avaliaÇÃo tomogrÁfica da morfologia e de …

PONTIFÍCIA UNIVERSIDADE CATÓLICA DE MINAS GERAIS

Programa de Pós-graduação em Odontologia

Tania Mara de Souza Ianni

AVALIAÇÃO TOMOGRÁFICA DA MORFOLOGIA E DE POSICIONAMENTO DO

PROCESSO CONDILAR EM PACIENTES COM MÁ-OCLUSÃO

Belo Horizonte

2020




Dissertação apresentada ao Programa de Pós-

graduação em Odontologia da Pontifícia

Universidade Católica de Minas Gerais, como

requisito parcial para obtenção do título de

Mestre em Odontologia, Área de Concentração:

Clínicas Odontológicas, Área Temática:

Radiologia Odontológica e Imaginologia.

Linha de pesquisa: Métodos de diagnóstico por

imagem, radiobiologia e radioproteção.

Orientador: Prof. Dr. Amaro Ilídio Vespasiano

Silva

Belo Horizonte

2020

FICHA CATALOGRÁFICA

Elaborada pela Biblioteca da Pontifícia Universidade Católica de Minas Gerais

Ianni, Tania Mara de Souza

I11a Avaliação tomográfica da morfologia e de posicionamento do processo

condilar em pacientes com má-oclusão / Tania Mara de Souza Ianni. Belo

Horizonte, 2020.

63 f. : il.

Orientador: Amaro Ilídio Vespasiano Silva

Dissertação (Mestrado) - Pontifícia Universidade Católica de Minas Gerais.

Programa de Pós-Graduação em Odontologia

1. Articulação temporomandibular - Tomografia. 2. Maloclusão -

Tratamento. 3. Tomografia computadorizada de feixe cônico. 4. Côndilo

mandibular. 5. Diagnóstico por imagem. 6. Mandíbula. I. Silva, Amaro Ilídio

Vespasiano. II. Pontifícia Universidade Católica de Minas Gerais. Programa de

Pós-Graduação em Odontologia. III. Título.

CDU: 616.314-073

Ficha catalográfica elaborada por Fernanda Paim Brito - CRB 6/2999




Dissertação apresentada ao Programa de Pós-

graduação em Odontologia da Pontifícia

Universidade Católica de Minas Gerais, como

requisito parcial para obtenção do título de

Mestre em Odontologia. Área de Concentração:

Clínicas Odontológicas – Área Temática:

Radiologia Odontológica e Imaginologia.

COMPOSIÇÃO DA BANCA EXAMINADORA:

1- Profa. Dra. Cláudia Assunção e Alves Cardoso – Faculdade Promove BH 2- Prof. Dr. Flávio Ricardo Manzi – PUC Minas 3- Prof. Dr. Amaro Ilídio Vespasiano Silva – PUC Minas

DATA DA APRESENTAÇÃO E DEFESA: 21 de fevereiro de 2020

A dissertação, nesta identificada, foi aprovada pela Banca Examinadora

Prof. Dr. Amaro Ilídio Vespasiano Silva Prof. Dr. Rodrigo Villamarim Soares Orientador Coordenador do Programa de Pós-graduação

em Odontologia

AGRADECIMENTOS

À minha querida mãe por ser meu amparo e proteção, meu porto seguro

sempre.

À Beatriz, antes de filha, amiga e confidente.

À Helena, por preencher tudo com sua alegria.

À Márcia, Andrea, Carlinha e Claudinho, obrigada por todo esse amor e

amizade. A confiança de vocês me faz acreditar sempre.

Ao professor, orientador, mas antes de tudo amigo, Amaro Vespasiano.

Obrigada pela paciência nesta jornada e principalmente pela generosidade em

compartilhar seus conhecimentos. Seu apoio tornou tudo mais simples. Sua

simplicidade tornou tudo possível.

Ao professor e amigo Flávio Ricardo Manzi pela confiança e por ser sempre

uma inspiração como profissional e como pessoa.

Aos colegas do mestrado pela amizade, companheirismo.

Aos funcionários da PUC pela ajuda, em especial Silvania e Angélica.

Agradeço de maneira muito especial à Deus por tudo que tem me ajudado e

por todos que coloca em meu caminho.

RESUMO

O objetivo no presente estudo foi analisar a articulação temporomandibular (ATM),

utilizando tomografias computadorizadas de feixe cônico (TCFC), verificando se

alterações de posição e morfologia, estão relacionadas com os tipos de má-oclusão

de classe I, II e III. Os métodos consistem na análise de 329 imagens de TCFC de

pacientes provenientes do banco de imagens da Clínica de Radiologia do

Departamento de Odontologia da Pontifícia Universidade Católica de Minas Gerais.

Esses pacientes foram classificados em más-oclusões classe I, II e III pela

metodologia proposta na análise de Steiner. A posição condilar foi aferida por meio

da medição dos espaços articulares (anterior, superior e posterior), da profundidade

da fossa mandibular, da inclinação dos processos condilares nos planos sagital,

coronal e axial e ainda pelo alinhamento dos processos condilares. A classificação

da morfologia foi realizada no plano coronal, definindo as formas condilares como

arredondadas, planas ou anguladas. Os dados obtidos foram submetidos à análise

estatística pelo teste de ANOVA com um critério com nível de significância de 5%,

além de correlacionados entre si, a fim de se verificar possíveis correlações entre as

variáveis e as más-oclusões de classe I, II e III. Foram obtidos resultados

estatisticamente significantes na inclinação sagital entre os grupos classe I e II, e

classe II e III. Na inclinação coronal entre os grupos classe II e III. No grupo de

classe II o espaço articular posterior mostrou-se significativamente maior, quando

comparados com os espaços anterior e superior. Comparando-se o espaço superior

entre os três grupos vemos uma diferença estatisticamente significante entre os

grupos de classe I e III. O teste estatístico utilizado para análise morfológica foi o

Teste de Kruskall Wallis (p 0,05) e mostrou uma predominância do formato redondo

nos três grupos. Após analisar todas as medições, podemos concluir que há uma

menor inclinação sagital e maior inclinação coronal no grupo de classe II. Este grupo

apresenta ainda a cabeça da mandíbula anteriorizada enquanto nos grupos de

classe I e III o processo condilar apresenta-se centralizado. O espaço articular

superior apresenta-se significativamente maior no grupo de classe III. Houve uma

predominância do formato condilar arredondado em todos os grupos estudados.

Palavras-chave: Má-oclusão. Tomografia computadorizada de feixe cônico. Côndilo

mandibular. Diagnóstico por imagem. Mandíbula.

ABSTRACT

The objective of the present study was to analyze the temporomandibular joint (TMJ),

using cone beam computed tomography (CBCT), verifying changes in position and

morphology, related to the types of class I, II and III malocclusions. The methods

consist of the analysis of 329 images of the TCFC of patients using the image bank

of the Radiology Clinic of the Dentistry Department of the Pontifical Catholic

University of Minas Gerais. These patients were classified into class I, II and III

malocclusions by the methodology proposed in Steiner's analysis. A conditional

position was assessed by using the articular spaces (anterior, superior and

posterior), the depth of the mandibular fossa, the inclination of the conditional

processes in the sagittal, coronal and axial planes and also by the alignment of the

conditional processes. The classification of the morphology was performed in the

coronal plane, defining conditional shapes as rounded, flat or angled. The analyzed

data were analyzed with ANOVA test analysis with a significance level of 5%, in

addition to being correlated with each other, in order to verify possible correlations

between variables and class I, II and III malocclusions. Statistically significant results

were selected in sagittal inclination between the class I and II, class II and III groups.

In coronal inclination between class II and III groups. No class II group or posterior

joint space showed a greater increase, when compared to the anterior and upper

spaces. Comparing the upper space between the three groups, we see a statistically

significant difference between the class I and III groups. The statistical test used for

morphological analysis was the Kruskall Wallis test (page 0.05) and showed a

predominance of the round shape in three groups. After analyzing all the

measurements, we can conclude that there is less sagittal tilt and greater coronal tilt

in the class II group. This group also presents the head of the anterior mandible,

while in the groups of class I and III or conditional process it is centralized. The upper

articular space is larger in the class III group. There was a predominance of the

rounded shape in all groups studied.

Keywords: Malocclusion. Cone-beam computed tomography. Mandibular condyle.

Diagnosis by image. Jaw.

LISTA DE ABREVIATURAS E SIGLAS

ANB Ângulo formado pela diferença entre SNA e SNB

ATM Articulação Temporomandibular

CBCT Cone-beam computed tomography (Tomografia computadorizada de

feixe cônico)

FOV Field of View (campo de visão)

PUC Minas Pontifícia Universidade Católica de Minas Gerais

SNA Ângulo formado entre o plano Sela-Násio e ponto A

SNB Ângulo formado entre o plano Sela-Násio e ponto B

SN-MP Ângulo formado entre plano Sela-Násio e Plano Mandibular

TCFC Tomografia Computadorizada de Feixe Cônico

LISTA DE FIGURAS

Figura 1: Classificação da amostra .......................................................................... 21

Figura 2: Classificação baseada na Análise de Steiner ............................................ 22

Figura 3: Profundidade da fossa mandibular ............................................................ 23

Figura 4: Inclinação do processo condilar/plano sagital ........................................... 24

Figura 5: Inclinação do processo condilar/plano coronal .......................................... 24

Figura 6: Inclinação do processo condilar/plano axial .............................................. 25

Figura 7: Espaços articulares: anterior (A), superior (B) e posterior (C) ................... 26

Figura 8: Alinhamento dos processos condilares ..................................................... 26

Figura 9: Classificação da morfologia do processo condilar ..................................... 27

SUMÁRIO

1 INTRODUÇÃO ...................................................................................................... 17

2 OBJETIVOS ......................................................................................................... 19

2.1 Objetivo geral ................................................................................................... 19

2.2 Objetivos específicos ...................................................................................... 19

3 MATERIAL E MÉTODOS ..................................................................................... 21

3.1 Seleção da amostra ......................................................................................... 21

3.2 Obtenção das imagens .................................................................................... 23

3.3 Análise da posição do processo condilar ...................................................... 23

3.4 Análise da morfologia condilar ....................................................................... 26

3.5 Análise estatística ............................................................................................ 27

4 ARTIGO CIENTÍFICO ........................................................................................... 29

5 CONSIDERAÇÕES FINAIS .................................................................................. 55

REFERÊNCIAS ....................................................................................................... 57

ANEXO A - Parecer Consubstanciado do CEP PUC Minas ................................. 59

17

1 INTRODUÇÃO

A articulação temporomandibular (ATM) é uma articulação bastante

especializada que possui uma série de características próprias e pode apresentar

considerável variação de forma. Articula os arcos dentais: superior e inferior, onde

os dentes exercem uma grande influência nas posições da mandíbula e nos seus

movimentos (TEIXEIRA, REHER, 2012).

O processo condilar, bem como as outras estruturas da ATM, é importante

para sustentar uma boa oclusão e um sistema estomatognático balanceado. Existem

vários fatores que podem afetar a morfologia e a posição desta articulação, como

idade, sexo, padrão de crescimento facial, alterações patológicas e/ou funcionais,

atividade muscular diminuída ou aumentada, força oclusal e alterações da oclusão

dentária (ARIETA-MIRANDA et al., 2013).

Com a introdução da tomografia computadorizada de feixe cônico (TCFC) na

odontologia, exames tomográficos são cada vez mais utilizados, pois oferecem

benefícios para o diagnóstico das estruturas ósseas craniofaciais, especialmente a

posição e a morfologia da ATM (ROQUE-TORRES et al., 2018).

Parece haver uma mudança posicional condilar apenas em pacientes com

tendência de crescimento vertical mostrando que o padrão de crescimento tem

influência na posição condilar (GANUGAPANTA et al., 2017). A morfologia condilar

varia de acordo com morfologia facial vertical e esta variação deve ser considerada

para predição e estabelecimento de plano de tratamento adequado para desordens

temporomandibulares durante tratamento ortodôntico (PARK; KIM; PARK, 2015).

Em pacientes que apresentam desvios de linha média dentária ou esquelética

ou que apresentem ainda má oclusão de classe II subdivisão, ocorre uma assimetria

de posicionamento dos processos condilares (MATTOS et al., 2017; ROQUE-

TORRES et al., 2018).

Deslocamento anterior dos processos condilares independente do tipo de má

oclusão e prevalência de morfologia convexa em grupos de má oclusão de classe I e

II foram achados em pesquisas que buscam avaliar a concentricidade e posição

condilar (MERIGUE et al., 2016).

Articulações com desordens temporomandibulares apresentaram o ângulo

médio do côndilo axial menor, significando que os côndilos das articulações afetadas

podem girar para dentro (AL-RAWI; UTHMAN; SODEIFY, 2017).

18

Algumas medidas lineares, angulares e volumétricas dos processos

condilares diferem significantemente entre os três padrões esqueléticos (I, II, III) e a

posição vertical dos côndilos e altura do ramo mandibular podem contribuir

significativamente para o deslocamento do queixo (ZHANG et al., 2013).

Esforços para relacionar os processos condilares com as más oclusões

mostraram um posicionamento anteriorizado em pacientes com padrão esquelético

classe II (PAKNAHAD; SHAHIDI, 2017).

Podemos observar que a pesquisa da morfologia e do posicionamento

condilar, não obstante a ajuda de uma ferramenta de imagem de grande acurácia,

como a TCFC, ainda não é unânime em sua relação com as más oclusões

ortodônticas.

Correlacionar o formato do processo condilar e sua posição dentro da fossa

mandibular com as más oclusões ortodônticas podem oferecer subsídios para um

plano de tratamento ortodôntico e das disfunções temporomandibulares mais

adequado e abrangente.

19

2 OBJETIVOS

2.1 Objetivo geral

O objetivo neste estudo foi verificar a relação entre posição e morfologia do

processo condilar da mandíbula com as más-oclusões de classe I, classe II e classe

III, por meio de TCFC.

2.2 Objetivos específicos

a) mensurar os espaços intra-articulares superior, anterior e posterior

relacionando com o tipo de má-oclusão;

b) classificar o formato do processo condilar e relacionar com o tipo de má-

oclusão;

c) avaliar e comparar a posição do processo condilar nos planos sagital,

coronal e axial.

21

3 MATERIAL E MÉTODOS

Este trabalho foi aprovado pelo Comitê de Ética em Pesquisa da Pontifícia

Universidade Católica de Minas Gerais, CAEE: 97241718.5.0000.5137 (ANEXO A).

3.1 Seleção da amostra

Figura 1: Classificação da amostra

Fonte: Elaborado pela autora

Este estudo é uma pesquisa do tipo corte transversal retrospectivo onde

foram utilizados 329 exames de TCFC, previamente obtidas de um banco de

imagens, por meio de uma amostra de conveniência, derivada da população de

pacientes que procuraram o Departamento de Odontologia da PUC Minas, Clínica

de Radiologia, para diagnóstico inicial de tratamento ortodôntico.

As imagens selecionadas para este trabalho foram obtidas de pacientes sem

perdas de dentes permanentes (exceto terceiros molares), abrangendo toda a

329 indivíduos

176 mulheres/153 homens

189 classe I

60 classe II

80 classe III

22

estrutura crânio-maxilofacial, sem apresentar grandes assimetrias nas estruturas

faciais, com idade entre 18 e 60 anos (idade média de 39 anos).

Foram usados como critérios de exclusão os pacientes com história de

cirurgia ou trauma na região crânio facial, presença de doenças sistêmicas que

afetem a morfologia articular como doenças inflamatórias ou degenerativas das

articulações. Pacientes com história de desordens temporomandibulares como: dor,

desconforto articular, presença de ruído, crepitação e limitação de abertura também

foram excluídos.

Todas as 329 imagens tomográficas dos pacientes foram classificadas como

má oclusão classe I, II e III baseado na metodologia da análise de Steiner (Fig. 2).

Nesta análise o ângulo ANB é dado pela diferença dos ângulos SNA (formado

pelos pontos Sela, Násio e ponto A) e SNB (formado pelos pontos Sela, Násio e

ponto B). Pacientes com ângulo ANB entre 0 e 4,5 foram classificados como má

oclusão de classe I, maior que 4,5 como má oclusão de classe II e menor que 0,

como má oclusão de classe III (OLIVEIRA JÚNIOR et al., 2007).

Figura 2: Classificação baseada na Análise de Steiner


23

3.2 Obtenção das imagens

As imagens de TCFC foram adquiridas utilizando o tomógrafo i-CAT® (Imaging

Sciences, Hatfield, PA, EUA), com os parâmetros de exposição de 120kV e 7 mA,

tempo de aquisição de 40s e de reconstrução de 62s, com voxel de 0,3 mm e FOV

(Field of View) de 23 x 17 cm. Todas as imagens utilizadas nesse estudo foram

obtidas com os pacientes posicionados sentados, com a posição da cabeça

estabilizada pelos próprios dispositivos do aparelho, de modo que o plano sagital

mediano ficasse perpendicular ao plano horizontal e o Plano de Frankfurt paralelo ao

plano horizontal.

Todas as imagens utilizadas no presente estudo apresentavam-se adequadas

nos aspectos de densidade, contraste e nitidez para avaliação das estruturas

pesquisadas, além de se enquadrarem nos critérios de inclusão da pesquisa.

3.3 Análise da posição do processo condilar

Os dados tomográficos para posição foram reconstruídos pelo software Kodak

Dental Imaging Software® versão 6.11.7.0-B, (Carestream Health, Rochester, Nova

York, EUA).

A profundidade da fossa mandibular (Fig. 3) será a medida de uma reta

perpendicular que passe pelo ponto mais superior da fossa mandibular (C) em

direção ao plano formado pelo ponto mais inferior do tubérculo articular (A) e o ponto

mais inferior do canal auditivo (B) (ROQUE-TORRES et al., 2018).

Figura 3: Profundidade da fossa mandibular


A

C

B

24

A inclinação do processo condilar no plano sagital corresponde ao ângulo

formado entre o longo eixo do processo condilar e o plano oclusal em uma

reconstrução sagital (Fig. 4) (ROQUE-TORRES et al., 2018).

Figura 4: Inclinação do processo condilar/plano sagital


A inclinação do processo condilar no plano coronal corresponde ao ângulo

formado entre o longo eixo do processo condilar e o plano oclusal em uma

reconstrução coronal (Fig. 5) (ROQUE TORRES et al., 2018).

Figura 5: Inclinação do processo condilar/plano coronal


A inclinação do processo condilar no plano axial (Fig. 6) corresponde ao

ângulo formado entre uma linha que passe pelo centro geométrico do processo

condilar da mandíbula até o plano sagital mediano (plano que une a espinha nasal

anterior e espinha nasal posterior), em uma reconstrução axial (ROQUE TORRES et

al., 2018).

25

Figura 6: Inclinação do processo condilar/plano axial


O espaço articular anterior (A) corresponde a distância linear da superfície do

processo condilar e a parede anterior da fossa mandibular sobre a bissetriz anterior

formada entre os planos vertical e horizontal que se tangenciam no centro

geométrico do processo condilar. O espaço articular superior (B) corresponde à

distância linear entre a superfície do processo condilar e a cortical do ponto mais

superior da fossa mandibular seguindo o plano vertical que tangencia o centro do

processo condilar. O espaço articular posterior (C) corresponde à distância linear

entre a superfície do processo condilar e a cortical da parede posterior da fossa

mandibular sobre a bissetriz posterior formada entre os planos vertical e horizontal

que se tangenciam no centro geométrico do processo condilar (Fig. 7) (ROQUE-

TORRES et al. 2018).

26

Figura 7: Espaços articulares: anterior (A), superior (B) e posterior (C)


Para o alinhamento dos processos condilares foi realizado a medida da

distância entre os pontos dos centros geométricos dos processos condilares direito e

esquerdo projetados perpendicularmente sobre plano sagital mediano (ROQUE

TORRES et al., 2018).

O ponto que representa o centro geométrico do processo condilar direito

projetado no plano sagital mediano é considerado o ponto 0 (zero). Os valores

localizados acima do ponto zero serão considerados positivos, e abaixo, negativos

(Fig. 8).

Figura 8: Alinhamento dos processos condilares


3.4 Análise da morfologia condilar

A classificação da morfologia do processo condilar foi realizada em um plano

coronal, baseado no proposto por Kinzinger, Kober e Diedrich (2007) que define as

formas condilares como arredondadas (a), planas (b) e anguladas (c) (Fig. 9).

Ponto zero

Acima valores positivos

Abaixo valores negativos

27

Figura 9: Classificação da morfologia do processo condilar


3.5 Análise estatística

Para avaliação das mensurações da profundidade da fossa mandibular, dos

espaços articulares (anterior, superior e posterior), da inclinação dos processos

condilares nos cortes sagital, coronal e axial e posição geométrica no plano axial, o

teste estatístico executado foi ANOVA um critério e no caso de significância

estatística executou-se o pós-hoc de Tukey. Para avaliação da morfologia dos

processos condilares foi utilizado Teste de Kruskall Wallis (p 0,05). Toda a análise

estatística foi realizada considerando nível de significância de 5% (α =0.05).

29

4 ARTIGO CIENTÍFICO

Tomographic evaluation of the morphology and positioning of the

condillary process in patients with malocclusion

Artigo apresentado de acordo com as normas do periódico

Dentomaxillofacial Radiology (Qualis A2).

Normas para submissão de artigos podem ser encontradas no endereço

eletrônico: http://www.birpublications.org/page/manuscripts/dmfr.

30

Tomographic evaluation of the morphology and positioning of the condillary process in

patients with malocclusion

T M S Ianni¹, P P S Carlos2, M N Azevedo¹, F R Manzi

3, A I V Silva

3

1 Master, Department of Dentistry, Pontifical Catholic University of Minas Gerais, Belo

Horizonte, Brazil.

2Graduation Student, Department of Dentistry, Pontifical Catholic University of Minas

Gerais, Belo Horizonte, Brazil.

3PhD, Department of Dentistry, Pontifical Catholic University of Minas Gerais, Belo

Horizonte, Brazil.

Correspondence to: Amaro Ilídio Vespasiano Silva, Pontifical Catholic University of Minas

Gerais (PUC Minas), Department of Dentistry – Radiology, Av. Dom José Gaspar, 500,

Prédio 46 - Coração Eucarístico, ZIP 30535-901, Belo Horizonte, MG, Brazil, Phone.: +55 31

3319-4414, Fax: +55 31 3319-4410, E-mail: [email protected].

31

Author Contribution Statement

DMFR requires that for all submitted papers:

all the authors have made substantive contributions to the article and assume full

responsibility for its content; and

all those who have made substantive contributions to the article have been named as

authors.

The International Committee of Medical Journal Editors recommends the following definition

for an author of a work, which we ask our authors to adhere to:

Authorship be based on the following 4 criteria [1]:

Substantial contributions to the conception or design of the work; or the acquisition,

analysis, or interpretation of data for the work; AND

Drafting the work or revising it critically for important intellectual content; AND

Final approval of the version to be published; AND

Agreement to be accountable for all aspects of the work in ensuring that questions

related to the accuracy or integrity of any part of the work are appropriately

investigated and resolved.

32

Please list below all authors of this work and a brief description of how they each contributed

towards your submission:

Author name Contribution

Tania Mara de Souza Ianni Acquisition, analysis and interpretation of research data;

Writing the content of the work

Paula Perdigão Starling Carlos Data acquisition for Research

Mariana Neves Azevedo Critical content review

Flávio Ricardo Manzi Interpretation of research data

Amaro Ilídio Vespasiano Silva Conception and design of the research; final approval of the work

Please continue on further pages if needed.

1 The International Committee of Medical Journal Editors, Roles and Responsibilities of

Authors, Contributors, Reviewers, Editors, Publishers, and Owners: Defining the Role of

Authors and Contributors, http://www.icmje.org/roles_a.html

http://www.icmje.org/roles_a.html

33

Morphological and positioning evaluation of the condylar process in patients with

malocclusion, in CFFC

Morphology / position evaluation of the condylar process in patients with malocclusion

Type of manuscript: Research article

Tania, MS Ianni - MSc - Department of Dentistry-Radiology-Pontifical Catholic University of

Minas Gerais

Paula, PS Carlos - Graduation Student - Department of Dentistry-Radiology-Pontifical

Catholic University of Minas Gerais

Mariana, N Azevedo – MSc - Department of Dentistry Pontifical Radiology Catholic

University of Minas Gerais

Flávio, R Manzi - PhD - Department of Dentistry-Radiology-Pontifical Catholic University of

Minas Gerais

Amaro, IV Silva - PhD - Department of Dentistry-Radiology-Pontifical Catholic University of

Minas Gerais

The present study had no external sources of funding and the authors state that there is no

conflict of interest in this research.

34

Abstract

Objectives: The objective of the present study was to analyze the temporomandibular joint

(TMJ), using cone beam computed tomography (CBCT), checking whether changes in

position and morphology are related to the types of class I, II and III malocclusions.

Methods: The methods consist of analyzing 329 CBCT images of patients from the image

bank of the Radiology Clinic of the Dentistry Department of the Pontifical Catholic

University of Minas Gerais. These patients were classified into class I, II and III

malocclusions based on the methodology of Steiner's analysis. The condylar position was

measured by measuring the joint spaces (anterior, superior and posterior), the depth of the

mandibular fossa, by measuring the inclination of the condylar processes in the sagittal,

coronal and axial planes and also by aligning the condylar processes. The classification of the

morphology was performed in the coronal plane, defining the condylar shapes as rounded, flat

or angled. The data obtained were subjected to statistical analysis by the ANOVA test with

one criterion, significance level of 5%, in addition to correlating each other, in order to verify

possible correlations between the variables and class I, II and malocclusions III.

Results: Significant results were obtained in the sagittal inclination between the class I and II,

and class II and III groups, as well as in the coronal inclination between the class II and III

groups. In the class II group, the posterior articular space was significantly larger when

compared with the anterior and superior spaces. Comparing the upper space between the three

groups, we see a statistically significant difference between the upper spaces between the

class I and III groups. The statistical test used for morphological analysis was the Kruskall

Conclusions: We can conclude that there is less sagittal inclination and greater coronal

inclination in the class II group. This group also presents the anterior mandible head while in

the class I and III groups the condylar process is centralized. The upper articular space is

significantly larger in the class III group. There was a predominance of the rounded condylar

shape in all groups studied.

Key Words: Malocclusion. Cone beam computed tomography. Mandibular condyle.

Diagnosis by image. Jaw.

35

Introduction

The TMJ is a very specialized joint that has a number of its own characteristics and

can vary considerably in shape. It articulates the upper and lower dental arches, where the

teeth exert a great influence on the positions of the jaw and its movements.1

The condylar processes, as well as the other structures of the TMJ, are important to

support a good occlusion and a balanced stomatognathic system. Several factors can affect the

morphology and position of this joint, such as age, sex, facial growth pattern, pathological

and/or functional changes, decreased or increased muscle activity, occlusal strength, and

changes in dental occlusion.2

Cone beam computed tomography (CBCT) in dentistry was an extraordinary advance

in the quality of diagnostic tests, and its superiority in evaluating the morphology and position

of condylar processes is clear among researchers.3-5

Although there has been research relating the characteristics of the TMJ with facial or

dental asymmetries2,6-9

, presenting samples with symptoms or asymptomatic10,11

, or with

normal occlusion12

, the findings are controversial.

For some time, interesting studies have been carried out on this joint using CT scans,

looking for evidence to show the relationship between the type of malocclusion and the shape

or position of the condylar process.2,13-20

Assessing the concentricity of the condylar processes, a prevalence of a more anterior

positioning of them, regardless of the type of malocclusion, was observed.13

Class II growth

pattern patients presented with the condylar processes previously positioned in comparison

with the class I and III groups.15

Al-Rawi NH et al.10

, comparing the condylar position in normal joints and with

temporomandibular disorders, observed that the affected condylar processes may be turned

inward.

36

Park et al.20

found that the morphology of the condylar process varies according to the

vertical facial pattern, and this variation must be considered for the prediction and

establishment of an adequate treatment plan for temporomandibular disorders during

orthodontic treatment.

As we can see, the results of the most current studies have brought important

information about the relationship between condylar position/morphology and growth

patterns or malocclusions. As occlusion is a factor that influences the temporomandibular

joints, the evaluation of the position and morphology of the condylar processes may help in

orthodontic planning. Despite the quality of the CBCT exams and the efforts of researchers,

there are still gaps in the knowledge of this relationship that can be useful in clinical practice

in the diagnosis and prognosis of orthodontic treatments and temporomandibular disorders.

Material and Methods

This work was approved by the Research Ethics Committee of the Pontifical Catholic

University of Minas Gerais, CAEE: 97241718.5.0000.5137.

In a retrospective cross-sectional study CT scans, previously obtained from an image

bank. The sample comprised 329 patients, 176 men and 153 women, and was a convenience

sample derived from the population of patients who sought the PUC Minas Dentistry

Department/Radiology Clinic for initial diagnosis of orthodontic treatment.

The images selected for this study were obtained from patients with no permanent

teeth loss (except third molars), covering the entire craniomaxillofacial structure, without

showing major asymmetries in the facial structures, aged between 18 and 60 years (mean age

39 years).

Exclusion criteria were patients with a history of surgery or trauma in the craniofacial

region, the presence of systemic diseases that affect joint morphology such as inflammatory

37

or degenerative diseases of the joints. Patients with a history of temporomandibular disorders

such as pain, joint discomfort, presence of noise, crackling, and limited opening were also

excluded.

All 329 tomographic images of the patients were classified as class I, II, and III

malocclusions according to the methodology of Steiner's analysis (189 class I patients, 60

class II patients, and 80 class III patients) (Figure 1). In this analysis, the ANB angle is given

by the difference between the angles SNA (formed by points Sela, Násio, and point A) and

SNB (formed by points Sela, Násio, and point B). Patients with an ANB angle between 0 and

4.5 were classified as class I malocclusion, greater than 4.5 as class II malocclusion, and

less than 0 as class III malocclusion.21

TCFC images were acquired using the i-CAT® Tomograph (Imaging Sciences,

Hatfield, PA, USA), with exposure parameters of 120 kV and 7 mA, 40s acquisition time, and

62s reconstruction time, with 0,3 mm, and FOV (Field of View) of 23 x 17 cm. All images

used in this study were obtained with the patients positioned seated, with the head position

stabilized by the device's own devices, so that the median sagittal plane was perpendicular to

the horizontal plane and the Frankfurt plane parallel to the horizontal plane.

All images used in the present study were adequate in terms of density, contrast, and

sharpness for the evaluation of the researched structures, in addition to meeting the inclusion

criteria of the research.

Tomographic data for position were reconstructed using Kodak Dental Imaging

Software® version 6.11.7.0-B (Carestream Health, Rochester, New York, USA).

Depth of the mandibular fossa

The depth of the mandibular fossa (Figure 2) will be the measurement of a

perpendicular straight line that passes through the uppermost point of the mandibular fossa

38

(C) towards the plane formed by the lowest point of the articular tubercle (A) and the lowest

point of the canal auditory (B).3

Inclination of the condylar process in the sagittal plane

The inclination of the condylar process in the sagittal plane corresponds to the angle

formed between the long axis of the condylar process and the occlusal plane in a sagittal

reconstruction (Figure 3).3

Inclination of the condylar process in the coronal plane

The condylar process inclination in the coronal plane corresponds to the angle formed

between the long axis of the condylar process and the occlusal plane in a coronal

reconstruction (Figure 4).3

Inclination of the condylar process in the axial plane

The inclination of the condylar process in the axial plane (Figure 5) corresponds to the

angle formed between a line that passes through the geometric center of the condylar process

of the mandible to the median sagittal plane (plane that joins the anterior nasal spine and

posterior nasal spine), in an axial reconstruction.3

Joint spaces: Anterior (A), Upper (B) and Posterior (C)

The anterior articular space (A) corresponds to the linear distance from the surface of

the condylar process and the anterior wall of the mandibular fossa on the anterior bisector

formed between the vertical and horizontal planes that are tangent in the geometric center of

the condylar process. The upper articular space (B) corresponds to the linear distance between

the surface of the condylar process and the cortical of the most superior point of the

39

mandibular fossa following the vertical plane that touches the center of the condylar process.

The posterior articular space (C) corresponds to the linear distance between the surface of the

condylar process and the cortical of the posterior wall of the mandibular fossa on the posterior

bisector formed between the vertical and horizontal planes that tangent in the geometric center

of the condylar process (Figure 6).3

Alignment of condylar processes

For the alignment of the condylar processes, the distance between the points of the

geometric centers of the right and left condylar processes was projected perpendicularly over

the median sagittal plane.3

The point that represents the geometric center of the right condylar process projected

on the median sagittal plane is considered the point 0 (zero). Values located above the zero

point will be considered positive, and below, negative (Figure 7).

The classification of the condylar process morphology was performed in a coronal

plane, based on the one proposed by Kinzinger et al.22

, which defines condylar shapes as

rounded (a), flat (b) and angled (c) (Figure 8).

To evaluate the measurements of the depth of the mandibular fossa, of the articular

spaces (anterior, superior and posterior), of the inclination of the condylar processes in the

sagittal, coronal, and axial sections, and geometric position in the axial plane, the statistical

test performed was ANOVA a criterion, and in the in case of statistical significance, Tukey's

post-hoc test was performed. To evaluate the morphology of the condylar processes, the

Kruskal-Wallis test was used (p0.05). All statistical analysis was performed considering a

significance level of 5% (α = 0.05).

40

Results

At the end of the analysis of the depth of the mandibular fossa, it was found that there

are no statistically significant differences between the groups of patients with class I, II, and

III malocclusions. However, analyzing the data, a slightly greater depth of the mandibular

fossa is noted in patients with class I malocclusion, although without statistically significant

differences (Table 1).

The analysis of the sagittal inclination of the condylar process showed statistical

significance in the comparison between the class I and II groups, where the class I

malocclusion group shows a greater sagittal inclination in relation to the class II malocclusion

group. There was also statistical significance in the comparison between the class II and class

III malocclusion groups, showing a greater sagittal inclination in the class III malocclusion

group. When comparing groups, I and III, there were no statistically significant differences.

When evaluating the three groups, the highest sagittal inclination of all groups is noted in the

class I group (Table 1).

After analyzing the inclination of the condylar process in the coronal plane, it was

found that there was a statistically significant difference between the groups of patients with

class II and III malocclusion, with patients with class II malocclusion having a greater coronal

inclination when compared to the coronal tilt of class III patients. There was no statistically

significant difference in the class II group when compared with the class I group and when we

also compared the class III group with the class I group (Table 1).

We can also see that the inclination of the condylar processes in the axial plane did not

present statistically significant differences between the groups of patients with class I, II, and

III malocclusions, and the axial inclinations of the three groups had approximate measures

(Table 1).

41

In the evaluation of joint spaces, the results showed statistically significant differences

only when we analyzed the upper joint space. This difference could be observed between

patients with class I and III malocclusion, where we found larger upper joint spaces in

patients with class III malocclusion (3.1 ± 1.3 mm). There were no significant differences in

the upper joint spaces when comparing the patients in the class I and II and class II and III

malocclusion groups, as shown in Table 2.

The tests did not show statistically significant differences for the anterior spaces.

However, in the data analysis, larger anterior articular spaces are observed in the class III

malocclusion group (3.1 ± 1.5), evidencing a more posterior positioning of the condylar

process in class III patients and joint spaces of very close sizes in class I patients, thus

demonstrating a trend towards centralized positioning of the condylar process in class I

patients.

When analyzing the posterior joint spaces, we found no statistically significant

differences between the three groups, but we can see the smallest sizes (2.8 ± 0.8) in the class

I malocclusion group.

The analysis of the alignment of the condylar processes in the axial plane did not show

statistically significant differences between the patients with class I, II, and III malocclusion,

although it can be observed in the patients of the three groups that the geometric centers of the

condylar processes are below the point considered zero point (projection of the geometric

point on the right side perpendicular to the median sagittal plane), as shown in Table 1, where

we only observed negative values.

The statistical tests for the morphological analysis showed that there is a

predominance of the rounded shape in the three groups studied, on both sides, left and right,

as shown in Table 3.

42

Discussion

In this research, the tomographic exams of the evaluated patients were previously

divided into class I, II, and III patients using the methodology proposed by Steiner's analysis,

which is based on the size of the ANB angle. Other studies were based on vertical

classifications2,15,18,20

on overbite and growth pattern14

, or even in normal occlusions.12

Different classifications of sample malocclusions can make it difficult to compare the

findings. For future research, standardized classifications of the types of malocclusions can be

useful in comparing the concentricity and morphology of the condylar processes.

Some studies sought to verify whether mandibular asymmetries observed on the face6

or asymmetric malocclusions such as subdivision class II malocclusion8,9

were also found in

condylar positioning. In the study by De Mattos et al.8, patients with class II subdivision

malocclusion presented right and left glenoid fossa asymmetrically, with class II side distally

and laterally, despite the condyles being positioned symmetrically within the glenoid fossa.

This shows that despite the asymmetry of the glenoid fossa, there was concentricity within the

joint. In our study, which did not aim to relate concentricity to midline deviations, a

concentricity of condylar processes was also found in the class I and III malocclusion groups.

Comparing the two studies, we can say that regardless of the type of malocclusion, the

condylar processes tend to be positioned concentrically within the glenoid fossa.

In their 2017 work, Huang et al.9 observed dental characteristics of the class II

subdivision malocclusion: the asymmetry and sagittal position of the upper and lower first

molars between the two sides and significant lingual inclination of the lower first molar on the

class II side. Condylar morphology and asymmetries in the position of the glenoid fossa were

the major components of skeletal asymmetry and were well correlated with the three-

dimensional position of the first molar. The findings of these authors show that the

asymmetries seen in the dental and facial midlines or the mandibular asymmetries are also

43

revealed in asymmetries in the position of the condylar processes. In the present study, the

correlation between midline deviations and malocclusions was not evaluated, but it is

worthwhile to highlight the influence of these asymmetries on condylar positioning.

In the work by Park et al.20

, among the several variables studied, a significant

difference was found in the upper condylar space in the hypodivergent and hyperdivergent

groups. In our study, we can also see that the class III malocclusion group presented the

largest upper joint space in a statistically significant way when we compared the three groups

of malocclusions. Although the samples are numerically different, and the classification of

malocclusions is not the same, there was agreement in the findings.

In their comparative study, Ganugapanta et al.14

evaluated individuals with normal

occlusion and malocclusion and found a significant change in the position of the condylar

process in patients with a vertical growth pattern compared to the average of patients with a

horizontal growth pattern. The left condylar process was more anteriorly located than the right

one in all groups they studied. In our research, we found statistically significant measures for

sagittal inclination in the group with class II malocclusion, showing the smallest measures for

this inclination, revealing the condylar process also more anterior. In Ganugapanta et al.14

paper, no significant change was found in the vertical depth of the mandibular fossa in all

three groups studied, another finding that also coincides with the findings for assessing the

mandibular depth of our research that found no significant differences for the depth of the

mandibular fossa for the three groups of malocclusions studied.

Our results are not in accordance with the study by Arieta-Miranda et al.2 in relation to

joint spaces. Arieta-Miranda et al.2 found a significant difference in the anterior joint space

when comparing class I with class II and class III groups; the superior articular space was

smaller in class II and class III when compared with the class I group and, finally, there was

no statistically significant difference in the posterior condylar space between the groups. Our

44

research found condylar processes with approximate values suggesting concentricity in the

class I and III groups, a statistically significant greater posterior joint space in the class II

group, suggesting an anteriorization of the condylar processes in this group, and even higher

upper joint spaces that are statistically significant in the class III group. Despite the disparity

in results, the two studies used the same methodology for classifying malocclusions, although

there is a considerable difference in the sample size.

In our study, the condylar morphology found, evaluated in a coronal section, was

predominantly rounded for the three groups of malocclusions studied. Merigue et al.13

most

often found convex condyles in their sample, which also used coronal slices in the

assessment. Park et al.20

found that condylar morphology varies according to facial

morphology. In fact, the findings of these authors do not coincide with our study, which

suggests that the sample size may have had an influence on the results, since these studies

have samples of 49 and 60 patients, respectively.

Conclusion

In all evaluations and tests in this sample of 329 patients, we can observe a lower

sagittal inclination and a greater coronal inclination in the class II group, as well as a tendency

towards centralized positioning of the condylar process for patients in the class I and III

groups, and positioning for patients in the class II group, in this population studied. We also

observed a predominance of the rounded shape in the morphology of all studied groups.

45

References

1. Teixeira LMS, Reher P. Anatomia aplicada à odontologia. 2. ed. Rio de Janeiro.

Guanabara Koogan; 2012.

2. Arieta-Miranda JM, Silva-Valencia M, Flores-Mir C, Paredes-Sampen NA, Arriola-

Guillen LE. Spatial analysis of condyle position according to sagittal skeletal

relationship, assessed by cone beam computed tomography. Prog Orthod. 2013; 14:36.

3. Roque-Torres GD, Peyneau PD, Costa ED, Bóscolo FN, Almeida SM, Ribeiro LW.

Correlation between midline deviation and condylar position in patients with Class II

malocclusion: A cone-beam computed tomography evaluation. Am J Orthod Dentofacial

Orthop. 2018; 154:99-107.

4. Ma RG, Yin S, Li G. The detection accuracy of cone beam CT for osseous defects of the

temporomandibular joint: a systematic review and meta-analysis. Sci Rep. 2016;

6:34714.

5. Ladeira DB, Cruz AD, Almeida SM. Digital panoramic radiography for diagnosis of the

temporomandibular joint: CBCT as the gold standard. Braz Oral Res. 2015; 29:1-7.

6. Endo M, Terajima M, Goto TK, Tokumori K, Takahashi I. Three-dimensional analysis of

the temporomandibular joint and fossa-condyle relationship. Orthodontics (Chic.). 2011;

12:210-221.

7. Zhang Y, Che B, Ni Y, Zhang H, Pan Y, Wang L, et al. Three-dimensional condylar

positions and forms associated with different anteroposterior skeletal patterns and facial

asymmetry in Chinese adolescents. Acta Odontol Scand. 2013: 71:1174-80.

8. De Mattos JM, Palomo JM, Ruellas AC, Cheib PL, Eliliwi M, Souki BQ. Three-

dimensional positional assessment of glenoid fossae and mandibular condyles in patients

with Class II subdivision malocclusion. Angle Orthodontist. 2017; 87:847-854.

46

9. Huang M, Hu Y, Yu J, Sun J, Ming Y, Zheng L. Cone-beam computed tomographic

evaluation of the temporomandibular joint and dental characteristics of patients with

Class II subdivision malocclusion and asymmetry. Korean J Orthod. 2017; 47:277-288.

10. Al-Rawi NH, Uthman AT, Sodeify SM. Spatial analysis of mandibular condyles in

patients with temporomandibular disorders and normal controls using cone beam

computed tomography. Eur J Dent. 2017; 11:99-105.

11. Dalili Z, Khaki N, Kia SJ, Salamat F. Assessing joint space and condylar position in the

people with normal function of temporomandibular joint with cone-beam computed

tomography. Dental Res J. 2012; 5:607-612.

12. Vitral RW, da Silva Campos MJ, Rodrigues AF, Fraga MR. Temporomandibular joint

and normal occlusion: Is there anything singular about it? A computed tomographic

evaluation. Am J Orthod Dentofacial Orthop. 2011; 140:18-24.

13. Merigue LF, Conti AC, Oltramari-Navarro PV, Navarro RL, Almeida MR. Tomographic

evaluation of the temporomandibular joint in malocclusion subjects: condylar

morphology and position. Braz Oral Res. 2016; 30:1-7.

14. Ganugapanta VR, Ponnada SR, Gadam KP, Perumalla K, Khan I, Mohammed NA.

Computed tomographic evaluation of condylar symmetry and condyle-fossa relationship

of the temporomandibular joint in subjects with normal occlusion and malocclusion: a

comparative study. J Clin Diagn Res. 2017; 11:29-33.

15. Paknahad M, Shahidi S. Association between condylar position and vertical skeletal

craniofacial morphology: A cone beam computed tomography study. Int Orthod. 2017;

15:740-751.

16. Lingchem D, Qiang Z, Meiy T, Chao H, Xuetao C, Qing L. Comparative study of the

condylar positions in different sagittal skeletal facial types with cone-beam computed

tomography. West China J Stomatol. 2014; 32:383-386.

47

17. Fraga MR, Rodrigues AF, Ribeiro LC, Campos MJ, Vitral RW. Anteroposterior condylar

position: A comparative study between subjects with normal occlusion and patients with

Class I, Class II Division 1, and Class III malocclusions. Med Sci Monit. 2013; 19:903-

907.

18. Paknahad M, Shahidi S, Abbaszde H. Correlation between condylar position and

different sagittal skeletal facial types. J Orofac Orthop. 2016; 77:350-356.

19. Kaur A, Natt AS, Mehra SH, Maheshwari K, Sing G, Kaur A. Improved visualization and

assessment of condylar position in the glenoid fossa for different occlusions: A CBCT

Study. J Contemp Dent Pract. 2016; 17:679-686.

20. Park IY, Kim JH, Park YH. Three-dimensional cone-beam computed tomography-based

comparison of condylar position and morphology according to the vertical skeletal

pattern. Korean J Orthod. 2015; 45:66-73.

21. Oliveira WM Jr, Vigorito JW, Tuma CESN, Cabral LS, Maia AS, Maia DSP.

Determinação dos valores cefalométricos de wits em jovens amazonenses, com oclusão

normal. Rev Dent Press Ortodon Ortop Facial. 2007; 12:118-124.

22. Kinzinger G, Kober C, Diedrich P. Topography and morphology of the mandibular

condyle during fixed functional orthopedic treatment - a magnetic resonance imaging

study. J Orofac Orthop. 2007; 68:124-47.

48

Tables

Table 1 Condylar positioning

Class I Class II Class III

Depth of the mandibular fossa (mm) 8,4 ± 1,3 A 8,2 ± 1,2 A 8,2 ± 0,9 A

Inclination of the condylar process in

the sagittal plane (°) 123,3 ± 8,5 A 111,8 ± 13,5 B 121,4 ± 7,9 A


the coronal plane (°) 98,1 ± 6,4 AB 99,9 ± 7,2 A 97,3 ± 6,8 B


the axial plane (°) 70,3 ± 7,6 A 69,7 ± 9,5 A 71,5 ± 7,5 A

Alignment of condylar processes (mm) -0,4 ± 1,9 A -0,5 ± 0,9 A -0,3 ± 1,6 A

Means and standard deviation followed by distinct letters, uppercase vertically and lowercase letters horizontally

differ statistically from each other, by the ANOVA test with a criterion

Table 2 Condylar positioning/articular spaces

Articular spaces


Anterior 2,6 ± 0,7 Aa 2,6 ± 0,9 Ba 3,1 ± 1,5Aa

Upper 2,8 ± 0,7 Ab 2,8 ± 1,6 Bab 3,1 ± 1,3 Aa

Posterior 2,8 ± 0,8 Aa 3,8 ± 1,9 Aa 3,0 ± 0,9 Aa

Means and standard deviation followed by distinct letters, uppercase vertically and lowercase letters horizontally

differ statistically from each other, by the ANOVA test with a criterion

49

Table 3 Condylar morphology

Condylar Morphology


R L R L R L Total

Flat 30 22 12 14 8 7 93

Rounded 140 129 38 37 62 63 469

Angled 19 38 10 9 10 10 96

Total 189 189 60 60 80 80 658

Kruskal Wallis test (p0.05). Statistical analysis performed considering a significance level of 5% (α = 0.05).

50

Figure Legends

Figure 1 Classification based on Steiner's Analysis

Figure 2 Depth of the mandibular fossa

Figure 3 Inclination of the condylar process / sagittal plane

Figure 4 Inclination of the condylar process/coronal plane

Figure 5 Inclination of the Condylar process/ axial plane

Figure 6 Articular spaces: anterior (A), upper (B) and posterior (C)

Figure 7 Alignment of condylar processes

Figure 8 Classification of the condylar process morphology

51

Figure 1

Figure 2

Figure 3

A

C

B

52

Figure 4

Figure 5

Figure 6

53

Figure 7

Figure 8

Ponto zero

Acima valores positivos

Abaixo valores negativos

55

5 CONSIDERAÇÕES FINAIS

Nesta população estudada não ocorreu a associação de um posicionamento

do processo condilar à uma má oclusão, embora o exame de tomografia

computadorizada de feixe cônico ofereça uma imagem precisa. Mas podemos

observar uma clara predominância do formato arredondado nos processos

condilares avaliados.

57

REFERÊNCIAS

ARIETA-MIRANDA, J.M. et al. Spatial analysis of condyle position according to sagittal skeletal relationship, assessed by cone beam computed tomography. Progress in Orthodontics, v.14, p. 1-9, Oct. 2013. AL-RAWI, N.H.; UTHMAN, A.T.; SODEIFY, S.M. Spatial analysis of mandibular condyles in patients with temporomandibular disorders and normal controls using cone beam computed tomography. European Journal of Dentistry, v.11, n.1, p. 99-105, Jan./Mar. 2017. GANUGAPANTA, V.R. et al. Computed tomographic evaluation of condylar symmetry and condyle-fossa relationship of the temporomandibular joint in subjects with normal occlusion and malocclusion: a comparative study. Journal of Clinical & Diagnostic Research, v.11, n.2, p. ZC29-ZC33, Feb. 2017. KINZINGER, G.; KOBER, C.; DIEDRICH, P. Topography and morphology of the mandibular condyle during fixed functional orthopedic treatment - a magnetic resonance imaging study. Journal of Orofacial Orthopedics, v.68, n.2, p. 124-147, Mar. 2007. MATTOS, J.M. et al. Three-dimensional positional assessment of glenoid fossae and mandibular condyles in patients with Class II subdivision malocclusion. The Angle Orthodontist, v.87, n.6, p. 847-854, Nov. 2017. MERIGUE, L.F. et al. Tomographic evaluation of the temporomandibular joint in malocclusion subjects: condylar morphology and position. Brazilian Oral Research, v.30, n.1, p. 1-7, 2016.

OLIVEIRA JÚNIOR, W.M. et al. Determinação dos valores cefalométricos de Wits em jovens amazonenses, com oclusão normal. Revista Dental Press de Ortodontia e Ortopedia Facial, v.12, n.1, p. 118-124, jan./fev. 2007.

PAKNAHAD, M.; SHAHIDI, S. Association between condylar position and vertical skeletal craniofacial morphology: a cone beam computed tomography study. International Orthodontics, v.15, n.4, p. 740-751, Dec. 2017

PARK, I.Y.; KIM, J.H.; PARK, Y.H. Three-dimensional cone-beam computed tomography-based comparison of condylar position and morphology according to the vertical skeletal pattern. The Korean Journal of Orthodontics, v.45, n.2, p. 66-73, Mar. 2015. ROQUE-TORRES, G.D. et al. Correlation between midline deviation and condylar position in patients with Class II malocclusion: A cone-beam computed tomography evaluation. American Journal of Orthodontic and Dentofacial Orthopedics, v.154, n.1, p. 99-107, July 2018.

TEIXEIRA, L.M.S.; REHER, P. Anatomia aplicada à odontologia. 2. ed. Rio de Janeiro. Guanabara Koogan, 2012.

58

ZHANG, Y. et al. Three-dimensional condylar positions and forms associated with different anteroposterior skeletal patterns and facial asymmetry in Chinese adolescents. Acta Odontologica Scandinavica, v.71, n.5, p. 1174-1180, Sept. 2013.

59

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