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Journal of Peking University (Health Sciences) ›› 2021, Vol. 53 ›› Issue (1): 109-119. doi: 10.19723/j.issn.1671-167X.2021.01.017

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Cone-beam CT evaluation of temporomandibular joint in skeletal class Ⅱ female adolescents with different vertical patterns

ZHOU Jing,LIU Yi()   

  1. Department of Orthodontics, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China
  • Received:2020-09-23 Online:2021-02-18 Published:2021-02-07
  • Contact: Yi LIU E-mail:lyortho@163.com
  • Supported by:
    Key Project of Ningxia Hui Autonomous Region Key Research and Development Program(2018BEG02012)

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Abstract:

Objective: To compare temporomandibular joint (TMJ) morphology and position among skeletal class Ⅱ female adolescents with different vertical patterns using cone-beam CT (CBCT). Methods: Diagnostic CBCT images of 80 female patients aged 11 to 14 years were assessed retrospectively. According to subspinale-nasion-supramental angle (ANB) and Frankfort horizontal plane-gonion-gnathion angle (FH-GoGn), the participants were categorized into four groups (20 subjects each), i.e. class Ⅰ normal angle (group 1, 0°≤ANB<4°, 22°≤FH-GoGn≤32°), class Ⅱ low (group 2, ANB≥4°, FH-GoGn<22°), normal (group 3, ANB≥4°, 22°≤FH-GoGn≤32°) and high angle (group 4, ANB≥4°, FH-GoGn>32°). Cephalometrics, morphology and position of TMJ were measured in Dolphin software. Using paired-samples t test to analyze TMJ symmetry, One-way analysis of variance (One-way ANOVA) and Chi-square tests to detect differences among the groups. The correlations between cephalometrics and TMJ measurements were also analysed within the skeletal class Ⅱ patients.Results: (1) Analysing TMJ morphologic symmetry, some measurements differed statistically although the mean diffe-rences were negligibly relative to their values. No statistically significant difference was found among the groups though group 4 showed the highest probability of condylar position asymmetry (65%). (2) Comparing group 1 with group 3, statistical difference was found in condylar position (χ2=6.936, P<0.05) instead of morphologic measurements. Anterior and concentric condylar position were more frequently observed in group 1, yet posterior position was more prevalent in group 3. (3) In groups 2, 3, and 4, statistically, group 2 had the deepest glenoid fossa depth (H2&4=10.517,P=0.002), biggest superior (LSD-t2&3=3.408, LSD-t2&4=5.369, P<0.001) and lateral (LSD-t2&3=2.767, LSD-t2&4=3.350, P=0.001) joint spaces, whereas group 4 showed the shortest condylar long axis diameter (H2&4=13.374, P<0.001), largest glenoid fossa vertical distance (LSD-t2&4=4.561, P<0.001, LSD-t3&4=2.713, P=0.007), smallest medial (LSD-t2&4=-4.083, P<0.001) and middle (LSD-t2&4=-4.201, P<0.001) joint spaces. The posterior condylar position proportion gradually increased from groups 2 to 3 to 4. Correlation analysis revealed ANB correlated with anterior joint space positively (r=0.270, P=0.037) and condylar long axis angle negatively (r=-0.296, P=0.022). FH-GoGn correlated with superior (r=-0.488, P<0.001), posterior (r= -0.272, P=0.035), mesial (r=-0.390, P=0.002), middle (r=-0.425, P=0.001), and lateral (r=-0.331, P=0.010) joint spaces, articular eminence inclination (r=-0.259, P=0.046), as well as condylar long axis diameter (r=-0.327, P=0.011) negatively, and glenoid fossa depth (r=0.370, P=0.004) positively. Conclusion: TMJ characteristics of skeletal class Ⅱ sagittal pattern mainly reflected in condylar position rather than morphology. TMJs of different vertical patterns differed more in joint spaces, position of condyle and glenoid fossa than in morphologic measurements. Vertical position of glenoid fossa and proportion of posterior condyle increased gradually from hypodivergent to hyperdivergent. Highest glenoid fossa position, maximum ratio of posterior positioned condyle, smallest joint spaces, shallowest glenoid fossa depth, and narrowest condylar long axis diameter were found in skeletal class Ⅱ high angle group, which means that patients with this facial type have considerable joint instable factors, and we should especially pay attention when orthodontic treatment is carried out on them.

Key words: Temporomandibular joint, Cone-beam computed tomography, Skeletal class Ⅱ, Vertical skeletal pattern, Adolescent

CLC Number: 

  • R783.5

Figure 1

a: Frankfort horizontal plane (FH plane) parallel to horizontal plane;b: Mid-sagittal plane passed through anterior nasal spine (ANS) point and basion (Ba) point"

Figure 2

Construction of landmarks used in cephalometric analysis and angular measurements ∠1, sella-nasion-supramental angle (SNB); ∠2, sella-nasion-subspinale angle (SNA); ∠3, subspinale-nasion-supramental angle (ANB); ∠4, Frankfort horizontal plane-gonion-gnathion angle (FH-GoGn). S, sella; P, porion; N, nasion; O, orbitale; A, subspinale; B, supramental; Co, superior point of the condyle; Go, gonion; Gn, gnathion."

Figure 3

Landmarks and measurements of sagittal projection of ascending rami Co, superior point of the condyle; Cc, the center of the largest circle which fit the condylar head arc; Sg, inferior point of the mandibular sigmoid incisure; Cm, the intersection of the horizontal line passing Sg point and L2, which passing Cc point and parallel to the tangent of condylar posterior border. L1, distance between Co point and Cc point; L2, distance between Cc and Cm; L3, condylar height, the vertical distance between Co and Sg; Condylar length, L1 plus L2. ∠1, condylar neck inclination (Cni): posterior superior angle between tangent line of condyle posterior border and horizontal line; ∠2, condylar head angle: angle between condylar head and neck, i.e., anterior angle between L1 and L2."

Figure 4

Measurements on the largest axial view of the condyle ∠1, condylar long axis angle: the angle between condylar mediolateral axis and mid-sagittal plane. L1, condylar long axis diameter: the largest mediolateral diameter of condyle; L2, condylar short axis diameter: the largest anteroposterior diameter of condyle, which perpendicular to L1."

Figure 5

Mid-sagittal plane (a) and Mid-coronal plane (b) of the condyle Ei, inferior point of the articular eminence; Fs, superior point of the glenoid fossa; Fp, the intersection of posterior slope of glenoid fossa and a line which parallel to the Frankfort horizontal (FH) plane as well as passing through Ei point. When posterior slope shorter than the anterior, use the inferior point of it. ∠1, articular eminence inclination (Aei): angle between the best fit line of the posterior slope of articular eminence and the horizontal plane. L1, glenoid fossa depth; L2, glenoid fossa width. A, anterior joint space: the shortest distance from the most prominent anterior point of the condyle to corresponding glenoid fossa bone; S, superior joint space: the shortest distance from the most superior point of the condyle to Fs point; P, posterior joint space: the shortest distance from the most prominent posterior point of the condyle to corresponding glenoid fossa bone. Mis, middle joint space, the shortest distance from the condylar most superior point to corresponding glenoid fossa bone; Mes, medial joint space, the shortest distance from the middle point of the condylar most medial and superior point to corresponding glenoid fossa bone; Las, lateral joint space, the shortest distance from the middle point of the condylar most lateral and superior point to corresponding glenoid fossa bone."

Figure 6

Location of glenoid fossa centre point and its’ vertical distance measurement (a, b); Locate sella point on the mid-sagittal plane,and orientate coronal plane through it (c); Coronal and sagittal distance measurements on axial view (d) Fc, glenoid fossa centre point, the most superior point of glenoid fossa on sagittal and coronal plane; S, sella point. L1, glenoid fossa vertical distance, the vertical distance between Fc point and Frankfort horizontal (FH) plane, positive when Fc is higher; L2, glenoid fossa sagittal distance, the sagittal projection distance of Fc point to S point; L3, glenoid fossa coronal distance, the distance of Fc point to mid-sagittal plane."

Table 1

Age and cephalometric measurements distribution of subjects among groups"

Variable Group 1 Group 2 Group 3 Group 4
Age/months, x-±s 154.20±10.07 152.55±12.70 153.20±12.03 151.65±11.47
ANB/(°), x-±s 2.51±1.01#△§ 4.98±0.89*§ 5.43±1.21* 6.36±1.48*#
FH-GoGn/(°), x-±s 26.18±2.10△§ 19.47±2.74*△§ 27.06±2.20#§ 33.71±1.89*#△

Table 2

Paired-samples t test of right and left sides in each group (right minus left, x-±s)"

Measurements Group 1 Group 2 Group 3 Group 4
Condylar length/mm -0.72±1.30* -0.10±1.35 -0.29±1.50 -0.31±1.45
Condylar height/mm -0.50±1.12 -0.12±1.38 -0.22±1.36 -0.51±1.43
Condylar neck inclination/(°) 1.88±4.17 -0.91±4.20 1.72±3.67* -0.60±3.90
Condylar head angle/(°) -1.51±7.10 -2.23±11.13 -1.95±12.44 -4.60±9.72*
Anterior joint space/mm -0.04±0.40 -0.16±0.46 -0.26±0.47* -0.21±0.49
Superior joint space/mm -0.08±0.47 -0.12±0.55 0.03±0.36 -0.01±0.70
Posterior joint space/mm 0.11±0.38 0.01±0.38 0.13±0.42 0.16±0.60
Glenoid fossa width/mm -0.11±1.96 0.45±1.23 0.41±1.37 -0.18±1.36
Glenoid fossa depth/mm 0.14±0.92 0.06±0.64 0.24±0.72 -0.27±0.74
Articular eminence inclination/(°) 3.16±8.46 -4.24±7.55* -3.01±6.28* -6.40±7.84*
Mesial joint space/mm -0.07±0.52 -0.11±0.55 0.10±0.55 -0.06±0.51
Middle joint space/mm -0.14±0.63 -0.02±0.60 0.02±0.54 -0.43±0.63*
Lateral joint space/mm -0.05±0.68 -0.09±0.52 -0.07±0.74 -0.03±0.62
Condylar long axis diameter/mm 0.05±1.12 0.36±0.95 0.22±1.50 -0.04±1.53
Condylar short axis diameter/mm 0.10±0.56 0.35±0.82 0.30±0.75 0.23±0.87
Glenoid fossa vertical distance/mm -0.15±0.95 -0.13±0.88 0.77±0.87** 0.00±0.75
Glenoid fossa coronal distance/mm 1.22±2.32* 1.73±2.37* 1.11±1.86* 1.25±2.04*
Glenoid fossa sagittal distance/mm -0.31±1.95 0.69±1.36* 0.22±1.16 0.27±2.21
Condylar long axis angle/(°) -0.19±7.56 -2.58±4.59* -1.53±7.25 -0.98±7.44

Table 3

Symmetry analysis of condylar position in each group [side (%)]"

Condylar position Group 1 Group 2 Group 3 Group 4
Symmetrical 10 (50) 13 (65) 12 (60) 7 (35)
Asymmetrical 10 (50) 7 (35) 8 (40) 13 (65)

Table 4

Comparison of measurements differences among groups (x-±s)"

Measurements Group 1 Group 2 Group 3 Group 4
Condylar length/mm 17.30±1.92 17.16±2.43 17.40±2.46 17.39±1.77
Condylar height/mm 16.48±1.76 16.39±2.42 16.54±2.39 16.63±1.76
Condylar neck inclination/(°) 73.48±6.07 73.23±6.01 72.46±4.95 73.99±6.47
Condylar head angleks/(°) 151.56±7.96 154.12±13.95 150.99±9.54 154.26±10.15
Anterior joint space/mm 1.55±0.56 1.71±0.40 1.56±0.54 1.82±0.60
Superior joint space/mm 2.23±0.63# 2.91±0.77*△§ 2.38±0.64# 2.07±0.74#
Posterior joint space/mm 1.65±0.48 1.68±0.48 1.54±0.42 1.49±0.46
Glenoid fossa width/mm 17.35±2.08 17.41±1.52 1.54±0.42 17.07±1.78
Glenoid fossa depthks/mm 6.62±1.33 7.37±1.03§ 6.85±0.96 6.50±1.15#
Articular eminence inclination/(°) 49.62±11.76 53.24±9.09 51.47±8.46 49.43±11.34
Mesial joint space/mm 2.11±0.62# 2.50±0.74*§ 2.24±0.60 1.91±0.62#
Middle joint space/mm 2.26±0.72 2.61±0.73§ 2.33±0.67 1.94±0.73#
Lateral joint space/mm 2.09±0.61 2.34±0.52△§ 1.96±0.66# 1.88±0.66#
Condylar long axis diameterks/mm 16.99±2.61 17.37±1.76§ 16.47±1.85 15.54±2.51#
Condylar short axis diameter/mm 7.73±1.01 7.85±1.14 7.53±0.89 7.55±1.00
Glenoid fossa vertical distance/mm 2.63±1.42# 1.53±1.36*§ 2.09±1.27§ 2.90±1.32#*
Glenoid fossa coronal distance/mm 49.02±2.44 48.56±1.87 48.74±2.08 48.59±2.40
Glenoid fossa sagittal distanceks/mm 9.65±3.12 9.60±3.11 10.16±2.09 9.67±2.76
Condylar long axis angleks/(°) 68.24±8.43 68.15±5.38 67.36±7.72 65.79±9.03

Table 5

Analysis of correlation between temporomandibular joint measurements and cepholometric values in skeletal class Ⅱ patients"

Variables ANB (n=60) FH-GoGn (n=60)
r P r P
Condylar length -0.245 0.059 0.091 0.491
Condylar height -0.228 0.080 0.091 0.487
Condylar neck inclination 0.074 0.572 0.038 0.771
Condylar head angle 0.143 0.275 -0.024 0.853
Anterior joint space 0.270 0.037* 0.037 0.778
Superior joint space -0.145 0.270 -0.488 <0.001**
Posterior joint space -0.196 0.133 -0.272 0.035*
Glenoid fossa width -0.114 0.386 -0.101 0.443
Glenoid fossa depth -0.130 0.321 -0.363 0.004**
Articular eminence inclination 0.120 0.363 -0.259 0.046*
Mesial joint space -0.149 0.256 -0.390 0.002**
Middle joint space -0.144 0.271 -0.425 0.001**
Lateral joint space -0.115 0.383 -0.331 0.010*
Condylar long axis diameter -0.154 0.240 -0.327 0.011*
Condylar short axis diameter -0.240 0.065 -0.143 0.276
Glenoid fossa vertical distance 0.161 0.220 0.370 0.004**
Glenoid fossa coronal distance 0.050 0.706 0.051 0.697
Glenoid fossa sagittal distance -0.170 0.193 -0.163 0.214
Condylar long axis angle -0.296 0.022* -0.211 0.105

Table 6

Distribution of condylar position in each group [side (%)]"

Condylar position Group 1 Group 2 Group 3 Group 4
Anterior 11 (27.5) 4 (10.0) 14 (35.0) 6 (15.0)
Concentric 22 (55.0) 25 (62.5) 11 (27.5) 16 (40.0)
Posterior 7 (17.5) 11 (27.5) 15 (37.5) 18 (45.0)
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