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0886-9634/3002-121$05.00/0, THEJOURNAL OFCRANIOMANDIBULARPRACTICE,Copyright © 2012by CHROMA, Inc.

ABSTRACT: The current study investigated the association between temporomandibular disorders,

malocclusion patterns, benign joint hypermobility syndrome and the initial condylar position. One hun-

dred sixty-two subjects were analyzed using the Rocabado Temporomandibular Pain Analysis; Helkimo

Index parameters; the Carter-Wilkinson modified test; and a mounting cast with condylar position

indicator registration (MPI). The study revealed a significant association between: 1. Delta H, skeletalpattern (p=0.034); 2. Delta Y, transversal malocclusion (p=0.04); 3. right and left, Delta Z, right and left

posteroinferior synovial pain (p<0.05); 4. hypermobility scale, gender (p<0.001), malocclusion pattern

(p=0.021); 5. TMJ function impairment, gender (p=0.043); 6. sagittal malocclusion pattern, right tem-

poromandibular pain analysis joint (TPAJ) (p=0.0034); 7. TMJ function impairment, left and right TPAJ

(p=0.007); and 8. mandibular motion, left and right TPAJ (p=0.035, p=0.015 ). The conclusion was

that anterior crossbite and condylar displacements in the vertical plane are risk factors in developing

TMJ symptoms.

Dr. José Mª Barrera-Mora obtained his

 D.D.S. degree from the School of  Dentistry, University of Seville in 2002,

where he later received a Masters degreein orthodontics in 2006 and a Ph.D.degree in 2010. He is currently a profes-

sor at the School of Dentistry, Universityof Seville, where he teaches orthodontics.

Currently, the etiology of temporomandibulardisorders (TMD) is sometimes still difficult todiagnose. Advances in the knowledge of joint bio-

mechanics, neuromuscular physiology, autoimmune andmuscle-skeletal disorders, and pain mechanismshave helped with understanding the mechanisms behindTMD. The etiology of TMD is currently1 thought to bemultifunctional, involving biological, environmental,social and emotional behaviors, and cognitive factors,individually or combined, all of which contribute to thedevelopment of signs and symptoms of TMD.

The position of the condyle has always been consid-ered an etiopathogenic factor and has been thoroughlydiscussed throughout medical history. However, thereare few studies that suggest there is a correlation betweenthis etiopathogenic factor and a disorder that could jeop-ardize the human orthopedic system compared to others,such as dento-skeletal malocclusion patterns and benignsystemic joint hypermobility.

Does the ideal condylar position in centric relation orin a relaxed muscle position, which would involve a morephysiological position of the condyle-disc and temporal

The Relationship Between Malocclusion, Benign Joint

Hypermobility Syndrome, Condylar Position and TMD

Symptoms

José Mª Barrera-Mora, D.D.S., Ph.D.; Eduardo Espinar Escalona, D.D.S., Ph.D.;Camilo Abalos Labruzzi, D.D.S., Ph.D.; José Mª Llamas Carrera, D.D.S., Ph.D.;Emilio Jiménez-Castellanos Ballesteros, D.D.S., Ph.D.; Enrique Solano Reina, D.D.S.,Ph.D.; Mariano Rocabado, P.T., D.P.T.

CLINICAL PRACTICE

Manuscript received April 20, 2011; revisedmanuscript receivedJuly 26, 2011; acceptedJuly 27, 2011

 Address for correspondence:Dr. José Mª Barrera-MoraFacultad de Odontologíade Sevilla

Dept. de EstomatologíaCalle Avicena S/N41009 Sevilla, SpainEmail: JmbMora@us.es

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eminence relation, truly exist? After doing a literaturereview, it can be concluded that there is no universal con-cept of the ideal condylar position.2-5 At the same time,malocclusion patterns seem not only to influence condy-lar position, but also the position of the glenoid fossa,

which makes this relationship much more complicated.6

Many studies7,8 have reported that there is a relationshipbetween patients with Class II and III Angle malocclu-sion pattern, with an anterior condylar displacement, andthose patients with a horizontal and vertical craniofacialpattern with an anterior and posterior condylar inclina-tion, respectively. However, in a sample with normalocclusion, the evaluation of the concentric position of thecondyles in their respective mandibular fossae alsoshowed a noncentralized position for the right and leftsides.9 In most cases, the neuromusculature places themandible in such a position that the highest number of 

occlusal contacts is established without taking intoaccount the final condylar position.

Could malocclusion patterns and benign joint hyper-mobility syndrome both be risk factors of orthopedicinstability? Despite the contradictory results reported inthe literature, these could theoretically be consideredinstability factors. A few existing studies10,11 also ana-lyzed the link between malocclusion, condylar position,and the presence of TMJ symptoms and signs.

The aim of the current study was to determine the asso-ciation between TMD symptoms and condylar position,dento-skeletal malocclusion pattern, and benign joint

hypermobility syndrome.

Materials and Methods

Subjects

A total of 140 newly arrived patients, who neededorthodontic treatment (53 male, 87 female, age range 15-50), were selected from the Department of Orthodonticsand Dentofacial Orthopedics of the Dental School of theUniversity of Seville, from 2005 to 2009. Twenty-twostudents from the Dental School (10 male, 12 female, agerange 20-30) were selected as the control group (normal

occlusion with no orthodontic treatment). The followingexclusion criteria were used for subject participation inthe study12: under 15 years of age, malocclusion patients,history of previous orthodontic treatment, and existenceof rheumatic sickness or degenerative joint disease. Innormal occlusion patients: under 15 years of age, absenceof a bilateral molar and cuspid Angle Class I, bone/toothdiscrepancy exceeding two mm (negative or positive),anterior or posterior crossbite, overjet greater than twomm or less than zero mm, overbite greater than four mmor less than two mm, posterior and anterior rotations

exceeding 15º and that affected more than two teeth of theincisor sector, previous history of orthodontic treatment,and finally, the presence of rheumatic sickness or degen-erative joint disease.

 Exploration Report In order to evaluate the malocclusion three-dimension-

ally, and to assess condylar sliding using the mandibularposition indicator (MPI) (Great Lakes Orthodontics, Ltd.,Tonawanda, NY), a mounting cast was made into a semi-adjustable articulator (SAM 3) (Great Lakes Orthodontics,Ltd., Tonawanda, NY) with a wax record using Roth’s power centric technique13 in all subjects. A cephalometricstudy with an orthopedic scanner (Promax, Planmeca,Finland) was also done to establish skeletal malocclu-sion and craniofacial structure, according to the Jacobson’sWits appraisal,14 the Bjork-Jaraback15 criteria (difference

between anterior and posterior facial height), and theSolano16 retroclusion (difference between anterior andposterior dental-alveolar height) (Figure 1). The Beightonscore17 was used to establish the degree of joint hyper-mobility. It is currently used as part of the Brighton diag-nostic criteria. To obtain a positive Beighton score, fouror more points out of nine are required. Hypermobilitysyndrome was included in the analysis as a categoricalvariable with three subdivisions, based on the Grahame18

studies: Zero category, none of the joints had hypermo-bility; First category, from one to three joints had hyper-mobility; and Second category, from four to nine joints

had hypermobility.Considering the evolution of hypermobility withage,19 a classification dependant on this factor was usedin the study. Subjects of up to 40 years old were includedin the anterior distribution. Forty-year-old patients andolder were distributed in the following categories: Zerocategory, none of the joints had hypermobility; First cat-egory, one joint had hypermobility; and Second category,from two to nine joints had hypermobility.

The TMJ examination was done using the temporo-mandibular pain analysis of Rocabado20,21 (Figure 2), andtwo parameters of the Clinical Helkimo index (range of 

mandibular motion and TMJ function impairment).

Statistical Analysis

The SPSS (IBM Corp.) statistical package for Windows,version 15, was used for data analysis. It was observedthat, to obtain a statistical power of 85% reliability with asignificance level of 0.05, a sample of 80 subjects wasneeded. The current study included 162 patients, twicethe required number, for two main reasons: first, to obtaina similar or larger sample size in comparison to other cur-rent studies in the literature for an accurate discussion;

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and second, given the number of variables that were stud-ied, to ensure enough reliability and level of significanceto respond to the hypothetical variability that any of theparameters of the study could exercise. The statisticalpower was calculated with the program nQuery Advisor(Statistical Solutions, Boston, MA).

The χ2 test was used for comparison of two non-numer-ical variables, such as gender, benign joint hypermobilitysyndrome score, positive or negative temporomandibularpain analysis, Helkimo Index parameters, and dento-skeletal malocclusion three-dimensional parameters. TheAnova test was used to study the possible statistical rela-tionships among MPI values (that dictate the amount anddirection of condylar movement in maximal intercuspa-tion), with the variables that define a malocclusion pat-tern in the three levels of space at dento-skeletal levels,degree of hypermobility joint, as well as the joint dys-function parameters of the TMJ. The Bonferroni andWelch tests were used to adjust probability.

To test the intraoperative variability of MPI, 15 castsof the same patient were mounted, on different days,within a month. The intraclass correlation coefficient(ICC) was calculated for each parameter measuring the

MPI. The results were as follows:Delta X right ICC=0.759 for p=0.001;Delta X left ICC=0.866 for p=0.000;Delta Z right ICC=0.847 for p=0.000;Delta Z left ICC=0.983 for p=0.000;Delta Y ICC=0.846 for p= 0.000; andDelta H ICC=0.520 for p=0.048.

All the results were significant. Therefore, the resultscorroborate other studies13,22-24 that consider the use ofa MPI a highly reproducible procedure using differ-ent operators.

Results

The average age of patients was 22.9. Tables 1-3 showthe frequency and distribution of TMD symptoms, hy-perlaxity degree, and different malocclusion patterns.Figure 3 presents the distribution of the different types of temporomandibular pain according to Rocabado’s painanalysis. The most frequent pain was pain 5 (posteroinfe-rior synovial), right and left (11.1-11.7%), followed bypain 3 (external collateral ligament) (7.4-8.6%) and pain6 (synovial posterosuperior) (4.9-3.7%). Tables 4-7

show a statistically significant correlation among MPI

values (dictate the amount and direction of condylarmovement in maximum intercuspation) with variablesthat define the malocclusion pattern three-dimensionallyat the dento-skeletal level: skeletal class, sagittal maloc-clusion; and those that determine the symptomatology of TMD: pain 5 or synovial posteroinferior, right and left.Results also revealed an increase in vertical discrepancyof centric sliding (Delta H) in the skeletal Class I maloc-clusion pattern compared with the skeletal Class II mal-occlusion pattern (1.81-0.87 mm; p=0.034). The trans-verse displacement of both condyles (Delta Y) is greater

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APRIL 2012, VOL. 30, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 123

Figure 1Cephalometric parameters of Jacobson,14 Bjork-Jaraback,15 andSolano.16

Figure 2Rocabado’s temporomandibular pain analysis: 1. Anteroinferiorsynovial; 2. Anterosuperior synovial; 3. Lateral collateral ligament;4. Temporomandibular ligament; 5. Posteroinferior synovial;6. Posterosuperior synovial; 7. Bilaminar zone; and 8. Retro disc.

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when an anterior crossbite exists compared to when theoverjet is increased, both on the right side (0.40-0.15mm;p=0.04). The right and left temporomandibular pain more

frequent in our sample (pain 5 or synovial posteroinfe-rior) revealed a statistically significant correlation withcondylar vertical discrepancies (Delta Z) from 0.89 to0.98 mm; p<0.05. However, no statistically significant

correlation (p>0.05) was found among condylar displace-ment, degree of hypermobility, malocclusion pattern, andthe Helkimo Index parameters described in this study.

The possible statistical relations among different non-numerical variables were analyzed, such as gender, jointhypermobility, Rocabado’s temporomandibular painanalysis, Helkimo Index parameters and dento-skeletalthree-dimensional malocclusion parameters.

A statistical significance (p<0.001) was observedamong gender and joint hypermobility. Females had ahigher degree of hypermobility than males (Table 8).Females also revealed a higher rate of clicking (Table 9),

and deviation on opening to males (parameter of tem-poromandibular dysfunction from Helkimo Index,p=0.043).

Class II Malocclusion pattern and open bite (Table 10)presented the highest percentage of joint hypermobilitycases, category 2 (p=0.021). Moreover, no significant sta-tistical relationship was found (p>0.05) among jointhypermobility and the clinical parameters of temporo-mandibular dysfunction (Helkimo Index parameters, andRocabado’s temporomandibular pain analysis.)

Anterior cross-bite (Table 11) showed a high positive

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Table 1

Frequency of TMD SymptomsTMD symptoms Frequency Percentage (%)Range of mandibular motion

Normal 139 85.830-39 mm opening, 4-6 mm laterality 22 13.6<30 mm opening and <3 mm laterality 1 0.6

TMJ function impairmentNormal 112 69.1Joint noises and deviationon opening or mouth closure 46 28.4

Locking or dislocation of the TMJ 4 2.5

Right temporomandibular pain analysisNegative temporomandibular pain 128 79.0Positive temporomandibular pain 34 21.0

Left temporomandibular pain analysisNegative temporomandibular pain 131 80.9Positive temporomandibular pain 31 19.1

Table 2

Frequency of Benign JointHypermobility Syndrome

Categories Frequency Percentage (%)Normal 92 56.8Category 1 24 14.8Category 2 46 28.4

Table 3

Frequency of Malocclusion Patterns

Categories Frequency Percentage (%)Normal occlusion 22 13.6Class I 38 23.5Class II 54 33.3Class III 15 9.3Open bite 33 20.4

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rate in the exploration of the temporomandibular painanalysis of the right joint (p=0.034).

The parameters of the Helkimo Index selected in thecurrent study (range of mandibular motion and TMJfunction impairment) revealed a correlation with the pos-

itive right and left palpation of temporomandibular painanalysis, (p=0.007; TMJ function impairment, right andleft TMJ pain analysis; and range of mandibular motion,

right and left TMJ pain analysis, p=0.035, p=0.015 )(Tables 12 and 13).

The variables dictating the condylar position (MPIdata), according to the Pearson coefficient, revealed adirectly proportional correlation of 0.5 between right and

left Delta Z (vertical displacement of both condyles), and0.3 between right and left Delta X (sagittal displacementof both condyles), both statistically significant, p<0.001.

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Figure 3Rocabado’s temporomandibularpain analysis distribution in thesample.

Table 4

Vertical Discrepancy Between CR (CentricRelation) and MI (Maximum Intercuspation)

Delta H and Skeletal ClassDelta H Avg. Dif. Avgs.

Skeletal Class I Skeletal Class II .9419*

1.81Skeletal Class III .5225

Skeletal Class II Skeletal Class I -.9419*0.87

Skeletal Class III -.4195Skeletal Class III Skeletal Class I -.5225

1.29Skeletal Class II .4195

*Difference is the significant average levelof 0.05 (p=0.034)

Table 5

Condylar Transverse Discrepancy (Delta Y) and

Sagittal MalocclusionDelta Y Avg. Dif. Avgs.

Normal overjet 0.26 Anterior crossbite -.1402Increased overjet .2417

Anterior crossbite 0.40 Normal overjet -.1402Increased overjet -.3820*

Increased overjet 0.15 Normal overjet -.2417Anterior crossbite -.3820*

*Difference is the significant average levelof 0.05 (p=0.04)

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Table 6

Right Posteroinferior Synovial Pain (5)

Condylar Vertical Discrepancy(Right and Left Delta Z)

Delta Z Right N Average ANOVA p<0.05Pain - 143 0.37

0.032Pain + 19 0.92

Delta Z Left N Average ANOVA p<0.05Pain - 143 0.26

0.014Pain + 19 0.90

Table 7

Left Posteroinferior Synovial Pain (5)Condylar Vertical Discrepancy

(Right and Left Delta Z)Delta Z Right N Average ANOVA p<0.05

Pain - 144 0.370.019

Pain + 18 0.98

Delta Z Left N Average ANOVA p<.0.05

Pain - 144 0.260.020

Pain + 18 0.89

Table 8

Gender - Hyperlaxity DegreeGender Category

0 1 2   χ2 test p<0.05

Female 44 17 380.001

Male 48 7 8

Category 0: Smooth regular motion w/o noises in the TMJ;mandibular deviation less than 2 mm during mouth open-ing or closing.Category 1: Noises in one or both TMJs or mandibulardeviation equal to or greater than 2 mm during mouthopening or closing.Category 2: Locking or dislocation of the TMJ.

Table 9

Gender - TMJ Function ImpairmentGender Category

0 1 2   χ2 test p<0.05

Female 62 33 40.043

Male 50 13 0

Category 0: Smooth regular motion w/o noises in the TMJ;mandibular deviation less than 2 mm during mouth open-ing or closing.Category 1: Noises in one or both TMJs or mandibulardeviation equal to or greater than 2 mm during mouthopening or closing.Category 2: Locking or dislocation of the TMJ.

Table 10

Malocclusion Pattern - Hyperlaxity DegreeMalocclusion Category

pattern 0 1 2   χ2 test p<0.05

Normal occlusion 5 7 10 0.021Class I 26 4 8Class II 33 7 14Class III 12 1 2

Open bite 16 5 12Category 0: Smooth regular motion w/o noises in the TMJ;mandibular deviation less than 2 mm during mouth open-ing or closing.Category 1: Noises in one or both TMJs or mandibulardeviation equal to or greater than 2 mm during mouthopening or closing.Category 2: Locking or dislocation of the TMJ.

Table 11

Sagittal Malocclusion PatternRight Temporomandibular Pain Analysis

Right painSagittal M. - +   χ2 test p<0.05Normal 70 13Anterior crossbite 20 12 0.034

Overjet 38 9

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Discussion

Over a century ago,25 a relationship between temporo-mandibular disorders, such as internal derangement andosteoarthritis, and benign generalized articular hypermo-bility was suggested. Theoretically, ligamentous hyper-laxity causes the joint to overload, producing degenerativechanges that could lead to internal derangements and/orinflammation.26 Up to the present, numerous studies27-38

have been conducted that obtained contradictory results.

Some studies have found an association between TMDand benign generalized articular hypermobility, whereasthe current study and others did not.30,34-37 Disparity38

could be due to the differing exclusion and inclusion cri-teria for the subject sample, the number of subjects of thesamples, and the number of joints rated.

Hirsch39 used the Beighton criteria to classify thebenign hyperlaxity syndrome, and the Dworkin40 criteriafor examining the TMJ, demonstrating that subjects whosuffer from generalized joint hypermobility had a greaterrisk of suffering nonpainful clicks and lesser of mouth

opening limitation. These patients, however, did not havea greater risk of TMJ pain, either as myalgia or arthralgia,although the cross-sectional study did not take intoaccount that widespread joint pain increases with age,while generalized joint mobility decreases with age.

The sample included for the current study had a genderdimorphism, as have other existing studies,41-45 on thedegree of systemic benign hypermobility. Females have ahigher percentage of hypermobility—a score of four ormore joints (23.46% versus 4.94%).

No prior attempt has been made to investigate the linkbetween benign joint hypermobility syndrome and themalocclusion pattern. Open bite and Class II malocclu-sion pattern, with dental and skeletal parameters, have astatistically significant relationship (p=0.021), with a cat-egory degree two, according to the modified Beightonand Horan index.

Dental occlusion has been ascribed an important etio-logical role,46 but has now been given lessened impor-tance as a contributory factor to TMD47,48; however,certain malocclusion patterns, in post-mortem andepidemiological46-55 studies, have occasionally demon-strated the role of occlusal factors (in the case of dentalmalocclusion) as a risk indicator in developing TMD.These would be according to an Angle Class II malocclu-sion pattern with increased overjet, Angle Class III mal-occlusion pattern, as well as open and crossbites. Thisassociation is due to the less stable occlusion found inthese types of malocclusion.50-53 However, several studies

have found no clear association.54-56,59-61

Similarly, thecurrent literature does not show much progress in variousocclusal aspects.

Motegi and Cols62 present a very similar distributionbetween genders, unlike that found in other samples.Patients with increased crowding and overjet displayed ahigh percentage of disorders, while anterior crossbites,open bites, overbites, and posterior crossbites had feweror no symptoms, although increasing slightly with age.

Hwang, Sung and Kim,57 using cephalometric recordsand measurements, determined that patients with hyper-divergent facial profiles, retroinclined maxillary incisors,

and very inclined occlusal planes revealed TMD signs.John, et al.,58 concluded that wide ranges of overjet andoverbite were consistent with the normal functioning of masticatory muscles and the TMJ.

Egermark, Magnusson and Carlsson63 reported that alateral discrepancy between maximal intercuspation andcentric relation, such as a unilateral crossbite, might be arisk factor that should be taken into account in somepatients.

Selaimen, et al.,64 also stated in their investigations thatsome occlusal factors, such as malocclusion Class II, and

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Table 12

TMJ Function Impairment

Right/Left Temporomandibular Pain AnalysisTMJ function Right pain Left painCategory - + - +   χ2 test p<0.05

0 96 16 98 14 right/left1 29 17 30 16 0.007/0.0072 3 1 3 1

Category 0: Opening ≥40 mm and laterality >0=7 mmCategory 1: Opening 30-39 mm and laterality 4-6 mmCategory 2: Opening <30 mm and laterality <3 mm

Table 13

Range of Mandibular MotionRight/Left Temporomandibular Pain Analysis

Range ofmand. Right pain Left painCategory - + - +   χ2 test p<0.05

0 114 25 117 22 right/left1 13 9 13 9 0.035/0.0152 1 0 1 0

Category 0: Opening ≥40 mm and laterality >0=7 mmCategory 1: Opening 30-39 mm and laterality 4-6 mmCategory 2: Opening <30 mm and laterality <3 mm

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the lack of canine guidance on lateral exclusions can beconsidered as risk indicators of TMD.

Gidarakou, et al.,65 compared a sample of symptomaticand asymptomatic females to identify skeletal and dentalfactors between the groups. Magnetic resonance images

(MRI) were performed to verify that there was no discdisplacement. Their results showed no significant differ-ence except for the lower incisors being more retruded inasymptomatic patients.

The results of the current investigation classify anteriorcrossbite, pathognomonic sign of Class III malocclusionpattern, as a risk factor. The examination of painful sitesin the right joint revealed significant values (Table 11),when associated with malocclusion in the sagittal plane(p= 0.034). The patients with anterior crossbite, in pro-portion, showed a greater percentage of positives in theright joint. The current study’s results revealed that these

patients had a larger transversal condylar shift to the right joint (Delta Y), although this displacement was not statis-tically correlated with joint discomfort.

Several studies66-68 reported that posterior condylepositioning could lead to disc alterations (anterior dis-placement). Incesu, et al.,69 pointed out an existing rela-tionship between the posterior positioning of the condyleand anterior disc displacement, but did not find any sta-tistical significance in terms of disc morphology.

Williams70 used lateral tomograms to analyze condylarposition, before and after TMJ treatment in 40 dysfunc-tional patients. It was found that 32% of patients dis-

played no concentric condylar position. Moreover, oncethe TMJ treatment was completed using splints, ortho-dontics or both, and the patient was stable, no statisticalchange was found in the condylar position.

Ren,71 however, concluded that the condyle positionsof the TMJ with normal disc positions are distributed ran-domly and can include anterior, central and posteriorpositions, although a posterior condyle position was moreprevalent in joints with anterior disc displacement. A pos-terior condyle position cannot be interpreted as a diag-nostic sign for internal derangements of the TMJ whenanterior or centered condyle positions are also often seen

in patients with internal derangements. More recently,others have stated that this relationship is not present inall cases.3,72

Statistical studies73 have highlighted a relationshipbetween TMD symptoms and centric slide. Lotzmann74

suggested that slides under 0.5 mm might involve moreor less discomfort in the patient’s head or face. Further-more, the results of the current investigation agree withthe other studies that also showed how discrepancies of less than 1.0 mm in the vertical plane might lead to TMJsymptoms. These findings contradict current studies that

state that TMD develops when centric displacement of the condyle is greater than 1.0 mm in the vertical andsagittal planes.75,76

Temporomandibular disorders have been clinicallydescribed as a combination of signs and symptoms,

in indexes or classifications (Helkimo Index55), Cranio-mandibular Index (Fricton and Shiffman77; Frictonand Shiffman78) and Temporomandibular Joint Scale(Levitt79). Generally speaking, a diagnosis should be abrief and useful way to define the clinical conditions.Although many systems have been suggested to diagnosethe TMJ (Eversole and Machado80; Talley81), currentlyonly two studies are widely used: the Clinical Guidelinesof the American Academy of Orofacial Pain (Okeson82),and the Research Diagnostic Criteria for Temporo-mandibular Disorders (Dworkin and LeResche40). Bothanalyses have areas that overlap and are in agreement.

John83 evaluated the high reliability of the last analysis(statistical significant coefficient of intraclass correla-tion) in a large study conducted in 10 internationalclinical centers, with 30 professionals and including230 patients. A current investigation, carried out bySchmitter,84 concluded that this classification method forTMD has some minor variables, such as palpation of theopening and closing muscles of the TMJ, as they do notprovide much information for TMD diagnosis.

Based on previous studies, the current authors estab-lished an examination form that included most of thedescribed factors, as well as an unusual palpation method

that excluded the masticatory muscles (due to the low sig-nificance), known as the “Temporomandibular PainAnalysis” described by Rocabado.21 It was also includedas a part of the Clinical Helkimo Index, already in full usein the earlier pilot study85 of this project, excluded in thisnew research were items that have not previously reportedany information. A significant correlation was observedbetween the right and left pain analysis within the selectedparameters of the Helkimo Index: p=0.007; right and leftpain analysis, TMJ function impairment (Table 12), andp=0.035, p=0.015 right and left pain analysis, range of mandibular motion (Table 13). These results confirm

that the parameters selected, in this study, to examine theTMJ are consistent with each other.The authors in the current study concluded that there is

no well-defined initial condylar position that is statisti-cally significant, neither for normal occlusion nor for thedifferent malocclusion patterns. There is no statisticallysignificant relationship between benign joint hypermobil-ity syndrome and the amount of condylar displacement orTMD, but such a relationship does exist with malocclu-sion patterns, especially, malocclusion Class II and openbite. Finally, anterior crossbite could be a risk factor in

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developing TMJ symptoms, and patients with verticalcondylar displacements from 0.88 to 0.97 mm developed,significantly, left and right posteroinferior synovial pain(pain 5).

References

1. Scrivani, et al.: Temporomandibular disorders. N Engl J Med 2008; 359:2693-2705.

2. Ash M: Occlusion: reflections on science and clinical reality. J Prosthet Dent 

2003; 90(4):373-384.3. Vasconcelos Filho JO, Menezes AV, Freitas DQ, Manzi FR, Bóscolo FN, de

Almeida SM: Condylar and disk position and signs and symptoms of tem-poromandibular disorders in stress-free subjects. J Am Dent Assoc 2007;138:251-255.

4. Bonilla-Aragon H, Tallents RH, Katzberg RW, Kyrkanides S, Moss ME:Condyle position as a predictor of temporomandibular joint internalderangement. J Prosthet Dent 1999; 82:205-208.

5. Dawson P: Evaluation, diagnosis, and treatment of occlusal problems. 2nded., Kansas City, MO: Mosby Company; 1989.

6. Baccetti, et al.: Glenoid fossa position in different facial types: a cephalomet-ric study. Br J Orthod 1997; 24:55–59.

7. Katsavrias E, Halazonetis D: Condyle and fossa shape in Class II and ClassIII skeletal patterns: a morphometric tomofigure study. Am J Orthod 

 Dentofac Orthop 2005; 128:337-346.8. Pullinger A, et al.: Relationship of mandibular condylar position to dental

occlusion factors in an asymptomatic population. Am J Orthod Dentofac

Orthop 1987; 91:200-206.9. Vitral R, Campos M, Rodrigues A, Fraga M: Temporomandibular joint and

normal occlusion: is there anything singular about it? A computed tomo-graphic evaluation. Am J Orthod Dentofacial Orthop 2011; 140:18-24.

10. Artun J, Hollender L, Truelove E: Relationship between orthodontic treat-ment, condylar position, and internal derangement in the temporomandibu-lar joint. Am J Orthod Dentofac Orthop 1992; 101:48-53.

11. Crawford SD: Condylar axis position, as determined by the occlusion andmeasured by the C.P.I. instrument, and signs and symptoms of temporo-mandibular dysfunction. Angle Orthod 1999; 69(2):103-115

12. Wadhwa L, Utreja A, Tewari A: A study of typical signs and symptoms of temporomandibular dysfunction in subjects with normal occlusion,untreated and treated malocclusions.  J Orthod Dentofac Orthop 1993;103:54-61.

13. Wood DP, Elliott RW: Reproducibility of the centric relation wax bite tech-nic. Angle Orthod 1994; 64:211-221.

14. Jacobson A: The “Wits” appraisal of jaw disharmony. Am J Orthod Dentofac

Orthop 1975; 67:125-138.15. Gregoret J: Ortodoncia y cirgugía ortognática; diagnóstico y planificación.

Barcelona: ESPAXS, S.A., 1997.16. Solano E: Nueva aproximación al diagnóstico ortodóncico a través del plano

oclusal: cefalometría M.S.E. Ortod Esp 2009; 49(3):180-207.17. Beighton PH, Horan FT: Dominant an heritance in familial generalized

articular hypermobility. J Bone Joint Surg 1970; 52(1):145-147.18. Grahame R, Bird HA, Child A: The revised (Brighton 1998) criteria for the

diagnosis of benign joint hypermobility syndrome (BJHS).  J Rheumatol

2000; 27:1777-1779.19. Hakim AJ, Cherkas LF, Grahame R, Spector TD, MacGregor AJ: The genetic

epidemiology of joint hypermobility: a population study of female twins. Arth Rheum 2004; 50:2640-2644.

20. Rocabado M: Arthrokinematics of the temporomandibular joint. Dent Clin

 North Am 1983; 27(3):573-594.

21. Rocabado M: A university student with chronic facial pain. In: Jones M,Rivett D eds. Clinical reasoning for manual therapists. 1st ed. Edinburgh:Butterworth-Heinemann: 2004:243-261.

22. Alexander SR, Moore RN, Dubois LM: Mandibular condyle position: com-parison of articular mounting and magnetic resonance imaging.  Am J 

Orthod Dentofac Orthop 1993; 104:230-239.23. Lavine D, Kulbersh R, Bonner P, Pink F: Reproducibility of the condylar

position indicator. Semin Orthod 2003; 9(2):96-101.24. Hicks ST, Wood DP: Recording condylar movement with two facebow sys-

tems. Angle Orthod 1996; 66:293-300.25. Annandale T: Displacement of the inter-articular cartilage of the lower jaw,

and its treatment by operation. Lancet 1887; 1:411.26. Dijkstra PU: Temporomandibular joint: osteoarthrosis and joint mobility

(dissertation). Groningen, 1993: Univ. of Groningen, the Netherlands.27. Bates RE, Stewart CM, Atkinson WB: The relationship between internal

derangements of the temporomandibular joint and systemic joint laxity.

 J Am Dent Assoc 1984; 109:446-447.28. Plunkett GA, West VC: Systemic joint laxity and mandibular range of move-

ment. J Craniomandib Pract 1988; 6:320-326.29. Chun DS, Koskinen ML: Distress, jaw habits, and connective tissue laxity as

predisposing factors to TMJ sounds in adolescents. J Craniomandib Disord 1990; 4:165-176.

30. Conti PCR, Miranda JES, Araujo CRP: Relationship between systematic

 joint lax ity , TMJ hyp ert ransla tion and int ra-art icu lar disorders . J Craniomandib Pract 2000; 18:192-197.31. Blasberg B, Hunter T, Philip S: Peripheral joint mobility in individuals with

and without temporomandibular disorders. J Dent Res 1991; 70:278.32. Dijkstra PU, de-Bont LG, Stegenga B, Boering G: Temporomandibular joint

osteoarthrosis and generalized joint hypermobility. J Craniomandib Pract 

1992; 10:221-227.33. Aravena H, Rocabado M: Valoración de la hipermovilidad articular y para-

funciones en casos de disfunción temporomandibular. Kinesiologia 1995;43:72-77.

34. De Coster PJ, Van den Berghe LI, Martens LC: Generalized joint hypermo-bility and temporomandibular disorders: inherited connective tissue diseaseas a model with maximum expression. J Orofac Pain 2005; 19:47-57.

35. Elfving L, Helkimo M, Magnusson T: Prevalence of different temporo-mandibular joint sounds, with emphasis on disc displacement, in patientswith temporomandibular disorders and controls. Swed Dent J 2002; 26:9-19.

36. Seckin U, Tur BS, Yilmaz O, Yagci I, Bodur H, Arasil T: The prevalence of  joint hypermobility among high school students. Rheumatol Int  2005;25:260-263.

37. Winocur E, Gavish A, Halachmi A, Bloom E, Gazit A: Generalized jointlaxity and its relation with oral habits temporomandibular disorders in ado-lescent girls. J Oral Rehabil 2000; 27:614-622.

38. Dijkstra PU, Kropmans TJ, Stegenga B: The association between generalized joint hypermobilty and temporomandibular joint disorders: a systematicreview. J Dent Res 2002; 81(3):158-163.

39. Hirsch C, John MT, Stang A: Association between generalized joint hyper-mobility and signs and diagnoses of temporomandibular disorders. Eur J 

Oral Sci 2008; 116:525-530.40. Dworkin SF, LeResche L: Research diagnosis criteria for temporomandibu-

lar joint disorders: review, criteria, examinations and specifications, cri-tique. J Craniomandib Disord 1992; 6:301-355.

41. Kavuncu V, Sahin S, Kamanli A, Karan A, Aksoy C: The role of systemichypermobility and condylar hypermobility in temporomandibular jointdysfunction syndrome. Rheumatol Int 2006; 26:257-260.

42. Dubs L, Gschwend N, Sonney F: Die messung der bandlaxität beim gesun-den. messergebnisse bei verschiedenen bevölkerungskollektiven. Orthopäde

1984; 13:25-30.43. Al-Rawi ZS, Al-Aszawi AJ, Al-Chalabi T: Joint mobility among university

students in Iraq. Br J Rheumatol 1985; 24:326-331.44. Larsson LG, Baum J, Mudholkar GS: Hypermobility: features and differen-

tial incidence between the genderes. Arth Rheum 1987; 30:1426-1430.45. Wordsworth P, Ogilvie D, Mith R, Sykes B: Joint mobility with particular ref-

erence to racial variation and inherited connective tissue disorders. Br J  Rheumatol 1987; 26:9-12.

46. Ramfjord SP, Ash MM: Diagnosis and treatment of functional disturbance of temporomandibular joints and muscles. In: Ramfjord SP, Ash MM, eds.Occlusion. Philadelphia, PA: W.B. Saunders; 1966:355-388.

47. Suvinen TI, Reade PC, Kemppainen P, Könönen M, Dworkin SF: Review of aetiological concepts of temporomandibular pain disorders: towards abiopsychosocial model for integration of physical disorder factors withpsychological and psychosocial illness impact factors. Eur J Pain 2005;9:613-633.

48. Carlsson GE: Critical review of some dogmas in prosthodontics. J Prosthodont  Res 2009; 53:3-10.

49. Dworkin SF, Huggings KH, Le Reche L, Von Korff M, Howard J, TrueloveE, et al.: Epidemiology of signs and symptoms in temporomandibular dis-orders: clinical signs in cases and controls.  J Am Den t Assoc 1990;120:273-281.

50. Egermark-Eriksson I, Carlsson GE, Magnusson T, Thilander B: A longitudi-nal study on malocclusion in relation to signs and symptoms of cran-iomandibular disorders in children and adolescents.  Eur J Orthod 1990;12:399-407.

51. Solberg WK, Bibb CA, Nordström BB, Hansson T: Malocclusion associatedwith temporomandibular joint changes in young adults at autopsy.  Am J 

Orthod Dentofacial Orthop 1986; 89:326-330.52. Henriksson T: Temporomandibular disorders and mandibular function in

relation to Class II malocclusion and orthodontic treatment [thesis]. Swed 

 Dent J [Suppl.] 1999:134.53. Mohlin B, Derweduwen K, Pilley R, Kingdon A, Shaw W, Kenealy P:

Malocclusion and temporomandibular disorder: a comparison of adoles-

BARRERA-MORA ET AL. RELATIONSHIP OF MALOCCLUSION AND TMD SYMPTOMS

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cents with moderate to severe dysfunction with those without signs andsymptoms of temporomandibular disorder and their further development to30 years of age. Angle Orthod 2004; 74:319-327.

54. Thilander B, Rubio G, Pena L, Mayorga C: Prevalence of temporomandibu-lar dysfunction and its association with malocclusion in children and ado-lescents: an epidemiologic study related to specified stages of dentaldevelopment. Angle Orthod 2002; 72:146-154.

55. Helkimo M: Studies on function and dysfunction of the masticatory system.Part II. Index for anamnestic and clinical dysfunction and occlusal state.Sven Tandlak Tidskr 1974; 67:101-121.

56. Mohlin B: TMD in relation to malocclusion and orthodontic treatment: a sys-tematic review. Angle Orthod 2007; 77(3):542-548

57. Hwang CJ, Sung SJ, Kim SJ: Lateral cephalometric characteristics of maloc-clusion patients with temporomandibular joint disorder symptoms.  Am J Orthod Dentofacial Orthop 2006; 129:497-503.

58. John M, Hirsch C, Drangsholt M, Mancl M, Setzl J: Overbite and overjet arenot related to self-report of temporomandibular disorder symptoms. J Dent 

 Res 2002; 81(3):164-169.59. Gesch D, Bernhardt O, Kocher T, Ulrich J, Hensel E, Alte D: Association of 

malocclusion and functional occlusion with signs of temporomandibulardisorders in adults: results of the population-based study of health inPomerania. Angle Orthod 2004; 74:512-520.

60. Gesch D, Bernhardt O, Kocher T, Ulrich J, Hensel E, Alte D.: Associationof malocclusion and functional occlusion with subjective symptoms of TMD in adults: results of the study of health in Pomerania.  Angle Orthod 

2005; 75:183-190.61. Kahn J, Tallents RH, Katzberg RW, Moss ME, Murphy WC: Association

between dental occlusal variables and intraarticular temporomandibular joint disorders: hor izontal and vertical overlap.  J Prosthet Dent 1998;79:658-662.

62. Motegi E, Miyazaki H, Ogura S, Konishi H, Sebata M: An orthodontic studyof temporomandibular joint disorders. Part 1: Epidemiological research inJapanese 6-18 years old. Angle Orthod 1992; 62:249.

63. Egermark I, Magnusson T, Carlsson G: A 20-year follow-up of signs andsymptoms of temporomandibular disorders and malocclusions in subjectswith and without orthodontic treatment in childhood.  Angle Orthod 2003;73:109-115.

64. Selaimen, et al.: Occlusal risk factors for temporomandibular disorders. Angle

Orthod 2007; 77(3):471-477.65. Gidarakou L, et al.: Comparison of skeletal and dental morphology in asymp-

tomatic volunteers and symptomatic patients with normal temporo-mandibular joints. Angle Orthod 2003; 73(2):121-127.

66. Cholasueksa P, Warita H, Soma K: Alterations of the rat temporomandibular joint in functional posterior displacement of the mandible. Angle Orthod 

2004; 74:677-683.67. Weinberg LA: Posterior bilateral condylar displacement: its diagnosis and

treatment. J Prosthet Dent 1976; 36:426-440.68. Di Paolo C, D’Ambrosio F, Panti F, Papa M, Mancini P: The condyle-fossa

relationship in temporomandibular disorders. Considerations on the patho-genetic role of the disk. Minerva Stomatol 2006; 55:409-422.

69. Incesu L, Taskaya-Yılmaz N, Ögütcen-Toller M, Uzun E: Relationship of condylar position to disc position and morphology.  Eur J Radiol 2004;51:269-273.

70. Williams B: Tomofigure stability of condyle fossa relationships in 40 treatedtemporomandibular disorder patients. J Prosthet Dent 1998; 79:570-574.

71. Ren YF, Isberg A, Westesson PL: Condyle position in the temporomandibu-lar joint: comparison between asymptomatic volunteers with normal diskposition and patients with disk displacement. Oral Surg Oral Med OralPathol 1995; 80:101-107.

72. Pereira LJ, Gavião M, Bonjardim LR, Castelo PM: Ultrasound and tomo-graphic evaluation of temporomandibular joints in adolescents with andwithout signs and symptoms of temporomandibular disorders: a pilot study.

 Dentomaxillofac Radiol 2007; 36:402-408.73. Pullinger AG, Seligman DA, Solberg WK: Temporomandibular disorders.Part II, Occlusal factors associated with temporomandibular tenderness anddysfunction. J Prosthet Dent 1988; 59:363-367.

74. Lotzmann U: Entwicklung und anwendung des temporo-mandibular.Positions-comparators (TMPC) zur dreidimensionalen erfassung staticherverlagerungen der Mandibula. Med Habil Göttingen, 1994.

75. Koveleski WC, DeBoever J: Influence of occlusal splints on jaw position andmusculature in patients with TMJ dysfunction.  J Prosthet Dent 1975;33:321-327.

76. Ari-Demirkaya A, Biren S, H Küçkkeles ON: Comparison of deep bite andopen bite cases: normative data for condylar positions, paths and radiofig-ure appearances. J Oral Rehabil 2004; 31:213-224.

77. Fricton JR, Schiffman EL: Reliability of a craniomandibular index. J Dent  Res 1986; 65:1359-1364.

78. Fricton JR, Schiffman EL: The craniomandibular index: validity. J Prosthet 

 Dent 1987; 58:222-228.79. Levitt SR, Lundeen TF, McKinney MW: Initial studies of a new assessment

method for temporomandibular joint disorders.  J Prosthet Dent 1988;59:490-495.

80. Eversole LR, Machado L: Temporomandibular joint internal derangementsand associated neuromuscular disorders. J Am Dent Assoc 1985; 110:69-79.

81. Talley RL, Murphy GJ, Smith SD, Baylin MA, Haden JL: Standards for thehistory, examination, diagnosis, and treatment of temporomandibular dis-orders (TMD): a position paper. American Academy of Head, Neck andFacial Pain. J Craniomandib Pract 1990; 8:60-77.

82. Okeson JP, ed.: Guidelenes for the assessment, diagnosis and management .Chicago: Quintessence, 1996.

83. John M, Dworkin S, Mancl LI: Reliability of clinical temporomandibular dis-order diagnoses. Pain 2005; 118:61-69.

84. Schmitter M. et al.: Validity of temporomandibular disorder examination pro-cedures for assessment of temporomandibular joint status.  Am J Orthod 

 Dentofac Orthop 2008; 133:796-803.85. Barrera J, Espinar E, Carbajosa A, Abalos C, Solano E: Valor pronóstico del

indicador de posición mandibular M.P.I. Ortod Esp 2008; 48(1):48-55.

Dr. Eduardo Espinar Escalona received his M.D. degree in 1983 and his D.D.S degree from the School of Dentistry, University of Seville in

1987, where he later received a Masters degree in orthodontics and aPh.D. degree in 2006. He is currently an assistant professor of the

 Department of Orthodontic Dentistry, School of Dentistry, University of 

Seville, Spain.

Dr. Camilo Abalos Labruzzi received his M.D. degree in 1982 at theSeville School of Medicine, his D.D.S. degree in 1995 and his Ph.D. indentistry at the Seville School of Dentistry, University of Seville, Spain

in 1995. He is currently an assistant professor of the Department of Conservative Dentistry, School of Dentistry, University of Seville, Spain.

Dr Jose Ma Llamas Carrera holds Ph.D., M.D. and D.D.S. degrees. Heworks as an orthodontist in Seville, Spain, where he is a part-time profes-

sor at the University of Seville. He is an active member in the AngleSociety of Europe and of the European Board in Orthodontics.

Dr. Emilio Jimenez-Castellanos Ballesteros received his M.D. degreein 1983 and his Ph.D. in stomatology in 1983 at the School of Dentistry,University of Seville, Spain. He is currently a professor of prostheticdentistry in the Stomatology Department, School of Dentistry, University

of Seville, Spain.

Dr. Enrique Solano Reina received his M.D. degree in 1978 at theSeville School of Medicine, his D.D.S. degree in 1980, and his Ph.D. indentistry at the Madrid School of Dentistry, Complutense de Madrid 

University, Spain in 1982. He is currently a full professor of the Department of Orthodontics and is also Chairman of the Postgraduate

Orthodontics Training Program of the Faculty of Dentistry, Universityof Seville.

Dr. Mariano Rocabado received his D.P.T degree in 1966 at the

University of Chile, his Ph.D. degree in physical therapy at theUniversity of Saint Augustine, Florida, U.S.A. in 2003. He has been a full professor at the University of Chile and an adjunct professor at theUniversity of St. Augustine, Florida, U.S.A. Currently, he is the head of 

Physical Therapy and Physical Medical Rehabilitation at Integramedica,Santiago, Chile and a professor of head and neck biomechanics. Heteaches a postgraduate course in the Orthodontics Program at the School

of Dentistry, University of Chile. He is also the director of CEDIME (Centro de Estudios de las Disfunciones Músculo Esqueléticas).

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