Achieving improved visualization of the

temporomandibular joint condyle and fossa in the

sagittal cephalogram and a pilot study of their
relationships in habitual occlusion
Stanley Braun, DDS, MME a
Indianapolis, Ind.

Improved glenoid fossa and condyle visualization is achieved by adapting the Denar TMJ
Orthoceph Slimline Cassette (Denar Corp., Anaheim, Calif.) to sagittal cephalometry. This cassette
contains rare-earth intensifying screens to enhance the temporomandibular joint region. A plastic
template of circles of varying diameters is positioned so that the appropriate circle size is tangent to
the superior, anterior, and posterior borders of the glenoid fossa seen on the resultant radiograph.
The planar geometric center of the glenoid fossa is then identified coincident with the center of the
template circle. The condyle planar geometric center is similarly identified. The relationships of
these centers with respect to each other is described by using a rectangular coordinate system with
the origin at the glenoid fossa geometric center. The condyle center is further described as being
in any one of four quadrant locations or concentric with the glenoid fossa geometric center. This
method was then applied to 38 patients who were free of temporomandibular joint symptoms in a
pilot study relating the condyle quadrant location with the dentition in habitual occlusion. Findings
revealed 89% of the condyles were in any one of the four possible quadrants. Fifty-three percent of
the condyles were located in a downward and forward position (quadrant IV). Eleven percent of
the condyle geometric centers were concentric with the glenoid fossa geometric center. (Am J
Orthod Dentofac Orthop 1996;109:635-8.)

A vital consideration in orthodontic Many methods, including magnetic resonance

treatment is the recognition of the importance that
the dentition be in harmony with related muscu-
loskeletal structures. In this context, condylar po-
sition is an important concern in maintaining or
restoring temporomandibular harmony with the
dentition. 1-3 Researchers have found that temporo-
mandibular joint (TMJ) symptoms can be exacer-
bated by a lack of harmony between habitual oc-
clusion and centric relation, 4-6 whereas others have
failed to establish a clear relationship between
dental occlusion and the incidence of TMJ symp-
toms. 7-1° It has been shown that the TMJ symptoms
are multifactorial in origin, but occlusal factors and
condylar position cannot be ignored. 11'12 Investiga-
tors have shown that when disharmony occurs be-
tween condyle-disk-fossa positions and occlusal in-
dexing, muscular hyperactivity, internal derange-
ments, and pain may result. 13"14
aClinical Professor, Department of Orthodontic, Pediatric and Geriatric
Dentistry, School of Dentistry, University of Louisville.
Copyright © 1996 by the American Association of Orthodontists.
0889-5406/96/$5.00 + 0 8/1/60019
imaging, transcranial radiographs, and tomography
have been used to study the internal structures of
the temporomandibular joint. Correlating the im-
ages obtained by these methods to the dentition is
difficult. Articulator mounted dental casts are most
often used to visualize this relationship. 15-1s It is
therefore the purpose of this article to describe a
method of simultaneously visualizing condyle/fossa
positions relative to maximum dental intercuspa-
tion (habitual occlusion) on the standard sagittal
cephalometric radiograph. It is expected this tech-
nique will help considerably to bridge the gap in
relating the positions of the hard tissue structures
of the temporomandibular joint to the various
planes formed by the dentition (e.g., the functional
occlusal plane) and perhaps to other similar cepha-
lometric landmarks.
MATERIALS AND METHODS
Hard tissues of the temporomandibular joint are
difficult to visualize on a sagittal cephalometric radio-
graph, principally because of the superimposition of the
petrous portion of the temporal bone. 19'2°To reduce this
effect, the TMJ Orthoceph Slimline Cassette (Denar
635
636 Braun
INTENSIFIEAREA
D y / Ge°rnetri~°Cne¢'
GLENOIDFOSSA / / / ~ -
GEOMETRICCENTER
-~ ~ L
/
CONDYLE I ....... ~A ) /
Fig. 1. Geometric centers of glenoid fossa and mandibular
condyle.
Corp., Anaheim, Calif.), originally designed for use in
oblique cephalometric radiography, has been adapted to
the standard sagittal view. The cassette incorporates
rare-earth phosphor intensifying screens in the region of
the temporomandibular joints and surrounding struc-
tures to improve the visualization of this area. 21 Rare-
earth screens produce three to four times more light
photons for each x-ray photon absorbed, permitting
greater energy conversion in areas of increased attenua-
tion. Improved imaging of the joints and surrounding
areas is achieved in this way, without subjecting patients
to increased radiation. Standard x-ray machine settings
employed for conventional sagittal cephalometric radiog-
raphy are used. Panchromatic T-MAT x-ray film (East-
man Kodak, Rochester, N.Y.) is used, because it closely
matches the energy spectrum output of the rare-earth
intensifying screens of the cassette. The glenoid fossa
and condyle may now be more Clearly visualized.
A template consisting of several circles whose radii
are increased in 0.5 mm increments was constructed. By
superimposing the largest template circle tangent to the
anterior, posterior, and superior borders of the glenoid
fossa, the corresponding circle center is identified by a
pinhold in the radiograph. This center is the planar
geometric center of the glenoid fossa. Similarly, a tem-
plate circle is selected by fitting it to the superior, mesial,
and distal borders of the condyle. Its geometric center is
similarly identified. Because the right and left condyles
are at differing distances from the cassette, a double
image may be seen. The average of the two images was
used to identify the condyle geometric center in these
instances.
If a cephalogram exhibited a larger than average
double image difference of the condyle/fossa beyond that
which is related to the relative enlargement of the
structures farthest from the cassette, it was not included
in the study. When this was observed, it was assumed to
American Journal of Orthodontics and Dentofacial Orthopedics
June 1996
OriginatGlenoidFossa
::rGe°rnetri
; center
c /
1 x t -
x(7 ',
"
\
///
Fig. 2. Coordinate and quadrant relationship of fossa and
condyle.
be due to one or more possible causes: (1) poor position
of the head in the cephalostat; (2) an asymmetry in
centric occlusion (CO), which significantly altered the
condyle positions; (3) .asymmetry in the condyle position
without a corresponding asymmetry in the dentition; (4)
asymmetry in the cranium, which would affect the gle-
noid fossae, and (5) significant variations between left
and right condylar angles relative to the sagittal plane.
Two planar geometric centers are thus identified:
one for the glenoid fossa and one for the condyle (Fig. 1).
Their relationship to each other can be described with a
rectangular coordinate system. Orthogonal axes were
drawn through the glenoid fossa geometric center with
the x-axis parallel to Frankfort horizontal (SN-7°), as
seen in Fig. 2. The x and y coordinates of the condyle
geometric center are now identified relative to the fossa
center. The condyle center is further described as located
in quadrant I, II, III, or IV. Thus, if the condyle is
displaced downward and forward, it is described as being
in a quadrant IV location. If it is displaced superiorly and
distally, it is in a quadrant II location. When the geomet-
ric centers are not displaced with respect to each other,
they are concentric: the condyle is located at the origin of
the axes.
A pilot study was conducted to apply this method to
examine the condyle/fossa relationships at maximum
dental intercuspation (centric occlusion). Thirty-eight
patients seeking orthodontic treatment at the University
of Louisville Orthodontic Clinic participated in this
study. All patients were free of TMJ symptoms. The
patients ranged in age from 7.6 to 44 years. Twenty-four
of the patients were female and 14 were male. A lateral
cephalometric radiograph was exposed of each patient,
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 109, No. 6 Braun 637

/"" ^I"

I
t
II - 1
I

%%% ti

D~itized Description
i~oint
1 Sella
2 Nasion
3 Along SN-7 ° Line
4 Pin Point of Fossa Geometric Center
5 Pin Point of Condyle Geometric Center
6 Point on Line Through Fossa Center
Parallel to SN-7 ° Line
Defining X-axis
Perpendicular to Sn-7 ° Line
Defining Y-axis

Fig. 3, Digitized cephalometric landmarks.

using the cassette and film described previously. Each of 100

the radiographs was digitized by the same operator, using 90
a modified Dentofacial Planner computer program
(Dentofacial Software, Inc., Toronto, Canada). The 80
condyle and fossa geometric centers previously described 70-
were digitized, as well as the reference axes, and are c
shown in Fig. 3. Ten radiographs were chosen at random 60.
¢.)
and digitized a second time by the same operator. The x 0 5o-
and y coordinates of the condyle geometric center with E
~ 40"
respect to the glenoid fossa geometric center were found
to vary less than 0.025% of the original coordinate ~ 30"
dimensions.
20-
RESULTS 10-

The occurrence of various condyle/fossa quad- I I I I

rant relationships in maximal dental intercuspation 0 I II III IV

are shown in Fig. 4. Fifty-three percent of the
subjects exhibited an inferior, anterior position of
the condyle (quadrant IV). Eleven percent exhib-
ited condyle/fossa concentricity. Nineteen percent
exhibited an inferior, posterior condyle position
(quadrant III). The remaining 17% of the subjects
were equally divided between condyle positions
superior, anterior (quadrant I) and superior, poste-
rior (quadrant II). These findings are statistically
significant at p < 0.001. Thus the null hypothesis
that the four quadrants may occur with equal
probability can be rejected. The chi-square good-
ness-of-fit statistical test was used.
Quadrant
Fig. 4. Frequency of condyle location by quadrant in habitual
occlusion.
DISCUSSION AND CONCLUSIONS
A method of describing the geometric relation-
ship of the condyle within the glenoid fossa on a
sagittal cephalometric radiograph has been de-
scribed. While it is recognized this is a two-dimen-
sional representation of complex three-dimensional
structures, there is sufficient precedent of estab-
lished useful two-dimensional representations of
638 Braun
many other dentofacial structures in general cepha-
lometry. It is believed the method described will be
explored further by other researchers to potentially
further our understanding of the structures of the
temporomandibular joint, not only in relation to
the dentition, but to surrounding dentofacial struc-
tures as well.
Applying this condyle/fossa location method to
the dentition in habitual occlusion revealed that
89% of subjects studied exhibited nonconcentric
condyle positions, while free of TMJ symptoms. In
a recent study correlating magnetic resonance im-
aging images with articulator mounted casts, Alex-
ander et al. 22 found approximately 50% of the
condyles were not concentrically located in a group
of 28 patients who were free of TMJ symptoms.
This augments my finding suggesting that concen-
tricity alone may not be a valid measurement of
TMJ health. The articular disk should be included
in any assessment of temporomandibular joint im-
pairment.
REFERENCES
1. Mongini F, Schmid W. Assessment of the therapeutic posi-
tion for orthodontic diagnosis and treatment. Am J Orthod
1982;82:513-8.
2. Graber TM, Swain BF. Orthodontics: current principles and
techniques. St Louis: CV Mosby, 1985:229-42.
3. Gilboe DB. Centric relations as the treatment position.
J Prosthet Dent 1983;50:685-9.
4. Williamson EH. Occlusion and TMJ dysfunction: J Clin
Orthod 1981;15:333-50.
5. Dawson PE. Centric relation: its effect on occluso-muscle
harmony. Dent Clin North Am 1979;23:169-80.
6. McNeil C. The optimum TMJ condyle position in clinical
practice. Int J Periodontic Restorative Dent 1985;6:53-76.
7. Parker MW. A dynamic model of etiology in temporoman-
dibular disorders. J A m Dent Assoc 1990;120:283-90.
8. Sadowski C, Poison AM. Temporomandibular disorders and
functional occlusion after orthodontic treatment: results of
two long-term studies. Am J Orthod 1984;86:386-90.
9. Greene CS. Orthodontics and temporomandibular disor-
ders. Dent Clin North Am 1988;32:529-38.
10. Egerrnark-Eriksson I, Carlsson GE, Magnusson T. A long-
term epidemiologic study of the relationship between oc-
American Journal of Orthodontics and Dentofacial Orthopedics
June 1996
elusal factors and mandibular dysfunction in children and
adolescents. J Dent Res 1987;66:67-71.
11. Loft GH, Reynolds JM, Zwemer JD, Thompson WO,
Dushku J. The occurrence of craniomandibular symptoms in
healthy young adults with and without prior orthodontic
treatment. Am J Orthod Dentofac Orthop 1989;96:
264-5.
12. Pullinger A, Monteiro A, Liu S. Etiological factors associ-
ated with temporomandibular disorders (Abstract 848).
J Dent Res 1985;64:269.
13. Williamson GH. The role of craniomandibular dysfunction
in orthodontic diagnosis and treatment planning. Dent Clin
North Am 1983;27:541-60.
14. Thompson JR. Abnormal function of the temporomandibu-
lar joints and related musculature: orthodontic implications,
part 1. Angle Orthod 1986;56:143-63.
15. Roth RH. Temporomandibular pain-dysfunction and oc-
clusal relationships. Angle Orthod 1973;43:136-53.
16. Wyatt WE. Preventing adverse effects on the temporoman-
dibular joint through orthodontic treatment. Am J Orthod
Dentofac Orthop 1987;91:493-9.
17. Reuling N. Comparative study of clinical examination, oc-
clusal analysis and new radiologic imaging procedures in
patients with functional TMJ disorders. J Oral Rehabil
1987;14:165-74.
18. Williamson EH. Occlusion and TMJ dysfunction. J Clin
Orthod 1981;15:333-50.
19. Baumriud S, Frantz RC. The reliability of head film mea-
surements and landmark identification. Am J Orthod 1971;
60(29):11t-27.
20. McNamara JA. A method of cephalometric analysis. Am J
Orthod 1984;86:449-69.
21. Mamoru W, Farman AG, Nishikawa K, Kuroyangi K, Scarfe
WC, Braun S. A dual sensitivity screen system for TMJ
image enhancement in cephalometric radiography: sensito-
metric evaluation. Dentomaxifac Radiol (in press).
22. Alexander SR, Moore RN, DuBois LM. Mandibular
condyle position: comparison of articulator mountings and
magnetic resonance imaging. Am J Orthod Dentofac
Orthop 1993;104:230-9.
Reprint requests to:
Dr. Stanley Braun
Department of Orthodontic, Pediatric and
Geriatric Dentistry
School of Dentistry
University of Louisville
7940 Dean Rd.
Indianapolis, IN 46240