Art-4
www.stomaeduj.com DENTAL RADIOLOGY
EFFECTS OF CLEFT LIP AND PALATE ON TEMPOROMANDIBULAR
Original Articles
JOINT COMPONENTS: A CBCT STUDY
Ahmad Reza Talaeipour1a , Bita Kiaee2b , Shohreh Ghasemi3c , Alireza Mirzaei1d , Faezeh Amiri2e ,
Ayda Jamilian4f , Alireza Darnahal5g , Abdolreza Jamilian2h*
¹Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Cranio-Maxillofacial Research Center, Tehran Medical Sciences, Islamic Azad University,
Tehran, Iran
²Department of Orthodontics, Faculty of Dentistry, Tehran Medical Science, Islamic Azad University, Tehran, Iran
³Department of Oral and Maxillofacial Surgery, Dental College of Georgia, University of Augusta, GA, United States
⁴Department of Psychology, York University, Toronto, Canada
⁵Division of Periodontology, Harvard School of Dental Medicine, Boston, MA, United States
a
DDS, MSc, Professor; e-mail: ar_talai@yahoo.com; ORCIDiD: https://orcid.org/0000-0001-9219-2975
b
DDS, MSc, Assistant Professor; e-mail: dr.bitakia@gmail.com; ORCIDiD: https://orcid.org/0000-0002-9117-3593
c
DDS, OMFS, Clinical Assistant Professor; e-mail: sghasemi@augusta.edu; ORCIDiD: https://orcid.org/0000-0003-4489-2891
d
DDS, MSc; e-mail: Mirzayi.alireza70@gmail.com; ORCIDiD: https://orcid.org/0000-0002-1569-6130
e
DDS; e-mail: dr.faezehamiri1989@gmail.com; ORCIDiD: https://orcid.org/0000-0002-8390-1052
f
BSc Student (1st year); e-mail: aydajamilian@gmail.com
g
Periodontics Resident; e-mail: alirezadarnahal@gmail.com; ORCIDiD: https://orcid.org/0000-0001-9629-731X
h
DDS, MSc, Professor; email: info@jamilian.net; ORCIDiD: https://orcid.org/0000-0002-8841-0447
ABSTRACT https://doi.org/10.25241/stomaeduj.2022.9(1).art.4
Introduction To assess the effects of cleft lip and palate (CLP) on the temporomandibular joint (TMJ)
components using cone-beam computed tomography (CBCT).
Methodology This historical cohort study evaluated 20 CBCT scans of the TMJ area of patients with unilateral
CLP as the test group and 20 CBCT scans of the TMJ area of non-CLP controls with class I occlusion. The
morphological properties and dimensions of the condyle, the thickness of the glenoid fossa and articular
eminence, and the articular eminence angle were measured and recorded. The two groups were compared
regarding the above-mentioned variables by the Chi-square or t test (alpha=0.05).
Results The left and right axial condylar angles in CLP patients were significantly lower than the corresponding
values in the control group by 1.8 degrees in the left and 2 degrees in the right side (p=0.005). The mediolateral
condylar dimension at both sides was significantly lower in CLP patients than in the controls (p=0.001). The
differences between the two groups were not significant in the anteroposterior condylar dimension, glenoid
fossa thickness, and articular eminence thickness (p>0.05). The CLP patients had significantly lower articular
eminence angle in the right side (p=0.016) but not in the left side (p>0.05), compared with the controls.
Conclusion Unilateral CLP patients have lower axial condylar angle and mediolateral condylar dimension at
both sides, and lower articular eminence angle in the right side than the controls.
KEYWORDS
Dental Radiology; Cone-Beam Computed Tomography; Orofacial Cleft; Temporomandibular Joint.
1. INTRODUCTION has advantages over 2D images, including providing
The temporomandibular joint (TMJ) is a complex joint 1 : 1 orthogonal representations of structures. CBCT
located between the mandible and the temporal bone images can be used in the area of other 2D images,
[1]. The loads applied to this joint affect both of the such as panoramic radiographic projection and lateral
involved skeletal components, and can cause some cephalogram, with the software capable of creating
alterations in their shape and thickness. In case of these images from the 3D data. Caution should be
application of excessive forces, such alterations may exercised to minimize radiation doses to patients.
exceed the normal range of variations (remodeling) Studies have shown great variability in the amount of
and necessitate elimination of the etiology [2]. radiation exposure between different CBCT machines
Cone beam computed tomography (CBCT) has gained and the control of the field of view and intensity can
popularity in recent years for imaging the craniofacial help to minimize these levels. In addition, in cases with
complex. CBCT delivers a significantly lower dose of impacted teeth, CBCT images can provide a number of
radiation compared to conventional CT methods and advantages over periapical and occlusal films for the
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Talaeipour AR, Kiaee B, Ghasemi S, Mirzaei A, Amiri F, Jamilian A, Darnahal A, Jamilian A. Effects of cleft lip and palate on temporomandibular
joint components: a CBCT study Stoma Edu J. 2022;9(1):38-44.
Received: February 23, 2022; Revised: March 17, 2022; Accepted: March 30, 2022; Published: March 31, 2022.
*Corresponding author: Prof. Abdolreza Jamilian, DDS, MSc, Department of Orthodontics, Faculty of Dentistry, Tehran Medical Science, Islamic Azad
University, Tehran, Iran. Tel.: +982122011892; Fax: 7346457077; e-mail: info@jamilian.net
Copyright: © 2022 the Editorial Council for the Stomatology Edu Journal.
38 Stoma Edu J. 2022;9(1): 38-44 pISSN 2360-2406; eISSN 2502-0285
Talaeipour AR, et al.
www.stomaeduj.com
localization of these teeth, since they provide images diagnosis of unilateral CLP and 20 non-CLP controls.
Original Articles
free of distortion and overlapping structures [3]. The CBCT scans had been taken for purposes not
Approximately 60% to 70% of the populations related to this study such as evaluation of impacted
worldwide show signs and symptoms of teeth, or orthodontic treatment in both the test and
temporomandibular disorders; however, only control groups.
one-fourth of them are aware of these signs and The sample size was calculated to be 20 CBCT scans
symptoms [4]. Temporomandibular disorders are in each group according to previous studies [11-14].
often characterized by pain at the TMJ, pain or The inclusion criteria for the CLP patients were aged
tenderness of the muscles of mastication, mandibular between 15 to 22 years, and surgical closure of the
movement limitation, mandibular deviation, and lip and hard tissue before the age of 3.5 years. The
clicking of the TMJ. exclusion criteria were history of previous orthodontic
The pathognomonic signs and symptoms include treatment, orthognathic surgery, trauma, systemic and
pain or tenderness of the TMJ and periauricular syndromic conditions, and history of degenerative
areas, mouth opening limitation, and TMJ sounds in
joint disease.
function. The patients feel pain in an area anterior to
The patients were selected by targeted sampling such
the ear. Alternatively, they may complain of recurrent
that the medical records of patients with definite
pain in the temporal region, neck, or shoulders [4].
diagnosis of CLP who already had CBCT of the head
Orofacial clefts including cleft lip, cleft palate, or cleft
lip and palate (CLP) are the most common congenital and neck region were retrieved from the archives of the
anomalies of the head and neck region, which often School of Dentistry of of Azad and several private oral
involve the lips, hard palate, soft palate, and alveolar and maxillofacial radiology clinics until the required
bone[5]. CLP patients have numerous problems sample size was reached. Also, medical records of non-
such as dental anomalies, malocclusions, facial and CLP patients with class I occlusion who already had
nasal deformities, and nutritional, respiratory, auditory, CBCT scans of the head and neck region and matched
and speech problems [6]. Several congenital and the test group in terms of age and sex were selected
environmental factors are involved in the occurrence as the control group. The study was approved by the
of CLP, such that it is considered a multifactorial Ethics committee of School of Dentistry (Number
disorder [7]. 577226984). The CBCT scans had been taken in an
Since the dentomaxillofacial tissues in CLP patients upright position with maximum intercuspation by
have a different growth pattern than that of normal NewTom CBCT scanner with a maximum voltage of
individuals, anterior and posterior crossbite are 110 kVp, 17 s scanning time, and 8 x 12, 12 x 15, or
common in such patients [8]. Evidence shows that 15 x 15 cm fields of view. Image reconstruction was
the presence of crossbite, especially posterior performed by NNT Viewer 2.21 software.
unilateral crossbite, is correlated with the asymmetric All images were evaluated by an oral and maxillofacial
function of the facial muscles in involved patients radiologist in a mildly lit room. The observer was
[9,10]. Also, considering the dental changes related allowed to observe the images in all orthogonal
to CLP and also occlusal changes and malocclusions planes (axial, sagittal and coronal). Also, the examiner
in such patients, alterations of the condyles are also was free to adjust the brightness, or zoom the images.
expected since condyles are among the most sensitive After observation of the images, the radiologist
areas to occlusal changes [11]. recorded the morphological characteristics of the
A number of studies have addressed the effects of CLP condyles, condylar dimensions, glenoid fossa and
on the condylar position and dimensions, relationship articular eminence thickness, and the articular
of the condyle and the glenoid fossa, and mandibular eminence angle. The measurements were made
ramus height. For example, Ucar et al. [12] evaluated
using NNT Viewer 2.21 software. For this purpose,
the condylar position and temporomandibular fossa in
the images were reoriented in the software such
CLP patients and found a significant difference in the
that the horizontal reference plane was the Frankfurt
condylar angle between the patients and the controls.
plane (passing through the right and left porion
Kurt et al. [13] assessed the mandibular asymmetry
in CLP patients and found no significant difference and orbitale) and the sagittal reference plane was
between the patient and control groups in this respect. perpendicular to the horizontal plane and passed
Considering the existing controversy in the available from the basion, mid-orbital, and nasion. The coronal
literature on this topic, and limited number of studies plane was perpendicular to the previous two planes,
focusing on the changes in skeletal components of and passed through the nasion. After standardization
the TMJ in CLP patients, this study aimed to assess the of images in terms of orientation, axial sections with
effect of CLP on skeletal components of the TMJ using 0.5 mm slice thickness were reconstructed. In the
cone-beam computed tomography (CBCT). largest mediolateral dimension of the condyle on
the axial section at both sides, the mediolateral and
2. METHODOLOGY the anteroposterior dimensions of the condyles and
the axial condylar angle relative to the sagittal axis
This historical cohort study was conducted on the (the line passing through the basion, mid-orbital, and
available CBCT scans of 20 patients with definite nasion) were all measured [12,15](Fig. 1).
Stoma Edu J. 2022;9(1): 38-44 pISSN 2360-2406; eISSN 2502-0285 39
Temporomandibular joint components: a CBCT study
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Original Articles
Figure 4. Reference regions for skin color measurement from portrait
photographs.
The articular eminence measurements were made
using the following points and lines:
Ce: The point at which line F intersects with the
posterior surface of the eminence.
Cu: Peak of the condyle
Po: Porion (the highest point of the external ear)
R: The highest point of the fossa
T: The lowest point of the articular eminence
Using the above-mentioned points, the following lines
were drawn:
Ebf line: The best fit of the articular eminence angle
by passing through the Ce
F line: The Frankfurt plane
F1 line: A line parallel to the F line passing through
the Cu point
F2 line: A line parallel to the F line passing through
the R point
The articular eminence angle was calculated by
measuring the angle formed between the Ebf and F
lines [17] (Fig. 4).
The articular eminence height (Eh) was measured by
measuring the vertical distance between the highest
point of the fossa (R) and lowest point of the articular
eminence (T) [17] (Fig. 4).
Figure 1. Reference regions for skin color measurement from portrait
photographs.
To obtain coronal and sagittal views of the condyles,
lateral sections perpendicular to the longitudinal axis
of the condyle were made with 1 mm slice thickness,
and coronal sections were made parallel to the
longitudinal axis of the condyle with 1 mm thickness.
The condylar morphology in the coronal view was
categorized into four shapes of convex, round, flat, and
angulated. This view was prepared from the widest
mediolateral section of the condyle in the axial view
[16] (Fig. 2).
Figure 4. Reference regions for skin color measurement from portrait
photographs.
The thickness of the glenoid fossa was measured at
the thinnest part in the sagittal plane [16] (Fig. 4).
The above-mentioned variables were measured in
the right and left sides for CLP patients and controls.
Figure 1. Reference regions for skin color measurement from portrait To evaluate intra-observer reliability, 10 CBCT images
photographs. were randomly selected from the two groups and were
re-measured 2 weeks later by the same investigator,
In the sagittal plane, the condylar morphology was and the reliability of the measurements was ensured
categorized as round, flat, worn (between round and by test-retest reliability. Since R was found to be >0.8,
flat), and with osteophytes [17] (Fig. 3). the results were found to be adequately reliable.
40 Stoma Edu J. 2022;9(1):38-44 pISSN 2360-2406; eISSN 2502-0285
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The data were analyzed using SPSS version 25. The
Original Articles
Table 2. Frequency distribution of different morphologies of the condyle
Kolmogorov-Smirnov test was applied to assess the in the coronal view in CLP and non-CLP groups.
normality of data distribution. The two groups were Left Right
compared with the t-test for normally distributed data Morphology
and Mann-Whitney test for the data with non-normal Non-CLP CLP Non-CLP CLP
distribution. The level of significance was set at 0.05. Round 9 5 6 4
Convex 8 14 13 13
3. RESULTS
Flat 2 0 0 1
This study evaluated 40 participants including 20 Angulated 1 1 1 2
unilateral CLP patients and 20 non-CLP controls. There Total 20 20 20 20
were 12 females and 8 males in the CLP group with
a mean age of 17.7±2.8 years, and 9 females and 11 Table 3. Frequency distribution of different morphologies of the condyle
males with a mean age of 18.7±1.9 years in the control in the sagittal view in CLP and non-CLP groups.
group. The two groups were not significantly different Left Right
in terms of age (p=0.215) or gender (p=0.342). Morphology
Table 1 presents the mean mediolateral dimension Non-CLP CLP Non-CLP CLP
of the condyle, anteroposterior dimension of the Round 18 16 17 16
condyle, glenoid fossa thickness, articular eminence Flat 1 2 2 3
thickness, articular eminence angle, and axial condylar With osteophytes 0 1 1 0
angle relative to the sagittal plane in CLP patients and
non-CLP controls. The results showed that the axial AWorn 1 1 0 1
condylar angle in CLP patients was significantly lower Total 20 20 20 20
than that in the non-CLP controls at both the right
(p=0.035) and left (p=0.005) sides. The mediolateral 4. DISCUSSION
dimension of the condyle in the CLP patients was also
significantly lower than that of the non-CLP controls in Maxillofacial clefts are the most common congenital
both the right (p=0.001) and left (p=0.001) sides. The anomalies of the head and neck region, which can
anteroposterior dimension of the condyle was not affect the lips, hard and soft palate, and alveolar bone
significantly different between the two groups in the [18]. CLP patients have many problems such as dental
right (p=0.308) or left (p=0.737) sides. The thickness anomalies, malocclusion, facial and nasal deformities,
of the glenoid fossa was not significantly different and nutritional, respiratory, auditory, and speech
between the two groups, neither in the right (p=0.327) problems [6,19]. This study aimed to assess the effect
nor in the left (p=0.925) side. The articular eminence of CLP on skeletal components of the TMJ using CBCT.
thickness was also approximately the same in the two Different radiographic modalities may be used to
groups in the right (p=0.094) and left (p=0.094) sides. assess mandibular asymmetry. However, accurate
The articular eminence thickness was significantly measurement is not possible by using panoramic
lower in the CLP group than the control group in the radiography due to errors related to the patients’ head
right side (p=0.016) but not in the left side (p=0.63). position and limitations such as magnification [20].
Table 2 presents the frequency distribution of different The accurate evaluation of the TMJ by conventional
morphologies of the condyle in the coronal view radiography is limited by the structure superimposition.
in CLP and non-CLP groups. Table 3 presents the Cone beam computed tomography (CBCT) provides
frequency distribution of different morphologies of high-resolution multiplanar images and delivers
the condyle in the sagittal view in the CLP and non- substantially lower radiation dose, compared with
CLP groups. multi-slice CT. CBCT allows examination of TMJ
Table 1. Mean mediolateral dimension of the condyle, anteroposterior dimension of the condyle, glenoid fossa thickness, articular eminence thickness,
articular eminence angle, and axial condylar angle relative to the sagittal plane in CLP patients and non-CLP controls.
Left Right
Variable
Non-CLP CLP P value Non-CLP CLP P value
Axial condylar angle relative to
28.5 ± 3.1 26.7 ± 2.1 0.005 29.3 ± 2.2 27.3 ± 1.9 0.035
sagittal plane
Mediolateral condylar dimension 18 ± 1.8 15.6 ± 0.99 0.001 18.1 ± 1.6 15.6 ± 1.2 0.001
Anteroposterior condylar dimension 6.9 ± 0.8 6.8 ± 0.94 0.737 6.9 ± 0.8 6.7 ± 0.6 0.308
Glenoid fossa thickness 1.16 ± 0.4 1.2 ± 0.4 0.925 1.17 ± 0.3 1.1 ± 0.4 0.327
Articular eminence thickness 6.7 ± 0.8 6.7 ± 0.8 0.094 6.7 ± 0.7 6.2 ± 0.9 0.094
Articular eminence angle 55.9 ± 3.8 53.2 ± 5.2 0.63 56.2 ± 3.9 52.8± 4.7 0.016
Stoma Edu J. 2022;9(1): 38-44 pISSN 2360-2406; eISSN 2502-0285 41
Temporomandibular joint components: a CBCT study
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Original Articles anatomy without superimposition and distortion
to facilitate the analysis of bone morphology, joint
space and dynamic function in all three dimensions.
left sides in bilateral CLP patients than in the controls.
Ejima et al. [16] evaluated the correlation of glenoid
fossa root thickness, condylar morphology, and the
It is good to know that the goals of TMJ imaging number of residual teeth. The results showed that the
by CBCT are to evaluate the integrity of the bony thickness of glenoid fossa roof was not affected by
structures when disorders are suspected, to confirm the condylar head morphology in the coronal view.
the extent and stage of progression of disorders, and Joints with osteoarthritis had increased thickness of
to evaluate the effects of the treatment [23]. Also, glenoid fossa roof.
posteroanterior cephalometry may yield unreliable In the present study, the articular eminence angle in
results due to the patients’ head rotation [7]. However, the right side was significantly lower in CLP patients
3D radiographic modalities such as CBCT and MRI can than in the controls. In the study by IIguy et al. [17],
overcome limitations such as magnification. CBCT can the maximum articular eminence angle was recorded
provide 3D images with higher resolution at a shorter in 30-39-year-olds. In the present study, the condylar
time and lower patient radiation dose compared with morphology was classified into different shapes
computed tomography [21]. according to Ejima et al. [16] and IIguy et al. [17].
The present results revealed significantly lower axial The most common morphology in the coronal view
condylar angle relative to the sagittal plane in both was the convex morphology in both groups while
the right and left sides in CLP patients compared with the most common morphology in the sagittal view
the non-CLP controls. Ucar et al. [12] reported that the was the round morphology. In the study by Ejima et
axial condylar angle in the right side in CLP patients al. [16] round morphology was the most common
was lower than that in the non-CLP controls, which morphology in the sagittal view (128 out of 154
was in agreement with the present result. Also, Kurt condyles) while the convex morphology was most
et al. [13] assessed mandibular asymmetry in CLP and common in the coronal view (111 out of 154 condyles).
non-CLP patients and reported that the gonial angle This study had a retrospective design and was based
of the mandible in CLP patients was significantly larger on patient records. Thus, some limitations existed with
than that in the non-CLP controls. regard to the role of confounders since we did not
In the present study, the mediolateral condylar have access to patients.
dimension at both sides was significantly smaller Future studies are required to compare bilateral
in CLP patients; however, this difference was not and unilateral CLP patients with non-cleft controls
significant in anteroposterior dimension of the with class III malocclusion since most studies have
condyle. Veli et al. [11] evaluated the mandibular
evaluated healthy controls with class I occlusion.
asymmetry in unilateral CLP patients and non-
CLP controls. They reported that the mediolateral
5. CONCLUSION
dimension of the right condyle in unilateral CLP
patients was smaller than that in the non-CLP controls.
This difference was approximately 0.4 mm in the left Unilateral CLP patients have lower axial condylar angle
side, and not significant, which was almost similar to and mediolateral condylar dimension at both sides
the present result. In the study by Ucar et al, [12] the and lower articular eminence angle in the right side
condylar volume in bilateral CLP patients was lower than controls.
than that in the healthy controls, but not significantly.
Kurt et al. [13] evaluated mandibular asymmetry in AKNOWLEDGEMENTS
vertical dimension in subjects with and without cleft None to declare.
palate. The condylar height in cleft palate patients was
significantly higher than that in non-cleft controls. FUNDING
Paknahad et al. [14] showed higher prevalence of This research did not receive any specific grant from funding
different types of mandibular asymmetries (condylar, agencies in the public, commercial, or not-for-profit sectors.
ramal, and combined condylar and ramal) in unilateral
CLP patients compared with bilateral CLP and control COMPETING INTERESTS
subjects, which was in agreement with the present None to declare.
findings. Veli et al. [11] reported smaller mandibular
body volume in CLP patients than healthy controls, DATA AVAILABILITY
which was in accordance with the present results. The authors confirm that the data supporting the findings of this
Celikoglu et al. [22] found no significant difference study are available within the article or its supplementary materials.
regarding the thickness of glenoid fossa roof and
the articular eminence thickness between CLP AUTHOR CONTRIBUTIONS
patients and healthy controls, which was similar ART: drating the manuscript. BK, SG and FA: data collection.
to the findings of the present study. This topic has AM: statistics. AJ: literature review. AD: manuscript revision and
been rarely addressed in studies on CLP patients. submission. AJ: study concept and design; critical revision of the
However, Ucar et al. [12] reported insignificantly manuscript for important intellectual content; administrative,
lower articular eminence thickness in the right and technical, and material support; study supervision.
42 Stoma Edu J. 2022;9(1):38-44 pISSN 2360-2406; eISSN 2502-0285
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Ahmad Reza TALAEIPOUR
DDS, MSc, Professor
Department of Oral and Maxillofacial Radiology Faculty of Dentistry
Cranio-Maxillofacial Research Center
Tehran Medical Sciences, Islamic Azad University
Tehran, Iran
CV
Dr. Ahmad Reza Talaeipour is the first Oral and Maxillofacial Radiologist in Iran. He has been a faculty member for 32 years at the
Azad Tehran University of Medical Sciences. He is currently chair of the Iranian association of Radiologists, and Vice President of
the Iranian dental association.
Stoma Edu J. 2022;9(1): 38-44 pISSN 2360-2406; eISSN 2502-0285 43
Temporomandibular joint components: a CBCT study
www.stomaeduj.com
Questions
Original Articles
1. Which of the following is not an exclusion criterion for this study?
qa. History of previous orthodontic treatment;
qb. Orthognathic surgery;
qc. Trauma;
qd. Malocclusion.
2. What is the aim of this study?
qa. Assess the effect of CLP on skeletal components of the TMJ;
qb. Assess the effect of CLP on Dental components of the TMJ;
qc. Both;
qd. None.
3. Which of the following is not an inclusion criterion for this study?
qa. CLP patients age between 15 to 22 years;
qb. Surgical closure of the lip and hard tissue before the age of 3.5 years;
qc. CLP patients aged more than 22 years;
qd. None of the above.
4. Which statistical test was used to assess normality of the data in this study?
qa. Kolmogorov-Smirnov test;
qb. T-Test;
qc. Q-square test;
qd. None of the above.
https://www.wfo.org
44 Stoma Edu J. 2022;9(1):38-44 pISSN 2360-2406; eISSN 2502-0285