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International Journal of Paediatric Dentistry 2002; 12: 109 115

A three-dimensional method of visualizing the

Blackwell Science Ltd

temporomandibular joint based on magnetic resonance

imaging in a case of juvenile chronic arthritis

N. KITAI1,2, S. KREIBORG2,3, S. MURAKAMI4, M. BAKKE5, E. MLLER5,

T. A. DARVANN2 & K. TAKADA1
1Department of Orthodontics and Dentofacial Orthopedics, Graduate School of
Dentistry, Osaka University, Osaka, Japan, 2Department of Paediatric Dentistry and
3D-Laboratory, School of Dentistry, Faculty of Health Sciences, University of
Copenhagen, Copenhagen, Denmark, 3The Juliane Marie Centre, Copenhagen
University Hospital, Copenhagen, Denmark, 4Department of Oral and Maxillofacial
Radiology, Graduate School of Dentistry, Osaka University, Osaka, Japan and
5Department of Oral Function and Physiology, School of Dentistry, Faculty of Health

Sciences, University of Copenhagen, Copenhagen, Denmark

Summary. Aim. The purpose of this study was to present a new visualizing method for
temporomandibular joint (TMJ) pathology in 3D at several condylar positions and to
apply the method to a case of juvenile chronic arthritis (JCA) with previously diagnosed
bilateral TMJ disorder and to a subject without signs and symptoms from the TMJ.
Subject. The 20-year-old female patient had suffered from polyarticular JCA from the
age of 6 years 8 months. The present study is based on a follow-up examination after
the completion of orthodontic treatment with the Herbst appliance. Both TMJs were
examined using magnetic resonance imaging (MRI) at closed and open mouth positions.
The mandibular condyle, the glenoid fossa and the articular disc were segmented and
3D reconstruction of these structures was carried out.
Results. The condyle was characterized by an increased sagittal diameter with
osteophyte-like formation at the anterior aspect of the condylar head and flattening
of the superior surface. The depth of the glenoid fossa was reduced and the articular
eminence was remarkably flat. The articular disc was markedly diminished and posteriorly
placed on the condylar head. The distance of the condylar path during mouth opening was
reduced and the curvature of the condylar path was quite flat. The disc moved slightly post-
eriorly on the condylar head and remained in the glenoid fossa during mouth opening.
Conclusion. The imaging modality described improves visualization of TMJ morphology
and gains insight into the TMJ pathology of the JCA patient, adding to understanding
of the clinical problems.

high frequencies of temporomandibular joint (TMJ)

Introduction
Several radiographic studies of children with
juvenile chronic arthritis (JCA) have documented
Correspondence: Noriyuki Kitai, Department of Orthodontics and
Dentofacial Orthopedics, Graduate School of Dentistry, Osaka University,
18 Yamadaoka, Suita, Osaka, Japan. E-mail: nkitai@dent.osaka-u.ac.jp
involvement [14] and TMJ involvement has re-
peatedly been shown to lead to dysplastic mandi-
bular growth, micrognathia, malocclusion and disturbed
oral function [110].
The reported radiographic signs of change in the
TMJs seen in orthopantomograms have varied from

2002 BSPD and IAPD 109

IPD_340.fm Page 110 Tuesday, March 12, 2002 6:25 PM
110 N. Kitai et al.
minor erosions of the condylar head to total destruc-
tion of the condyle [3]. Studies using tomography,
computerized tomography (CT scanning) or mag-
netic resonance imaging (MRI) of the TMJ have
reported similar findings [1114]. Flattening of the
articular eminence and shallow articular fossa were
shown in patients with JCA who had TMJ involve-
ment using plain radiographs, tomography or MRI
[11,12]. Using MRI, the shape of the articular disc
was considered to be normal in almost all newly
diagnosed JCA patients by Kseler et al. [14]; how-
ever, abnormal disc shape was observed in two-
thirds of JCA patients with known TMJ involvement
by Larheim et al. [11] and Taylor et al. [12]. Almost
all previous studies of the morphology of the TMJ
components in JCA patients have employed conven-
tional radiographic techniques, a few have used CT
imaging, and only a very few have been based on
MRI. All previous studies have been strictly two-
dimensional (2D). There have been no reports that
showed the three-dimensional (3D) characteristics of
the TMJ in JCA patients.
Using radiographs and MRI, several studies have
shown impairment of oral function in children with
JCA and TMJ involvement, including clinically
reduced mouth opening capacity [1,4,9,10] or
reduced movement of the condylar head concur-
rently with normal mouth opening [12,15]. Thus,
although the condylar movement as well as the
mouth opening capacity should be examined, there
have been very few reports that examined the move-
ment of the condyle and the disc in relation to the
glenoid fossa in JCA patients.
The purpose of this study was to present a new
visualizing method for TMJ pathology in 3D at sev-
eral condylar positions and to apply the method to
a case of JCA with previously diagnosed bilateral
TMJ involvement and to a subject without signs and
symptoms from the TMJ.
Subjects and methods
Subjects
The patient was a 20-year-old female who had
suffered from polyarticular JCA from the age of
6 years and 8 months. Radiographic and clinical find-
ings had shown that both TMJs had been affected
by the disease. The patient was followed at the School
of Dentistry at the University of Copenhagen from
10 to 20 years of age because of her bilateral TMJ
2002 BSPD and IAPD, International Journal of Paediatric Dentistry 12: 109 115
involvement. The present study is based on a follow-
up examination after completion of orthodontic treat-
ment with the Herbst appliance. The control subject
was a 25-year-old female volunteer who had normal
occlusion and no signs and symptoms from her TMJs.
The subjects gave consent to the study after receiving
a full explanation of the aim and design of the study.
Examination methods
Both subjects were examined using a Magnetom
Vision 15T MR-scanner with bilateral surface coils
(Siemens, Erlangen, Germany). Twelve images of
each TMJ were obtained in the oblique sagittal plane
perpendicular to the transverse axis of the condyle
(as seen in the axial plane), with the teeth in occlu-
sion. The slice thickness was 20 mm and the slice
gap 02 mm. This procedure was repeated with a
distance between the incisors of 1, 2 and 3 cm.
Scanning parameters included a TR of 456 ms, TE
of 20 ms and T1-weighted spin echo sequence.
Scanning time for each mandibular position was
3 min for each joint and total scanning time was
thus about 30 min.
Data analysis
All data sets were transferred to a graphic com-
puter (Silicon Graphics, Inc., Mountainview, Cali-
fornia, USA). Four data sets (occlusion, 1, 2 and
3 cm between the incisors) for each joint were re-
gistered according to the temporal region structures,
including the brain, by volumetric registration using
the mutual information algorithm in the software
package AnalyseTM (AnalyseDirect.com, Inc., Lenexa,
Kansas, USA). Subsequently, the mandibular condyle,
the glenoid fossa and the articular disc were
segmented and 3D reconstruction of these structures
was carried out using the software package MvoxTM
(Anamedic, http://www.anamedic.com). On the left
side 3D objects of the control subject, the mirror
images of the right side objects, were used.
Results
The 3D reconstructed images shown in Figs 1, 2 and
3 were used for the qualitative assessment of
morphological differences in the anatomical struc-
tures of the patient and the control subject.
It was found that in the patient the condyle was
characterized by an increased sagittal diameter.
IPD_340.fm Page 111 Tuesday, March 12, 2002 6:25 PM
Fig. 1. 3D reconstructed images of the mandibular condyle in the
patient and the control subject.
Fig. 2. 3D reconstructed images of the glenoid fossa in the
patient and the control subject.
There was osteophyte-like formation at the anterior
aspect of the condylar head bilaterally, and the pos-
terior surface of the condylar head was more bulbous
than normal, especially on the right side (Fig. 1).
The superior surfaces of the condylar heads in the
patient were flat compared with the more pointed
shape in the control subject.
It was recognized that the depth of the glenoid fossa
was reduced and that both articular eminences in the
patient were remarkably flat compared with the more
curved shape in the control subject (Fig. 2). The
deviation was most pronounced on the right side.
It was found that in the patient the sagittal dia-
meter of the articular disc was markedly diminished
on the right side and moderately diminished on the
2002 BSPD and IAPD, International Journal of Paediatric Dentistry 12: 109115
3D method of TMJ based on MRI in JCA 111
Fig. 3. 3D reconstructed images of the articular disc in the
patient and the control subject.
Fig. 4. 3D reconstructed images of the TMJ components at
closed, 1, 2 and 3 cm open mouth positions in the patient and
the control subject.
left side, and the thickness of the disc was thin on
the right side, whereas the transverse diameters of
the disc on both sides were fairly similar to those
in the control subject (Fig. 3).
In Fig. 4 the lateral views of the 3D reconstructed
images of the TMJs at closed, 1, 2 and 3 cm open
mouth positions are illustrated in the patient and the
control subject.
At closed mouth position, it was found that the
diminished disc in the patient was positioned pos-
teriorly on the condylar head, whereas the disc was
situated anterior and superior to the condylar head
in the control subject.
At mouth opening from closed to 3 cm open
mouth position, the condylar head in the patient
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112 N. Kitai et al.
Fig. 5. The length and the curvature of the condylar path from
closed to 3 cm open mouth position in the patient and the control
subject (0 = closed mouth position; 1 = 1 cm open; 2 = 2 cm
open; 3 = 3 cm open mouth position).
moved a much lesser distance forwards than in the
control subject; the disc in the patient moved slightly
posteriorly on the condylar head and remained in the
glenoid fossa, whereas it moved forwards under the
articular eminence in the control subject.
Figure 5 illustrates the length and the curvature of
the condylar path from closed to 1, 2 and 3 cm open
mouth position in the patient and the control. It can
be seen that the distance of the condylar path
between 2 cm and 3 cm open mouth positions in the
patient was much reduced. The curvature of the con-
dylar path resembled that of the articular eminence
in both subjects, i.e. it was quite flat in the patient
whereas it was curved in the control subject.
Discussion
The present report documents, for the first time, 3D
morphological characteristics of the TMJ and the
positional relationship between TMJ components at
sequential open mouth positions in a JCA patient.
The increased sagittal diameter of the condylar head
in the JCA patient could be explained by osteophyte-
like formation on the anterior aspect of the condyle
and formation of a bulge on the posterior surface.
The osteophyte-like formation on the anterior
aspect of the condyle in JCA patients with TMJ
involvement has previously been documented in 2D
studies but the axial view of the formation was
observed in the present report for the first time
2002 BSPD and IAPD, International Journal of Paediatric Dentistry 12: 109 115
[11,16]. It is well known that in long-standing
inflammatory disease, bone sclerosis and bony out-
growth, such as osteophyte-like formation, may
occur as characteristics of osteoarthritis [11,16]. The
osseous bulge on the posterior surface of the con-
dylar head could be explained by the effect of treat-
ment with the Herbst appliance. Apposition of bone
at both mandibular condyles was shown superiorly
and posteriorly in a report that examined the change
of 3D mandibular morphology and position before
and after treatment with the Herbst appliance in the
same patient as reported here [17]. Normal subjects
with extreme overjet and mandibular retrognathia
treated in adolescence or adulthood with the Herbst
appliance have been reported to show signs of bone
apposition on the distocranial surface of the man-
dibular condyle [18,19].
Flatness of the superior surface of the condyle and
of the articular eminence has previously been
observed in JCA subjects with TMJ affection using
2D radiography or CT imaging [12,16]. It has been
suggested that this is caused by destruction of
cartilage and bone secondary to joint inflammation
[11,20].
The reduced depth of the glenoid fossa in the
patient could be explained by the flattening of the
articular eminence. However, signs of bone apposi-
tion at the roof of the glenoid fossa have been
observed in normal patients [18,21,22] and in a JCA
patient [17] after the treatment with the Herbst
appliance. A similar effect could be one of the
causes for the reduced depth of the glenoid fossa in
the present case. Although it has proved difficult to
demonstrate the depth of the glenoid fossa using
conventional radiograph, 3D reconstructed MRI
seems to be a better way to show the characteristics
of the glenoid fossa.
The markedly reduced sagittal diameter of the
articular disc in the JCA patient described here was
probably caused by previous inflammatory processes
in the joints. The observations are in agreement with
several 2D MR-studies of JCA children with previ-
ous affection of the TMJ showing various degrees
of disc destruction [11,12]. Kseler et al. [14] found
that the disc was fairly normal in 15 children sub-
jects with newly diagnosed JCA. The degree of
destruction of the discs observed in this patient,
thus, corresponds well with the prolonged course of
the disease.
The posterior displacement of the articular disc on
the condylar head in the patient could probably be
IPD_340.fm Page 113 Tuesday, March 12, 2002 6:25 PM
related to the destructive process of the articular
disc. It is suggested that the initial destruction of the
articular disc leads to segmentation of the disc into
two parts, i.e. an anterior and a posterior part, as
previously observed in a JCA subject by Larheim
et al. [11]. Further destruction of the anterior part
of the disc then occurs as a result of continuous for-
ward movement of the condyle. Finally, only the
posterior remnant of the articular disc remained.
The reduced condylar movement during mouth
opening seen in the present patient was in accord-
ance with the observations of Taylor et al. [12], who
examined 15 JCA children with TMJ involvement
by means of 2D MRI. These authors found a
reduced range of movement of the condyle during
mouth opening in about 75% of the TMJs examined.
The authors suggest this reduced condylar move-
ment could probably be explained by the osseous
changes and fibrous tissue in the joints.
The extremely reduced condylar path between the
2 cm and 3 cm open mouth positions in the present
JCA patient would seem to indicate that only rota-
tion of the condyle took place during the last phase
of mouth opening. The direction of the condylar
movement from closed to 3 cm open mouth position
was close to horizontally forward in the patient,
whereas it had a distinct downward component in
the control subject. The curvature of the condylar
path seems to follow the shape of the articular emin-
ence in both subjects. The flat condylar path in the
patient was associated with flattening of the articular
eminence, whereas the curved condylar path in the
control subject followed the curvature of the arti-
cular eminence. This finding is in agreement with a
previous report on the TMJ using MRI that docu-
mented that the inclination of the condylar path cor-
related with the steepness of the articular eminence
in normal TMJs [23].
Conclusions
Three-dimensional characteristics of the TMJ
morphology and simulation of the movement of the
condylar head and the disc were documented in
the present JCA patient and control subject. Using
the evaluation method described, it was possible
to improve the visualization of TMJ morphology and
gain insight into the TMJ pathology of the JCA
patient at several condylar positions, adding to our
understanding of the clinical problems. Accord-
ingly, it is suggested that the present analysis is a
2002 BSPD and IAPD, International Journal of Paediatric Dentistry 12: 109115
3D method of TMJ based on MRI in JCA 113
more useful method for the diagnostic purpose of the
TMJ involvement than the previous methods. The
analysis method is likely to be applicable to
evaluation in children. Several of the present
findings are in accordance with previous 2D studies
in children.
Acknowledgements
The authors are grateful to the Department of Radi-
ology at the Copenhagen University Hospital for
providing the MR data. This study was supported
in part by The John and Birthe Meyer Foundation,
Schioldanns Fund and Hamiltons Fund.
Rsum. Objectif. Cette tude a eu pour objectif de
prsenter une nouvelle mthode de visualisation en
3D de pathologie de lATM en plusieurs positions
de condyle, et dappliquer la mthode un cas
darthrite chronique juvnile (JCA) avec diagnostic
antrieur de dsordre bilatral des ATM et un
sujet prsentant signes et symptmes au niveau de
lATM
Sujet. la patiente ge de 20 ans avait souffert de
JCA polyarticulaire depuis lge de 6 ans et 8 mois.
Cette tude est base sur un suivi aprs traitement
orthodontique par systme de Herbst. Les deux ATM
ont t observes par image en rsonance magntique
(MRI) en positions ouverte et ferme. Le condyle
mandibulaire, la cavit glnode et le disque articu-
laire ont t segments et une reconstitution 3D de
ces structures a t ralise.
Rsultats. Le condyle tait caractris par une
augmentation du diamtre sagittal avec formation
de type ostophyte dans la partie antrieure de la
tte condylienne et un aplatissement de la face
suprieure. La profondeur de la cavit glnode tait
rduite et lminence articulaire tait remarquable-
ment plate. Le disque articulaire tait notoirement
diminu et en plac postrieurement la tte con-
dylienne. La longueur du trajet condylien lors de
louverture buccale tait rduite et son incurvation
presque plate. Le disque se dplaait lgrement
postrieurement sur la tte condylienne et restait
dans la cavit glnode durant louverture de la
bouche.
Conclusion. La modalit dimagerie dcrite aml-
iore la visualisation de la morphologie de lATM
ainsi que la vision de la pathologie de lATM du
patient atteint de JCA, permettant une meilleure
comprhension des problmes cliniques.
IPD_340.fm Page 114 Tuesday, March 12, 2002 6:25 PM
114 N. Kitai et al.
Zusammenfassung. Ziel. Diese Studie wurde
durchgefhrt, um ein neues bildgebendes Verfahren
zur dreidimensionalen Darstellung von Kieferge-
lenksvernderungen zu prsentieren und anhand
eines Falles von juveniler chronischer Arthritis
und vordiagnostizierter Kiefergelenksprobleme und
eines Vergleichsfalles ohne Symptome anzuwenden.
Proband. Die 20-jhrige Patientin litt seit dem Alter
von 6 Jahren und 8 Monaten an juveniler chronischer
Arthritis verschiedener Gelenke. Diese Studie basiert
auf einer Nachuntersuchung nach einer zuvor abge-
schlossenen kieferorthopdischen Behandlung mit
einer Herbst-Schiene. Beide Kiefergelenke wurden
mit Kernspintomographie untersucht bei geschloss-
enem und geffnetem Mund. Der Kondylus, die
Fossa glenoidea und der Discus wurden segmentiert,
daraus wurde eine 3D Rekonstruktion ausgefhrt.
Ergebnisse. Der Kondylus war charakterisiert durch
einen vergrerten sagittalen Durchmesser mit oste-
ophytenartigen Formationen anterior des Gelenkkopfes
und einer Abflachung dessen Gelenkoberflche. Die
Tiefe der Fossa glenoidea war reduziert und die
Eminentia articularis war bemerkenswert flach. Der
Gelenkdiskus war reduziert und nach dorsal pos-
itioniert. Die Kondylenbahn erschien verkrzt und
abgeflacht in ihrem Verlauf. Der Diskus bewegte sich
leicht dorsal des Kondylenkopfes und blieb whrend
der ffnungsbewegung in der Fossa glenoidea.
Schlussfolgerung. Die beschriebene Vorgehensweise
verbessert die Bildgebung des Kiefergelenkes und
erlaubt Einblick in die Vernderungen des Kieferge-
lenkes des Patienten, damit trgt sie zum Verstndnis
der klinischen Probleme bei chronischer juveniler
Arthitis bei.
Resumen. Objetivo. El propsito de este estudio
fue presentar un nuevo mtodo de visualizacin para
la patologa de la ATM en 3D en varias posiciones
condilares y aplicar el mtodo a un caso de ACJ pre-
viamente diagnosticada como alteracin bilateral de
la ATM a un paciente sin signos, ni sntomas de ATM.
Paciente. Una mujer de 20 aos afectada de ACJ
poliarticular desde los 6 aos y 8 meses. El presente
estudio est basado en un examen de seguimiento
despus de haber completado el tratamiento
ortodncico con el dispositivo de Herbst. Ambas
ATMs se examinaron usando imgenes de resonancia
magntica nuclear (IRM) en posiciones de boca
cerrada y abierta. Se segmentaron el cndilo man-
dibular, la fosa glenoidea y el disco articular y se
realiz la reconstruccin en 3D de estas estructuras.
2002 BSPD and IAPD, International Journal of Paediatric Dentistry 12: 109 115
Resultados. El cndilo se caracteriz por un aumento
en el dimetro sagital con formacin osteoftica en
la parte anterior de la cabeza condilar y aplanamiento
de la superficie superior. La profundidad de la fosa
glenoidea se redujo y la eminencia articular estaba
marcadamente plana. El disco articular disminuy
de forma notable y posteriormente se coloc encima
de la cabeza condilar. Se redujo la distancia de la
gua condilar durante la apertura de la boca y la cur-
vatura de la gua condilar era casi plana. El disco
se situ ligeramente en zona posterior encima de la
cabeza condilar y permaneci en la fosa glenoidea
durante la apertura de la boca.
Conclusin. La modalidad de la imagen descrita
mejora la visualizacin de la morfologa de la ATM,
aumenta la percepcin de la patologa de la ATM
del paciente con ACJ favoreciendo el conocimiento
de los problemas clnicos.
References
1 Larheim TA, Hoyeraal HM, Stabrun AE, Haanaes HR. The
temporomandibular joint in juvenile rheumatoid arthritis. Radio-
graphic changes related to clinical and laboratory parameters
in 100 children. Scandinavian Journal of Rheumatology
1982; 11: 5 12.
2 Karhulahti T, Rnning O, Jms T. Mandibular condyle
lesions, jaw movements, and occlusal status in 15-year-old
children with juvenile rheumatoid arthritis. Scandinavian
Journal of Dental Research 1990; 98: 1726.
3 Kreiborg S, Holm K, Nodal M, Pedersen FK. Juvenil chronisk
arthritis En klinisk og radiologisk underslgese af tyggeap-
paratet. Tandlaegernes Nye Tidsskrift 1991; 6: 168178.
4 Olson L, Eckerdal O, Hallonsten AL, Helkimo M, Koch G,
Gare BA. Craniomandibular function in juvenile chronic
arthritis. A clinical and radiographic study. Swedish Dental
Journal 1991; 15: 71 83.
5 Larheim TA, Haans HR, Ruud AF. Mandibular growth, tem-
poromandibular joint changes and dental occlusion in juvenile
rheumatoid arthritis. A 17-year follow-up study. Scandinavian
Journal of Rheumatology 1981; 10: 225233.
6 Stabrun AE. Impaired mandibular growth and micrognathic
development in children with juvenile rheumatoid arthritis. A
longitudinal study of lateral cephalographs. European Journal
of Orthodontics 1991; 13: 423 434.
7 Mericle PM, Wilson VK, Moore TL et al. Effects of poly-
articular and pauciarticular onset juvenile rheumatoid arthritis
on facial and mandibular growth. Journal of Rheumatology
1996; 23: 159 165.
8 Hanna VE, Rider SF, Moore TL et al. Effects of systemic
onset juvenile rheumatoid arthritis on facial morphology and
temporomandibular joint form and function. Journal of
Rheumatology 1996; 23: 155 158.
9 Kreiborg S, Bakke M, Kirkeby S et al. Facial growth and oral
function in a case of juvenile rheumatoid arthritis during an
8-year period. European Journal of Orthodontics 1990; 12:
119 134.
10 Karhulahti T, Ylijoki H, Rnning O. Mandibular condyle
IPD_340.fm Page 115 Tuesday, March 12, 2002 6:25 PM
lesions related to age at onset and subtypes of juvenile rheu-
matoid arthritis in 15-year-old children. Scandinavian Journal
of Dental Research 1993; 101: 332338.
11 Larheim TA, Smith HJ, Aspestrand F. Rheumatic disease of
the temporomandibular joint: MR imaging and tomographic
manifestations. Radiology 1990; 175: 527 531.
12 Taylor DB, Babyn P, Blaser S et al. MR evaluation of the tem-
poromandibular joint in juvenile rheumatoid arthritis. Journal
of Computer Assisted Tomography 1993; 17: 449 454.
13 Hu YS, Schneiderman ED. The temporomandibular joint in
juvenile rheumatoid arthritis. I. Computed tomographic find-
ings. Pediatric Dentistry 1995; 17: 46 53.
14 Kseler A, Pedersen TK, Herlin T, Gelineck J. Contrast
enhanced magnetic resonance imaging as a method to dia-
gnose early inflammatory changes in the temporomandibular
joint in children with juvenile chronic arthritis. Journal of
Rheumatology 1998; 25: 14061412.
15 Larheim TA, Floystrand F. Temporomandibular joint abnorm-
alities and bite force in a group of adults with rheumatoid
arthritis. Journal of Oral Rehabilitation 1985; 12: 477 482.
16 Raustia AM, Pyhtinen J. Computed tomography of the mastic-
atory system in rheumatoid arthritis. Journal of Rheumatology
1991; 18: 11431149.
17 Kitai N, Kreiborg S, Bakke M et al. 3D MRI of the mandible
2002 BSPD and IAPD, International Journal of Paediatric Dentistry 12: 109115
3D method of TMJ based on MRI in JCA 115
and masticatory muscles in a case of juvenile chronic arthritis
treated with the Herbst appliance. The Angle Orthodontist
(in press).
18 Paulsen HU, Karle A, Bakke M, Herskind A. CT-scanning
and radiographic analysis of temporomandibular joints and
cephalometric analysis in a case of Herbst treatment in late
puberty. European Journal of Orthodontics 1995; 17: 165175.
19 Paulsen HU. Morphological changes of the TMJ condyles of
100 patients treated with the Herbst appliance in the period
of puberty to adulthood: a long-term radiographic study.
European Journal of Orthodontics 1997; 19: 657668.
20 Yulish BS, Lieberman JM, Newman AJ, Bryan PJ, Mulopulos GP,
Modic MT. Juvenile rheumatoid arthritis: assessment with
MR imaging. Radiology 1987; 165: 149 152.
21 Pancherz H. Treatment of class II malocclusions by jumping
the bite with the Herbst appliance. A cephalometric investigation.
American Journal of Orthodontics 1979; 76: 423442.
22 Wieslander L. Intensive treatment of severe class II malocclu-
sions with a headgear-Herbst appliance in the early mixed
dentition. American Journal of Orthodontics 1984; 86: 113.
23 Isberg A, Westesson PL. Steepness of articular eminence and
movement of the condyle and disk in asymptomatic tem-
poromandibular joints. Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology, and Endodontics 1998; 86: 152157.