, unknown addresses or other reasons, but two of them returned the completed questionnaire. The total number of individuals participating in the longitudinal study was thus 238 and the age and sex distribution is shown in Fig. 1. Methods Clinical examination Occlusal conditions such as morphological and functional malocclusions (occlusal interference) and dental wear (according to a 5-point scale) were registered. Different signs of CMD such as mandibular mobility, TMJ function, pain on palpation of TMJs and muscles, as well as pain on movement of the mandible were also registered, and from these recordings a clinical dysfunction index according to Helkimo (1974) was constructed. Exam II
11 yr n=54
yr «=66 (?36,cT30)
15yrn=135
15 yr /r=53 (925,cf28)
20yrn=119($55,Cf64) Figure 1 A random sample of 255 out of 402 children in the original study (Exam I) were called for a follow-up 4-5 years later. 238 (93%) took part in the second examination (Exam II). , same individuals.
Downloaded from by guest on October 29, 2014
cured by occlusal adjustment has been demonstrated by several authors (Magnusson and Carlsson, 1983; Forsell, 1985; Wenneberg et ai, 1988). Furthermore, orthodontically treated individuals show lower prevalences of signs and symptoms of CMD than those reported from epidemiological studies (Larsson and Ronnerman, 1981; Carlsson, 1984). However, it is difficult to draw any clear conclusions about the role of occlusal factors. One way to determine whether occlusal factors are of importance or not would be to follow individuals from childhood through adolescence to adulthood. The purpose of this study was, thus, to reexamine a group of children and adolescents after an interval of 4-5 years with respect to some occlusal factors as well as signs and symptoms of CMD. Furthermore, in a group of 20-year-olds, we studied whether any differences in these respects could be found between those who had received orthodontic treatment at earlier ages and those who had not.
401
CRANIO-MANDIBULAR DISORDERS
background for this paper are presented in Figs 2-4.
Questionnaire The participants were asked to answer a questionnaire concerning different symptoms of CMD. Details of the methods used have been given elsewhere (Egermark-Eriksson, 1982; Magnusson et al., 1985, 1986; Egermark-Eriksson et al., 1987). Some results relevant as a
Orthodontic treatment Information on interceptive and corrective orthodontic treatment was obtained from the clinical
100
80
I
60
I
II
I
II
I
II
I
II
II
40
20
11
11 15
15 20
7 11 11 15 15 20 AGE (YEARS) UNILATERAL CONTACT IN RCP
•
-FUNCTIONAL INTERF. WITHIN 3 MM EXCURSION
L J = I N EXTREME EXCURSIONS >3 MM Figure 2 Prevalence of functional malocclusions in the different age groups (n = 238). I = first examination, 11 = second examination.
I
II
I
II
I
I
II
7
11
I
II
II
l~ln fin fin 7 11
11 15
15 20
GREAT SAGITTAL DEVIATION RCP-IP ( 21.5 MM)
11 15
15 20
AGE (YEARS)
LATERAL DEVIATION RCP-IP
• •
•0.5 MM •>1.0 MM
Figure 3 Prevalence of functional malocclusions in the different age groups (n = 238). I = first examination, 11 = second examination.
Downloaded from by guest on October 29, 2014
7
NON-WORKING SIDE INTERFERENCE
402
I. EGERMARK-ERIKSSON ET AL.
I
II
7
11
I
II
11 15
I II
15 20
SUBJECTIVE SYMPTOMS OF CMD
I
7 11
II
11 15
15 20
AGE (YEARS)
CLINICAL SIGNS OF CMD
L J - OCCASIONAL
L J - Dl I
•
E S J - D i 11—Iff
• FREQUENT
I
record cards of those 20-year-olds who had earlier received orthodontic treatment.
except a few subjects that still had a deep bite (overbite > 5 mm). Furthermore, some of the 20year-olds had received interceptive treatment Statistics during a short period in order to guide the eruption of the teeth or to prevent oral parafuncWilcoxon's matched-pairs signed rank test was tions. In these subjects, morphological maloccluused for analysis of differences between the two sion often persisted, but to a minor degree examinations. Correlations (rs) between varicompared to the pretreatment status. Those of ables were calculated by means of Spearman's the 20-year-olds that had received orthodontic rank correlation test (Siegel, 1956). A regression treatment showed no higher prevalences of analysis has also been performed and the results occlusal interferences or subjective or clinical were checked with non-parametric methods signs of CMD than those who had not received (Bradley, 1968; Egermark-Eriksson, 1982). The such treatment. following levels of significance have been used: *** = p
