|Year : 2016 | Volume
| Issue : 4 | Page : 358-363
Assessment of joint space and arthritic changes in temporomandibular joint as visualized on cone beam computed tomography scan
Priyanka Verma1, Varun Surya2, Sonali Kadam3, Hemant R Umarji3, Nandita Gupta4, Ajas Gogri3
1 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Nagpur, Maharashtra, India
2 Department of Oral Pathology, Maulana Azad Institute of Dental Sciences, New Delhi, India
3 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra, India
4 Department of Oral Medicine and Radiology, Institute of Technology and Science Dental College, Hospital and Research Centre, Greater Noida, Uttar Pradesh, India
|Date of Submission||26-Mar-2016|
|Date of Acceptance||01-Feb-2017|
|Date of Web Publication||21-Feb-2017|
32-B Empress Mill Colony, Behind Ajni Police Station, Near Vishwakarma Nagar, Nagpur - 440 027, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Cone beam computed tomography (CBCT) has been recognized as a reliable method for the examination of the osseous components of the temporomandibular joint (TMJ). Aims and Objectives: The aim of this study is to assess the joint space and arthritic changes in TMJ, as visualized on the CBCT scan. Materials and Methods: The study comprised 60 patients attending the outpatient department (120 joints) with temporomandibular dysfunction. All the patients were subjected to CBCT scan using Planmeca Promax 3D Mid machine. TMJ evaluation included bony changes (flattening, erosion, osteophytes, sclerosis, Ely's cyst and joint mice) and measurement of joint space (normal, increased, reduced, bony contact) between the condyle and the mandibular fossa. Results: No statistically significant differences were found between symptomatic and asymptomatic joints and radiographic arthritic changes (P = 0.437) and distribution of osseous changes in condyle among the symptomatic and asymptomatic joints (P = 0.428). Statistically significant difference was found between diminution in joint space with increased mean age (P = 0.001). Conclusion: The radiographic findings may not truly reflect the clinical signs and symptoms. Asymptomatic joints may present with radiographic changes and few of the symptomatic joints may fail to reveal radiographic changes. Radiographically manifested osseous changes, i.e., flattening, osteophyte, sclerosis, erosion etc., had no significant correlation with the symptomatic and asymptomatic joints. In older age groups, patients are expected to have severe progressive degenerative bony changes than those in patients of younger age groups.
Keywords: Cone beam computed tomography, osteoarthritis, temporomandibular joint
|How to cite this article:|
Verma P, Surya V, Kadam S, Umarji HR, Gupta N, Gogri A. Assessment of joint space and arthritic changes in temporomandibular joint as visualized on cone beam computed tomography scan. J Indian Acad Oral Med Radiol 2016;28:358-63
|How to cite this URL:|
Verma P, Surya V, Kadam S, Umarji HR, Gupta N, Gogri A. Assessment of joint space and arthritic changes in temporomandibular joint as visualized on cone beam computed tomography scan. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2017 Jul 27];28:358-63. Available from: http://www.jiaomr.in/text.asp?2016/28/4/358/200645
| Introduction|| |
Because temporomandibular joint (TMJ) is in constant use throughout life, it is not surprising that the individual components of the joint whether osseous or soft tissue show signs of wear and tear. Therefore, age associated degenerative changes manifested as osteoarthritis are commonly encountered in clinical practice. The TMJ imaging protocol begins with hard-tissue imaging to evaluate the bony contours, the positional relationship of the condyle and fossa and the range of motion. In many cases, a radiographic examination is a decisive factor for the differential and final diagnosis of several pathological conditions of the TMJ.,, The introduction of the cone beam computed tomography (CBCT) technology specifically designed for use in dentistry has opened up new opportunities in TMJ imaging. CBCT has been recognized as a reliable method for the examination of the osseous components of the TMJ. This technique is easy to perform, is reproducible and delivers a relatively low dose to the patient.,, CBCT provides images that can be reconstructed in planes parallel or perpendicular to the long axis of the condyle instead of the true anatomic coronal and sagittal planes.
| Aim|| |
The aim of this study is to assess joint space and arthritic changes in TMJ, as visualized on CBCT scan.
| Materials and Methods|| |
This study received approval from the ethical board of the institutional ethics committee. CBCT images and clinical records of 60 patients (120 joints) with TMJ osteoarthritis who sought treatment during December 2012 to September 2014 were reviewed in this study. The age of the patients ranged 16–70 years, with a mean age of 39.65 years. Inclusion criteria for this study included temporomandibular dysfunction comprising TMJ pain on palpation and on jaw functions in either or both TMJ, joint sounds such as crepitus, clicking, or popping, and limited range of motion, or CBCT bony changes including flattening, erosion, osteophyte formation, sclerosis, Ely's cyst, joint mice, and joint space evaluation. Exclusion criteria included a history of TMJ surgery, condylar fracture, jaw trauma and polyarthritis (such as rheumatoid arthritis, gout arthritis, and psoriatic arthritis). The CBCT images were obtained using Planmeca Promax 3D Mid machine with an effective dose of approximately 18.9 µSv. Right and left TMJs were examined separately, and all examinations were performed in a central occlusal relationship according to the technique described in literature.
The osseous changes noted were as follows: (a) Flattening, defined as a flat bony contour deviating from the convex form [Figure 1]a and [Figure 1]b; (b) Erosion, defined as an area of decreased density of the cortical bone and the adjacent subcortical bone [Figure 2]a and [Figure 2]b; (c) Osteophytes, defined as marginal bony outgrowths on the condyle [Figure 3]a, [Figure 3]b, [Figure 3]c; (d) Sclerosis, defined as an area of increased density of cortical bone extending into the bone marrow [Figure 4]a; (e) Ely's cyst (subcortical cyst), rounded radiolucent area that may be just below the cortical plate or deep in trabecular bone [Figure 4]a and [Figure 4]b; (f) Joint mice, defined as a detached osteophyte fragment lying freely in the joint space [Figure 1]b.
|Figure 1: Sagittal section of TMJ displaying flattening of the (a) superior surface, and (b) anterosuperior surface of condyle with a small radiopacity seen freely floating in the joint space, suggestive of joint mice|
Click here to view
|Figure 2: TMJ (a) sagittal section showing moderate to severe erosion of the condyle with osteophyte formation on the anterosuperior surface, and (b) coronal section showing erosion on superior surface of the condyle|
Click here to view
|Figure 3: Showing osteophyte in (a) axial, (b) coronal and (c) sagittal sections of TMJ|
Click here to view
|Figure 4: TMJ (a) sagittal section showing diffuse subchondral sclerosis with Ely's cyst, and (b) coronal section showing a well circumscribed radiolucency surrounded by sclerotic margins suggestive of Ely's cyst|
Click here to view
The distance between the condylar head and mandibular fossa was measured to assess the joint space and was categorized as follows: Joint space was considered  (1) Increased, when the distance between the condylar head and mandibular fossa was more than 4 mm; (2) Normal, when the distance between the condylar head and mandibular fossa was between 1.5 mm and 4 mm; (3) Reduced, when the distance between the condylar head and mandibular fossa was less than 1.5 mm [Figure 5]; and (4) Absent, when there was bony contact between condyle and mandibular fossa. For the measurement of joint space, sagittal section passing through the centre of the condyle was chosen. The operator subjectively chose the minimal distance between the condyle and mandibular fossa on the anterosuperior and posterosuperior surfaces. Measurement tool provided by the software was utilized to obtain two readings (anterosuperior and posterosuperior), and the mean of the measurements was recorded as the joint space.
|Figure 5: Sagittal section of TMJ showing uniform reduction of the joint space with osteophyte formation on the anterosuperior surface of the condyle|
Click here to view
Two experienced oral radiologists were asked to evaluate all images independently and to record the findings on a specific evaluation sheet. All images were viewed on the same monitor under the same conditions.
The data obtained after critical evaluation of clinical and CBCT findings were carefully recorded, and the entire data was analyzed using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL - version 20) for Microsoft Windows. Chi-square test was applied and the confidence interval was set at 95%, which reflects a significance level of 0.05.
| Results|| |
Gender and age-wise distribution of the cases is shown in [Table 1]. TMJ arthritis was seen more commonly in females, i.e., 38 cases (63.33%) compared to males i.e., 22 cases (36.67%). Maximum (14 nos., 23.33%) cases belonged to age groups 20–29 years and 50–59 years. The distribution of the type of bony change in condyle, articular eminence (AE), and glenoid fossa (GF) were as follows: In condyle, the most common radiographic change observed was flattening (66.67%) followed by osteophyte formation (45%), sclerosis (41.67%), and erosion (35%). Ely's cyst (10%) was the least common finding. In articular eminence, the most common radiographic change was sclerosis (30%) followed by erosion (3.33%) and Ely's cyst (1.67%). Least common radiographic change was osteophyte (0.8%) seen only in a single joint. In glenoid fossa, the most common arthritic change observed was sclerosis (28.33%), and osteophyte (1.67%) was the least common change.
Following findings were observed when surface-wise distribution of condylar osseous changes was studied. Out of the total 120 joints observed, condylar flattening was seen in 80 joints. Most commonly involved surface was anterosuperior (81.2%) followed by posterosuperior (33.7%) and superior surfaces (13.7%). Condylar osteophyte was observed in 54 joints. The most common involved surface was anterosuperior (88.8%) followed by superior surface (14.8%) and posterosuperior surface (5.5%) was the least common. Condylar erosion was observed in a total of 42 joints, the superior surface (61.9%) was most commonly affected followed by anterosuperior (47.6%) and posterosuperior surfaces (21.4%). Ely's cyst and subchondral sclerosis are essentially changes observed in the subchondral portion of the joint, and hence, not included in the table describing surface changes.
[Table 2] shows the correlation between symptomatic and asymptomatic joints and radiographic arthritic changes. Out of the total 120 joints, 55 joints were symptomatic. Out of these 55 symptomatic joints, 54 showed positive CBCT findings whereas 1 did not show any CBCT findings. The total number of asymptomatic joints was 65. Out of the 65 asymptomatic joints, 55 showed positive CBCT findings and 10 did not show any CBCT findings. P value was found to be >0.05, which is statistically nonsignificant. Hence, it can be concluded that the radiographic findings may not truly reflect the clinical signs and symptoms. Asymptomatic joints may present with radiographic changes, and few of the symptomatic joints may fail to reveal radiographic changes.
|Table 2: Correlation between symptomatic and asymptomatic joints and radiographic arthritic changes|
Click here to view
[Table 3] shows the distribution of osseous changes in condyle among the symptomatic and asymptomatic joints. P value was found to be >0.05, which suggests that there was no statistically significant difference in the presence of radiographic osseous changes in symptomatic and asymptomatic joints. [Table 4] shows joint space evaluation of TMJ per mean age; diminution in joint space was observed with an increased mean age and this correlation between diminished joint space, and mean age was found to be statistically significant (P < 0.05).
|Table 3: Distribution of osseous changes in condyle among the symptomatic and asymptomatic joints|
Click here to view
| Discussion|| |
In the present study, osteoarthritis of TMJs was seen more frequently in women (63.33%) than in men (36.67%), which is in accordance with the study performed by dos et al. and Alexiou et al. In their study, 84.5% of the patients were females and 15.5% were males. Leresche  found that pain in the temporomandibular region is twice as common in women than that in men. The greater occurrence in women may be explained by the hormonal influences of estrogen and prolactin, which may exacerbate the degradation of cartilage and articular bone in addition to stimulating a series of immunological responses in the TMJ.
In this study, the part of TMJ most frequently affected by arthritis was condyle followed by articular eminence and glenoid fossa. These results are in agreement with the findings of previous studies by Campose et al., Guler et al., and Muller-Leisse. Gynther et al. also reported that radiographic changes primarily affected condyle in patients with generalized osteoarthritis and rheumatoid arthritis.
In condyle, the most common radiographic change observed was flattening (66.67%) followed by osteophyte formation (45%), sclerosis (41.67%), and erosion (35%). Ely's cyst (10%) was the least common finding. These results are in general agreement with the findings of Mathew et al. who reported flattening in 80% joints followed by osteophyte (16%), sclerosis (12%), erosion (8%), and Ely's cyst (6.7%). Sato et al., Hiltunen et al., and Takayama et al. also reported similar results.
The most common radiographic osseous change seen in the glenoid fossa was sclerosis in 34 joints (28.33%) followed by erosion in 11 joints (9.11%). This was in accordance to the studies by Alexiou et al. Honda et al. reported that mechanical stimulation may cause an increase in bone thickness in the glenoid fossa because of an incomplete shock absorption function resulting from a perforation of the disc or retrodiscal connective tissue.
There was no statistically significant association between radiographic changes in the condylar morphology and clinical signs and symptoms of TMJ dysfunction, and this was in accordance with the findings of Sato et al., Hiltunen et al., Crow et al., Hansson et al., Bush et al., and Huumonen et al. Wiese et al., De Leeuw, and Pertes  reported that radiographic evidence of osteoarthritis is a consequence of remodeling when the condition has clinically stabilized, i.e. radiographs do not depict the ongoing process but show the effect of the previous process.
[Table 3] shows the distribution of osseous changes in condyle among the symptomatic and asymptomatic joints. Detailed perusal of voluminous data available in literature failed to show any study presenting distribution of osseous changes among symptomatic and asymptomatic joints, and hence, the authors could not compare it with other studies.
One of the most common findings in patients with degenerative arthritis is reduced joint space. In this study, reduced joint space was observed in 25% of the joints, with a mean age of 42.26 years. Bony contact between condylar head and mandibular fossa was observed in 3.3% of the joints, with a mean age of 61.75% years. Joint mice were observed in 3.3% with a mean age of 56.5 years. These findings show that the severity of joint space reduction increases with age. The results of this study are in accordance with the findings of Alexiou et al.
| Conclusion|| |
It can be concluded from this study that the radiographic findings may not truly reflect the clinical signs and symptoms. Asymptomatic joints may present with radiographic changes, and few of the symptomatic joints may fail to reveal radiographic changes. Radiographically manifested osseous changes, i.e., flattening, osteophyte, sclerosis, erosion etc., had no significant correlation with the symptomatic and asymptomatic joints. In older age groups, patients are exposed to severe progressive degenerative bony changes than those in patients of younger age groups.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Roberts D, Pettigrew J, Udupa J, Ram C. Three-dimensional imaging and display of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1984;58:461-74.
Benson BW, Otis LL. Disorders of the temporomandibular joint. Dent Clin North Am 1994;38:167-85.
Nilner M, Petersson A. Clinical and radiological findings related to treatment outcome in patients with temporomandibular disorders. Dentomaxillofac Radiol 1995;24:128-31.
Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K. Development of a compact computed tomographic apparatus for dental use. Dentomaxillofac Radiol 1999;28:245-8.
Honda K, Larheim TA, Johannessen S, Arai Y, Shinoda K, Westesson PL. Ortho cubic super-high resolution computed tomography: A new radiographic technique with application to the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91(2): 239-43.
Honda K, Larheim TA, Maruhashi K, Matsumoto K, Iwai K. Osseous abnormalities of the mandibular condyle: Diagnostic reliability of cone beam computed tomography compared with helical computed tomography based on an autopsy material. Dentomaxillofac Radiol 2006;35:152-7.
Tsiklakis K, Syriopoulos K, Stamatakis HC. Radiographic examination of the temporomandibular joint using cone beam computed tomography. Dentomaxillofac Radiol 2004;33:196-201.
Alexiou KE, Stamatakis HC, Tsiklakis K. Evaluation of the severity of temporomandibular joint osteoarthritic changes related to age using cone beam computed stomography. Dentomaxillofacial Radiology 2009;38:141-7.
dos Anjos Pontual ML, Freire JS, Barbosa JM, Frazão MA, dos Anjos Pontual A. Evaluation of bone changes in the temporomandibular joint using Cone Beam CT. Dentomaxillofac Radiol 2012;41:24-9.
LeResche L. Epidemiology of the temporomandibular disorders: Implications for the investigation of etiologic factors. Crit Rev Oral Biol Med 1997;8:291-305.
Okuda T. Effect of estrogen replacement on temporomandibular joint remodeling in ovariectomized rats. J Oral Maxillofac Surg 2000;58:189-97.
Campos MI, Campos PS, Cangussu MC, Guimaraes RC, Line SR. Analysis of magnetic resonance imaging characteristics and pain in temporomandibular joints with and without degenerative changes of the condyle. Int J Oral Maxillofac Surg 2008;37:529-34.
Guler N, Yatmaz PI, Ataoglu H, Emlik D, Uckan S. Temporomandibular internal derangement: Correlation of MRI findings with clinical symptoms of pain and joint sounds in patients with bruxing behaviour. Dentomaxillofac Radiol 2003;32:304-10.
Muller-Leisse C, Augthun M, Bauer W, Roth A, Gunther R. Anterior disc displacement without reduction in the temporomandibular joint: MRI and associated clinical findings. J Magn Reson Imaging 1996;6:769-74.
Gynther G, Tronje G. Radiographic changes in the temporomandibular joint in patients with generalized osteoarthritis and rheumatoid arthritis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:613-8.
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.
Sato H, Osterberg T, Ahlqwist M, Carlsson GE, Grondahl HG, Rubinstein B. Association between radiographic findings in the mandibular condyle and temporomandibular dysfunction in an elderly population, Acta Odontol Scand 1996;54:384-90.
Hiltunen K, Vehkalahti MM, Peltola JS, Ainamo A. A 5-year follow-up of occlusal status and radiographic findings in mandibular condyles of the elderly. Int J Prosthodont 2002;15:539-43.
Takayama Y, Miura E, Yuasa M, Kobayashi K, Hosoi T. Comparison of occlusal condition and prevalence of bone change in the condyle of patients with and without temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2008;105:104-12.
Honda K, Larheim TA, Sano T, Hashimoto K, Shinoda K, Westesson PL. Thickening of the glenoid fossa in osteoarthritis of the temporomandibular joint: An autopsy study. Dentomaxillofac Radiol 2001;30:10-3.
Hiltunen K, Peltola JS, Vehkalahti MM, Narhi T, and Ainamo A. A 5 year follow-up of signs and symptoms of TMD and radiographic findings in the elderly population. Int J Prosthodont 2003;16:631-4.
Crow HC, Parks E, Campbell JH, Stucki DS, Daggy J. The utility of panoramic radiography in temporomandibular joint assessment. Dentomaxillofac Radiol 2005;34:91-5.
Hansson LG, Hansson T, Petersson A. A comparison between clinical and radiologic findings in 259 temporomandibular joint patients. J Prosthet Dent 1983;50:89-94.
Bush FM, Harrington WG, Harkins SW. Interexaminer comparison of bone scintigraphy and panoramic radiography of temporomandibular joints: Correlation with signs and symptoms. J Prosthet Dent 1992;67:246-51.
Huumonen S, Sipila K, Zitting P, Raustia M. Panoramic findings in 34 year-old subjects with facial pain and pain-free control. J Oral Rehabil 2007;34:456-62.
Wiese M, Svensson P, Bakke M, List T, Hintze H, Petersson A, et al
. Association between temporomandibular joint symptoms, signs, and clinical diagnosis using the RDC/TMD and radiographic findings in temporomandibular joint tomograms. J Orofac Pain 2008;22:239-51.
De Leeuw R, Boering G, Stegenga B, De Bont LG. Symptoms of temporomandibular joint osteoarthrosis and internal derangement 30 years after non-surgical treatment. J Craniomand Prac 1995;13:81-8.
Pertes RA, Gross SG. Disorders of the temporomandibular joints. In: Pertes RA, Gross SG (eds.). Clinical Management of Temporomandibular Disorders and Orofacial Pain. Carol Stream, IL: Quintessence Publishing Co; 1995. p. 69-89.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]