CBCT evaluation of condylar changes

in children with unilateral posterior

crossbites and a functional shift
Lance Pittman, Thomas S. Shipley, Chris A. Martin, Jun Xiang, and
Peter W. Ngan

Posterior crossbite is one of the most frequently occurring malocclusions in

adolescents with a prevalence of 7% to 23%. The most common form of pos-
terior crossbite is a unilateral posterior crossbite with a functional side shift.
It has been suggested that functional posterior crossbites (FUPXB) may
result in right-to-left-side differences in the condyle fossa relationship, result-
ing in temporomandibular joint (TMJ) problems. The objective of this study
was to determine if pathological position of the condyles can cause condylar
signs or symptoms like degenerative joint disease (DJD) or juvenile condylar
resorption (JCR), or if the position of the condyle is just an altered position
within the TMJ. Sixty patients with an average age of 9.6 years were ran-
domly selected from the office of one of the investigators (T.S.). The study
group consisted of 29 patients with a FUPXB and the control group had 31
patients with no posterior crossbite. All patients had multislice CT scans of
the TMJ taken as part of the orthodontic records. Transverse widths were
measured at the skeletal base and the dentoalveolar base. Molar inclina-
tions, condylar angulations, condylar anterior joint space, superior joint
space, and posterior joint space were measured. Independent sample t-tests
were used to compare different measurements between groups and paired
sample t-tests were used to compare differences within the same patient.
Reliability of measurements were determined using pairwise correlation.
For dentoalveolar measurements of transverse width, the maxillomandibu-
lar difference for the study group was -8.2 mm and for the control group was
-4.0 mm. No significant differences were found between the molar inclina-
tions, condylar width, angulation, or any joint space measurements between
the two groups. A total of 61.3% of the subjects in the control group and
72.4% in the study group had a radiographic sign of joint disease. The lack of
condylar positional differences between the control and crossbite groups
suggests that TMJ signs and symptoms in the study group may be related
to remodeling in the TMJ instead. (Semin Orthod 2019; 25:36–45) © 2019
Published by Elsevier Inc.

Introduction
Martinsburg, West Virginia, United States; Peoria, Arizona,
he unilateral posterior crossbite with a func-
United States; Department of Orthodontics, West Virginia University,
United States; Department of Family Medicine, West Virginia
University, United States.
T tional shift (FUPXB) is one of the most
common early adolescent malocclusions with a
Corresponding author at: West Virginia University Department of prevalence of 7%¡23%.1,2 5 Frequency of uni-
Orthodontics, 1073 Health Science Center North, P.O Box 9480,
Morgantown, WV 26506, United States. E-mail: pngan@hsc.wvu.edu
lateral posterior crossbite (UPXB) occurs in
© 2019 Published by Elsevier Inc.
5.9% to 9.4% of the total population, while
1073-8746/12/1801-$30.00/0 FUPXB is the most common form of posterior
https://doi.org/10.1053/j.sodo.2019.02.005 crossbite occurring in 80% to 97% of all

36 Seminars in Orthodontics, Vol 25, No 1, 2019: pp 36 45

 CBCT evaluation of condylar changes in children
posterior crossbite cases.1,6 9 The prevalence of
FUPXB is 8.4% in the primary dentition and
7.2% in the mixed dentition.4 The etiology of pos-
terior crossbite is unclear but has been related to a
combination of many factors that included dental,
skeletal, soft tissue, respiratory, functional neuro-
muscular, or habitual abnormalities.10 14 Posterior
crossbite can be caused by a deficient maxilla rela-
tive to the mandible, resulting in a convenient shift
of the mandible to one side for better interdigita-
tion. This functional shift may cause a right-to-left-
side differences in the condyle fossa relationship,
resulting in temporomandibular joint (TMJ) prob-
lems.15 18 Much attention has been given recently
to the effects of this functional shift on the
condyles.
In animal studies, altering mandibular posi-
tion with bite planes or occlusal grinding results
in skeletal growth pattern changes at the ramus
and condyle,15 17 change in cartilage thickness,7
and gene expression differences with insulin-like
growth factor-1 (IGF-1) and fibroblast growth
factor-2 (FGF2) and mRNA expression on pro-
truded and non-protruded condylar sides.18 Liu,
found that rats exposed to a 2 mm shift of the
condyle to the left side developed asymmetric
mandibles.19 The length of the condylar head
was greater on the protruded side, and the man-
dible on the protruded side grew in a more ante-
rior superior direction.
Only a few studies have evaluated condylar posi-
tion within the TMJ using CBCT, with varying and
inconclusive results. In 2009, Ikeda and Kawamura
published a study where limited CBCT was used to
find the optimal position of the mandibular con-
dyle within the glenoid fossa.20 In all subjects, the
joints were completely symptom free, and the posi-
tion of the articular disc was verified by MRI analy-
sis. The joint spaces found were found to be
significantly altered. The anterior joint space (AS)
was 1.3 mm, superior joint space (SS) was 2.5 mm,
and the posterior joint space (PS) was 2.1 mm.20
Hesse, performed a tomographic analysis of the
condylar position in patients with a FUPXB in
1997 on patients before and after maxillary expan-
sion.21 The non-crossbite condyle moved posteri-
orly and superiorly from before to after expansion
treatment, and the superior joint space was the
greatest on the non-crossbite side before treat-
ment. Relative condylar position was more ante-
rior on the non-crossbite side before treatment,
but both sides were similar after treatment. In
37
2012, Leonardi performed a low dose CT study
analyzing the crossbite and non-crossbite side con-
dyles pretreatment and post treatment.22 No dif-
ferences in position of the condyles pre-treatment
were found, but significant increases in superior
joint space on the non-crossbite side, and relative
increases in anterior and posterior joint spaces on
the non-crossbite sides occurred post treatment.
In addition, the posterior joint space increased
only on the crossbite side after treatment.
The objective of this study was to determine if
the presence of a unilateral posterior crossbite
with a functional shift results in altered condylar
position within the TM joint. In specific, the con-
dylar width and condylar angle to the midsagittal
plane, positional differences between crossbite
side and non- crossbite side condyles, and condy-
lar osseous changes, such as progressive condylar
resorption (PCR) will be determined in both the
study and the control groups.
Methods and materials
The subjects were randomly selected from the
office of one of the investigators (T.S.). The clini-
cal findings together with CBCT scans were used
to place subjects in either the control or the study
group. The CBCT images were all taken on the
same i-CAT machine3 with a setting of 14.7 acqui-
sition time, 20.27 mA, 120 kVp, a field of view of
17 mm x 23 mm and voxel size of 0.3 mm x
0.3 mm. The inclusion criteria included adoles-
cent patients seeking orthodontic treatment with
a good quality DICOM file image. The study
group had a maxillary transverse deficiency with
posterior crossbite (involving greater than one
tooth) on one side only with the teeth at maxi-
mum intercuspal position as indicated by the clini-
cal exam. Subjects were excluded based on the
presence of artifacts, developmental or acquired
craniofacial deformity with or without mandibu-
lar/condylar involvement, systemic disease, his-
tory of orthodontic treatment, anterior crossbite,
signs or symptoms of TMD according the AAO
medical history/exam, missing teeth (excluding
third molars), carious lesions, extensive resto-
rations, or pathologic periodontal status. The
final sample consisted of 31 subjects in the
control group without a functional crossbite
and 29 in the study group with a crossbite.
The sixty DICOM files were analyzed using the
In Vivo Dental 4.1 imaging software. Each file
38
was oriented according to criteria set forth by
Cho.23 The sagittal plane was derived from a best
fit of the landmarks Nasion, Crista galli, Sella,
and Basion. The axial plane was set parallel to
Frankfort Horizontal, and the axial pane was set
parallel to the frontozygomatic points (FZ). A lat-
eral cephalometric radiograph and posterior
anterior cephalometric radiograph were formed
from oriented CBCT images. Maxillary position
(SNA), mandibular position (SNB), relative posi-
tion of the maxilla to the mandible (ANB), man-
dibular plane (SN-MP and FMA), maxillary
incisor inclination (Upper I to SN), and mandib-
ular incisor inclination (IMPA) were measured
from the lateral cephalometric radiograph, and
the maxillary width (AG-GA) and mandibular
width (JR-JL) were measured from the P-A cepha-
lometric radiograph to calculate the maxilloman-
dibular transverse differential index.24 Within
each CBCT image the maxillomandibular differ-
ence according to Miner25 was completed
(Fig. 1). The axial angle of the maxillary and man-
dibular first molars compared to the functional
occlusal plane and the maxillary and mandibular
mid-alveolar process widths were measured.
Each condyle had a sagittal section deter-
mined by a vertical plane bisecting the long axis.
In the axial section, anterior joint space (AS),
superior joint space (SS), and posterior joint
Figure 1. Image of the dental transverse measurements and the molar inclinations as described by Miner.25
Pittman et al
space (PS) were measured at the bisected sagittal
section and 5 mm medial and lateral to this sec-
tion. The angle of the long axis of the condyle
was measured from the midsagittal plane
(Fig. 2). Each joint measurement was made twice
over a 2-week period for reliability.
Signs of active and reparative progressive con-
dylar resorption and/or degenerative joint dis-
ease were recorded. Defects were classified
according to the following criteria, flattening,
osteophytes, cup shaped defects, cortical surfaces
defined but not corticated, and beaking, but due
to inadequate resolution of some of the images,
an exact identification was not always possible.
Statistical analysis
All statistical tests were performed using SAS
(version 9.3, 2012, SAS institute Inc., Cary, NC).
Independent sample t-tests were used to deter-
mine differences between the control and study
groups for both Vanarsdall and Miner’s trans-
verse analysis, between the crossbite and non-
crossbite side molar inclinations, between the
condyle widths and midsagittal angles, and
between the AS, SS, and PS for the medial pole,
center position, and lateral pole of the condyles
from the crossbite side to the non-crossbite side,
and to the controls. Paired t-tests were done to
 CBCT evaluation of condylar changes in children
Figure 2. View of the imaging planes for joint space analysis.
determine differences between crossbite and
non-crossbite sides within the same patient. All
joint space measurements were measured twice
with a 2-week interval. Pairwise correlation tests
were performed to determine examiner reliabil-
ity. All statistical tests were two-sided and p-val-
ues<0.05 were considered statistically significant.
Results
The experimental design was reviewed and con-
sidered Exempt by the Institutional Review
Board at West Virginia University (protocol num-
ber 1,310,115,425).
The final sample consisted of 60 total subjects;
31 subjects in the control group and 29 in the
study group. The mean age of the control group
was 9.8 § 1.3 yrs and the study sample was
9.4 § 2.0 yrs. (Table 1). A total of 120 temporo-
mandibular joints, including 62 from the control
group and 58 (29 crossbite sides and 29 non-
39
crossbite sides) from the study group were ana-
lyzed. Among the 29 study group subjects, 19 had
crossbite to the left and 10 had crossbite to the
right.
Craniofacial morphology
Table 1 compared the craniofacial morphology
between the two groups. No significant differen-
ces were found except the variable IMPA which
was more proclined in the control group
(p = 0.03). The average ANB was 3.6°with a range
from ¡3.0° to 9.7°, which stated that the sample
consisted of skeletal Class I, II, and III subjects.
The average mandibular plane of the sample
(SN-MP) was 33.9° with a range of 25.5° to 43.2°
Transverse measurements
Table 2 shows the transverse differential index
for the control and study groups. No significant
40 Pittman et al

Table 1. Mean differences in age and craniofacial morphology between the control and the study group
Overall N = 60 Control (n = 31) Study (n = 29) p-value
Age (yr) 9.6 § 1.7 9.8 § 1.3 9.4 § 2.0 0.43
Craniofacial morphology (deg)
SNA 82.2 § 3.7 82.0 § 3.8 82.4 § 3.7 0.72
SNB 78.6 § 3.7 78.3 § 3.7 79.0 § 3.8 0.50
ANB 3.6 § 2.5 3.7 § 1.9 3.4 § 3.0 0.66
SN-MP 33.9 § 4.4 33.4 § 4.0 34.4 § 4.78 0.37
FMA 24.6 § 3.8 24.1 § 3.6 25.3 § 4.0 0.24
Upper 1-SN 107.7 § 8.2 107.6 § 9.3 107.8 § 6.9 0.95
IMPA 92.6 § 7.2 94.5 § 6.8 90.5 § 7.1 0.03*

*p-value>.05.

differences were found between the two groups.
The maxillo-mandibular differences were also
measured at the mid-alveolar level.25 The man-
dibular widths were significantly wider on the
study group compared to the control group
(33.0 mm vs. 31.0 mm, p = 0.002). The maxillary
widths were significantly narrower for the study
group than the control group (24.8 mm vs.
27.0 mm, p = 0.0003). The study group had larger
maxillo-mandibular difference than the control
group (¡8.2 mm vs. ¡4.0 mm, p = 0.0001). The
maxillary width was narrower than the mandibu-
lar width for both groups.
Table 4 shows the results of comparison
between the molar inclinations of the right
molars to the left molars on the control group.
There was no difference in inclination when
comparing the right molar inclination to the left
for both the maxillary and the mandibular
molars. We also compare the molar inclination
for the crossbite side molars to the non-crossbite
molars for the study group (Table 5). The results
indicates that the mandibular molar inclination
on the crossbite side was significantly more lin-
gually inclined (107.1° vs. 104.1°, p = 0.002).

Condyle size and orientation

Molar angle to the functional occlusal plane Table 3 shows the condylar width and condylar
angle with reference to the midsagittal plane for
Table 3 shows the first molar axial inclination for the control and study groups. No significant dif-
both the control and study groups. For both max- ferences were found between the condyle width
illary and mandibular molars, no significant dif- and condyle angle to the midsagittal plane when
ferences were found when comparing right and
left molar inclination from the control group to
Table 3. Mean differences in molar angle to the func-
the same molar on the study group.
tional occlusal plane between the control and the
study group
Control Study P-Value
Table 2. Mean differences in transverse measure- (n = 31) (n = 29)
ments between the control and the study group
Upper and lower right and left first molar axial inclination to
Control Study p-Value the functional occlusal plane (deg)
(n = 31) (n = 29) d R 6 Axial inclination 105.1 § 4.5 107.1 § 6.2 0.15
Md L 6 Axial 105.4 § 5.3 104.1 § 6.1 0.37
Transverse Differential Index inclination
GA-AG (mm) 74.7 § 3.9 75.4 § 3.7 0.49 Mx R 6 Axial 80.1 § 5.0 78.8 § 4.4 0.29
JR-JL (mm) 57.9 § 2.9 57.0 § 2.5 0.21 inclination
Exp Mx Md Diff (mm) 14.7 § 0.8 14.8 § 1.1 0.88 Mx L 6 Axial 80.1 § 6.1 80.3 § 4.7 0.86
Act. Mx Md Diff (mm) 16.9 § 3.7 18.4 § 3.3 0.09 inclination
Transverse Diff Index ¡2.1 § 3.9 ¡3.6 § 3.3 0.11 Condylar width and Condylar angle with reference to the mid-
Miner’s Transverse Analysis sagittal plane
Md Width (mm) 31.0 § 2.5 33.0 § 2.3 0.002** R Condylar width, mm 16.5 § 1.6 16.5 § 1.8 0.99
Mx Width (mm) 27.0 § 1.8 24.8 § 2.5 0.0003*** L Condylar width, mm 16.5 § 1.4 16.4 § 1.7 0.75
Mx-Md Diff (mm) ¡4.0 § 2.7 ¡8.2 § 3.0 0.0001*** R Mid Sag 68.3 § 7.8 68.9 § 4.4 0.74
angulation (deg)
*p<.05. L Mid Sag 68.4 § 8.4 68.8 § 5.0 0.78
**p<.01. angulation (deg)
***p<.001.
 CBCT evaluation of condylar changes in children 41

Table 4. Comparison for the control group within the differences comparing the left side condyles
same patient (n = 31) from the control group to the non-crossbite side
Right Left P-Value condyle form the study group.
The comparison in condylar width and mid-
Upper and lower right and left first molar axial inclination to
the functional occlusal plane (deg) sagittal angles between the right and left sides
Md 6 Axial 105.1 § 4.5 105.4 § 5.3 0.60 for the control group and between the crossbite
inclination side and non-crossbite side for the study group
Mx 6 Axial 80.1 § 5.0 80.1 § 6.1 0.88
inclination are also shown on Tables 4 and 5, respectively.
Condylar width and Condylar angle with reference to the For both groups, the condylar width and condy-
midsagittal plane lar angle to the midsagittal line seem to be simi-
Condyle width (mm) 16.5 § 1.6 16.5 § 1.4 0.99
Mid Sag Angle (°) 68.3 § 7.8 68.4 § 8.4 0.99 lar in patients with or without a unilateral
Condyle joint spaces posterior crossbite.
Med AS, mm 1.8 § 0.5 1.83 § 0.7 0.74
Med SS, mm 2.7 § 0.7 2.6 § 0.7 0.61
Med PS L 2.7 § 0.9 2.6 § 0.9 0.43
Med PS, mm
Ctr AS, mm 1.7 § 0.4 1.6 § 0.5 0.54 Condyle position within glenoid fossa
Ctr SS, mm 2.5 § 0.7 2.5 § 0.8 0.82
Ctr PS, mm 2.1 § 0.8 2.1 § 0.7 0.97 All joint space measurements were measured
Lat AS, mm 1.7 § 0.8 2.0 § 0.5 0.02* twice with a two-week interval (Table 6). The two
Lat SS, mm 2.5 § 0.8 2.6 § 0.7 0.39
Lat PS, mm 2.7 § 1.1 2.5 § 0.9 0.27
lowest values of the correlation coefficients were
for the right condyles center AS at 0.96 and the
AS = anterior joint space, SS = superior joint space, and left condyle’s lateral PS at 0.97. The rest had val-
PS = posterior joint space. Med = medial pole, Ctr = central
pole, and Lat = lateral pole. ued of 0.98 or 0.99. This indicates high consis-
*p-value <.05. tency of the measurements.
When evaluating the joint space at the medial,
comparing the right condyles from the control central, and lateral pole of the condyle, Table 6
group to the crossbite side condyle from the shows no significant differences in joint space
study group, and there was no significant when comparing the right side of the control
group to the non-crossbite side joint space of the
Table 5. Comparison for the study group within the
study group. On the medial pole of the condyle,
same patient (n = 29)
AS was slightly smaller for the non-crossbite side,
Right Left P-Value and the PS was slightly larger for the non-cross-
Upper and lower right and left first molar axial inclination bite side. This is consistent with the non-crossbite
to the functional occlusal plane (deg) condyle being in a forward and medial position
Md 6 Axial 107.1 § 6.2 104.1 § 6.1 0.002**
Mx 6 Axial 78.8 § 4.4 80.3 § 4.7 0.14
Condylar width and Condylar angle with reference to the Table 6. Reliability Coefficients of all joint space
midsagittal plane measurements
Condyle 16.5 § 1.8 16.40 § 1.7 0.07
Width (mm) Joint space measurement Reliability Coefficient
Mid Sag 68.9 § 4.3 68.8 § 5.0 0.93
Angle (°) RM AS 0.98
Crossbite Non-crossbite RM SS 0.98
Condyle joint spaces RM PS 0.99
Med AS, mm 1.6 § 0.6 1.7 § 0.6 0.40 RC AS 0.96
Med SS, mm 2.5 § 0.7 2.4 § 0.9 0.82 RC SS 0.98
Med PS, mm 2.8 § 0.9 2.6 § 0.7 0.06 RC PS 0.99
Ctr AS, mm 1.5 § 0.4 1.5 § 0.6 0.48 RL AS 0.98
Ctr SS, mm 2.5 § 0.8 2.4 § 0.8 0.67 RL SS 0.99
Ctr PS, mm 2.3 § 0.2 2.1 § 0.7 0.23 RL PS 0.99
Lat AS, mm 1.7 § 0.5 1.7 § 0.7 0.90 LM AS 0.98
Lat SS, mm 2.6 § 0.9 2.3 § 0.8 0.04* LM SS 0.99
Lat PS, mm 3.1 § 1.5 2.6 § 1.1 0.60 LM PS 0.99
LC AS 0.98
AS = anterior joint space, SS = superior joint space, and LC SS 0.98
PS = posterior joint space. Med = medial pole, Ctr = central LC PC 0.98
pole, and Lat = lateral pole. LL AS 0.98
*p-value <.05. LL SS 0.98
**p-value <.01. LL PS 0.97
42 Pittman et al

within the glenoid fossa as a patient has a func- 19 of 31 (61.3%) subjects had a radiographic
tional shift towards maximum intercuspation. sign of joint disease present. Among the 19, two
There were no significant differences between had a sign on the right side only, 4 on the left
the any of the crossbite side condylar joint spaces only, and 13 had a sign bilaterally. For the study
when compare to the left side of the control group, 21 of the 29 (72.4%) subjects had a radio-
(Table 7). graphic sign of joint disease present. 9 of the 21
Table 4 also shows the comparison in the joint had a sign on the crossbite side, 6 on the non-
spaces between the right and the left sides for crossbite side only, and 6 had a sign bilaterally.
the control groups. There was a significant differ-
ence between the AS of the lateral pole, with the
Discussion
right side being smaller than the left (1.7 mm vs.
2.0 mm, p = 0.02). When evaluating the medial The anatomical position of TMJ within the fossa
and lateral pole of the condyle, the joint spaces is difficult to evaluate with traditional radiogra-
were very similar. phy. Tsiklakis et al. showed that CBCT images
Table 5 compared the crossbite and non-cross- are of high diagnostic quality for morphologic
bite side condylar spaces to each other for the assessment of the bony structures of the TMJ and
study group, and the only significant difference are recommended to be the technique of choice
was between the SS of the lateral pole. The cross- when investigating boney changes of the TMJ.26
bite side SS was smaller than the non-crossbite Every joint was measured twice in this study to
side (2.3 mm vs. 2.6 mm, p = 0.04). determine the reliability with these measure-
A qualitative analysis of the condyles that had ments using CBCT images. The pairwise correla-
a radiographic sign of joint disease was tabulated. tion test showed there was a high reliability for
The signs included flattening on anterior, supe- all the measurements. This coincides with a pre-
rior, or posterior parts of the medial, central, vious study by Honda et al. showing high accu-
and/lateral poles, beaking, cortical irregularities, racy in measurements.27 The largest downside to
osteophytes, and cupping. For the control group, CT imaging of the TMJ is that it cannot image
the soft tissue structures, particularly the articu-
lar disc.
Table 7. Mean differences in measurements of joint This study focused on subjects in the mixed to
spaces between the control and the study groups early permanent dentition and determined if
Right/non-crossbitea Control (n = 31) study (n = 29) P- Value there were differences in maxillomandibular
width in patients with a unilateral posterior cross-
Med AS, mm 1.8 § 0.5 1.6 § 0.6 0.21
Med SS, mm 2.7 § 0.7 2.5 § 0.7 0.32 bite and a functional shift. In specific, this study
Med PS, mm 2.7 § 0.9 2.8 § 0.9 0.73 investigated if the presence of a unilateral poste-
Ctr AS, mm 1.7 § 0.4 1.5 § 0.4 0.18 rior crossbite with a functional shift alone could
Ctr SS, mm 2.5 § 0.7 2.5 § 0.8 0.99
Ctr PS, mm 2.1 § 0.8 2.3 § 0.2 0.35 alter the position of the condyles within the gle-
Lat AS, mm 1.7 § 0.8 1.7 § 0.5 0.99 noid fossa leading to signs and symptoms of TMJ.
Lat SS, mm 2.5 § 0.8 2.6 § 0.9 0.59 It was advantageous for this study that the skele-
Lat PS, mm 2.7 § 1.1 3.1 § 1.5 0.20
Left/crossbiteb tal patterns and age were consistent between the
Med AS, mm 1.8 § 0.7 1.7 § 0.6 0.39 two groups because It has been documented that
Med SS, mm 2.6 § 0.7 2.4 § 0.9 0.47 skeletal pattern can affect the position of the
Med PS, mm 2.6 § 0.9 2.6 § 0.7 0.90
Ctr AS, mm 1.6 § 0.5 1.47 § 0.6 0.30 condyles within the glenoid fossa.28,29
Ctr SS, mm 2.5 § 0.8 2.4 § 0.8 0.63 In 1996, Brin evaluated the transverse dimen-
Ctr PS, mm 2.1 § 0.7 2.1 § 0.7 0.92 sion in patients in the mixed dentition with a uni-
Lat AS, mm 2.0 § 0.5 1.7 § 0.7 0.08
Lat SS, mm 2.6 § 0.7 2.3 § 0.8 0.10 lateral posterior crossbite with a functional shift
Lat PS, mm 2.5 § 0.9 2.6 § 1.1 0.70 using the Transverse Differential Index.30 The
authors found the maxillary width for the cross-
AS = anterior joint space, SS = superior joint space, and
PS = posterior joint space. Med = medial pole, Ctr = central bite group was reduced at 52 mm, which was
pole, and Lat = lateral pole. reduced more than the 57 mm reported in the
a
Measurement of joint spaces for the right side of the control present study. The mandibular width was 76 mm
group compared to the non-crossbite of the study group.
b
Measurement of joint spaces for the left side of the control compared to our results of 75 mm. Within this
group compared to the crossbite of the study group. study, there was no significance between the TDI
 CBCT evaluation of condylar changes in children
of the control or study groups, but the study
group had a slightly higher maxillomandibular
difference. Evaluating the maxillomandibular
difference by measurements at the mid alveolar
width showed a large difference between our
control and study groups. Our control maxillo-
mandibular difference was ¡4.0 mm compared
to our study maxillomandibular difference,
which was ¡8.0 mm. Greater maxillomandibular
differences can be expected in the presence of a
posterior crossbite compared to dentitions with-
out a posterior crossbite.25
Dental compensation, in the form of buccal
tipping of the maxillary molars, is often observed
in patients with a unilateral posterior crossbite
with a functional shift. In the control groups, the
maxillary right and left molars were inclined
80.1° and 80.1° respectively. This was more buc-
cally inclined than the 98.0° and 98.3° published
by Miner.25 For the control group, the mandibu-
lar molars in the present study were inclined
105.1° and 105.4° compared to the 103.9° and
104.4° published by Miner.25 For the study group
our maxillary molars were inclined 78.8° for the
non-crossbite side and 80.3° for the crossbite
side, compared to 101.5 on the non-crossbite
side and 97.0° on the crossbite side reported by
Miner.25 For the study group our mandibular
molars were inclined 107.1° on the non-crossbite
side and 104.1° on the crossbite side, compared
to 105.9° non-crossbite side and 99.81° crossbite
side as published.25
The differences in angulation of the condyles
between the groups were not statistically signifi-
cant. The control group was angulated 68.3° for
the right side and 68.4° for the left to the midsag-
ittal plane, and the study group was angulated
68.8° for the non-crossbite and 68.9° for the
crossbite side. The right and left condylar widths
in the current study were both measured at
16.5mmand 16.5 mm, respectively for the control
group and the widths for the study group were
16.5 mm for the crossbite side and 16.4 mm for
the non-crossbite side. Two studies published by
Vitral in 2002 and 2004 measured the condylar
angle and width.31,32 Condylar angle to the mid-
sagittal plane was found to be 64.73° and 65.77°,
which is slightly more angulated than what was
found in the current study. Condylar widths were
17.83 mm and 17.68 mm, which was slightly
larger than in our group, but they studied an
43
older population ranging from 12.8 - 42.0 years-
old with a Class II div 2 morphology.
This study attempted to evaluate the relation-
ship of the medial, central, and lateral sections
of the condyles to the glenoid fossa. We only
found differences in joint space on the SS when
measured on the lateral pole, but Ikeda showed
landmark identification became more difficult in
the lateral areas of the condyle so the reliability
of these findings is uncertain.20 Small differences
in mean values were observed for the AS for both
crossbite and non-crossbite sides, for the SS of
the crossbite side, and the PS of the non-crossbite
side. The As for both sides was slightly reduced
compared to the control groups. The SS for the
crossbite side was slightly reduced compared to
the control side and it hints at a small tendency
for the condyle to be more superior in the gle-
noid fossa. The PS for the non crossbite side was
slightly increased compared to the control sides
and it also hints at a small tendency for the con-
dyle to be more anteriorly positioned on the
non-crossbite side.
Ikeda used limited view CBCT and found that
the AS was 1.3 mm, SS was 2.5 mm, and the PS
was 2.1 mm.20 When those values were compared
to those of Kinniburgh, they were found to be
smaller, but Ikeda believe that their values indi-
cated a smaller range for optimally healthy joints,
even though Kinniburgh used MRI analysis to
determine healthy from pathologic joints. Kinni-
burgh did not use as rigorous a method to classify
the healthy or optimal joints.20,33 Kinniburgh
used MRI and tomograms to evaluate the con-
dyles in normal patients and those with anteri-
orly displaced discs, and they found that the
anterior joint space was 1.92 mm, the superior
joint space was 3.62 mm, and the posterior joint
space was 2.95 mm.33 Major, in 2002, used MRI
and tomograms to study joint position and they
found that osseous adaptations occur within the
TMJ if internal derangements are present and
that disc displacement is associated with a
reduced joint space.34 Katsavrias and Halazone-
tis, in 2005, using axially corrected tomograms
found that class III subjects had a more elon-
gated and anteriorly inclined condylar head and
a wider and more shallow fossa. In the Class III
group, the condyle was closer to the roof of the
fossa.35 The Class II Division 1 and Division 2, dif-
fered only in the position of the condyle. The
44 Pittman et al
condyle of the Class II div 2 was situated more
anteriorly in the fossa.
In 2012, Leonardi performed a low dose CT
study analyzing the crossbite and non-crossbite
side condyles pretreatment and post treatment.22
There were no differences in position of the con-
dyles pre-treatment, but they measured signifi-
cant increases in superior joint space post-
treatment on the non-crossbite side, and relative
increases in anterior and posterior joint spaces
on the non-crossbite sides. The posterior joint
space increased only on the crossbite side post
treatment. Lam used horizontally corrected
tomograms and found large standard deviations
resulting in the inability to detect any significant
differences within or between groups.36
From studies more recently published, it has
been found that positional differences between
crossbite and non-crossbite side condyles is not
present pre-treatment in patients with a unilat-
eral posterior crossbite with a functional shift. A
strong theory behind the symmetry found in
joint spaces on crossbite and non-crossbite sides
recorded before treatment could be explained
by compensatory condyle fossa remodeling and/
or variation in thickness of the articular TMJ disc
as described by Hesse and Wang.21 Wang sug-
gested that the TMJ disc has the ability to adapt
to any alteration caused by occlusal changes
occurring in the space between the condyle and
fossa.37 Myers also concluded there is the poten-
tial for adaptive growth changes to occur if the
mandibular shifting occurred resulting from
malocclusion.38
The present study reported a wide range of
signs of progressive condylar resorption includ-
ing erosions, sclerosing, flattening, cupping and
osteophytes on both sides of the control and
crossbite subjects. Yamada, in 2004, studied sub-
jects with and without TMD signs and/or symp-
toms who were about to undergo orthognathic
surgery.39 Their results suggested that eminence
flattening might occur as a result of TMJ changes
from erosion to osteophyte formation and from
anterior disc displacement with reduction to
anterior disc displacement without reduction.
The clinical examination alone is not adequate
for evaluating TMJ status, but provides for a base-
line from where further analysis can initiate. Hav-
ing a wide range of skeletal morphologies and age
groups could have added unaccounted variables
potentially affecting the results. The positioning
of the subjects within the CBCT machine can
affect the condylar position if not performed by a
single operator. Positioning in the current study
was based on Frankfort’s horizontal, as reported
in the study by Leonardi,22 while Ikeda20 paral-
leled the transverse plane from superior points of
the external auditory meatus and the glenoid
fossa.
Conclusion
The lack of condylar positional differences
between the control and crossbite groups sug-
gests that TMJ signs and symptoms in the study
group may be related to remodeling in the TMJ
instead.
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