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Received: 14 July 2022    Revised: 30 January 2023    Accepted: 17 April 2023

DOI: 10.1111/joor.13471

ORIGINAL ARTICLE

Longitudinal trends in temporomandibular joint disorder

symptoms, the impact of malocclusion and orthodontic
treatment: A 20-­year prospective study

Myllymäki Emmi1  | Heikinheimo Kaisa1 | Suominen Auli2  | Evälahti Marjut1  |

Michelotti Ambra3  | Svedström-­Oristo Anna-­Liisa4  | Rice P. David1,5

1
Orthodontics, Oral and Maxillofacial
Diseases, University of Helsinki, Helsinki, Abstract
Finland
Background: Studies on the association between malocclusion and temporomandibu-
2
Department of Community Dentistry,
Institute of Dentistry, University of Turku,
lar joint disorder (TMD) have reported conflicting results.
Turku, Finland Objectives: To determine the impact of malocclusion and orthodontic treatment on
3
Department of Neurosciences, symptoms of TMD.
Reproductive Sciences and Oral
Sciences, School of Orthodontics and Methods: At 12 years, 195 subjects fulfilled a questionnaire regarding TMD symp-
Temporomandibular Disorders, University toms and participated in an oral examination including preparation of dental casts.
of Naples Federico II, Naples, Italy
4 The study was repeated at ages 15 and 32. The occlusions were assessed by applying
Pediatric Dentistry and Orthodontics,
University of Turku, Turku, Finland the Peer Assessment Rating (PAR) Index. Associations between the changes in PAR
5
Orthodontics, Oral and Maxillofacial scores and TMD symptoms were analysed with the chi-­square test. A multivariable
Diseases, Helsinki University Hospital,
Helsinki, Finland logistic regression was used to calculate the odds ratios (OR) and 95% confidence
intervals (CI) of TMD symptoms at 32 years predicted by sex, occlusal traits and or-
Correspondence
Rice P. David, Orthodontics, Oral and thodontic treatment history.
Maxillofacial Diseases, University of Results: One in three subjects (29%) was orthodontically treated. Sex was associated
Helsinki, Biomedicum 1, Haartmaninkatu
8, Helsinki 00014, Finland. with more self-­reported headaches by females at 32 years (OR 2.4, 95% CI 1.05–­5.4;
Email: [email protected] p = .038). At all time points, any crossbite was significantly associated with greater
odds for self-­reported temporomandibular joint (TMJ) sounds at 32 years (OR 3.5,
95% CI 1.1–­11.6; p = .037). More specifically, association occurred with posterior
crossbite (OR 3.3, 95% CI 1.1–­9.9; p = .030). At 12 and 15 years, boys whose PAR score
increased were more likely to develop TMD symptoms (p = .039). Orthodontic treat-
ment had no impact on the number of symptoms.
Conclusions: Presence of crossbite may increase the risk of self-­reported TMJ sounds.
Also, longitudinal changes in occlusion may have an association with TMD symptoms
while orthodontic treatment is not associated with the number of symptoms.

KEYWORDS
cohort study, malocclusion, orthodontics, Peer Assessment Rating Index, questionnaire,
temporomandibular joint disorders

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2023 The Authors. Journal of Oral Rehabilitation published by John Wiley & Sons Ltd.

J Oral Rehabil. 2023;00:1–7.  |

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2      EMMI et al.

1  |  I NTRO D U C TI O N 2  |  M ATE R I A L S A N D M E TH O DS

Temporomandibular disorders (TMDs) form a heterogeneous group 2.1  |  Subjects

of disorders involving masticatory muscles, temporomandibular joints
(TMJs) and their associated structures.1,2 The most common signs and The study sample comprised a previously described31,32 prospective
symptoms include TMJ sounds, pain in the area of TMJ and in muscles cohort with longitudinal follow-­up of occlusal traits and temporo-
of mastication, and limited or asymmetric mandibular movements.1,2 mandibular disorders. The original cohort consisted of 200 Finnish
Temporomandibular disorders are common in the adult population children (100 girls and 100 boys) born in 1967 in the city of Jyväskylä,
and most symptoms improve without treatment. Therefore, only 5% Finland (Figure S1). The children were chosen from classes of seven
1,3,4
to 10% of those with symptoms require treatment. The female-­ different elementary schools situated in different parts of the city. In
to-­male ratio of patients has been reported to range between 3:1 and an attempt to minimise possible selection bias and maintain sample
9:1.1 The aetiology of TMD is reportedly multifactorial involving be- size, in the two schools with poor attendance at the examination,
havioural, environmental, biological, social and emotional factors, ge- additional children from parallel classes were included in the series.
netic domains, parafunctional habits and malocclusion, however, the These children were chosen in alphabetical order until 100 girls and
cause-­and-­effect relationship remains unclear.1,3,5–­9 100 boys were collected. Ethical approval was given by the Ethical
The overall prevalence of TMD varies between 10%–­31% for Board of Central Finland Hospital Region, Dnro 33/2000. One par-
adults and 4%–­11% for adolescents.10–­12 TMD remains the most ent or guardian signed an informed consent allowing their child to
2,13
common source of non-­dental orofacial pain and is characterised participate.
by fluctuations in symptoms over time.3,9 The symptoms are usually
worse in the morning, especially in patients who clench or grind their
teeth at sleep.1 The pain usually affects temporal and peri-­auricular 2.2  |  Clinical examinations
areas as well as cheek and is provoked by chewing, yawning or
talking.10 Treatment modalities for TMD include combinations of Clinical examinations were carried out at ages 7, 12, 15 and 32 years
home self-­care, counselling, physiotherapy, pharmacotherapy, oc- and were complemented with registration of occlusion and intra-
clusal splint, physical medicine, behavioural medicine and surgery.1 ­ and extraoral inspection of soft tissues. Assessed occlusal traits
The evidence supporting an association between malocclu- are presented in Table 1. In addition, supernumerary or congenitally
sions and TMD is controversial.14–­17 It has been hypothesized that missing or extracted teeth were registered. Occlusal relationships
unilateral posterior crossbite increases the risk for myofascial pain, were registered on both sides in molars and canines according to
arthralgia and TMJ clicking.6,13,18–­21 This link is based on the hy- Angle's classification. Functional examination included assessments
pothesis that the abnormal occlusal contacts may affect the rela- of maximal opening capacity, laterotrusion, mediotrusion and pro-
tionship between the mandibular condyle and fossa and thus create trusion contacts and joint sounds. Two experienced orthodontists
an asymmetric activation of the masticatory muscles.13 In contrast, performed all clinical examinations at the same time. Alginate im-
TMJ symptoms can persist after the correction of crossbite. 22 pressions for study models were taken at every time point and or-
Besides posterior crossbite, mediotrusive interferences have been thopantomograms were taken when needed.
suggested to predispose to TMD.18,23–­25 Orthodontic treatment is
not indicated for TMD management.10,13 In summary, some connec-
tion between occlusal traits and TMD has been described; however, 2.3  |  Questionnaire
18
results remain inconsistent across studies. Moreover, orthodontic
treatment, regardless of the type of intervention, has neither been During all appointments, subjects filled in a questionnaire on symp-
reported to prevent nor to predispose to TMD.13,26,27 toms of TMD. The questionnaire was formulated for this study
Since the introduction of the Primary Health Care Act 1972, 28 using commonly accepted and slightly modified questions included
free, population-­based dental visits have been provided to all chil- in the Helkimo index, 33 which is a validated tool for TMD assess-
dren and adolescents in Finland. These enable occlusal screening ment. The questionnaire and the response alternatives are listed
and monitoring of dental development in municipal health care. in Table 2.
Orthodontic treatment need is assessed using a 10-­grade assess-
ment method by Heikinheimo29 and its updates.30 Orthodontic
treatment is provided to the children and adolescents in health cen- 2.4  |  Occlusal indices
tres according to the severity of malocclusion. This context provides
the opportunity to evaluate in population-­based longitudinal mate- Occlusal characteristics were analysed by applying the Peer
rial, whether malocclusions or orthodontic treatment are associated Assessment Rating (PAR) Index.34,35 It consists of five components
with TMD symptoms. We hypothesized that neither orthodontic (upper and lower anterior segments, left and right buccal occlusions,
treatment, nor malocclusion, nor longitudinal changes in occlusion overjet, overbite and centre line) assessed from study models. The
are associated with the number of experienced TMD symptoms. scores for each component are multiplied by respective weightings
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EMMI et al.       3

TA B L E 1  Occlusal features assessed at ages 12, 15 and 32.

Age at follow-­up visit

12 years (n = 189) 15 years (n = 182) 32 years (n = 133)

Mean (range) Mean (range) Mean (range)

Occlusal trait
Overjet (mm) 4.4 (1.0–­11.0) 3.8 (−1.0–­10.0) 3.2 (−2.0–­12.0)
Overbite (mm) 3.5 (−2.0–­7.0) 3.3 (−2.0–­8.0) 3.1 (0.0–­11.0)
Maximal opening (mm) 51 (40–­65) 55 (43–­68) 52 (37–­66)
PAR score 11.8 (1.0–­32.0) 10.1 (0.0–­4 4.0) 11.0 (1.0–­42.0)

n (%) n (%) n (%)

Overjet
≤1 mm 1 (0.5) 4 (2.2) 11 (8.3)
2–­4 mm 104 (55.0) 124 (68.1) 97 (72.9)
≥5 mm 84 (44.4) 53 (29.1) 25 (18.7)
Missing 0 1 (0.5) 0
Overbite
≤1 mm 11 (5.8) 15 (8.2) 20 (15.0)
2–­4 mm 125 (66.1) 130 (71.4) 91 (68.4)
≥5 mm 50 (26.4) 37 (20.3) 22 (16.5)
Missing 3 (1.6) 0 0
Crossbite
No 164 (86.8) 155 (85.2) 115 (86.5)
a
Anterior 3 (1.6) 5 (2.7) 3 (2.3)
Posterior 22 (11.6) 22 (12.1) 10 (7.5)
Unilateral with displacement 4 5 2
Unilateral without displacement 7 3 5
Bilateral with displacement 1 3 0
Bilateral without displacement 3 0 3
Missing 0 0 5 (3.8)
a
Including 1 subject with anterior and unilateral posterior and 1 with anterior and bilateral posterior crossbite at 12 years and 1 subject with anterior
and bilateral posterior crossbite at ages 15 and 32. In all age groups, 1 subject with anterior crossbite only was registered with displacement.

(1–­6, depicting the degree of severity) and summed. Sum score zero 2.5  |  Outcome
refers to an ideal occlusion, whereas higher scores indicate larger
deviations from normal. The difference between the pre-­ and post-­ A categorical variable (TMD dysfunction score) was created merg-
treatment PAR scores reflects the degree of improvement. ing the seven TMD symptoms: locking of the jaw, experienced pain
All assessments were performed by one experienced ortho- in the area of TMJ, pain during mouth opening and/or chewing,
dontist who was calibrated with the use of occlusal indices. A total headache, TMJ clicking and/or crepitation. Each of these variables
of 21%–­31% of all assessments were repeated after an interval of was first dichotomized into non-­symptomatic (score 0—­including
4–­5 weeks. The reliability for PAR scores was good to excellent, with response alternatives ‘no’, ‘do not know’, ‘never’, ‘rarely’) and symp-
Chronbach's α .932 (12 years), .968 (15 years) and 0.894 (32 years) tomatic categories (score 1—­including response alternatives ‘yes’,
and Spearman correlations .820, .913 and .898, respectively. All p ‘sometimes’, ‘almost daily’, ‘once a week’, ‘two or three times per
values were <.001. month’) after which the final scores were summed.
For each subject, longitudinal changes in PAR scores were
analysed between ages 12–­15, 15–­32 and 12–­32 years. Based
on the PAR score changes, patients were categorised into three 2.6  |  Statistical methods
groups: worse occlusion, no difference and improved occlusion.
The PAR scores (mean values and range) are presented in Table 1, Comparisons between the longitudinal changes in groups were
Figure S2. made according to the patients' sex, TMD dysfunction score, PAR
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4      EMMI et al.

TA B L E 2  List of TMD symptoms included in the questionnaire and their prevalence at 12, 15 and 32 years as a percentage of the age
cohort (n = 195, n = 190 and n = 135, respectively).

12 years 15 years 32 years

Sample Treateda Untreated Sample Treateda Untreated Sample Treateda Untreated

Headache
Almost daily 2.3 5.3 1.1 0.8 0 1.1 1.5 0 2.0
Once a week 4.6 2.6 5.4 5.4 2.6 6.7 10.4 11.8 10.1
Two or three times per month 19.2 15.8 20.7 17.1 23.1 14.4 22.4 14.7 24.2
Rarely 60.8 71.1 56.5 62.8 64.1 62.2 55.2 70.6 50.5
Never 13.1 5.3 16.3 14.0 10.3 15.6 10.4 2.9 13.1
Pain during mouth opening 3.1 5.3 2.2 3.9 7.7 2.2 5.2 8.8 4.0
Pain during chewing 8.8 8.3 9.0 5.6 2.7 6.7 12.8 15.2 12.1
Pain in the area of TMJ 18.9 20.6 18.2 13.4 10.5 14.6 23.9 26.5 23.2
Locking of the jaw 3.2 0 4.4 8.7 5.2 10.1 15.8 12.1 16.2
TMJ clicking or crepitation 22.0 25.7 20.5 30.5 37.8 27.2 43.4 42.4 43.2
Tiredness or stiffness of the jaws 15.5 17.1 14.8 20.3 15.8 22.4 36.8 35.3 36.7

Note: The response alternatives were ‘yes’, ‘sometimes’, ‘no’ and ‘do not know’ excluding the question about headache (how often the symptom
appeared). For this table, the subjects were divided into non-­symptomatic (response alternatives ‘no’ and ‘do not know’) and symptomatic groups
(response alternatives ‘yes’ and ‘sometimes’). Regarding headache, the respondent was asked how often it appears.
a
Subjects with a history of orthodontic treatment.

score category and orthodontic treatment history. Differences be- crossbite alone or in combination with other deviations. A total of
tween the groups were analysed using cross-­t abulation and the chi-­ 57 subjects (29%) had received orthodontic treatment by the end of
square test. A multivariable logistic regression model was applied the follow-­up. In addition, there were seven subjects who had had
with subjective TMD symptoms (headache, pain symptoms and TMJ tooth extractions to relieve crowding. At 12 years, 23 orthodontic
sound—­all dichotomous variables) at 32 years as dependent varia- treatments were completed and 5 were ongoing; at 12–­15 years, the
bles, and sex, occlusal traits and orthodontic treatment as independ- numbers were 20 and 9, respectively. Twelve treatments were com-
ent variables. Separately for 12, 15 and 32 years old, a univariable pleted after the age of 15. Two patients discontinued orthodontic
logistic regression model was applied with the crossbite (including treatment during the follow-­up. At the last follow-­up, three patients
all types of crossbites) at 12, 15 or 32 years old as independent vari- were excluded from the study due to a history of jaw surgery (two
able and subjective TMD symptoms (headache, pain symptoms and orthognathic surgery patients and one trauma patient).
TMJ sound) as dependent variables. For statistically significant as- In general, subjective symptoms of TMD were common and their
sociations, the logistic regression was repeated with dichotomized prevalence seemed to increase with age (Table  2). Although 26%
crossbite (A) anterior crossbite only or anterior and posterior cross- of 12-­year-­olds, 23% of 15-­year-­olds and 34% of 32-­year-­olds re-
bite (including all anterior crossbites); (B) posterior crossbite only or spondents reported headache at least twice a month, headache on
anterior and posterior crossbite (including all posterior crossbites) a daily basis was reported by 0.8%–­2.3% of respondents in these
versus no crossbite. Results of the logistic regression model were age groups. The mean PAR score in the 12-­year-­olds was 12, in the
reported as odds ratios (OR) and 95% confidence intervals (CI). The 15-­year-­olds 10 and in the 32-­year-­olds 11.
association of categorised longitudinal changes in PAR scores and Boys whose PAR score increased between 12 and 15 years had
the crossbite were examined with the chi-­square test. p value .05 a simultaneous increase in the number of TMD symptoms as well.
was used as a cut-­off point for statistical significance. Data were This change was statistically significant (p = .039). Among all partic-
analysed with IBM SPSS Statistics 27. ipants, no other change reached statistical significance. According
to the logistic regression model, female sex was significantly as-
sociated with more self-­reported headache at 32 years of age (OR
3  |  R E S U LT S 2.4, 95% CI 1.05–­5.4; p = .038, Table 3). Any crossbite at 12, 15 or
32 years of age, whether treated or untreated, was significantly as-
A total of 97.5%, 95% and 67.5% of subjects were evaluated at 12, sociated with TMJ sounds (clicking or crepitation) at 32 years of age
15 and 32 years, respectively (Figure  S1). At age 32 years, there (OR 3.5, 95% CI 1.1–­11.6; p = .037). The association was not found
were 22 subjects who could not be reached; 10 subjects declined with anterior crossbite only (OR 0.9, 95% CI 0.1–­5.8; p = .874), while
to participate at the last follow-­up. The most common malocclusions with posterior crossbite association was found (OR 3.3, 95% CI 1.1–­
were crowding, Angle Class II division 1 malocclusion and posterior 9.9; p = .030).
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EMMI et al.       5

TA B L E 3  Adjusted odds ratios (OR) with 95% confidence intervals (CI) in multinomial logistic regression models by symptoms as predicted
by sex, occlusal traits and orthodontic treatment history.

TMJ sound at
Headache at 32 years Pain symptoms at 32 years 32 years

Characteristic OR (95% CI) OR (95% CI) OR (95% CI)

Female sex 2.4 (1.05–­5.4) 1.4 (0.6–­3.4) 0.9 (0.4–­2.1)

Prior orthodontic treatment 0.6 (0.3–­1.5) 1.0 (0.4–­2.6) 0.8 (0.3–­1.9)
Crossbite 1.1 (0.4–­3.3) 0.4 (0.1–­1.8) 3.5 (1.1–­11.6)
Anterior 0.9 (0.1–­5.8)
Posterior 3.3 (1.1–­9.9)
Overjet (reference = normal, 2 to 4 mm)
Low <1 mm 0.8 (0.1–­4.6) 1.1 (0.2–­6.8) 2.6 (0.4–­15.7)
High >5 mm 1.1 (0.5–­2.5) 1.5 (0.6–­3.6) 0.5 (0.2–­1.1)
Overbite (reference = normal, 2 to 4 mm)
Low <1 mm 1.4 (0.4–­4.6) 1.3 (0.4–­4.6) 0.4 (0.1–­1.3)
High >5 mm 1.0 (0.4–­2.4) 1.5 (0.6–­3.6) 1.5 (0.6–­3.7)

Note: Values with p < .05 bolded.

4  |   D I S C U S S I O N received or did not receive orthodontic treatment during the fol-

low-­up. Olliver et al.46 suggested that high overbite during adoles-
Considerable fluctuation of all TMD symptoms could be seen during cence is negatively associated with TMJ clicking later in life. Thus, a
the long follow-­up period. These findings are in line with few previ- growing body of evidence suggests no role for occlusion and ortho-
ous longitudinal studies on TMD signs and symptoms: Magnusson dontic treatment in the aetiology of TMD.
36
et al. followed subjects over two decades from childhood to adult- On closer inspection, there was a statistically significant associ-
hood and Mohlin et al.37 investigated the development of signs and ation between the longitudinal changes in PAR score and the TMD
symptoms of TMD between age 11 and 30 years. Könönen et al.38 symptom score for boys; subjects whose PAR score increased had an
studied TMJ clicking in young adults over 9 years. In these studies, increase in the number of TMD symptoms as well. Similar finding was
substantial fluctuations in TMD signs and symptoms were observed reported by Mohlin et al.,39 concluding that subjects with the most
and some severe TMD symptoms showed reduced severity or even severe TMJ dysfunction had significantly higher PAR scores com-
complete recovery over time.36,39 The current association between pared to subjects without signs and symptoms of TMD.39 However,
female sex and self-­reported headache is in agreement with prior there is still no consistent evidence supporting a causal relationship
epidemiological studies showing female predominance in the life- between these two variables.13,18
40
long prevalence of headache. Migraine is two to three times more The major strengths of this longitudinal study are the prospec-
common in women than in men possibly because of different sex tive design and the length of follow-­up time. The vast majority of
hormones and genetic factors.41 The results of this study may be previous studies investigating associations between occlusion and
confounded by the inclusion of headache in the TMD dysfunction TMD have been cross-­sectional19,20,23,24,47 and therefore they have
score. Prior studies have indicated a close relationship between not been able to follow individual changes occurring in occlusion and
headache and TMD.42–­4 4 However, besides TMD, headache can be TMD symptoms over time. The few other longitudinal studies with
related to other health problems like infections, vascular diseases longer follow-­up times36,39,46,48,49 support our finding that ortho-
and traumas.40 dontically treated subjects do not have a higher risk of TMD.
Certain types of malocclusion, such as unilateral posterior cross- From the current perspective, the lack of a validated TMD as-
bite, have been suggested to predispose to TMD symptoms.6,13,18–­20 sessment protocol can be seen as a methodological limitation.
We found that crossbite was associated with greater odds for self-­ Today, the Diagnostic Criteria for TMD (DC/TMD) and the Helkimo
reported TMJ sounds at 32 years. This finding is not supported by Dysfunction Index (HDI) provide widely used and validated tools for
recently published studies. Manfredini et al.18 concluded that the TMD assessment.8,33 At the inception of the current study, the HDI
evidence supporting associations between malocclusions and TMD was published only 3 years earlier and it was not used widely; the
is scarce, weak and inconsistent, and Farella et al.45 found no as- DC/TMD was not yet established. Thus, there were no commonly
sociation between unilateral posterior crossbite and TMJ clicking. accepted clinical tools to be used in the assessment of children or
Further, based on the results of a 10-­year follow-­up of unilateral adolescents. Recently, a panel of experts has developed new in-
crossbite patients, Michelotti et al. 22 concluded that the prevalence struments for the evaluation of TMD in children and adolescents
of self-­reported TMJ clicking did not differ between subjects who by modifying the DC/TMD.50 Moreover, due to the biopsychosocial
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6      EMMI et al.

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The authors have no conflict of interest.
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The data from this study are available from the corresponding au-
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