Volume 8 • Issue 1 • 1000305

Case Report Open Access

OMICS Journal of RadiologyOMI

CS Jo

urnal of Radiology

ISSN: 2167-7964

Derwich, OMICS J Radiol 2019, 8:1DOI: 10.4172/2167-7964.1000305

OMICS J Radiol, an open access journalISSN: 2167-7964

*Corresponding author: Derwich Marcin, Doctor of Dental Surgery, Certified Specialist of Orthodontics, ORTODENT Derwich Lekarze Dentysci Sp.P., Mieszka I 7b Street, 86-300 Grudziadz, Poland, Tel: +48660723164; E-mail: derwichm@tlen.pl

Received January 22, 2019; Accepted February 07, 2019; Published February 14, 2019

Citation: Derwich M (2019) Severe Temporomandibular Joint Osteoarthritis: A Case Report. OMICS J Radiol 8: 305. doi: 10.4172/2167-7964.1000305

Copyright: © 2019 Derwich M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

AbstractBackground: Temporomandibular joint disorders are part of musculoskeletal pathologies. Clinical signs and

symptoms of temporomandibular joint disorders most commonly mentioned are: clicking, crepitation, joint pain, muscle pain, mouth-opening limitation. Cone beam computed tomography has become very efficient method of viewing bony changes in TMJ.

Case Report: A 50-year-old woman was referred for the specialist orthodontic consultation. The patient was diagnosed with skeletal open bite, skeletal class I with tendency to class II due to clockwise rotation of the mandible, maxillary constriction, crossbite on maxillary right second molar, dentoalveolar discrepancy, teeth malposition, missing teeth: 16, 36, 37, 47, teeth attrition and temporomandibular joint dysfunction. Cone beam computed tomography revealed signs of severe osteoarthritis of both TMJs.

Discussion and Conclusion: Osteoarthritis is an age-related, chronic and progressive degenerative joint disease. It occurs more often in women. It is considered to be an inflammatory disease. Typical radiological signs of osteoarthritis are: osteophyte, subcortical sclerosis, subcortical cyst, surface erosion, articular surface flattening and generalized sclerosis. Thorough examination of TMJ function and morphology is necessary at the beginning of any orthodontic and dental treatment. Undiagnosed TMJ dysfunction may cause further problems with entire masticatory system, including joints, muscles and teeth.

Severe Temporomandibular Joint Osteoarthritis: A Case ReportDerwich M*Doctor of Dental Surgery, Certified Specialist of Orthodontics, ORTODENT Derwich Lekarze Dentysci Sp.P., Grudziadz, Poland

Keywords: Osteoarthritis; Temporomandibular joint; Temporoman-dibular joint disorder; Skeletal open bite

IntroductionTemporomandibular joint (TMJ) disorders are part of

musculoskeletal pathologies [1]. Problems of temporomandibular joint dysfunction unfortunately often remain undiagnosed among both orthodontists and general dentists.

Temporomandibular joint dysfunction’s diagnosis is based on both clinical and radiological examination. Cone beam computed tomography (CBCT) has become very efficient method of viewing bony changes in TMJ. Comparing to conventional computed tomography, CBCT has two major advantages, which are: lower cost of examination and lower dose of radiation [1,2].

Any symptoms of TMJ dysfunction should be thoroughly examined. Clinical signs and symptoms of temporomandibular joint disorders most commonly mentioned are: clicking, crepitation, joint pain, muscle pain, mouth-opening limitation [1-3].

Case ReportA 50-year-old woman was referred to the orthodontic office for

a specialist consultation. Her chief complains were: anterior open bite and crowding in the lower arch. She had never undergone any orthodontic treatment.

According to the general medical history questionnaire, patient suffered form: heart arrhythmia, gastroesophageal reflux disease and was allergic to nickel. Patient also complained about her musculoskeletal system. She had occasionally suffered from severe fingers’ joints pain that was not clearly diagnosed by the rheumatologist; in addition, her rheumatoid factor level was normal. As a child, she had undergone purulent tonsillitis several times.

Standard orthodontic diagnosis was performed. It included: extraoral and intraoral examination, analysis of extraoral and intraoral photographs (Figures 1a-1e), analysis of study models (Figures 2a-2e)

and finally analysis of orthopantomogram (Figure 3) and lateral X-ray (Figure 4).

The patient presented mandibular deviation to the left while opening, mandibular deviation to the right while closing, maximum mandibular opening: 37 mm, maximum mandibular movement to the right: 3.5 mm, maximum mandibular movement to the left: 4.5 mm, maximum mandibular advancement: 7 mm. Clinical examination of TMJ revealed severe crepitation in left TMJ and mild pain in the area of: lateral collateral ligament in right TMJ and anterior inferior synovial region in left TMJ according to Rocabado map of pain.

The patient was finally diagnosed with severe skeletal open bite (FMA=45°, ML/NL=40°), skeletal class I with tendency to class II due to clockwise rotation of the mandible, maxillary constriction, crossbite on maxillary right second molar, dentoalveolar discrepancy, teeth malposition, missing teeth: 16, 36, 37, 47, teeth attrition and temporomandibular joint dysfunction. Suspicion of obstructive sleep apnea syndrome due to reduction of airways volume in lateral X-ray and clinical symptoms such as snoring and permanent sleepiness.

Because of severe teeth attrition and symptoms of temporomandibular joint disorder, extended orthodontic diagnosis and cone beam CT of TMJs were indicated. Plaster casts were mounted in articulator (Panadent PCH) with a face bow and very precise bite

Citation: Derwich M (2019) Severe Temporomandibular Joint Osteoarthritis: A Case Report. OMICS J Radiol 8: 305. doi: 10.4172/2167-7964.1000305

Page 2 of 5

OMICS J Radiol, an open access journalISSN: 2167-7964 Volume 8 • Issue 1 • 1000305

(b)(a)

(c) (d)

(e)

Figure 1: Intraoral photographs, presenting anterior open bite, crossbite on maxillary right second molar, dentoalveolar discrepancy, teeth malposition, missing teeth: 16, 36, 37, 47 and teeth attrition; (a) Frontal View, (b) Right side view, (c) Left side view, (d) Upper arch view, (e) Lower arch view.

(a) (b)

(c) (d)

(e)

Figure 2: Study models, presenting anterior open bite, crossbite on maxillary right second molar, dentoalveolar discrepancy, teeth malposition, missing teeth: 16, 36, 37, 47 and teeth attrition; (a) Frontal View, (b) Right side view, (c) Left side view, (d) Upper arch view, (e) Lower arch view.

Figure 3: Orthopantomogram, presenting asymmetry between right and left condyle, tooth 46 after root canal treatment and missing teeth: 16, 36, 37, 47.

Figure 4: Lateral X-ray, presenting increased vertical dimension (FMA=45°, ML/NL=40°) and skeletal class I with tendency to class II due to clockwise rotation of the mandible.

registration (Almore wax). A bite record was the bite du jour. Due to the fact that the patient was very easy to manipulate, arc of closure was effortlessly registered. Therefore, it can be assumed that bite du jour was very close to the patient’s centric relation (CR).

There was a discrepancy between patient’s bite du jour, that was close to centric relation (CR) and centric occlusion (CO) (Figures 5a-5f). First occlusal contact appeared between palatal cusp of upper right third molar and distal part of masticatory surface of lower right third molar. According to Condylar Position Indicator (CPI) in the right TMJ: CO position was shifted 1.2 mm backwards and 2.2 mm downwards form CR position and in the left TMJ: CO position was shifted 1.2 mm backwards and 2.3 mm downwards form CR position. There was also 0.5 mm mandibular shift to the right while moving form CR to CO position.

Cone beam CT of TMJs was taken in the position of maximum intercuspidation and it revealed severe osteoarthritis in both TMJs with severe radiolucency in right TMJ suggesting presence of active disease.

The dimension of right condyle’s head was: 16.8 mm (transverse dimension) by 6.1 mm (A-P dimension) (Figure 6), the depth of right condylar fossa was 8.3 mm (Figure 7) and the width of right TMJ

Citation: Derwich M (2019) Severe Temporomandibular Joint Osteoarthritis: A Case Report. OMICS J Radiol 8: 305. doi: 10.4172/2167-7964.1000305

Page 3 of 5

OMICS J Radiol, an open access journalISSN: 2167-7964 Volume 8 • Issue 1 • 1000305

(a) (b)

(c) (d)

(e) (fmm)

Figure 5: Plaster casts mounted in articulator (Panadent PCH), presenting first occlusal contact between palatal cusp of upper right third molar and distal part of masticatory surface of lower right third molar; (a) Frontal View from left side, (b) Frontal View from right side, (c) Right side view,(d) Left side view, (e) Upper arch view, (f) Lower arch view

Figure 6: The transverse and anterio-posterior dimension of the right condyle-axial view.

Figure 7: The depth of right condylar fossa - sagittal view.

articular space measured at the top of right condyle was 2.1 mm (Figures 8a and 8b). Condyle osteophyte was present in the anterior area of right condyle (Figure 9). Furthermore, right condyle’s cortical bone was both disintegrated and the density of its cortex was decreased. Severe round-shaped radiolucency area in the medial part of right condyle (Figures 10a-10c) was present. The dimension of the radiolucency area was: 4.3 mm (A-P) x 4.2 mm (horizontal) x 3.3 mm (vertical).

The dimension of left condyle’s head was: 15.0 mm (transverse

(a)

(a)

(b)

Figure 8: The width of right TMJ articular space; (a) Sagittal view, presenting severely decreased width of anterior part of articular space, (b) Coronal view, presenting central position of right condyle in fossa.

Figure 9: Condyle osteophyte in anterior part of right condyle-sagittal view.

Citation: Derwich M (2019) Severe Temporomandibular Joint Osteoarthritis: A Case Report. OMICS J Radiol 8: 305. doi: 10.4172/2167-7964.1000305

Page 4 of 5

OMICS J Radiol, an open access journalISSN: 2167-7964 Volume 8 • Issue 1 • 1000305

(a)

(a)

(b)

(b)

(c)

Figure 10: Round-shaped radiolucency in right condyle, presenting severe destruction of right condyle; (a) Axial View, (b) Coronal View (c) Sagittal view.

dimension) by 5.7 mm (A-P dimension) (Figure 11), the depth of left condylar fossa was 5.6 mm (Figure 12) and the width of left TMJ articular space measured at the top of left condyle was decreased and measured 0.9 mm (Figures 13a and 13b). Both the articular tubercle and anterior-superior surface of left condyle were severely flattened (Figures 14a and 14b). Condyle osteophyte was present in the anterior area of left condyle (Figure 15). Left condyle’s cortical bone was also disintegrated and the density of its cortex was decreased.

DiscussionAccording to the American Academy of Oral and Maxillofacial

Radiology (AAOMR) [4], there are four guidelines that are suggested for the use of CBCT in orthodontics. These are: image appropriately according to clinical condition, assess the radiation dose risk, minimize patient radiation exposure and maintain professional competency in performing and interpreting CBCT studies. The safe use of CBCT in dentistry is supported by AAOMR [4].

One of the most common temporomandibular joint diseases is osteoarthritis [3]. Osteoarthritis is an age-related, chronic and progressive degenerative joint disease which is characterized by gradual deterioration of joint’s cartilage [1-3]. Osteoarthritis occurs more frequently in women than in men [1-3]. According to the recent research [5,6], osteoarthritis is considered to be an inflammatory disease. Ahmad et al. [7] described radiological criteria for osteoarthritis. These were: osteophyte, subcortical sclerosis, subcortical cyst, surface erosion, articular surface flattening and generalized sclerosis. Despite the fact that these descriptions were made for CT scans, their value is equal for CBCT images [2,3,8,9]. Most of the previously mentioned features appeared on CBCT scans belonging to described patient.

Osteoarthritis may simultaneously be characterized by appearance of both bone proliferation and bone erosion. Erosive osteoarthritis is a type of disease when destruction processes appear with little or no bone proliferation [8,10]. It may be very hard to distinguish erosive osteoarthritis form rheumatoid arthritis or another inflammatory arthritis [8,10].

Rheumatoid arthritis is the most frequent rheumatic disease and is characterized by areas of erosions without bone proliferation [8]. Areas of bone destruction may be extensive. In cases of prolonged disease, typical symptoms (cortical erosions) not only may be accompanied by osteoarthritic signs (flattening, sclerosis and osteophyte) but they also become less pronounced [8]. It is impossible to differentiate primary osteoarthritis from inflammatory arthritis with secondary osteoarthritis

Figure 11: The transverse and anterio-posterior dimension of left condyle – axial view.

Figure 12: The depth of left condylar fossa-sagittal view.

(a) (b)

Figure 13: The width of left TMJ articular space; (a) Sagittal view, presenting severe decrease in width of anterior and central part of articular fossa, (b) Coronal view, presenting severe decrease in width of lateral and central part of articular fossa.

Figure 14: Flattening of left articular tubercle and left condyle; (a)Flattening of left articular tubercle-sagittal view, (b) Flattening of anterior-superior part of left condyle and erosion in posterior part of left condyle-sagittal view.

(a) (b)

Citation: Derwich M (2019) Severe Temporomandibular Joint Osteoarthritis: A Case Report. OMICS J Radiol 8: 305. doi: 10.4172/2167-7964.1000305

Page 5 of 5

OMICS J Radiol, an open access journalISSN: 2167-7964 Volume 8 • Issue 1 • 1000305

with CBCT images [8].

Treatment of TMJ osteoarthritis often requires complex approach. Multidisciplinary treatment includes cooperation of gnathologist, orthodontist, physiotherapist and quite often also maxillofacial surgeon and prosthodontist. Sometimes additional pharmacotherapy is indicated. Suggested treatment protocol for the described patient is splint therapy, orthodontics and bimaxillary maxillofacial surgery (impaction of the maxilla with counterclockwise rotation of the mandible) with additional prosthodontic restorations. Always the first step is rheumatological consultation. If any type of rheumatological diseases is diagnosed, it ought to be treated prior to the onset of interdisciplinary orthodontics and maxillofacial surgery treatment.

ConclusionMany patients who are referred for either orthodontic or dental

treatment present symptoms of temporomandibular joint disorders. Some patients may be clinically asymptomatic and at the same time have radiological signs of TMJ destruction. TMJ disorders may contribute to certain types of malocclusions, one of which is skeletal open bite due to severe clockwise rotation of mandible. CBCT plays a significant role in

extended diagnosis of TMJ osseous changes. It is important to examine thoroughly TMJ function and morphology at the beginning of both orthodontic and dental treatment. Undiagnosed TMJ dysfunction may lead to further unexpected problems with entire masticatory system, including joints, muscles and teeth.

References

1. Ajos PML, Freire JSL, Barbosa JMN, Frazao MAG, Anjos PA, et al. (2012) Evaluation of bone changes in the temporomandibular joint using cone beam CT. Dentomaxillofac Radiol 41: 24-29.

2. Comert KS, Kilic N, Sumbullu MA (2015) Temporomandibular joint osteoarthritis: cone beam computed tomography findings, clinical features, and correlations. Int J Oral Maxillofac Surg 44: 1268-1274.

3. Su N, Liu Y, Yang X, Luo Z, Shi Z (2014) Correlation between bony changes measured with cone beam computed tomography and clinical dysfunction index in patients with temporomandibular joint osteoarthritis. J Craniomaxillofac Surg 42: 1402-1407.

4. American Academy of Oral and Maxillofacial Radiology (2013) Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol 116: 238-257.

5. Berenbaum F (2013) Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!). Osteoarthritis Cartilage 21: 16-21.

6. Wenham CY, Conaghan PG (2013) New horizons in osteoarthritis. Age Ageing 42: 272-278.

7. Ahmad M, Hollender L, Anderson Q, Kartha K, Ohrbach R, et al. (2009) Research diagnostic criteria for temporo- mandibular disorders (RDC/TMD): development of image analysis criteria and examiner reliability for image analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107: 844-860.

8. Larheim TA, Abrahamsson AK, Kristensen M, Arvidsson LZ (2015) Temporomandibular joint diagnostics using CBCT. Dentomaxillofac Radiol 44: 20140235.

9. Barghan S, Tetradis S, Mallya SM (2012) Application of cone beam computed tomography for assessment of the temporomandibular joints. Aust Dent J 57: 109-118.

10. Boeddinghaus R, Whyte A (2013) Computed tomography of the temporomandibular joint. J Med Imaging Radiat Oncol 57: 448-454.

Figure 15: Condyle osteophyte in anterior part of left condyle-sagittal view.