Protocols for orthodontic treatment of patients with temporomandibular joint disorders Gye Hyeong Lee, a Jae Hyun Park, b Da Nal Moon, c and Sang Mi Lee d Gwangju and Seoul, South Korea, and Mesa, Ariz Orthodontists often have trouble treating patients who have temporomandibular joint disorders because occlu- sion changes depend on the position of unstable condyles. This characteristic means the patients do not have definite criteria with which to make an accurate orthodontic diagnosis, so clinicians are unable to establish a reli- able treatment plan. This article reports on the treatment of a patient with skeletal Class II relationship and condylar resorption. A stabilization splint was used before any active orthodontic tooth movement to stabilize her condylar position. Although the patient exhibited dramatically increased open bite and a retruded mandibular position after splint therapy, her occlusion and facial esthetics were resolved by orthodontic camouflage treat- ment with appropriate orthodontic mechanics after extraction of 4 premolars. (Am J Orthod Dentofacial Orthop 2021;159:373-88) O rthodontic treatment of patients with a tempo- romandibular joint disorder (TMD) is one of the most challenging tasks for orthodontists because of constantly changing occlusion during the treatment as a consequence of the patient's unstable condylar po- sition. Patients with TMD often show degenerative changes of the temporomandibular joint (TMJ) struc- tures characterized by lysis and repair of the articular fibrocartilage and underlying subchondral bone. Degen- erative changes in TMJs are regarded as the result of a decreased adaptability in the articulating structures caused by unsuitable physical stress on the TMJ struc- tures. 1,2 These changes at the condylar level conse- quently result in specific skeletal and dental characteristics such as a retrusion of the chin and an anterior open bite. 3-5 Although a patient's TMD might not have progressed into a severe degenerative state, the condyles of TMD patients are usually in an unstable position because of comprehensive changes in the surrounding articular and muscular structures. This condition appears as dis- crepancies between centric relation occlusion (CRO) and maximum intercuspal position (MIP) at the occlu- sion level. In daily practice, clinicians are often horrified to find that a patient who originally presented with an Angle Class I canine and molar relationship has devel- oped a Class II relationship once orthodontic treatment has begun. Having CRO-MIP discrepancy means that or- thodontists lack definitive criteria for orthodontic diag- nosis because the condition denies them access to reliable information about the patient's occlusion. 1,6,7 Therefore, clinicians need a way to establish the sta- bility of the patient's TMJ, and splint therapy is regarded as the most effective and reliable tool for stabilization of the TMJ. Stabilization splints have been popular in treat- ing musculoskeletal disorders in TMJs. They also allow clinicians to predict patient response to future occlusal reconstruction with orthodontic treatment. 6,8-11 Patients with TMD often undergo significant changes in occlusion and facial profile after the use of a stabilization splint. The patient's Class II relationship usually worsens with a tendency to open bite and some- times facial asymmetry if unilateral changes are outstanding. It is not a pathologic change, but the result a Roth Orthodontic Society, and Department of Orthodontics, School of Dentistry, Kyung Hee University, Seoul, South Korea; Department of Orthodontics, Grad- uate School of Dentistry, Chonnam National University, Gwangju, South Korea. b Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Ariz; Graduate School of Dentistry, Kyung Hee Univer- sity, Seoul, South Korea. c Graduate School of Dentistry, College of Medicine, The Catholic University of Korea, Seoul, South Korea. d Graduate School of Dentistry, Chonnam National University, Gwangju, South Korea; College of Medicine, The Catholic University of Korea, Seoul, South Korea. All authors have completed and submitted the ICMJE Form for Disclosure of Po- tential Conflicts of Interest, and none were reported. Address correspondence to: Jae Hyun Park, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, 5835 E Still Circle, Mesa, AZ 85206; e-mail, [email protected]. Submitted, April 2020; revised, August 2020; accepted, September 2020. 0889-5406/$36.00 Ó 2020 by the American Association of Orthodontists. All rights reserved. https://doi.org/10.1016/j.ajodo.2020.09.023 373 CLINICIAN'S CORNER
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