THE COURTROOM DRAMA:
In 1987, a legal case shook the foundations of orthodontic practice: Brimm vs Malloy, Michigan.
- Susan Brimm, 16, underwent orthodontic treatment involving upper premolar extractions, fixed appliances, and headgear to correct a Class II Div. I malocclusion with a 7 mm overjet.
- She had no signs of TMD before or during treatment.
- Post-treatment, she developed TMJ pain and headaches aggravated by her retainer.
- Oral surgery to remove mandibular third molars worsened her symptoms—leading to clicking and chronic TMJ pain.
Two
lawsuits followed. The oral surgeon settled for $2,500, but the orthodontist
was found liable in court—despite defense by licensed specialists—and Brimm was
awarded $850,000.
The
allegations? That extractions led to
over-retraction, mandible displacement, and internal derangement of the TMJ.
Research Responds: The
1992 AJODO Landmark:
In response
to the controversy, the American
Association of Orthodontists formed
a task force in 1988: the Scientific
Studies Committee. They launched a series of rigorous
investigations—both cross-sectional and longitudinal—to address concerns about
orthodontics and TMD.
The
findings were published in a dedicated 1992
issue of AJODO, marking a turning point in the profession. The
evidence clarified:
1. No
significant associations between occlusion/skeletal structures and TMD.
2. TMD
development cannot be reliably predicted.
3. No
validated method of prevention exists.
4. Symptoms
often begin in adolescence—during treatment but not caused by it.
5.
Orthodontic treatments do not cause TMD.
6.
Orthodontics may help some TMD patients as part of interdisciplinary care.
7. Once present,
TMD symptoms cannot be assumed to be curable.
Science
spoke. Loudly. But confusion lingered—especially online and in clinical
conversations.
Three Decades of Evidence
on TMDs and Orthodontics (1992–2022)
Orthodontic Treatment and
TMDs:
Over 30
years of research shows no causal link between orthodontic treatments
(with or without extractions, use of headgear, elastics, etc.) and the
development of temporomandibular disorders (TMDs).
Incisor
retraction does not displace condyles or lead to TMJ disk issues.
Debunking Mechanical
Theories:
Traditional concepts like achieving canine-protected occlusion or matching centric relation (CR) with maximum intercuspation (MI) have been shown to be clinically irrelevant for TMD prevention or cure.
Physiological Approach:
Maintaining the patient’s original condyle-fossa relationship and avoiding unnecessary repositioning is the safest.
Biopsychosocial Model of TMD Care
TMDs are now understood as multifactorial neuromuscular
conditions, influenced by biological, psychological, and social factors—not
just occlusion or jaw position.
Studies (e.g., OPPERA trials) and placebo-controlled
experiments demonstrate that conservative, reversible treatments are
often as effective as aggressive dental interventions.
Modern TMD care involves interdisciplinary collaboration
with physicians, psychologists, and pain specialists.
Orthodontist's Clinical
Takeaways
1. Stay
updated with modern TMD research.
2. Avoid
outdated mechanical models for TMD diagnosis or treatment.
3. Perform
TMD screening before starting orthodontic care.
4. Educate
patients about TMD risks and findings.
5. Document
thoroughly and obtain informed consent.
6. Pause
treatment if TMD symptoms emerge.
7. Use conservative,
non-invasive approaches for managing TMDs.
REFERENCES:
- Temporomandibular Disorders and
Orthodontics: What Have We Learned From 1992–2022?
- Temporomandibular Disorders – Current Concepts* by Rosaria Bucci, Roberto Rongo, Ambra Michelotti
Nice research - good effort in summarization of evidence. Thank you doc for sharing! Keep posting such interesting topics😄
ReplyDeleteThank you 😊
DeleteYou should not stop your reading of TMD research in 1992 nor limit it to articles commissioned by the AAO in response to a lawsuit.
ReplyDeleteNor should you educate colleagues on occlusion and TMD without engaging with the current body of research in the field. Peer-reviewed studies published in the last decade have established a correlation between premolar extraction and TMD risk. Londono (2022), for example, found that 25% of extracted subjects demonstrated altered mandibular kinematics—changes identified as a potential risk factor for TMD.
The claim that “no causal link has been proven” reflects limitations of study design in previous studies, not absence of evidence.
The 1992 literature (e.g., Rinchuse et al.) was based on the premise that occlusion has no relationship to the TMJs. This premise is no longer accepted. Current TMD studies recognize occlusion as a potential contributing factor to TMD. Contemporary orthodontic training programs in TMD management also recognize this relationship.
Basic anatomy contradicts the claim that occlusion and jaw positioning are irrelevant to TMJs. Mandibular position determines the condylar position; posterior displacement alters joint loading.
For accuracy, the Brimm vs. Malloy case docket is 1986.
How are you so god damn thick!? you're in denial of basic anatomy. of course the teeth affect how the jaw works. it's a basic application of netwon;s third law.
ReplyDeleteAntes de tratar de estúpido a alguien debes mirarte al espejo, atiendo hace 30 años pacientes con problemas articulares, soy especialista en 3 áreas ortodoncia, rehabilitación oral (prostodoncia) y trastornos temporomandibulares, he diagnosticado y atendido mas de 10.000 pacientes, yo soy clínico no investigador, yo veo dolencias y resultados, y puedo confirmar que lo que comenta el colega es muy certero...no hay evidencia ni para uno ni para otro lado, muchos factores afectan la ley de Newton en atm la cual actúa como palanca de clase 3, altura, peso, sexo, simetría facial y corporal, tamaño óseo, hábitos, tamaño y proporcionalidad del cuerpo, actividad física y laboral, antecedentes de enfermedades respiratorias, accidentes, cirugías, anestesias generales al cual se haya sometido el paciente, alteraciones posturales, alimentación, enfermedades sistémicas etc, podría llenar la pagina de factores que predisponen los trastornos temporomandibulares, por lo que afirmar que es un factor desencadenante es una falacia que solo puede mencionar un ignorante e inexperto del area
DeleteWhat a surprise. The exact same thing happened to me. Extracted premolars for orthodontic treatment then removed impacted wisdoms. Now my lower jaw is misaligned. I was diagnosed with TMJ and it impacts my ears too. Noone is willing to take responsibility for their actions! They just normalize removing teeth, so sad. If your toes don’t fit in your narrow shoes, will you cut the pinky off?
ReplyDeleteThe amount of abuse and gaslighting from the medical field is stunning. People who never had any condition keep telling people living with the condition what they can feel and what the can not feel.
ReplyDeleteThere is a huge body of research showing that TMD is heavily influenced by mandible position - the lower jaw displaced back causes TMD symptoms. All retraction actions causes this posterior displacement (IPR, premolar extractions, 3-d molar extractions). Yet you keep denying it.
It doesn’t make sense that when the condyle is shifted that it won’t affect TMJ function. This is a delicate complex system that works together with many parts, of course it can be negatively affected by any change. That would be like saying if you move a wheel to the very edge of a wheel well and suddenly have clunking, wear and the car has trouble driving straight that it can’t be due to changing the location of the wheel. Orthodontists study mechanics, they should know this and shouldn’t be so susceptible to misinformation even if it conveniently absolves them from liability.
ReplyDelete