Digital panoramic radiography for diagnosis of the temporomandibular joint: CBCT as the gold standard

The utilization of decision trees on orthopantomographic and lateral panoramic graphs for the diagnosis of unilateral anterior disc displacement of the temporomandibular joint

BACKGROUND

Investigation is to utilize decision trees in conjunction with orthopantomography (OPT) and lateral panoramic graphy (LPG) to diagnose unilateral anterior disc displacement (ADD) of the temporomandibular joint.

METHODS

In this study, 161 patients with images obtained through all three imaging methods, MRI, OPT, and LPG, were selected from the archives. The participants were categorized into two groups: the study group, comprising 89 patients with unilateral anterior disc displacement, and the control group, consisting of 72 healthy individuals. Measurements, including 2 angles (antero-posterior angle and superior-inferior angle) and 3 distance parameters (anterior joint space distance, superior joint space distance, and posterior joint space distance), were conducted on each imaging modality dataset. To assess the obtained measurement data within each patient, the differences from each measurement were calculated. Statistical analysis of the measurement differences between the control and study groups was carried out with independent t test, and decision trees were generated using the SPSS 25 decision tree module 5.0.

RESULTS

In ADD patients, it was statistically significantly found that the APA increased while the SIA decreased for angle measurements. But for linear measurements, AS increased while the SS and PS decreased in MRI, OPT, and LPG.

CONCLUSION

ADD can be diagnosed in OPT and LPG. The identification of the specific type of ADD that occurs in the temporomandibular joint is not feasible.

Noise-Optimized CBCT Imaging of Temporomandibular Joints-The Impact of AI on Image Quality

Background: Temporomandibular joint disorder (TMD) is a common medical condition. Cone beam computed tomography (CBCT) is effective in assessing TMD-related bone changes, but image noise may impair diagnosis. Emerging deep learning reconstruction algorithms (DLRs) could minimize noise and improve CBCT image clarity. This study compares standard and deep learning-enhanced CBCT images for image quality in detecting osteoarthritis-related degeneration in TMJs (temporomandibular joints). This study analyzed CBCT images of patients with suspected temporomandibular joint degenerative joint disease (TMJ DJD). Methods: The DLM reconstructions were performed with ClariCT.AI software. Image quality was evaluated objectively via CNR in target areas and subjectively by two experts using a five-point scale. Both readers also assessed TMJ DJD lesions. The study involved 50 patients with a mean age of 28.29 years. Results: Objective analysis revealed a significantly better image quality in DLM reconstructions (CNR levels; p < 0.001). Subjective assessment showed high inter-reader agreement (κ = 0.805) but no significant difference in image quality between the reconstruction types (p = 0.055). Lesion counts were not significantly correlated with the reconstruction type (p > 0.05). Conclusions: The analyzed DLM reconstruction notably enhanced the objective image quality in TMJ CBCT images but did not significantly alter the subjective quality or DJD lesion diagnosis. However, the readers favored DLM images, indicating the potential for better TMD diagnosis with CBCT, meriting more study.

Diagnosis of TMJ degenerative diseases by panoramic radiography: is it possible? A systematic review and meta-analysis

OBJECTIVE

The objective of this work was to determine the diagnostic accuracy of panoramic radiography in detecting degenerative diseases of the temporomandibular joint.

METHOD

The protocol was registered at the PROSPERO website. To consider the eligibility of studies to be included/excluded from this review, the acronym "PIRDS" was used and appropriate word combinations and truncations were adapted in the following electronic databases: PubMed/Medline, EMBASE, Latin American and Caribbean Literature on Health Sciences, Web of Science, Scopus, and Cochrane Library.

RESULTS

A total of 2572 references, after the removal of duplicates, were retrieved from the eight electronic databases. After reading the titles and abstracts, a total of 26 articles were selected for full reading, of which ten were excluded, resulting in 16 articles included for qualitative synthesis. All in vivo studies were classified as having a low risk of bias. Regarding in vitro studies none of the included studies scored below 80% in the overall evaluation.

CONCLUSIONS

Both in vitro and in vivo studies consistently report a low accuracy in detecting degenerative diseases of the temporomandibular joint using panoramic radiography.

CLINICAL RELEVANCE

Cone-beam computed tomography offers a superior image quality without overlapping structures and a higher accuracy compared to panoramic radiography. However, panoramic radiography can still serve as an initial examination when combined with a clinical assessment. CBCT should be reserved for cases where there are evident clinical and/or radiographic alterations that recommend its use. This approach ensures a judicious and cost-effective use of CBCT resources.

The prevalence of temporomandibular disorder and temporomandibular morphology among diverse chronotype profiles

This study investigates the influence of chronotype on the prevalence of temporomandibular joint disorders (TMD) and the morphology of temporomandibular joint (TMJ). According to the Morningness-Eveningness Questionnaire-Self-Assessment, the participants were divided into morning group (n = 30), intermediate group (n = 83), and evening group (n = 30). Thirty participants were randomly selected from the intermediate group for subsequent examination and measurements. The morphology of TMJs was investigated using questionnaire and clinical examination form in Diagnostic Criteria for Temporomandibular Disorder. Meanwhile, the morphological results of TMJs were measured from cone-beam computed tomography images. The prevalence rate of TMD in the morning group (23%) was significantly lower than that in the intermediate group (56.7%), while there was no difference between the evening (53.4%) and intermediate groups. As to morphological measurements, there was no significant difference among three groups in mediolateral width of condylar process, anteroposterior width of condylar process, radius of condyle, medial joint space, lateral joint space, condylar stress angle, horizontal condylar inclination, width of glenoid fossa, depth of glenoid fossa, and posterior joint space, while there was a significant difference in horizontal condylar angle (p = 0.00490), articular eminence inclination (p < .0001), anterior joint space (p = 0.0163), and superior joint space (p = 0.0004). The morphology of TMJ in the morning group was better than that in the evening and intermediate groups. An association was found between TMD prevalence, temporomandibular morphology, and chronotype.

Are morphological and morphometric characteristics of maxillary anterior region and nasopalatine canal related to each other?

OBJECTIVES

The main purpose of this article was to clarify the relationship of anterior bone and tooth morphology with NPC. The anatomical features of the NPC region in three dimensions from coronal, axial, and sagittal directions were analyzed using CBCT and the effects of age, gender, sagittal root positions (SRPs) of central teeth, anterior overbite depth (AOD), central incisor (CI)/palatal plane (PP) angle, NPC/PP angle, and collum angles (CA) on NPC were evaluated in a group of the Turkish population.

MATERIALS AND METHODS

In this retrospective study, CBCTs of a total of 330 individuals between the ages of 17 and 82 were evaluated. The effects of SRP, AOD, CI/PP angle, NPC/PP angle and CA on the anatomical features of NPC were examined on the basis of age and gender. Descriptive statistics, Kolmogorov-Smirnov, Chi-square, Wilcoxon, Mann-Whitney-U, Kruskal-Wallis, and Spearman correlation tests were used. p values of < 0.05 were accepted as statistically significant.

RESULTS

While the SRPs, CI/PP angle, NPC/PP angle, CA, and age did not differ statistically according to NPC shape (p > 0.05), NPC shape varied according to gender and AOD (p < 0.05). It was found that cylindrical NPC (32.8%) was more common in females, while conical-shaped NPC (30.7%) was more common in males (p < 0.01). While most conical NPC was detected in individuals with Class I overbite depth, cylindrical NPCs were found in Class II and III individuals (p < 0.01).

CONCLUSIONS

The results showed that gender and AOD are influential factors on NPC shape. While conical-shaped NPC is more common in individuals with bite depth incisal, cylindrical-shaped NPC is more likely to be seen in individuals with middle and cervical thirds.

Artificial intelligence and infrared thermography as auxiliary tools in the diagnosis of temporomandibular disorder

OBJECTIVE

To assess three machine learning (ML) attribute extraction methods: radiomic, semantic and radiomic-semantic association on temporomandibular disorder (TMD) detection using infrared thermography (IT); and to determine which ML classifier, KNN, SVM and MLP, is the most efficient for this purpose.

METHODS AND MATERIALS

78 patients were selected by applying the Fonseca questionnaire and RDC/TMD to categorize control patients (37) and TMD patients (41). IT lateral projections of each patient were acquired. The masseter and temporal muscles were selected as regions of interest (ROI) for attribute extraction. Three methods of extracting attributes were assessed: radiomic, semantic and radiomic-semantic association. For radiomic attribute extraction, 20 texture attributes were assessed using co-occurrence matrix in a standardized angulation of 0°. The semantic features were the ROI mean temperature and pain intensity data. For radiomic-semantic association, a single dataset composed of 28 features was assessed. The classification algorithms assessed were KNN, SVM and MLP. Hopkins's statistic, Shapiro-Wilk, ANOVA and Tukey tests were used to assess data. The significance level was set at 5% (p < 0.05).

RESULTS

Training and testing accuracy values differed statistically for the radiomic-semantic association (p = 0.003). MLP differed from the other classifiers for the radiomic-semantic association (p = 0.004). Accuracy, precision and sensitivity values of semantic and radiomic-semantic association differed statistically from radiomic features (p = 0.008, p = 0.016 and p = 0.013).

CONCLUSION

Semantic and radiomic-semantic-associated ML feature extraction methods and MLP classifier should be chosen for TMD detection using IT images and pain scale data. IT associated with ML presents promising results for TMD detection.

Evaluation of the dimensions, morphology, and position of the mandibular condyles in individuals with neurofibromatosis 1: a case-control study

OBJECTIVES

The aim of this study was to evaluate the mandibular condyles of neurofibromatosis 1 (NF1) individuals without facial plexiform neurofibroma using cone beam computed tomography images.

MATERIALS AND METHODS

Eighty cone beam computed tomography scans (160 mandibular condyles) were analyzed: 40 from NF1 individuals (study group) and 40 from individuals without NF1 (control group). The anteroposterior and mediolateral dimensions, height, and volume of the mandibular condyles were measured. The mandibular condyles were classified according to their morphology: healthy (absence of morphological changes), with flattening (loss of rounded contour of at least one of the surfaces), with erosion (loss of continuity of the cortical bone), with osteophyte (exophytic formation of the condyle surface), and with sclerosis (any increase in the cortical thickness in the load-bearing areas). Furthermore, the position of the mandibular condyles in relation to the joint fossa in an anteroposterior view was classified as anterior, concentric, or posterior.

RESULTS

The study group had a higher anteroposterior dimension of the mandibular condyles compared with the control group (p < 0.05). There were no differences in condylar morphology and position between both groups (p > 0.05). The morphological alterations were not associated with sex or age in any group evaluated (p > 0.05). For both groups, the concentric position was the most common. For the study group, there was a significant difference in the condylar position between the sides (p < 0.05).

CONCLUSIONS

NF1 individuals without facial plexiform neurofibroma present a high prevalence of condyles with a large anteroposterior dimension and asymmetric position in the joint fossa. However, no morphological and volumetric changes were observed in the mandibular condyles of them.

CLINICAL RELEVANCE

The knowledge of the TMJ alterations in individuals with NF1 is important to establish an evaluation protocol, which would allow early intervention if indicated.

Temporomandibular Disorders: Current Concepts and Controversies in Diagnosis and Management

Temporomandibular disorders (TMD) are a group of orofacial pain conditions which are the most common non-dental pain complaint in the maxillofacial region. Due to the complexity of the etiology, the diagnosis and management of TMD remain a challenge where consensus is still lacking in many aspects. While clinical examination is considered the most important process in the diagnosis of TMD, imaging may serve as a valuable adjunct in selected cases. Depending on the type of TMD, many treatment modalities have been proposed, ranging from conservative options to open surgical procedures. In this review, the authors discuss the present thinking in the etiology and classification of TMD, followed by the diagnostic approach and the current trend and controversies in management.

Understanding the mandibular condyle morphology on panoramic images: A conebeam computed tomography comparison study

Objective: To compare variations in condylar morphology (CM) in panoramic images with those demonstrated in cone beam computed tomography (CBCT) and to investigate factors related to the variations.Methods: Three thousand panoramic images were analyzed for CM classification and relationship between CM and patient factors. Then, CM of 178 cases of panoramic and CBCT images were compared.Results: CM was classified into five types: round (70.63%), pointed (15.12%), angled (8.43%), flat (4.53%), and irregular (1.28%). CM was significantly related to all patient factors (p < 0.001). Round CM in panoramic images presented as round in CBCT images. Pointed and flat CM were observed mainly in the lateral aspect of the condyle, and no angle-shaped CM was found, according to CBCT images.Conclusion: Round, flat, and pointed CM seen on panoramic images possibly reflected the actual shape of the condyle, as confirmed by CBCT, whereas angled CM appeared not to exist.

Optimal Use of a Panoramic Radiograph as a Screening Tool for Condylar Resorption in Patients Undergoing Active Orthodontic Treatment: A Case Series

Condylar resorption of temporomandibular joint findings in the panoramic radiographs is an indication of bone resorption suggesting possible degenerative joint disease that warrants early screen and subsequent referral to a dedicated specialist. This case series reports three patients that underwent the active orthodontic treatment for the duration of approximately 24-36 months. The patients were asymptomatic at the initial examination. The clinical examination was negative for clicking; the range of motion on opening, lateral excursion, and protrusion was normal. Neither of these patients had a history of rheumatic disease or bruxism. During the later stages of orthodontic treatment, two of the three patients reported mild pain and clicking during mastication, which was also confirmed chairside on clinical evaluation. Patients were referred to the orofacial pain specialist, were they were prescribed specific medication for the symptoms, along with cognitive behavioral therapy, and were further evaluated for splint therapy. Panoramic radiographs taken before the start of the treatment, during the treatment and at the completion of the orthodontic treatments indicate the progression in the resorption of mandibular condyle in all three patients suggesting possible degeneration that warrants further investigation and therapy.

Diagnostic accuracy and reliability of panoramic temporomandibular joint (TMJ) radiography to detect bony lesions in patients with TMJ osteoarthritis

Background/purpose

The value of the temporomandibular joint (TMJ) projections of panoramic radiography for diagnosing TMJ osteoarthritis is not completely elucidated. This study aimed to assess the diagnostic accuracy and reliability of panoramic TMJ radiography to detect bony lesions in patients with TMJ osteoarthritis.

Materials and methods

This study included 55 TMJs of 44 subjects who were diagnosed with TMJ osteoarthritis. They underwent panoramic radiography (PanRad), lateral (LatTMJ) and frontal (FrnTMJ) projection panoramic TMJ radiography, and cone-beam computed tomography (CBCT). All images were examined by two observers for flattening, erosion, and osteophytes on the condylar head and articular eminence of the TMJ.

Results

For detecting flattening lesions on the mandibular condyle, the sensitivities of PanRad, LatTMJ, and FrnTMJ were less than 67% and the combination of LatTMJ and FrnTMJ (ComTMJ) had the highest sensitivity for both observers (67.6% and 79.7%, respectively). For erosion lesions, the sensitivity of ComTMJ for observer 1 was the highest, at 84.3%, whereas the specificity of ComTMJ was the lowest, at 37.5%. The sensitivities of all four methods for observer 2 were less than 54% and the specificities ranged from 75.0% to 100%. The overall diagnostic accuracy was highest for ComTMJ (64.3%), followed by LatTMJ (59.5%). The intraobserver reliability was good for one observer and excellent for the other, and the interobserver reliability was fair or moderate.

Conclusion

Panoramic TMJ radiography demonstrated limited diagnostic accuracy and acceptable reliability in detecting bony lesions of the TMJ, although it was better than conventional panoramic radiography.

Assessment of Interexaminer Agreement in the Detection of Condyle Morphology and positioning with Two Methods: Radiographic and Tomographic

AIM

This study aims at evaluating the interexaminer agreement between radiographic and tomographic methods to determine condyle morphological variations and positioning.

MATERIALS AND METHODS

The sample comprised 100 individuals aged 13 to 30 years, from the patient files of University of North Paraná. The assessment of condyles morphology and positioning was performed in images of digital panoramic radiography (DPR) and reconstructed panoramic images from the cone beam computed tomography (CBCT) scans, by using the Dolphin three-dimensional (3D) program. The condyle morphology was categorized as flat, convex, and angular as well as its positioning classified into anterior, posterior, and concentric. Three calibrated examiners performed this subjective evaluation. After that, another examiner performed an objective assessment of the condyles positioning using tomographic sagittal scans of the condyles, applying the same 3D program. This objective evaluation of the condyle position, considered the gold standard (GS), was achieved by using a formula based on the measurement values of the joint spaces, anterior and posterior. The kappa test was used to assess the interexaminer agreement in determining the condyles morphology and positioning, as well as between the condyle positioning results determined by the examiners and the GS.

RESULTS

The results showed poor agreement among examiners and between the subjective and objective condyle positioning evaluation.

CONCLUSION

It was concluded that the panoramic radiography (PR), either digitalized or reconstructed from CBCT scans, is not suitable for determining variations in condyle morphology and position.

CLINICAL SIGNIFICANCE

Whenever it is necessary to evaluate the mandibular condyle during the orthodontic screening, the orthodontist should consider another image modality better than the PR.