Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 7-13

Correlations between tomographic findings related to degenerative changes, condylar excursions and position, and pain symptomatology in temporomandibular disorders


1 Department of Oral and Maxillofacial Surgery, Division of Radiology, School of Dentistry, University of São Paulo, Brazil
2 Department of Stomatology, Division of Radiology, School of Dentistry, University of São Paulo, Brazil

Date of Web Publication9-Jul-2018

Correspondence Address:
Dr. João Gualberto Cerqueira Luz
Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo, Av. Prof. Lineu Prestes, 2227-Cidade Universitária, 02036-021 São Paulo, SP
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jofs.jofs_89_17

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  Abstract 


Aim: This study analyzed possible correlations between tomographic findings related to degenerative changes and condylar excursions and position with pain symptomatology in temporomandibular disorders (TMD). Materials and Methods: Sixty patients (40 women and 20 men; mean age: 37.9 years) with a diagnosis of TMD, according to the Diagnostic Criteria for Temporomandibular Disorders, were evaluated. The data of their tomographic examinations were retrieved in relation to their degenerative changes, estimations of condylar excursion, and condylar position. Associations between the variables were analyzed using the chi-square test (P ≤ 0.050). Results: There was a predominance of myopain (M) (35% left side), which was followed by arthralgia plus disc displacement (ADD) (23% left side) and latter myopain plus arthralgia and disc displacement (MADD) (18% left side). Regarding the degenerative changes, there was the predominance of flattening (100%), which was followed by sclerosis (85%). The estimation of condylar excursion was more frequent in the hyperexcursion form, followed by the normoexcursion form, and the hypoexcursion form, all on both sides. The position of the condyle was predominantly posterior and less frequently anterior, and there were few cases in the equidistant position. Considering the sides independently, hyperexcursion and MADD were correlated to the left side. For the total sample, condylar hyperexcursion and ADD, and also sclerosis and MADD, were correlated. There was no correlation between condylar position and symptomatology. Conclusion: There was a correlation between hyperexcursion and symptomatology, especially articular, few correlations between degenerative changes and symptomatology, and no correlation between condylar position and symptomatology.

Keywords: Facial pain, mandibular condyle, signs and symptoms, temporomandibular joint


How to cite this article:
de Carvalho EF, Chilvarquer I, Luz JC. Correlations between tomographic findings related to degenerative changes, condylar excursions and position, and pain symptomatology in temporomandibular disorders . J Orofac Sci 2018;10:7-13

How to cite this URL:
de Carvalho EF, Chilvarquer I, Luz JC. Correlations between tomographic findings related to degenerative changes, condylar excursions and position, and pain symptomatology in temporomandibular disorders . J Orofac Sci [serial online] 2018 [cited 2018 Sep 24];10:7-13. Available from: http://www.jofs.in/text.asp?2018/10/1/7/236211




  Introduction Top


The chief complaints of patients with temporomandibular disorders (TMD) are from localized or diffuse pain in the temporomandibular joint and masticatory muscles, as well as from articular sounds and functional disorders.[1],[2],[3] In general, the diagnosis is reached by a combination of clinical features and diagnostic imaging confirmation.[4] Diagnostic imaging, when indicated, is an important part of the examination process for patients with TMD. It may be used to confirm suspected disease, rule out disease, or obtain additional information when the clinical diagnosis is unclear.[5]

Computed tomography (CT) and magnetic resonance imaging are considered the gold standard assessments for evaluating the hard and soft tissues, respectively.[6],[7],[8] Familiarity with these imaging modalities results in them being used more effectively.[9] CT has been used for the diagnosis of degenerative joint diseases. Degenerative bone changes are characterized by pathologic or adaptive bony changes.[4],[10]

CT may also demonstrate condylar excursion according to its location in relation to the articular eminence.[11] The ranges of motion in joints can be affected by factors such as laxity and increased joint mobility, which are considered risk factors for TMD.[12]

Condylar position is the spatial relationship of the mandibular condyle with the glenoid fossa in maximum intercuspation, and the optimum position is the uppermost and middlemost location facing the articular eminence.[13],[14] There are significant differences in the joint space and condylar position in anterior disc displacement.[15]

The purpose of this study was to analyze possible correlations between tomographic findings related to degenerative changes, condylar excursions, or condylar position and pain symptomatology in a group of patients with TMD.


  Materials and Methods Top


Sixty patients (40 women and 20 men; mean age: 37.9 years) were selected from 80 consecutive patients who had been diagnosed with TMD and were referred to the Temporomandibular Disorders and Orofacial Pain Clinic of the Oral and Maxillofacial Surgery Department, regardless of their race and social status. The patients came from public dental or medical health services with a diagnosis of TMD that was provisional, and previously determined TMD. TMD was diagnosed based on the chief complaint presented by the patients, and a clinical examination that was conducted according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD).[16] The examinations were supervised by the third author (who is an expert clinician). The TMD diagnosis was established using the DC/TMD diagnostic decision tree, the completed clinical examination form, and the symptom questionnaire. The patients who presented with previous orthodontic treatment, maxillofacial trauma, orthognathic or temporomandibular joint surgery, fibromyalgia syndrome, neurological disorders or congenital craniofacial abnormalities, as well as those without pain symptomatology or whose tomographic views were unavailable, were excluded from the study. Ethical approval for this study (Protocol CAAE 36601914.0.0000.0075) was provided by the Research Ethics Committee of the School of Dentistry, University of S�o Paulo, on 11 March 2015.

Prior to the initiation of the clinical examination, the first author (research fellows) underwent calibration sessions with a specialist who is trained in the use of the DC/TMD protocol.[16] The examiner evaluated the patients and was not informed of the subjective symptoms before performing the physical examination. The scores between the examiners were attributed as a consensus. The palpation of muscles for myalgia was under a pressure that corresponded to 1 kg for 5 s on the locations of interest, and this pressure was calibrated with the use of an algometer (Pain Diagnosis and Treatment, Inc., Great Neck, NY, USA).

All of the tomographic images were made at the same radiological facility using a linear tomographic apparatus (Quint Sectograph, Los Angeles, CA, USA) with a distance of 1.52 mm between the X-ray source and the film, ensuring a constant factor of magnification equal to 10%. The sagittal and coronal tomographic views were analyzed under standard conditions separately by the second and third authors. No tomographic examinations were made to this study. The presence of degenerative bony changes was analyzed in the mandibular condyle and in the articular eminence as a flattening of the condylar head characterized by a loss of condylar convexity, as sclerosis characterized by an increased bone density, as osteophyte formation identified as a bony protrusion on the condylar margins, as erosion, which presents as a decrease in the cortical and subcortical bone densities, as subchondral cysts, which are single or multiple pyriform-shaped subchondral lesions possessing sclerotic margins, and as loose bodies within the joint space [Figure 1].[4],[5]
Figure 1: Degenerative bony changes: (A) erosion; (B) sclerosis; (C) flattening; (D) osteophyte

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The condylar excursion estimation was obtained in the sagittal images while the patient was at an unassisted, maximum opening of the mouth position. The condylar excursion was classified as normal excursion when the top-to-top position of the apex of the articular eminence and the condyle was present, as hyperexcursion when the condylar location was anterior to the apex of the articular eminence, and as hypoexcursion in cases in which the condyle was positioned below the apex of the articular eminence [Figure 2].[12],[17] The linear measurements of the superior, anterior, and posterior joint spaces were performed on the images of the patient in maximum intercuspation to evaluate the position of the condyle in the mandibular fossa, using the following formula: (posterior−anterior)/(posterior + anterior). A zero value indicated a concentric location of the condyle within the fossa (equidistant), a positive value indicated an anterior condylar position (anteriorized), and a negative value indicated a posterior position of the condyle within the fossa (posteriorized) [Figure 3].[15],[18]
Figure 2: Condylar excursion estimation: (A) hypoexcursion; (B) normal excursion; (C) hyperexcursion

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Figure 3: Position of the condyle in the mandibular fossa: (A) anteriorized; (B) equidistant; (C) posteriorized

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Two methods of analysis for the obtained data were established. The first one considered independent joints, whereas the second worked with the total sample. For independent articulations, the symptomatology and tomographic images data for each side were kept paired, and tests to the right and left sides were used separately. The total sample studied the relationship between the symptomatology and tomographic images with the sides paired, with the right and left sides in the same group. Statistical analyses were performed using the Minitab 16 software (Minitab Inc., State College, PA, USA). The Pearson’s chi-square test was used to verify the associations between the symptomatology and tomographic findings variables. The level of significance was set at 5% (P ≤ 0.050).


  Results Top


There was a predominance of the female gender, with 67% of the patients in this study being female. The most prevalent age groups were the 29–38 years age group (40%) and the 39–48 years age group (32%). Concerning the chief complaints, pain was the most commonly reported, with 47% of the patients reporting pain as the chief complaint. Joint noises were the second most commonly reported chief complaint (43%), followed by parafunctional habits (21%). The main TMD diagnoses were myopain (M) (35% on the left side), followed by arthralgia plus disc displacement (ADD) (23% on the left side), and latter myopain plus arthralgia and disc displacement (MADD) (18% on the left side).

Regarding the degenerative changes, there was a predominance of flattening (100% of the patients), and this was followed by sclerosis (85%). There were a few patients with erosion (5%) and a few patients with osteophytes (2%). There were no patients who had subchondral cysts or loose bodies.

The estimation of condylar excursion was more frequent in the form of hyperexcursion (48% on the right side; 50% on the left side), followed by normoexcursion (40% on the right side; 38% on the left side) and hypoexcursion (12% on both sides).

The position of the condyle was predominantly posterior (53% on the right side; 62% on the left side) and less frequently anterior (28% on the right side; 33% on the left side), and a few patients had a condyle of an equidistant position (18% on the right side; 5% on the left side).

Regarding the mouth opening, there was a predominance of a normal amplitude (73%), and the amplitude was decreased (27%) less frequently [Graph 1]. Deviation in the opening occurred in a portion of the cases (25%), whereas the others were normal (75%).



For the total sample, there was a statistically significant association between a jaw opening of ≥40 mm and bilateral condylar hyperexcursion (P < 0.050). Likewise, condylar hyperexcursion was associated with the presence of articular and muscular pain on the left side (P < 0.050) but not on the right side (P > 0.050) [Table 1].
Table 1: Cross-tabulation of the tomographic findings and the joint and muscular pain symptomatology of the total sample and the significance of the chi-square test [n (%)]

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When the statistical analysis was performed considering the joints independently, a correlation was observed between condylar hyperexcursion and articular pain (P < 0.050), when the data were paired for each side. A statistically significant association between sclerosis and the presence of articular and muscular pain (P < 0.050) was also observed from this analysis [Table 2]. The condylar position and symptomatology were not correlated (P > 0.050). There were no tests performed to verify the association between certain degenerative findings and pain symptomatology because flattening occurred in all of the patients and erosion and osteophytes were very rare.
Table 2: Cross-tabulation of tomographic findings and painful articular and muscular symptomatology of the independent joints and the significance of the chi-square test [n (%)]

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  Discussion Top


The present study evaluated the tomographic findings, which are represented by degenerative changes and the estimations of condylar excursion and condylar position in the articular fossa, of patients with TMD and verified the correlation between hyperexcursion and pain symptoms, mainly articular pain symptoms. However, there were few correlations between degenerative alterations and pain symptomatology, and no correlation between condylar position and pain symptomatology.

Considering the personal data of the patients in the sample that was studied, they presented with characteristics similar to those of patients with TMD. There was a predominance of patients of the female gender and of the age group of 29–38 years, which is in agreement with the literature.[2],[12],[19],[20],[21]

In regards to the chief complaints, there was a predominance of pain complaints, followed by joint noises and parafunctional habits.[1],[22],[23] In the pain symptomatology, there was a predominance of M, followed by ADD and MADD, which are observed in TMD.[22],[23]

Regarding the degenerative changes, it was observed that all of the patients presented with flattening on the articular surfaces, many presented with sclerosis, and a few presented with erosion and osteophytes. There were no tests performed to verify the association between certain degenerative findings and pain symptomatology because flattening occurred in all of the patients and erosion and osteophytes were rare. Corrected lateral tomographies were used in this study, and it was possible to identify the degenerative changes present. A study showed that there was no significant difference between conventional tomography and cone beam tomography with respect to the ability to identify degenerative joint changes.[24] A high frequency of radiographic abnormalities has been demonstrated in patients with temporomandibular joint pain. A predominance of flattening and osteophytes, with associations of other degenerative alterations on a smaller scale, has been described.[24],[25] On the other hand, other studies pointed to a higher prevalence of erosion, followed by flattening[26] or a higher frequency of sclerosis, followed by erosion, flattening and, finally, osteophytes.[27]

Degenerative bone changes may represent pathologic or adaptive bony changes to the joint.[4],[5],[10] In TMD progression, hard tissue remodeling may occur and radiographic changes become evident on the condylar head and occasionally on the articular eminences. If remodeling is successful, patients can progress to a normal opening with minimal pain but joint noise often persists. In other patients, the bony degenerative changes can progress with various consequences, including severe erosion, occlusal changes, severe joint and muscle pain, and a compromised jaw function.[28] In patients with a displacement of the articular disc, there is a tendency for altered joint dynamics which, under a sustained mechanical load that exceeds the adaptive capacity of the joint, the tissue responses can be changed to degeneration, resulting in the destruction of hard tissue and secondary inflammatory changes.[15],[29],[30] Degenerative findings are frequently observed in joints with long-standing ADD without reduction.[4] In the present study, when the analysis considered the joints independently, there was a correlation observed between sclerosis and the presence of MADD. However, few correlations between pain symptomatology and degenerative findings have been observed in the literature. Correlations between erosion and pain complaints have been reported in the literature,[27] as well as those between flattening and the displacement of the articular disc and those between osteophytes and osteoarthritis or joint locking.[10]

The estimation of condylar excursion had the highest occurrence in the form of hyperexcursion, which was followed by normoexcursion, and hypoexcursion was rare. There was a correlation observed between a maxillary mouth opening ≥40 mm and condylar hyperexcursion and between a maxillary mouth opening ≥40 mm and the presence of MADD. For the total sample, a correlation between condylar hyperexcursion and ADD was observed. A study using magnetic resonance imaging showed that an increased condylar excursion is an important factor in increasing the perception of pain in patients with dysfunctions.[11] Recently, based on the clinical examination of patients with TMD and hypermobility, it has been noted that pain in the region of the temporomandibular joint is correlated with an enlarged maximal mouth opening [12] and that patients with disc dysfunctions are more likely to have joint hypermobility.[31]

Regarding the positioning of the condyle, there was a predominance of a bilateral posterior position in the patients with TMD, which is in accordance with the findings reported in the literature.[11],[15],[18] In this study, the condylar position and pain symptomatology were not correlated. There has been a lack of correlation between pain symptomatology and posterior condylar position.[11] However, a correlation between posterior condylar position and muscular pain symptomatology has been described.[32] Studies using tomography and magnetic resonance imaging showed correlations between the anterior articular space enlargement, posterior condylar position, and anterior displacement of the articular disc.[5],[15],[18] A possible contribution to this correlation would be in patients with the clinical signs of a dislocated joint disc and who have tomography in the absence of magnetic resonance imaging since the posterior condylar positioning would be an indication of this displacement.


  Conclusion Top


In this study, which analyzed correlations between the tomographic characteristics of the temporomandibular joint and pain symptomatology in TMD, the findings of flattening, condylar hyperexcursion, and a posterior condylar position were frequently observed in the patients. Additionally, there was a correlation observed between hyperexcursion and painful symptoms, mainly articular pain symptoms. Finally, few correlations between degenerative changes and pain symptoms were observed, as well as no correlation between the condylar position and pain symptomatology.

Acknowledgements

The authors thank Dr. Mirte Façanha Bassani for her help in the statistical analyses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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