1http://dx.doi.org/10.20396/bjos.v21i00.8665442 Volume 21 2022 e225442 Original Article 1 Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo, São Paulo, Brazil. 2 Department of Stomatology, Division of Radiology, School of Dentistry, University of São Paulo, São Paulo, Brazil. Corresponding author: João Gualberto C. Luz, Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo – USP. Av. Prof. Lineu Prestes, 2227 - Cidade Universitária, 05508–900, São Paulo – SP, Brazil. Phone: 5511 3091-7887, Fax: 5511 3091-7879. E-mail address: jgcluz@usp.br Editor: Altair A. Del Bel Cury Received: April 25, 2021 Accepted: September 02, 2021 Cone-beam computed tomography analysis of degenerative changes, condylar excursions and positioning and possible correlations with temporomandibular disorder signs and symptoms Nayara Stefany Leite-de-Lima1 , Eduardo Felippe Duailibi-Neto2 , Israel Chilvarquer 2 , João Gualberto Cerqueira Luz 1* Aim: To describe cone-beam computed tomography (CBCT) features in patients with temporomandibular disorders (TMDs), in terms of degenerative changes, condylar excursions and positioning as well as their possible correlations with signs and symptoms. Methods: Clinical records of patients diagnosed with TMD who were seen between January 2018 and December 2019 were retrospectively evaluated. These patients were divided into the following groups based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): arthralgia, myalgia, and arthralgia and myalgia groups. The CBCT examination findings of the patients were evaluated in relation to degenerative changes, estimates of condylar excursion, and condylar positioning. The likelihood ratio test was used to verify the possible differences among the three groups, whereas the chi-square test was used to verify the possible differences among the signs and symptoms for the tomographic findings (p ≤ 0.050). Results: In this study, 65 patients with TMD were included. These patients were predominantly female (84.6%) with a mean age of 40.6 years. Tomographic findings of flattening, hyperexcursion and posterior condylar positioning were frequent. A significant correlation was noted between osteophyte and lateral capsule pain (p = 0.027), erosion and posterior capsule pain (p = 0.026), and flattening, pseudocysts (p < 0.050) and condylar excursion (p < 0.001) with mouth opening. Conclusion: Few correlations were noted between degenerative changes and signs of joint pain as well as degenerative changes and condylar hypoexcursion with mouth opening. These correlations were likely associated with division by diagnosis, whereas condylar positioning did not correlate with signs and symptoms. Keywords: Cone-beam computed tomography. Mandibular condyle. Signs and symptoms. Temporomandibular joint disorders. https://orcid.org/0000-0002-6968-5082 https://orcid.org/0000-0002-1226-0366 https://orcid.org/0000-0003-3967-0143 https://orcid.org/0000-0002-7686-7829 2 Leite-de-Lima et al. Introduction Temporomandibular disorders (TMDs) are diagnosed on the basis of a combination of clinical features and diagnostic imaging findings1. When indicated, diagnostic imaging is an important part of the examination process for patients with TMD. Diagnostic imaging is used to confirm suspected disease, rule out disease, or obtain additional information2. Computed tomography (CT) is considered valuable for evaluating tissues3. However, the identification of pathologies on the basis of imaging findings can be difficult4. In recent years, cone-beam computed tomography (CBCT) has been the method of choice for assessing the bone morphology of the temporomandibular joint (TMJ)5,6. CBCT provides high-resolution multiplanar images with a lower radiation dose than multislice CT. This imaging technique allows examination of the TMJ with- out superimposition or distortion, facilitating the analysis of bone morphology, joint spaces and dynamic function5,6. The signs and symptoms of patients with TMD include localized or diffuse pain in the TMJ and masticatory muscles, articular sounds and functional disorders, which can occur in isolation or in association7,8. Pain-related TMD can impact the individual’s daily activities, psychosocial functioning, and quality of life9. The main functional disorder is partial limitation of mouth opening. This condition occurs predominantly in females, rep- resenting from 67 to 82.2% of cases7,8. Myalgia (M) is classified into three types: local myalgia, which is defined as pain localized to the site of palpation; myofascial pain, which is defined as pain spreading beyond the site of palpation but within the boundary of the muscle being palpated; and myofascial pain with referral, which is defined as pain at a site beyond the boundary of the muscle being palpated. Arthralgia with disc displacement (ADD) represents three main types: disc displacement with reduction, disc displacement without reduction and degenerative joint disease. Finally, myopain with arthralgia and disc displacement (MAAD) represents the association of the two main previous diagnoses9. Many types of degenerative bone changes identified by CBCT, such as flattening, ero- sion, sclerosis and osteophytes, have been described in individuals with TMD, and the changes reported vary in different studies10,11. However, degenerative alterations are common in asymptomatic individuals, representing up to 40% of cases12. In addition, there are reports of some correlations between hypermobility and joint symptoms13,14. On the other hand, correlations as well as an absence of correlations between con- dylar positioning and certain symptoms of TMD have been described15,16. Thus, it is important to describe these features of CBCT in patients with TMD due to the contro- versy regarding the presence or absence of correlations between tomographic find- ings and signs and symptoms of TMD. The objective of this study was to describe CBCT features in patients with TMD in terms of degenerative changes, condylar excursions and positioning as well as their possible correlations with signs and symptoms. Materials and Methods A retrospective study was conducted with information collected from the medical charts of patients with TMD seen between January 2018 and December 2019 and 3 Leite-de-Lima et al. aged 18 years or older regardless of their gender, race and social status. Patients with dental absences of up to three elements were admitted provided that they were isolated and included two posterior and one anterior teeth and did not include central incisors. Patients with a history of parafunctional habits (e.g., bruxism) were admit- ted. Patients who presented a history of previous orthodontic treatment, maxillofa- cial trauma, orthognathic or TMJ surgery or neurological disorders were excluded from the study. TMD was diagnosed on the basis of the chief complaint and the find- ings from a clinical examination conducted according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD)9. TMD was diagnosed using the DC/TMD diagnostic decision tree, the completed clinical examination form, and the symptom questionnaire. The patients were divided into groups based on their TMD diagnosis to assess for possible correlations between CBCT findings and dysfunction groups or specific symptoms. The cases were divided into 3 groups according to the TMD diagnosis: M - comprising localized myalgia, myofascial pain, and myofascial pain with referral; ADD - comprising disc displacement with reduction, disc displacement without reduction and degenerative joint disease; and MADD - comprising the associ- ation of the two main above diagnoses9. Prior to the initiation of the clinical examina- tion, the first author (research fellow) underwent calibration sessions with a specialist trained in the use of the DC/TMD protocol9. Ethical approval for this study was pro- vided by the Human Research Ethics Committee of the School of Dentistry, University of São Paulo, Brazil (Protocol CAAE 09536918.5.0000.0075). All of the tomographic images were obtained at the same radiological facility using a Carestream Dental CS 9600 scanner (Carestream Dental LLC, Atlanta, GA, USA). The sagittal and coronal tomographic views were analyzed under standard condi- tions separately by the authors. The second author, who specializes in dentomaxil- lofacial radiology, analyzed the CBCT findings. No tomographic examinations were performed for the purpose of this study. The occurrence of degenerative bony changes was defined as the presence of flatten- ing of the condylar head due to loss of condylar convexity; sclerosis due to increased bone density; osteophyte formation as the result of a bony protrusion on the condylar margins; erosion, which represents a decrease in cortical and subcortical bone densi- ties; and single or multiple subchondral cysts (SCs) or pseudocysts, which represent pyriform-shaped subchondral lesions with sclerotic margins (Figure 1)1,2. Figure 1. Examples of degenerative bone changes. (A) erosion; (B) sclerosis; (C) flattening; (D) osteophytes; (E) subchondral cysts. A B C D E 4 Leite-de-Lima et al. To obtain condylar excursion estimations, sagittal images that were taken while the patient was in maximum opening were used. The type of condylar excursion was classified as: normal excursion when top-to-top positioning of the apex of the artic- ular eminence and the condyle was present, hyperexcursion when the condylar loca- tion was in front of the apex of the articular eminence, and hypoexcursion when the condyle was positioned below the apex of the articular eminence (Figure 2)14,17. Linear measurements of the superior, anterior, and posterior joint spaces were made using the following formula, and the images of the patient were obtained in maximum intercuspation to evaluate the positioning of the condyle in the mandibular fossa: (posterior − anterior)/(posterior + anterior). A zero value was classified as the equi- distant position, a positive value was classified as the anteriorized position, and a negative value was classified as the posteriorized position (Figure 3)18,19. Figure 2. Examples of condylar excursion estimates. (A) hypoexcursion; (B) normal excursion; (C) hyperexcursion. A B C Figure 3. Example positions of the condyle in the mandibular fossa. (A) equidistant; (B) anteriorized; (C) posteriorized. A B C 5 Leite-de-Lima et al. The data were submitted for statistical analysis. The likelihood ratio test was used to verify the possible differences among the three groups studied in the variables of interest. The chi-square test was used to verify the possible differences among the categories of signs and symptoms for the tomographic findings of interest. The Sta- tistical Package for Social Sciences (SPSS) version 25.0 (IBM Software Group, Chi- cago, USA) was used for the analysis. The level of significance adopted was p ≤ 0.050. Results In this study, 78 cases of TMD were identified and 65 cases were included. The mean age of the patients was 40.6 years, with an age range of 18 to 74 years, and a pre- dominance of females (84.6%). The main diagnoses were myopain with arthralgia and disc displacement (MAAD) in 32 cases (49.2%), myopain (M) in 26 cases (40.0%) and arthralgia with disc displacement (ADD) in 7 cases (10.8%). There was a predom- inance of normal amplitude of mouth opening (73.1% of cases). The most frequent degenerative change was flattening. In the ADD group, flattening (55.6%) was followed by erosion (27.8%). In the MADD group, flattening (60.2%) was followed by osteophytes (22.7%). Finally, in the M group, flattening (64.6%) was followed by osteophytes (21.5%) (Table 1). No significant differences were noted among groups. The most common condylar excursion estimate was hyperexcursion. In the ADD group, hyperexcursion (64.3%) was followed by hypoexcursion (21.4%). In the MADD group, hyperexcursion (67.2%) was followed by normoexcursion (18.8%). Finally, in the M group, hyperexcursion (59.6%) was followed by hypoexcursion (21.2%) (Table 1). No significant differences were noted among groups. Table 1. Cross tabulation of the occurrence of degenerative changes, estimates of condylar excursion and positions, the DC/TMD and the significance of the likelihood ratio test. Variable Category DC/TMD classification* P valueADD MADD M n % n % N % Degenerative changes  Flattening  P  10  71.4  53  82.8  42  80.8  0.619  A  4  28.6  11  17.2  10  19.2  Sclerosis  P  0  0.0  8  12.5  5  9.6  0.366  A  14  100.0  56  87.5  47  90.4  Osteophyte  P  2  14.3  20  31.3  14  26.9  0.432  A  12  85.7  44  68.8  38  73.1  Erosion  P  5  35.7  3  4.7  0 0.0  0.109  A  9  64.3  61  95.3  52  100.0  SCs P  1  7.1  4  6.3  3  5..8  0.981  A  13  92.9  60  93.8  49  94.2  Condylar excusions  Hyperexcursion  9  64.3  43  67.2  31  59.6  0.853 Hypoexcursion  3  21.4  9  14.1  11  21.2  Normoexcursion  2  14.3  12  18.8  10  19.2  Continue 6 Leite-de-Lima et al. No predominant condylar position was common to the three groups. In the ADD group, there was a predominance of the equidistant position (50.0%) followed by the posteriorized (28.6%) position. In the MADD group, there was a predominance of the posteriorized position (43.8%) followed by the anteriorized (31.3%) position. Finally, in the M group, there was a predominance of the anteriorized (46.2%) position fol- lowed by the posteriorized (32.7%) position (Table 1). No significant differences were noted among groups. The distribution of the occurrence of muscle signs regarding degenerative changes is shown in Table 2. In the category of masseter muscle pain, flattening (82.7%) was more frequent, followed by osteophytes (31.6%). In the temporal muscle, there was a predominance of flattening (82.7%) followed by osteophytes (28.6%). Finally, in the medial pterygoid muscle, there was a predominance of flattening (83.8%) followed by osteophytes (33.8%) (Table 2). No significant differences were noted among groups. Continuation Condylar position  Anterior  3  21.4  20  31.3  24  46.2  0.109 Equidistant  7  50.0  16  25.0  11  21.2  Posterior  4  28.6  28  43.8  17  32.7  *According to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD).15 M=myopain, ADD=arthralgia with disc displacement, MADD= myopain with arthralgia and disc displacement. P=present, A=absent. Total degenerative changes exceed 100%, as many patients had more than one finding. Table 2. Cross tabulation of the occurrence of degenerative changes and muscle signs and the significance of the chi-square test. Degenerative changes Category Muscle signs Masseter Temporal Medial pterygoid Y N Y N Y N n % n % N % N % N % n % Flattening P 81 82.7 24 75.0 81 82.7 24 75.0 62 83.8 43 76.8 A 17 17.3 8 25.0 17 17.3 8 25.0 12 16.2 13 23,2 P value 0.340 0.340 0.316 Sclerosis P 10 10.2 3 9.4 11 11.2 2 6.3 7 9.5 6 10.7 A 88 89.8 29 90.6 87 88.8 30 93.8 67 90.5 50 89.3 P value 0.892 0.415 0.813 Osteophyte P 31 31.6 5 15.6 28 28.6 8 25.0 25 33.8 11 19.6 A 67 68.4 27 84.4 70 71.4 24 75.0 49 66.2 45 80.4 P value 0.079 0.695 0.074 Erosion P 0 0.0 8 25.0 0 0.0 8 25.0 0 0.0 8 14.3 A 96 100.0 24 75.0 98 100.0 24 75.0 74 100.0 48 85.7 P value 0.072 0.068 0.069 SCs P 7 7.1 1 3.1 6 6.1 2 6.3 5 6.8 3 5.4 A 91 92.9 31 96.9 92 93.9 30 93.8 69 93.2 53 94.6 P value   0.412 0.979 0.742 Y=yes, N=no, P=present, A=absent. 7 Leite-de-Lima et al. The distribution of articular signs in relation to the occurrence of degenerative changes is shown in Table 3. Regarding the presence of lateral pain to the capsule, there was a predominance of flattening (83.7%) followed by osteophytes (32.7%). Regarding the presence of posterior pain to the capsule, flattening (82.7%) was most frequent followed by osteophytes (27.1%). In the presence of clicking, there was a predominance of flattening (81.3%) followed by osteophytes (27.1%). Finally, when crepitation was present, there was a predominance of flattening (75.0%) followed by osteophytes (50.0%). There was a significant difference in osteophyte findings in the group with lateral pain to the capsule, and in erosion findings in the group with pos- terior pain to the capsule. The distribution of muscle signs according to the excursion estimates and condylar positioning is shown in Table 4. In the masseter muscle, the most frequent type was hyperexcursion (65.3%) followed by hypoexcursion (20.4%). In the temporal muscle, the most frequent type was hyperexcursion (64.3%) followed by normoexcursion (20.4%). Finally, in the medial pterygoid muscle, the most frequent type was hyperex- cursion (60.8%) followed by normoexcursion (21.6%). No significant differences were noted among groups. Table 3. Cross tabulation of the occurrence of degenerative changes and articular signs and the significance of the chi-square test. Articular signs Degenerative changes Category Lateral pain to the capsule Posterior pain to the capsule Clicking Crepitation Y N Y N Y N Y N n % n % n % N % n % n % n % n % Flattening P 82 83.7 23 71.9 81 82.7 24 75.0 39 81.3 66 80.5 6 75.0 99 81.1 A 16 16.3 9 28.1 17 17.3 8 25.0 9 18.8 16 19.5 2 25.0 23 18.9 P value 0.141 0.340 0.915 0.669 Sclerosis P 8 8.2 5 15.6 11 11.2 2 6.3 5 10.4 8 9.8 0 0.0 13 10.7 A 90 91.8 27 84.4 87 88.8 30 93.8 43 89.6 74 90.2 8 100.0 109 89.3 P value 0.222 0.415 0.904 0.330 Osteophyte P 32 32.7 4 12.5 29 29.6 7 21.9 13 27.1 23 28.0 4 50.0 32 26.2 A 66 67.3 28 87.5 69 70.4 25 78.1 35 72.9 59 72.0 4 50.0 90 73.8 P value 0.027 0.397 0.905 0.146 Erosion P 6 6.1 3 9.4 4 4.1 5 15.6 3 6.3 6 7.3 1 12.5 8 6.6 A 92 93.9 29 90.6 94 95.9 27 84.4 45 93.8 76 92.7 7 87.5 114 93.4 P value 0.529 0.026 0.817 0.521 SCs P 7 7.1 1 3.1 8 8.2 0 0.0 2 4.2 6 7.3 0 0.0 8 6.6 A 91 92.9 31 96.9 90 91.8 32 100.0 46 95.8 76 92.7 8 100.0 114 93.4 P value   0.412 0.095 0.471 0.455 Y=yes, N=no, P=present, A=absent. 8 Leite-de-Lima et al. For condylar positioning, when pain in the masseter muscle was present, there was a predominance of the anteriorized condylar position (38.8%) followed by the pos- teriorized (35.7%) position. In the temporal muscle, there was a predomince of the anteriorized position (43.9%) followed by the posteriorized (34.7%) position. Finally, in the medial pterygoid muscle, there was a predominance of the anteriorized posi- tion (43.2%) followed by the posteriorized position (35.1%). No significant differences were noted among groups. The distribution of articular signs according to the excursion estimates and condy- lar positioning is shown in Table 5. In the presence of pain lateral to the capsule, there was a predominance of hyperexcursion (64.3%) followed by normoexcursion (18.4%). In the presence of posterior pain to the capsule, there was a predominance of Table 4. Cross tabulation of the excursion estimates, condylar positions, muscular signs and the significance of the chi-square test. Variable Category Masseter Temporal Medial pterygoid Y N Y N Y N  n % n % n % N % n % N % Hiperexcursion 64 65.0 19 59.4 63 64.3 20 62.5 45 60.8 38 67.9 Condilar excursion Hipoexcursion 20 20.4 3 9.4 15 15.3 8 25.0 13 17.6 10 17.9 Normoexcursion 14 14.3 10 31.3 20 20.4 4 12.5 16 21.6 8 14.3 P value 0.062 0.348 0.555 Condilar position Anteriorized 38 38.8 9 28.1 43 43.9 4 12.5 32 43.2 15 26.8 Equidistant 25 25.5 9 28.1 21 21.4 13 40.6 16 21.6 18 32.1 Posteriorized 35 35.7 14 43.8 34 34.7 15 46.9 26 35.1 23 41.1 P value   0.540 0.140 0.133 Y=yes, N=no. Table 5. Cross tabulation of the excursion estimates, condylar positions, articular signs and the significance of the chi-square test. Variable Category Lateral pain to the capsule Posterior pain to the capsule Clicking Crepitation Y N Y N Y N Y N n % n % n % n % n % n % n % N % Condilar excursion Hiperexcursion 63 64.3 20 62.5 63 64.3 20 62.5 33 68.8 50 61.0 4 50.0 79 64.8 Hipoexcursion 17 17.3 6 18.8 19 19.4 4 12.5 8 16.7 15 18.3 3 37.5 20 16.4 Normoexcursion 18 18.4 6 18.8 16 16.3 8 25.0 7 14.6 17 20.7 1 12.5 23 18.9 P value 0.980 0.440 0.621 0.315 Anteriorized 37 37.8 10 31.3 36 36.7 11 34.4 14 29.2 33 40.2 1 12.5 46 37.7 Condilar position Equidistant 24 24.5 10 31.3 25 25.5 9 28.1 14 29.2 20 24.4 2 25.0 32 26.2 Posteriorized 37 37.8 12 37.5 37 37.8 12 37.5 20 41.7 29 35.4 5 62.5 44 36.1 P value   0.703 0.951 0.447 0.257 Y=yes, N=no. 9 Leite-de-Lima et al. hyperexcursion (68.8%) followed by hypoexcursion (19.4%). When clicking was pres- ent, there was a predominance of hyperexcursion (68.8%) followed by hypoexcursion (16.7%). Finally, in the presence of crepitation, there was a predominance of hyperex- cursion (50.0%) followed by hypoexcursion (37.5%). No significant differences were noted among groups. For condylar positioning, when pain lateral to the capsule was present, the anterior- ized and posteriorized positions were the most frequent (37.8%). In the presence of pain posterior to the capsule, the posterior position was most frequent (37.8%), fol- lowed by the anterior position (36.7%). In cases with clicking, the posteriorized posi- tion was more frequent (41.7%) followed by the anteriorized and equidistant posi- tions (29.2%). Finally, when crepitation was present, there was a predominance of the posterior position (62.5%) followed by the equidistant position (25.0%). No significant differences were noted among groups. The distribution of the amplitudes of mouth opening in relation to the occurrences of degenerative changes is shown in Table 6. In patients with decreased mouth open- ing, flattening (92.9%) was predominant followed by osteophytes (32.1%). In patients with normal opening, flattening (75.0%) was the most frequent condition followed by osteophytes (25.0%). Significant differences in the degenerative changes regarding flattening and the formation of subchondral cysts were noted. The distribution of the excursion estimates and condylar positioning in relation to the mouth opening classifications is shown in Table 7. In cases of hyperexcursion, there was a predominance of normal mouth opening (71.1%) and in cases of hypo- excursion and normoexcursion, decreased mouth opening predominated (42.9% and 28.6%, respectively). A significant difference was noted. In cases with the anteriorized Table 6. Cross tabulation of the occurrence of degenerative changes, the mouth opening and the significance of the chi-square test. Degenerative change Category Mouth opening P valueDecreased Normal n % n % Flattening P 26 92.9 57 75.0 0.044 A 2 7.1 19 25.0 Sclerosis P 2 7.1 6 7.9 0.898 A 26 92.9 70 92.1 Osteophyte P 9 32.1 19 25.0 0.466 A 19 67.9 57 75.0 Erosion P 3 10.7 4 5.3 0.325 A 25 89.3 72 94.7 SCs P 5 17.9 1 1.3 0.001 A 23 82.1 75 98.7 P=present, A=absent. 10 Leite-de-Lima et al. position, decreased mouth opening predominated (42.9%); in cases with the equidis- tant position, normal opening predominated (26.3%); and in cases with the posteri- orized position, decreased opening predominated (42.9%). No significant differences among groups were noted. Discussion The present study revealed few correlations between degenerative changes and signs of joint pain as well as degenerative changes and condylar hypoexcursion with mouth opening, whereas condylar positioning did not correlate with signs and symptoms. There was a predominance of females, and the mean age was 40.6 years. These findings are consistent with the characteristics reported in the liter- ature7,8,20,21. However, given the wide age range, age-related degenerative changes could be present in this sample22,23. Regarding degenerative changes, most patients had flattening, many exhibited osteo- phytes, and few showed sclerosis, erosion and SCs. The predominance of flattening and osteophytes has been reported8,10,11. Other studies have suggested that the preva- lence of erosion or sclerosis represents the condition with the greatest prevalence24,25. Studies with CBCT in TMJ osteoathritis showed common flattening, erosion and osteophytes26,27. A correlation between disc displacement and condylar degenerative changes has been demonstrated28. However, asymptomatic individuals can also pres- ent degenerative changes on CBCT, and such findings should be exclusively used with care12. In older age groups, TMD patients are expected to exhibit more degenerative bony changes22,23. A study reported that no significant correlation was found between degenerative changes verified in CBCT and clinical symptoms of TMD29. Another study evaluated whether a relationship existed between degenerative changes and bone quality of the mandibular condyle and articular eminence in patients with TMD, and no causality relationship between these factors was found30. It should be considered that these Table 7. Cross tabulation of the condylar excursion estimates, condylar positions, the mouth opening and the significance of the chi-square test Variable Category Mouth opening P valueDecreased Normal n % n % Condylar excursion Hiperexcursion 8 28.6 54 71.1 < 0.001Hipoexcursion 12 42.9 9 11.8 Normoexcursion 8 28.6 13 17.1 Condylar position Anteriorized 12 42.9 25 32.9 0.392Equidistant 4 14.3 20 2.3 Posteriorized 12 42.9 31 40.8 11 Leite-de-Lima et al. studies did not classify the cases according to groups of diagnoses in contrast to our study, which may have provided some correlations between degenerative alterations and signs and symptoms of TMD. There was a predominance of hyperexcursion in the three groups based on the con- dylar excursion estimates. Patients with intra-articular dysfunctions are more likely to have joint hypermobility13,17. Hyperexcursion can lead to internal derangement, which can damage articular tissues. Condylar excursion can significantly influence pain perception in patients with TMD15. It has been noted that pain in the TMJ is correlated with a large amplitude of maximal mouth opening14. The predominant condylar position varied among the diagnostic groups, but without significant differences. Our findings are not consistent with those in previous stud- ies. The condyle is more commonly positioned posteriorly in patients with TMD, and anterior and equidistant positions are more common in asymptomatic patients15,18. A relationship was found between the condylar position and tenderness of a specific muscle group16. The posterior condylar position is associated with anterior disc dis- placement18. A study that evaluated the bone components of the TMJ in asymptom- atic individuals and patients with TMD using CBCT demonstrated that the presence of TMD was associated with the condylar position with the anterior joint space being larger31. Again, this study did not divide the cases according to groups of diagnoses, unlike our study, which may have led to no correlations between condylar positions and signs and symptoms of TMD. There was a predominance of amplitudes of mouth opening that were considered normal. However, degenerative changes, especially flattening and SCs, were more prevalent in the group with decreased mouth opening compared with the other groups. CBCT studies have revealed a weak correlation with reduced maximum mouth opening26. No significant difference was noted between the categories of tomographic findings and the groups of diagnoses according to DC/TMD9. Additionally, no significant differ- ences were noted between the tomographic findings and the signs of muscular pain. Few significant differences were noted between degenerative tomographic findings and signs of articular pain. The probability of these signs of articular pain being asso- ciated with intra-articular dysfunctions with articular disc displacement and degen- erative joint disease must be considered7,9. Additionally, few significant differences were noted between degenerative changes and condylar hipoexcursion with mouth opening. The probability of these mouth opening limitations being associated with intra-articular dysfunctions with articular disc displacement must be considered7,9. One of the limitations of this study could be the sample size. Although 65 cases of TMD were included, the sample size was not calculated. Another limitation is the wide age range, which would lead to the inclusion of age-related degenerative changes. This study confirmed that CBCT can reveal degenerative changes with high precision and detail. A previous study that used the same criteria for diagnosing dysfunctions and degenerative findings but used conventional CT reported a lower incidence of degenerative changes, such as osteophytes and erosion, and no cases of SCs8. Most likely, due to the use of CBCT, these findings were more frequent in this study. 12 Leite-de-Lima et al. Based on the data collected in this study, it was concluded that few correlations exist between degenerative changes and signs of joint pain as well as degenerative changes and condylar hypoexcursion with mouth opening. These correlations are likely associated with division by diagnosis. In contrast, condylar positioning exhib- ited no correlations with signs and symptoms. Statement of Ethics: This study was approved by the research ethics committee of the School of Dentistry, University of São Paulo, Brazil. Disclosure Statement: The authors declare that there are no conflicts of interest regarding the publication of this paper. 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