Part I: Development and Physiology of the Temporomandibular Joint

Low skeletal bone mineral density as a potential aetiological factor towards idiopathic condylar resorption

The aim of this study was to investigate the contributing factor of impaired skeletal quality in the pathogenesis of idiopathic condylar resorption (ICR). One hundred and twenty-six patients with MRI-confirmed ICR and 596 patients with disc displacement (DD) without a diminished condyle, of both sexes, were included. Dental examinations and retrospective surveys regarding temporomandibular joint symptoms and progression of maxillofacial deformities were conducted. Skeletal bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DXA) and converted to T-scores and Z-scores. Results showed that ICR patients had a smaller overbite (1.56±3.3 vs 3.05±2.0mm), larger overjet (4.9±2.4 vs 3.5±1.9mm), larger range of mouth opening (36.5±6.7 vs 33.6±7.1mm), and higher rates of anterior open bite and mandibular retrusion compared to DD patients (all P<0.001). ICR was associated with an increased probability of low skeletal BMD at chronological age in females (P=0.020) but not in males (P=0.095). This study indicates that reduced BMD may predispose females to an exacerbated condylar resorption process in addition to increased joint loading initiated from DD.

Effect of functional lateral shift of the mandible on hyaluronic acid metabolism related to lubrication of temporomandibular joint in growing rats

BACKGROUND

Hyaluronic acid (HA) is a major molecular component of the articular cartilage of the temporomandibular joint (TMJ) influencing joint lubrication. Functional lateral shift of the mandible (FLSM) can lead to malocclusion. This study investigated the effects of FLSM on HA metabolism and lubrication of the TMJ in growing rats.

METHODS

Thirty 5-week-old male Wistar rats were divided into shift, recovery, and control groups. Rats in the shift and recovery groups were fitted with guiding plates to produce a 2-mm FLSM which were removed from the rats in the recovery group 14 days later. Animals were sacrificed at 14 and 28 days after the appliances were attached. Immunohistochemistry of HA-binding protein (HABP), hyaluronan synthase (HAS), and hyaluronoglucosaminidases (HYALs) was examined.

RESULTS

The thickness of HABP-positively stained areas in the lateral regions in the bilateral condyle was reduced during the experimental period in the shift group compared with that in the control group. The proportion of HAS2-stained areas was bilaterally decreased in different regions of condylar cartilage during the experimental period in the shift group. The reduction of the HYAL2-stained area proportion in the condylar cartilage was more significant than that of HYAL1 at 14 days after appliance attachment in the shift group. HAS2 staining was not recovered in the recovery group.

LIMITATIONS

This research was based on animal experiments with a limited experimental period.

CONCLUSION

FLSM altered lubrication related HA metabolism in the articular cartilage of the TMJ in growing rats.

Long non-coding RNA XIST regulates chondrogenic differentiation of synovium-derived mesenchymal stem cells from temporomandibular joint via miR-27b-3p/ADAMTS-5 axis

OBJECTIVE

Temporomandibular joint osteoarthritis (TMJOA) is a common degenerative disease in jaw joint, accompanied by articular cartilage destruction. Differentiation of stem cells to cartilage has important therapeutic implications in TMJ cartilage repair. Previous studies revealed that lncRNA XIST participated in various biological processes. However, the effect of XIST on chondrogenic differentiation of synovium-derived mesenchymal stem cells (SMSCs) remains unclear. Our study aimed to investigate the function of XIST in chondrogenic differentiation of human SMSCs from TMJ.

METHODS

Alcian blue staining was performed to determine proteoglycan in SMSCs. qPCR, western blotting and immunofluorescence assays were allowed to assess sex determining region Y-box 9 (SOX9), Collagen type II alpha 1 chain (COL2A1) and Aggrecan (ACAN) expression. The direct interaction between miR-27b-3p and XIST or ADAMTS-5 was confirmed by dual luciferase reporter assay or RNA immunoprecipitation (RIP) assay.

RESULTS

XIST was remarkably down-regulated in chondrogenic differentiation of SMSCs. Functional analysis demonstrated that XIST silencing promoted chondrogenic differentiation of SMSCs. Dual luciferase reporter and RIP assays identified that XIST acted as a sponge for miR-27b-3p. Moreover, XIST regulated ADAMTS-5 expression by directly binding miR-27b-3p. More importantly, miR-27b-3p/ADAMTS-5 rescued the effects of XIST on chondrogenic differentiation of SMSCs.

CONCLUSION

The results suggest that XIST modulates SMSCs chondrogenic differentiation via the miR-27b-3p/ADAMTS-5 axis, which provides new targets for TMJOA treatment.

Dentin Sialophosphoprotein Deletion Leads to Femoral Head Cartilage Attenuation and Subchondral Bone Ill-mineralization

Dentin sialophosphoprotein (DSPP), which expresses and synthesizes in odontoblasts of dental pulp, is a critical protein for normal teeth mineralization. Originally, DSPP was identified as a dentin-specific protein. In 2010, DSPP was also found in femoral head cartilage, and it is still unclear what roles DSPP play in femoral head cartilage formation, growth, and maintenance. To reveal biological functions of DSPP in the femoral head cartilage, we examined Dspp null mice compared with wild-type (WT) mice to observe DSPP expression as well as localization in WT mice and to uncover differences of femoral head cartilage, bone morphology, and structure between these two kinds of mice. Expression data demonstrated that DSPP had heterogeneous fragments, expressed in each layer of femoral head cartilage and subchondral bone of WT mice. Dspp null mice exhibited a significant reduction in the thickness of femoral head cartilage, with decreases in the amount of proliferating cartilage cells and increases in apoptotic cells. In addition, the subchondral bone mineralization decreased, and the expressions of vessel markers (vascular endothelial growth factor [VEGF] and CD31), osteoblast markers (Osterix and dentin matrix protein 1 [DMP1]), osteocyte marker (sclerostin [SOST]), and osteoclast marker (tartrate-resistant acid phosphatase [TRAP]) were remarkably altered. These indicate that DSPP deletion can affect the proliferation of cartilage cells in the femoral head cartilage and endochondral ossification in subchondral bone. Our data clearly demonstrate that DSPP plays essential roles in the femoral head cartilage growth and maintenance and subchondral biomineralization.

TLR4 contributes to the damage of cartilage and subchondral bone in discectomy-induced TMJOA mice

The abundance of inflammatory mediators in injured joint indicates innate immune reactions activated during temporomandibular joint osteoarthritis (TMJOA) progression. Toll‐like receptor 4 (TLR4) can mediate innate immune reaction. Herein, we aimed to investigate the expression profile and effect of TLR4 in the cartilage and subchondral bone of the discectomy‐induced TMJOA mice. The expression of TLR4 and NFκB p65 in the synovium of TMJOA patients was measured by immunohistochemistry, Western blotting and RT‐PCR. H&E and Masson staining were utilized to assess the damage of cartilage and subchondral bone of the discectomy‐induced TMJOA mice. A TLR4 inhibitor, TAK‐242, was used to assess the effect of TLR4 in the cartilage and subchondral bone of the discectomy‐induced TMJOA mice by Safranin O, micro‐CT, immunofluorescence and immunohistochemistry. Western blotting was used to quantify the expression and effect of TLR4 in IL‐1β–induced chondrocytes. The expression of TLR4 and NFκB p65 was elevated in the synovium of TMJOA patients, compared with the normal synovium. TLR4 elevated in the damaged cartilage and subchondral bone of discectomy‐induced TMJOA mice, and the rate of TLR4 expressing chondrocytes positively correlated with OA score. Intraperitoneal injections of TAK‐242 ameliorate the extent of TMJOA. Furthermore, TLR4 promotes the expression of MyD88/NFκB, pro‐inflammatory and catabolic mediators in cartilage of discectomy‐induced TMJOA. Besides, TLR4 participates in the production of MyD88/NFκB, pro‐inflammatory and catabolic mediators in IL‐1β–induced chondrocytes. TLR4 contributes to the damage of cartilage and subchondral bone in discectomy‐induced TMJOA mice through activation of MyD88/NFκB and release of pro‐inflammatory and catabolic mediators.

The Temporomandibular Joint: A Critical Review of Life-Support Functions, Development, Articular Surfaces, Biomechanics and Degeneration

The temporomandibular joint is a highly conserved articulation because it promotes survival and propagation via the essential functions of mastication, communication, and routine mating success (dentofacial esthetics). The temporomandibular joint is a unique secondary joint formed between the endochondral temporal bone and the mandibular secondary condylar cartilage via Indian hedgehog and bone morphogenetic protein signaling that is closely related to ear development. A dynamic epigenetic environment is provided by Spry1 and Spry2 genetic induction of the lateral pterygoid and temporalis muscles. Mechanical loading of the condylar periosteum during fetal development produces a superficial layer of fibrocartilage that separates from the condyle to form the interposed temporomandibular joint disc. The articular surfaces of the condyle and fossa are dynamically modified periosteum that has healing and regenerative capability. This unique tissue is composed of a superficial fibrous layer (synovial surface) with an underlying proliferative (cambium) layer that produces a cushioning layer of fibrocartilage which subsequently forms bone. Prior to occlusion of the first primary (deciduous) molars at about 16 months, facial development is dominated by primary genetic mechanisms. After achieving posterior functional occlusion, biomechanics enhances temporomandibular joint maturation, and assumes control of facial growth, development and adaptation. Concurrently, hypothalamus control of musculoskeletal physiology shifts from insulin-like growth factor IGF2 to IGF1, which affects bone via muscular loading (biomechanics). Three layers of temporomandibular joint fibrocartilage are resistant to heavy functional loading, but parafunctional clenching may result in degeneration that is first manifest as trabecular sclerosis of the mandibular condyle.

Efficacy of arthrocentesis and lavage for treatment of post-traumatic arthritis in temporomandibular joints

Objectives

Joint injuries frequently lead to progressive joint degeneration that causes articular disc derangement, joint inflammation, and osteoarthritis. Such arthropathies that arise after trauma are defined as post-traumatic arthritis (PTA). Although PTA is well recognized in knee and elbow joints, PTA in the temporomandibular joint (TMJ) has not been clearly defined. Interestingly, patients experiencing head and neck trauma without direct jaw fracture have displayed TMJ disease symptoms; however, definitive diagnosis and treatment options are not available. This study will analyze clinical aspects of PTA in TMJ and their treatment outcomes after joint arthrocentesis and lavage.

Materials and Methods

Twenty patients with history of trauma to the head and neck especially without jaw fracture were retrospectively studied. Those patients developed TMJ disease symptoms and were diagnosed by computed tomography or magnetic resonance imaging. To decrease TMJ discomfort, arthrocentesis and lavage with or without conservative therapy were applied, and efficacy was evaluated by amount of mouth opening and pain scale. Statistical differences between pre- and post-treatment values were evaluated by Wilcoxon signed-rank test.

Results

Patient age varied widely between 20 and 80 years, and causes of trauma were diverse. Duration of disease onset was measured as 508 posttrauma days, and 85% of the patients sought clinic visit within 2 years after trauma. In addition, 85% of the patients showed TMJ disc derangement without reduction, and osteoarthritis was accompanied at the traumatized side or at both sides in 40% of the patients. After arthrocentesis or lavage, maximal mouth opening was significantly increased (28-44 mm on average, P<0.001) and pain scale was dramatically decreased (7.8-3.5 of 10, P<0.001); however, concomitant conservative therapy showed no difference in treatment outcome.

Conclusion

The results of this study clarify the disease identity of PTA in TMJ and suggest early diagnosis and treatment options to manage PTA in TMJ.

HIF-1α Mediates Osteoclast-Induced Mandibular Condyle Growth via AMPK Signaling

During the mandibular condylar growth, the absorption of calcified cartilage matrix induced by osteoclasts is crucial for the continuous endochondral osteogenesis. Meanwhile, recent studies showed that subchondral bone resided within the low-oxygen microenvironment, and our previous study revealed that hypoxia-inducible transcription factor 1α (HIF-1α) promoted osteoclastogenesis under hypoxia. However, whether HIF-1α regulates the function of osteoclasts in the mandibular condyle cartilage remains elusive. Our study indicated that severe deformity of the mandibular condyle was displayed in 10-wk-old osteoclast-specific HIF-1α conditional knockout (CKO) mice, accompanied by shortened length of condylar process and disorganized fibrocartilage. In 1-, 2-, and 4-wk-old CKO mice, the size of the hypertrophic layer and chondrocytic layer was significantly thickened. In the chondrocytic layer, chondrocytes were atrophied, showing a form of apoptosis in 4-wk-old CKO mice. Furthermore, an increase in the thickness of the fibrous and proliferating layer was observed in 10-wk-old CKO mice, as well as a significant decrease in that of the chondrocytic and hypertrophic chondrocyte layers. Interestingly, the articular surface of the condylar process abnormally presented a horizontal concave shape, and a disk-like acellular connective tissue appeared. In addition, genetic ablation of HIF-1α blunted cartilage matrix loss by subchondral osteoclast deficiency, resulting in a high subchondral bone mass phenotype, accompanied with a decreased number of blood vessels, alkaline phosphatase staining, and vascular endothelial growth factor (VEGF) expression. Mechanistically, the number of osteoclasts in the center of the condyle in CKO mice was significantly reduced by attenuated expression of adenosine 5′-monophosphate-activated protein kinase (AMPK) signaling. These findings reveal a novel influence of HIF-1α function in osteoclasts on maintenance of osteoclast-induced resorption of calcified cartilage matrix via AMPK signaling, as well as subchondral bone formation through VEGF-dependent angiogenesis in bone marrow.

Temporomandibular Joints' Morphology and Osteoarthritic Changes in Cone-Beam Computed Tomography Images in Patients with and without Reciprocal Clicking-A Case Control Study

Background: Patients referred for orthodontic treatment often present symptoms of temporomandibular joints’ disorders (TMD), predominantly clicking. The objective was to analyze the morphology of the temporomandibular joints in cone-beam computed tomography (CBCT) images based on the presence of reciprocal clicking before orthodontic treatment. Methods: 105 participants took part in the study. 210 temporomandibular joints (TMJs) were allocated into one of two groups regarding the presence of reciprocal clicking. Morphology of condyle’s head, glenoid fossa, and articular eminence as well as condylar head position in the glenoid fossa and osteoarthritic changes in the area of the condylar head were examined for each TMJ in the CBCT images. Statistical analysis was performed with STATISTICA version 12.0. The following tests were performed: U-Mann Whitney, Kruskal-Wallis, t-Student, and chi-square. The statistical significance level was p = 0.05 for all the measurements included. Results: Significantly smaller condylar A-P dimension (p = 0.040) characterized temporomandibular joints with reciprocal clicking. Condyles were substantially more often positioned posteriorly (p = 0.043) and were significantly more often accompanied by subcortical cysts and pathologic osteoarthritic bone changes (p < 0.001). Conclusions: The early stages of internal derangements stay with alterations in morphology and position of TMJs as well as with the presence of osteoarthritic changes.

Mouth breathing impairs the development of temporomandibular joint at a very early stage

OBJECTIVES

The study aimed to explore the effects of mouth breathing and hypoxia on the condyle of temporomandibular joint (TMJ) via two animal models.

METHODS

24 four-week-old rats were randomly separated into three groups, consisting of eight control rats, eight intermittent hypoxia (IH) rats, and eight intermittent nasal obstruction (INO) rats. We use the IH model and the INO model to simulate children suffering from hypoxia and mouth breathing. After 16 days, the condyle of TMJ and surrounding white adipose tissue (WAT) and skeletal muscle tissue were obtained for further staining and qRT-PCR. Finally, RNA-seq was used to verify the results.

RESULTS

The intermittent hypoxia cannot significantly change the overall structure in the cause of short-term hypoxia stimulation, but the intermittent nasal obstruction can alter the condyle, WAT, and muscle, while also introducing noticeable structural changes in tissue hypoxia and macrophage infiltration. Sequencing data verified these findings and also suggested that this process might involve the Hif-1α/Vegf axis.

CONCLUSIONS

Our findings reveal the very early structural impact of mouth breathing on condyle reconstruction in rat models, and hypoxia does not induce evident alteration on condyle. However, since these results are mainly focused on rats, further studies are needed to understand its effects on humans.

Single Nucleotide Polymorphisms (SNPs) of COL1A1 and COL11A1 in Class II Skeletal Malocclusion of Ethnic Javanese Patient

Background

The prevalence of malocclusion cases in the orthodontic specialist clinic in Airlangga University’s Dental Hospital in Surabaya, Indonesia, in 2014–2016 is fairly high, as 55.34% of the occurrences were identified as class II skeletal malocclusion. This type of skeletal malocclusion, which is usually recognized in adults, occurs as a result of variation during growth and development. Lately, there have been many reports on gene polymorphisms of COL1A1 and COL11A1, which are assumed to be associated with class II skeletal malocclusion in Caucasians.

Purpose

This study aims to analyze the relationship between single nucleotide polymorphisms (SNPs) of COL1A1 and COL11A1 with class II skeletal malocclusion in Javanese ethnic group patients with mandibular micrognathism.

Materials and Methods

The diagnosis of class II skeletal malocclusion was established using the lateral cephalometric radiographs (ANB angle ≥4°) (n=50). DNA was extracted from the patient’s peripheral blood. After that, PCR, electrophoresis, and DNA sequencing were conducted on the extracted DNA based on COL1A1 and COL11A1 primers.

Results

The SNPs in COL1A1 are c.20980G/A in 27 patients and c.20980G>A in 8 patients, whereas SNPs in COL11A1 are both c.134373C/A and c.134555C/T in 8 patients and both c.[134373A>C] and c.134582G>A in 10 patients. All samples show the deletion (c.[134227delA]) in COL11A1.

Conclusion

SNPs in COL1A1 and COL11A1 have been found in class II skeletal malocclusion of Javanese ethnic group patients. Seventy percent of SNPs in COL1A1 occur in rs.2249492, whereas 36% of newly discovered SNPs appear in COL11A1. All samples also have deletion in COL11A1.

Reduction of osteoarthritis severity in the temporomandibular joint of rabbits treated with chondroitin sulfate and glucosamine

Osteoarthritis is a degenerative disease that causes substantial changes in joint tissues, such as cartilage degeneration and subchondral bone sclerosis. Chondroitin sulfate and glucosamine are commonly used products for the symptomatic treatment of osteoarthritis. The aim of the present study was to investigate the effects of these products when used as structure-modifying drugs on the progression of osteoarthritis in the rabbit temporomandibular joint. Thirty-six New Zealand rabbits were divided into 3 groups (n = 12/group): control (no disease); osteoarthritis (disease induction); and treatment (disease induction and administration of chondroitin sulfate and glucosamine). Osteoarthritis was induced by intra-articular injection of monosodium iodoacetate. Animals were killed at 30 and 90 days after initiation of therapy. The treatment was effective in reducing disease severity, with late effects and changes in the concentration of glycosaminoglycans in the articular disc. The results indicate that chondroitin sulfate and glucosamine may have a structure-modifying effect on the tissues of rabbit temporomandibular joints altered by osteoarthritis.

Role of thyroid hormones in craniofacial development

The development of the craniofacial skeleton relies on complex temporospatial organization of diverse cell types by key signalling molecules. Even minor disruptions to these processes can result in deleterious consequences for the structure and function of the skull. Thyroid hormone deficiency causes delayed craniofacial and tooth development, dysplastic facial features and delayed development of the ossicles in the middle ear. Thyroid hormone excess, by contrast, accelerates development of the skull and, in severe cases, might lead to craniosynostosis with neurological sequelae and facial hypoplasia. The pathogenesis of these important abnormalities remains poorly understood and underinvestigated. The orchestration of craniofacial development and regulation of suture and synchondrosis growth is dependent on several critical signalling pathways. The underlying mechanisms by which these key pathways regulate craniofacial growth and maturation are largely unclear, but studies of single-gene disorders resulting in craniofacial malformations have identified a number of critical signalling molecules and receptors. The craniofacial consequences resulting from gain-of-function and loss-of-function mutations affecting insulin-like growth factor 1, fibroblast growth factor receptor and WNT signalling are similar to the effects of altered thyroid status and mutations affecting thyroid hormone action, suggesting that these critical pathways interact in the regulation of craniofacial development.

Cone-beam CT evaluation of temporomandibular joint in permanent dentition according to Angle's classification

OBJECTIVES

To compare characteristics of temporomandibular joint (TMJ) and related structures according to Angle class I, II¹, II², and III.

METHODS

123 Chinese patients (13-36 years old, 60 males, and 63 females) were classified in four groups according to Angle's classification: skeletal class I (31 patients), skeletal class II division 1 (30 patients), skeletal class II division 2 (30 patients), and skeletal class III (32 patients). Left and right TMJs of each subject were evaluated independently with cone-beam computed tomography (CBCT). The position of condyle in the joint fossa was analyzed according to Pullinger.

RESULTS

There were significant differences between class III subjects and class I, II¹, II² in the superior joint space (p < 0.05). Compared with class II¹, II², and III subjects, the height and diameter of condyle in class I was significantly larger (p < 0.05). The width of joint fossa was significantly larger in Angle class III than in Angle class I, II¹, and II², while the depth was significantly smaller. The condyle position in class III subjects was more anteriorly displaced compared with that in class I subjects. In class II² patients, the condyle position was mainly concentric and posterior.

CONCLUSIONS

There are significant differences in condylar morphology, joint space, joint fossa morphology, and condylar position between different Angle classifications.

Part II: Temporomandibular Joint (TMJ)-Regeneration, Degeneration, and Adaptation

PURPOSE OF REVIEW

Elucidate temporomandibular joint (TMJ) development and pathophysiology relative to regeneration, degeneration, and adaption.

RECENT FINDINGS

The pharyngeal arch produces a highly conserved stomatognathic system that supports airway and masticatory function. An induced subperiosteal layer of fibrocartilage cushions TMJ functional and parafunctional loads. If the fibrocartilage disc is present, a fractured mandibular condyle (MC) regenerates near the eminence of the fossa via a blastema emanating from the medial periosteal surface of the ramus. TMJ degenerative joint disease (DJD) is a relatively painless osteoarthrosis, resulting in extensive sclerosis, disc destruction, and lytic lesions. Facial form and symmetry may be affected, but the residual bone is vital because distraction continues to lengthen the MC with anabolic bone modeling. Extensive TMJ adaptive, healing, and regenerative potential maintains optimal, life support functions over a lifetime. Unique aspects of TMJ development, function, and pathophysiology may be useful for innovative management of other joints.