ORIGINAL ARTICLE

Lateral cephalometric characteristics of malocclusion patients with temporomandibular joint disorder symptoms
Chung-Ju Hwang,a Sang-Jin Sung,b and Suk-Joo Kimc Seoul, South Korea Introduction: There is much controversy about the relationship between temporomandibular joint (TMJ) disorders and the skeletal structures of the lower face. It is not clear whether the disharmony of the facial skeletal structure is caused by the TMJ disorder or vice versa. The aim of this study was to determine the relationship between craniofacial skeletal structures and TMJ disorders by using lateral cephalogram measurements to examine the characteristics of the facial prole of patients with TMJ disorders. Methods: Of 111 patients over 18 years of age from the Department of Orthodontics, Dental Hospital, Yonsei University, those showing symptoms of TMJ disorders were chosen as the experimental group (56 patients), and patients without TMJ disorders were chosen as the control group (55 patients). A lateral cephalogram of each subject was taken and traced to conrm the signicance of the craniofacial measurements between the experimental group and the control group of Class I (mean ANB angle, 2.89), Class II (mean ANB angle, 6.32), Class III (mean ANB angle, 2.02) patients, who were grouped according to ANB-angle difference. Results: Each experimental subject with a TMJ disorder had a hyperdivergent facial prole, more lingual tilting of the maxillary incisors, and a steeper inclined occlusal plane. Conclusions: There was a signicant correlation between the structure of the lower face and the temporomandibular disorder. (Am J Orthod Dentofacial Orthop 2006;129:497-503)

temporomandibular disorder is an orofacial disorder that causes many clinical problems in the temporomandibular joint (TMJ), the masticatory muscles, the dental occlusion, and the neuromuscular system. The main symptoms of TMJ disorder are mandibular joint and masticatory muscle pain, a TMJ sound, headache, and pain in adjacent muscles.1-3 These symptoms can appear alone or simultaneously as the disorder progresses.4 Temporomandibular disorders are divided into joint and muscle disorders. Internal derangements comprise 80% of TMJ disorders.5 The causes of TMJ disorder are complex. There have been many studies on the structural factors of the joint.6-10 But many studies mainly used computerized tomography (CT) or magnetic resonance imaging (MRI). CT and MRI
a

Professor, Department of Orthodontics, College of Dentistry, Yonsei University, Seoul, South Korea. b Assistant professor, Department of Orthodontics, Asan Medical Center, Seoul, South Korea. c Resident, Department of Orthodontics, College of Dentistry, Yonsei University, Seoul, Korea. Supported by the Korean Foundation for Gnatho-Orthodontic Research in 2003. Reprint requests to: Chung-Ju Hwang, Department of Orthodontics, College of Dentistry, Yonsei University, Seoul, South Korea; e-mail, [email protected]. ac.kr. Submitted, June 2004; revised and accepted, December 2004. 0889-5406/$32.00 Copyright 2006 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2004.12.019

can be used to observe the shape of the TMJ and the joint disc. MRI shows the mutual relationship between the joint and the disc inside the joint space. However, it is more important to observe the TMJ disorder and the craniofacial relationship of orthodontic patients from general x-ray images because it is difcult to perform both CT and MRI on orthodontic patients, whereas panoramic x-rays and lateral cephalograms are routinely taken. A lateral cephalogram is commonly used because it shows the craniofacial structures. These studies reported that the lengths of the mandible and the maxilla of the TMJ disorder patient were shorter than those of normal patients,6 and vertical ramus height and length of the mandible were strongly related to TMJ disorders.7,8 Several reports also showed that the steep maxillary incisor angle is strongly related to temporomandibular disorders.9,10 However, some authors reported no signicant relationship between the vertical skeletal pattern and the structure of the mandible and maxilla, and only the SNB angle showed a relationship. Nickerson and Moystad11 and Stringert and Worms12 examined the relationship between craniofacial skeletal structures and TMJ disorders. There has been much debate about the relationship between a TMJ disorder and the lower face skeletal structures.
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Understanding the facial characteristics of TMJ disorder patients might be a key to explaining these relationships. There has been much research about Class II patients and temporomandibular disorders, but few reports on the lateral cephalometric characteristics of Class III patients with temporomandibular disorders. Therefore, this study was performed by comparing Class I, Class II, and Class III patients. This grouping was made according to their ANB-angle differences, which showed a subjective anteroposterior skeletal relationship. The purpose of this study was to investigate the relationship between lower facial skeletal structure and TMJ disorder. We compared the locations and the structural relationships of the craniofacial bones and the occlusal plane relationship of patients from 3 malocclusion groups with temporomandibular disorders and compared them with patients without temporomandibular disorders according to their lateral cephalograms.
SUBJECTS AND METHODS

Fig 1. Positive responses to clinical tests by subjects in experimental group.

Ages of subjects (years)

A total of 111 patients (50 men, 61 women) over 18 years of age with no systemic disease, skeletal asymmetry, or loss of posterior support due to missing posterior teeth were chosen as the subjects from the Department of Orthodontics, Dental Hospital, Yonsei University. Clinical tests were performed to investigate TMJ disorder symptoms. Joint sound was investigated by palpating each TMJ with both index ngers during opening and closing movements of the jaw. Joint pain during the opening and closing movements was examined; pain in the joint area was examined by palpating both joints with both index ngers. The ability of the jaw to open at least 40 mm was examined. In addition, functional movement exceeding the edge-to-edge range during the lateral and anterior movement range was examined. After examining the TMJs, we divided the patients into experimental (n 56) and control (n 55) groups, based on a positive response to at least 1 clinical test. Figure 1 shows the distribution of symptoms in the 56 TMJ-disorder patients. Any patient showing unilateral TMJ symptoms was excluded. All patients in the experimental group had at least a 1-year history (average, 4.78 years) of the disorder; patients in the control group had no history of the disorder. Table I shows the ages of the patients in both groups. The experimental and control groups were subdivided into Class I, Class II, and Class III according to their ANB angles (Table II).

Lateral cephalometric images were taken on a 26 36-cm computed radiography (Fuji, Tokyo, Japan) cassette at a 5-foot distance, 10mA and 70Kvp, by using a Cranex3 (Soredex, Helsinki, Finland) at the Department of Oral and Maxillofacial Radiology, Dental Hospital, Yonsei University. An image of each lateral cephalogram was drawn on acetate paper, and landmarks and reference lines were marked. The measuring points and lines are shown in Figure 2. Fourteen measuring categories (9 angular, 5 linear) related to horizontal and vertical skeletal relationship, tooth locations, and mandibular movement according to the measured points and lines were established. Each measured point was input by using a Graphite Digitizer KD 4030B software (Summagraphics, Scottsdale, Ariz). In addition, the measured categories were established by using the Yonsei Cephalometric Analysis Program (Dencom, Seoul, Korea) according to the measured records; the established measured categories are shown in Figure 3. The measured records were statistically processed with version 8.2 statistics package (SAS, Cary, NC). The averages and standard deviations of the Class I experimental and control patients grouped according to anteroposterior skeletal relationship were calculated. Two-sample t tests were performed on each measured

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Table II.

Distribution of malocclusions
Class I Control Experiment 8 12 Control 8 13 Class II Experiment 9 9 Control 8 9 Class III Experiment 8 10

Men Women

9 8

Fig 2. A, Cephalometric landmarks: N (nasion), junction of frontal nasal suture at most posterior point on curve at bridge of nose; S (sella), midpoint of sella turcica; A (subspinale), point of greatest concavity on anterior border of maxilla; B (supramentale), point of greatest concavity on anterior border of mandible; Go (gonion), meeting point of posterior border of ramus and mandibular plane; Co (condylion), highest point of mandibular condyle; Gn (gnathion), meeting point of line passing facial line and mandibular plane of S between Pog and Me; Pog (pogonion), most anterior point on contour of symphysis; Me (menton), lowest point of mandibular midsagital suture; U1 (upper incisal tip), incisal edge of maxillary central incisor; L1 (lower incisal tip), incisal edge of mandibular central incisor; U1R (upper incisal root apex), root apex of maxillary central incisor; L1R (lower incisal root apex), root apex of mandibular central incisor; U6 (upper molar mesiobuccal cusp tip), mesiobuccal cusp tip of maxillary rst molar. B, Reference planes and lines: SN P, line connecting S and Na; Occlusal P, line drawn between midpoints of rst permanent molars and incisors; Mandibular P, line connecting lowest point of ramus and Me; N-A L, line connecting Na and Point A; N-B L, line connecting Na and Point B; N-Pog L, line connecting Na and Pog; U1 L, line connecting U1 and U1R; L1 L, line connecting L1 and L1R.

category to examine the signicance of the differences between the 2 groups. In addition, the differences between the experimental and control group according to sex were examined. The same statistical process was done for the Class II and Class III groups.
RESULTS

The means and standard deviations of each measured category were calculated, and signicant differences

between the experimental and control groups were examined by t test. The results are shown in Table III. The skeletal Class I experimental group showed high mandibular plane to sella-nasion plane (Mn to SN) (P .01) and gonial angle (P .01) values, and the differences were statistically signicant. In addition, the skeletal Class I experimental group showed low incisal edge of maxillary dentral incosor to sella-nasion plane (U1 to SN) (P .01) and ramus height (P .001)

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Fig 3. Angular and linear measurements. 1, SNA angle; 2, SNB angle; 3, ANB difference; 4, mandibular plane to SN plane; 5, occlusal plane to mandibular plane; 6, occlusal plane to SN plane angle; 7, IMPA; 8, U1 line to SN plane angle; 9, gonial angle; 10, mandibular ramus height (Go-Ar); 11, mandibular body length (Go-Me); 12, anterior cranial base; 13, effective mandibular length (Co-Gn); 14, effective maxillary length (Co-Point A); 15, anterior cranial base/mandibular body length (S-N/Go-Me).

values (Table III). In the comparison of the experimental and control groups according to sex, signicant differences were shown in the same measured categories when compared with differences between the whole experimental group and the control group of Class I patients (Mn to SN, gonial angle, U1 to SN, ramus height), and there was a more denite difference in the gonial angle (P .01) and U1 to SN (P .01) values among the men. The skeletal Class II experimental group showed signicantly high gonial angle (P .05) and U1 to SN (P .01) values, and low ramus heights (P .01), and effective mandibular length (P .01) values (Table III). In the comparison of the experimental and control groups according to sex, signicant differences were shown in same measured categories when compared with differences between the whole experimental group and the control group of the Class II patients (gonial angle, U1 to SN, ramus height, effective mandibular length), and there were greater differences in the U1 to SN (P .001) and effective mandibular length (P .01) values among the women. The skeletal Class III experimental group showed signicantly high occlusal plane to sella-nasion plane angle (Occ to SN) (P .01), anterior cranial base/

mandibular length (Ant cra base/Mn length) (P .01), occlusal plane to mandibular plane (Occ to Mn) (P .05), ramus height (P .01), mandibular body length (P .05) values, and signicantly low effective mandibular length (P .05) values (Table III). In the comparison of the experimental and control groups according to sex, a signicant difference was observed in the same measured categories when compared with differences between the whole experimental group and the control group of the Class III patients (Occ to Mn, Ant cra base/Mn length, Occ to Mn, ramus height, mandibular body length, effective mandibular length), and there were larger differences in maxillary body length and Ant cra base/Mn length among the men.
DISCUSSION

There have been many studies about how TMJ disorders affect craniofacial structures, including some that examined the asymmetry of the mandible.13,14 If a patient has an internal derangement because of dislocation of the TMJ disc, underdevelopment of the mandibular condyle at the affected side might result in facial asymmetry.15,16 This was observed in rabbit experiments when their condylar discs were intentionally dislocated.14,17

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Table III.

Measurements in samples
Class I Control Experiment Mean SD P value Control Mean SD Class II Experiment Mean SD P value Control Mean SD Class III Experiment Mean SD P value

Measurement

Mean SD

SNA () 81.71 2.58 82.50 3.15 SNB angle () 79.00 2.80 79.46 3.42 ANB angle () 2.71 0.95 3.04 0.75 Mn to SN () 33.38 7.11 36.66 5.33 Occ to Mn () 16.96 4.18 18.94 4.26 Occ to SN () 16.42 5.07 17.72 4.25 Gonial angle () 117.52 9.52 124.28 5.71 U1 to SN () 109.47 9.04 99.31 5.84 IMPA () 94.34 6.52 91.77 6.21 Ramus height (mm) 55.76 5.97 44.80 6.68 Mandibular body length (mm) 80.89 6.00 78.76 4.89 Effective mandibular length (mm) 126.41 5.89 125.02 6.99 Effective maxillary length (mm) 90.76 4.17 89.48 5.34 Ant cra base/Mn length (%) 90.65 4.50 89.84 4.19 *P .05; P .01; P .001.

83.19 3.96 82.24 3.01 77.12 4.61 75.62 3.17 6.07 1.04 6.62 1.19 39.81 7.00 40.13 6.53 20.61 6.86 22.14 6.18 19.20 4.01 17.99 5.02 120.01 6.86 124.28 5.71 107.70 5.95 98.64 6.36 96.97 7.55 96.92 7.78 51.69 5.11 47.18 4.21 76.75 5.30 75.13 4.89

81.48 4.36 80.56 3.59 83.15 4.92 82.92 4.43 1.66 3.89 2.36 2.77 35.18 9.35 35.33 7.33 19.71 5.95 17.10 4.48 15.47 4.71 18.23 5.93 124.11 8.32 124.17 6.86 112.10 6.11 111.47 6.63 83.55 7.30 83.04 9.02 55.78 6.25 50.80 5.46 86.09 5.19 83.04 3.73

* *

123.57 6.00 118.82 4.38 90.30 3.84 92.65 5.20 88.67 6.00 93.84 2.92

134.88 9.88 130.88 9.99 89.49 2.03 85.49 4.23 87.49 5.73 88.30 3.56

There are reports on craniofacial structures with lateral cephalograms by Brand et al,18 Nebbe et al,8,19-21 Nickerson and Moystad,11 and Stringert and Worms.12 Thus far, many studies have focused on the TMJ relationships of Class II patients. This study was based on earlier reports and was designed to determine the structural problems related to a TMJ disorder of the craniofacial area by investigating the relationships between craniofacial structures, measured records of mandibular structures, and TMJ disorders observed from lateral cephalograms of patients without skeletal asymmetries. According to the results from each group, no measurement showed signicant sex differences. In all groups, among both sexes, the TMJ-disorder patients had short mandibular rami than the control-group patients. Di Paolo et al22 reported a close relationship between posterior facial height and a TMJ disorder, and Nebbe et al8 and Gidarakou et al13 reported that TMJ-disorder patients had short mandibular rami. It was reported that the dislocation of the mandibular joint disc produces an environment that inhibits the growth of the mandible.14,17 Therefore, the patients in the TMJ-disorder group with shorter mandibular rami and mandibles had a relationship between the dislocation of the mandibular condyle disc and the growth of the lower facial prole. The Mn to SN and gonial angle measurements in the Class I experimental patients, and the gonial angle

in the Class II experimental patients showed statistically signicant and larger values than the controls. This means that these experimental groups were more hyperdivergent. Signicant differences were not observed in the effective mandibular length of the Class I groups, but it was seen in the Class II and Class III groups. The effective mandibular length of the experimental group was shorter. In addition, in the Class III patients, the experimental group showed a signicantly shorter mandibular length and a signicantly longer Ant cra base/Mn length. The shorter mandibular length in the experimental group patients agrees with the results of Nebbe et al.20 In addition to the skeletal factors discussed above, the maxillary-tooth axis, which is closely related to the mandibular joint movement pathway during protrusion of the mandible, was inclined more lingually in the Class I and Class II experimental groups. This means that the dental factor is also closely related to TMJ disorders. This agrees with the results of Stringert and Worms12 in that a chronic posterior dislocation of the mandibular condyle can be induced in Class II Division 2 patients with little overjet and severe overbite. However, signicant differences in the angles between the occlusal and SN planes (P .01), and between the occlusal and mandibular planes (P .05), were observed in the Class III patients. In the experimental group, the occlusal plane was more inclined from the SN plane, and less inclined

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from the mandibular plane than the control group. This result indicates that the occlusal plane in relation to the vertical plane was more inclined in the TMJ-disorder patients. Along with the inclination of the anterior area, the inclination of the occlusal plane is a structural factor that can affect the movement of the mandibular condyle during protrusive movements. This means that condylar and anterior guidances act as anterior-guidance factors during protrusive movements in Class I and Class II patients. However, disocclusion of the posterior teeth as a result of anterior guidance during the protrusive movement of the mandible does not occur because of cross-bite occlusions in Class III patients. Instead, the cusp inclination of the molars and the occlusal plane affect the protrusive movement of the mandibular condyle. Therefore, the more inclined occlusal plane shows the same effect as the more lingually inclined maxillary incisors. Brand et al18 reported that the lengths of the maxilla and the mandible of TMJ-disorder patients were shorter than those in the normal group, but no difference was found in this study. In contrast to earlier studies with lateral cephalograms, the difference between the experimental and control groups among the Class I, Class II, and Class III groups, grouped according to the anteroposterior skeletal relationship, was examined to observe the structural characteristics of the craniofacial area more specically and accurately. Although lateral cephalometric images are dimensional, they can show facial structural problems that are related to TMJ disorders. An analysis of the craniofacial structure with lateral cephalogram images showed their further use in orthodontic diagnosis and treatment planning for TMJ-disorder patients. In this study, patients with bilateral TMJ disorders were examined. Further studies on patients with unilateral TMJ disorders and asymmetries, and patients during the growth period, are needed to determine whether facial structures affect the induction of TMJ disorders. In addition, examining the craniofacial-structure characteristics of TMJ-disorder patients with 3-dimensional diagnostic tools will be important in the future.
CONCLUSIONS

.05) value of the Class II patients showed significant differences. The maxillary anterior teeth of the Class II patients were inclined more lingually (Class I, U1 to SN [P .01]; Class II, U1 to SN [P .01]). 3. The experimental groups of Class II (P .01) and Class III (P .01) patients showed shorter effective mandibular lengths than the control group, but there was no signicant difference in the Class I patients. 4. In the Class III patients, Ant cra base/Mn length were signicantly high (P .01), and the occlusal plane was more inclined (Occ to SN [P .01], Occ to Mn [P .05]). The TMJ-order group showed characteristics of hyperdivergent facial proles and lingually inclined maxillary anterior teeth, along with severely inclined occlusal planes. A TMJ disorder has a close relationship with lower facial structure, which must be considered during treatment planning and treatment.

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1. Class I, Class II, and Class III subjects with at least 1 bilateral TMJ-disorder symptom had shorter mandibular rami compared with the control group of Class I (P .001), Class II (P .01), and Class III (P .01) subjects. 2. Mn to SN (P .01) and gonial angle (P .01) values of the Class I patients, and gonial angle (P

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18. Brand JW, Nielson KJ, Tallents RH, Nanda RS, Currier GF, Owen WL. Lateral cephalometric analysis of skeletal patterns in patients with and without internal derangement of the temporomandibular joint. Am J Orthod Dentofacial Orthop 1995;107:121-8. 19. Nebbe B, Major PW. Prevalence of TMJ disk displacement in a pre-orthodontic adolescent sample. Angle Orthod 2000;70:454-63. 20. Nebbe B, Major PW, Prasad NG. Female adolescent facial pattern associated with TMJ disk displacement and reduction in disk length. Part I. Am J Orthod Dentofacial Orthop 1999;116:168-76. 21. Nebbe B, Major PW, Prasad NG. Male adolescent facial pattern associated with TMJ disk displacement and reduction in disk length. Part II. Am J Orthod Dentofacial Orthop 1999;116:301-7. 22. Di Paolo C, Panti F, Migliau G. Posterior vertical dimension and condylo-discal non-coordination of temporomandibular joint. Hypothesis on correlation. Minerva Stomatol 2000;49:527-34.

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