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ORIGINAL ARTICLE
Year : 2016  |  Volume : 8  |  Issue : 2  |  Page : 102-108

Radiographic structural findings in mandibular condyle of orthodontically treated young patients, a possibility of an iatrogenic temporomandibular joint involvement


Department of Oral Medicine and Radiology, Sharad Pawar Dental College (SPDC), Datta Meghe Institute of Medical Sciences (Deemed University) (DMIMSDU), Wardha, Maharashtra, India

Date of Web Publication16-Dec-2016

Correspondence Address:
Arati Panchbhai
Sharad Pawar Dental College (SPDC), F1-8, Paloti Road, Sawangi-M, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-8844.195916

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  Abstract 

Aim: Temporomandibular disorders joint disorders (TMD) are commonly seen in population. There can be varied etiology to this. The purpose of the study was to study the possible association between orthodontic treatment and TMD. Materials and Methods: For the present study, the 720 subjects were assessed in 2 groups as orthodontically treated group (370) and control group without malocclusion (350). The structural findings were assessed as per the criteria. The data were subjected to statistical analysis using Chi-square test and Pearson's correlation. Results: For all the intergroup and intragroup, the findings were insignificant. Though insignificantly, marginal erosion was common finding followed by flattening and rarefaction. Conclusion: Overall, the study could not confirm the association that orthodontic treatment may lead to TMD. The next extensive study needs to be conducted considering clinical signs and symptoms and the long-term follow-ups.

Keywords: Joint disorders, mandibular condyle, orthodontic treatment, structural findings, temporomandibular


How to cite this article:
Panchbhai A, Bhowate R. Radiographic structural findings in mandibular condyle of orthodontically treated young patients, a possibility of an iatrogenic temporomandibular joint involvement. J Orofac Sci 2016;8:102-8

How to cite this URL:
Panchbhai A, Bhowate R. Radiographic structural findings in mandibular condyle of orthodontically treated young patients, a possibility of an iatrogenic temporomandibular joint involvement. J Orofac Sci [serial online] 2016 [cited 2017 Mar 22];8:102-8. Available from: http://www.jofs.in/text.asp?2016/8/2/102/195916


  Introduction Top


The possible association between orthodontic treatment and temporomandibular disorders has been studied earlier; however there is no consensus regarding its clinical implications in relation to orthodontic treatment. Temporomandibular joint disorders (TMDs) are commonly seen in population, India is no exception to that. Bell suggested the term “TMD” that includes problems isolated to temporomandibular joint (TMJ) as well as all disturbances associated with function of masticator system.[1] Various studies suggested that almost 40-60% of the population is having one detectable sign associated with TMD. The prevalence of 16-59% for the clinical symptoms and of 35-80% for the clinical signs were reported in the worldwide review of epidemiological studies.[1],[2],[3],[4],[5] Nilner and Lassing noted the higher prevalence of TMD in the age group 15-18 years (41%) as compared to that in age group 7-14 years (36%).[4],[5] Symptoms of TMD occur in approximately 6-12% of the adult population or approximately 10 million individuals in the United States.[6]

TMD can be very disabling at times, the multifactorial etiology associated with TMD are trauma, malocclusion, occlusal interferences and associated pathophysiologic, and psychological factors such as stress, parafunctional habits, and systemic diseases. Additionally, the structural and morphological variations in the condyle and the factors, such as orthodontic treatment, may lead to TMD. The pressure exerted on the jaws and teeth through orthodontic treatment may lead to TMD by causing changes in mandibular condyle. In view of this, orthodontic treatment and associated changes in the condyle may be studied.[1],[7],[8],[9],[10],[11],[12],[13],[14] During chewing and swallowing, the forces applied to the masticatory system are in vertical direction and that are accepted well by the supporting structures of teeth. During parafunctional habits and orthodontic treatment, the forces applied may be in horizontal or in direction other than vertical. If these forces will not be dissipated effectively, these in turn may increase the likelihood of damage to both teeth and supporting system. These forces may create pathologic bone resorption in the mandibular condyle or elicit neuromuscular reflex activity in an attempt to avoid and guard against incline contacts.[15],[16],[17] The effect of orthodontic treatment on the TMJ apparatus has been studied earlier; however, the role of orthodontic therapy on the occurrence of TMD is still uncertain.[7],[10],[11] Hence, the present research was undertaken with the purpose to study the possible association between TMJ diseases and orthodontic treatment.

The panoramic radiography is one of the most commonly employed diagnostic modalities. Examination of mandibular condyle was done on orthopantomogram (OPG) as it is being used routinely as screening tool for the teeth and jaws at the start of an orthodontic treatment.[18]

The present study is conducted with objectives as follows:

  • To estimate the radiographic structural findings in mandibular condyle in orthodontically treated patients on orthopantomogram.
  • To estimate the radiographic structural findings in mandibular condyle in the control group (healthy subjects without malocclusion) on orthopantomogram.
  • To compare the radiographic condylar findings in subjects in two study groups—orthodontically treated group and control group (intergroup comparison).
  • To compare the radiographic condylar findings in treated group according to gender, age, side, type of malocclusion, duration of treatment, and orthodontic appliances used (intragroup comparison).



  Materials and Methods Top


For the present institutional ethics committee approved study, the total of 763 subjects in the age range of 16-30 years were examined, out of which 413 subjects were orthodontically treated and 350 were in the control group. The study participants were recruited on voluntary basis. However, the participants in the treated group were needed to be excluded for various reasons, and finally the study included a sample of 370 subjects.

Exclusion criteria

  • The subjects with TMJ problems observed on clinical examination at the entry level.
  • The subjects who had condylar changes at the entry level on radiographic assessment
  • The subjects who had interrupted the treatment or have not completed the orthodontic treatment
  • Medically compromised subjects or with systemic disease affecting bone
  • The subjects with parafunctional habits


At the entry, each study subject underwent clinical examination followed by radiographic examination for which orthopantomogram was taken on PM 2002 proline CC (Planmeca) OPG machine ensuring that the condyles are clearly visible for the radiographic assessment. The patients were followed up during the period of treatment for the development of TMJ symptoms, also the posttreatment orthopantomogram were taken to assess the changes in condylar morphology. Thus, the structural findings in condyle and TMJ problems developed over the course of orthodontic treatment, i.e., incident cases were recorded.

The radiographs of study participants were assessed using the following assessment criteria:[19],[20],[21],[22]

  • Flattened articular surface
  • Cortical/subcortical sclerosis
  • Osteophyte
  • Microcysts
  • Marginal erosion
  • Periarticular ossicle
  • Shape deformity
  • Other findings


To determine the magnitude of each finding, the scale applied was as 0 — no finding, 1 — mild/initial, and 2 — clear/pronounced.[23],[24]

The presence or absence of the findings was determined on each radiograph along with its magnitude to derive the proportion of subjects with each finding in study group. The radiographs were studied under standardized conditions using magnifying glass and viewing light with adjustable brightness. The intraexaminer and interexaminer test was done for the assessment of condylar changes for 30 randomly selected radiographs in 2-month interval, the variations in the assessment were found to be insignificant.

The data were analyzed using Statistical Package for the Social Science (SPSS) version 11.5 (SPSS-Inc., Chicago, IL). The P-value less than 0.05 was taken as significant. Chi-square test was used to assess the statistical difference between the groups; intergroup comparison was assessed by using Fisher's exact test. Correlation of duration of treatment and condylar changes was carried by using Pearson's correlation.


  Results Top


In the present study, the study groups were subjected to various intragroup and intergroup comparisons. The age- and gender-wise distributions of study subjects are shown in [Table 1]. Each radiographic condylar finding was noted for its presence or absence in the study subjects, i.e., number and the percentage of subjects in which the condylar findings were seen was derived for both study groups [Table 2]. Intergroup comparisons between treated group and control group for the variations in radiographic condylar findings were found to be insignificant. Considering the magnitude, the findings were graded as mild in two groups, except for a few subjects in the treated group [Table 3].
Table 1: Distribution of study subjects in the treated group and control group according to age range and gender

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Table 2: Condylar finding wise distribution (number and percentage) in the treated group and control group according to gender with intergroup comparison

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Table 3: Distribution of condylar finding in the treated group and control group according to grade or magnitude of findings — Intergroup comparison

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Intergroup and intragroup comparisons for gender and age for each study group found to be insignificant [Table 2] and [Table 3]. Comparing of right- and left-sided condyle, the right side condyle showed more condylar involvement, though insignificantly [Table 4]. In orthodontically treated group; the intragroup comparison was made for the condylar involvement according to the malocclusion, duration, and type of appliance used for the treatment [Table 5]a and [Table 5]b; however, the findings were insignificant.
Table 4: Distribution of subjects with condylar findings according to side of condyle

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Table 5

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  Discussion Top


In the present study, the study sample was in the age group of 16-30 years, the sample size included approximately corresponds to that in earlier studies.[25],[26] The mean age for active orthodontic treatment was 2 years as in the previous study by Rendell et al.[27] The study included all possible variables in relation to the orthodontic treatment. Overall, for most of the comparisons, the results were insignificant. The prevalence of condylar findings in the control group was comparable to that in orthodontically treated group. This is in agreement to previous studies [27],[28] while in contradiction to study by Peltola.[24] The most commonly observed condylar structural finding was marginal erosion [Figure 1] followed by flattening [Figure 2] and rarefactions [Figure 3], remaining findings as sclerosis [Figure 3] and shape deformity [Figure 4] were found in very insignificant proportions. While flattening and subcortical scleroses were found to be more common in earlier studies.[20],[24] Overall, the magnitude or grades of the findings were mild in two groups, except for a few subjects (1.04%) in treated group [Figure 5] who showed the considerable degree of changes [Table 3].
Figure 1: Cropped radiographs showing mild/marginal and pronounced erosions

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Figure 2: Cropped radiographs showing initial and pronounced flattening

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Figure 3: Cropped radiographs showing rarefaction and sclerosis(arrow)

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Figure 4: Cropped radiograph showing various shape deformities

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Figure 5: Cropped radiographs showing pretreatment condyle (a and c) and posttreatment condyle (b and d) with structural changes in treated patient

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Intergroup and intragroup comparisons for gender and age for each study group found to be insignificant, although, the previously, the increased prevalence was observed in 15-the 16 years of age.[9],[12] In treated group, the study sample showed female predominance as more female patients underwent orthodontic treatment than males [Table 2]. However, the proportionate involvement in males was more compared to females [Table 2]. None of the condylar findings showed any predilection for gender in the study groups. This is in accordance with the finding by Peltola [24] while in contrast to study by Wadhwa et al. who showed striking female predilection for TMDs.[8] Overall, in two study groups, right-sided condyle showed more involvement, the bilateral involvement of the condyle was seen in negligible proportion (1.1-3.3%) of study subjects.

In treated subjects, most of the study patients had Class II malocclusion (48.21%), followed by Class I (45.54%) and Class III cases (6.25%); however this has made no difference to the incidence of condylar findings.

The three broad categories made as per appliances used for the orthodontic treatment, were removable (5.13%), fixed (73.78%), and myofunctional appliances (21.08%). The myofunctional appliances may have more bearing on the condylar involvement as the pressure is exerted on jawbones in attempt to redirect their growth. In myofunctional appliances, the patients treated with anterior and posterior bite planes showed trend toward higher condylar involvement followed by twin block appliances. This is contradictory to earlier study that have shown more condylar findings in patients treated by activators.[9] While Cachoa and Martinb showed that activator do not have any effect on the development of TMD.[29]

Additionally, it was observed that the duration of orthodontic treatment do not have any influence on the condylar involvement in terms of occurrence of condylar findings or its severity. Though, insignificantly, the higher prevalence of condylar changes was observed in the group with treatment duration of 1.5 years to 2 years as compared to the rest of the categories, this is in agreement with the previous studies.[9]

The prevalence of condylar findings noted in the control group was comparable to that in treated group. Irrespective of the presence of condylar changes, the subjects were asymptomatic. Altogether, in two groups, only 1.1-1.6% of subjects with condylar involvement showed clinical symptoms in the form of TMJ pain. The patients who were symptom free on entering the treatment and developed condylar changes during orthodontic treatment do not show any clinical symptoms of TMD, except for very few (1.6%). Also, the occurrence of condylar findings and the TMJ pain was not simultaneous. Hence, no such association could be established between the presence of condylar findings in treated patients and the occurrence of clinical symptoms. This is in line with some of the studies.[14],[27],[28],[30],[31] while other studies showed reduced symptoms with the treatment.[25],[26],[30],[32],[33],[34]

The structural changes in the condyle are thought to be related to the TMJ dysfunction. The condylar remodeling is known to continue even after the completion of growth. It is considered as a reactive physiologic process in response to the functional demands and reflects as an adaptive capacity of a condyle, this may lead to structural changes in condyle. The TMJ dysfunction may be related to these structural changes, they are more frequently seen in patients with loss of teeth and with aging, although the mechanism has not been completely clarified.[20],[35]


  Conclusion Top


The purpose of the study was to assess the possible relationship between the orthodontic treatment and the TMD. For all the intergroup and intragroup comparisons, the differences noted were insignificant. The association between TMD and orthodontic treatment has always been a complex issue. The present study brought to light that orthodontic treatment causes condylar changes leading to TMD in very negligible proportion of subjects. Importantly, the fact to be noted is that condylar findings were present in the subjects even before the treatment as well as in the control group without malocclusion. Moreover, developmental variations were also present in mandibular condyle. Other factors, such as unstable disc-condyle relationship and muscle incoordination should also be taken into consideration. Overall, on the basis of observations of present study, it suggests the dubious role of orthodontic treatment in causing TMD. However, this may be a preliminary study; it is recommended that the next study ought to be conducted with broader representation with the focus on the association between condylar findings and clinical symptoms in orthodontically treated patients supplemented with advanced assessment modalities and long-term follow-ups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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