Vol. 114 No.

4 October 2012

Occlusal risk factors associated with temporomandibular disorders

in young adults with normal occlusions
Chen Wang, PhD, and Xinmin Yin, MD, Nanjing, China
NANJING MEDICAL UNIVERSITY

Objective. The aim of this study was to characterize occlusal stability in young adults with temporomandibular disorder
(TMD).
Study Design. Thirty-one patients (aged 19-31 years) with complete natural dentition and Angle class I occlusion who
exhibited TMD were compared with 31 age- and sex-matched healthy control subjects. The occlusal registrations were
performed using the T-Scan II occlusal imaging and analysis system. Center of occlusal force, asymmetry index of occlusal
force, maximal movement of COF, premature contacts, clusion time, and disclusion time were recorded.
Results. Compared with control subjects, TMD subjects had a significantly higher frequency of premature contacts (16/32,
50.0%) and greater bilateral asymmetry in the occlusal force. Furthermore, prolonged clusion time and disclusion time also
were observed in TMD subjects.
Conclusions. These results suggest that a significant association exists between occlusal stability and TMD in young adults.
(Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:419-423)

Temporomandibular disorder (TMD) is one of the most
common diseases of the craniofacial region and is char-
acterized by functional disturbances of the masticatory
system, which leads to pain and dysfunction in the
temporomandibular joint, masticatory muscles, and as-
sociated structures.1 The etiology of TMD has received
a great deal of attention in recent years. Thilander et al.2
investigated the prevalence of temporomandibular dys-
function and its association with malocclusion in chil-
dren and adolescents; their results suggested that TMD
was associated with posterior crossbite, anterior open
bite, Angle class III malocclusion, and extreme maxil-
lary overjet. Marklund et al.3,4 also implied that cross-
bite and asymmetry of occlusal contacts increased the
incidence and duration of TMD. Some articles reported
that oral parafunctions, such as bruxism, might play a
role in the development of TMD.5-15 Moreover, psy-
chologic status has been suggested to be involved in the
presence of TMD.16,17 There is now a general consen-
sus that the pathogenesis of TMD is multifactorial, and
it is accepted that the condition should be compre-
hended in a biopsychosocial context.18
Occlusion has been investigated as a causative factor
in TMD.2-4,19 Indeed, although occlusion as a whole is
commonly considered to be a major risk factor for
TMD, there is limited understanding of the causal re-
Institute of Stomatology, Nanjing Medical University and Depart-
ment of Prosthodontics, Stomatologic Hospital affiliated to Nanjing
Medical University, Nanjing, China.
Received for publication Mar 29, 2011; returned for revision Oct 20,
2011; accepted for publication Oct 31, 2011.
© 2012 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
doi:10.1016/j.oooo.2011.10.039
lationship between the occurrence of TMD symptoms
and occlusion and of the possible role of different
aspects of occlusion in the etiology of TMD.
Dental occlusion determines the motion pattern and
position of the mandible. Occlusal instability may be a
reason for the overload of the masticatory system and
might also lead to temporomandibular joint (TMJ)
damage. An exhaustive investigation of factors affect-
ing occlusal stability will enable us to better compre-
hend their association with TMD; with this knowledge,
effective strategies can be developed for prevention and
treatment of TMD, such as orthodontics, occlusal ad-
justments, and occlusal reconstructions. However, to
our knowledge, few studies have examined the relation-
ship between occlusal instability and TMD,4,19-21 and
their results are both controversial and inconclusive.
Furthermore, the issue is complicated by difficulties in
diagnosing dynamic occlusal features over the entire
range of mandibular movement, as well as by a lack of
clear distinction between instrumentally detected oc-
clusal contact and premature contact.
Therefore, in the present study, we used a quantita-
tive occlusal imaging and analysis system to investigate
occlusal stability in young adults with natural complete
Statement of Clinical Relevance
Our findings provide evidence that occlusal insta-
bility is involved in the pathogenesis of temporo-
mandibular disorder (TMD); with this knowledge,
effective strategies can be developed for prevention
and treatment of TMD, such as orthodontics, occlu-
sal adjustments, and occlusal reconstructions.

419
ORAL AND MAXILLOFACIAL SURGERY
420 Wang and Yin
dentition and Angle class I occlusion exhibiting signs
or symptoms of TMD, and explored whether any dif-
ference exists in healthy subjects.
MATERIALS AND METHODS
Subjects
The study was approved by the Ethics Committee at
Nanjing Medical University, and each of the partici-
pants gave his or her informed consent.
Thirty-one subjects (15 women and 16 men, ages 19-31
years) were selected from patients in our TMD Clinic. The
following inclusion criteria were used: presence of ⱖ2 of
TMJ sounds (clicking or crepitation) with gentle digital
palpation, pain to palpation of the TMJ or of the masti-
catory muscles and painful limitations of mandibular
movements, deviation and deflection along the opening
path of the mandible, and limited maximum mouth open-
ing (maximum unassisted opening without pain ⱖ3
mm)22; complete natural dentition except for the third
molars; normal overbite, overjet and Angle class I occlu-
sal relation; no periodontal disease; teeth without restora-
tions; good compliance with oral hygiene; no history or
clinical evidence of tooth grinding, orthodontic, or TMD
therapy; and no neurologic disturbances.
Control subjects (age and sex matched) were ran-
domly selected from healthy undergraduate dental stu-
dents at the College of Stomatology, Nanjing Medical
University. Control subjects met the same inclusion
criteria of the TMD group, except for the presence of
signs and symptoms of TMD.
Examination procedure
The T-Scan II occlusal imaging and analysis system (Tek-
scan, Boston, MA) was used to record the subjects’ oc-
clusion. Briefly, before the examination, the subjects were
instructed to practice 3 mandibular movements—swallow
and then occlude into the maximum intercuspal position
(MIP), and laterotrusive and protrusive mandibular excur-
sions (a habitual gliding mandibular movement from the
MIP to the maximal anterior or lateral position)— until
they could reliably perform those movements. The sub-
jects were seated upright in a dental chair with the Frank-
furt plane parallel to the floor. The appropriate sensor was
placed on the mandible occlusal surface. The subject was
asked to close into maximum intercuspation and perform
the laterotrusive and protrusive mandibular excursions as
described previously. Each movement was repeated 3
times and monitored by the operator. A new sensor was
used for each subject. The same dentist made recordings
for all subjects.
Data collection and statistical analysis
The center of occlusal force (COF) is indicated as a
point in the T-Scan II system. In the study, the location
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October 2012
Fig. 1. COF in MIP and MMCOF during occluding into MIP.
In TMD group, COF and MMCOF were significantly longer
than in controls (*P ⬍ .01).
of COF is defined as the distance from the point to the
center line of the dental arch. Asymmetry index of
occlusal force (AOF) implies the difference of occlusal
force between right and left sides, and it was calculated
as follows:
AOF (%) ⫽ occlusal force of left side ⫺
occlusal force of right side/total occlusal force ⫻ 100%
COF and AOF were examined in MIP. Maximal
movement of COF (MMCOF) describes the maximum
distance between 2 COF. MMCOF, premature contacts,
and clusion time were detected during occluding into
MIP. Disclusion time (DT) in laterotrusive and protru-
sive mandibular excursions were also recorded. Both
clusion time and DT were evaluated according to timed
occlusion. Clusion time is the time from the beginning
of bite to the MIP. DT is the time from the MIP to the
disclusion in laterotrusive and protrusive mandibular
excursions. A different, blinded operator examined all
occlusal records.
Premature contacts were analyzed using the ␹2 test;
Student t test was used for all other comparisons. Re-
sults were considered to be significant at the 5% critical
level (P ⬍ .05). All statistical analysis was carried out
using SPSS 11.0 software package (Chicago, USA).
RESULTS
In TMD subjects, COF and MMCOF were 4.39 ⫾ 0.15
mm and 6.86 ⫾ 0.10 mm, respectively. These values
were longer than those of the control subjects, and there
were statistically significant differences between the 2
groups, as shown in Figure 1 (P ⬍ .01).
Perfect symmetry (bilateral difference equal to 0) in
relation to occlusal force in MIP was not found in any
subjects with TMD, but was found in 3 control subjects
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Volume 114, Number 4
Fig. 2. AOF in MIP. In the TMD group, AOF was 16.66%
and significantly larger than in controls (*P ⬍ .05).
(9.4%). In the TMD group, AOF was 16.66 ⫾ 0.47%
and significantly larger than in control subjects (P ⬍
.05; Figure 2).
The clusion time was 2.05 ⫾ 0.06 seconds in sub-
jects with TMD and 0.69 ⫾ 0.03 seconds in control
subjects (P ⬍ .01). Furthermore, the protrusive disclu-
sion time was 1.96 ⫾ 0.05 seconds in the TMD group
and 0.72 ⫾ 0.02 seconds in the control group (P ⬍ .01).
The corresponding values on the right side were 1.84 ⫾
0.05 seconds in TMD subjects and 0.68 ⫾ 0.02 seconds
in control subjects (P ⬍ .01), and on the left side they
were 1.68 ⫾ 0.04 seconds and 0.92 ⫾ 0.03 seconds,
respectively (P ⬍ .01). Both the clusion time and
disclusion time were significantly longer in subjects
with TMD than in control subjects (Figure 3).
Premature contacts appeared in both groups, and its
frequency was dominant in TMD subjects; there were
statistically significant differences between the 2 groups,
as presented in Table I (P ⬍ .05).
DISCUSSION
The relationship between occlusal stability and TMD is
not well defined. The objective of the present study was
to examine the factors affecting the occlusal stability of
subjects with TMD and of healthy young adults with
complete natural dentition and normal occlusion.
Existing reports of occlusion in TMD subjects vary
widely.2-4 The disparity of results may be attributed in
large part to the different materials and methods used to
record occlusion. Furthermore, inhomogeneity in pop-
ulation samples and diversity among data collection
procedures may be additional reasons for the different
conclusions reached by various investigators. In the
present study, we used the T-Scan system to analyze
occlusal stability. Unlike numerous qualitative meth-
ods, which may be affected by saliva, the T-Scan sys-
tem showed acceptable pressure sensitivity, precision,
ORIGINAL ARTICLE
Wang and Yin 421
Fig. 3. Clusion time during occluding into MIP and disclu-
sion time in laterotrusive and protrusive mandibular excur-
sions. Both the clusion time and disclusion time were signif-
icantly longer in TMD than in controls (*P ⬍ .01). PDT:
disclusion time in protrusive mandibular excursion, LLDT:
disclusion time in left laterotrusive mandibular excursion,
RLDT: disclusion time in right laterotrusive mandibular ex-
cursion.
Table I. Frequency of premature contact while occlud-
ing into MIP
TMD subjects Control subjects
(n ⫽ 32) (n ⫽ 32) P value
Premature contact 16 7 .019*
Nonpremature 16 25
contact
*Statistically significant.
and stability of force recordings for repeated loading in
the oral environment.23-26 Moreover, the T-Scan sys-
tem can record timed occlusal contacts quantitatively
and dynamically during a continuous mandibular
movement, which is very important for the estimation
of occlusal stability. In our investigation, the population
sample was homogeneous and the experimental condi-
tions were strictly defined and carefully checked. There
were strict admission criteria, and a single operator and
assayer were used to minimize experimental variables.
The relative position of the center of occlusal force
could imply the occlusal balance status. It is mainly
determined by the dentition occlusion and may also be
affected by the function of masticatory muscles. Mizui
et al.27 used the T-Scan system to evaluate the distri-
bution of force; they found that 60 normal subjects
exhibited bilateral balance and an anteroposterior cen-
ter of force in the first molar region. However, subjects
with craniomandibular disorders showed significant
differences from the control group. In the present study,
COF was 1.77 mm in the control group. COF that was
located at the exact center line of the dental arch oc-
curred only in 21.9% of control subjects, which sug-
ORAL AND MAXILLOFACIAL SURGERY
422 Wang and Yin
gests that there is a minor variance in COF even for a
healthy population. Nevertheless, significant deviation
of COF and MMCOF were present in the TMD group
and were longer than those of control subjects, suggest-
ing a deterioration in occlusal stability in subjects with
TMD.
Maximum voluntary biting force has been used as an
indicator of the health of the dentition, masticatory
muscles, and the temporomandibular joint.28 However,
this force varied widely among the population; there-
fore, we used AOF as another parameter to reflect
occlusal balance. In the present study, although AOF
was quite common in both TMD and healthy subjects,
it was greater in TMD subjects. Yamada et al.29 inves-
tigated the distribution of occlusal force in 45 female
orthodontic patients with and without TMD. They
found that the AOF was smaller in the TMD-free group
than in the TMD group; their conclusions were thus in
agreement with ours. There are reciprocal correlations
between the activity of masticatory muscles and man-
dibular movement, and when AOF is large enough,
asymmetries in the activity of masticatory muscles may
result in abnormal mandibular movement, thus induc-
ing the occurrence of TMD.
In this study, the incidence of premature contacts
was higher and clusion time was significantly longer in
TMD than in control subjects. Premature contacts can
result in condyle displacement, which may potentially
cause friction and increased intra-articular pressure on
the TMJ. Both situations are harmful to the TMJ and
contribute to alteration of the structure of the TMJ. If
the capacity of a subject to adapt to the situation is
exceeded, TMJ and disorders of the masticatory mus-
cles may occur. To reduce the incidence of premature
contacts, reflex contraction of masticatory muscles can
occur; this is responsible for altered mandibular posi-
tion and the prolongation of clusion time.
Disclusion might be preferable in the natural denti-
tion and significant to avoid occlusal interference.
Therefore, to a certain extent, disclusion could be a
reference for the general status of occlusal health. In the
present study, timed occlusal contacts and occlusal
force were quantitatively recorded and DT was pre-
cisely calculated with the T-Scan II system.24,26,30 Re-
sults disclosed that both laterotrusive and protrusive
disclusion time were significantly longer in TMD than
in control subjects.
Michelotti et al.31 confirmed that there is an associ-
ation between tooth grinding and disk displacement.
Prolonged disclusion time can lead to higher electro-
myographic activity of masticatory muscles, and the
abnormal distribution of stresses in the disk that result
from masticatory muscles can facilitate the occurrence
of TMD symptoms. Clinicians should therefore pay
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October 2012
more attention to detecting and correcting situations
where damage is being caused to components of the
masticatory system by excessive functional or para-
functional occlusal forces.
Long-term controlled clinical trials involving longi-
tudinal study of patients, clinical evaluations of func-
tion and the symptoms of TMJ, and larger cohorts
would all contribute to a deeper understanding of the
relationship between occlusal stability and TMD.
CONCLUSION
In this study, the occlusal stability of subjects with
TMD was assessed and compared with that of healthy
subjects with the T-Scan II system. Within the limita-
tions of the study, a significant association between
occlusal stability and TMD was found in young adults
with complete natural dentitions and Angle class I
normal occlusion. The possible reciprocal etiopathoge-
netic role of occlusion and TMD should be further
investigated.
The authors thank the voluntary participation of the 31
undergraduate dental students from the College of Stoma-
tology, Nanjing Medical University.
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Reprint requests:
Xinmin Yin
Institute of Stomatology
Nanjing Medical University and
Department of Prosthodontics
Stomatological Hospital affiliated to
Nanjing Medical University
140, Han-zhong Road
Nanjing 210029
P. R. China.
chwang9122@sina.com