A study of temporomandibular joint osteoarthritis using computed tomographic imaging

Abstract

Background: This study aimed to determine the various bony changes in osteoarthritis (OA) of elderly patients who are suffering from temporomandibular joint dysfunction (TMD) and to find if all the changes manifesting in generalized OA were presented in temporomandibular joint (TMJ).
Methods: Thirty TMJs of fifteen elderly patients who were diagnosed with TMD were selected for the study. Patient with TMD were subjected to computerized tomographic (CT) imaging, and the various bony changes in the TMJ were recorded.
Results: CT study of TMJ showed that there is a positive evidence of joint involvement in 80% of the cases. In this study, female patients were more commonly affected by OA than the males. The condylar changes (69.93%) are more common than the changes in the articular eminence (6.6%) and condylar fossa (10%). About 56.6% of TMJ in the study was affected by the early manifestations of the OA.
Conclusion: CT study showed that there is a positive evidence of TMJ involvement in the elderly patients with TMD. The results show that condylar changes are more common than the changes in the articular eminence and condylar fossa. The study also shows that most of the patients are affected by early TMJ OA; hence, initiating treatment at early stages may prevent the disease progression.

Full text

Original Article
A study of temporomandibular joint osteoarthritis
using computed tomographic imaging
F. Massilla Mani
a,*
, S. Satha Sivasubramanian
b
a
Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
b
Department of Oral Medicine and Radiology, Sri Ramachandra Dental College and Hospital, Chennai, Tamil Nadu,
India
article info
Article history:
Received 5 February 2015
Accepted 4 November 2015
Available online xxx
Keywords:
Computed tomography
Temporomandibular joint
Temporomandibular joint dysfunc-
tion
Osteoarthritis
abstract
Background: This study aimed to determine the various bony changes in osteoarthritis (OA)
of elderly patients who are suffering from temporomandibular joint dysfunction (TMD) and
to find if all the changes manifesting in generalized OA were presented in temporoman-
dibular joint (TMJ).
Methods: Thirty TMJs of fifteen elderly patients who were diagnosed with TMD were
selected for the study. Patient with TMD were subjected to computerized tomographic (CT)
imaging, and the various bony changes in the TMJ were recorded.
Results: CT study of TMJ showed that there is a positive evidence of joint involvement in
80% of the cases. In this study, female patients were more commonly affected by OA than
the males. The condylar changes (69.93%) are more common than the changes in the
articular eminence (6.6%) and condylar fossa (10%). About 56.6% of TMJ in the study was
affected by the early manifestations of the OA.
Conclusion: CT study showed that there is a positive evidence of TMJ involvement in the
elderly patients with TMD. The results show that condylar changes are more common than
the changes in the articular eminence and condylar fossa. The study also shows that most
of the patients are affected by early TMJ OA; hence, initiating treatment at early stages may
prevent the disease progression.
*Corresponding author. Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, C5, Paramount Park, Velachery,
Vijayanagar, Chennai 600 042, Tamil Nadu, India. Tel.: þ91 44 24530002; fax: þ91 44 24530009.
E-mail address: drravikumar19@gmail.com (F. Massilla Mani).
Peer review under responsibility of Chang Gung University.
Available online at www.sciencedirect.com
ScienceDirect
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2319-4170/©2016 Chang Gung University. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Massilla Mani F, Sivasubramanian SS, A study of temporomandibular joint osteoarthritis using
computed tomographic imaging, Biomedical Journal (2016), http://dx.doi.org/10.1016/j.bj.2016.06.003

At a glance commentary
Scientific background on the subject
Osteoarthritis is a degenerative disease affecting the
temporomandibular joint. It was observed in the study
that more than 80% of the elderly patients with tempo-
romandibular joint dysfunction were more commonly
affected by early stage of osteoarthritis.
What this study adds to the field
Advocating early treatment such as topical NSAIDS,
occlusal adjustments, jaw self-care, physiotherapy, oral
appliance therapy, and intraarticular injection of corti-
costeroids may help to prevent the disease progression.
Osteoarthritis (OA) is defined as a degenerative condition
of the joint characterized by deterioration of articular tissue
and concomitant remodeling of underlying subchondral
bone [1]. OA is an age-related disease, and the WHO esti-
mates that globally 25% of adults aged over 65 years suffer
from pain and disability associated with this disease [2].The
percentage of temporomandibular joint (TMJ) OA in age
group 9e90 years range from 28% to 38% and incidence in-
creases with advancing age. The incidence of TMJ OA has
received a little attention in past literature and studies are
onlyafew.
OA is caused primarily by the degeneration of collagens
and proteoglycans in cartilage leading to fibrillation, erosion,
and cracking in the superficial cartilage layer [2]. This pro-
cess spreads to a deeper layer of cartilage and eventually
enlarges to form erosions. The articular surface of TMJ has
the remarkable adaptive capacity. Hyaline cartilage of the
load-bearing joints of the body are more resistant to
compressive loading, but the fibrocartilage of TMJ better
withstands shear force [3]. When functional demand exceeds
the adaptive capacity of the TMJ or if the affected individual
is susceptible to maladaptive response, then the disease
state will ensue [3].
The cardinal features of TMJ OA are both clinical and
radiographic [4]. The clinical features are tenderness in
the joint region, pain on movement of the joint during
mouth opening and lateral excursion, and hard grating or
crepitus [4,5]. Radiographic signs of the disease are
cortical bone erosion, flattening of joint compartments
with productive bone changes such as sclerosis and
osteophyte [6]. These signs of TMJ OA represent different
stages of the disease process. Erosive lesions and joint
space narrowing indicate acute or early change, whereas
sclerosis, flattening, subchondral cyst, and osteophyte
may indicate late changes in TMJ [7]. This study was done
to determine the various bony changes in OA of elderly
patients who are suffering from temporomandibular joint
dysfunction (TMD) using computed tomography (CT) and
to find if all the changes manifesting in generalized OA
were present in TMJ.
Materials and methods
The study group selected consisted of 15 patients out of whom
10 were female and 5 were male from Outpatient Department
of Oral Medicine and Radiology. The age range was within
50e80 years with the mean average age of 63.06 years. These
patients were examined for TMD. The clinical criteria for TMD
were formulated using the standard TMJ questionnaire by
Okeson, which includes: (1) tenderness present in the pre-
auricular region, (2) tenderness in the muscles of mastication,
(3) limitation or deviation in the mandibular range of motion,
and (4) clicking, or popping, or crepitus [8].
The inclusion criteria include patients with age >50 years,
generalized OA, TMD at least on one side. The exclusion
criteria include the patients who had various problems in the
TMJ such as TMJ surgery, direct trauma, fracture of TMJ,
myalgia, and congenital craniofacial anomalies. Other than
joint problems, patients with pain in the TMJ region due to
tooth pain, impacted teeth, ENT surgeries, ear infections, and
neuralgias were excluded from the study.
The TMJ pain during mandibular function was evaluated
by bilateral manual palpation of the preauricular region and
intraauricular region by means of firm pressure. TMJ pain was
identified during palpation, mandibular range of motion, or
assisted mandibular opening. Tenderness in the muscles of
mastication was checked by palpation of each muscle. The
mandibular range of motion was evaluated by maximum
mouth opening, which was measured from incisal edge of
upper central incisor to lower central incisor with a Digital
Vernier Caliper or millimeter ruler [9]. The lateral movements
were measured relative to the maxillary midline with teeth
slightly separated.
On palpation, bilaterally on the lateral side of both TMJ
near preauricular region, clicking was elicited [9]. Ausculta-
tion was carried out with the diaphragm side of the stetho-
scope at the preauricular region, with the subject performing
three opening and three lateral and protrusive movements [9].
Joint sounds like single or reciprocal click [9] and hard grating
or crepitus were evaluated.
The patients satisfying these criteria were subjected to CT
scan using multi-slice helical CT. The patient is explained
about the entire procedure of the scan and requested to sign
the consent form and was advised to remove metal objects
such as hair pins and hair clips before the procedure. The
patient was taken to the CT scanner (SEIMENS, 125 kV,
500 mA) and placed in supine position on the scanning table
with the head placed on the headrest. A small sponge is
placed on either side of the head to limit the lateral
movements.
The scan was performed with the patient's mouth closed
and that the rays were directed parallel to the Frankfort's
horizontal plane over a distance of 5 cm at 120 kV and 333 mA,
with the scanning table advancing with an increment of 1 mm
per rotation [1]. In bone display mode, the scan data were
reformed into 0.625 mm interaxial image. The scanning pro-
cedure was carried out for 2 min. The axial CT images were
taken and reconstructed into sagittal or coronal images,
which were obtained by orientation to the long axis of the
condyle.
biomedical journal xxx (2016) 1e62
Please cite this article in press as: Massilla Mani F, Sivasubramanian SS, A study of temporomandibular joint osteoarthritis using
computed tomographic imaging, Biomedical Journal (2016), http://dx.doi.org/10.1016/j.bj.2016.06.003

The CT scan images were recorded and interpreted by a
qualified radiologist, and the following radiographic changes
are defined as.
1. Erosion is an interruption or absence of cortical lining
2. Sclerosis is increased density of cortical lining or the sub-
chondral bone
3. An osteophyte is a marginal bone outgrowth
4. Geodes/subchondral cyst are single or multiple pyriform
shape subchondral lesions possessing sclerotic margins of
0.5e2 mm size
5. Joint space narrowing is a reduction in space between the
condyle and glenoid fossa in all directions (anterior, su-
perior, and posterior) [10].
As stated by Gynther et al. [11], Hansen et al., have classi-
fied joint space narrowing as, reduced e<1.5 mm, normal e
between 1.5 and 4 mm, or increased emore than 4 mm. Of five
changes stated above even if one change is evident in any one
joint, it is considered as TMJ OA [12].
Results
The results of the study showed that out of the 30 joints
evaluated, bony changes were presented in 21 (70%) joints
[Tables 1 and 2], either in the condyle, glenoid fossa or the
articular eminence or a combination. Nine joints showed no
changes either in the condyle, glenoid fossa, and articular
eminence. Of 30 joints, erosion in condyle was present in 17
joints, joint space narrowing in 12 joints, subchondral cyst or
geode of the condyle in four joints, osteophyte in five joints,
and sclerosis in five joints were present. One joint showed
erosion in the articular eminence, and two joints showed
Table 1 eCT finding of TMJ OA (Case 1e8).
Joint number Case no Age/sex TMJ Joint space
narrowing
Erosion Geode Osteophyte Sclerosis Condylar fossa Articular
eminence
1 Case 1 62/female Right þ  
2 Left þþ  þ þCyst
3 Case 2 60/female Right þ  
4 Left þ  
5 Case 3 78/female Right þþ  
6 Left þþþ  
7 Case 4 50/female Right þþþþ þ 
8 Left þþþþ þ þErosion
þCyst
9 Case 5 69/male Right þþ þ 
10 Left þþ þ 
11 Case 6 73/female Right   
12 Left þ  
13 Case 7 66/female Right þ  
14 Left þ  
15 Case 8 55/female Right þ þ 
16 Left   
Abbreviations: TMJ: Temporomandibular joint; OA: Osteoarthritis; CT: Computed tomography.
Table 2 eCT finding of TMJ OA (Case 9e15).
Joint number Case no Age/sex TMJ Joint space
narrowing
Erosion Geode Osteophyte Sclerosis Condylar
fossa
Articular
eminence
17 Case 9 50/female Right þþþ þCyst
þSclerosis

18 Left þþ  
19 Case 10 80/female Right þ þþSclerosis 
20 Left þþ þþSclerosis 
21 Case 11 50/female Right þ þ 
22 Left þ  
23 Case 12 60/female Right   
24 Left   
25 Case 13 72/male Right   
26 Left þ  
27 Case 14 61/male Right   
28 Left   
29 Case 15 60/male Right   
30 Left   
Abbreviations: TMJ: Temporomandibular joint; OA: Osteoarthritis; CT: Computed tomography.
biomedical journal xxx (2016) 1e63
Please cite this article in press as: Massilla Mani F, Sivasubramanian SS, A study of temporomandibular joint osteoarthritis using
computed tomographic imaging, Biomedical Journal (2016), http://dx.doi.org/10.1016/j.bj.2016.06.003

subchondral cyst in the eminence. Two joints showed scle-
rosis in the condylar fossa, and one joint had subchondral cyst
in the condylar fossa.
Condylar changes were found to be more predominant than
temporal bone changes in the articular eminence and glenoid
fossa. Erosion was the predominant finding [Fig. 1] 56.6%, fol-
lowed in descending order by joint space narrowing 40% [Fig. 1],
sclerosis 30% [Figs. 1 and 2], osteophyte 16.6% [Figs. 3 and 4]
geode 13.3% [Figs. 5 and 6] changes in the condylar fossa were
10%, and articular eminence 6.6% [Fig. 3]. The percentages of
various bony changes were shown in [Fig. 7].
Discussion
OA has been considered as an age-related degenerative change
of the articular cartilage and the subchondral bone in synovial
joints including TMJ leading to pain and disability [1]. de Leeuw
et al. 1995 stated that of the disorders afflicting the TMJ, OA, and
internal derangement are frequently observed [13,14].Itis
stated that progressive nature of internal derangement by
Fig. 1 eCoronal section showing condylar changes in
temporomandibular joint osteoarthritis.
Fig. 3 eCoronal section showing osteophyte in condyle and
cyst in eminence.
Fig. 2 eCoronal section showing sclerosis and joint space
narrowing.
Fig. 4 eCoronal section showing osteophyte.
biomedical journal xxx (2016) 1e64
Please cite this article in press as: Massilla Mani F, Sivasubramanian SS, A study of temporomandibular joint osteoarthritis using
computed tomographic imaging, Biomedical Journal (2016), http://dx.doi.org/10.1016/j.bj.2016.06.003

several consecutive stage will lead to radiographically visible
degenerative changes, which may be extensive [15,16]. Con-
troversy exists that OA can also lead to disc displacement [7].
This study was carried out to find the various bony changes in
TMJ OA in the elderly patients so that initiating treatment at
early stages may prevent the disease progression.
Wiberg and W€
anman 1998 stated that OA of TMJ seldom
occurs in young adults, and it is an age-related disease [7]. All
patients included in the study had generalized OA and were in
the age range 50e80 years with mean age of 63.06 years. This is
in accordance with the American College of Rheumatology
criteria for the diagnosis of OA where the age range is
described to be above 50 years [17,18]. OA has a predilection
for female sex, and it is more severe in nature involving more
number of joints [5,7]. Low levels of estrogens at the time of
menopause have detrimental effect on the intrinsic material
property of articular cartilage causing degeneration and
erosion. In the present study, out of 15 patients, 10 were fe-
male and five were male similar to the earlier studies where
the number of females was greater than males [7,12]. The
patient with TMJ OA usually present with TMD such as
tenderness in the joint region, pain on movement of the joint
during mouth opening, and lateral excursion with a hard
grating or crepitus as evident as in our study [4,5].
Various imaging modalities have been used for assessment
of morphological changes in the TMJ [19]. From the early 1980s,
CT has been the method of choice for evaluating osseous ab-
normalities in the TMJ [3,6,12,14], and so used in the present
study for evaluation of TMJ OA. Cara et al. stated that CT is an
accurate technique and permits visualization of the upper and
medial portion of the mandibular condyle and the articular
fossa [20]. Despite the highly absorbed dose, CT has greater
potential when osseous TMJ abnormalities are of primary
concern [6,15]. Multi-slice helical CT represents a potential
advancement in CT that allows obtaining thinner slice and
high quality images in less acquisition time [20,21]. In multi-
slice CT, multiple overlapping images can be reconstructed
from single examination permitting higher quality recon-
structed images without additional patient radiation [20,21].
Images were obtained in all three planes axial, sagittal, and
coronal plains. The sagittal plane is valuable for evaluation of
osteophyte, erosion, flattening, and sclerosis [6]. The coronal
plane is useful for finding erosion, flattening, and sclerosis; the
axial plane for evaluation of erosion and sclerosis [6].
In the present study group, 12 out of 15 patients had OA of
TMJ and hence 80% involvement was present which is in
Fig. 7 ePercentage of various bony changes in
temporomandibular joint osteoarthritis. E: Erosion; JSN: Joint
space narrowing; S: Sclerosis; O: Osteophyte; G: Geode; FC:
Fossa changes; EC: Eminence changes.
Fig. 6 eSagittal section showing geode.
Fig. 5 eAxial section showing Geode (subchondral cyst).
biomedical journal xxx (2016) 1e65
Please cite this article in press as: Massilla Mani F, Sivasubramanian SS, A study of temporomandibular joint osteoarthritis using
computed tomographic imaging, Biomedical Journal (2016), http://dx.doi.org/10.1016/j.bj.2016.06.003

accordance to the previous studies [7,11]. Thirty TMJ were
examined for OA changes out of which 21 joints (70%) showed
changes in the condyle, glenoid fossa, or articular eminence,
or in combination. The study shows that condylar bone
changes (69.93%) were greater as compared to the temporal
bone changes such as fossa changes (10%), and eminence
changes (6.6%) were similar to studies where the condylar
bone changes were greater than the temporal bone changes
[1,13]. Erosion (56.6%) and joint space narrowing (40%) were
the most predominant finding in this study, which indicates
the early changes and osteophyte, sclerosis, and geode were
less predominant and represent the advanced stage of the
disease. Hence, most of the patients in the study were affected
by early manifestation of the disease. Advocating early treat-
ment such as occlusal adjustments, jaw self-care, physio-
therapy, oral appliance therapy, topical NSAIDS, and
intraarticular injection of corticosteroids may help to prevent
the disease progression.
Comparison was made with grades of generalized OA and
TMJ OA, but no significant correlation was obtained. Patient
with an early stage of generalized OA also present with early
lesion of TMJ OA, but in a patient with advanced disease of
generalized OA also had an early lesion of TMJ OA. There is an
approved grading system for evaluation of generalized OA,
which is not present for TMJ OA. This study conducted with a
large sample size may yield appropriate results.
Conclusion
CT study showed that there is a positive evidence of TMJ
involvement in the elderly patients with TMD. The results
show that condylar changes are more common than the
changes in the articular eminence and condylar fossa. The
study also shows that most of the patients are affected by
early TMJ OA; hence, initiating treatment at early stages may
prevent the disease progression.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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computed tomographic imaging, Biomedical Journal (2016), http://dx.doi.org/10.1016/j.bj.2016.06.003