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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 129-138

Evaluation of condylar changes in relation to various malocclusions: A systematic review

1 Department of Prosthetic, Dental Clinic of Monastir, University of Monastir, Monastir, Tunisia
2 Department of Prosthetic, Hospital Taher Maamouri, Nabeul, Tunisia

Date of Submission06-May-2021
Date of Acceptance24-Aug-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Prof. Imed Ouni
Department of Prosthetic, Dental Clinic of Monastir, University of Monastir, Avicenna Avenue, Monastir 5019
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoralsci.sjoralsci_25_21

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Introduction: Variability in the size and shape of mandibular condyles among individuals of different sexes and ages may appear as a remodeling process to accommodate malocclusion. Hence, the aim of this study was to assess whether or not associations exist between different types of malocclusions and morphological modifications of the mandibular condyle.
Materials and Methods: A systematic literature search was conducted on the Medline database via PubMed interface and supplemented by a manual search via Google Scholar to identify more articles reporting the subject of the review. A combination of controlled vocabulary was used in the search strategy and the final update was stopped on January 2021. The risk of bias was assessed based on the Newcastle–Ottawa Scale.
Results and Discussion: Considering the preestablished inclusion and exclusion criteria, 20 articles were retained with 2607 human subjects (967 males/1299 females and 341 not specified, age: 4–60 years). Eighty percent of the selected articles reported associations between malocclusion and morphological changes of the condylar head. Sagittal plane malocclusions produce more changes to the temporomandibular joint components (head of condyle and joint space) (71.93%), while vertical malocclusions lead to the most severe manifestations.
Conclusions: Cone-beam computed tomography is the most useful tool for the assessment of osseous morphology of mandibular head condyles and detection of cortical erosion (21.7%). Associations between morphological changes of the condylar head and specific types of malocclusions were proven. However, there is still a need for more clinical studies.

Keywords: Abnormalities, condylar head, dental occlusion, malocclusions, mandibular condyle

How to cite this article:
Ouni I, Ammar S, Charfeddine A, Chouchen F, Mansour L. Evaluation of condylar changes in relation to various malocclusions: A systematic review. Saudi J Oral Sci 2021;8:129-38

How to cite this URL:
Ouni I, Ammar S, Charfeddine A, Chouchen F, Mansour L. Evaluation of condylar changes in relation to various malocclusions: A systematic review. Saudi J Oral Sci [serial online] 2021 [cited 2023 Jan 27];8:129-38. Available from: https://www.saudijos.org/text.asp?2021/8/3/129/333550

  Introduction Top

Mandibular condyle appearance varies widely both in shape and size among individuals of different sexes and ages.[1],[2] Yale et al. classified condylar head shape into four categories: Rounded, angled, flattened, and convex based on autopsy on dry skull and radiological observation.[3],[4]

Morphologic condyle changes may appear as a remodeling process to accommodate malocclusion, trauma, and other developmental variability and abnormalities.[5] Variability in the size and shape of mandibular condyles should be considered as an important causative factor in internal disorders of the temporomandibular joint (TMJ).[6]

Various investigations have reported that condylar and disk position in the glenoid fossa varies depending on malocclusion type.[7],[8],[9] However, the morphologic changes of the condylar head have not been well stated. The rationale of the study is to evaluate the possible association between malocclusion and morphologic changes of the condyle which has never been reviewed systematically, despite the importance to differentiate between abnormal variations and anatomical conditions of the condylar head as a diagnostic challenge for the practitioner. The current review aimed to clarify the relationship between malocclusion and morphological modification of the condylar head, type of malocclusions which leads to significant condylar changes, which changes in the condyle is associated with most serious manifestations, the location of these lesions in relation to types of malocclusion, and the most effective means of diagnosis used to detect the condylar changes.

  Materials and Methods Top

Ethical committee clearance was not required since it is a systematic review and was exempted. The systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses 2020 guidelines.[10] The literature medical search for relevant articles was conducted in MEDLINE database using PubMed. The following search query was used “malocclusion (MeSH term)” AND “mandibular condyle (MeSH term).” The data collection was started in October 2020 and the final update of the search was in January 2021. Filters were set to human studies, English language, and available abstract with a date of publication after 1990. Based on abstract and title evaluation, the studies that answer the issue in question were selected for full-text examination.

Additional studies were supplemented by a manual literature search in Google Scholar and Scopus databases and in the reference lists of relevant articles to identify more papers reporting the subject of the review.

The inclusion criteria included all human clinical studies assessing the association between mandibular condylar changes and various features of dental malocclusion, by means of radiological, clinical, or validated assessment approaches. Studies with unclear protocol, or involving population with orthodontic treatment, history of trauma, edentulism, TMJ disorders, and extensive stomatognathic surgery were excluded from the review.

Two reviewers performed data extraction independently using a preestablished checklist. In case of disagreement, the consensus decision was achieved by discussion.

Assessment of the risk of bias of selected studies was performed based on the Newcastle–Ottawa Scale (NOS) for nonrandomized studies, including cohort and case–control studies, that is recommended by the Cochrane collaboration.[11] The NOS evaluates eight items in the reviewed article. A maximum of one star can be attributed for each item, except for the comparability category that can be given two stars. A maximum of nine stars can be awarded for a study.

  Results Top

General characteristics of the included studies

The search query resulted in 1396 articles, 615 papers were excluded when search filters were applied, and then, 739 articles were considered not pertinent to the aim of the study based on title and abstracts. As shown in [Figure 1], the 42 remaining relevant articles in the full text were assessed using preestablished checklist. Thirty-one of the 42 papers were excluded for the reasons described in [Table 1].[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42]
Table 1: Excluded articles after full-text screening

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Figure 1: Flow diagram

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Manual search expansion allowed finding 9 additional studies, thus resulting in a total of 20 articles included in this review.[6],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61]

Only four papers were awarded 7-star scores. The majority of studies received 3–6 stars. The most frequent gaps were the unclear representativeness of the cases, selection of controls was not endorsed for community samples, and unspecified nonresponse rate. The quality assessment of the included papers showed a poor to moderate level as well as methodological heterogeneity that prevents conducting meta-analysis [Table 2].
Table 2: Quality assessment based on the Newcastle-Ottawa Scale of nonrandomized studies

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The twenty included studies comprised 2607 human subjects, 37% (967) males, 49.8% (1299) females, and 13% (341) not specified. Their age ranged from four to 60 years old. Almost all subjects had a good general condition (98.61%) [Table 3].
Table 3: Characteristics of the patients included in the selected studies

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Thousand eight and thirty-one subjects (70.2%) had at least one type of malocclusion: 41.2% had sagittal plane malocclusions (10.23% angle Class III, 31% angle Class II), 16.56% had transversal plane malocclusions (12.65% unilateral posterior cross-bite, 3.9% bilateral posterior cross-bite), and 10.56% had vertical plane malocclusions (5.63% anterior open bite, 1.06% anterior deep bite, and 3.87% anterior cross-bite). The other subjects had normal occlusion (control group) [Table 4].
Table 4: Effect of various malocclusions on condyle morphology

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Methods of morphological change evaluation

Various techniques to evaluate the morphology of condyles were stated in different studies. Autopsies on dry skulls were performed in 1.98% of the study population. Two-dimensional imaging techniques were used in 68.75% of cases (lateral cephalometric radiograph [47.4%], panoramic radiography [53.8%], and corrected lateral tomograms [7%]).

Cone-beam computed tomography (CBCT) method was used in 21.7% of the cases for assessment of bone changes. Computerized tomography (CT) scan was performed on 3.75% of the subjects. Magnetic resonance imagery (MRI) was used in 0.6% of the study population mainly to evaluate soft tissue changes [Table 3].

Size and shape of condyle in relation to various malocclusions

Eighty percent of the included articles showed significant associations between malocclusion and different morphological aspects of condyles. However, other studies failed to identify positive associations.[44],[45],[46],[52],[61]

The most frequent condylar changes were found in sagittal plane malocclusion (71.93%), followed by transversal malocclusion (49.3%) and vertical malocclusion (20.86%). Morphological changes are more important in CL II division 2 and anterior deep bite compared to other types of malocclusions [Table 4].

The morphological modifications described in the various articles are in relation to the size and/or inclination of the condylar head, anterior and posterior joint space, and the location of bone changes [Table 4].

  Discussion Top

The aim of this review was to summarize the literature about osseous changes of the mandibular head condyle in relation to different kinds of morphologic or functional malocclusions and to identify whether the features of malocclusion influence the prevalence and severity of bone variations.

The study compromised 2607 human subjects, which is considered a great number to draw significant results and conclusions. The study sample in the majority of papers included only subjects without history of trauma, history of orthodontic treatment, history of temporomandibular disorder (TMD), edentulism, and defective dental restorations because all these factors have a high risk of producing morphological changes in the condylar head.

Different techniques were used to evaluate the morphology of the condyles. Two dimensional-imaging techniques were performed in 68.75% of cases. However, they are not a reliable method for accurately analyzing the shape of the mandibular condyle.[2],[62]

CBCT is the most used tool for the assessment of osseous morphology of mandibular head condyles and detection of cortical erosion.[63],[64],[65] Compared to CT-scan, Hintze et al.[66] had found no statistically significant difference in diagnostic accuracy. They are both useful for bone scanning and early detection of biomechanical and functional osseous changes.

MRI is considered the examination of choice to evaluate juxta-condylar soft tissue changes.[67],[68]

The present study showed a significant relationship between functional and parafunctional malocclusion and degenerative and adaptive changes in the loadbearing of the condylar head. Furthermore, the various morphological aspects of the condyles radiologically observed have been classified relative to the different types of malocclusion as follows [Table 4].

Sagittal plane malocclusions

They are more prevalent in the study population with dominance of patients with Class II malocclusion. The mandibular condyle presented linear erosive lesions in the anterosuperior part, they are characterized by small size, tapered, and thinned appearance with posterior tilt. It has been reported also that changes are more important in Class II division 2 (deep bite) than in Class II division 1 malocclusions. These findings coincide with those reported in previous studies showing that Class II division 2 subjects seem to be notably susceptible to higher intracapsular pressure leading to condylar bone changes and mandibular retrusion.[69],[70],[71]

Patients with Class III malocclusion are characterized by visible changes on the anterior and superior surface of the condyle head (which usually undergo linear resorption) leading to an enlargement of the anterior and superior right and left joint space. Condyles are characterized by an increase in size, a globular and convex aspect, and wide in the frontal plane. This may reflect the continuous growth of the condylar head with the advancement of age in skeletal Class III, when such growth has stopped in Class II malocclusions.[72],[73]

Transversal plane malocclusions

Specific morphological changes associated with transversal malocclusion are rare. For patients with unilateral cross-bite, the only finding was the presence of a small condyle on the cross-bite side. However, for patients with bilateral cross-bite, no specific morphological changes were noted.[48],[49],[52],[54],[61]

The condylar head is generally sensitive to transversal malocclusion in growing subjects.[74] However, these morphological changes are not statistically significant compared to the control group.

Vertical plane malocclusions

The results of this review showed that bone changes of the condylar head in patients with anterior open or deep bites are the most severe; they are characterized by an erosive appearance, poorly limited osteoarthritis, irregular, with blurred images up to the exposure of the spongy bone. Those osseous lesions are located mainly at the upper articular surface with flattening of the mandibular condyle.[27],[47] These arthritic changes may be best seen on CBCT.[75]

Ari-Demirkaya et al.[50] stated that anterior open bite is considered as a predictive sign of erosive bone changes.

Morphologic changes in the size and shape of the mandibular condyle may be one of the causative factors of internal derangement of TMJ by the loss of functional cohabitation between different TMJ components, and as consequence the development of signs and symptoms of TMD. This suggests an indirect relationship between various malocclusions and tendency for TMD.[6]

For this reason, it is important to perform clinical and radiographic examinations of the TMJ for all patients with malocclusions before planning any treatment to prevent any unplanned complications during and after therapy.

However, morphologic changes of mandibular condyle are also influenced by multiple others factors such as genetic, age and ethnic groups, eating habits, and functional factors which are not well considered across included studies which is the limitation of the study. This risk of bias will simply compound the errors and produce a mislead result if meta-analysis was conducted.

  Conclusion Top

There is a significant association between malocclusion and morphological changes of the mandibular condyle. These bone changes are more frequent in sagittal malocclusion and more severe in cases with vertical malocclusion. It is therefore essential to consider correcting these malocclusions as early as possible; especially in young subjects, to avoid these condylar changes and their consequences on TMJ. Among the different imaging techniques used for TMJ screening, CBCT images are accurate over others for the evaluation of the bony changes of mandibular condyles.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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