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The validity of temporomandibular joint radiographs using the head positioner
The validity of temporomandibular using the head positioner Mongi
G. Mikhail,
Louisiana Montreal,
B.D.S.,
State University, Canada
H.D.D.,
M.Sc.,*
School of Dentistry,
and Harry
New Orleans,
1 he phrase, “ temporomandibular joint dysfunction,” is an umbrella term covering a variety of problems. These problems may include the entire classification of temporomandibular joint (TMJ) disorders, whether intra-articular or extra-articular. However, the common denominator of temporomandibular joint disorders is known as the myofasda1 pain-dysfunction (MPD) syndrome.’ Zech’ and Yune” believe that radiography is one of the most important diagnostic aids in studying &eases of the TMJ. Zech believes that clearly defined radiographs are difficult to obtain, and even an investigator with a conscientious technique may become discouraged. Ramfjord” believes that TMJ radiographs are wseful for differential diagnosis but are valueless in diagnosis and treatment of TMJ dysfunction. Many factors are involved in obtaining accurate dWms of the TMJ. The first factor is the large amount af structure which must be penetrated by the roentn rays before they arrive at the site being examidled. The rays must pass obliquely through the dintire head before arriving at the TMJ. This produces considerable scattered radiation which muses fogging of the film. Furthermore, the central nay must avoid the dense petrous portion of the tmporal bone to prevent superimposition of the j&t being examined and subsequent obliteration of etontrast. In addition, there is variation in the cranial r&e, form, and bony structure of individuals.‘, ’ Abner3 also points out the anatomic variations of the TRlj structures in the same individual. With these thoughts in mind, the operator readily
*Assistant siana
Professor, Department State University, School
**Professor Dentistry),
002%3913/79/100441
of Fixed Prosthodontics, of Dentistry, New Orleans,
and Director of Graduate Prosthodontics McGill University, Montreal, Canada.
+ 06$00.60/O
is 1979 The C. V. Mosby
Rosen D.D.S.** La., and McGill
University,
School of Dentistry.
appreciates the difficulties in establishing a standardized technique of film placement and exposure time which is expected to produce excellent results in all applications. Yale” in his study of 1,700 mandibular condyles believes that correct radiographic evaluation of the TMJ requires specialized procedures and thorough knowledge of the range of variation in condylar forms. Greene and associates’ believe that the radiographic examination is often incomplete and that it is erroneously concluded that the patient’s problem is functional or psychosomatic. Dawson’. ’ believes that if severe symptoms can be triggered by tooth interferences which deviate the condyle position less than the thickness of thin cellophane, it is unrealistic to think that such minute deviations can be detected by any existing radiographic technique. Dawson adds that while it is unusual for TMJ radiographs to affect the choice of treatment, they should nevertheless be a part of the differential diagnosis of any TMJ syndrome. Taylor and associates”’ believe that the diagnosis and treatment of the symptomatic TMJ continues to be a challenge. Radiographic architecture of the joint has not been well delineated, a situation which contributes to confusion in the interpretation of these symptoms. Rozencweig” believes that radiographic examination of the TMJ often becomes an essential diagnostic tool, particularly in obscure and difficult problems of pain and dysfunction. In 1972 Weinberg” introduced a technique for making TMJ radiographs using the bead positioner,* which was constructed to record the threedimensional position of the patient’s head. In a series of publications he drew attention to the importance
LouiLa.
(Restorative
Co.
joint
*TMJ Head N. Y.
Positioner.
THE
JOURNAL
A-B
Tool
and
Mfg.
OF PROSTHETIC
(21..
High
DENTISTRY
Bridge,
441
MIKHAIL
Fig. 1. Bilateral Right TMJ.
condylar
retrusion.
A, Left TMJ.
B,
of TMJ radiographs in diagnosis and treatment of TMJ dysfunction.13. I4 He concluded that a relationship exists between MPD syndrome and condylar position. Later he suggested treatment procedures to suit the individual type of condylar displacement.‘“-‘8 Weinberg8 believes that when dealing with dysfunctional centric relation, a therapeutic centric occlusion should be established by the dentist with the aid of TMJ radiographs. Controversy exists about his findings and recommendations. More study by independent investigators is required. METHODS The aim of this study was to determine whether a true correlation could be demonstrated between the signs and symptoms of MPD and the location of the condyle within the glenoid fossa by measuring TMJ space on radiographs taken with the head positioner. This was achieved by examining three groups of patients: (1) patients with MPD syndrome, (2) a random sample, and (3) patients who had undergone occlusal rehabilitation. The third group was subdivided into (a) patients that had signs and symptoms prior to occlusal rehabilitation and whose signs and
442
AND
ROSEN
Fig. 2. Unilateral condylar retrusion. A, Right TMJ. Left TMJ. Note the retruded condyle.
B,
symptoms disappeared or improved subsequent to treatment, (b) patients without signs and symptoms prior to or following treatment, (c) patients with signs and symptoms prior to occlusal rehabilitation who demonstrated signs and symptoms following rehabilitation, and (d) patients without signs and symptoms prior to occlusal rehabilitation who demonstrated signs and symptoms following rehabilitation. The following information was recorded for each patient; the chief complaint, medical and dental history, evidence of psychic stress or emotional disturbance, and previous therapy and its results. The muscles associated with jaw movement were palpated for tenderness and/or firmness. Evidence of crepitus, disc derangement, deviation of the mandible during opening and closing, and limitation of mandibular movement were noted. The occlusion was carefully examined for a deflective slide from centric relation to maximum intercuspation of the teeth (centric occlusion). The direction and magnitude of the deflection were recorded. The methods employed were visual inspection during guided or manipulated centric relation closure, occlusal indica-
OCTOBER
1979
VOLUME
42
NUMBER
4
HEAD
POSITIONER
IN TMJ RADIOGRAPHS
Fig. 3. Bilateral Left TM-J.
condylar
protrusion.
A, Right TMJ.
B,
Note
tor wax, articulating paper, and palpation over teeth with suspected premature contacts during terminal hinge closure. Balancing interferences as well as interferences in lateral and protrusive excursions were noted when present. Evidence of posterior occlusal collapse, suspected overclosure, and/or oeclusal instability were recorded. The TMJ radiographs with the teeth in maximum intercuspation were subsequently taken. The head positioner was employed as described in Weinberg’s publication.” The TMJ radiographs were cut suitably, fitted into cardboard mounts, and projected onto a white cardboard screen 14 times their normal size. The measurements were then recorded and reduced mathematically by a factor of 14 to produce accurate measurement of the joint space.lg
RESULTS Arralysis of patients with MPD Sixty three patients were examined: 23 patients (36.5%) had a bilateral condylar retrusion (Fig. 1); 14 (22.2%) had a unilateral condylar retrusion (Fig. 2); 9 (14.2%) had a bilateral condylar protrusion (Fig. 3); 6 (9.5%) had a unilateral condylar protru-
THE JOURNAL
OF PROSTHETIC
Fig. 4. Unilateral
DENTISTRY
the
protruded
condylar protrusion. A, Right condyle. B, Left TMJ
‘TM.J.
sion (Fig. 4); 5 (7.9%) had bilateral symmetric TMJ spaces (Fig. 5); 4 (6.3%) had bilateral asymmetric TMJ spaces (Fig. 6); 2 (3.1%); had bilateral symmetric TMJ spaces (extremely narrow) and one patient had the condyle ankylosed with the glenoid fossa. Of the total 63 patients with signs and symptoms, 54 patients had asymmetric TM,] spaces, six had bilateral symmetric TMJ spaces, and two had extremely narrow TMJ spaces representing possible changes in disc morphology or disc perforations.
Analysis of the random sample of patients Of the 50 patients examined, 12 had crepitus, clicking, and/or deviation during opening and closing of which they were unaware. Of the I2 patients, 2 (16.6%) had a bilateral condylar rctrusion; 7 (58.3%) had a unilateral condylar retrusion; 1 (8.3%) had a bilateral condylar protrusion; 1 (8.3%) had a unilateral condylar protrusion; and 1 (8.3%) had bilateral symmetric TMJ spaces. Of the remaining 38 patients, who had no signs or symptoms, 10 (26.3%) had bilateral condylar retrusion; 3 (7.8%) had unilateral condylar retrusion: 11 (28.9%) had bilateral condylar protrusion; 3 (7.8%) had unilater-
443
MIKHAIL
Fig. 5. Bilateral
asymmetric
TMJ space.
Fig. 6. Bilateral
symmetric
AND
ROSEN
TMJ space.
al condylar protrusion; 7 (18.4%) had bilateral asymmetric joint spaces; and 4 (10.5%) had bilateral symmetric joint spaces.
occlusal rehabilitation. lar retrusion.
Analysis of patients who had undergone occlusal rehabilitation
Of the patients with MPD 88.8% had asymmetric joint spaces, 58.7% had condylar retrusion, and 23.7% had condylar protrusion. Of the patients in the random sample, 25.0% had some signs and symptoms of which they were unaware, and 89.5% had asymmetric joint spaces. Of the random sample, 34.1% had condylar retrusion and 36.7% had condylar protrusion. Of the patients who had undergone occlusal rehabilitation with signs and symptoms prior to rehabilitation and who improved after treatment, 81.3% had bilateral symmetric joint spaces and 18.7% had bilateral asymmetric joint spaces. This information leads to the conclusion that for most of the patients who had been occlusally rehabilitated and improved after treatment, the condyles were concentrically placed within the glenoid fossae. Of the patients who had undergone occlusal rehabilitation without signs and symptoms before and after treatment, 62.5% had bilateral symmetry,
Of 16 patients with signs and symptoms prior to rehabilitation who improved following the treatment, 3 (18.7%) had bilateral asymmetric joint spaces (Fig. 7), and 13 (81.3%) had bilateral symmetric joint spaces (Fig. 8). Of 16 patients without signs and symptoms prior to and following treatment, 3 (18.75%) had bilateral condylar retrusion (Fig. 9), 3 (18.75%) had bilateral condylar protrusion, and 10 (62.5%) had bilateral symmetric joint spaces. Of 11 patients who had signs and symptoms prior to treatment with no improvement following, 7 (63.6%) had bilateral condylar retrusion; 1 (9.0%) had unilateral condylar retrusion; 2 (18.0%) had bilateral condylar protrusion; and 1 (9.0%) had bilateral symmetric joint spaces. One patient who had no signs and symptoms before presented with signs and symptoms after
444
She had a unilateral
condy-
SUMMARY
OCTOBER
1979
VOLUME
42
NUMBER
4
HEAD
POSITIONER
IN TMJ RADIOGRAPHS
Fig. 7. Bilateral
asymmetric
joint space.
18.75% had bilateral condylar protrusion, and 18.75% had bilateral condylar retrusion. For those patients who had signs and symptoms prior to treatment and with no improvement after treatment, 91.07~ had asymmetric joint spaces. Of this group, 72.6% had condylar retrusion. The only patient who had not demonstrated symptoms prior to treatment and developed symptoms after the occlusal rehabilitation had a unilateral condylar retrusion. DISCUSSION A comparison of MPD patients and random sample patients reveals that no statistically significant relationship exists between MPD and condylar symmetry. However a statistically significant relationship does exist between MPD and condylar retrusion. Caution must be exercised in determining the clinical significance of radiographic condylar retrusion. Distinction must be made between true condylar rctmion and retrusion as seen radiographically as a result of mandibular overclosure. It is possible that sagittal displacement of the working condyle during lateral
TH#$ JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 8. Bilateral
symmetric
joint space.
deflective movement could produce a radiographic picture of unilateral condylar retrusion. Bilateral symmetric joint spaces became apparent in the analysis of the patients who had undergone occlusal rehabilitation, where most patients who displayed no signs and symptoms or who demonstrated an improvement after treatment had bilateral symmetric joint spaces. The disparity between these groups of patients and the first two groups examined is explained by the fact that all treated patients had deflective contacts eliminated through occlusal adjustment by selective grinding and restorative procedures. All treated patients presented with stable occlusions. No clinical evidence of mandibular overclosure was apparent during the examination. Among the patients who had been rehabilitated without demonstrating improvement in signs and symptoms, a statisticaily significant 72.5’3 radiographically demonstrated condylar retrusion. Furthermore, the one patient who had no signs and symptoms before rehabilitation, but developed signs and symptoms after, had a radiographic unilateral condylar retrusion.
445
MMHAIL
2.
3.
4. 5.
6. 7.
8. 9. 10.
11.
12. 13.
Fig. 9. Bilateral
condylar
retrusion.
CONCLUSIONS
15.
1. TMJ radiographs made using the head positioner provide a valuable adjunct to diagnosis and treatment planning for patients with MPD syndrome. 2. Where extensive restorative procedures are anticipated, TMJ radiographs can be useful before embarking on a treatment plan and in documenting the postoperative results. 3. Bilateral condylar symmetry is a reasonable objective of extensive restorative dentistry. 4. Radiographic retrusion is more frequently accompanied by signs and symptoms than bilateral condylar symmetry and protrusion. REFERENCES 1.
446
Yavelow, I., and Oral Surg 36:632,
Winninger, 1973.
M.:
Mandibular
16. 17. 18.
ROSEN
Z&h, J.: A comparison and analysis of three technics of taking roentgenograms of the temporomandibular joint. J Am Dent Assoc 59:725, 1959. Yune, H.: Roentgenologic diagnosis in chronic temporomandibular joint dysfunction syndrome. Am J Roentgenol, vol. CXVIII, No. 2, June 1973. Ramfjord, S., and Ash, M.: Occlusion. Philadelphia, 1971, W. B: Saunders Co. Amer, A.: Approach to surgical diagnosis of the temporomandibular articulation through basic studies of the normal. J Am Dent Assoc 45:688, 1952. Yale, S.: Radiographic evaluation of the temporomandibular joint. J Am Dent Assoc 79:102, 1969. Greene, C.S., Lerman, M. D., Sutcher, H. D., and Laskin, D. M.: TMJ pain-dysfunction syndrome: heterogeneity of patient population. J Am Dent Assoc 72:1168, 1969. Dawson, P.: Temporomandibular joint pain dysfunction problems can be solved. J PROSTHET DENT 29:100, 1973. Dawson, P.: Evaluation, Diagnosis and Treatment of Occlusal Problems. St. Louis, 1974, The C. V. Mosby Co. Taylor, R.: A study of temporomandibular joint morphology and its relationship to the dentition. Oral Surg 33:1002, 1972. Rozencweig, D.: Three-dimensional tomographic study of the temporomandibular articulation. J Periodontol 46:348, 1975. Weinberg, L.: Technique for temporomandibular joint radiographs. J PROSTHET DENT 28:284, 1972. Weinberg, L.: What we really see in a TMJ radiograph. J PROSTHET
14.
AND
DENT
30:898,
1973.
Weinberg, L.: Correlation of temporomandibular dysfunction with radiographic findings. J PROSTHET DENT 28:519, 1972. Weinberg, L.: Superior condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 34:59, 1975. Weinberg, L.: Anterior condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 34:195, 1975. Weinberg, L.: Posterior bilateral condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 36:426, 1976. Weinberg, L.: Posterior unilateral condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 37:559, 1977.
19.
Weinberg, mandibular
L.: An evaluation joint radiographs.
of duplicability J PROSTHET
of temporoDENT
24:512,
1970.
Reprint requests to: DR.
MONCI
LAXWANA
G. MIKHAIL
STATE UNIVERSITY
SCHOOL OF DENTISTRY 1100 FLORIDA AVE. NEW ORLEANS, LA. 70119
relearning.
OCTOBER
1979
VOLUME
42
NUMBER
4
G. Mikhail,
Louisiana Montreal,
B.D.S.,
State University, Canada
H.D.D.,
M.Sc.,*
School of Dentistry,
and Harry
New Orleans,
1 he phrase, “ temporomandibular joint dysfunction,” is an umbrella term covering a variety of problems. These problems may include the entire classification of temporomandibular joint (TMJ) disorders, whether intra-articular or extra-articular. However, the common denominator of temporomandibular joint disorders is known as the myofasda1 pain-dysfunction (MPD) syndrome.’ Zech’ and Yune” believe that radiography is one of the most important diagnostic aids in studying &eases of the TMJ. Zech believes that clearly defined radiographs are difficult to obtain, and even an investigator with a conscientious technique may become discouraged. Ramfjord” believes that TMJ radiographs are wseful for differential diagnosis but are valueless in diagnosis and treatment of TMJ dysfunction. Many factors are involved in obtaining accurate dWms of the TMJ. The first factor is the large amount af structure which must be penetrated by the roentn rays before they arrive at the site being examidled. The rays must pass obliquely through the dintire head before arriving at the TMJ. This produces considerable scattered radiation which muses fogging of the film. Furthermore, the central nay must avoid the dense petrous portion of the tmporal bone to prevent superimposition of the j&t being examined and subsequent obliteration of etontrast. In addition, there is variation in the cranial r&e, form, and bony structure of individuals.‘, ’ Abner3 also points out the anatomic variations of the TRlj structures in the same individual. With these thoughts in mind, the operator readily
*Assistant siana
Professor, Department State University, School
**Professor Dentistry),
002%3913/79/100441
of Fixed Prosthodontics, of Dentistry, New Orleans,
and Director of Graduate Prosthodontics McGill University, Montreal, Canada.
+ 06$00.60/O
is 1979 The C. V. Mosby
Rosen D.D.S.** La., and McGill
University,
School of Dentistry.
appreciates the difficulties in establishing a standardized technique of film placement and exposure time which is expected to produce excellent results in all applications. Yale” in his study of 1,700 mandibular condyles believes that correct radiographic evaluation of the TMJ requires specialized procedures and thorough knowledge of the range of variation in condylar forms. Greene and associates’ believe that the radiographic examination is often incomplete and that it is erroneously concluded that the patient’s problem is functional or psychosomatic. Dawson’. ’ believes that if severe symptoms can be triggered by tooth interferences which deviate the condyle position less than the thickness of thin cellophane, it is unrealistic to think that such minute deviations can be detected by any existing radiographic technique. Dawson adds that while it is unusual for TMJ radiographs to affect the choice of treatment, they should nevertheless be a part of the differential diagnosis of any TMJ syndrome. Taylor and associates”’ believe that the diagnosis and treatment of the symptomatic TMJ continues to be a challenge. Radiographic architecture of the joint has not been well delineated, a situation which contributes to confusion in the interpretation of these symptoms. Rozencweig” believes that radiographic examination of the TMJ often becomes an essential diagnostic tool, particularly in obscure and difficult problems of pain and dysfunction. In 1972 Weinberg” introduced a technique for making TMJ radiographs using the bead positioner,* which was constructed to record the threedimensional position of the patient’s head. In a series of publications he drew attention to the importance
LouiLa.
(Restorative
Co.
joint
*TMJ Head N. Y.
Positioner.
THE
JOURNAL
A-B
Tool
and
Mfg.
OF PROSTHETIC
(21..
High
DENTISTRY
Bridge,
441
MIKHAIL
Fig. 1. Bilateral Right TMJ.
condylar
retrusion.
A, Left TMJ.
B,
of TMJ radiographs in diagnosis and treatment of TMJ dysfunction.13. I4 He concluded that a relationship exists between MPD syndrome and condylar position. Later he suggested treatment procedures to suit the individual type of condylar displacement.‘“-‘8 Weinberg8 believes that when dealing with dysfunctional centric relation, a therapeutic centric occlusion should be established by the dentist with the aid of TMJ radiographs. Controversy exists about his findings and recommendations. More study by independent investigators is required. METHODS The aim of this study was to determine whether a true correlation could be demonstrated between the signs and symptoms of MPD and the location of the condyle within the glenoid fossa by measuring TMJ space on radiographs taken with the head positioner. This was achieved by examining three groups of patients: (1) patients with MPD syndrome, (2) a random sample, and (3) patients who had undergone occlusal rehabilitation. The third group was subdivided into (a) patients that had signs and symptoms prior to occlusal rehabilitation and whose signs and
442
AND
ROSEN
Fig. 2. Unilateral condylar retrusion. A, Right TMJ. Left TMJ. Note the retruded condyle.
B,
symptoms disappeared or improved subsequent to treatment, (b) patients without signs and symptoms prior to or following treatment, (c) patients with signs and symptoms prior to occlusal rehabilitation who demonstrated signs and symptoms following rehabilitation, and (d) patients without signs and symptoms prior to occlusal rehabilitation who demonstrated signs and symptoms following rehabilitation. The following information was recorded for each patient; the chief complaint, medical and dental history, evidence of psychic stress or emotional disturbance, and previous therapy and its results. The muscles associated with jaw movement were palpated for tenderness and/or firmness. Evidence of crepitus, disc derangement, deviation of the mandible during opening and closing, and limitation of mandibular movement were noted. The occlusion was carefully examined for a deflective slide from centric relation to maximum intercuspation of the teeth (centric occlusion). The direction and magnitude of the deflection were recorded. The methods employed were visual inspection during guided or manipulated centric relation closure, occlusal indica-
OCTOBER
1979
VOLUME
42
NUMBER
4
HEAD
POSITIONER
IN TMJ RADIOGRAPHS
Fig. 3. Bilateral Left TM-J.
condylar
protrusion.
A, Right TMJ.
B,
Note
tor wax, articulating paper, and palpation over teeth with suspected premature contacts during terminal hinge closure. Balancing interferences as well as interferences in lateral and protrusive excursions were noted when present. Evidence of posterior occlusal collapse, suspected overclosure, and/or oeclusal instability were recorded. The TMJ radiographs with the teeth in maximum intercuspation were subsequently taken. The head positioner was employed as described in Weinberg’s publication.” The TMJ radiographs were cut suitably, fitted into cardboard mounts, and projected onto a white cardboard screen 14 times their normal size. The measurements were then recorded and reduced mathematically by a factor of 14 to produce accurate measurement of the joint space.lg
RESULTS Arralysis of patients with MPD Sixty three patients were examined: 23 patients (36.5%) had a bilateral condylar retrusion (Fig. 1); 14 (22.2%) had a unilateral condylar retrusion (Fig. 2); 9 (14.2%) had a bilateral condylar protrusion (Fig. 3); 6 (9.5%) had a unilateral condylar protru-
THE JOURNAL
OF PROSTHETIC
Fig. 4. Unilateral
DENTISTRY
the
protruded
condylar protrusion. A, Right condyle. B, Left TMJ
‘TM.J.
sion (Fig. 4); 5 (7.9%) had bilateral symmetric TMJ spaces (Fig. 5); 4 (6.3%) had bilateral asymmetric TMJ spaces (Fig. 6); 2 (3.1%); had bilateral symmetric TMJ spaces (extremely narrow) and one patient had the condyle ankylosed with the glenoid fossa. Of the total 63 patients with signs and symptoms, 54 patients had asymmetric TM,] spaces, six had bilateral symmetric TMJ spaces, and two had extremely narrow TMJ spaces representing possible changes in disc morphology or disc perforations.
Analysis of the random sample of patients Of the 50 patients examined, 12 had crepitus, clicking, and/or deviation during opening and closing of which they were unaware. Of the I2 patients, 2 (16.6%) had a bilateral condylar rctrusion; 7 (58.3%) had a unilateral condylar retrusion; 1 (8.3%) had a bilateral condylar protrusion; 1 (8.3%) had a unilateral condylar protrusion; and 1 (8.3%) had bilateral symmetric TMJ spaces. Of the remaining 38 patients, who had no signs or symptoms, 10 (26.3%) had bilateral condylar retrusion; 3 (7.8%) had unilateral condylar retrusion: 11 (28.9%) had bilateral condylar protrusion; 3 (7.8%) had unilater-
443
MIKHAIL
Fig. 5. Bilateral
asymmetric
TMJ space.
Fig. 6. Bilateral
symmetric
AND
ROSEN
TMJ space.
al condylar protrusion; 7 (18.4%) had bilateral asymmetric joint spaces; and 4 (10.5%) had bilateral symmetric joint spaces.
occlusal rehabilitation. lar retrusion.
Analysis of patients who had undergone occlusal rehabilitation
Of the patients with MPD 88.8% had asymmetric joint spaces, 58.7% had condylar retrusion, and 23.7% had condylar protrusion. Of the patients in the random sample, 25.0% had some signs and symptoms of which they were unaware, and 89.5% had asymmetric joint spaces. Of the random sample, 34.1% had condylar retrusion and 36.7% had condylar protrusion. Of the patients who had undergone occlusal rehabilitation with signs and symptoms prior to rehabilitation and who improved after treatment, 81.3% had bilateral symmetric joint spaces and 18.7% had bilateral asymmetric joint spaces. This information leads to the conclusion that for most of the patients who had been occlusally rehabilitated and improved after treatment, the condyles were concentrically placed within the glenoid fossae. Of the patients who had undergone occlusal rehabilitation without signs and symptoms before and after treatment, 62.5% had bilateral symmetry,
Of 16 patients with signs and symptoms prior to rehabilitation who improved following the treatment, 3 (18.7%) had bilateral asymmetric joint spaces (Fig. 7), and 13 (81.3%) had bilateral symmetric joint spaces (Fig. 8). Of 16 patients without signs and symptoms prior to and following treatment, 3 (18.75%) had bilateral condylar retrusion (Fig. 9), 3 (18.75%) had bilateral condylar protrusion, and 10 (62.5%) had bilateral symmetric joint spaces. Of 11 patients who had signs and symptoms prior to treatment with no improvement following, 7 (63.6%) had bilateral condylar retrusion; 1 (9.0%) had unilateral condylar retrusion; 2 (18.0%) had bilateral condylar protrusion; and 1 (9.0%) had bilateral symmetric joint spaces. One patient who had no signs and symptoms before presented with signs and symptoms after
444
She had a unilateral
condy-
SUMMARY
OCTOBER
1979
VOLUME
42
NUMBER
4
HEAD
POSITIONER
IN TMJ RADIOGRAPHS
Fig. 7. Bilateral
asymmetric
joint space.
18.75% had bilateral condylar protrusion, and 18.75% had bilateral condylar retrusion. For those patients who had signs and symptoms prior to treatment and with no improvement after treatment, 91.07~ had asymmetric joint spaces. Of this group, 72.6% had condylar retrusion. The only patient who had not demonstrated symptoms prior to treatment and developed symptoms after the occlusal rehabilitation had a unilateral condylar retrusion. DISCUSSION A comparison of MPD patients and random sample patients reveals that no statistically significant relationship exists between MPD and condylar symmetry. However a statistically significant relationship does exist between MPD and condylar retrusion. Caution must be exercised in determining the clinical significance of radiographic condylar retrusion. Distinction must be made between true condylar rctmion and retrusion as seen radiographically as a result of mandibular overclosure. It is possible that sagittal displacement of the working condyle during lateral
TH#$ JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 8. Bilateral
symmetric
joint space.
deflective movement could produce a radiographic picture of unilateral condylar retrusion. Bilateral symmetric joint spaces became apparent in the analysis of the patients who had undergone occlusal rehabilitation, where most patients who displayed no signs and symptoms or who demonstrated an improvement after treatment had bilateral symmetric joint spaces. The disparity between these groups of patients and the first two groups examined is explained by the fact that all treated patients had deflective contacts eliminated through occlusal adjustment by selective grinding and restorative procedures. All treated patients presented with stable occlusions. No clinical evidence of mandibular overclosure was apparent during the examination. Among the patients who had been rehabilitated without demonstrating improvement in signs and symptoms, a statisticaily significant 72.5’3 radiographically demonstrated condylar retrusion. Furthermore, the one patient who had no signs and symptoms before rehabilitation, but developed signs and symptoms after, had a radiographic unilateral condylar retrusion.
445
MMHAIL
2.
3.
4. 5.
6. 7.
8. 9. 10.
11.
12. 13.
Fig. 9. Bilateral
condylar
retrusion.
CONCLUSIONS
15.
1. TMJ radiographs made using the head positioner provide a valuable adjunct to diagnosis and treatment planning for patients with MPD syndrome. 2. Where extensive restorative procedures are anticipated, TMJ radiographs can be useful before embarking on a treatment plan and in documenting the postoperative results. 3. Bilateral condylar symmetry is a reasonable objective of extensive restorative dentistry. 4. Radiographic retrusion is more frequently accompanied by signs and symptoms than bilateral condylar symmetry and protrusion. REFERENCES 1.
446
Yavelow, I., and Oral Surg 36:632,
Winninger, 1973.
M.:
Mandibular
16. 17. 18.
ROSEN
Z&h, J.: A comparison and analysis of three technics of taking roentgenograms of the temporomandibular joint. J Am Dent Assoc 59:725, 1959. Yune, H.: Roentgenologic diagnosis in chronic temporomandibular joint dysfunction syndrome. Am J Roentgenol, vol. CXVIII, No. 2, June 1973. Ramfjord, S., and Ash, M.: Occlusion. Philadelphia, 1971, W. B: Saunders Co. Amer, A.: Approach to surgical diagnosis of the temporomandibular articulation through basic studies of the normal. J Am Dent Assoc 45:688, 1952. Yale, S.: Radiographic evaluation of the temporomandibular joint. J Am Dent Assoc 79:102, 1969. Greene, C.S., Lerman, M. D., Sutcher, H. D., and Laskin, D. M.: TMJ pain-dysfunction syndrome: heterogeneity of patient population. J Am Dent Assoc 72:1168, 1969. Dawson, P.: Temporomandibular joint pain dysfunction problems can be solved. J PROSTHET DENT 29:100, 1973. Dawson, P.: Evaluation, Diagnosis and Treatment of Occlusal Problems. St. Louis, 1974, The C. V. Mosby Co. Taylor, R.: A study of temporomandibular joint morphology and its relationship to the dentition. Oral Surg 33:1002, 1972. Rozencweig, D.: Three-dimensional tomographic study of the temporomandibular articulation. J Periodontol 46:348, 1975. Weinberg, L.: Technique for temporomandibular joint radiographs. J PROSTHET DENT 28:284, 1972. Weinberg, L.: What we really see in a TMJ radiograph. J PROSTHET
14.
AND
DENT
30:898,
1973.
Weinberg, L.: Correlation of temporomandibular dysfunction with radiographic findings. J PROSTHET DENT 28:519, 1972. Weinberg, L.: Superior condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 34:59, 1975. Weinberg, L.: Anterior condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 34:195, 1975. Weinberg, L.: Posterior bilateral condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 36:426, 1976. Weinberg, L.: Posterior unilateral condylar displacement: Its diagnosis and treatment. J PROSTHET DENT 37:559, 1977.
19.
Weinberg, mandibular
L.: An evaluation joint radiographs.
of duplicability J PROSTHET
of temporoDENT
24:512,
1970.
Reprint requests to: DR.
MONCI
LAXWANA
G. MIKHAIL
STATE UNIVERSITY
SCHOOL OF DENTISTRY 1100 FLORIDA AVE. NEW ORLEANS, LA. 70119
relearning.
OCTOBER
1979
VOLUME
42
NUMBER
4