Oral Maxillofac Surg (2014) 18:397401
DOI 10.1007/s10006-013-0424-3
ORIGINAL ARTICLE
Factors related to the incidence of anterior disc
displacement without reduction and bony
changes of the temporomandibular joint in patients
with anterior open bite
Kazuhiro Ooi & Shinya Yura & Nobuo Inoue &
Yasunori Totsuka
Received: 17 February 2013 / Accepted: 26 June 2013 / Published online: 9 July 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose We aimed to investigate factors related to the
prevalence of anterior disc displacement without reduction
(ADDwoR) and bony changes of the condylar head (bony
changes) in the temporomandibular joints (TMJs) of patients
with anterior open bite.
Methods Subjects are comprised of 36 preoperative patients
(72 joints) with skeletal anterior open bite without facial
asymmetry who had undergone orthognathic surgery at the
Hokkaido University Hospital; magnetic resonance imaging
of the TMJ and cephalometric analysis were performed before
treatment. Logistic regression analysis was performed to
clarify relationships among age, overbite, overjet, ANB angle,
sella to nasion (SN) to mandibular plane angle (SNMP
angle), SN to ramus plane angle (GZN angle), gonial angle,
and incidence of ADDwoR or bony changes in patients with
anterior open bite.
K. Ooi (*) : Y. Totsuka
Department of Oral and Maxillofacial Surgery, Division of Oral
Pathobiological Science, Graduate School of Dental Medicine,
Hokkaido University, Kita 13 Nishi 7, Kita-ku,
Sapporo 060-8586, Japan
e-mail: ooi@den.hokudai.ac.jp
S. Yura
Department of Oral and Maxillofacial Surgery, Tonami General
Hospital, Tonami, Toyama 939-1395, Japan
N. Inoue
Department of Gerodontology, Division of Oral Health Science,
Graduate School of Dental Medicine, Hokkaido University,
Kita-ku, Sapporo 060-8586, Japan
Results Fifteen patients had bilateral ADDwoR, and five
patients had unilateral ADDwoR; 17 patients had bilateral
bony changes, and five patients had unilateral bony changes.
SNMP angle was greater in 20 patients with ADDwoR than
that in 16 patients without ADDwoR (p<0.05). GZN angle
was greater in the 20 patients showing bony changes than that
in the 16 patients without bony changes (p<0.05).
Conclusion In terms of dentofacial morphology, SNMP
angle appears to be associated with the incidence of
ADDwoR, and GZN angle appears to be associated with
bony changes in the TMJ.
Keywords Anterior open bite . Anterior disc displacement
without reduction . Bony changes of temporomandibular joint
Several studies have assessed the associations between the
radiographic depiction of osseous temporomandibular joint
(TMJ) components and dentofacial morphology in adoles-
cents [1, 2], associations between clinical signs and
symptoms of temporomandibular disease and malocclusion
[37], morphological features of the condyles as related to
malocclusion [8], and associations between facial skeletal
patterns and magnetic resonance imaging of the TMJ [811].
Anterior open bite is known to be associated with internal
derangement of the TMJ [12]. Condylar degenerative
changes with TMJ disorders may also lead to deformities
resulting in decreased vertical dimension in the proximal
mandibular segments [13, 14]. The reported incidence of
TMJ symptoms in patients with deformities of the jaw is
high, but the relationship between position of the TMJ disc
398 Oral Maxillofac Surg (2014) 18:397401

and types of skeletal abnormalities is not sufficiently known

[15, 16]. To evaluate the relationship between TMJ disorders
and deformity of the jaw, results of magnetic resonance
imaging (MRI) of the TMJ need to be compared between
patients with these deformities and volunteers with no such 1N
S 2
deformities. We have already reported that the incidence of 4
anterior disc displacement without reduction and bony 5

changes is higher among patients with anterior open bite

3
than that in the TMJ of patients without dentoalveolar Ar

deformities [17]. In previous studies, however, relationships A

between anterior disc displacement without reduction, bony 6
changes in TMJs, and the dentofacial morphology of patients Go
with anterior open bite have not been investigated. The
present study aimed to clarify morphological factors related B

to the prevalence of anterior disc displacement without

Me
reduction and bony changes in the TMJ of patients with
anterior open bite. Fig. 1 Lateral cephalometric analysis. Cephalometric landmarks: sella
(S), nasion (N), point A (A), point B (B), menton (Me), gonion (Go),
articulare (Ar). Angular measurements: 1 SNA angle, 2 SNB angle, 3
ANB angle, 4 GZN angle, 5 SN-MP angle, and 6 Gonial angle
Patients and methods

Subjects in this study are comprised of 36 preoperative

reduction and bony changes bilateral or unilateral. The
women with anterior open bite without asymmetry who had
factors related to the incidence of anterior disc displacement
orthognathic surgery at the Hokkaido University Hospital,
without reduction were compared between group A (with
Sapporo, Japan. Mean age at the time of surgery was 26 years
anterior disc displacement without reduction (ADDwoR))
(range, 1545 years). None of the patients had previously
and group B (without ADDwoR). The factors related to the
been diagnosed with juvenile rheumatoid arthritis. Cases
bony change were compared between group C (with bony
with facial asymmetry showing less than 2 mm of deviation
changes) and group D ( without bony changes). We used the
between the menton and facial midline were excluded from
logistic analysis to assess the significance of differences, and
this study. Subjects included some women with clinically
probabilities of less than 0.05 were accepted.
detectable TMJ signs and symptoms (capsular pain, joint
sounds, masticatory muscle tenderness) and some without
symptoms. The TMJ of patients with anterior open bite was
Results
examined using MRI to assess the position of the disc and
bony changes. The position of the disc was examined using
Table 1 shows the incidence of anterior disc displacement
sagittal and coronal slices (thickness, 3 mm) and T1-
without reduction and bony changes. Table 2 shows
weighted or proton density MRI with the mouth closed and
differences in cephalometric measurements among subjects
open. Results of MRI were classified as with or without
with and without anterior disc displacement without reduction.
anterior disc displacement without reduction. Anterior disc
While univariate logistic regression analysis demonstrated
displacement without reduction was considered present if the
many significant differences among these groups, only sella to
disc was displaced anteriorly relative to the posterior slope of
nasion (SN) to mandibular plane angle (SNMP) angle was
the articular eminence and head of the condyle but without
reduction of the disc on mouth opening. Bony changes were
classified as normal (normal cortical bone without erosions
Table 1 Anterior disc displacement without reduction (ADDwoR) and
or deformity) or abnormal (cortical bone with erosions or bony changes of TMJ in 36 female patients with anterior open bite
deformity, Wilkes classification V). Lateral cephalometric
radiographs were traced, and the tracings were digitized TMJ ADDwoR Bony changes
using a digitizer interfaced with a desktop computer. Seven (n=36 patients) (n=36 patients)
landmarks were digitized on each radiograph, from which six None 16 16
cephalometric variables were calculated. Cephalometric Unilateral 5 3
landmarks and measurements are illustrated in Fig. 1. We Bilateral 15 17
examined the incidence of anterior disc displacement without
Oral Maxillofac Surg (2014) 18:397401
Table 2 Comparison of means
and ranges of age, overjet, over- Variables
bite, and cephalometric variables
of subjects with ADDwoR
(group A) and those without Age (yrs)
ADDwoR (group B)univariate Overjet (mm)
analysis Overbite (mm)
SNA angle ()
SNB angle ()
ANB angle ()
GZN angle ()
SN-MP angle ()
Gonial angle ()
significantly greater in subjects with anterior disc displace-
ment without reduction than in those without anterior disc
displacement without reduction using multivariate logistic
regression analysis (p=0.031; odds ratio, 1.129) (Table 3).
Table 4 indicates differences in cephalometric measurements
among subjects with and without bony changes. While
univariate logistic regression analysis demonstrated many
significant differences among groups, only SN to ramus plane
angle (GZN angle) was significantly greater in subjects with
bony changes than in those without bony changes using
multiple logistic regression analysis (p=0.032; odds ratio,
1.194) (Table 5).
Discussion
The anterior position of the disc observed in asymptomatic
TMJs should, to some extent, be considered as a normal
variation [18]. On the other hand, there have been studies
showing that the surgical induction of anterior disc
displacement (ADD) in rabbits results in degenerative
changes of the condylar cartilage [19]. Additionally, there
have been several studies suggesting ADD as an etiological
factor of osteoarthritis and/or to be associated with
osteoarthritis, a degenerative joint disease accompanied by
clinical pain [20]. Occlusal relationships such as skeletal
anterior open bite, reduced overbite, and increased overjet
have been shown to be associated with TMJ osteoarthrosis
[21]. To evaluate the relationship between TMJ disorders and
dentofacial abnormalities, it is necessary to examine the
Table 3 Factors related to incidence of ADDwoR of TMJ in dentofacial
deformity with anterior open bite (multivariate analysis)
Odds ratio 95 % confidence interval
SN-MP angle () 1.129 0.7810.988
399
Group A (n=20) Group B (n=16) p value
mean SD (range) mean SD (range)
277.3 (1545) 266.5 (1535) .6294
6.14.6 (0.110.5) 2.82.7 (09) .0386
3.92.3(9.20.3) 4.52.9 (0.29.8) .2998
80.92.4 (75.884.5) 84.23.2 (78.589.8) .8911
74.74.6 (67.283.8) 80.43.3 (75.588.0) .7932
6.44.0 (1.712.3) 3.73.2 (1.29.4) .2106
93.57.6 (83.2116.1) 89.67.3 (80.0104.9) .1158
49.36.4 (38.461.7) 42.46.1 (34.955.5) .0306
135.66.7 (120.4143.8) 132.84.3(124.3142.7) .6349
prevalence not only of TMJ symptoms but also of disc
displacement and bony changes in the TMJ. Various imaging
techniques can be used to evaluate the TMJ, such as
transcranial radiography, tomography, arthrography, com-
puted tomography, and MRI. In particular, MRI shows a high
diagnostic accuracy in determining the articular disc position
related to the condyle and articular eminence [22]. This
imaging modality also offers many advantages, such as non-
invasiveness, minimal pain, minimal risk, and freedom from
exposure to ionizing radiation. The aim of this study was to
determine which cephalometric variables provide informa-
tion on TMJ internal derangement in women with anterior
open bite, using MRI as the gold standard. A causal
relationship has been reported between internal derangement
of the TMJ and an abnormal facial skeleton, which is
characterized primarily by a retrognathic mandible, mandib-
ular asymmetry, and occlusal instability [23]. However,
Brand et al. [10] found no distinct relationship between the
morphological features of the face and internal derangement
of the TMJ. These different conclusions are probably the
result of differing methods of sample selection. For example,
Schellhas et al. [8] included patients with an externally
visible mandibular deformity. In the present study, anterior
disc displacement was observed mostly on the deviated side
in patients with mandibular deviation [24]. The TMJ is a
unique joint which functions with both sides operating in
tandem. As different forces act on each side, cases with facial
asymmetry showing less than 2 mm of deviation between the
menton and facial midline were excluded from this study.
Likewise, the adult females showed steeper mandibular and
occlusal plane angles than the male samples. [25] Consid-
ering sex-related differences, men were not included in the
study. We found that the SNMP angle of patients with
anterior disc displacement without reduction was greater than
that of the patients without anterior disc displacement
p value
without reduction (p<0.05). The GZN angle of patients with
.031 bony changes was greater than that of the patients without
bony changes (p<0.05). No significant relationships were
400
Table 4 Comparison of means
and ranges of age, overjet, over- Variables
bite, and cephalometric variables
of subjects with bony changes
(group) C and those without bony Age (yrs)
changes (group D)univariate Overjet (mm)
analysis Overbite (mm)
SNA angle ()
SNB angle ()
ANB angle ()
GZN angle ()
SN-MP angle ()
Gonial angle ()
identified between overbite and either anterior disc displace-
ment without reduction or bony changes. These results
suggest that, potentially, the increased mandibular plane
angle may be the cause of increased likelihood of anterior
disc displacement without reduction, and potentially, the
increased ramus angle may be the cause of increased
likelihood of bony changes in the TMJ.
In our previous study, the prevalence of bony changes was
40 % in closed lock cases. As disc displacement was supposed
to have occurred before the joint had degenerated, this type of
joint disease was considered secondary [13]. The incidence of
anterior disc displacement without reduction was higher in
patients with skeletal open bite than in volunteers (p<0.01),
and in joints that were much affected, the incidence of bony
change in the TMJ was higher for patients with skeletal open
bite than for patients with closed lock (p<0.05) [17]. These
results suggest that skeletal open bite may be a factor
associated with increased incidence of anterior disc displace-
ment without reduction and bony changes in the TMJ.
Although the underlying mechanisms remain uncertain, one
possibility is that excessive mandibular stress on the condylar
heads in patients with skeletal open bite overloads the TMJ
[15]. Measurement of differences in intra-articular pressure
between patients with skeletal open bite and control subjects
without dentofacial abnormalities during mandibular function
should help to clarify the mechanisms involved. Chen et al.
[13] reported that condylar degenerative changes may lead to
deformities of the jaw, in turn resulting in decreased vertical
dimension of the proximal mandibular segments. We found
that some patients with skeletal open bite showed worn facets
and no protuberances on the incisal edges. Simultaneous
Table 5 Factors related to incidence of Bone changes of TMJ in
dentofacial deformity with anterior open bite -multivariate analysis-
Odds ratio 95 % confidence interval p value
GZN angle () 1.194 0.6900.984 .032
Oral Maxillofac Surg (2014) 18:397401
Group C (n=20) Group D (n=16) p value
mean SD (range) mean SD (range)
256.0 (1536) 287.3 (1545) .2507
6.74.3 (0.115.0) 2.11.8 (05.9) .0054
3.92.3 (9.20.3) 4.52.8 (9.80.2) .4450
81.83.1 (75.888.6) 83.13.3 (77.588.8) .5467
75.44.5 (67.283.8) 79.54.8 (68.984.1) .6497
6.33.7(1.711.4) 3.73.2 (1.212.3) .0684
95.67.2 (83.3116.1) 87.04.7 (80.093.5) .0030
49.27.3 (36.461.7) 42.64.5 (34.950.2) .0121
133.36.5(120.4144.2) 135.74.6 (128.9143.8) .2345
evaluation of the increase in the degenerative change of the
TMJ and the reduction in vertical dimension of the ramus may
help to elucidate the relationship between these two
phenomena.
Given the above findings, the consequences due to the
shortening of the condylar bone changes occurring subsequent
to anterior disc displacement without reduction suggest the
possibility of increased GZN angle clockwise rotation which
occurs in the lower jaw. More previous studies have suggested
that internal derangement of the TMJ is associated with altered
facial morphology. Adolescents with internal derangement of
the TMJ show decreased ramus and facial heights and
posterior rotation of the ramus and mandibular plane [8, 10].
These studies indicate that facial morphology with internal
derangement of the TMJ is related to the skeletal open bite
tendency. In contrast to previous studies, subjects of our study
were restricted to women with anterior open bite, who have a
high possibility of potential internal derangement. Subdividing
malocclusion patients, as performed in this study, increases the
ease and accuracy of investigating associations between disc
displacement and dentofacial morphological changes.
Such changes in dentofacial morphology might be associated
with mandibular morphology. A reduction in mandibular body
length and effective mandibular length has been associated with
skeletal Class II and a retrognathic mandible, whereas posterior
rotation of the mandibular ramus and reduction in ramus height
have been associated with a reduction in total posterior facial
height and a steep mandibular plane. Cartilage changes have
been shown to link retrognathic mandibular growth to TMJ
disc displacement in a rabbit model [26].
According to the present results, care is required in cases
with dentofacial deformity with a large angle of SN-MP or
GZN regarding the presence of anterior disc displacement
without reduction or bony changes. Regardless of the
existence of open bite, if patients with large SN-MP or GZN
can be followed longitudinally and investigated radiologically
and clinically, the clinical relationships between TMJ disorder
and growth of the facial skeleton will be clarified.
Oral Maxillofac Surg (2014) 18:397401
Conflict of interest The authors declare that they have no conflict of
interest.
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