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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 195-198

Assessment of degenerative changes in the temporomandibular joint: A retrospective cone-beam computed tomography study


1 Consultant Oral Diagnostician and Maxillofacial Radiologist, Mangaluru, Karnataka, India
2 Department of Oral Medicine and Radiology, A J Institute of Dental Sciences, Mangaluru, Karnataka, India

Date of Submission22-Aug-2020
Date of Acceptance19-Nov-2020
Date of Web Publication05-Feb-2021

Correspondence Address:
Dr. Valen Dela Dsouza
A.J Institute of Dental Sciences, Kuntikana, Mangalore 575003, Karnataka
India
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DOI: 10.4103/srmjrds.srmjrds_69_20

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  Abstract 

Context: Degenerative temporomandibular joint (TMJ) disorders may show radiological characteristics similar to remodeling changes in an asymptomatic joint. Aims: The aim of the study was to evaluate the bone changes in the condylar process of the TMJ in patients and associate the changes with age and gender. Settings and Design: The study was conducted in the Department of Oral Medicine and Radiology, AJ Institute of Dental Sciences over a period of 2 years following institutional ethical clearance. Data were retrieved from the computer database and assessed using cone-beam computed tomography (CBCT) (NewTom VGi evo). Subjects and Methods: Two hundred TMJ CBCT images were assessed in 100 patients. The study sample was carefully selected to exclude patients with any medical problems. The same bone changes in the condylar process were found in at least two consecutive slices by a single observer to avoid misinterpretation. Statistical Analysis: Data were collected and subjected to statistical analysis using kappa statistics for intraobserver reliability and using Chi-square test for comparison of parameters (P < 0.05). Results: Out of the 200 TMJs assessed, no changes were seen in 96 (48%) joints. The most common degenerative change seen was flattening, followed by erosion. When associated with gender, a statistically significant difference was found between males and females (P < 0.05). A statistically significant increase in changes was found with age (P < 0.05). The intraobserver agreement in assessing the CBCT images was carried out using kappa statistic and was found to be in almost perfect agreement (κ = 94.59%, P < 0.005). Conclusion: The study revealed a high frequency of TMJ alterations in male patients with degenerative changes, beginning in individuals <25 years of age and increasing with age. The high prevalence of TMJ changes in patients without complaints, suggests that some people with joint structural damage may not display clinical manifestations.

Keywords: Cone-beam computed tomography, osseous changes, temporomandibular joint


How to cite this article:
Dsouza VD, Rao PK, Kini R. Assessment of degenerative changes in the temporomandibular joint: A retrospective cone-beam computed tomography study. SRM J Res Dent Sci 2020;11:195-8

How to cite this URL:
Dsouza VD, Rao PK, Kini R. Assessment of degenerative changes in the temporomandibular joint: A retrospective cone-beam computed tomography study. SRM J Res Dent Sci [serial online] 2020 [cited 2021 Mar 2];11:195-8. Available from: https://www.srmjrds.in/text.asp?2020/11/4/195/308788


  Introduction Top


The temporomandibular joint (TMJ) has various functional and anatomic features that make it a unique joint.[1] The etiologies of TMJ disorders (TMD) are complex and controversial. Under similar conditions, an individual's TMJ may appear to deteriorate, while others may not. Once degenerative changes begin in the TMJ, this pathology can be progressive and lead to a variety of morphological and functional deformities.[2]

Remodeling is a constant process that occurs throughout all the joints in the body which have been revealed by skeletal and histological studies.[3] Continuous condylar remodeling adapts the joint to meet its functional demands. It is based on the interaction between the adaptive capacity of the condyle and the mechanical forces sustained by the TMJ.[1]

Radiographic imaging is an important component in visualizing the joint in the diagnosis of TMD. Various imaging modalities such as panoramic radiography and the TMJ views have exhibited drawbacks due to the complicated TMJ anatomy, its position at the skull base, and limitations in various techniques of radiologic evaluation.[4]

With the introduction of cone-beam computed tomography (CBCT) and its utilization in the maxillofacial region, due to lower radiation compared to CT, the use of CT in TMJ evaluation has become limited. CBCT enables the assessment of bone, articular space, and dynamic function in the axial, sagittal, and coronal planes without superimposition of structures.[5]

The radiographic features of remodeling are subtle. They include sclerosis which is caused by thickening of the cortical plate and erosion of the cortical plate. Peripheral remodeling may also result in the presence of joint osteophytes.[6]

The purpose of this study was to evaluate the degenerative bone changes in TMJs as seen on CBCT images and to associate the changes with age and gender.


  Subjects and Methods Top


On obtaining institutional ethical clearance, CBCT images of 100 patients between 18 and 80 years with no TMJ-related complaints were retrieved from the computer database and evaluated using CBCT (NewTom, Verona, Italy), operating at 110 kVp and 18.0 mA. Lateral and coronal cross-sections of the right and left TMJ in maximum intercuspation were viewed at a thickness of 0.3 mm on a personal computer with a 27” LED monitor display with installed and integrated NNT Viewer software (NewTom, Verona, Italy). The same bony changes were confirmed on two consecutive joint slices by a single observer.

The bony changes evaluated were flattening of the condylar head which was confirmed by a flat bony contour, erosion or decreased density of the cortical and adjacent subcortical bone, osteophytes or osseous outgrowths seen on the surface of the condyle, sclerosis which is an area of increased cortical bone density, and pseudocysts which represent well-circumscribed osteolytic areas, as shown in [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d,[Figure 1]e,[Figure 1]f. Data were collected and subjected to statistical analysis for intraobserver reliability using kappa statistic and Chi-square test with SPSS software version 17.0 (IBM, India). The statistical significance was set at 5% level of significance (0.05).
Figure 1: Degenerative changes seen on cone-beam computed tomography cross-sections (viewed on NNT Viewer) representing (a) normal, (b) flattening, (c) erosion, (d) osteophytes, (e) sclerosis, and (f) pseudocyst

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  Results Top


Out of the 200 TMJs assessed, no changes were seen in 96 (48%) joints. Out of the changes seen, flattening of the condylar surface was the most predominant feature, seen in 77 (38.5%) TMJs. This was followed by erosion of the condylar head seen in 10 (5%) TMJs. Flattening with erosion was present in seven (3.5%) TMJs, osteophytes were seen in five (2.5%), and sclerosis was seen in two (1%) joints. Combination of flattening with sclerosis was seen in one (0.5%), erosion with sclerosis in one (0.5%), and erosion with pseudocyst in one (0.5%) joint [Table 1].
Table 1: Distribution of degenerative bone changes of TMJ and their combinations as seen on CBCT

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A highly statistically significant difference was observed between the presence of bony changes in males and females (P = 0.00086). Out of the 38 (100%) female patients, 17 (44.7%) showed bony changes and out of the 62 (100%) male subjects, 48 (77.4%) showed bony changes on CBCT [Table 2].
Table 2: Gender distribution of subjects based on the presence of degenerative bone changes in TMJ seen on CBCT

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The age-wise distribution of the study subjects revealed that all the five (100%) patients ≤66 years showed bony changes on CBCT. Out of the subjects ≤25 years, 17 (41.5%) showed bony changes and 30 (78.9%) subjects with bony changes were in the 26–45 years' age group. In the 46–65 years' age group, 13 (81.3%) showed bony changes. The results showed a high significance between the presence of bony changes seen on CBCT with various age groups with P = 0.000863 [Table 3].
Table 3: Age wise distribution of patients based on the presence of degenerative bone changes in TMJ on CBCT

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The intraobserver agreement in assessing the CBCT images was carried out using kappa statistic and was found to be in almost perfect agreement (κ = 94.59%, P < 0.005).


  Discussion Top


The study evaluated 100 asymptomatic patients for TMJ changes on CBCT. Out of the 200 (100%) TMJs evaluated, osseous changes were seen in 104 (52%). The most predominant change seen was flattening in 77 (38.5%) joints. The high frequency of bony changes in patients may be due to the unwanted selection of individuals with problems in anatomic regions close to TMJ, though they would have not presented TMJ complaints. The evaluated subjects in our study were not a sample of normal population but patients with dental or facial disorders (most commonly prior to orthognathic surgery or partially edentulous individuals for dental implants) other than TMJ. This finding may suggest that the disorders involving such structures may be associated with the development of bony changes in TMJ. In accordance with this finding, Edwards et al. reported that TMJ alterations represented 12.6% of incidental findings in CBCT of 427 orthodontic patients.[7] Previous studies wherein CBCT images were taken for dental implants have demonstrated a prevalence of 3.9%–6.2% of TMJ changes.[8] The high prevalence of bony changes among asymptomatic individuals could also be attributed to the compensatory potential of TMJ. Because the joint encompasses various adaptive mechanisms, the structural damages may be asymptomatic or minimally apparent for a long time.[9]

On associating the bone changes with gender, the prevalence of degenerative changes was highest (77.4%) in males unlike numerous studies which show female predominance in osteoarthritis of TMJ. This study supports the findings of Crusoé-Rebello et al. who concluded that there was no relationship between gender and hormones with TMJ derangement.[10]

The prevalence of degenerative changes in our study was 41.5%, 78.9%, 81.3%, and 100%, in age groups of ≤25 years, 26–45 years, 46–65 years, and ≥66 years, respectively, showing a significant increase with age, similar to a study by Alexiou et al. where patients in older age groups had more severe and frequent bone changes.[11] Although degenerative changes are commonly seen with aging, recent research has indicated that osteoarthritis is seen in a majority of young patients.[12] An autopsy study by Pereira et al. also showed that signs of degenerative changes on the TMJ articular surfaces were prevalent in both the younger and older age groups.[13]


  Conclusion Top


By employing CBCT as a diagnostic imaging tool, this study revealed that there is a high frequency of TMJ alterations in male patients with degenerative changes, beginning in individuals <25 years of age and increasing with age, suggesting that some people with joint structural damage may not display clinical manifestations. CBCT imaging may be useful in visualizing the remodeling changes of the joint but may not be a sign of temporomandibular dysfunction; clinical examination is required to establish the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mathew AL, Sholapurkar AA, Pai KM. Condylar changes and its association with age, TMD, and dentition status: A cross-sectional study. Int J Dent 2011;2011:413639.  Back to cited text no. 1
    
2.
Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: Etiology, diagnosis, and treatment. J Dent Res 2008;87:296-307.  Back to cited text no. 2
    
3.
Hegde SS, Rao GS, Sattur AP, Nandimath KR, Shetty RS, Madi M. Role of digital volumetric tomography in assessing morphological variations in condyle and temporal components of patients with asymptomatic temporomandibular joint. J Indian Acad Oral Med Radiol 2019;31:140.  Back to cited text no. 3
  [Full text]  
4.
Pontual A, Freire JS, Barbosa JM, Frazão MA, Pontual AA. Evaluation of bone changes in the temporomandibular joint using cone beam CT. Dentomaxillofac Radiol 2012;41:24-9.  Back to cited text no. 4
    
5.
Hossein S, Zarch H, Langrodi AJ, Bahramian L, Keihani FJ. The evaluation of position and degenerative changes of condyle in CBCT. Radiography 2017;2017:1-5. [Doi: 10.15713/ins.ijcdmr. 119].  Back to cited text no. 5
    
6.
Muir CB, Goss AN. The radiologic morphology of asymptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol 1990;70:349-54.  Back to cited text no. 6
    
7.
Edwards R, Alsufyani N, Heo G, Mir FC. The frequency and nature of incidental findings in large-field cone beam computed tomography scans of an orthodontic sample. Prog Orthod 2014;15:37.  Back to cited text no. 7
    
8.
Allareddy V, Vincent SD, Hellstein JW, Qian F, Smoker WR, Ruprecht A. Incidental findings on cone beam computed tomography images. Int J Dent. 2012;2012:1-9. Article ID 871532.  Back to cited text no. 8
    
9.
Shahidi S, Salehi P, Abedi P, Dehbozorgi M, Hamedani S, Berahman N. Comparison of the bony changes of TMJ in patients with and without TMD complaints Using CBCT. J Dent (Shiraz) 2018;19:142-9.  Back to cited text no. 9
    
10.
Crusoé-Rebello IM, Campos PS, Rubira IR, Panella J, Mendes CM. Evaluation of the relation between the horizontal condylar angle and the internal derangement of the TMJ A magnetic resonance imaging study. Pesqui Odontol Bras 2003;17:176-82.  Back to cited text no. 10
    
11.
Alexiou KE, Stamatakis HC, Tsiklakis K. Evaluation of the severity of temporomandibular joint osteoarthritic changes related to age using cone beam computed tomography. Dentomaxillofac Radiol 2009;38:141-7.  Back to cited text no. 11
    
12.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2nd ed. Philadelphia: Saunders; 2002. p. 755.  Back to cited text no. 12
    
13.
Pereira FJ Jr., Lundh H, Westesson PL. Morphologic changes in the temporomandibular joint in different age groups. An autopsy investigation. Oral Surg Oral Med Oral Pathol 1994;78:279-87.  Back to cited text no. 13
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Subjects and Methods
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