European Journal of Orthodontics 35 (2013) 737744 The Author 2013.

r 2013. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:doi:10.1093/ejo/cjt024 All rights reserved. For permissions, please email: journals.permissions@oup.com
Advance Access publication 18 April 2013

Association between posterior crossbite, masticatory muscle

pain, and disc displacement: a systematicreview
GiorgioIodice*, GianlucaDanzi*, RobertaCimino*, SergioPaduano**, and
AmbraMichelotti*
*
Department of Dental and Maxillo-Facial Sciences, Section of Orthodontics and Gnathology, University of Naples
Federico II and **Department of Orthodontics, University of Catanzaro, Magna Graecia, Italy

Correspondence to: Giorgio Iodice, School of Dentistry, Department of Dental and Maxillo-Facial Sciences,
University of Naples Federico II, Via Pansini, 5, I-80131 Naples, Italy. E-mail: iodicegiorgio@gmail.com

SUMMARY
Background Among different malocclusions, posterior crossbite is thought to have a strong impact on
the correct functioning of the masticatory system.
Objective To assess, by systematically reviewing the literature, the association between posterior
crossbite and different temporomandibular disorder (TMD) diagnosis: disc displacement and masticatory
muscle pain.
Materials and methods Aliterature survey covering the period from January 1965 to April 2012 was
performed. Two reviewers extracted the data independently and assessed the quality of the studies.
Results The search strategy resulted in 2919 citations, of which 43 met the inclusion criteria. The
scientific and methodological quality of these studies was found to be medium-low, independently by
association reported. In several studies, posterior crossbite is reported to be associated to the develop-
ment of disc displacement, muscular pain, and tenderness, possibly linked to a skeletal and muscular
adaptation of the stomatognathic system. However, the lack of consistency of the results reported
deeply reduces the external validity of the studies, with a consequent impossibility to draw definite
conclusions.
Conclusions It is not possible to establish an association between posterior crossbite, muscle pain, and
disc displacement because the distribution of the studies supporting or not supporting the association
is similar. The consequences of posterior crossbite on the development of TMDs deserve further inves-
tigations, with high sample size, well-defined diagnostic criteria, and rigorous scientific methodologies.
Finally, long-term controlled studies are needed to identify posterior crossbite as a possible risk factor for
TMDs.

the masticatory muscles (Sonnesen etal., 2001) and head-

Introduction
Posterior crossbite is defined as the presence of one or more
teeth of the posterior group (from canine to second molar)
in an irregular (at least one cusp wide) bucco-lingual or
bucco-palatal relationship, with one or more opposing teeth
in centric occlusion (Daskalogiannakis, 2000). It is one of
the most prevalent malocculsions in the primary and early
mixed dentition and is reported to occur in 822% of ortho-
dontic patients (Sonnesen et al., 1998) and in 515% of the
general population (Thilander and Myrberg, 1973; Helm
and Pryds, 1979; Ciuffolo et al., 2005; Farella et al., 2007).
Among different malocculsions, posterier crossbite is
thought to have a strong impact on the correct function-
ing of the masticatory system (Proffit, 2000; McNamara,
2002). It has been suggested that the altered morphologi-
cal relationship between the upper and lower dentition may
result in righttoleftside differences in masticatory mus-
cles and condylefossa relationship. The asymmetric work
of the masticatory muscles could determine tenderness of
ache (Sonnesen etal., 1998), occurring more frequently in
the crossbite group than in the control group. Furthermore,
according to the proposed causal chain of events, the alter-
ations of the disccondyle relationship consequent to pos-
terior crossbite may be responsible for disc displacement
and temporomandibular joint (TMJ) clicking (Wilkinson,
1991; Pullinger et al., 1993; Egermark et al., 2003;
Buranastidporn etal., 2006; Michelotti and Iodice, 2010).
However, a significant association between posterior
crossbite and temporomandibular disorders (TMDs)
is not consistently reported in the literature across
time (Seligman and Pullinger, 1991; Vanderas, 1993;
McNamara etal., 1995; Sonnesen etal., 1998; Sari etal.,
1999; Alamoudi, 2000; Sonnesen etal., 2001; Thilander
et al., 2002; Vanderas and Papagiannoulis, 2002;
Egermark et al., 2003; Pereira et al., 2009; Marklund
and Wnman, 2010; Tecco et al., 2011) and definitive
conclusions cannot be drawn. Therefore, a systematic
review addressing a carefully formulated question (List
738
and Axelsson, 2010) is needed. Hence, we carried out a
systematic review focusing specifically on the association
between posterior crossbite, muscular pain, and disc
displacement, analysing the quality of the methodological
soundness of the studies.
Materials and methods
To identify the studies that examined the correlations
between posterior crossbite and different TMD diagnoses, a
literature survey was carried out through the Medline data-
base (Entrez PubMed, http://www.ncbi.nim.nih.gov). The
survey covered the period from 1 January 1966 to 30 April
2012 and used the medical subject heading term: crossbite,
which was crossed with the keywords Temporomandibular
disorder*, disc displacement, click*, masticatory mus- t-test were used for statistical analysis. Statistical sig-
cle pain, masticatory myofascial pain, muscular pain, nificance was set at P < 0.05. All the statistical proce-
and myalgia.
The studies were selected on the basis of specific inclu-
sion and exclusion criteria by three researchers, reading the
titles, and the abstracts. The inclusion criteria were human
studies, posterior crossbite, lateral crossbite, TMDs, ret-
rospective studies with and without controls or reference
group, and prospective studies. Exclusion criteria were
articles not in English language, case reports and case
series, reviews, studies with unclear diagnosis or poorly
defined samples, treatment strategies and appliances,
craniofacial syndrome diagnosis possibly influencing the
prevalence of TMD, full text not available, and experimen-
tal animal studies. All the studies not pertinent with the
aim of the review (i.e. not investigating on the relation-
ship between posterior crossbite and TMD symptoms) and
the studies analysing the anterior crossbite were excluded.
Furthermore, some studies retrieved more times by using
different keywords were counted only ones. Finally, two
researchers analysed the full-text version of all included
studies independently, and the studies were catalogued on
the basis of the associations between crossbite and muscu-
lar pain, disc displacement, or the generic term TMD. between posterior crossbite and disc displacement
When the full-text version of the study was not directly
available, the manuscript was requested to the correspond-
ing author by email. Some studies investigating on more
items were reported in two or more groups of associations.
Afterwards, the researchers independently evaluated the
scientific and methodological soundness of each study
using a published quality score (Figure 1; Andrade etal.,
2009). Each study was categorized as low (05 points),
medium (68 points), or high (9 or 10 points). The data
were extracted from each article, studies authors were
not blinded to the examiners, and intra-examiner conflicts
were resolved by discussion of each article to reach a
consensus.
Data were analysed by conventional descriptive statis-
tics. Pearson product-moment correlation supplemented
by linear regression and unpaired Students two-tailed
G. IODICE ET AL.
Figure1 Quality assessment of the studies.
dures were performed with the Statistical Package for
the Social Sciences (SPSS 20.0, SPSS Inc., Chicago,
Illinois, USA).
Results
A flow chart of the search strategy is represented in Figure
2. Initial search yielded 2919 citations. Screened on the
basis of the inclusion and exclusion criteria, 43 articles were
analysed.
Crossbite and disc displacement
On the basis of the inclusion/exclusion criteria, the search
strategy resulted in 27 articles investigating specifically
the relationship between crossbite and disc displacement.
The scientific and methodological evaluation was high
in 3 (11.2%) studies, medium in 12 (44.4%), and low in
12 (44.4%; Table 1 and Supplementary Table 1, available
online).
Fifteen studies (55.5%) reported a significant association
(association) with a mean score of 5.5: 2 (13.3%) with
a high score, 7 (46.7%) with a medium score, and 6 (40%)
with a low score. Twelve studies (44.5%) did not find any
significant association between posterior crossbite and disc
displacement signs and symptoms (no association) with
a mean score of 5.7: 1 (8.3%) with a high score, 5 (41.7%)
with a medium score, and 6 (50%) with a low score. Mean
years of publication for the articles were, respectively,
14.7years for the association and 12.6years for the no
association articles. Both scientific and methodological
quality assessment and studies years of publication were not
statistically different between groups (P=0.71 and P=0.55,
respectively). Six out of 27 studies used research diagnostic
criteria (RDC)/TMD for the evaluation of click, 2 reporting
association with a mean score of 7.5 (by the same authors
in different years: Marklund and Wnman, 2007, 2010),
CROSSBITE AND TEMPOROMANDIBULAR DISORDERS 739

Figure2 Flow chart of the search strategy.

and 4 reporting no association with a mean score of 6.2.
Eight studies were based on adolescent samples (2 reporting
association; 6 reporting no association), 5 studies on
adult samples (4 reporting association; 1 reporting no
association), and 11 on samples including both adolescent
and adult subjects (8 reporting association; 3 reporting
noassociation). Three studies did not report the age of
Table1 Crossbite and disk displacement.
Association No association
the sample (2 reporting association; 1 reporting no
association).
Crossbite and masticatory musclepain
On the basis of the inclusion/exclusion criteria, the search
strategy resulted in 19 articles investigating specifically the
relationship between crossbite and masticatory muscle pain.
The scientific and methodological evaluation was high in 1
(5.3%) study, medium in 10 (52.6%) studies, and low in 8
(42.1%) studies (Table2 and Supplementary Table2, avail-
able online).

Author Year Score Author Year Score

Table2 Crossbite and masticatory muscle pain.

Marklund 2010 9 Chiappe 2009 9

Pullinger 2000 9 Farella 2007 7 Association No association
Egermark-Eriksson 1987 8 Pahkala 2004 7
Egermark-Eriksson 2003 7 Keeling 1994 6
Author Year Score Author Year Score
Egermark-Eriksson 1990 6 Sonnesen 1998 6
Marklund 2007 6 Vanderas 2002 6
Miyawaki 2004 6 Egermark- 1983 5 Egermark-Eriksson 1987 8 Marklund 2010 9
Eriksson Egermark-Eriksson 2003 7 Marklund 2008 8
Pullinger 1993 6 Runge 1989 5 Egermark-Eriksson 1990 6 Demir 2005 7
Thilander 2002 6 Seligman 1989 5 Fantoni 2010 6 Sonnesen 1998 6
Pullinger 1988 5 Tecco 2011 5 Pullinger 1993 6 Vanderas 2002 6
Berg 2008 3 Pellizzoni 2006 4 Thilander 2002 6 Landi 2004 5
Corvo 2003 3 Sonnesen 2001 4 Egermark-Eriksson 1983 5 Seligman 1989 5
Miyazaki 1994 3 Sonnesen 2001 4 Seligman 1988 5
Roberts 1987 3 Helm 1984 2 Tecco 2011 5
Helm 1984 2 Helm 1989 2
740 G. IODICE ET AL.

Nine studies reported a significant association between posterior crossbite and TMD (no association) with a mean
posterior crossbite and masticatory muscle pain (associa- score of 5.7: 1 (9%) with a high score, 5 (45.5%) with
tion) with a mean score 5.6: none with a high score, 6 a medium score, and 5 (45.5%) with a low score. Mean
(66.7%) with a medium score, and 3 (33.3%) with a low years of publication for the articles were, respectively, 10.8
score. Ten studies did not find a significant association for the association and 13.4 for the no association articles.
between posterior crossbite and masticatory muscle pain Both scientific and methodological quality assessment and
(no association) with a mean score of 5.8: 1 (10%) with studies years of publication were not statistically differ-
a high score, 4 (40%) with a medium score, and 5 (50.0%) ent between groups (P=0.84 and P=0.47, respectively).
with a low score. Mean years of publication for the arti- Two out of 20 studies used RDC/TMD for the evaluation
cles were, respectively, 17.2years for the association and of TMD symptoms, 1 reporting association (mean score:
11.6years for the no association articles. Both scientific 5)and 1 reporting no association (mean score: 9). Eleven
and methodological quality assessment and studies years of studies were based on adolescent samples (7 reporting
publication were not statistically different between groups association; 4 reporting no association), 8 studies on
(P=0.77 and P=0.20, respectively). Three out of 19 stud- adult samples (4 reporting association; 4 reporting no
ies used RDC/TMD for the evaluation of muscle pain, 1 association), and 10 on samples including both adoles-
reporting association (mean score: 6)and 2 reporting no cent and adult subjects (7 reporting association; 3 report-
association (mean score: 5). Eleven studies were based on ing no association). One study did not report the age of
adolescent samples (6 reporting association; 5 reporting the sample, reporting no association.
no association), 4 studies on adult samples (1 reporting
association; 3 reporting no association), and 5 on sam-
Discussion
ples including both adolescent and adult subjects (2 report-
ing association; 3 reporting no association). This systematic review aimed to select all prospective and
retrospective observational studies with or without control
groups verifying the association between posterior crossbite
Crossbite andTMD and specific TMD signs and symptoms, such as masticatory
On the basis of the inclusion/exclusion criteria, the search muscle pain and TMJ disc displacement. Forty-three studies
strategy resulted in 20 articles investigating specifically the were retrieved. Some of them were included in more than
relationship between crossbite and the generic term TMD. one group of association.
The scientific and methodological evaluation was high in From a methodological point of view, the scientific
1 (5%) study, medium in 10 studies (50%), and low in 9 quality of most part of the studies analysed in this
studies (45%; Table3 and Supplementary Table3, available review was medium-low, deeply influencing the impor-
online). tance and reliability of their relative results. Though the
Nine studies reported a significant association between poor quality of the studies affects the current knowl-
posterior crossbite and TMD (association) with a mean edge on the relationship between posterior crossbite and
score of 5.6: none with a high score, 5 (55.6%) with a TMD signs and symptoms, no significant difference
medium score, and 4 (44.4%) with a low score. Eleven was found in terms of quality between articles reporting
studies did not find a significant association between association or not. Moreover, no significant association
was found between the year of publishing of the studies
and the associations found. Indeed, the association (or
Table3 Crossbite and temporomandibular disorder. not) between posterior crossbite and TMDs seems to be
transversal across time and not influenced by trends of
Association No association the moment.
Nevertheless, publication bias, that is the likelihood
Author Year Score Author Year Score that negative findings on the outcome of a particular
treatment may be published less frequently than
Gesch 2004b 8 Marklund 2010 9 association ones, may represent a problem given the
Egermark-Eriksson 2003 7 Gesch 2004a 8
Egermark-Eriksson 1990 6 Gesch 2005 7
nature of the issue under review. Furthermore, even if
Sonnesen 1998 6 Liu 1997 7 we excluded studies using the same research sample,
Vanderas 2002 6 Pahkala 2004 7 redundancy concerns, that are the problem of duplication
Alamoudi 2000 5 List 2001 6
Tecco 2011 5 Egermark- 1983 5
studies on the same study populations, cannot be ruled
Eriksson out. This problem could be mainly ascribed to the
Pereira 2009 4 Godoy 2007 5 relatively few groups involved in this clinical research
Miyazaki 1994 3 Tanne 1993 4 field, some of them contributing with multiple papers on
Motegi 1992 3
Helm 1989 2 populations of different size (Egermark-Eriksson etal.,
1983, 1987, 1990, Egermark et al., 2003; Seligman
CROSSBITE AND TEMPOROMANDIBULAR DISORDERS
et al., 1988, Seligman and Pullinger, 1989; Pullinger
etal., 1988, 1993, Pullinger and Seligman, 2000; Gesch
et al., 2004a,b, 2005; Marklund and Wnman, 2007,
2008, 2010).
The representativeness of a sample to its disease/disorder
target population is important when the sample is being used
to draw generalized conclusions or to estimate the strength
of possible risk factors (Farella and Palla, 2009). This is often
the case with the vast majority of studies on the aetiology of
TMD and is the main cause for the still present confusion
that is apparent over the role of occlusion inTMD.
The inclusion criteria we used were limited to the articles
in peer-reviewed journal and in English language to enhance
the methodological rigor of the studies examined and the
conclusion drawn. However, this strategy did not exclude the
possibility that some publications in other languages and/or
publications included only in other databases were unjustly
excluded and should be considered in future reviews.
According to our review, results of the scientific litera-
ture are not consistent, and different opinions have been
presented across time. Consistency of the observed associa-
tion across studies represents the fifth criterion of the Hills
suggestions (Hill, 1965; Gordis, 2009). It means that the
association should be repeatedly observed in independent
studies, that is, in different individuals and settings under
different methods. Lack of consistency may imply that
the observed association between two variables appeared
because of chance or error (Trp and Schindler, 2012).
A possible explanation to this controversial view could
arise from the use of vague and unspecific terms as maloc-
clusion and TMD, instead of specific and validated diag-
nosis (i.e. crossbite, TMD diagnoses, etc.). Indeed, a major
shortcoming of most studies seems to be focused on TMD
as a whole. On the other hand, several studies, even though
evaluating TMD signs and symptoms during the clinical
examinations, pooled them in a unique variable (with TMD
versus without TMD) in the statistical analysis and in the
results (Motegi etal., 1992; Alamoudi, 2000; List etal., 2001;
Gesch etal., 2005; Godoy etal., 2007). However, TMDs are
actually considered not a single pathology but a heterogene-
ous group of different diseases involving the stomatognathic
system (De Boever et al., 2000). Furthermore, the use of
TMD as a collective term of all TMD signs and symptoms
may mislead the reader to incorrect conclusions. This could
be the case of Tecco etal. (2011), who found an important
association between posterior crossbite and TMD symptoms
(P = 0.000), without any significant association between
posterior crossbite, TMJ sound (P=0.22), and myofascial
pain (P=0.97). Similarly, a significant association between
posterior crossbite and TMD signs and symptoms has been
reported, when only headache was significantly associated
(Sonnesen etal., 1998).
Moreover, it has to be remarked that only in the last
1015years, the introduction of validated diagnostic cri-
teria, calibrated examiners, and appropriate imaging as in
741
the RDC/TMD and DC/TMD has improved the reliability
of investigations and of classification systems (Ahmad
et al., 2009; Anderson et al., 2010; List and Greene,
2010; Schiffman et al., 2010). According to our opin-
ion, the spreading of its use in the research and clinical
settings will improve the methodological and scientific
soundness and appropriateness of the future surveys.
Another important confounding factor in the analysis of
the association between crossbite and TMDs may be repre-
sented by the selection of the samples. Indeed, most of the
studies are based on orthodontic patients or selected con-
trols among dental students or staff members that are not
representative of the general population. In such cases, for
instance, patients could seek orthodontic treatment because
they are alerted on the potential role of malocclusion as
risk factor of TMD, and on the other side, dental students
and/or staff members can be aware of oral behaviours being
considered TMD risk factors and avoid it. The consequence
is a selection bias leading to unreliable results (Farella and
Palla, 2009). Furthermore, many studies suffer from sam-
ples barely described (Seligman etal., 1988), small sample
size (Miyawaki etal., 2004; Pahkala and Qvarnstrm, 2004;
Pellizoni etal., 2006; Berg etal., 2008) or investigated fea-
tures poorly represented in the sample (i.e. only 16 of 106
patients presented crossbite in Corvo etal., 2003 and 2 of
127 in List etal., 2001), and predetermined sample sizes are
reported in very few studies (Farella etal., 2007). Similarly,
the age of the sample used influence the associations found,
preventing the comparison between results of studies on
children and on adults (Thilander and Bjerklin, 2012).
The main limitation of investigations evaluating the
relative importance of single risk factors for disorders
having a multifactorial aetiology is the difficulty in
controlling for all of the other variables (Slade et al.,
2008; Greene 2011). Consequently, TMDs, as the other
multifactorial complex pathologies, should be evaluated
using multivariate statistical analyses, as univariate
models may overestimate some resulting associations
(Pullinger etal., 1993; Landi etal., 2004). Even though
the harmful/detrimental effects of unilateral versus
bilateral crossbite on single signs/symptoms of TMD
could be particularly interesting to be investigated, it was
not possible to draw conclusions because it was analysed
in very few studies. Finally, very few studies on the
topic reported long-term data (Egermark-Eriksson etal.,
1987, 1990, Egermark et al., 2003; Berg et al., 2008),
deeply influencing the actual knowledge on the topic,
and preventing to the elucidate if posterior crossbite is a
cause, an effect, or unrelated to the temporomandibular
muscular and articular disorders.
Crossbite and disc displacement
Twenty-seven articles evaluate the association between posterior
crossbite and TMJ disc displacement. The existing relationship
742
between posterior crossbite and TMJ disc displacement is still
an unsolved question because several studies obtained differ-
ent results (Keeling etal., 1994; Sonnesen etal., 2001; Farella
etal., 2007). According to the most part of studies available
at today, the altered morphological relationship between the
upper and lower dentition seems to result in alterations of the
disccondyle relationship, which in turn are possibly respon-
sible for disc displacement and TMJ clicking (Wilkinson,
1991; Pullinger etal., 1993; McNamara etal., 1995; Egermark
etal., 2003). Indeed, positive associations between unilateral
posterior crossbite and TMJ clicking are supported by several
studies, suggesting that the crossbite increases the risk of disc
displacement by a factor of up to 3 (Kritsineli and Shim, 1992;
Pullinger et al., 1993; Tanne et al., 1993; McNamara et al.,
1995; Thilander etal., 2002; Egermark etal., 2003). It must
be stressed that, according to our findings, among the studies
based on adolescent samples two out of eight (25%) reported
a significant association, whereas, among the studies based on
adult samples, four out of five (80%) reported significant asso-
ciation between posterior crossbite and disc displacement. The
higher association between crossbite and disc displacement in
adults than in adolescents could be explained by the adaptive
of the stomatognathic system in adolescents. Consequently, the
persisting exposition to the risk factor (i.e. posterior crossbite)
could determine the development of disk displacement in the
adult age. This chain of events represents only a hypothesis at
today because long-term controlled studies are still lacking.
Nevertheless, considering that the 80% of studies on adults and
25% of studies on adolescents reported significant association
between posterior crossbite and disc displacement, the ortho-
dontic correction of a posterior crossbite could be suggested to
reduce the adaptation demands of the stomatognathic system
in growing subjects (Thilander and Bjerklin, 2012), whereas it
is not warranted in adults to prevent TMJ derangement because
skeletal adaptation has already taken place.
Crossbite and masticatory musclepain
Nineteen articles evaluate the association between poste-
rior crossbite and masticatory muscle pain. The existing
relationship between posterior crossbite and masticatory
muscle pain is still an unsolved question too. Comparing
normocclusive and posterior crossbite subjects, Alarcon
etal. (2000) found that in the right posterior crossbite sub-
jects, the left posterior temporal showed higher electromyo-
graphic (EMG) activity than the right posterior temporal,
possibly consequent to the functional mandibular shift.
Such a shift could act as a mechanism for reaching a certain
degree of occlusal stability (Alarcon etal., 2000; Andrade
etal., 2009). Nevertheless, the same authors found that the
right anterior temporal demonstrated a higher EMG activity
than the left anterior temporal in the normocclusive group,
suggesting that some cases of muscular asymmetry could
be considered as physiological and compatible with normal
function (Alarcon etal., 2000; Andrade etal., 2009).
G. IODICE ET AL.
Moreover, tenderness of the anterior temporalis and
superficial masseter muscles is reported to occur more
frequently in the crossbite group than in the control
group (Egermark-Eriksson etal., 1983, 1990; Sonnesen
et al., 2001). Nevertheless, oral parafunctions, such as
clenching and object biting, significantly increase the
probability of having muscle tenderness independently
from and more than malocclusion (Vanderas, 1993;
Michelotti et al., 2010). Finally, psychosocial status of
TMD patients could be a confounding factor because
several studies showed an association between TMD pain
and disorders such as depression, somatization, and anxi-
ety (Rollman and Gillespie, 2000; Suvinen etal., 2005;
Sonnesen and Svensson, 2008; Manfredini etal., 2011).
Crossbite andTMD
Twenty articles evaluate the association between posterior
crossbite and TMD. Temporomandibular disorders is a term
to define a number of clinical conditions that involve the
masticatory muscles, the TMJs, or both (Okeson, 2008).
These conditions include articular and/or muscular pain,
alteration in mandibular dynamics, and TMJ noises (click-
ing and crepitus), recognizing different possible aetiologies
and risk factors. On this basis, the introduction of tools, such
as RDC/TMD (Dworkin and Le Resche, 1992) well defin-
ing the different categories of TMDs, has increased the level
of consistency between studies. Nevertheless, some studies
still continue to analyse TMD as a unique dependent vari-
able, possibly producing misleading results. This approach,
even if useful to increase the statistical power of the analy-
sis, can be a confounder when investigating on risk factors.
However, analysing the studies that investigated the
TMD as a whole, the relationship between posterior
crossbite and TMD signs and symptoms still remains
a controversial issue. According to some studies
(Egermark-Eriksson et al., 1990; Alamoudi, 2000),
posterior crossbite is one of the most important occlusal
features significantly associated to TMDs suggesting
the importance of an early orthodontic intervention to
prevent the development of TMDs. Conversely, according
to some other studies (Gesch, 2004a; Godoy etal., 2007),
no significant association was found between posterior
crossbite and TMDs, suggesting caution when it is a
matter of altering the existing occlusion to prevent or to
treat temporomandibular dysfunction.
Conclusions
1 The relationship between posterior crossbite and articu-
lar and muscular disorders is still an unsolved issue.
2 The literature available on the matter suffers of medium-
low scientific and methodological quality, independent
of the association reported.
3 Definitive conclusions cannot be drawn, and the possi-
ble association should be addressed by future researches,
CROSSBITE AND TEMPOROMANDIBULAR DISORDERS
with rigorous scientific methodology (see Strobe-
Statement checklist).
4 Very few studies on the topic reported long-term data,
deeply influencing the actual knowledge on the topic, and
preventing us from elucidating if the posterior crossbite is
a cause, an effect, or unrelated to the temporomandibular
muscular and articular disorders. Future surveys with long-
term control are needed, especially in adolescent samples.
Supplementary material
Supplementary material is available at European Journal of
Orthodontics online.
References
Alamoudi N 2000 The correlation between occlusal characteristics and
temporomandibular dysfunction in Saudi Arabian children. The Journal
of Clinical Pediatric Dentistry 24: 229236
Alarcon J A, Martin C, Palma J C 2000 Effect of unilateral posterior crossbite
on the electromyographic activity of human masticatory muscles. American
Journal of Orthodontics and Dentofacial Orthopedics 118: 3234
Ahmad M etal. 2009 Research diagnostic criteria for temporomandibu-
lar disorders (RDC/TMD): development of image analysis criteria and
examiner reliability for image analysis. Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology, and Endodontics 107: 844860
Anderson G C etal. 2010 The research diagnostic criteria for temporoman-
dibular disorders. VI: future directions. Journal of Orofacial Pain 24: 7988
Andrade A d a S, Gameiro G H, Derossi M, Gavio M B 2009 Posterior
crossbite and functional changes. A systematic review. The Angle
Orthodontist 79: 380386
Berg R E, Espeland L, Stenvik A 2008 A 57-year follow-up study of occlu-
sion. Part 3: oral health and attitudes to teeth among individuals with cross-
bite at the age of 8years. Journal of Orofacial Orthopedics 69: 463483
Brandt D 1985 Temporomandibular disorders and their association with
morphologic malocclusion in children. In: Carlson D S, McNamara J A,
Ribbens K A (eds). Developmental Aspects of Temporomandibular Joint
Disorders. Monograph No. 16, Craniofacial growth series. Center for
Human Growth and Development, University of Michigan, Ann Arbor,
pp. 279298
Buranastidporn B, Hisano M, Soma K 2006 Effect of biomechani-
cal disturbance of the temporomandibular joint on the prevalence of
internal derangement in mandibular asymmetry. European Journal of
Orthodontics 28: 199205
Chiappe G, Fantoni F, Landi N, Biondi K, Bosco M 2009 Clinical value of
12 occlusal features for the prediction of disc displacement with reduction
(RDC/TMD axis Igroup IIa). Journal of Oral Rehabilitation 36: 322329
Ciuffolo F, Manzoli L, DAttilio M, Tecco S, Muratore F, Festa F, Romano
F 2005 Prevalence and distribution by gender of occlusal characteristics
in a sample of Italian secondary school students: a cross-sectional study.
European Journal of Orthodontics 27: 601606
Corvo G, Tartaro G, Giudice A, Diomajuta A 2003 Distribution of cra-
niomandibular disorders, occlusal factors and oral parafunctions in a
paediatric population. European Journal of Paediatric Dentisty 4: 8488
Daskalogiannakis J 2000 Glossary of Orthodontic Terms. Quintessence
Publishing, Chicago, p. 79
De Boever J A, Carlsson G E, Klineberg I J 2000 Need for occlusal therapy
and prosthodontic treatment in the management of temporomandibu-
lar disorders. Part I. Occlusal interferences and occlusal adjustment.
Journal of Oral Rehabilitation 27: 367379
Demir A, Uysal T, Basciftci F A, Guray E 2005 The association of occlusal
factors with masticatory muscle tenderness in 10- to 19-year old Turkish
subjects. The Angle Orthodontist 75: 4046
Dworkin S F, Le Resche L 1992 Research diagnostic criteria for temporo-
mandibular disorders: review, criteria, examinations and specifications,
critique. Journal of Craniomandibular Disorders 6: 301355
743
Egermark I, Magnusson T, Carlsson G E 2003 A 20-year follow-up of signs
and symptoms of temporomandibular disorders and malocclusions in
participants with and without orthodontic treatment in childhood. Angle
Orthodontist 73: 109115
Egermark-Eriksson I, Carlsson G E, Magnusson T 1987 A long-term
epidemiologic study of the relationship between occlusal factors and
mandibular dysfunction in children and adolescents. Journal of Dental
Research 66: 6771
Egermark-Eriksson I, Ingervall B, Carlsson G E 1983 The dependence of
mandibular dysfunction in children on functional and morphologic mal-
occlusion. American Journal of Orthodontics 83: 187194
Egermark-Eriksson I, Carlsson G E, Magnusson T, Thilander B 1990 A
longitudinal study on malocclusion in relation to signs and symptoms
of cranio-mandibular disorders in children and adolescents. European
Journal of Orthodontics 12: 399407
Fantoni F, Chiappe G, Landi N, Romagnoli M, Bosco M 2010 A stepwise
multiple regression model to assess the odds ratio between myofas-
cial pain and 13 occlusal features in 238 Italian women. Quintessence
International 41: 5461
Farella M, Palla S 2009 External validity: a forgotten issue? Journal of
Orofacial Pain 23: 297298
Farella M, Michelotti A, Iodice G, Milani S, Martina R 2007 Unilateral
posterior crossbite is not associated with TMJ clicking in young adoles-
cents. Journal of Dental Research 86: 137141
Gesch D, Bernhardt O, Alte D, Kocher T, John U, Hensel E 2004a Malocclusions
and clinical signs or subjective symptoms of temporomandibular disorders
(TMD) in adults. Results of the population-based Study of Health in
Pomerania (SHIP). Journal of Orofacial Orthopedics 65: 88103
Gesch D, Bernhardt O, Kocher T, John U, Hensel E, Alte D 2004b
Association of malocclusion and functional occlusion with signs of
TMD in adults: results of the study of the population-based study of
Health in Pomerania. Angle Orthodontist 74: 512520
Gesch D, Bernhardt O, Mack F, John U, Kocher T, Alte D 2005 Association
of malocclusion and functional occlusion with subjective symptoms of
TMD in adults: results of the Study of Health in Pomerania (SHIP). The
Angle Orthodontist 75: 183190
Godoy F, Rosenblatt A, Godoy-Bezerra J 2007 Temporomandibular dis-
orders and associated factors in Brazilian teenagers: a cross-sectional
study. The International Journal of Prosthodontics 20: 599604
Gordis L 2009 Epidemiology, 4th edn. Saunders, Philadelphia.
Greene C S 2011 Relationship between occlusion and temporomandibu-
lar disorders: implications for the orthodontist. American Journal of
Orthodontics and Dentofacial Orthopedics 139: 11, 13, 15
Helm S, Petersen P E 1989 Mandibular dysfunction in adulthood in rela-
tion to morphologic malocclusion at adolescence. Acta Odontologica
Scandinavica 47: 307314
Helm S, Pryds U 1979 Prevalence of malocclusion in medieval and modern
Danes contrasted. Scandinavian Journal of Dental Research 87: 9197
Helm S, Kreiborg S, Solow B 1984 Malocclusion at adolescence related to
self-reported tooth loss and functional disorders in adulthood. American
Journal of Orthodontics 85: 393400
Hill A B 1965 The environment and disease: association or causation?
Proceedings of the Royal Society of Medicine 58: 295300
Keeling S D, McGorray S, Wheeler T T, King G J 1994 Risk factors associ-
ated with temporomandibular joint sounds in children 6 to 12years of age.
American Journal of Orthodontics and Dentofacial Orthopedics 105: 279287
Kritsineli M, Shim Y S 1992 Malocclusion, body posture, and temporo-
mandibular disorder in children with primary and mixed dentition. The
Journal of Clinical Pediatric Dentistry 16: 8693
Landi N, Manfredini D, Tognini F, Romagnoli M, Bosco M 2004
Quantification of the relative risk of multiple occlusal variables for mus-
cle disorders of the stomatognathic system. The Journal of Prosthetic
Dentistry 92: 190195
List T, Axelsson S 2010 Management of TMD: evidence from systematic
reviews and meta-analyses. Journal of Oral Rehabilitation 37: 430451
List T, Greene C S 2010 Moving forward with the RDC/TMD. Journal of
Oral Rehabilitation 37: 731733
List T, Wahlund K, Larsson B 2001 Psychosocial functioning and dental
factors in adolescents with temporomandibular disorders: a case-control
study. Journal of Orofacial Pain 15: 218227
744
Liu J K, Tsai M Y 1997 Relationship between morphologic malocclusion
and temporomandibular disorders in orthodontic patients prior to treat-
ment. The Functional Orthodontist 14: 1316
Manfredini D, Ahlberg J, Winocur E, Guarda-Nardini L, Lobbezoo F 2011
Correlation of RDC/TMD axis Idiagnoses and axis II pain-related dis-
ability. Amulticenter study. Clinical Oral Investigations 15: 749756
Marklund S, Wnman A 2007 Incidence and prevalence of temporoman-
dibular joint pain and dysfunction. Aone-year prospective study of uni-
versity students. Acta Odontologica Scandinavica 65: 119127
Marklund S, Wnman A 2008 Incidence and prevalence of myofascial pain
in the jaw-face region. Aone-year prospective study on dental students.
Acta Odontologica Scandinavica 66: 113121
Marklund S, Wnman A 2010 Risk factors associated with incidence and
persistence of signs and symptoms of temporomandibular disorders.
Acta Odontologica Scandinavica 68: 289299
McNamara JA Jr 2002 Early intervention in the transverse dimension: is
it worth the effort? American Journal of Orthodontics and Dentofacial
Orthopedics 121: 5724
McNamara J A Jr, Seligman D A, Okeson J P 1995 Occlusion, orthodon-
tic treatment, and temporomandibular disorders: a review. Journal of
Orofacial Pain 9: 7390
Michelotti A, Iodice G 2010 The role of orthodontics in temporomandibu-
lar disorders. Journal of Oral Rehabilitation 37: 411429
Michelotti A, Cioffi I, Festa P, Scala G, Farella M 2010 Oral parafunc-
tions as risk factors for diagnostic TMD subgroups. Journal of Oral
Rehabilitation 37: 157162
Miyawaki S, Tanimoto Y, Araki Y, Katayama A, Kuboki T, Takano-
Yamamoto T 2004 Movement of the lateral and medial poles of the
working condyle during mastication in patients with unilateral pos-
terior crossbite. American Journal of Orthodontics and Dentofacial
Orthopedics 126: 549554
Miyazaki H, Motegi E, Isoyama Y, Konishi H, Sebata M 1994 An orthodon-
tic study of temporomandibular joint disorders. Part 2: clinical research
in orthodontic patients. The Bulletin of Tokyo Dental College 35: 8590
Motegi E, Miyazaki H, Ogura I, Konishi H, Sebata M 1992 An orthodon-
tic study of temporomandibular joint disorders. Part 1: epidemiological
research in Japanese 6-18year olds. The Angle Orthodontist 62: 249256
Okeson J P (ed.) 2008 Management of temporomandibular disorders and
occlusion, 6th edn. St Louis: Elsevier Mosby, 334375
Pahkala R, Qvarnstrm M 2004 Can temporomandibular dysfunction signs
be predicted by early morphological or functional variables? European
Journal of Orthodontics 26: 367373
Pellizoni S E, Salioni M A, Juliano Y, Guimares A S, Alonso L G 2006
Temporomandibular joint disc position and configuration in children
with functional unilateral posterior crossbite: a magnetic resonance
imaging evaluation. American Journal of Orthodontics and Dentofacial
Orthopedics 129: 785793
Pereira L J, Costa R C, Frana J P, Pereira S M, Castelo P M 2009 Risk
indicators for signs and symptoms of temporomandibular dysfunction in
children. The Journal of Clinical Pediatric Dentistry 34: 8186
Proffit W R 2000 Treatment of orthodontic problems in preadolescent chil-
dren (section VI). In: Proffit W R (ed.). Contemporary orthodontics, 3rd
edn. Mosby, St Louis, pp. 435439
Pullinger A G, Seligman D A 2000 Quantification and validation of pre-
dictive values of occlusal variables in temporomandibular disorders
using a multifactorial analysis. The Journal of Prosthetic Dentistry
83: 6675
Pullinger A G, Seligman D A, Gornbein J A 1993 A multiple logistic
regression analysis of the risk and relative odds of temporomandibular
disorders as a function of common occlusal features. Journal of Dental
Research 72: 968979
Pullinger A G, Seligman D A, Solberg W K 1988 Temporomandibular disor-
ders. Part II: occlusal factors associated with temporomandibular joint ten-
derness and dysfunction. The Journal of Prosthetic Dentistry 59: 363367
Roberts C A, Tallents R H, Katzberg R W, Sanchez-Woodworth R E,
Espeland M A, Handelman S L 1987 Comparison of internal derange-
ments of the TMJ with occlusal findings. Oral Surgery, Oral Medicine,
Oral Pathology and Oral Radiology 63: 645650
G. IODICE ET AL.
Rollman G B, Gillespie J M 2000 The role of psychosocial factors in tem-
poromandibular disorders. Current Review of Pain 4: 7181
Runge M E, Sadowsky C, Sakols E I, BeGole E A 1989 The relationship
between temporomandibular joint sounds and malocclusion. American
Journal of Orthodontics and Dentofacial Orthopedics 96: 3642
Sari S, Sonmez H, Oray G O, Camdeviren H 1999 Temporomandibular
joint dysfunction and occlusion in the mixed and permanent dentition.
The Journal of Clinical Pediatric Dentistry 24: 5962
Schiffman E L et al. 2010 The research diagnostic criteria for temporo-
mandibular disorders. I: overview and methodology for assessment of
validity. Journal of Orofacial Pain 24: 724
Seligman D, Pullinger A 1991 The role of intercuspal occlusal relationships
in temporomandibular disorders: a review. Journal of Craniomandibular
Disorders: Facial & Oral Pain 5: 96106 and 265278
Seligman D A, Pullinger A G 1989 Association of occlusal variables among
refined TM patient diagnostic groups. Journal of Craniomandibular
Disorders: Facial & Oral Pain 3: 227236
Seligman D A, Pullinger A G, Solberg W K 1988 Temporomandibular dis-
orders. Part III: occlusal and articular factors associated with muscle
tenderness. The Journal of Prosthetic Dentistry 59: 483489
Slade G D, Diatchenko L, Ohrbach R, Maixner W 2008 Orthodontic
Treatment, genetic factors and risk of temporomandibular disorder.
Seminars in Orthodontics 14: 146156
Sonnesen L, Svensson P 2008 Temporomandibular disorders and psycho-
logical status in adult patients with a deep bite. European Journal of
Orthodontics 30: 621629
Sonnesen L, Bakke M, Solow B 1998 Malocclusion traits and symptoms
and signs of temporomandibular disorders in children with severe mal-
occlusion. European Journal of Orthodontics 20: 543559
Sonnesen L, Bakke M, Solow B 2001 Temporomandibular disorders
in relation to craniofacial dimensions, head posture and bite force
in children selected for orthodontic treatment. European Journal of
Orthodontics 23: 179192
Strobe-Statement checklist .http://www.strobe-statement.org/index.php?id=a
vailable-checklists (1 March 2013, date last accessed)
Suvinen T I, Reade P C, Kemppainen P, Kononen M, Dworkin S F 2005
Review of aetiological concepts of temporomandibular pain disorders: a
biopsychosocial model for integration of physical disorder factors with
psychological and psychosocial illness impact factors. European Journal
of Pain: EJP 9: 613633
Tanne K, Tanaka E, Sakuda M 1993 Association between malocclusion
and temporomandibular disorders in orthodontic patients before treat-
ment. Journal of Orofacial Pain 7: 156162
Tecco S, Crincoli V, Di Bisceglie B, Saccucci M, Macr M, Polimeni A,
Festa F 2011 Signs and symptoms of temporomandibular joint disorders
in Caucasian children and adolescents. Cranio 29: 7179
Thilander B, Bjerklin K 2012 Posterior crossbite and temporomandibular
disorders (TMDs): need for orthodontic treatment? European Journal of
Orthodontics 34: 667673
Thilander B, Myrberg N 1973 The prevalence of malocclusion in
Swedish schoolchildren. Scandinavian Journal of Dental Research
81: 1221
Thilander B, Rubio G, Pena L, de Mayorga C 2002 Prevalence of tempo-
romandibular dysfunction and its association with malocclusion in chil-
dren and adolescents: an epidemiologic study related to specified stages
of dental development. The Angle Orthodontist 72: 146154
Trp J C, Schindler H 2012 The dental occlusion as a suspected cause for
TMDs: epidemiological and etiological considerations. Journal of Oral
Rehabilitation 39: 502512
Vanderas A P 1993 Relationship between malocclusion and cranioman-
dibular dysfunction in children and adolescents: a review. Pediatric
Dentistry 15: 317322
Vanderas A P, Papagiannoulis L 2002 Multifactorial analysis of the aetiol-
ogy of craniomandibular dysfunction in children. International Journal
of Paediatric Dentistry 12: 336346
Wilkinson T M 1991 The lack of correlation between occlusal factors and
TMD. In: McNeil C (ed.). Current controversies in temporomandibular
disorders. Quintessence Publishing, New York, pp. 9094
Copyright of European Journal of Orthodontics is the property of Oxford University Press /
USA and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.