Microsoft Word - 172 2023.docx Evalua&on of Glenoid Fossa Morphology in Different Facial Growth Pa=erns: A Cone Beam Computed Tomography Study Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.172 h#p://den*stry3000.pi#.edu Evaluation of Glenoid Fossa Morphology in Different Facial Growth Patterns: A Cone Beam Computed Tomography Study Maryam Karandish1, Somaye Farmani1, Bahar Khademi1, Maryam Paknahad2 1Orthodontic Department, Dental School, Shiraz University of Medical Sciences, Shiraz, Iran 2Oral and Dental Disease Research Center, Dental School, Shiraz University of Medical Sciences, Shiraz, Iran Abstract PURPOSE: The aim of current study was to assess the glenoid fossa morphology among different ver&cal skeletal pa=erns using cone beam computed tomography (CBCT). MATERIALS AND METHODS: The CBCT images of 63 pa&ents with Class I sagi=al skeletal pa=ern were classified into three groups based on posterior facial height (PFH)/anterior facial height (AFH) ra&o. Each group divided in to normal, horizontal, and ver&cal growth pa=ern groups. Depth, width, and inclina&on of glenoid fossa were measured and assessed on CBCT images. One-way analysis of variance (ANOVA) and Tukey post-hoc test were used to compare mean values of measured variables among the groups. RESULTS: The width (28.76 ± 0.79) and depth (14.61 ± 0.514) of glenoid fossa were lower in horizontal in comparison to ver&cal and normal growth pa=erns (P-value < 0.05). Although steepness of glenoid fossa was higher in normal growth pa=ern (123.8 ± 16.68), no sta&s&cally significant differences were seen (P-value = 0.819). CONCLUSION: The width and depth of glenoid fossa were significantly lower in horizontal growth pa=ern. KEYWORDS: Glenoid Fossa; Growth Pa=ern; CBCT; TMJ Cita9on: Karandish, M et al. (2023) Evalua9on of Glenoid Fossa Morphology in Different Facial Growth PaPerns: A Cone Beam Computed Tomography Study Den9stry 3000. 1:a001 doi:10.5195/d3000.2023.172 Received: April 21, 2021 Accepted: September 28, 2021 Published: January 4, 2023 Copyright: ©2023 Karandish, M et al. This is an open access ar9cle licensed under a Crea9ve Commons APribu9on Work 4.0 United States License. Email: maryampaknahad@yandex.com Introduction Temporomandibular joint (TMJ) is one of the most complex joints due to its anatomical, histological, and biomechanical characteristics [1]. TMJ is the joint between the mandible and the temporal bone of the skull that consists of mandibular condyle, glenoid fossa and articular eminence of the temporal bone [2]. Some previous studies showed association between the joint morphology and different facial patterns. Therefore, knowing about the articular eminence inclination could help clinician in the diagnosis, establishing more biological treatment modalities and treatment response between different facial types [3,4]. Several recent studies have investigated the association between joint morphology and sagittal craniofacial patterns [5-13]. Little is known about the association between the growth pattern and glenoid fossa morphology. To the best of our knowledge, there were only two studies that evaluated the association between the glenoid fossa morphology and vertical craniofacial morphology [14,15]. The study conducted by Lin et al. evaluated articular eminence angle Evalua&on of Glenoid Fossa Morphology in Different Facial Growth Pa=erns: A Cone Beam Computed Tomography Study Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.172 h#p://den*stry3000.pi#.edu using lateral cephalometry [14]. The other study assessed the position and morphology of the temporomandibular joint in skeletal Class II females using CBCT [15]. CBCT is a choice to evaluate TMJ structures because of several advantages including high-resolution images, short scanning times, reduced radiation dose and no magnification or distortion for accurate measurement of joint structure dimensions [16,17]. Therefore, the aim of present study was to assess the glenoid fossa morphology among different vertical skeletal patterns using CBCT. Material and Methods This cross-sectional study protocol was approved by institutional Research Ethics Committee of Shiraz University of Medical Sciences (SUMS) (IR.SUMS.DENTAL.REC.1399.005). Diagnostic CBCT images of 63 adult patients (17 verticals, 29 horizontals and 17 normal) who referred to Radiology Department of Dental School of SUMS for dental services such as impacted teeth, PNS, maxillofacial CBCT and etc. entered this study. The inclusion criterion follows: sufficient image sharpness and contrast to visualize the structure to be evaluated (glenoid fossa , articular eminence, sella turcica, mandible and nasion), and patients with skeletal Class I relationships on the basis of ANB angle, 0 to 4 degrees [18]. The exclusion criteria were symptoms of temporomandibular disorders, history of TMJ surgery and/or TMJ trauma, or fracture in the TMJ region, any congenital abnormalities or systemic diseases potentially affecting joint morphology. CBCT of patients presenting evidence of degenerative joint disease in the images were excluded from the study. All CBCT scans were taken by the same clinician using New Tom VGi. The exposure factors set at 120 kVp, 4.6 mA, exposure time of 20 s, and a field of view of 15 × 15 cm. The CBCT images were taken with the participants biting in maximum dental intercuspation and their heads positioned so that the Frankfort plane was parallel to the floor. The images divided into three groups according to growth pattern based on posterior facial height (PFH)/anterior facial height (AFH) ratio (Table 1). On the axial view, the section of the condylar process that had the widest mediolateral diameter on the left and right sides was chosen as the reference view for reconstruction of the sagittal slices. In this section, a line parallel to the long axis of the condylar process was drawn and sagittal images were reconstructed as 0.5 mm slice interval/thickness. The measurements were establishing on the central sagittal section of the condyle. The glenoid fossa depth was established by measuring the perpendicular distance between the highest point of fossa and the line passing through the most inferior point on the articular eminence and the posterior glenoid process (Figure 1.b). The glenoid fossa width defined as the distance between the most inferior point on the articular eminence and the posterior glenoid process (Figure 1.b). The articular eminence inclination was measured by top-roof line method, i.e., the angle between Frankfort plane and the plane passing through the highest point in the roof of glenoid fossa and the lowest point at the crest of the articular eminence (Figure 1.c). Variables Growth pattern group (Valid percent) Vertical (N= 17) Normal (N=17) Horizontal (N=29) PFH/AFH < 62 62- 65 > 65 Table 1. Distribution of subjects according to different growth patterns Evalua&on of Glenoid Fossa Morphology in Different Facial Growth Pa=erns: A Cone Beam Computed Tomography Study Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.172 h#p://den*stry3000.pi#.edu Statistical analysis Data were analyzed using SPSS software package V.18 (version 18, SPSS Inc, Chicago, IL, USA). All CBCT images were re-measured by the same examiner after a 2-week interval to confirm intra-observer reliability. Intra-Class correlation coefficient was used to assess the reliability of the measurements. One- way analysis of variance (ANOVA) and Tukey post-hoc test were used to evaluate the association between different growth patterns and glenoid fossa morphology. P-value less than 0.05 was considered significant. Results A total of 63 adult patients were included in this study. Distribution of glenoid fossa morphology based on the width, depth and inclination is shown in Table 2. The width (28.76 ± 0.79) and depth (14.61 ± 0.514) of glenoid fossa in horizontal growth pattern were the least of all groups (P-value < 0.05). Although not statistically significant, the inclination of glenoid fossa was highest in normal growth pattern (123.8 ± 16.68). Growth pattern group Variables Normal Mean ± SD* Vertical Mean ± SD Horizontal Mean ± SD P-value Width 32.11 ± 0.79 30.33 ± 0.79 28.76 ± 0.79 0.017 Depth 15.34 ± 0.514 16.49 ± 0.514 14.61 ± 0.514 0.043 Inclination 123.8 ± 16.68 114.66 ± 16.68 109.013 ±16.68 0.819 Discussion Sagittal and vertical facial disharmonies can affect the relationship of the mandible to the cranial base. Therefore, glenoid fossa position is likely to play an important role in the establishment of different craniofacial patterns and orthopedic/orthodontic therapies [19-21]. In current study we determined the association between glenoid fossa morphology and different growth patterns using CBCT images. The variability and complexity of the TMJ make it difficult for accurate radiographic examination and clinical diagnosis [22]. Different radiographic methods have been used in previous studies to examine the TMJ morphology, such as computed tomography [23], magnetic resonance imaging [24], conventional tomography [25], and CBCT [26-28]. Standard 2D radiographs of the TMJ have several limitations including superimposition of overlying structures, magnification and distortion that limit the ability to evaluate TMJ [29,30]. CBCT, a recently developed imaging technology, has been used for 3D imaging of the TMJ and has been shown to delineate the joint Figure 1. Axial view of the condylar process (a); linear measurements of depth and width of glenoid fossa (b); inclination of glenoid (c). Table 2. Distribution of glenoid fossa morphology based on the width, depth, and inclination of glenoid fossa *Standard Deviation Evalua&on of Glenoid Fossa Morphology in Different Facial Growth Pa=erns: A Cone Beam Computed Tomography Study Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.172 h#p://den*stry3000.pi#.edu structures with high accuracy [26]. Therefore, in our study we used CBCT images for evaluation of joint morphology. There are two methods for measuring articular eminence inclination [4,31,32]. The first method is to measure the angle between FH plane and the line of deepest point of the roof of the fossa and the top of the articular eminence. The second method defines articular eminence inclination as the angle between the best fit line drawn along the posterior slope of articular eminence and FH plane. It should be noted that both angles really show the eminence inclination; the first method focuses on the location of eminence crest relative to the fossa roof, whereas the second method focuses on the posterior surface of eminence. The second method represents the actual condylar path, whereas the first method depicts the morphology of articular eminence better. In the present study the former method has been used the same as Katsavrias et al. [4] , Sümbüllü et al. [31] and Kranjčić et al. [32]. Inclination is defined as an angle between posterior slope of the articular eminence and any other horizontal plane such as FH plane, occlusal plane, and palatal plane [4,32]. The line frequently used is FH plane [31-34]. Cohlmia et al. used the superior border of a tomographic film [35], whereas Keller and Carano used the angle between the posterior surface of the articular eminence and the posterior occlusal plane [34]. Since some other previous studies selected the FH plane as the reference plane. We also used FH plane as the reference plane in the present study like Sümbüllü et al. [31], Kranjčić et al. [32] , Wu et al. [33] and Gökalp et al. [34]. There were different concepts about the depth and width of the glenoid fossa. Our results showed that the depth and width of glenoid fossa in horizontal growth pattern was significantly smaller than other groups in skeletal Cl I. Lower depth seems to be in accordance with clockwise rotation of anterior and posterior cranial bases [36]. Lin et al. [15] and Katsavrias et al. [37] expressed that the depth of the glenoid fossa in high-angle was significantly smaller than control and the low-angle groups but there were no statistical differences between three groups in regard to width of glenoid fossa. The differences might be due to different case selections; skeletal Cl I in current study vs skeletal class II female cases and different sagittal skeletal patterns in Lin's and Katsavrias' respectively. The inclination of the glenoid fossa was lower although not statistically significant in the horizontal compared with vertical and normal growth pattern groups. On the other hand, Lin et al. [15] and Widman et al. [14] demonstrated that inclination of articular eminence and mandibular plane angle were inversely related. The variation in the results from these studies might be due to different radiographic methods and the index for growth pattern classification with varying accuracy. Current study analyzed CBCT images of Class I adult patients and adopted Jaraback's as a reliable index to represent the growth pattern. Widman et al. [14] and Lin et al. [15] examined the angle of articular eminence with lateral cephalometry and adopted mandibular plane angle to classify patients. 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