Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1402e1407

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Correlation between bony changes measured with cone beam

computed tomography and clinical dysfunction index in patients with
temporomandibular joint osteoarthritis
Naichuan Su a, b, Yan Liu a, c, Xianrui Yang a, d, Zhiqiang Luo e, Zongdao Shi a, c, *
a
State Key Laboratory of Oral Disease, West China School of Stomatology, Sichuan University, Chengdu, China
b
Department of Prosthodontics, West China School of Stomatology, Sichuan University, Chengdu, China
c
Department of Oral and Maxillofacial Surgery, West China School of Stomatology, Sichuan University, Chengdu, China
d
Department of Orthodontics, West China School of Stomatology, Sichuan University, Chengdu, China
e
Department of Prosthodontics, School of Stomatology, Peking University, Beijing, China

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To investigate the correlation between clinical dysfunction index (Di) and condylar bony
Paper received 31 January 2014 changes, glenoid fossa bony changes and joint space changes.
Accepted 8 April 2014 Methods: Clinical data and cone beam computed tomography (CBCT) images of 240 patients with
temporomandibular joint osteoarthritis (TMJ OA) were analyzed. The patients were assigned a score of
Keywords: Helkimo’s clinical Di ranging from 1 to 25 and thereafter divided into 3 groups by the degree of Helkimo’s
Cone beam computed tomography
Di. The condylar bony changes observed with CBCT were graded by the classification method of Koyama
Temporomandibular joint
et al. Glenoid fossa bony changes and joint space changes were both classified as “positive” or “negative”.
Osteoarthritis
Spearman’s rank correlation test was used to correlate the score or degree of Helkimo’s Di with the
maximum condylar bony changes, glenoid fossa bony changes, and joint space changes.
Results: There was a significant correlation between the Helkimo’s Di score and the maximum condylar
bony changes (P
0.0001) and glenoid fossa bony changes (P
0.0001), and there was a poor correlation
between the Helkimo’s Di score and joint space changes (P ¼ 0.184). Furthermore, there was a significant
correlation between the degree of Helkimo’s Di and the maximum condylar bony changes (P
0.0001)
and glenoid fossa bony changes (P
0.0001), but there was a poor correlation between the degree of
Helkimo’s Di and joint space changes (P ¼ 0.346).
Conclusions: Both the score and degree of Helkimo’s Di were highly correlated with maximum condylar
changes and glenoid fossa bony changes, but not with joint space changes.
Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction
The temporomandibular joint (TMJ), which comprises the
mandibular condyle, the inferior component, and the temporal
bone forming the superior component, is one of the most complex
joints in the body (Wu et al., 2012). Temporomandibular disorders
(TMD) are clinically manifested by craniofacial pain, limited mouth
opening, and TMJ click occurring in the TMJ, masticatory muscles
and other relevant structures (John et al., 2007). Approximately
* Corresponding author. Department of Oral and Maxillofacial Surgery, West
China School of Stomatology, Sichuan University, No. 14, South Renmin Rd, Chengdu
610041, China.
E-mail address: shizd_0663@163.com (Z. Shi).
10%e70% of the population presents with some type of TMD, such
as myofascial dysfunction, internal derangement or degenerative
joint disease. TMD is epidemic in women between 20 and 40 years
old (Barros Vde et al., 2009). Osteoarthritis of the TMJ (TMJ OA) is a
degenerative joint disease and is an age-related disorder charac-
terized by the progressive destruction of articular tissues in the
mandibular condyle and glenoid fossa often brought about by
increased loading on the joint (Okeson, 2008). With advanced
degeneration, loss of the subchondral cortical layer, erosion and
other radiographic signs will occur (Stegenga et al., 1989, 1991).
Cone beam computed tomography (CBCT), a new imaging
modality used in dentistry, is thought to have high dimensional
accuracy in measuring facial structures, including the TMJ (Lascala
et al., 2004) and may be the modality of choice for assessing the

http://dx.doi.org/10.1016/j.jcms.2014.04.001
1010-5182/Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
 N. Su et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1402e1407 1403

osseous morphology of the TMJ (Hilgers et al., 2005). CBCT is
increasingly popular for use in TMJ imaging.
Many authors have noted the need to have a standardized
classification for assessing the signs and symptoms of TMD,
measuring and comparing the severity of TMJ disorders among
populations, and assessing patients’ condition after treatment; they
also require a useful implement to study the etiological factors
(Miller et al., 2000). Helkimo was a pioneer in developing indexes
to measure the severity of TMJ disorders and pain in TMJ. Helkimo’s
clinical dysfunction index (Di), developed in 1974, is the first such
relevant index (Helkimo, 1974). Di is a functional evaluation of the
masticatory system and classifies individuals on 5 basic signs,
including impaired range of mandibular movement, TMJ function
impairment, pain during mandibular movement, TMJ pain during
palpation, and muscle tenderness (Shahidi et al., 2013).
Many researchers have evaluated the correlation between the
presence of symptoms or signs of TMD and radiographic changes in
the TMJ using different imaging modalities (Crow et al., 2005;
Palconet et al., 2012; Ohlmann et al., 2006; Huh et al., 2003;
Emshoff et al., 2003), and the outcomes were controversial. Some
studies demonstrated correlations between symptoms or signs
such as pain intensity and the radiographic findings in OA, disc
displacement and joint effusions (Huh et al., 2003; Emshoff et al.,
2003), while others failed to find a correlation (Crow et al., 2005;
Palconet et al., 2012; Ohlmann et al., 2006).
The aim of this study is to determine whether bony changes,
including condylar bony changes, glenoid fossa bony changes and
joint space changes, measured with CBCT are correlated with Hel-
kimo’s clinical Di in TMJ OA patients.
2. Materials and methods
and 4.0 mA and an exposure time of 17.5 s. The voxel size was
0.125 mm, and the slice thickness was 1.0 mm. The field of view
(FOV) size was 120 mm. The images were analyzed with inbuilt
software (i-Dixel one volume viewer 1.5.0) using a Dell Precision
T5400 workstation (Dell, Round Rock, TX, USA). Axial, coronal, and
sagittal 2D sectional images were displayed on a 32-inch Dell LCD
screen with a resolution of 1280  1024 pixels in a dark room. Two
independent oral and maxillofacial specialists interpreted all of the
images. Any doubt about which classification to assign was deci-
sively evaluated by a third specialist. Based on the CBCT images, the
type of condylar bony changes was classified using the classifica-
tion system of Koyama et al. (Koyama et al., 2007) as follows:
Type N: No proliferation or thickening on the cortical surface of
the condyle; displaying typical morphology;
Type F: Flattened contour at the antero- and/or postero-superior
portions of the condyle;
Type E: Proliferation or partial hypodense change with or
without roughening on the cortical surface of the condyle;
Type D: A deformed contour on the condyle, such as a beak,
without proliferation or partial hypodense change on the
condylar surface;
Type S: Type D accompanied by Type E.
Glenoid fossa bony changes were classified as “positive” in the
presence of flattening, erosion and/or sclerosis in either joint, or as
“negative” if the glenoid fossa was normal in both joints. Joint space
changes were classified as “positive” in the presence of the devia-
tion of joint space, including increase, reduction or bony contact
between the condyle head and mandibular fossa in either joint, or
as “negative” if the joint space was normal in both joints.

2.1. Study design 2.2. Statistical analysis

The study was approved by the Ethics Committee of the West The statistical analysis was conducted using SPSS 15.0 (SPSS Inc.,
China Hospital of Stomatology at Sichuan University (WCHSIRB-D- Chicago, USA) software. Only the maximum bony change of the
2013-092). CBCT images and clinical records of TMJ OA patients condyle was used as a covariate. Spearman’s rank correlation test
who sought treatment at the Hospital’s Orofacial Pain Clinic from was used to correlate both the scores and degrees of Helkimo’s Di
July 2012 to July 2013 were reviewed in this study. The inclusion with the maximum condylar bony change, glenoid fossa bony
criteria were: diagnosis of TMJ OA according to the Research changes and joint space changes.
Diagnostic Criteria for TMDs (RDC/TMD axis I group IIIb), defined by For testing inter-examiner reliability, the measurements by the
the presence of arthralgia and either TMJ crepitation or CBCT bony two specialists for interpreting the CBCT images were evaluated by
changes, including erosion, flattening or sclerosis of joint surfaces the Kappa test. For testing intra-examiner reliability, 72 subjects
or osteophyte formation (Dworkin and LeResche, 1992). The were randomly selected 2 weeks after the initial review, and their
exclusion criteria were the following: other types of TMD such as radiological reports were reviewed again under the same stan-
myofascial disorder syndrome but normal TMJ structure or rheu- dardized conditions. The consistency between the first and second
matic diseases; a history of TMJ surgery, condylar fracture, jaw measurements of each specialist was also evaluated by the Kappa
trauma or polyarthritis; subjects with missing data. test.
The clinical signs, including TMJ function impairment, muscle
tenderness during palpation, TMJ pain during palpation, pain during
Table 1
mandibular movement and range of mandibular mobility (5 items), Kappa coefficients of inter- and intra-examiner reliability of different variables.
based on the definition of Helkimo’s clinical Di (Helkimo, 1974),
Variables Kappa value Error P value
were extracted from all included patients. Depending on the pres-
ence and/or severity of these clinical symptoms, each patient was Inter-examiner reliability (N ¼ 240)
assigned a score of 0, 1 or 5 points for each item. Depending on the Specialist 1 vs. Specialist 2
Condylar bony changes 0.847 0.028
0.0001
total score, the individuals were divided into 4 groups: Fossa glenoid bony changes 0.848 0.041
0.0001
Joint space changes 0.943 0.025
0.0001
Di 0: 0 point e absence of clinical symptoms; Intra-examiner reliability (N ¼ 72)
Di 1: 1e4 points e mild dysfunction symptoms; Specialist 1
Condylar bony changes 0.922 0.024
0.0001
Di 2: 5e9 points e moderate dysfunction symptoms;
Fossa glenoid bony changes 0.954 0.020
0.0001
Di 3: 10e25 points e acute/serious dysfunction symptoms. Joint space changes 0.954 0.020
0.0001
Specialist 2
The CBCT images of the bilateral TMJ were obtained with a 3D Condylar bony changes 0.896 0.028
0.0001
Accuitomo CBCT machine (MCT-1 [EX-2F], Morita Manufacturing Fossa glenoid bony changes 0.900 0.028
0.0001
Joint space changes 0.908 0.027
0.0001
Corp, Kyoto, Japan) with image capture parameters set at 85.0 kV
1404 N. Su et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1402e1407

Table 2 joint space changes are shown in Table 3. Some examples of find-
Distributions of number of patients based on the Helkimo’s Di scores and degrees. ings of bony changes and joint space changes observed by CBCT and
Helkimo’s Di degrees Helkimo’s Number of their associated scores and degrees of Helkimo’s Di are shown in
Di scores patients Figs. 1e3.
Di 0 0 0 According to Spearman’s rank correlation test, the score for
Di 1 1 7 Helkimo’s clinical Di is significantly associated with maximum
2 18 condylar bony changes (P
0.0001) and glenoid fossa bony changes
3 16
(P
0.0001), but not with joint space changes (P ¼ 0.84). The de-
4 8
Total 49 gree of Helkimo’s clinical Di (Di0eDi3) is significantly associated
Di 2 5 7 with maximum condylar bony changes (P
0.0001) and glenoid
6 17 fossa bony changes (P
0.0001), but not with joint space changes
7 18
(P ¼ 0.346) (Table 4).
8 21
9 21
Total 84 4. Discussion
Di 3 10 6
11 15 OA is defined as a low-inflammatory arthritis condition, either
12 24
primary or secondary to trauma or other acute or chronic overload
13 18
15 3 situations, and it is characterized by the erosion of articular carti-
16 13 lage that becomes soft, frayed and thinned, resulting in eburnation
17 12 of the subchondral bone and outgrowth of marginal osteophytes
20 7
(Lohmander et al., 1996). OA is the most common type of TMD in the
21 7
25 2 clinic. The general symptoms of TMJ OA include pain or stiffness in
Total 107 the face and jaws, pain on wide opening, pain on chewing, inability
to open wide, locking or catching of the mandible, and joint noise
(Zarb and Carlsson, 1999). The clinical signs include tenderness to
3. Results palpation of the TMJ and/or the muscles of mastication, limited or
deviated mandibular movements, pain with movement, locking or
A total of 240 patients (194 females and 46 males) met the in- subluxation, and joint sounds (Zarb and Carlsson, 1999).
clusion criteria and were enrolled in the study. Their mean age was Various imaging modalities have been used for evaluating the
36  15.6 years. Strong inter- (Kappa coefficient 0.847e0.943) and morphological bony changes of TMJ OA. Panoramic radiography,
intra- (Kappa coefficient 0.896e0.954) examiner agreements were conventional linear or complex motion tomography, and CT are used
observed for all variables (Table 1). to assess the osseous components of the joints, while magnetic
According to Helkimo’s Di among the total study sample, 0 (0%) resonance imaging (MRI) is used to assess the soft tissue compo-
patients were classified as absent clinical symptoms (Di 0), 49 nents of the TMJ (Barghan et al., 2012). However, panoramic radi-
(20.4%) as mild (Di 1), 84 (35.0%) as moderate (Di 2) and 107 (44.6%) ography has several limitations, such as structural distortion,
as severe (Di 3). The mean score of Helkimo’s Di of the 240 patients superimposition from the zygomatic process, and the inability to
was 9.52 (standard deviation, SD ¼ 5.35). The distribution of pa- show the entire articular surface of the TMJ (Crow et al., 2005).
tients based on the Helkimo’s Di scores and the degrees are shown Panoramic radiographs also have low reliability and low sensitivity
in Table 2. for detecting osseous changes in the TMJ (Ahmad et al., 2009) and
Furthermore, for the maximum condylar bony changes, 0 (0%) thus are of limited value in TMJ assessments. Conventional linear or
patients were classified as Type N, 81 (33.7%) as Type F, 90 (37.5%) complex motion tomography underestimates small bone abnor-
as Type E, 33 (13.8%) as Type D and 36 (15.0%) as Type S. Addi- malities, and the diagnostic accuracy of TMD is limited, although it is
tionally, 54 patients (22.5%) were classified as positive for glenoid superior to panoramic radiographs in sensitivity and specificity for
fossa bony changes, while 186 (77.5%) were negative. Moreover, 185 detecting osseous changes (Flygare et al., 1995). CT has high cost and
patients (77.1%) were classified as positive for joint space changes, relatively high radiation, and there is low access to equipment, all of
while 55 patients (22.9%) were negative. The distributions of scores which limit its use for evaluation of the TMJ (Barghan et al., 2012).
and degrees of Helkimo’s Di and the number of patients based on Helkimo’s Di, which has been widely used in dentistry, espe-
maximum condylar bony changes, glenoid fossa bony changes, and cially in TMD, since 1974, is considered a practical and useful tool

Table 3
Distribution of scores and degrees of Helkimo’s Di and number of patients based on maximum condylar bony changes, fossa glenoid bony changes, and joint space changes.

Bony changes Number Scores of Helkimo’s Degrees of Helkimo’s Di

of patients Di (mean  SD)
1 2 3

Maximum condylar bony changes

Type F 81 6.33  4.16 34/81 (42.0%) 30/81 (37.0%) 17/81 (21.0%)
Type E 90 9.03  4.26 13/90 (14.4%) 41/90 (45.6%) 36/90 (40.0%)
Type D 33 12.09  4.50 2/33 (6.1%) 8/33 (24.2%) 23/33 (69.7%)
Type S 36 15.53  4.90 0/36 (0.0%) 5/36 (13.9%) 31/36 (86.1%)
Fossa glenoid bony changes
Negative 186 8.76  5.02 45/186 (24.2%) 69/186 (37.1%) 72/186 (38.7%)
Positive 54 12.13  5.69 4/54 (7.4%) 15/54 (27.8%) 35/54 (64.8%)
Joint space changes
Negative 55 8.65  5.36 15/55 (27.3%) 17/55 (30.9%) 23/55 (41.8%)
Positive 185 9.77  5.34 34/185 (18.4%) 67/185 (36.2%) 84/185 (45.4%)

SD, standard deviation.

 N. Su et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1402e1407 1405

Fig. 1. Sample images of different types of condylar bony changes according to Koyama et al.’s criteria. Images were from subjects in this study. (a) Female aged 28 years with
maximum bony change of condyle was Type F; the score of Helkimo’s Di was 2, and the degree was 1. (b) Female aged 21 years with maximum bony change of condyle was Type E;
the score of Helkimo’s Di was 5, and the degree was 2. (c) Female aged 40 years with maximum bony change of condyle was Type D; the score of Helkimo’s Di was 9, and the degree
was 2. (d) Female aged 39 years with maximum bony change of condyle was Type S; the score of Helkimo’s Di was 17, and the degree was 3.

for evaluation of TMD and makes between-study comparison
possible (Larsson and Rönnerman, 1981). Hekimo’s Di has been
extensively used to evaluate the clinical or radiographic conditions
of TMD (Shahidi et al., 2013; Kordass et al., 2012; He et al., 2010;
Barrera-Mora et al., 2012; Perillo et al., 2011; Rauhala et al., 1999).
Shahidi et al. (2013) investigated the correlation between articular
eminence steepness measured with CBCT and Helkimo’s Di and
failed to find a correlation. Kordass et al. (2012) investigated the
correlation between computer-assisted measurements of mandib-
ular opening and closing movements and Helkimo’s Di and found a
significant correlation between Helkimo’s Di and frequent popping
sounds in jaw joints and deviation. He et al. (2010) investigated the
relationship between centric relationemaximum intercuspation
discrepancy and Helkimo’s Di in pre-treated orthodontic patients
and found CReMI discrepancy in most of the pre-treated patients
with signs and symptoms of TMD. This discrepancy may be a factor
contributing to the development of TMD in these patients.
The above-mentioned barriers have been overcome with the
advent of CBCT. CBCT has several advantages over CT, such as lower
cost, better access to equipment, lower radiation, and diagnostic
efficacy as high as CT, but superior to those of panoramic radiog-
raphy and linear tomography (Barghan et al., 2012). CBCT is also
superior to CT for visualizing bony changes in TMJ patients,
analyzing lateral slices in isolation, and combining coronal and
lateral slices (Koyama et al., 2007; Honey et al., 2007). Therefore,
CBCT was the imaging method used in this study.
In this study, the condylar bony changes were detected using the
classification of Koyama et al., which was more practical and
convenient for the evaluation of bone changes in TMD patients
compared with other classifications (Koyama et al., 2007). In this
classification, types F and E are comparatively the initial stages of
bony changes. Flattening, which is a typical change of Type F, may
be an adaptive alteration (Crusoe-Rebello et al., 2003) and the first
change of progressive disease (Katzberg, 1989). Type F transitions
to Type E as the disease proceeds, indicating that TMJ is unstable
and that the bone surface will change. Moreover, some clinical
follow-up studies demonstrated that type E might advance to type
D or type S because of the progression of condylar resorption, while
type D might advance to type S after the cortical surface is restored
(Koyama et al., 2007). Thus, condylar bony changes were classified
as the progression stage of TMD in the classification of Koyama et al.
This system of classification was already introduced into the eval-
uation of condylar bony changes observed by CBCT in TMJ OA pa-
tients and was proven accurate for diagnosing condylar bony
changes (Palconet et al., 2012).
The results in this study showed that the score and degree of
Helkimo’s Di were both significantly associated with maximum
condylar bony changes and glenoid fossa bony changes evaluated
by CBCT. The development of the OA symptomatology has already
been described clinically (Rasmussen, 1983). In the initial stage, the
diagnosis of OA was difficult to separate from other types of TMD,
such as internal derangement of the TMJ, by clinical or radiographic
examination. That is, extremely few patients had symptoms of pain
or abnormal function at this stage. Instead, patients might have
clicking or periodic locking of the TMJ. Therefore, the score and
degree of Helkimo’s Di were low. In the second stage, TMJ pain
occurred. The pain may be caused by the soft tissues around the
affected joint under tension and the masticatory muscles in pro-
tective reflex co-contraction as a result of Hilton’s Law (Mercuri,
2008). Moreover, the procession of OA can lead to degradation on
the surface of the articular soft tissue. When there were large
quantities of degraded products that could not be efficiently
resorbed from the joint cavity by the synovial membrane, an in-
flammatory response might be elicited to develop synovitis and

Fig. 2. Sample images of different types of glenoid fossa bony changes classified into “negative” and “positive”. Images were from subjects in this study. (a) Female aged 25 years
with negative glenoid fossa bony change; the score of Helkimo’s Di was 7, and the degree was 2. (b) Male aged 48 years with positive glenoid fossa bony change; the score of
Helkimo’s Di was 20, and the degree was 3. (c) Female aged 49 years with positive glenoid fossa bony change; the score of Helkimo’s Di was 17, and the degree was 3. (d) Female
aged 30 years with positive glenoid fossa bony change; the score of Helkimo’s Di was 11, and the degree was 3.
1406 N. Su et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1402e1407
Fig. 3. Sample images of different types of joint space changes classified into “negative” and “positive”. Images were from subjects in this study. (a) Female aged 33 years with
negative joint space change; the score of Helkimo’s Di was 9, and the degree was 2. (b) Male aged 35 years with positive joint space change (anterior joint space was increased); the
score of Helkimo’s Di was 9, and the degree was 2. (c) Female aged 45 years with positive joint space change (posterior joint space was increased); the score of Helkimo’s Di was 7,
and the degree was 2. (d) Female aged 52 years with positive joint space change (joint space was decreased); the score of Helkimo’s Di was 13, and the degree was 3.
cause pain (Saxne et al., 1993). Pain also arose from the subchondral
bone undergoing destruction as a result of the arthritic process
(Mercuri, 2008). In the late stage of OA, a reduced normalization of
mandibular function or even late-stage ankylosis and joint insta-
bility occurred, while radiography revealed increased bone defor-
mation (Mercuri, 2006). Therefore, in the last stage, the score and
degree of Helkimo’s Di might be high and reasonably significantly
associated with condylar bony changes.
Meanwhile, bony changes of the glenoid fossa might occur
because the cases with more severe OA frequently had perforation
or erosion of discs belonging to the most advanced group of ab-
normalities (Honda et al., 2001). That is, when bony changes of the
glenoid fossa were positive, OA was in the late stage, and the score
and degree of Helkimo’s Di were high with the disc perforation or
erosion. Therefore, that may explain why the score and degree of
Helkimo’s Di were both significantly associated with bony changes
of the glenoid fossa. However, little attention has been paid to these
bony changes in previous clinical studies.
We did not find an association between the score or degree of
Helkimo’s Di and joint space changes. Some clinical studies showed
that chronic disk displacement was a common cause of OA, and
reduced joint space was the most common finding in OA patients
(Alexiou et al., 2009). Joint space was found to be normal in only 24%
of the joints, while it was reduced in 50%, increased in 4%, and bony
contact was observed between the condylar head and mandibular
fossa in 22% of TMJ OA patients (Alexiou et al., 2009). Bony contact
was expected to be observed in groups of older patients (Alexiou
et al., 2009). In our study, joint space changes occurred in 77% of
OA patients, which included increase, reduction or bony contact
between the condyle head and mandibular fossa in either of the
patient’s joints. Therefore, we conclude that the occurrence of joint
space variation is not an indication of OA severity.
Some clinical studies suggested no significant correlation
between the presence of symptoms or signs and the degree of
radiographic changes in the TMJ (Crow et al., 2005; Palconet et al.,
Table 4
Correlation of the scores or degrees of Helkimo’s Di with maximum condylar bony
changes, fossa glenoid bony changes, or joint space changes (N ¼ 240).
Variables Scores of Helkimo’s Di Degrees of Helkimo’s
Di
r P value r P value
Maximum condylar 0.561
0.0001 0.500
0.0001
bony changes
Fossa glenoid bony 0.245
0.0001 0.235
0.0001
changes
Joint space changes 0.086 0.184 0.061 0.346
r, correlation coefficient.
2012; Ohlmann et al., 2006). Poor correlation was reported be-
tween CBCT-observed condylar changes classified by Koyama’s
classification and pain, mouth opening, protrusion, or lateral
movement of the mandible in TMJ OA patients (Palconet et al., 2012).
The reasons may be attributed to differences in inclusion criteria;
previous studies (Crow et al., 2005; Ohlmann et al., 2006) included
patients with TMD and some subtypes diagnosed by RDC/TMD,
while our study included only patients with TMJ OA diagnosed by
RDC/TMD. Additionally, the sample sizes in these studies were
limited, and the power might be low. Second, the symptoms and
signs were considered separately in these studies, but signs or
symptoms alone may be insignificantly correlated with radio-
graphic findings. In our study, therefore, we used a widely used
index to evaluate TMJ OA, which considered the symptoms and signs
as a whole. Moreover, the methods of pain evaluation were different.
Palconet et al. (2012) used a verbal rating scale (VRS) in which 0 was
“no pain” and 10 was “the worst pain possible”, and the pain was
evaluated by the patients. In our study, the pain was evaluated as the
number of pain sites in muscle palpation, TMJ palpation and
mandibular movements. The pain was evaluated by the doctors, and
the assessment might be more objective. Furthermore, the imaging
modalities used in these studies, including panoramic radiography
(Crow et al., 2005) and MRI (Ohlmann et al., 2006), were different
from ours. These reasons explain the differences.
However, this study was subject to some limitations. The in-
clusion criteria of a small number of cited references (Honda et al.,
2001) used for the explanation of the outcomes was not totally the
same as ours, and this might cause some bias. Additionally, the TMJ
is a bilateral articulation with movements on each side. We only
considered the side with maximum condylar bony changes, which
might cause some deviation in the outcomes. Furthermore, the
glenoid fossa bony changes and joint space changes were only
classified into two categories of “positive” and “negative”. Although
this classification is convenient and has been used in other clinical
studies (Palconet et al., 2012), it may be not detailed enough for
evaluating the changes that occur in OA.
5. Conclusions
In conclusion, the results showed that both the score and degree
of Helkimo’s Di were highly correlated with maximum condylar
changes and glenoid fossa bony changes, but not with joint space
changes.
Acknowledgments
The authors declare no potential conflicts of interest with
respect to the authorship and/or publication of this article.
 N. Su et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1402e1407 1407

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