Dental Press Jounal of Orthodontics
Dental Press International

v. 15, no. 3

Dental Press Journal of Orthodontics – ISSN 2176-9451

Dental Press J. Orthod.

v. 15, no. 3

May / June



Treatment of temporomandibular disorders (TMD) and orofacial pain

Jorge Faber

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It is intriguing to see how information flows in the healthcare area. It is particularly curious to note that certain obsolete concepts and old, threadbare themes are sometimes reinstated and infect many practitioners. These treatment approaches are enough to spoil the mood of any scientifically-minded professional and—worse still—can wreak havoc with the victims of such treatments. The less lethal this condition, the more susceptible to such impropriety. An article in this issue provides a unique insight into one of the subjects most affected by what I just described: the treatment of temporomandibular disorders and orofacial pain.

Consider the following questions concerning TMD. Is your TMD treatment controversial? Is orthodontics an integral part of TMD treatment methods? Should TMJ CT’s be routinely used to assess the problem? Is joint space relevant to the diagnosis and treatment goal? Is treatment aimed at adjusting the joint spaces? If you answered yes to one or more of these questions you must read the article by Carrara, Conti and Barbosa.

A close relationship between dentition and TMD was erroneously established decades ago. The mistaken conclusions stemmed from an interpretation of retrospective case series studies. This study design is most often performed by practitioners in the office setting, simply because that is where patients go for treatment. Thus, after a few years, material is collected from a series of cases on a given subject. To better understand why this study design is inefficient in pinpointing solutions to the problems that confront us, let us consider the following line of reasoning.

A hypothetical professional analyzes the results of orthodontic treatment of 41 patients in her office. All complained of pain and were diagnosed with TMD at the beginning of followup. To simplify my reasoning, let us consider that we have two possible treatment outcomes: improvement and no improvement. If the final results indicate that 35 patients improved, treatment as a whole was a success, right? The correct answer is: wrong. We cannot conclude anything other than that this treatment might work.

Some conditions are cyclical or transitory, and it might be that the patients who improved with this TMD therapy would eventually get better anyway. Therefore, a control group should be included, provided that the researcher finds it ethically acceptable to deprive these people of treatment. Thus, if the control group was included in the study and only 20 patients improved without treatment (Table 1), we would have a statistically significant difference between treatment and control groups (p<0.001), with the latter group showing more improvement than the former. Can we now conclude that this treatment is effective? No. At least not yet.

Furthermore, it is perfectly conceivable that a portion of those treated improved as a result of the placebo effect. It would be all but impossible to include a placebo effect per se in a non-drug therapy such as TMD. To achieve such effect, one could implement false treatments such as, for example, brackets bonded to teeth without de-livering any actual forces, or an acrylic plate that does not cover the occlusal surfaces of the teeth. In our hypothetical study, a Fake Treatment was evaluated. The results showed that 33 patients improved with the fake treatment and no difference was found between Treatment and Fake Treatment groups (p = 0.63). Thus the new therapy—or old therapy, if it happens to be the new edition of an old concept—is not more effective than the fake treatment.

The table showing the clinical trials with the three groups, described above, gives an overview of the process of assembling information for clinical decision making. However, the mere creation of the three groups is still a relatively incomplete action and therefore insufficient. Important issues regarding the randomness of patient selection for treatment, the fact that it is a prospective study, the analysis of intention to treat, among other items relevant to the design of a clinical trial, were not even mentioned. Mainly because it would require many pages to elaborate on these details.

Additionally, the sketch depicts a common shortcoming, namely, many well-intentioned professionals take advantage of conferences and other channels as a platform to disseminate findings from a series of cases treated in their offices, without realizing the complexity that lies behind the formulation of clinical studies.

It was in an attempt to help these people, who are part of the dental and medical communities, and also the people who suffer from TMD and orofacial pain, that Carrara, Conti and Barbosa wrote the Statement of the 1st Consensus on Temporomandibular Disorders and Orofacial Pain. This article is unique because it not only reflects the authors’ opinion, but also that of today’s leading Brazilian professionals. They endorsed the article and proved that the subject is not controversial.

Furthermore, the article shows that the available evidence can suggest many things: that orthodontics is not an integral part of routine TMD treatment methods, that TMJ CT’s should not be used routinely, that joint space analysis is not relevant to the diagnosis and that adjusting the joint spaces is not a treatment goal, among other conclusions. The article is a landmark in the area and I strongly recommend that all read it in full.


Orthodontic Insight

Saucerization of osseointegrated implants and planning of simultaneous orthodontic clinical cases

Alberto Consolaro, Renato Savi de Carvalho , Carlos Eduardo Francischone Jr., Maria Fernanda M-O Consolaro, Carlos Eduardo Francischone Junior

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The field for Orthodontics has seen significant expansion with the advent of new diagnostic and therapeutic approaches in all specialties, such as medical and dental implantology, sleep medicine, orthognathic surgery, computed tomography, gerodontology, etc. This requires the mastery of new concepts and technical terms typical of the jargon used by each specific area. Such mastery plays a key role in discussions about diagnosis and planning of clinical cases with professionals from other specialties.

Dental osseointegrated implants, for example, completely changed the practice and scope of dentistry in the last 20 years. Many adult orthodontic patients have already had one or more osseointegrated implants installed or may be planning, or need to do so. Many young orthodontic patients have also had osseointegrated implants installed because of tooth loss caused by trauma or partial anodontia.

Osseointegrated implant saucerization is a phenomenon worthy of recognition and consideration in orthodontic planning to establish functional and aesthetic prognosis. With this insight in mind, we intend to discuss the concept of saucerization, with the specific purpose of answering a few important questions. Given the occurrence of saucerization, should special care be given to teeth located in the neighborhood of osseointegrated implants when moving teeth and finishing orthodontic cases?


An interview with Ademir Roberto Brunetto

Ademir Roberto Brunetto

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• DDS, Federal University of Paraná State (UFPR), 1976.

• Postgraduate Orthodontics and Dentofacial Orthopedics, University of California, Los Angeles, USA, 1984.

• Scientific Advisor, Dental Press Journal of Orthodontics.

• Renowned Lecturer in Brazil and abroad.

• Diplomate, Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO), 2004.

• Director, Brazilian Board of Orthodontics and Facial Orthopedics (BBO).

Online Article

Evaluation of the applicability of a North American cephalometric standard to Brazilian patients subjected to orthognathic surgery

Fernando Paganeli , Machado Giglio , Eduardo Franzotti Sant’Anna

Orthognathic surgery. Facial analysis. Cephalometric standard.

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Objectives: To study the applicability of a North American cephalometric standard to Brazilian patients subjected to orthognathic surgery by comparing the post-surgical/orthodontic treatment cephalometric tracings of 29 patients who had undergone surgery of the maxilla and mandible with the cephalometric standard used as guidance in planning the cases.

Methods: The tracings were generated by the Dolphin Imaging 9.0 computer program from scanned lateral cephalograms in which 48 dental, osseous and tegumentary landmarks were defined. Thus, were obtained 26 linear and angular cephalometric measurements to be compared with normative values, considering sexual dimorphism and possible modifications to the treatment plan to meet the individual needs of each case, as well as any possible ethnic and racial differences. The sample data were compared with the standard using Student’s t-test means and standard deviations.

Results: The results showed that for males, the sample means were significantly different from the standard in five of the measurements, while for women, nine were statistically different. However, despite the similarity of the means of most measurements in both genders, the data showed marked individual variations.

Conclusions: An analysis of the results suggests that the North American cephalometric standard is applicable as a reference for planning orthodontic-surgical cases of Brazilian patients, provided that consideration is given to variations in the individual needs of each patient.

Analysis of biodegradation of orthodontic brackets using scanning electron microscopy

Luciane Macedo de Menezes, Rodrigo Matos de Souza , Gabriel Schmidt Dolci , Berenice Anina Dedavid

Corrosion. Biocompatibility. Orthodontic brackets. Nickel.

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Objectives: The purpose of this study was to analyze, with the aid of scanning electron microscopy (SEM), the chemical and structural changes in metal brackets subjected to an in vitro biodegradation process.

Methods: The sample was divided into three groups according to brackets commercial brand names, i.e., Group A = Dyna-Lock, 3M/Unitek (AISI 303) and Group B = LG standard edgewise, American Orthodontics (AISI 316L). The specimens were simulated orthodontic appliances, which remained immersed in saline solution (0.05%) for a period of 60 days at 37°C under agitation. The changes resulting from exposure of the brackets to the saline solution were investigated by microscopic observation (SEM) and chemical composition analysis (EDX), performed before and after the immersion period (T0 and T5, respectively).

Results: The results showed, at T5, the formation of products of corrosion on the surface of the brackets, especially in Group A. In addition, there were changes in the composition of the bracket alloy in both groups, whereas in group A there was a reduction in iron and chromium ions, and in Group B a reduction in chromium ions.

Conclusions: The brackets in Group A were less resistant to in vitro biodegradation, which might be associated with the type of steel used by the manufacturer (AISI 303).

Original Article

Nasopharyngeal and facial dimensions of different morphological patterns

Murilo Fernando Neuppmann Feres, Carla Enoki, Wilma Terezinha Anselmo-Lima, Mirian Aiko Nakane Matsumoto

Mouth breathing. Nasopharynx. Cephalometry.

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Objective: The purpose of this study was to compare the dimensions of the nasopharynx and the skeletal features—evaluated by cephalometric examination—of individuals with different morphological patterns.

Methods: Were used cephalometric radiographs of 90 patients of both genders, aged 12 to 16 years, which were divided into three distinct groups, according to their morphological patterns, i.e., brachyfacials, mesofacials and dolichofacials. Measurements were performed of specific nasopharyngeal regions (ad1-Ptm, ad2-Ptm, ad1-Ba, ad2-S0, (ad1-ad2-S0-Ba-ad1/Ptm-S0-Ba-Ptm) X 100, and Ptm-Ba), and relative to the facial skeletal patterns.

Results: Dolichofacial patients were found to have smaller sagittal depth of the bony nasopharynx (Ptm-Ba) and lower nasopharyngeal airway depth (ad1-Ptm and ad2-Ptm). Arguably, these differences are linked to a relatively more posterior position of the maxilla, typical of these patients. No differences were found, however, in the soft tissue thickness of the posterior nasopharyngeal wall (ad1-Ba and ad2-S0), or their proportion in the whole area bounded by the nasopharynx [(ad1-ad2-S0-Ba-ad1/Ptm-S0-Ba-Ptm) X 100].

Conclusions: We therefore suggest that the excessively vertical facial features found in dolichofacial patients may be the result, among other factors, of nasopharyngeal airway obstruction, since such dimensions were shown to be smaller in dolichofacials.

Cephalometric evaluation of vertical and anteroposterior changes associated with the use of bonded rapid maxillary expansion appliance

Moara De Rossi , Maria Bernadete Sasso Stuani, Léa Assed Bezerra da Silva

Bonded rapid maxillary expansion appliance. Rapid maxillary expansion. Cephalometry.

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introduction: Bonded rapid maxillary expansion appliances have been suggested to control increases in the vertical dimension of the face after rapid maxillary expansion but there is still no consensus in the literature concerning its actual effectiveness. Objective: The purpose of this study was to evaluate the vertical and anteroposterior cephalometric changes associated with maxillary expansion performed using bonded rapid maxillary expansion appliances. Methods: The sample consisted of 25 children of both genders, aged between 6 and 10 years old, with skeletal posterior crossbite. After maxillary expansion, the expansion appliance itself was used for fixed retention. Were analyzed lateral teleradiographs taken prior to treatment onset and after removal of the expansion appliance. Conclusion: Based on the results, it can be concluded that the use of bonded rapid maxillary expansion appliance did not significantly alter the children’s vertical and anteroposterior cephalometric measurements.

Evaluation of maxillary atresia associated with facial type

Marina Gomes Pedreira, Katia de Jesus Novello Ferrer, Renato Castro de Almeida, Maria Helena Castro de Almeida

Maxillary atresia. Schwarz’s analysis. Facial types.

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Objectives: To associate maxillary atresia with facial types, investigating whether dimorphism occurs between males and females and evaluating the percentage of such dimorphism according to gender and facial type.

Methods:Initially, the sample consisted of 258 lateral cephalometric radiographs. After analyzing Ricketts’ VERT index, 108 radiographs were excluded for not meeting the selection criteria. Therefore, the sample consisted of 150 lateral cephalometric radiographs and 150 models of 150 Caucasian individuals aged 14 years to 18 years and 11 months, regardless of malocclusion type. The sample was divided into 50 mesofacials, 50 brachyfacials and 50 dolichofacials. The Schwarz’s analysis was applied to all 150 models.

Results: The presence of maxillary atresia in the sample consisted of 64% in dolichofacials, 58% in brachyfacials and 52% in mesofacials.

Conclusions: There was no evidence showing that atresia is in any way associated with facial type. Gender dimorphism was proportionally greater in dolichofacial males while females did not exhibit different proportions.

Possible etiological factors in temporomandibular disorders of articular origin with implications for diagnosis and treatment

Aline Vettore Maydana, Ricardo de Souza Tesch, Odilon Vitor Porto Denardin, Weber José da Silva Ursi, Samuel Franklin Dworkin

Temporomandibular disorders. RDC/TMD. Disk displacement. Osteoarthritis. Malocclusion.

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The authors reviewed the factors involved in the etiology, diagnosis and treatment of temporomandibular joint disorders (TMD). Although essential, specific criteria for inclusion and exclusion in TMD diagnosis have shown limited usefulness. Currently, the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) offer the best evidence-based classification for the most common TMD subgroups. The RDC/ TMD includes not only methods for physical diagnostic classification, comprised in Axis I, but also methods to assess the intensity and severity of chronic pain and the levels of non-specific depressive and physical symptoms, in Axis II. Although historically malocclusions have been identified as risk factors for the development of TMD—including those predominantly joint-related—in many cases the association established between these variables seems to have taken opposite directions. Regarding internal TMJ derangements, the results of studies on the induced shortening of the mandibular ramus, secondary to anterior articular disk displacement, indicate that repositioning the displaced disk in children or young adolescents may make more sense than previously imagined. The therapeutic use of dietary supplements, such as glucosamine sulfate, seems to be a safe alternative to the anti-inflammatory drugs commonly used to control pain associated with TMJ osteoarthritis, although evidence of its effectiveness for most TMD patients has yet to be fully established.

Factors predisposing 6 to 11-year old children in the first stage of orthodontic treatment to temporomandibular disorders

Patrícia Porto Loddi , André Luis Ribeiro de Miranda, Marilena Manno Vieira, Fernanda C. Goldenberg, Savério Mandetta

Temporomandibular joint disorders/diagnosis. Temporomandibular Joint Dysfunction Syndrome. Epidemiology. Children.

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introduction: The etiology of temporomandibular disorders (TMD’s) is currently considered multifactorial, involving psychological factors, oral parafunctions, morphological and functional malocclusion.

Objectives: In keeping with this reasoning, we evaluated children who seek preventive orthodontic treatment, to better understand their grievances and to assess the prevalence of TMD signs and symptoms in these patients.

Methods: Two examiners evaluated 65 children aged 6 to 11 years.

Results: In our sample, bruxism featured the highest prevalence rate, whereas atypical swallowing displayed the highest rate among predisposing factors.

Conclusion: We therefore recommend that the evaluation of possible TMD signs and symptoms in children be adopted as routine in the initial clinical examination.

Extraction of upper second molars for treatment of Angle Class II malocclusion

Maurício Barbieri Mezomo, Manon Pierret, Gabriella Rosenbach , Carlos Alberto E. Tavares

Orthodontic treatment. Second molars. Extractions. Class II.

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The purpose of this article is to present an alternative approach to the orthodontic treatment of Angle Class II malocclusion. According to a literature review it was observed that the extraction of upper second molars has proven to be a viable alternative for the treatment of this type of malocclusion. This therapeutic option enables faster first molar retraction and requires less patient compliance. However, the level of development, intraosseous position and morphology of the third molar should be carefully evaluated to ensure its correct positioning in place of the extracted second molar. Two clinical case reports will demonstrate that the sequence of diagnosis and treatment used with this mechanics yields satisfactory functional and aesthetic results.

Evaluation of shear bond strength of brackets bonded with orthodontic fluoride-releasing composite resins

Marcia Cristina Rastelli, Ulisses Coelho, Emígdio Enrique Orellana Jimenez

Shear bond strength. Brackets. Composite fluoride resin.

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Objective:To evaluate the shear bond strength of stainless steel brackets bonded with fluoride releasing composite resins, comparing them with a conventional resin and to analyze the amount of resin left on the enamel surface.

Methods:Sixty premolars were randomly divided into three groups: Group I – Concise (3M), Group II – Ultrabond (Aditek do Brasil) and Group III – Rely-a-Bond (Reliance). After bonding, the samples were thermocycled (500 cycles) at 5ºC and 55ºC temperatures. After 48 hours they were subjected to shear bond strength testing, in the occluso-gingival direction, using an MTS 810 Universal Testing Machine with load speed of 0.5 mm/min.

Results: The results demonstrated a mean shear bond strength of 24.54 ± 6.98 MPa for Group I, 11.53 ± 6.20 MPa for Group II, and 16.46 ± 5.72 MPa for Group III. Analysis of Variance (ANOVA) determined a statistical difference in the mean shear bond strengths between groups (p < 0.001). The Tukey test evidenced that the averages of the three groups were significantly different (p < 0.05), with the highest values for Group I and the lowest for Group II. The Kruskal-Wallis test did not show significant differences in the amount of resin left on the enamel in any of the three groups (p = 0.361).

Conclusion: All materials exhibited adequate adhesive bond strength for clinical use. Concise exhibited the highest degree of shear bond strength but no significant differences were found in Adhesive Remnant Index (ARI) between the groups.

Statement of the 1st Consensus on Temporomandibular Disorders and Orofacial Pain

Simone Vieira Carrara , Paulo César Rodrigues Conti, Juliana Stuginski Barbosa

Bruxism. TMJ. Temporomandibular joint disorders. Headache. Dentistry. Cervicalgia (neck pain).

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This Statement of the 1st Consensus on Temporomandibular Disorders and Orofacial Pain* was created with the purpose of substituting controversies for scientific evidence within this specialty field of dentistry. The document provides clear and well-grounded guidance to dentists and other health professionals about the care required by patients both in the process of differential diagnosis and during the stage when they undergo treatment to control pain and dysfunction. The Statement was approved in January 2010 at a meeting held during the International Dental Congress of São Paulo and draws together the views of Brazil’s most respected professionals in the specialty of Temporomandibular Disorders and Orofacial Pain.

Race versus ethnicity: Differing for better application

Diego Junior da Silva Santos, Nathália Barbosa Palomares, David Normando, Cátia Cardoso Abdo Quintão

Ethnicity and health. Distribution by race or ethnicity. Ethnic groups.

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Studies involving populations are often questioned as to the homogeneity of their samples relative to race and ethnicity. Such questioning is justified because sample heterogeneity can increase the variability of and even mask results. These two concepts (race and ethnicity) are often confused despite their subtle differences. Race includes phenotypic characteristics such as skin color, whereas ethnicity also encompasses cultural factors such as nationality, tribal affiliation, religion, language and traditions of a particular group. Despite the widespread use of the term “race”, geneticists are increasingly convinced that race is much more a social than a scientific construct.

BBO Case Report

Angle Class II, division 2 malocclusion with severe overbite and pronounced discrepancy*

Daniela Kimaid Schroeder

Class II, division 2. Crossbite. Severe overbite. Prolonged retention of deciduous teeth.

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This article reports the treatment of a young patient at 13.8 years of age who presented with an Angle Class II, division 2 malocclusion, prolonged retention of deciduous teeth, dental crossbite and severe overbite, among other abnormalities. At first, the approach involved rapid maxillary expansion followed by the use of Kloehn headgear and fixed orthodontic appliance. Treatment results demonstrate the importance of careful diagnosis and planning as well as the need for patient compliance during treatment. This case was presented to the Brazilian Board of Orthodontics and Facial Orthopedics (BBO). It is representative of the free category and fulfills part of the requirements for obtaining the BBO Diploma.

Special Article

Tooth extraction in orthodontics: an evaluation of diagnostic elements

Antônio Carlos de Oliveira Ruellas, Ricardo Martins de Oliveira Ruellas, Fábio Lourenço Romano, Matheus Melo Pithon, Rogério Lacerda dos Santos

Corrective Orthodontics. Diagnosis. Tooth extraction. Orthodontic planning.

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Certain malocclusions require orthodontists to be capable of establishing a diagnosis in order to determine the best approach to treatment. The purpose of this article was to present clinical cases and discuss some diagnostic elements used in drawing up a treatment plan to support tooth extraction. All diagnostic elements have been highlighted: Issues concerning compliance, tooth-arch discrepancy, cephalometric discrepancy and facial profile, skeletal age (growth) and anteroposterior relationships, dental asymmetry, facial pattern and pathologies. We suggest that sound decision-making is dependent on the factors mentioned above. Sometimes, however, one single characteristic can, by itself, determine a treatment plan.

Dental Press Journal of Orthodontics

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