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Unilateral Posterior Crossbite is Not Associated with TMJ Clicking in Young Adolescents
M. Farella, A. Michelotti, G. Iodice, S. Milani and R. Martina J DENT RES 2007 86: 137 DOI: 10.1177/154405910708600206 The online version of this article can be found at: http://jdr.sagepub.com/content/86/2/137

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RESEARCH REPORTS
Clinical

M. Farella1*, A. Michelotti1, G. Iodice1, S. Milani2, and R. Martina1

1 School of Dentistry, Department of Oral, Dental and Maxillo-Facial Sciences, Section of Orthodontics and Clinical Gnathology, University of Naples "Federico II", Via Pansini, 5, I-80131, Naples, Italy; and 2Institute of Medical Statistics and Biometry, University of Milan, Italy; *corresponding author, farella@unina.it

Unilateral Posterior Crossbite is Not Associated with TMJ Clicking in Young Adolescents

J Dent Res 86(2):137-141, 2007

ABSTRACT
Unilateral posterior crossbite has been considered as a risk factor for temporomandibular joint clicking, with conflicting findings. The aim of this study was to investigate a possible association between unilateral posterior crossbite and temporomandibular disk displacement with reduction, by means of a survey carried out in young adolescents recruited from three schools. The sample included 1291 participants (708 males and 583 females) with a mean age of 12.3 yrs (range, 10.1-16.1 yrs), who underwent an orthodontic and functional examination performed by two independent examiners. Unilateral posterior crossbite was found in 157 participants (12.2%). Fifty-three participants (4.1%) were diagnosed as having disk displacement with reduction. Logistic regression analysis failed to reveal a significant association between unilateral posterior crossbite and disk displacement with reduction (odds ratio = 1.3; confidence limits = 0.6-2.9). Posterior unilateral crossbite does not appear to be a risk factor for temporomandibular joint clicking, at least in young adolescents. KEY WORDS: temporomandibular disorders, crossbite, malocclusion, cross-sectional study, young adolescents.

INTRODUCTION
different malocclusions, posterior thought have Amongprevious findings correctsuggested crossbite ismasticatorytosystem.a stronger impact on the functioning of the Indeed, have that persons with unilateral posterior crossbite contracted their jaw muscles asymmetrically (Troelstrup and Mller, 1970; Ingervall and Thilander, 1975; Ferrario et al., 1999; Alarcon et al., 2000), and that they exerted lower bite forces than did control participants (Sonnesen et al., 1998, 2001b). A reduced thickness of the masseter muscle ipsilaterally to the crossbite side has also been reported (Kiliaridis et al., 2000). It has been suggested that, in persons with unilateral posterior crossbite, the altered morphological relationship between the upper and lower dentition may result in right-to-left-side differences in the condyle-fossa relationship (O'Byrn et al., 1995; Hesse et al., 1997; Nerder et al., 1999; Pinto et al., 2001), and may induce asymmetrical mandibular growth (Mongini and Schmid, 1987; Lam et al., 1999; Pinto et al., 2001). The proposed causal chain of events suggests that these asymmetries may also result in alterations of the disk-condyle relationship, which in turn are responsible for disk displacement and temporomandibular joint (TMJ) clicking (Wilkinson, 1991; Pullinger et al., 1993; McNamara et al., 1995b; Egermark et al., 2003). Indeed, positive associations between unilateral posterior crossbite and TMJ clicking are supported by several studies, the results of which suggest that the crossbite increases the risk of disk displacement by a factor of up to 3 (Kritsineli and Shim, 1992; Pullinger et al., 1993; Tanne et al., 1993; McNamara et al., 1995a; Thilander et al., 2002; Egermark et al., 2003). Nevertheless, the existing relationship between posterior crossbite and TMJ disk displacement has also been questioned, since other studies obtained different results (Keeling et al., 1994; Sonnesen et al., 2001a). The main reasons for such controversies may be ascribed to the different clinical criteria for the definition of TMJ clicking across studies, and to the different study designs. Indeed, several studies (Pullinger et al., 1993; List et al., 2001; Sonnesen et al., 2001b) investigating the relationship between occlusal factors and temporomandibular disorders have been carried out with small sample sizes, or have used dental students/staff as controls in case-control design; this might lead to selection bias, particularly if potential confounding variables have not been taken into account in the analysis. A population-based study of risk factors for temporomandibular disorders has the advantage that cases and controls are not selected according to patient referral. Controls come from the same population as the cases, which reduces the possibility of selection bias and confounding. The aim of this cross-sectional study was, therefore, to investigate the association between TMJ disk displacement and posterior crossbite by means of well-defined criteria for the assessment of TMJ clicking and unilateral posterior crossbite and a population-based approach in a large

Received February 22, 2006; Last Revision October 14, 2006; Accepted November 5, 2006

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Table 1. Details about the Sampling Procedure Used for the Study

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was obtained only from 1291 (76.8%) out of 1680 students. The sample included 708 males (54.9%) and 583 females (45.1%), with a mean age ( standard School A School B School C Overall deviation) of 12.3 1.1 yrs. The age range, the tenth, and the ninetieth percentiles of the whole sample were Eligible students 619* 759 722 2100 10.1-16.1, 11.0, and 13.8 yrs, respectively. Distribution Students selected by randomization 495 607 578 1680 of participants by gender, age, and orthodontic treatment Parents' refusals to informed consent 121 138 130 389 for each school is given in Table 2. Students included in the study 378 471 442 1291 All the participants underwent an orthodontic and * Numbers represent absolute frequencies of participants. temporomandibular joint functional examination, performed independently by two dentists (i.e., the first two authors), who where calibrated to a gold standard a among Schools by Crossbite, Gender, Age, (for details, see International Consortium for Table 2. Distribution of Participants RDC/TMD-based Research, 2006). and Orthodontic Treatment Posterior crossbite was diagnosed when the participant had one or more teeth of the posterior group School A School B School C Overall (from canine to second molar) in an irregular (at least one cusp wide) bucco-lingual or bucco-palatal Posterior crossbite relationship, with one or more opposing teeth No 340b 399 395 1134 (Daskalogiannakis, 2000). TMJ disk displacement with Yes 38 72 47 157 reduction was diagnosed according to the Axis I-Group Gender II of the Research and Diagnostic Criteria for Boys 217 263 228 708 Temporomandibular Disorders (Dworkin and LeResche, Girls 161 208 214 583 1992). Positive diagnoses of right, left, and bilateral Age TMJ disk displacement with reduction were grouped < 11.6 104 151 186 441 into one dichotomous variable. 11.6 12.7 148 129 149 426 We assessed agreement between examiners by > 12.7 126 191 107 424 calculating kappa coefficients (Cohen, 1960) from Previous or current orthodontic treatment duplicate measurements obtained from a subgroup of 60 No 291 374 357 1022 participants. The coefficients for disk displacement Yes 87 97 85 269 with reduction and posterior crossbite assessments were a 0.72 (standard error = 0.06) and 0.95 (standard error = Number of observations, 1291. b Numbers represent absolute frequencies of participants. 0.03), respectively, indicating good to excellent agreement. Data collected were first analyzed by means of conventional descriptive statistics. Chi-square tests and multiple sample of young adolescents. The working hypothesis to be logistic regression were used for subsequent statistical analyses. tested was the assumption that co-morbidity between the two Age, gender, and self-report of current or previous orthodontic conditions would not exceed that expected by mere chance. treatment were entered into the multiple logistic model as potential confounding variables. Statistical analyses were carried out by MATERIALS & METHODS means of the statistical package SPSS software (Release 12.0, Participants were recruited from among secondary schools by Chicago, IL, USA), with a probability level of 0.05 considered means of a two-stage cluster sampling. First, 3 schools were statistically significant. randomly selected from among the 9 schools found in the vicinity of the Dental Clinic, University of Naples "Federico II". In each RESULTS school, students were selected from lists by means of an inclusion Fifty-three participants (4.1%) out of 1291 were diagnosed as probability (80%) related to the school's size. Details about the having disk displacement with reduction of the tempororecruitment process are given in Table 1. mandibular joint. Twenty-four participants had disk The determination of sample size was based upon previous displacement with reduction of the right TMJ, 20 participants estimates of the prevalence of joint clicking (about 9%) and had disk displacement with reduction of the left TMJ, and nine unilateral posterior crossbite (about 20%) in Europe (Ciuffolo et participants had disk displacement with reduction of both al., 2005; Gesch et al., 2005); calculations were performed with TMJs. Even though several participants (n = 25; 1.9%) had type I error set at 0.05 and power set at 80%; it was estimated that joint pain on palpation, none of the participants of the whole about 1100 people would be needed for the detection of an odds sample reported ongoing TMJ pain on opening and excursions ratio between 'exposed' and 'unexposed to the risk factor' equal to during the examination, or a history of significant limitation of or greater than 2. We aimed to recruit more than 1600 eligible jaw opening. An asymptomatic coarse crepitus in the right TMJ participants, predicting a 20-30% refusal rate. was found in one participant, who received a diagnosis of right The protocol used in this study was in accord with the osteoarthrosis. None of the participants was diagnosed as requirements of the Local Ethical Committee and of the principles having other joint disorders. of the Helsinki Declaration. Disk displacement with reduction of the temporoSelected students (n = 1680) received an informed consent mandibular joint was found in 31 out of 708 males (4.4%), and form to be signed by their parents. Informed consent, however,
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Table 3. Results of Multiple Regression Analysis with Temporomandibular Joint Disk in 22 out of 583 females (3.8%). The proportion of Displacement with Reduction as the Dependent Variable and Posterior Crossbite, disk displacement with reduction did not differ Gender, Age, and Orthodontic Treatment as Independent Variables significantly between genders (Chi-square = 0.30; degrees of freedom = 1; p = 0.59). 95% Confidence Intervals Unilateral posterior crossbite was found in 157 Independent Variable Odds Ratio Lower Upper P value out of 1291 participants (12.2%), 79 (50.3%) males and 78 (49.6%) females (Chi-square = 1.49; degrees Posterior crossbite of freedom = 1; p = 0.22). The association between Noa disk displacement with reduction (DDWR) and Yes 1.3 0.6 2.9 0.46 posterior crossbite was not statistically significant Gender (Chi-square = 0.44; degrees of freedom = 1; p = Boysa 0.50), and only eight participants out of 1291 (0.6%) Girls 0.8 0.5 1.5 0.52 were found to have, concurrently, disk displacement Age (yrs) with reduction and unilateral posterior crossbite. < 11.6a Four out of eight participants had a clicking joint 11.6 12.7 0.8 0.4 1.5 0.43 ipsilateral to the crossbite side, while the others had a > 12.7 0.8 0.4 1.5 0.42 clicking joint contralateral to the crossbite side. Previous or current orthodontic treatment We performed a multiple logistic regression, Noa considering the disk displacement with reduction Yes 1.0 0.5 2.0 0.93 diagnoses as the response variable (two modalities: present, absent), and unilateral posterior crossbite a Reference group; number of observations, 1291. (two modalities: yes, no), age (three modalities: upper, middle, and lower tertile), gender (two modalities: boys, girls), and orthodontic treatment (two modalities: yes, no) as independent variables. directly from schools and not from a dental clinic, and partly to The results of logistic regression analysis suggested that none the young age of the participants recruited for the present study. of the covariates included into the model was significantly The low frequency of disk displacement with reduction associated with the TMJ disk displacement with reduction, with diagnoses found in our sample might also be explained by the the odds ratios ranging from 0.8 to 1.3 (Table 3). different criteria we used to assess disk displacement (i.e., The proportion of disk displacement with reduction cases Research and Diagnostic Criteria; Dworkin and LeResche, and of unilateral posterior crossbite cases did not differ 1992), which are more conservative for clicking diagnoses than significantly between participants who never received any simple auscultation methods or self-reported methods (John et orthodontic treatment and those with previous or current al., 2002; Gesch et al., 2005). orthodontic treatment (Table 4). Indeed, based on these criteria, the prevalence of Neither the magnitude (odds ratio = 1.2) nor the level of reproducible joint clicking in a random selected sample of significance (p = 0.30) of the adjusted odds ratio for unilateral German children/adolescents was estimated at 4.3% (Hirsch et posterior crossbite changed noticeably when the participants al., 2005). This value was similar to the proportion of joint with previous or current orthodontic treatment were excluded clicking found in our study (i.e., 4.1%). from the sample investigated. The relative frequency of posterior crossbite found in our A post hoc power analysis revealed that the power of the study fits with previous prevalence estimates obtained in main statistical test was 63%, because only 53 cases diagnosed unselected participants of similar age (Thilander and Myrberg, as disk displacement with reduction were found in our sample. 1973; Helm and Prydso, 1979; Ciuffolo et al. 2005). In The actual sample size, however, ensured a 95% power in contrast, as expected, the occurrence of crossbite in our study detection of an odds ratio equal to 3 or higher. group was considerably lower than that found in studies with DISCUSSION selected pre-orthodontic samples (Sonnesen et al., 1998). The present findings suggest that, in young adolescents, The relative frequency of disk displacement with reduction found in our sample (about Table 4. Distribution of Clinical Diagnoses, Gender, and Age by Orthodontic Treatment in 1291 Participants 4%) was considerably lower than that obtained in Previous or Current Orthodontic Treatment other studies investigating No (n = 1022) Yes (n = 269) P value children of a similar age (Sonnesen et al., 2001b; Number of cases diagnosed as disk displacement with reduction (%) 42 ( 4.1) 11 ( 4.1) 0.99a Thilander et al., 2002; Number of cases diagnosed as unilateral posterior crossbite (%) 129 (12.6) 28 (10.4) 0.32b Egermark et al., 2003). Number of females (%) 450 (44.0) 133 (49.4) 0.11c This discrepancy may be Mean age in years (standard deviation) 12.3 (1.1) 12.3 (1.0) 0.51d partly ascribed to the different sampling a Chi square < 0.001; degrees of freedom = 1; p = 0.99. procedures used in b Chi square = 0.99; degrees of freedom = 1; p = 0.32. c previous studies, since we Chi square = 2.52; degrees of freedom = 1; p = 0.11. d Independent samples t test; t = 0.66. sampled participants
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unilateral posterior crossbite is not a risk factor for TMJ disk displacement, since the tested working hypothesis could not be rejected. Indeed, both chi-square test and multiple logistic regression analysis failed to demonstrate a significant association between this factor and disk displacement with reduction, showing an odds ratio very close to 1. The same result was obtained even after we excluded participants with current or previous orthodontic treatment. Interestingly, these participants were found to have a frequency of joint clicking (i.e., 4.1%) identical to that of the other participants. From a theoretical point of view, however, the previous or current orthodontic treatment may represent a confounding factor, since persons affected by both joint clicking and unilateral posterior crossbite may be more likely to be referred to orthodontists. For this reason, these participants were considered in this study. The lack of association between TMJ disk displacement and posterior crossbite is in contrast to previous reports obtained from both young adolescents and adults (Brandt, 1985; Pullinger et al., 1993; Tanne et al., 1993; McNamara et al., 1995a; Thilander et al., 2002; Egermark et al., 2003). Several reasons may contribute to an explanation of our contradictory findings. First, the present study was a population-based cross-sectional study of the relationship between unilateral posterior crossbite and disk displacement, with independently measured exposure and outcome variables, demonstrated reliability of temporomandibular joint clicking and crossbite assessments, and controlled for potentially confounding variables, whereas most previous studies (Pullinger et al., 1993; Tanne et al., 1993; Sonnesen et al., 1998; List et al., 2001; Thilander et al., 2002) have been carried out in universities or dental clinics. Second, our examiners were calibrated and made diagnoses of disk displacement with reduction by means of standardized methods, which are internationally accepted (Dworkin and LeResche, 1992; John et al., 2005). It should be noted that we have investigated the unilateral posterior crossbite as a static occlusal feature. Crossbite malocclusions, however, may be associated with mandibular functional shifts (Nerder et al., 1999). Therefore, the effects of functional occlusion on joint clicking need to be further investigated. It must also be stressed that the frequency of TMJ disk displacement diagnoses found in our sample was lower than expected. This has reduced the power of our statistical test. Post hoc power analysis, however, allowed us to be highly confident (i.e., with 95% power) that there was no relationship between disk displacement with reduction and posterior crossbite for a potential strength of association between the two conditions (i.e., odds ratio) equal to 3 or higher. This strength of association had been suggested from previous studies carried out in adult participants (Pullinger et al., 1993; Egermark et al., 2003). Our findings were obtained from a sample of young adolescents; therefore, it cannot be excluded that the unilateral posterior crossbite may become a significant risk factor with increasing age. Future studies, possibly with population-based sampling, might help to clarify this point. The present findings, which indicate a lack of association between posterior crossbite and disk displacement, suggest that there is an initial optimal TMJ functional adaptation to unilateral posterior crossbite, at least until young adolescence, since most participants (about 95%) with this malocclusion did

not have TMJ internal derangements. Based upon these observations, clinicians should be cautious in recommending early orthodontic treatment, in persons with unilateral posterior crossbite, aiming only to prevent joint clicking, since it seems unrelated to this occlusal condition. In conclusion, the findings of our study suggest that unilateral posterior crossbite is not a risk factor for TMJ disk displacement in young adolescents. Further studies are needed, however, to determine the long term-effect of this malocclusion on TMJ internal derangements.

ACKNOWLEDGMENTS
This study was supported by the fund number 2001062735, PRIN 2001 from the Italian Ministry for University and Research and was awarded the Gaetano Salvatore prize.

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