Editor's note: “Patient History 101” is a series of four articles from Dr. Jim McKee with advice on how to obtain accurate and helpful patient history:
• Lesson 1 (Jaw Joints)
• Lesson 2 (Joint Injuries)

Understanding the condition of joints through assessing the soft and hard tissue in the temporomandibular joints allows dentists to have realistic discussions with patients about the likelihood of successful restorative treatment. In many cases, it's possible to gain an insight into the joint condition by understanding previous dental treatments.

Questions about previous treatment

Have you ever had orthodontic treatment for a Class II occlusion (overbite/overjet)?
A common clinical presentation of Piper 4A/4B and 5A/5B joints is a Class II occlusion. Daniele Manfredini wrote his systematic review of literature in the Journal of Oral and Maxillofacial Surgery in 2016 in which he said, “It seems reasonable to suggest that skeletal Class II profiles and hyperdivergent growth patterns are likely associated with an increased frequency of TMJ disk displacement and degenerative disorders.”

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Did you have any teeth extracted for orthodontic treatment?
Extractions for orthodontic treatment are usually recommended if there is not enough growth of the mandible and the maxilla to accommodate the normal number of teeth. In many of these cases, the reason the mandible and the maxilla did not grow normally is due to changes in the jaw joints.

As Carlos Flores Mir wrote in his 2006 American Journal of Orthodontics and Dentofacial Orthopedics article, “TMJ disc abnormality was associated with reduced forward growth of the maxillary and mandibular bodies. TMJ disc abnormality was associated with reduced downward growth of the mandibular ramus.”

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Did you have headgear during orthodontics?
Headgear typically slows maxillary growth to allow for the mandible to “catch up.” The reality in many of these cases is the mandible is unable to catch up because the disk is not covering the bone to promote normal growth. As Hiroko Hasegawa wrote in the 2011 Journal of Craniomandibular Practice, “Alterations in disk position, evident on MRI, affect the normal physiology, lubrication, nutrition, and function of the joint. This may be adequate to disturb the normal adaptive capacity of the condylar cartilage, resulting in a loss of equilibrium in the growing condyle. Disk displacement may be associated with similar alterations in facial morphology.”

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Did you have an orthodontic appliance that moved your lower jaw forward?
Functional appliances, such as a Herbst appliance, advance the mandible with the hope the condyle will grow and fill the space that was created when the mandible was advanced. In many patients, the reason the mandible required advancement was due to an early joint injury, which displaced the disk and negatively impacted growth.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Did your orthodontic treatment take longer than two years?
When orthodontic treatment requires more time than normal, it would be prudent to evaluate the amount of tooth movement required. In many of these cases, there is a severe Class II occlusion or a facial asymmetry that is the result of a disk displacement with altered growth. In these cases, it may take longer than normal to complete orthodontic treatment given the altered tooth position from altered growth.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Have you ever had orthodontic treatment more than once?
Bite changes after orthodontic treatment can occur for several reasons. One reason could be a lack of joint stability if the disk does not cover the medial pole of the condyle. The occlusion can change due to changes in soft tissue anatomy (disk) or hard tissue anatomy (condyle/joint socket).

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Have you had multiple occlusal appliances?
An occlusal appliance is the most common initial treatment for patients with structurally altered joints. If multiple occlusal appliances trying to change the occlusion at the tooth level cannot resolve the problem, the issue may be at the joint level.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Have you had multiple bite adjustments?
Similar to occlusal appliances, if multiple attempts to balance the occlusion at the tooth level through equilibration are not successful, the changing bite may be due to structural changes at the joint level.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Have you had upper or lower jaw surgery to change your bite?
If a patient requires orthognathic surgery, there is an increased likelihood of altered growth of the mandible, maxilla, or both. Joint imaging with MRI and CBCT should be a routine part of the pre-surgical workup for all orthognathic cases.

If patient answers affirmatively, there is an increased chance for a Piper 4A/4B, 5A/5B joint.

Jim McKee, D.D.S., is a member of Spear Resident Faculty.

References

Flores-Mir C, Nebbe B, Heo G, Major P. Longitudinal study of TM joint disc status and craniofacial growth. American Journal of Orthodontics and Dentofacial Orthopedics. 2006;130(3):324-330.

Hasegawa H, Saitoh I, Nakakura-Ohshima K, Shigeta K, Yoshihara T, Suenaga S, et al. Condylar shape in relation to anterior disk displacement in juvenile females. CRANIO®. 2011;29(2):100–110.

Manfredini D, Segu M, Arveda N, Lombardo L, Siciliani G, Rossi A, et al. Temporomandibular joint disorders in patients with different facial morphology. a systematic review of the literature. Journal of Oral Maxillofacial Surgery. 2016;74(1):29–46.

Piper M. Temporomandibular Joint Imaging. In: Handbook of Research on Clinical Applications of Computerized Occlusal Analysis in Dental Medicine. Hershey, PA: Medical Information Science Reference; 2020:582-697.


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