Daniele Manfredini received his DDS from the University of Pisa, Italy in 1999, a MSc in occlusion and craniomandibular disorders in 2001 from the same University, a PhD in dentistry from ACTA Amsterdam, The Netherlands, in 2011, and a post-graduation specialty in orthodontics from the University of Ferrara, Italy, in 2017. After holding several teaching duties at the University of Padova, he currently undertakes teaching in oral physiology and in clinical gnathology at the School of Dentistry, University of Siena, Italy. He is also visiting professor at the School of Orthodontics, University of Ferrara, Italy. In January 2017, the Italian Ministry of University and Research appointed him a full professor by scientific merit.
Dr Manfredini has authored more than 180 papers in the field of bruxism and TMD. He has also edited or co-edited several textbooks and book chapters on bruxism, TMD, and orofacial pain. Based on publication ratings, since November 2013, the US agency, Expertscape, has ranked Dr Manfredini as the world #1 expert in the field of TMD as well as among the top three experts in the field of bruxism.
Temporomandibular Joint and Orthodontics
This lecture will provide an overview of the orthodontist’s role in the practice of temporomandibular disorders (TMDs). Decades of clinical research have provided growing scientific evidence on the absence of a relationship between features of dental occlusion or condylar position and TMDs. They also shed light on the need to focus on neurological and psychological issues for correct management of patients with temporomandibular joint (TMJ) and jaw muscle pain. Whilst this evidence is fully embraced by dentists with expertise in the orofacial pain field, it is still a difficult concept for some orthodontists. Claims that there is purported clinical evidence in support of mandibular repositioning and orthodontic finalization, on an anecdotal basis and inductive reasoning, is the best argument to confute any scientific reasoning. Invasive treatments in the form of irreversible occlusal changes and extended treatment are thus still proposed, against any recommendations by the expert academics.
Some arguments to discourage orthodontic treatment of TMDs are based on our knowledge of oral physiology. For instance, teeth almost never really touch in maximum intercuspation; movement guidance is important for an articulator, but never performed in real life; features of the interarch relationship are just a static frame; condylar position is asymmetric by definition; the condyle-fossa or condyle-disc relationship cannot be ‘corrected’ only on one side, and this is important if one considers that most patients have unilateral symptoms.
Consequently, it is not surprising that the literature dismantles such theories. For instance, how to explain TMD pain in patients with a good occlusion? What about the absence of symptoms in patients with a poor occlusion? What about the many patients with asymptomatic osteoarthrosis? Only anecdotes can help an occlusal practitioner find an explanation.
In summary, orthodontics can be considered neutral, at best, for the TMJ. It cannot cure TMD, but it is also unlikely that it causes TMJ symptoms. Knowledge on the epidemiology of TMJ sounds is fundamental for understanding the latter statement.
So, what should an orthodontist do? The key issue is understanding that TMDs are mainly due to an emotional overload, which leads to muscle tension and, via host response, to the onset of signs and symptoms. The orthodontist will often see an individual with emotional distress, and without any occlusal or TMJ positional clues to explain symptoms, when compared with asymptomatic individuals. Depending on the symptoms, management strategies range from very simple behavioural advice for the control of daytime bruxism to complex multimodal strategies. Within the concept of overload, an oral appliance is just a crutch…not the cure or a diagnostic device…and thinking of it makes everything immediately fit with all the clinical knowledge…easy, isn’t it?
Aim, Objectives & Learning Outcomes
- Aim: To describe the factors which contribute to the development of TMD and to highlight the role of the orthodontist in this area.
- Objectives: To illustrate the importance of understanding the key aetiological factors in the development of TMD and give practitioners guidance on the management strategies available.
- Learning outcomes: Following this presentation, attendees should have contemporary knowledge about TMD and be able to advise affected patients regarding the management options which exist.