Clinical evaluation of temporomandibular disorders in children and adolescents: a review of the literature

AIM

The abbreviation TMD (temporomandibular disorders) has been used to signify the variety of symptoms, signs and combinations that have often been assigned to the TMJ (temporomandibular joint) and its related structures (muscles, bone and facial structures). The prevalence of temporomandibular disorders in children and adolescents varies widely in literature. The most common signs and symptoms of TMD are: temporomandibular joint sounds, impaired movement of the mandible, limitation in mouth opening, preauricolar pain, facial pain, headaches and jaw tenderness on function. Many studies have shortcomings in their method of assessing or measuring TMD: the problem is probably due to the fact that temporomandibular disorders have multiple aetiological factors. The aim of this article is a review of the literature about the diagnostic procedures used to assess signs and symptoms of temporomandibular disorders in children and adolescents.

MATERIALS AND METHODS

Literature was searched using Medline, Embase, and Cochrane Library from 1992 to February 2008. Only articles written in English were included in the study. The key words and mesh used were: temporomandibular disorders, mandibular dysfunction, children, adolescents. The inclusion criteria were: symptoms and signs of TMD, questionnaire, clinical protocol examination. Clinical studies as well as cross-sectional studies, longitudinal and epidemiological researches were considered. The articles reviewed were grouped according to the diagnostic procedure used.

RESULTS

Out of the 37 articles selected, the Helkimo Clinical Dysfunction Index was used in 6 studies (16.22%), the CMI Index in 1 (2.70%), the RCD/TMD in 9 (24.33%) and a clinical protocol examination in 21 (56.75%) articles.

CONCLUSION

The review of the literature shows that clinical examination protocols without reproducible items and a measurable and reproducible classification into diagnostic subgroups was the type of investigation used in most of the cases. This ended in a multitude of different results depending on the criteria used and the method of data collection. Such methodological problems should be acknowledged in studies relating to TMD in order to obtain a reliable diagnostic procedure.

Absence of soluble CD14 in saliva of young patients with dental caries

It is generally accepted that salivary components are important for dental health, but to date no clear correlation has been found between one or more of these components and the outcome of dental caries. The identification of salivary factors preventing, favoring or signaling dental caries might help to control the disease. In the present study, western blotting analysis of whole saliva from 20 healthy caries-free children showed the presence of the soluble form of CD14, a bacterial pattern-recognition receptor for many bacterial components that is involved in the innate immune response. The identity of the protein was confirmed through N-terminal sequencing by Edman degradation, and by partial sequencing with mass spectrometry of tryptic peptides. Conversely, CD14 was completely absent in the saliva of 20 age-matched patients affected by two to eight carious lesions, but appeared in their saliva a few weeks after dental restoration. These results suggest that the absence of salivary soluble CD14 could represent an useful index of caries activity, and might be used to detect early carious lesions not visible by oral inspection.

TMJ internal derangement treatment in the growing patient: effect of functional appliance therapy on condyle and fossa relocation

New biodynamic factors seem to be involved on condyle and fossa remodeling and relocation, conditioning to mandibular growth direction, size and morphology. The understanding of the mechanism of action is critical for treatment of TMJ dysfunction in children and youths for those who hope to treat and retain the achieved correction during growth. The purpose of this article is to describe a specific, non-muscular hypothesis that explains the way the condyle modifies and the fossa remodels and relocates to achieved a new therapeutic, stable position, creating an anatomical base for long-term retention of the results. A case report of a young patient will be illustrated and available clinical data will be discussed.

The importance of early recognition of condylar fractures in children: a study of 2 cases

Maxillofacial fractures in general and mandibular fractures in particular seem to be less common in children than in adults; however, this finding might be influenced by the fact that condylar fractures in children are often undiagnosed and so the true incidence is likely to be higher than that reported in literature. Traumatic lesions of the temporomandibular joint often are overlooked as they can apparently occur with relatively little pain, few clinical signs, and insufficient reaction by the child to alert an adult to the seriousness of the injury. Only 1 to 2 years later, when growth disturbances appear, are they perceived as a problem, but by that time, the dysplastic growth pattern has stabilized and will continue over a period of years. The problem is frequently underestimated because of the difficulties inherent in pediatric pain assessment. The fact that the mechanisms of pain perception in children differ somewhat from adult pain perception mechanisms is one factor that can make pediatric pain assessment difficult. This paper outlines 2 case reports that draw attention to pain in children in the case of temporomandibular joint injury. The inability to assess pain adequately may lead to a delay in diagnosis and treatment and possibly result in future growth disturbances and facial asymmetries.

Scleroderma: a case report of possible cause of restricted movement of the temporomandibular joint with effects on facial development

Scleroderma is a rare abnormality in which fibrosis of the skin, subcutaneous tissues and muscle may occur. All forms of scleroderma are rare in childhood: the most common form is localized scleroderma. Localized scleroderma is often benign, but may cause significant deformity, if it occurs on the face or extends across joint surfaces. Structural changes may occur in the osseous tissue and result in mandibular joint restriction (pseudoankylosis) and facial and occlusal disharmonies. This article describes a case of facial linear scleroderma in a nine-year-old child and the treatment performed to minimize consequences on occlusion and face development. Available clinical data will be illustrated.

Biology and mechanics of facial asymmetries in children and youths

There is a need for further knowledge about the normal and abnormal growth patterns of bones and teeth. Genetic make-up, as well as various types of diseases and injuries such as trauma, inflammation, radiation and chemicals may affect skeletal and dental growth sites, thereby causing faulty growth. The degree of the subsequent deformity depends not only on the type, intensity, extent and chronology of the noxious agent, but also on the site and its particular involvement in growth activity. The knowledge of what happens to the stomatognathic system when some of its parts are altered is very important. Dentists are challenged to visualize the entire system in all its relationships: they must visualize the dynamics of how the system works. The relationship of the maxilla to the mandible and the mechanics of the stomatognathic system must be considered as a whole when considering the occlusion. The aim of this paper is to focus attention on the biologic basis of facial asymmetries and the functional reasons for their stabilization.

Post-traumatic TMJ internal derangement: impact on facial growth (findings in a pediatric age group)

Many clinical studies have shown how jaw injuries sustained during impact trauma to the face or mandible are the single most important cause of TMJ subsequent internal derangement. Proper function of the masticatory system is certainly the most influential variable in the TMJ remodelling; once a TMJ is internally deranged, adaptative or degenerative osteocartilagineous processes take place in the mandible, temporal bones and muscles. To evaluate relationships between consequences of post-traumatic TMJ internal derangement and disturbed facial skeleton growth in children, 25 patients (16 boys 9 girls), 14 year of age or younger, were selected out of a group of 74 and analysed. They all had been treated by physiotherapy and had undergone combined clinical and radiographic examination for five years. Symptoms included either individually or in various combination, pain, mechanical TMJ dysfunction and facial skeletal abnormalities, such as mandibular retrognathia and lower facial asymmetry manifested by chin deviation from the midline. Seventeen patients were found to have at least one abnormal and internally deranged TMJ on imaging studies; in twelve of them a mandibular asymmetry with chin deviation from the midline to the smaller or more degenerated TMJ was evident. Of the eight retrognathic patients, five were found to have bilateral TMJ derangement. In three patients both TMJ(s) were normal with normal facial structure. These data suggest that TMJ derangement in children may potentially have an impact on facial growth and lead to the development of retrognathia, with or without asymmetry, in many cases.

TMJ fractures in children and adolescents: treatment guidelines

TMJ fractures must be focused not only as a cause of direct damage to osseous structures, but also of future disturbances of dentofacial development. Treatment is aimed at restoring normal joint function, occlusion and symmetry. Any disturbance of condylar cartilage will result in alteration of mandibular development. The subsequent deformity of jaw and face will depend not only on the type, intensity extent and chronology of the noxious agent, but also on the particular time of occurrence and growth activity. Thus the effect will be more decided if the disturbance occurs early in life, during childhood, when growth activity is greater and mandibular shape and size have not been assumed yet. This report will include basic information on both prevention and first aid in these types of injuries. The correct application of these precautions immediately following the trauma should improve the short and long-term outcome. Information on diagnosis and treatment of lesions of the bone and soft tissues, which may coexist with dental trauma, a critical first step in the overall management of traumatized patients, will be given. Follow-up procedures of these patients will be illustrated. The guidelines described in this paper for the treatment of traumatic TMJ fractures in children and youths are based on our clinical experience. They are intended as an aid to practioners in the management and treatment of these traumas, by professional must always use professional judgement. There are no guarantees of any positive results associated with the use of these guidelines, although it is felt that time and proper treatment will maximize the chances of success.

[The role of saliva in maintaining oral health]

It is now established that saliva is important for the health of both soft and hard oral tissues. This article focuses on the role played by saliva in influencing oral structures: the most important factors related to it will be illustrated. The action of saliva and the multifunctional aspects of its components in both detrimental and beneficial effects on oral health are underlined.

TMJ fractures in children: importance of functional activation of muscles in preventing mandibular asymmetries and facial maldevelopment

Normal development of the mandible as well as some portions of the upper jaw and face are related to good function of the masticatory apparatus: the integrity and interaction of bony and soft-tissue structures may be highly disturbed by injury of the TM joints and result in facial and occlusal disharmonies. When the neuromuscular system is in harmony, the mandibular muscles collectively exert their effect on both position and movement of the jaw and the loading of forces on the TM joints is optimal and balanced. Unfortunately, TMJ fractures may alter completely this balance with loss of the support to the mandible against the temporal component and loss of the functional effect of the lateral pterygoid muscle on the mandible. Disturbances in the harmonious interplay of the masticatory muscles may result in facial alteration and asymmetries. If not treated, the dysplastic patterns of growth continues and worsens during the years.

Treatment of condylar fractures in children and youths: the clinical value of the occlusal plane orientation and correlation with facial development (case reports)

The relative position of the plane of occlusion to the cranial base determines the direction of the forces generated in the cranium during occlusal function. When the plane of occlusion is level and when the neuromuscular system is in harmony, the vectors of forces created by the closing muscles are directed to the central area of the cranium in a symmetrically balanced way. Unfortunately, TMJ fractures may alter completely this balance with loss of the support to the mandible against the temporal component and loss of the functional effect of the lateral pterygoid muscle on the mandible. Changes in orientation of the occlusal plane may result in facial alteration and asymmetries. In our experience, the restoration of a plan of occlusion orthogonally aligned to the forces of occlusion for a correct transfer of forces through the maxilla to the rest of the cranial bones is essential to allow proper face development. Two, quite similar cases of unilateral, dislocated condylar fracture treated in a different way, will be reported to demonstrate how this can occur. Available clinical data will be illustrated.

Condylar fractures treatment in children and youths: influence on function and face development (a five year retrospective analysis)

To evaluate relationship between consequences of TMJ fractures in children and disturbed facial skeleton growth, 46 children (18 girls, 28 boys), who were 14 years of age or younger and had undergone combined clinical and radiolographic examination for five years were retrospectively analyzed. Imaging studies were performed to investigate symptoms that included, either individually or in various combinations, pain, mechanical TMJ disfunction and facial skeleton abnormalities. The children were divided into two groups: those belonging to the former had been treated by functional orthopedic method alone, while the others had just been treated by physiotherapy. Both TMJs were normal in the patients treated functionally and they all showed normal facial structure, while different types of alterations (ranging from inflammatory to mechanical and structural ones) were observed in the others. We concluded that therapeutic procedures adopted after TMJ fractures in children are essential in minimizing consequences on occlusion and facial development.

Ankyloglossia and its influence on maxillary and mandibular development. (A seven year follow-up case report)

The consequences of not treating improper tongue function may be very important as this organ can influence face development and dental therapy. The role of the tongue in the development of the skeletal structures of the face has been considered in different perspectives over the years. For some, the tongue adapts to the "tongue box," for others the "tongue box" has been created and stabilized by the morphogenetic action of the tongue during development and growth. A case of ankyloglossia treated with lingual frenectomy and followed clinically and radiologically for seven years is reported. Spontaneous upper arch expansion occurred and therefore orthodontic treatment following surgical intervention was unnecessary.

The marginal seal of various restorative materials in primary molars

The use of resin composite restorations in posterior teeth has become an accepted clinical procedure. Microleakage at the posterior composite/tooth interface is a major problem. The in vitro quality of the marginal seal was tested in eighty teeth extracted for orthodontic reasons using a glass-ionomer cement reinforced with amalgam, two light self-curing glass-ionomer cements and a compomer. All the teeth were subjected to thermocycling to simulate clinical situation. Compomers showed the best mechanical and esthetic properties combined with a good marginal seal.

Apexification in the endodontic treatment of pulpless immature teeth: indications and requirements

The problems of performing the apexification technique, the indications and requirements for apexification are discussed. A case report is shown as an example.

[Dilacerations: the clinical, diagnostic and therapeutic problems]

The authors consider the problems connected with diagnosis and prognosis of dilaceration. Case reports of varying prognosis importance are given as examples.

A SEM investigation on pulpal-periodontal connections in primary teeth

The ideal goal of pulpotomy procedure in a primary tooth is to maintain space length, preserve masticatory function, and remove infection and chronic inflammation from the oral cavity. From a population of 150 patients between the ages of four and seven years, we collected a sample of 30 primary (nine maxillary and twenty-one mandibular) molars used in this investigation. The aim was to observe the presence of accessory channels on the pulpal floor; they were found in twenty-one of the thirty teeth examined. The scanning electron microscope proved to be an excellent means of evaluating the pulpal floor, where failure of pulp treatment often has its cause.

[The illustration of a health education program directed at children in the 1st and 2d elementary grades. Preliminary notes]

The paper describes an experimental health education plan for children in the first and second years of primary school. The plan focuses on nutritional and dietary aspects and the correlations between diet, oral hygiene and dental health.

[Space maintenance: indications and limits]

Space maintainers are very important in the prevention of malocclusions. Their indications and limits are described.

[The long-term clinical follow-up of a group of patients subjected to surgical intervention for the extraction of supernumerary impacted teeth]

A long-term clinical control carried out on 34 patients subjected to surgery for the removal of included extra teeth at the Odontostomatological Clinic of the University of Turin is reported. The patients had mostly been treated at ages between 7 and 12 followed up between 4 and 8 years later. Long-term damage, from an orthodontic viewpoint also, is not frequent and when present is not of particular importance. The operation, carried out early and with correct technique, does not cause particular damage to teeth or adjacent bone or nerve structures and does not create psychological traumas for the young patient. It is therefore advisable for the surgical removal of extra included teeth which are causing damage to adjacent structures to be programmed as early as possible so as to permit maximum functional and aesthetic recovery and to minimise to the utmost the consequences of the operation.

[Comparison of the P.C.F. orthodontic device and Bassani's orthodontic plate in the correction of malocclusion class II, division II]

We have described and compared the P.C.F. of protusiva and the plaque of Bassani in the correction of the II class and II division by mentioning the advantages of the first one.

[Clinico-surgical evaluation of supernumerary dental anomalies]

The pathology of extra teeth is evaluated on the basis of clinico-operative statistics for the years 1981-1985 and comprising 88 patients for a total of 115 treated teeth. The data obtained confirm the higher frequency of extra teeth in male patients. The most frequent site is easily the frontal sector of the upper arch. At that level, especially in males, two more or less symmetrical extra teeth are not infrequent. These data are in substantial agreement with the epidemiological data reported in the literature. Extra teeth are usually treated by surgical removal followed by orthodontic treatment to correct malformations caused by them and to recover the functional and aesthetic role of the upper front teeth.

[Recent findings on amelogenesis and mineralization of dental enamel]

The latest thinking reported by the literature on the amelogenesis and enamel mineralisation process has been synthesised.