n CLINICAL PRACTICE

The Relationship Between Malocclusion, Benign joint

Hypermobility Syndrome, Condylar Position and TMD
Symptoms
Jos M Barrera Mora, D.D.S., Ph.D.; Eduardo Espinar Escalona, D.D.S., Ph.D.;
Camilo Abalos Labruzzi, D.D.S., Ph.D.; Jos M Llamas Carrera, D.D.S., Ph.D.;
Emilio Jimnez-Castellanos Ballesteros, D.D.S., Ph.D.; Enrique Solano Reina, D.D.S.,
Ph.D.; Mariano Rocabado, P.T., D.P.T.

0886-9634/3002000$05.00/0, THE
JOURNAL OF
CRANIOMANDIBULAR
PRACTICE,
Copyright 2012
by CHROMA, Inc.
Manuscript received
April 20, 2011; revised
manuscript received
July 26, 2011; accepted
July 27, 2011
Address for correspondence:
Dr. Jos M Barrera Mora
Facultad de Odontologa
de Sevilla
Dept. de Estomatologa
Calle Avicena S/N
41009 Sevilla, Spain
Email: JmbMora@us.es

ABSTRACT: The current study investigated the association between temporomandibular disorders,
malocclusion patterns, benign joint hypermobility syndrome and the initial condylar position. One hundred 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, skeletal
pattern (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 temporomandibular 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.

urrently, the etiology of temporomandibular

disorders (TMD) is sometimes still difficult to
diagnose. Advances in the knowledge of joint biomechanics, neuromuscular physiology, autoimmune and
muscle-skeletal disorders, and pain mechanisms
have helped with understanding the mechanisms behind
TMD. The etiology of TMD is currently1 thought to be
multifunctional, involving biological, environmental,
social and emotional behaviors, and cognitive factors,
individually or combined, all of which contribute to the
development of signs and symptoms of TMD.
The position of the condyle has always been considered an etiopathogenic factor and has been thoroughly
discussed throughout medical history. However, there
are few studies that suggest there is a correlation between
this etiopathogenic factor and a disorder that could jeopardize the human orthopedic system compared to others,
such as dento-skeletal malocclusion patterns and benign
systemic joint hypermobility.
Does the ideal condylar position in centric relation or
in a relaxed muscle position, which would involve a more
physiological position of the condyle-disc and temporal

Dr. Jos M Barrera Mora obtained his

D.D.S. degree from the Dental School of
the University of Seville in 2002, where he
later gained a Masters degree in orthodontics in 2006 and a Ph.D. degree in
2010. He is currently a professor at the
Dental School of the University of Seville,
where he teaches orthodontics.

RELATIONSHIP OF MALOCCLUSION AND TMD SYMPTOMS

eminence relation, truly exist? After doing a literature

review, it can be concluded that there is no universal concept of the ideal condylar position.2-5 At the same time,
malocclusion patterns seem not only to influence condylar 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 relationship
between patients with Class II and III Angle malocclusion pattern, with an anterior condylar displacement, and
those patients with a horizontal and vertical craniofacial
pattern with an anterior and posterior condylar inclination, respectively. However, in a sample with normal
occlusion, the evaluation of the concentric position of the
condyles in their respective mandibular fossae also
showed a noncentralized position for the right and left
sides.9 In most cases, the neuromusculature places the
mandible in such a position that the highest number of
occlusal contacts is established without taking into
account the final condylar position.
Could malocclusion patterns and benign joint hypermobility syndrome both be risk factors of orthopedic
instability? Despite the contradictory results reported in
the literature, these could theoretically be considered
instability factors. A few existing studies10,11 also analyzed the link between malocclusion, condylar position,
and the presence of TMJ symptoms and signs.
The aim of the current study was to determine the association 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 needed
orthodontic treatment (53 male, 87 female, age range 1550), were selected from the Department of Orthodontics
and Dentofacial Orthopedics of the Dental School of the
University of Seville, from 2005 to 2009. Twenty-two
students from the Dental School (10 male, 12 female, age
range 20-30) were selected as the control group (normal
occlusion with no orthodontic treatment). The following
exclusion criteria were used for subject participation in
the study12: under 15 years of age, malocclusion patients,
history of previous orthodontic treatment, and existence
of rheumatic sickness or degenerative joint disease. In
normal occlusion patients: under 15 years of age, absence
of a bilateral molar and cuspid Angle Class I, bone/tooth
discrepancy exceeding two mm (negative or positive),
anterior or posterior crossbite, overjet greater than two
mm or less than zero mm, overbite greater than four mm
or less than two mm, posterior and anterior rotations

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MORA ET AL.

exceeding 15 and that affected more than two teeth of the

incisor sector, previous history of orthodontic treatment,
and finally, the presence of rheumatic sickness or degenerative joint disease.
Exploration Report
In order to evaluate the malocclusion three-dimensionally, and to assess condylar sliding using the mandibular
position indicator (MPI) (Great Lakes Orthodontics, Ltd.,
Tonawanda, NY), a mounting cast was made into a semiadjustable articulator (SAM 3) (Great Lakes Orthodontics,
Ltd., Tonawanda, NY) with a wax record using Roths
power centric technique13 in all subjects. A cephalometric
study with an orthopedic scanner (Promax, Planmeca,
Finland) was also done to establish skeletal malocclusion and craniofacial structure, according to the Jacobsons
Wits appraisal,14 the Bjork-Jaraback15 criteria (difference
between anterior and posterior facial height), and the
Solano16 retroclusion (difference between anterior and
posterior dental-alveolar height) (Figure 1). The Beighton
score17 was used to establish the degree of joint hypermobility. It is currently used as part of the Brighton diagnostic criteria. To obtain a positive Beighton score, four
or more points out of nine are required. Hypermobility
syndrome was included in the analysis as a categorical
variable with three subdivisions, based on the Grahame18
studies: Zero category, none of the joints had hypermobility; First category, from one to three joints had hypermobility; and Second category, from four to nine joints
had hypermobility.
Considering the evolution of hypermobility with
age,19 a classification dependant on this factor was used
in the study. Subjects of up to 40 years old were included
in the anterior distribution. Forty-year-old patients and
older were distributed in the following categories: Zero
category, none of the joints had hypermobility; First category, one joint had hypermobility; and Second category,
from two to nine joints had hypermobility.
The TMJ examination was done using the temporomandibular pain analysis of Rocabado20,21 (Figure 2), and
two 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 observed
that, to obtain a statistical power of 85% reliability with a
significance level of 0.05, a sample of 80 subjects was
needed. The current study included 162 patients, twice
the required number, for two main reasons: first, to obtain
a similar or larger sample size in comparison to other current studies in the literature for an accurate discussion;

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MORA ET AL.

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

and second, given the number of variables that were studied, to ensure enough reliability and level of significance
to respond to the hypothetical variability that any of the
parameters of the study could exercise. The statistical
power was calculated with the program nQuery Advisor
(Statistical Solutions, Boston, MA).

RELATIONSHIP OF MALOCCLUSION AND TMD SYMPTOMS

The 2 test was used for comparison of two non-numerical variables, such as gender, benign joint hypermobility
syndrome score, positive or negative temporomandibular
pain analysis, Helkimo Index parameters, and dentoskeletal malocclusion three-dimensional parameters. The
Anova test was used to study the possible statistical relationships among MPI values (that dictate the amount and
direction of condylar movement in maximal intercuspation), with the variables that define a malocclusion pattern in the three levels of space at dento-skeletal levels,
degree of hypermobility joint, as well as the joint dysfunction parameters of the TMJ. The Bonferroni and
Welch tests were used to adjust probability.
To test the intraoperative variability of MPI, 15 casts
of 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; and
Delta H ICC=0.520 for p=0.048.
All the results were significant. Therefore, the results
corroborate other studies13,22-24 that consider the use of
a MPI a highly reproducible procedure using different operators.
Results

Figure 2
Rocabados temporomandibular pain analysis: 1. Anteroinferior
synovial; 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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The average age of patients was 22.9. Tables 1-3 show

the frequency and distribution of TMD symptoms, hyperlaxity degree, and different malocclusion patterns.
Figure 3 presents the distribution of the different types of
temporomandibular pain according to Rocabados pain
analysis. The most frequent pain was pain 5 (posteroinferior synovial), right and left (11.1-11.7%), followed by
pain 3 (external collateral ligament) (7.4-8.6%) and pain
6 (synovial posterosuperior) (4.9-3.7%). Tables 4-7
show a statistically significant correlation among MPI
values (dictate the amount and direction of condylar
movement in maximum intercuspation) with variables
that define the malocclusion pattern three-dimensionally
at the dento-skeletal level: skeletal class, sagittal malocclusion; and those that determine the symptomatology of
TMD: pain 5 or synovial posteroinferior, right and left.
Results also revealed an increase in vertical discrepancy
of centric sliding (Delta H) in the skeletal Class I malocclusion pattern compared with the skeletal Class II malocclusion pattern (1.81-0.87 mm; p=0.034). The transverse displacement of both condyles (Delta Y) is greater

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MORA ET AL.

Table 1
Frequency of TMD Symptoms
TMD symptoms
Range of mandibular motion
Normal
30-39 mm opening, 4-6 mm laterality
<30 mm opening and <3 mm laterality

Frequency
139
22
1

85.8
13.6
0.6

112

69.1

46
4

28.4
2.5

Right temporomandibular pain analysis

Negative temporomandibular pain
Positive temporomandibular pain

128
34

79.0
21.0

Left temporomandibular pain analysis

Negative temporomandibular pain
Positive temporomandibular pain

131
31

80.9
19.1

TMJ function impairment

Normal
Joint noises and deviation
on opening or mouth closure
Locking or dislocation of the TMJ

Table 2
Frequency of Benign Joint
Hypermobility Syndrome
Categories
Normal
Category 1
Category 2

Frequency
92
24
46

Percentage (%)
56.8
14.8
28.4

Table 3
Frequency of Malocclusion Patterns
Categories
Frequency
Normal occlusion
22
Class I
38
Class II
54
Class III
15
Open bite
33

Percentage (%)
13.6
23.5
33.3
9.3
20.4

when an anterior crossbite exists compared to when the

overjet is increased, both on the right side (0.40-0.15mm;
p=0.04). The right and left temporomandibular pain more

Percentage (%)

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frequent in our sample (pain 5 or synovial posteroinferior) revealed a statistically significant correlation with
condylar vertical discrepancies (Delta Z) from 0.89 to
0.98 mm; p<0.05. However, no statistically significant
correlation (p>0.05) was found among condylar displacement, degree of hypermobility, malocclusion pattern, and
the Helkimo Index parameters described in this study.
The possible statistical relations among different nonnumerical variables were analyzed, such as gender, joint
hypermobility, Rocabados temporomandibular pain
analysis, Helkimo Index parameters and dento-skeletal
three-dimensional malocclusion parameters.
A statistical significance (p<0.001) was observed
among gender and joint hypermobility. Females had a
higher 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 temporomandibular dysfunction from Helkimo Index,
p=0.043).
Class II Malocclusion pattern and open bite (Table 10)
presented the highest percentage of joint hypermobility
cases, category 2 (p=0.021). Moreover, no significant statistical relationship was found (p>0.05) among joint
hypermobility and the clinical parameters of temporomandibular dysfunction (Helkimo Index parameters, and
Rocabados temporomandibular pain analysis.)
Anterior cross-bite (Table 11) showed a high positive

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RELATIONSHIP OF MALOCCLUSION AND TMD SYMPTOMS

Figure 3
Rocabados temporomandibular
pain analysis distribution in the
sample.

rate in the exploration of the temporomandibular pain

analysis of the right joint (p=0.034).
The parameters of the Helkimo Index selected in the
current study (range of mandibular motion and TMJ
function impairment) revealed a correlation with the positive right and left palpation of temporomandibular pain
analysis, (p=0.007; TMJ function impairment, right and
left TMJ pain analysis; and range of mandibular motion,

Table 4
Vertical Discrepancy Between CR (Centric
Relation) and MI (Maximum Intercuspation)
Delta H and Skeletal Class
Delta H
Skeletal Class I

Avg.
Skeletal Class II

Dif. Avgs.
.9419*

Skeletal Class III

Skeletal Class I

.5225
-.9419*

Skeletal Class III

Skeletal Class I

-.4195
-.5225

Skeletal Class II
*Difference is the significant average level
of 0.05 (p=0.034)

.4195

1.81
Skeletal Class II
0.87
Skeletal Class III
1.29

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right and left TMJ pain analysis, p=0.035, p=0.015 )

(Tables 12 and 13).
The variables dictating the condylar position (MPI
data), according to the Pearson coefficient, revealed a
directly proportional correlation of 0.5 between right and
left Delta Z (vertical displacement of both condyles), and
0.3 between right and left Delta X (sagittal displacement
of both condyles), both statistically significant, p<0.001.

Table 5
Condylar Transverse Discrepancy (Delta Y) and
Sagittal Malocclusion
Delta Y
Normal overjet

Avg.
0.26

Anterior crossbite
Increased overjet
Anterior crossbite 0.40 Normal overjet
Increased overjet
Increased overjet 0.15 Normal overjet
Anterior crossbite
*Difference is the significant average level
of 0.05 (p=0.04)

Dif. Avgs.
-.1402
.2417
-.1402
-.3820*
-.2417
-.3820*

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RELATIONSHIP OF MALOCCLUSION AND TMD SYMPTOMS

Table 6
Right Posteroinferior Synovial Pain (5)
Condylar Vertical Discrepancy
(Right and Left Delta Z)
Delta Z Right
Pain -

N
143

Average
0.37

ANOVA p<0.05
0.032

Pain +
Delta Z Left
Pain -

19

0.92

N
143

Average
0.26

19

0.90

ANOVA p<0.05
0.014

Pain +

Table 7
Left Posteroinferior Synovial Pain (5)
Condylar Vertical Discrepancy
(Right and Left Delta Z)
Delta Z Right
Pain -

N
144

Average
0.37

Pain +

18

0.98

N
144

Average
0.26

18

0.89

ANOVA p<0.05
0.019

Delta Z Left
Pain -

ANOVA p<.0.05
0.020

Pain +

MORA ET AL.

Table 9
Gender - TMJ Function Impairment
Gender
Female

0
62

Category
1
2
33
4

2 test p<0.05

0.043
Male
50
13
0
Category 0: Smooth regular motion w/o noises in the TMJ;
mandibular deviation less than 2 mm during mouth opening or closing.
Category 1: Noises in one or both TMJs or mandibular
deviation equal to or greater than 2 mm during mouth
opening or closing.
Category 2: Locking or dislocation of the TMJ.

Table 10
Malocclusion Pattern - Hyperlaxity Degree
Malocclusion
Category
pattern
0
1
2
2 test p<0.05
Normal occlusion
5
7
10
0.021
Class I
26
4
8
Class II
33
7
14
Class III
12
1
2
Open bite
16
5
12
Category 0: Smooth regular motion w/o noises in the TMJ;
mandibular deviation less than 2 mm during mouth opening or closing.
Category 1: Noises in one or both TMJs or mandibular
deviation equal to or greater than 2 mm during mouth
opening or closing.
Category 2: Locking or dislocation of the TMJ.

Table 8
Gender - Hyperlaxity Degree
Gender
Female

0
44

Category
1
2
17
38

2 test p<0.05
0.001

Male
48
7
8
Category 0: Smooth regular motion w/o noises in the TMJ;
mandibular deviation less than 2 mm during mouth opening or closing.
Category 1: Noises in one or both TMJs or mandibular
deviation equal to or greater than 2 mm during mouth
opening or closing.
Category 2: Locking or dislocation of the TMJ.

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Table 11
Sagittal Malocclusion Pattern
Right Temporomandibular Pain Analysis
Sagittal M.
Normal
Anterior crossbite

Right pain
+
70
13
12
20

Overjet

38

2 test p<0.05
0.034

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Table 12
TMJ Function Impairment
Right/Left Temporomandibular Pain Analysis
TMJ function Right pain Left pain
Category
2 test p<0.05
+
+
0
96
16
98 14
right/left
1
29
17
30 16
0.007/0.007
2
3
1
3
1
Category 0: Opening 40 mm and laterality >0=7 mm
Category 1: Opening 30-39 mm and laterality 4-6 mm
Category 2: Opening <30 mm and laterality <3 mm

Table 13
Range of Mandibular Motion
Right/Left Temporomandibular Pain Analysis
Range of
mand.
Right pain Left pain
Category
+
+
2 test p<0.05
0
114 25
117 22
right/left
1
13
9
13 9
0.035/0.015
2
1
0
1 0
Category 0: Opening 40 mm and laterality >0=7 mm
Category 1: Opening 30-39 mm and laterality 4-6 mm
Category 2: Opening <30 mm and laterality <3 mm

Discussion
Over a century ago,25 a relationship between temporomandibular disorders, such as internal derangement and
osteoarthritis, and benign generalized articular hypermobility was suggested. Theoretically, ligamentous hyperlaxity causes the joint to overload, producing degenerative
changes that could lead to internal derangements and/or
inflammation.26 Up to the present, numerous studies27-38
have been conducted that obtained contradictory results.
Some studies have found an association between TMD
and benign generalized articular hypermobility, whereas
the current study and others did not. 30,34-37 Disparity38
could be due to the differing exclusion and inclusion criteria for the subject sample, the number of subjects of the
samples, and the number of joints rated.
Hirsch 39 used the Beighton criteria to classify the
benign hyperlaxity syndrome, and the Dworkin40 criteria
for examining the TMJ, demonstrating that subjects who
suffer from generalized joint hypermobility had a greater
risk of suffering nonpainful clicks and lesser of mouth

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opening limitation. These patients, however, did not have

a greater risk of TMJ pain, either as myalgia or arthralgia,
although the cross-sectional study did not take into
account that widespread joint pain increases with age,
while generalized joint mobility decreases with age.
The sample included for the current study had a gender
dimorphism, as have other existing studies,41-45 on the
degree of systemic benign hypermobility. Females have a
higher percentage of hypermobilitya score of four or
more joints (23.46% versus 4.94%).
No prior attempt has been made to investigate the link
between benign joint hypermobility syndrome and the
malocclusion pattern. Open bite and Class II malocclusion pattern, with dental and skeletal parameters, have a
statistically significant relationship (p=0.021), with a category degree two, according to the modified Beighton
and Horan index.
Dental occlusion has been ascribed an important etiological role,46 but has now been given lessened importance as a contributory factor to TMD 47,48; however,
certain malocclusion patterns, in post-mortem and
epidemiological46-55 studies, have occasionally demonstrated the role of occlusal factors (in the case of dental
malocclusion) as a risk indicator in developing TMD.
These would be according to an Angle Class II malocclusion pattern with increased overjet, Angle Class III malocclusion pattern, as well as open and crossbites. This
association is due to the less stable occlusion found in
these types of malocclusion.50-53 However, several studies
have found no clear association.54-56,59-61 Similarly, the
current literature does not show much progress in various
occlusal aspects.
Motegi and Cols62 present a very similar distribution
between genders, unlike that found in other samples.
Patients with increased crowding and overjet displayed a
high percentage of disorders, while anterior crossbites,
open bites, overbites, and posterior crossbites had fewer
or no symptoms, although increasing slightly with age.
Hwang, Sung and Kim,57 using cephalometric records
and measurements, determined that patients with hyperdivergent facial profiles, retroinclined maxillary incisors,
and very inclined occlusal planes revealed TMD signs.
John, et al.,58 concluded that wide ranges of overjet and
overbite were consistent with the normal functioning of
masticatory muscles and the TMJ.
Egermark, Magnusson and Carlsson63 reported that a
lateral discrepancy between maximal intercuspation and
centric relation, such as a unilateral crossbite, might be a
risk factor that should be taken into account in some
patients.
Selaimen, et al.,64 also stated in their investigations that
some occlusal factors, such as malocclusion Class II, and

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the lack of canine guidance on lateral exclusions can be

considered as risk indicators of TMD.
Gidarakou, et al.,65 compared a sample of symptomatic
and asymptomatic females to identify skeletal and dental
factors between the groups. Magnetic resonance images
(MRI) were performed to verify that there was no disc
displacement. Their results showed no significant difference except for the lower incisors being more retruded in
asymptomatic patients.
The results of the current investigation classify anterior
crossbite, pathognomonic sign of Class III malocclusion
pattern, as a risk factor. The examination of painful sites
in 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 proportion, showed a greater percentage of positives in the
right joint. The current studys results revealed that these
patients had a larger transversal condylar shift to the right
joint (Delta Y), although this displacement was not statistically correlated with joint discomfort.
Several studies 66-68 reported that posterior condyle
positioning could lead to disc alterations (anterior displacement). Incesu, et al.,69 pointed out an existing relationship between the posterior positioning of the condyle
and anterior disc displacement, but did not find any statistical significance in terms of disc morphology.
Williams70 used lateral tomograms to analyze condylar
position, before and after TMJ treatment in 40 dysfunctional patients. It was found that 32% of patients displayed no concentric condylar position. Moreover, once
the TMJ treatment was completed using splints, orthodontics or both, and the patient was stable, no statistical
change was found in the condylar position.
Ren,71 however, concluded that the condyle positions
of the TMJ with normal disc positions are distributed randomly and can include anterior, central and posterior
positions, although a posterior condyle position was more
prevalent in joints with anterior disc displacement. A posterior condyle position cannot be interpreted as a diagnostic sign for internal derangements of the TMJ when
anterior or centered condyle positions are also often seen
in patients with internal derangements. More recently,
others have stated that this relationship is not present in
all cases.3,72
Statistical studies73 have highlighted a relationship
between TMD symptoms and centric slide. Lotzmann74
suggested that slides under 0.5 mm might involve more
or less discomfort in the patients head or face. Furthermore, the results of the current investigation agree with
the other studies that also showed how discrepancies of
less than 1.0 mm in the vertical plane might lead to TMJ
symptoms. These findings contradict current studies that

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state that TMD develops when centric displacement of

the condyle is greater than 1.0 mm in the vertical and
sagittal planes.75,76
Temporomandibular disorders have been clinically
described as a combination of signs and symptoms,
in indexes or classifications (Helkimo Index55), Craniomandibular Index (Fricton and Shiffman 77 ; Fricton
and Shiffman 78) and Temporomandibular Joint Scale
(Levitt79). Generally speaking, a diagnosis should be a
brief and useful way to define the clinical conditions.
Although many systems have been suggested to diagnose
the TMJ (Eversole and Machado80; Talley81), currently
only two studies are widely used: the Clinical Guidelines
of the American Academy of Orofacial Pain (Okeson82),
and the Research Diagnostic Criteria for Temporomandibular Disorders (Dworkin and LeResche40). Both
analyses have areas that overlap and are in agreement.
John83 evaluated the high reliability of the last analysis
(statistical significant coefficient of intraclass correlation) in a large study conducted in 10 international
clinical centers, with 30 professionals and including
230 patients. A current investigation, carried out by
Schmitter,84 concluded that this classification method for
TMD has some minor variables, such as palpation of the
opening and closing muscles of the TMJ, as they do not
provide much information for TMD diagnosis.
Based on previous studies, the current authors established an examination form that included most of the
described factors, as well as an unusual palpation method
that excluded the masticatory muscles (due to the low significance), known as the Temporomandibular Pain
Analysis described by Rocabado.21 It was also included
as a part of the Clinical Helkimo Index, already in full use
in the earlier pilot study85 of this project, excluded in this
new research were items that have not previously reported
any information. A significant correlation was observed
between the right and left pain analysis within the selected
parameters of the Helkimo Index: p=0.007; right and left
pain analysis, TMJ function impairment (Table 12), and
p=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 the
TMJ are consistent with each other.
The authors in the current study concluded that there is
no well-defined initial condylar position that is statistically significant, neither for normal occlusion nor for the
different malocclusion patterns. There is no statistically
significant relationship between benign joint hypermobility syndrome and the amount of condylar displacement or
TMD, but such a relationship does exist with malocclusion patterns, especially, malocclusion Class II and open
bite. Finally, anterior crossbite could be a risk factor in

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MORA ET AL.

developing TMJ symptoms, and patients with vertical

condylar displacements from 0.88 to 0.97 mm developed,
significantly, left and right posteroinferior synovial pain
(pain 5).

RELATIONSHIP OF MALOCCLUSION AND TMD SYMPTOMS

28.
29.

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Dr. Eduardo Espinar Escalona received his M.D. degree in 1983 and
his D.D.S degree from the Dental School of the University of Seville in
1987, where he later received a Masters degree in orthodontics and a
Ph.D. degree in 2006. He is currently an assistant professor of the
Department of Orthodontic Dentistry School Dentistry University of
Seville, Spain.
Dr. Camilo Abalos Labruzzi received his M.D. degree in 1982 at the
Seville School of Medicine, his D.D.S. degree in 1995 and his Ph.D. in
dentistry at the Seville School of Dentistry, Seville University, Spain in
1995. He is currently an assistant professor of the Departament of
Conservative Dentistry, School of Dentistry, Seville University, Spain.
Dr Jose Ma Llamas Carrera holds Ph.D., M.D. and D.D.S. degrees. He
works as an orthodontist in Seville, Spain, where he is a part-time professor at the Seville University. He is an active member in the Angle Society
of Europe and of the European Board in Orthodontics.
Dr. Emilio Jimenez-Castellanos Ballesteros received his M.D. degree
in 1983 and his Ph.D. in stomatology at the Seville Stomatology School
University Spain in 1983. He is currently a professor of prosthetic
dentistry in the Stomatology Department, School of Dentistry, Seville
University Spain.
Dr. Enrique Solano Reina received his M.D. degree in 1978 at the
Seville School of Medicine, his D.D.S. degree in 1980 and his Ph.D. in
dentistry 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 Chairman of the Postgraduate
Orthodontics Training Program of the Faculty of Dentistry of Seville
University.
Dr. Mariano Rocabado received his D.P.T degree in 1966 at the
University of Chile, his Ph.D. degree in Physical Therapy at the
University of Saint Agustine, Florida, U.S.A. in 2003. He has been a full
professor at the University of Chile and an adjunct professor at the
University 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. He
teaches 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 Msculo Esquelticas).

APRIL 2012, VOL. 30, NO. 2