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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

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

420 Wang and Yin October 2012

dentition and Angle class I occlusion exhibiting signs

or symptoms of TMD, and explored whether any dif-
ference exists in healthy 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 Fig. 1. COF in MIP and MMCOF during occluding into MIP.
movements, deviation and deflection along the opening In TMD group, COF and MMCOF were significantly longer
path of the mandible, and limited maximum mouth open- than in controls (*P ⬍ .01).
ing (maximum unassisted opening without pain ⱖ3
mm)22; complete natural dentition except for the third
of COF is defined as the distance from the point to the
molars; normal overbite, overjet and Angle class I occlu-
center line of the dental arch. Asymmetry index of
sal relation; no periodontal disease; teeth without restora-
occlusal force (AOF) implies the difference of occlusal
tions; good compliance with oral hygiene; no history or
force between right and left sides, and it was calculated
clinical evidence of tooth grinding, orthodontic, or TMD
as follows:
therapy; and no neurologic disturbances.
Control subjects (age and sex matched) were ran- AOF (%) ⫽ occlusal force of left side ⫺
domly selected from healthy undergraduate dental stu-
dents at the College of Stomatology, Nanjing Medical occlusal force of right side/total occlusal force ⫻ 100%
University. Control subjects met the same inclusion COF and AOF were examined in MIP. Maximal
criteria of the TMD group, except for the presence of movement of COF (MMCOF) describes the maximum
signs and symptoms of TMD. distance between 2 COF. MMCOF, premature contacts,
and clusion time were detected during occluding into
Examination procedure MIP. Disclusion time (DT) in laterotrusive and protru-
The T-Scan II occlusal imaging and analysis system (Tek- sive mandibular excursions were also recorded. Both
scan, Boston, MA) was used to record the subjects’ oc- clusion time and DT were evaluated according to timed
clusion. Briefly, before the examination, the subjects were occlusion. Clusion time is the time from the beginning
instructed to practice 3 mandibular movements—swallow of bite to the MIP. DT is the time from the MIP to the
and then occlude into the maximum intercuspal position disclusion in laterotrusive and protrusive mandibular
(MIP), and laterotrusive and protrusive mandibular excur- excursions. A different, blinded operator examined all
sions (a habitual gliding mandibular movement from the occlusal records.
MIP to the maximal anterior or lateral position)— until Premature contacts were analyzed using the ␹2 test;
they could reliably perform those movements. The sub- Student t test was used for all other comparisons. Re-
jects were seated upright in a dental chair with the Frank- sults were considered to be significant at the 5% critical
furt plane parallel to the floor. The appropriate sensor was level (P ⬍ .05). All statistical analysis was carried out
placed on the mandible occlusal surface. The subject was using SPSS 11.0 software package (Chicago, USA).
asked to close into maximum intercuspation and perform
the laterotrusive and protrusive mandibular excursions as RESULTS
described previously. Each movement was repeated 3 In TMD subjects, COF and MMCOF were 4.39 ⫾ 0.15
times and monitored by the operator. A new sensor was mm and 6.86 ⫾ 0.10 mm, respectively. These values
used for each subject. The same dentist made recordings were longer than those of the control subjects, and there
for all subjects. were statistically significant differences between the 2
groups, as shown in Figure 1 (P ⬍ .01).
Data collection and statistical analysis Perfect symmetry (bilateral difference equal to 0) in
The center of occlusal force (COF) is indicated as a relation to occlusal force in MIP was not found in any
point in the T-Scan II system. In the study, the location subjects with TMD, but was found in 3 control subjects
Volume 114, Number 4 Wang and Yin 421

Fig. 3. Clusion time during occluding into MIP and disclu-

Fig. 2. AOF in MIP. In the TMD group, AOF was 16.66% sion time in laterotrusive and protrusive mandibular excur-
and significantly larger than in controls (*P ⬍ .05). 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:
(9.4%). In the TMD group, AOF was 16.66 ⫾ 0.47% disclusion time in left laterotrusive mandibular excursion,
and significantly larger than in control subjects (P ⬍ RLDT: disclusion time in right laterotrusive mandibular ex-
.05; Figure 2). cursion.
The clusion time was 2.05 ⫾ 0.06 seconds in sub-
jects with TMD and 0.69 ⫾ 0.03 seconds in control Table I. Frequency of premature contact while occlud-
subjects (P ⬍ .01). Furthermore, the protrusive disclu- ing into MIP
sion time was 1.96 ⫾ 0.05 seconds in the TMD group TMD subjects Control subjects
and 0.72 ⫾ 0.02 seconds in the control group (P ⬍ .01). (n ⫽ 32) (n ⫽ 32) P value
The corresponding values on the right side were 1.84 ⫾ Premature contact 16 7 .019*
0.05 seconds in TMD subjects and 0.68 ⫾ 0.02 seconds Nonpremature 16 25
in control subjects (P ⬍ .01), and on the left side they contact
were 1.68 ⫾ 0.04 seconds and 0.92 ⫾ 0.03 seconds, *Statistically significant.
respectively (P ⬍ .01). Both the clusion time and
disclusion time were significantly longer in subjects
with TMD than in control subjects (Figure 3). and stability of force recordings for repeated loading in
Premature contacts appeared in both groups, and its the oral environment.23-26 Moreover, the T-Scan sys-
frequency was dominant in TMD subjects; there were tem can record timed occlusal contacts quantitatively
statistically significant differences between the 2 groups, and dynamically during a continuous mandibular
as presented in Table I (P ⬍ .05). movement, which is very important for the estimation
of occlusal stability. In our investigation, the population
DISCUSSION sample was homogeneous and the experimental condi-
The relationship between occlusal stability and TMD is tions were strictly defined and carefully checked. There
not well defined. The objective of the present study was were strict admission criteria, and a single operator and
to examine the factors affecting the occlusal stability of assayer were used to minimize experimental variables.
subjects with TMD and of healthy young adults with The relative position of the center of occlusal force
complete natural dentition and normal occlusion. could imply the occlusal balance status. It is mainly
Existing reports of occlusion in TMD subjects vary determined by the dentition occlusion and may also be
widely.2-4 The disparity of results may be attributed in affected by the function of masticatory muscles. Mizui
large part to the different materials and methods used to et al.27 used the T-Scan system to evaluate the distri-
record occlusion. Furthermore, inhomogeneity in pop- bution of force; they found that 60 normal subjects
ulation samples and diversity among data collection exhibited bilateral balance and an anteroposterior cen-
procedures may be additional reasons for the different ter of force in the first molar region. However, subjects
conclusions reached by various investigators. In the with craniomandibular disorders showed significant
present study, we used the T-Scan system to analyze differences from the control group. In the present study,
occlusal stability. Unlike numerous qualitative meth- COF was 1.77 mm in the control group. COF that was
ods, which may be affected by saliva, the T-Scan sys- located at the exact center line of the dental arch oc-
tem showed acceptable pressure sensitivity, precision, curred only in 21.9% of control subjects, which sug-
422 Wang and Yin October 2012

gests that there is a minor variance in COF even for a more attention to detecting and correcting situations
healthy population. Nevertheless, significant deviation where damage is being caused to components of the
of COF and MMCOF were present in the TMD group masticatory system by excessive functional or para-
and were longer than those of control subjects, suggest- functional occlusal forces.
ing a deterioration in occlusal stability in subjects with Long-term controlled clinical trials involving longi-
TMD. tudinal study of patients, clinical evaluations of func-
Maximum voluntary biting force has been used as an tion and the symptoms of TMJ, and larger cohorts
indicator of the health of the dentition, masticatory would all contribute to a deeper understanding of the
muscles, and the temporomandibular joint.28 However, relationship between occlusal stability and TMD.
this force varied widely among the population; there-
fore, we used AOF as another parameter to reflect CONCLUSION
occlusal balance. In the present study, although AOF In this study, the occlusal stability of subjects with
was quite common in both TMD and healthy subjects, TMD was assessed and compared with that of healthy
it was greater in TMD subjects. Yamada et al.29 inves- subjects with the T-Scan II system. Within the limita-
tigated the distribution of occlusal force in 45 female tions of the study, a significant association between
orthodontic patients with and without TMD. They occlusal stability and TMD was found in young adults
found that the AOF was smaller in the TMD-free group with complete natural dentitions and Angle class I
than in the TMD group; their conclusions were thus in normal occlusion. The possible reciprocal etiopathoge-
agreement with ours. There are reciprocal correlations netic role of occlusion and TMD should be further
between the activity of masticatory muscles and man- investigated.
dibular movement, and when AOF is large enough,
asymmetries in the activity of masticatory muscles may The authors thank the voluntary participation of the 31
result in abnormal mandibular movement, thus induc- undergraduate dental students from the College of Stoma-
ing the occurrence of TMD. tology, Nanjing Medical University.
In this study, the incidence of premature contacts
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