ARTÍCULOS ORIGINALES
Assessment of mandibular movements in 10 to 15 year-old patients with and without temporomandibular disorders
Silvina G. Cortese, Ana M. Biondi, Diana E. Fridman, Ingrid Guitelman, Catalina L. Farah
Department of Comprehensive Pediatric Dentistry, School of Dentistry, Buenos Aires University, Argentina
CORRESPONDENCE Dra. Silvina G Cortese Catedra de Odontologia Integral Ninos Facultad de Odontologia, UBA M.T. de Alvear 2142, 15A, (C1122AAH), Buenos Aires, Argentina sgcortese@hotmail.com
ABSTRACT
The aim of this study was to establish reference values for mandibular movements in 10- to 15-year-olds without dysfunction and compare these values to those in patients of the same age with tempromandibular disorders (TMD) and those found previously in a group of children younger than 11 years old without TMD. Children of both genders who visited the Department of Comprehensive Pediatric Dentistry at Buenos Aires University in 2013 and whose parents or guardians provided consent were evaluated using TMD/RDC by standardized pediatric dentists (Kappa 0.88). Three groups were formed according to diagnostic summary: Group C, without TMD; Group Ia, with myofascial pain, and Group Ib, pain with limited mouth opening. The following variables were analyzed: age, gender and mandibular movements. The sample included 169 patients aged 12.5±1.76 years, of whom 62.36% did not have TMD (C) while 37.27% were diagnosed with muscle disorder (29.58% Ia and 7.69% Ib). For Group C, the following values (in mm) were recorded: maximal unassisted opening: 48.28±6.14; right lateral movement 8.78±2.50; left lateral movement: 9.60±2.64; protrusion: 4.94±2.58 and overbite: 2.98 ± 2.5, with no variation associated to sex, but with differences in the values recorded for all movements compared to those obtained for mixed dentition (p=0.0001). Analysis of mean values for mandibular movements in all 3 groups only revealed differences for maximal unassisted opening (p= 0.0317). With relation to gender, TMD was more frequent in females, with significant differences between Groups C and Ia (p=0.019). In males without dysfunction, average maximal opening was 48.28±6.14mm, with lower values in patients with TMD. Mandibular movements in pediatric patients without TMD showed significant differences according to dentition type and age.
Key words: Temporomandibular joint disorders; Facial pain; Children.
RESUMEN
Valoración de movimientos mandibulares en pacientes de 10 a 15 años con y sin trastornos témporo-mandibulares
El objetivo del presente trabajo fue establecer valores de referencia de movimientos mandibulares en ninos de 10-15 anos sin disfuncion; compararlos con los de pacientes de la misma edad con trastornos temporomandibulares (TTM) y con los hallados anteriormente en un grupo menor de 11 anos sin TTM. Ninos de ambos sexos que acudieron a la Catedra Odontologia Integral Ninos de UBA en 2013 y cuyos responsa - bles brindaron consentimiento fueron evaluados con CDI/TTM por odontopediatras estandarizados (Kappa 0.88) conformandose 3 grupos en funcion del resumen diagnostico; C: sin TTM, Ia: con dolor miofacial e Ib: dolor con limitacion de la apertura bucal, para el analisis de las siguientes variables: edad, sexo y movimientos mandibulares. La muestra quedo constituida por 169 pacientes de 12.5±1.76 anos. El 62.36% no presento TTM (C) y en el 37.27% se establecio un diagnostico de trastorno muscular (29.58% Ia y 7.69% Ib). En C se registraron los siguientes valores en mm: Apertura maxima no asistida: 48.28±6.14; Lateralidad derecha 8.78±2.50; izquierda: 9.60±2.64; Protrusion: 4.94±2.58 y Sobremordida: 2.98 ± 2.5 sin variaciones en relacion al sexo, pero con diferencias en los registros de todos los movimientos comparados con los obtenidos en denticion mixta. (p=0.0001). El analisis de los valores medios de los movimientos mandibulares entre los 3 grupos solo revelo diferencias para la apertura maxima no asistida (p= 0.0317). En relacion al sexo, los TTM fueron mas frecuentes en ninas siendo significativa la diferencia entre C e Ia (p=0.019). En los ninos sin disfuncion se establecio una apertura maxima promedio de 48.28±6.14mm, observandose valores inferiores en los pacientes con TTM. Los movimientos mandibulares en pacientes pediatricos sin TTM mostraron diferencias significativas en funcion del tipo de denticion y la edad.
Palabras clave: Articulacion temporomandibular; Lesiones dolor facial; Niños.
INTRODUCTION
Mandibular movement measurements are a simple but
important parameter for evaluating and monitoring
dysfunctions of the masticatory system known as
temporomandibular disorders (TMD)1. In pediatric
patients, multifactorial etiology for muscle dysfunction is accepted; nevertheless, and less frequently,
mandibular mobility can also be affected by causes
such as severe trauma (fractures), developmental
alterations, tumors and rheumatoid arthritis, among
others.2 The temporomandibular joint (TMJ) is
affected in half of the children who have juvenile
idiopathic arthritis, causing limited opening; thus, these
measurements are also useful to rheumatologists3,4.
TMJ development begins during the eighth week of
intrauterine life and finishes in the second decade
of life. Postnatal development is closely related to
and interacts with maturation of masticatory and
swallowing functions; growth of mandibular,
masseter and temporal muscles; and development
of dentition5. Monitoring TMJ physiological
changes is relevant in pediatric patients. Condylar
growth, like growth in general, slows during
childhood, accelerates during adolescence and
slows again after the pubertal growth spurt.
Between the ages of 10 and 15 years, males have
greater growth potential than females6.
During mouth opening there are simultaneously
rotational and translational movements of the two
condyles and their disks along the articular eminence.
The articular eminence and the temporomandibular
ligament limit mouth opening. Mandibular closing
movement should not be considered the inverse of
opening because it is not limited by the same
anatomical structures, but rather, the condyle moves
against the anterior wall of the articular fossa
through the muscles of mastication. During
protrusion, the two condyles move forward and
downward, making contact with the articular
eminence. Lateral movements are more complex
than opening or protrusion because they are
asymmetrical, with the muscles on each side acting
in different ways1.
Very large range of movement (hypermobility) or
limited range (hypomobility) are considered signs of
dysfunction; therefore simple, objective recording
methods and reference values are needed for each
age group in order to facilitate TMD diagnosis7.
There is little information in this regard for children,
and the values reported are not consistent and have
been gathered by means of different sampling and
data recording methods8.
In view of the difficulties caused by methodological
differences for diagnosis, the International
Association for Dental Research (IADR) adopted
Research Diagnostic Criteria for Temporomandibular
Disorders (RDC/TMD) (index prepared by
Dworkin and LeResche), which provide a standardized
system for examining, diagnosing and
classifying the most common subtypes of TMD9.
These criteria, currently used by many research
groups, have been validated in 18 languages for
children as from 10 years of age, and were used
for our study. The system has two components for
evaluation. “Axis I” is a questionnaire and clinical
evaluation designed to distinguish myofascial
pain, disk displacement, arthralgia, arthritis and
arthrosis9.
The aims of this study were to establish reference
values for mandibular movements in 10- to 15-yearolds
without dysfunction and compare them to
those of patients of the same age with TMD and to
those found in a previous study on a group of
children younger than 11 years old without TMD10.
MATERIALS AND METHODS
Design, subject selection and methods
We designed an observational, prospective, crosssectional
study, which was approved by the Ethics
Committee of the School of Dentistry at Buenos
Aires University (code number 26/09/2012 – 27).
We evaluated all 10- to 15-year-olds of both genders
who sought care at any of the four different shifts
at the Department of Comprehensive Pediatric
Dentistry at Buenos Aires University from March
to August 2013, whose parents or guardians provided
consent for participation in this study. We excluded
children with medical compromise; developmental,
neurological and/or psychiatric disorders, and/or
undergoing orthodontic treatment. Patients were
evaluated using RDC/TMD Axis I by standardized
pediatric dentists (Kappa 0.88). Data were entered
into a spreadsheet (MS Excel 2010, version 14) for
subsequent statistical analysis.
Three groups were formed according to the results
of the RDC/TMD diagnostic summary: without
TMD (C), with myofascial pain (Ia) and with limited
mouth opening (Ib).
The following variables were analyzed: gender, age,
overbite in mm, maximal unassisted and assisted
mouth opening, right and left lateral movement
and protrusion. Frequencies were estimated using
percentages with confidence intervals (95%), and
the rest of the quantitative variables were analyzed
using means, standard deviation, Student and Welch
test, ANOVA analysis of variance and Chi squared
with 95% significance. The values recorded for C
were compared to previous findings for mixed
dentition and to findings for Ia and Ib
Reference values for opening were calculated by
subtracting overbite from maximal opening.
Clinical recording
Patients sat in a dental chair and were measured
using a millimeter ruler.
Maximal Unassisted Opening. The patient was
asked to open his/her mouth as wide as possible,
even if it caused discomfort. The edge of the
millimeter ruler was placed at the incisal edge of the
upper central incisor and the distance between it and
the incisal edge of the lower incisor (interincisal
distance) was measured and recorded (Fig. 1).
Fig. 1: Recording Maximal Opening.
Right and Left Lateral Movements. The patient was asked to open his/her mouth a little and move the mandible as far as possible to one side (right or left). With teeth slightly apart, the distance between the interdental space between upper central incisors and interdental space between lower incisors was measured and recorded, for both sides (Fig. 2).
Fig. 2: Recording Lateral Excursion.
Protrusion. The patient was asked to open his/her mouth slightly and protrude the mandible without interference from the incisors. The distance on the midline between upper and lower incisor edges was measured and recorded (Fig. 3).
Fig. 3: Recording Protrusion.
Table 1 shows diagnostic criteria used11.
Table 1: Summary of diagnostic criteria for TMD.
RESULTS
The sample comprised 169 patients; mean age was 12.5 years, SD 1.76. Of these, 62.36% (54.59- 69.67) did not have TMD (C), while 37.27% (CI 30-45,05) were diagnosed with muscle disorders: 29.58% (CI 22.80-37.09) in Group Ia and 7.69% (CI 4.14-12.80) in Group Ib.
Analysis of Group C: without TMD
Group C comprised 106 children, mean age 12.37±
1.6 years, of whom 41.50% (31.99-51.51) were
female. Table 2 shows the average values for final
maximal comfortable opening, with compensation
for overbite, broken down according to age.
Comparison for maximal opening according to
gender shows that males (age 12.5±1.55) had
48.38±6.47 mm and females (age 12.2±1.66) had
48.12±5.70 mm (p=0.83).
Table 2: Distribution of maximal opening according
to age.
Values in mm were: maximal unassisted opening 48.28±6.14 (CI 47.1-49.46), right lateral movement 8.78±2.50 (8.30-9.26), left lateral movement 9.60±2.64 (9.09-10.11), protrusion 4.94±2.58 (4.44-5.44) and overbite 2.98 ± 2.5 (1.61-2.38). Values in mm found previously in mixed dentition in a group of 107 children, mean age 6.9±1.65 were: maximal opening 41.9 ± 5.27 (40.96-42.98), right lateral movement 6.05±1.99 (5.67-6.43), left lateral movement 6.13±2.21 (5.75-6.51) and protrusion 3.96±1.92 (3.59-4.33)10. The differences recorded for all movements between the two groups were significant (p=0.0001, Fig. 4).
Fig. 4: Comparison of mandibular movements in permanent
and mixed dentition.
Analysis of Groups Ia and Ib
A total 63 patients had muscle disorders, 2 patients
from Group Ia also had disc displacement with
reduction (IIa) and 6 patients from Group Ib had
disc displacement without reduction (IIb). Table 3 shows the composition both groups. The values in
mm were: maximal unassisted opening 45.8±4.37,
33.38±5.63; right lateral movement 7.98±2.76, 8.53±2.25; left lateral movement
8.98±2.86, 9.30±2.78; protrusion
4.62±2.42, 4.92±2.49 and overbite
2.67±2.12, 3.38±1.93 for Groups Ia
and Ib, respectively.
In Group Ia, 17 patients had lower
values for maximal opening than
those found for Group C, considered
as reference values (42.14-54.42).
Table 3: Composition of Groups Ia and Ib.
Comparison of Groups C,
Ia and Ib
Fig. 5 shows mean values for mandibular
movements in all 3 groups.
TMD was more frequent in females,
with significant difference between
Groups C and Ia (p=0.019) (C-Ib
p=0.100; Ia-Ib p=0.499).
Comparison of all 3 groups revealed significant
differences for maximal unassisted opening (p=
0.0317), and no significant difference for the rest of
the variables analyzed. Table 4 shows the p values.
Fig. 5: Comparison of mandibular movements with and without TMD in permanent dentition.
Table 4: Comparison of C, Ia and Ib (ANOVA).
DISCUSSION
There is little available information on mandibular
movements in children, and results are inconsistent,
possibly due to differences in recording methodology
and inclusion criteria,12-16. In a previous paper,
reference values were established for primary and
mixed dentition without signs of TMD10.
Reference values for maximal opening in a group
of 4- to 17-year-olds have recently been published,
though without prior evaluation of the TMJ;
therefore the results reported with percentiles
include people with dysfunction3.
Cases have been evaluated with different methods,
ranging from the very simple and imprecise, such
as thickness of fingers, to the sophisticated, such as
the system used by Hayasaki et al. on a small
sample, which analyzes simultaneous movements
in three dimensions17-19. In addition, pantographic
and ultrasound systems have been designed and
placed on the market, though there has been little
application of them in epidemiological research and
clinical practice20.
The International Association for Dental Research
(IADR) recommends the use of the RDC/TMD21.
Their diagnostic parameters, which were followed in this research protocol, do not discriminate
variations in limited opening according to age.
Several studies have shown that opening increases
progressively from birth to the end of adolescence
and then decreases progressively with age12, 22, 24. Our
study considered opening less than 40 mm to be
limited, as provided in the RDC/TMD. Nevertheless,
the group without TMD had a mean value of
48.28±6.14mm, therefore in this age range, openings
lower than 43 mm should be considered limited.
The most extreme opening movements are observed
at puberty, which is believed to be a consequence
of the hyperlaxitude characteristic of this stage25, 26.
The increase in values for mandibular movement with
increasing age may be due to anatomical changes,
maturation of the central nervous system,
skeletal growth and maturation of the occlusal function10,14,15,27,28.
Ingervall suggests that by 10 years of age,
children have attained adult mandibular motion
range12. Thus, statistically significant differences were
found between values for Group C and those found
previously in a group of children younger than 11 years
for all variables in the mandibular motion ranges.
The values for protrusion movement that we found
for Group C were noticeably lower than those
reported by other authors5,12,14,16,18 , which may be
because they added overjet, which our study did not
take into account8,12,15,16,27.
For Group C lateral
movements, our study found higher values than
those reported by other authors15,16,27.
Our results for patients without TMD according to
gender are consistent with those published by Muller,
who reported no significant difference in opening
between genders up to the age of 13 years3. Female
joints are usually more flexible and laxer than male
joints, which would explain the greater incidence of
temporomandibular dysfunction in females1,8.
TMD frequency was 37.27%, with 29.58% in
Group Ia and 7.69% in Group Ib. Hirsch reported
for a group with mean age 13 years a frequency of
10.2 %, with 7.9% corresponding to IIa and 2.3 %
to Ia, III a/b 8. Our study only found 1.18% IIa and
3.55% IIb and high frequency of muscle disorders
without movement limitation (Ia).
Pizolato et al. report 26.3% TMD in 8- to 12-yearold
patients with no difference according to gender29.
In contrast, other authors found prevalences of over
70% in older adolescent patients30,31. According to
the RDC/TMD, Group Ia has no limitation of
movement; nevertheless, in our study and applying
those criteria, we found significantly lower maximal
opening values compared to Group C.
Our sample is made up of patients from a pediatric
dental care facility, where pathologies may be found
more often than in the general population. It would
be interesting to conduct a similar study on samples
of the population not demanding care.
The results of this study may contribute to providing
professionals with more precise indicators for early
diagnosis of TMD in patients in an age range at
which visits due to this problem are frequent and
information is scarce and controversial.
CONCLUSIONS
Mandibular movements in pediatric patients without TMD showed significant differences according to age and dentition type. Average maximal opening was established at 48.28±6.14mm, with no difference according to gender. In the 37.27% with TMD, maximal opening was significantly lower, at 45.8±4.37mm for the group with myofascial pain and 33.38±5.63 mm for the group with myofascial pain and limited opening.
ACKNOWLEDGMENTS
This work was supported by a grant from the Buenos Aires University (Program UBACyT, no 20720120200008BA). The authors wish to thank Od.Alicia Estikle for help with data collection.
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