Abstract
Abstract
Objective
The review involves the assessment of morphological variations in the temporomandibular joint (TMJ) and its associated structures in patients with temporomandibular disorder.
Introduction
Temporomandibular disorders (TMD) are debilitating conditions that affect the TMJ complex, surrounding musculature and osseous components. Studies have reported that TMD result from morphological alterations in TMJ. These alterations can be efficiently studied using three-dimensional imaging. This review will summarise the morphological changes in TMJ and associated structures based on studies with three-dimensional imaging in patients with TMD.
Inclusion criteria
The systematic review will include studies with adult subjects with any one symptom of TMD and those studies that assessed TMJ morphology using three-dimensional imaging like CT, cone beam CT, MRI or arthrography.
Methods
Systematic searches for relevant studies will be carried out in multiple databases. Sources will include MEDLINE, Scopus, Dentistry and Oral Sciences Source, Cochrane CENTRAL, CINAHL, Web of Science, ProQuest Dissertation and Thesis and Google Scholar. The databases will be searched from inception to November 2023. Analytical observational studies comprising retrospective and prospective cohort studies, case–control studies and analytical cross-sectional studies will be selected and critical appraisal will be performed. No restrictions will be imposed on the date and country of publication. Joanna Briggs Institute (JBI) guidelines for systematic effectiveness reviews will be followed for data appraisal, extraction and synthesis. The strength of evidence will be graded using the Grading of Recommendations, Assessment, Development and Evaluation method and the summary of findings will be created using GRADEpro software.
Ethics and dissemination
Ethical approval is not applicable for this study since this involves analysis of secondary data. Results will be disseminated through peer-reviewed publications and cnference presentations. A comprehensive summary of morphological alterations in TMJ is essential for assessing risk factors, accurate diagnosis, treatment planning and will collectively contribute to enhanced clinical care and overall patient well-being.
PROSPERO registration number
The protocol is registered in PROSPERO: CRD42023448882.
Keywords: Patients, Magnetic Resonance Imaging, Computed tomography, Temporomandibular Joint
STRENGTHS AND LIMITATIONS OF THIS STUDY.
A comprehensive systematic review methodology will be followed to assess morphological changes of the temporomandibular joint and associated structures using three-dimensional imaging.
This systematic review will follow the JBI methodology for aetiology and risk systematic reviews and the manuscript will adhere to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.
The search will be conducted across a wide range of databases including grey literature sources.
No language restriction will be applied in the selection of the studies.
The certainty of the evidence of this systematic review may be limited by the limited number of studies available and the possible low quality of the individual studies.
Background
The temporomandibular joint (TMJ) is a complex articular system that is placed between the temporal bone and the mandible. The articular disc is a biconcave-shaped fibrocartilaginous plate, interposed between the mandible and temporal bone and is divided into the anterior band, intermediate zone and posterior band. The disc is connected to the superior belly of the lateral pterygoid muscle anteriorly. Posteriorly, the disc is attached to the temporal bone by the retrodiscal tissue which is highly innervated and vascularised. In a healthy joint, the articular disc is precisely positioned between the articular surfaces throughout the mandibular movement. When the disc is in its normal position, the intermediate zone is placed between the articular eminence and mandibular condyle, while the posterior band is located above the head of the mandible.1,3
Temporomandibular disorders (TMD) are heterogeneous groups of neuromuscular and musculoskeletal conditions affecting the TMJ, osseous components and surrounding musculature. TMD occurs at a considerably higher rate in individuals with a relatively poor health condition, poor sleep quality, comorbid diseases or cigarette smoking.4 Risk factors contributing to TMD include age, genetics, occlusion, stress, poor posture, anxiety, rheumatoid arthritis and irregular breathing patterns.5,7
The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) is the most extensively used and standardised method for detecting and classifying TMD, with specificity and sensitivity defined for the diagnosis of TMD. TMD has two components namely biopsychosocial and structural, the DC/TMD assessment also has two Axes. Axis-I offers a predetermined physical examination protocol to arrive at a particular physical diagnosis of TMD with relation to the musculature and joint, whereas the psychological status of the patient is accessed using various instruments of Axis-II.8
A recent systematic review and meta-analysis reported on the prevalence of TMD in adolescents and children using DC/TMD. The study findings indicated TMD was prevalent in 44.7% of women and 30% of men. The overall prevalence of TMD in adolescents and children was 60% and 20%, respectively.9
Signs and symptoms of TMD include orofacial pain, pain on mastication, joint noise such as grinding, crepitation, clicking, locking of joints includes the inability to completely open or close, tenderness in relation to face, shoulder and neck muscles, ear ailments including tinnitus, otalgia and psychosocial issues.10 11
TMJ morphological changes can occur due to simple developmental variation as well as due to remodelling of associated structures like the glenoid fossa, mandibular condyle to compensate for the developmental variations, trauma, improper occlusion and other developmental defects and diseases.1 2 Previous studies have reported that TMD can result in alteration in the morphology of the TMJ and associated structures as there exists a close link between form and function.12 13 The volume of the TMJ may be related to the final measurement of the mandibular arch and its association between the maxillary and mandibular arches.14 The anteroposterior surface of the joint is completely convex. However, it is also mildly convex in the mediolateral direction. Additionally, the shape and dimension of the mandibular condyle may also vary.15 16 A markedly eccentric positioning of the mandibular condyle can lead to alterations in joint spaces. Displacement of articular disc, perforation, deformation or osteoarthritis can cause narrowing of joint space and the presence of fluid or blood within the joint space may lead to widening of joint space.17 The concaved mandibular fossa is three to four times bigger than the mandibular head.18 The degree of convexity of the articular tubercle is variable, and it has a crucial role in the anterior movement of the mandible.19 From a clinical standpoint, alterations in disc morphology serve as an indicator of TMJ dysfunction, which can potentially advance to disc displacement with or without reduction. Disc displacement is an intracapsular dysfunction that affects the disc and joint surfaces, which will ultimately lead to degenerative changes.20 Abnormalities or deviations in the joint’s structure can lead to various painful conditions.
Identifying these morphological variations is the preliminary phase in providing effective treatment for these disorders. Many radiographic techniques have been used to evaluate the positional and morphological aspects of hard and soft tissue components of TMJ including conventional two-dimensional (2D) imaging, CT, cone beam CT (CBCT) and MRI.21 22 However, the superimposition of neighbouring TMJ structures is the most frequent drawback of using traditional 2D radiography.23
Three-dimensional imaging provides a comprehensive view of the TMJ from multiple angles, allowing for a better understanding of its complex anatomy. In TMJ disc assessments, MRI is regarded as the gold standard imaging technique since it yields images with superior soft-tissue contrast.19 An alternate method for determining soft tissue derangements of TMJ is arthrography. Larheim and colleagues concluded that CBCT and CT are reliable examinations to diagnose degenerative joint diseases, CBCT is considered superior in detecting cortical bone contouring, remodelling, developmental abnormality and pathological alterations.24
TMD is a common health issue, and the data obtained from this research may help in a deeper understanding of the underlying causes and mechanisms of these disorders. This will also help in developing new diagnostic tools and leads to advancement in its management.
A preliminary search shows vast literature on the evaluation of different morphological aspects of TMJ. However, there is a lack of high-quality evidence that could be derived based on this research. Thus, a systematic review is warranted.
Morphological abnormalities can affect the bony structures, articular disc, ligaments, muscles or the joint capsule. Certain structural abnormalities of TMJ may lead to pain, and impaired function and can predispose to TMD. Evaluation of these morphological alterations can help in better understanding the underlying mechanisms of TMD. Accurate diagnosis and understanding of these abnormalities are crucial for effective treatment and management of TMD. This systematic review will provide a comprehensive summary of various morphological alterations in TMJ using three-dimensional imaging and will be of great use for the development of various diagnostic tools, treatment approaches and preventive measures for TMD.
An initial search across MEDLINE, PROSPERO, the Cochrane Database of Systematic Reviews and the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports were conducted and our search revealed no currently active or ongoing systematic reviews related to the topic.
Therefore, this review aims to summarise the morphological changes in the TMJ and its associated structures using three-dimensional imaging in adult patients with TMD.
Primary objective: ‘What are the morphological changes in TMJ and associated structures using three-dimensional imaging?’
Secondary objective: ‘What is the association between Gender and types of TMD?’
Methods and analysis
The systematic review will follow JBI methodology for aetiology and risk systematic reviews.25 The manuscript will adhere to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020.26 The review has been registered in PROSPERO. Amendments to the protocol shall be noted with a date, a description of the change and a justification. A list of abbreviations is added as a separate table in online supplemental appendix 1. This protocol has been reported in accordance with the PRISMA-Protocols (PRISMA-P) guidelines.27 PRISMA-P checklist is reported as online supplemental file 1.
Eligibility criteria
Inclusion and exclusion criteria are mentioned in online supplemental appendix 2.
Types of studies
This review will include analytical cross-sectional studies, analytical observational studies including retrospective and prospective cohort studies and case–control studies.
Types of participants
Patients with any one sign and symptom of TMD such as pain, TMJ sounds like clicking and crepitation, subluxation, trismus, hypomobility or hypermobility or patients diagnosed with TMD not limited to Research DC/TMD, DC/TMD, Helkimo index, Craniomandibular index, American Academy of Orofacial Pain Guidelines.
Type of exposure
This systematic review will include studies that have evaluated the morphology of TMJ and its associated anatomic structures in adult subjects with TMD using three-dimensional imaging, without any restriction on gender. Studies done in subjects having syndromes, facial asymmetry, facial trauma, orthodontic fixed appliances or intervention from previous treatment for TMJ will be excluded from the review in order to eliminate the other causes of variation in the morphology of the TMJ and its associated structures.
TMD encompass myogenous and arthrogenous TMD, categorised as either extra-articular or intra-articular, with the former primarily consisting of myogenous TMD.
Outcomes
This systematic review will consider studies that assessed the morphology of the TMJ and its associated structure including condyle, glenoid fossa, articular disc, joint space and articular eminence in adult patients with TMD.
Information sources
The electronic databases to be searched include MEDLINE (Ovid), Scopus (Elsevier), Cochrane CENTRAL (Wiley), Dentistry and Oral Sciences Source (DOSS), CINAHL and Web of Science (Clarivate). Furthermore, unpublished and grey literature sources, including ProQuest Dissertation and Thesis and Google Scholar will be explored.
Search strategy
A three-step comprehensive search strategy will be preferred to locate the pertinent studies. The search process will be mapped out and executed to find relevant published and unpublished studies. Initially, a search restricted to MEDLINE (Ovid) will be conducted to identify relevant studies.
Medical Subject Heading (MeSH) terms and text words will be used in the literature search. The consecutive search will be comprehensive and use all the identified index terms and keywords in a search strategy that is completely developed. The search strategy for each database is reported in online supplemental file 2. From their inception until July 2024, all databases will be searched; near the end of the review, an updated search will be conducted. The electronic databases to be searched include MEDLINE (Ovid), Scopus (Elsevier), Cochrane CENTRAL (Wiley), Dentistry and Oral Sciences Source (DOSS), CINAHL and Web of Science (Clarivate). Furthermore, unpublished and grey literature sources, including ProQuest Dissertation and Thesis and Google Scholar will be explored.
The initial search terms piloted in MEDLINE are as follows: ‘Temporomandibular Joint Disorders’, ‘Temporomandibular Joint Dysfunction Syndrome’, ‘craniomandibular disorders’, ‘Temporomandibular Joint Disc’, ‘Articular disc displacement’, ‘TMJ Osteoarthritis’, ‘Mandibular fossa’, ‘Temporomandibular joint morphology’, ‘Mandibular Condyle’, ‘Temporomandibular joint space’, ‘Condylar erosions’, ‘Articular eminence inclination’, ‘Tomography, X-Ray Computed’, ‘Cone-Beam Computed Tomography’, ‘CT’, ‘CBCT’. ‘Magnetic Resonance Imaging’, ‘MRI’, ‘Arthrography’. The keywords and index terms will be finalised and customised to individual databases.
No restrictions will be set on the date, language and country of publication. Articles in other languages will be converted to English language using DeepL software (DeepL SE, Cologne, Germany). The search strategies used for MEDLINE will be modelled to other databases. The cross-references would be verified on chosen studies to identify all relevant studies. Further, the reference section of the chosen studies will be searched for further studies, and hand-searching of relevant articles will also be attempted.
Study selection
After conducting the search, all the identified citations will be collated and added to Mendeley (V.2.64, Elsevier, Netherlands) and duplicates will be eliminated. After conducting a pilot test of 20 records, two independent reviewers (SK and PG) will assess the titles and abstracts for the inclusion criteria for the reviews. Potentially pertinent studies will be retrieved, and their citation information will be imported into the JBI System for Unified Management, Assessment and Information Review (JBI SUMARI) (JBI, Adelaide, Australia).28 The full text of selected citations will be evaluated completely against the inclusion criteria by two independent reviewers (SK and PG). The rationale for excluding full-text papers that do not meet the predefined inclusion criteria in the systematic review will be documented in the systematic review. Any discrepancies that occur among the reviewers at each stage of the process of selection will be addressed through discussion, or if necessary, by involving a third reviewer (VK). The results from the search and the process of selecting studies study will be documented completely in the final systematic review and these results will be presented in a PRISMA flow diagram.
Risk of bias
Two separate reviewers (SK and PG) will carry out a critical assessment of the methodological quality of individual studies during the review. Standardised critical appraisal tools from the JBI designed for analytical observational studies, which encompass prospective and retrospective cohort studies, case–control studies and analytical cross-sectional studies will be employed.29 If necessary, authors of the papers will be contacted to request missing or supplementary data for clarification. In case of any disagreements between reviewers, they will be resolved through discussion or by involving a third reviewer (VK). The outcomes of the critical appraisal will be presented in both narrative form and tables.
All studies, irrespective of their methodological quality outcomes, will undergo data extraction and synthesis whenever feasible. After the critical appraisal, studies failing to meet a specific quality threshold will be excluded from consideration, guided by predefined decision rules.
Data extraction
Two independent reviewers (SK and PG) will employ the standardised data extraction tools provided by JBI SUMARI to collect data from the papers included in the review.28 The authors will extract the following information from the included studies: Citation details, study design/type, country of origin, setting/context, time frame for data collection, participant characteristics (study inclusion/exclusion information), sample size, tool/scale for diagnosis of TMD, details of imaging used in the study, morphological variation used in the study and description of main results. Any discrepancies arising between the reviewers will be resolved through discussion, and if necessary, by involving a third reviewer (VK). Furthermore, the authors of the papers will be contacted to request any missing or additional data as needed. The data extraction instrument is given in online supplemental appendix 3.
Data synthesis
The selected literature would be screened and pooled for statistical meta-analysis using JBI SUMARI.28 For the analysis, the effect size will be computed and expressed as relative risks, ORs or other relevant measures of association, along with their corresponding 95% CIs. If effect estimates and SEs are unavailable, this will be computed using raw data and 95% CIs. In situations where correlation coefficients are used for the effect size measurement, the effect sizes will be transformed into a standard normal metric through Fisher’s r-to-Z transformation. Subsequently, a weighted average of these transformed scores will be computed. In the context of a random effects model, untransformed effect-size estimates will be employed for the purpose of calculating the weighted mean correlation coefficient.
The selection of a model (random or fixed effects) and method for meta-analysis will be determined following the recommendation by Tufanaru et al.30 Heterogeneity will be evaluated statistically using the standard χ2 and I2 tests. Subgroup analyses will be done to investigate gender and types of TMD. Sensitivity analyses will be conducted to test decisions made regarding sample size, methodological quality and heterogeneity. If statistical aggregation is not feasible, the results will be presented in a narrative format, supplemented with figures and tables when appropriate to enhance data presentation.
To evaluate the potential presence of publication bias, if the meta-analysis includes 10 or more studies, a funnel plot will be created using JBI SUMARI. When deemed suitable, statistical assessments, such as the Egger test, Begg test and Harbord test, will be conducted to investigate funnel plot asymmetry.
Confidence in cumulative evidence
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach will be adopted to assess the certainty of evidence. Subsequently, a summary of findings (SoF) using GRADEpro software from McMaster University in Ontario, Canada will be generated.31 The SoF will encompass relevant details including absolute risk for TMD, estimations of relative risk and an evaluation of the quality of evidence. This assessment will consider factors such as risk of bias, directness, heterogeneity, precision and the potential for publication bias within the review results.
Patient and public involvement
None.
Discussion
TMJ is a hinge synovial joint connecting the mandible to the skull. TMJ comprises bony components, fibrocartilaginous disc, supporting ligaments, muscles and a well-supplied neural network. Morphological alteration of the TMJ can result from various conditions, disorders or injuries. These abnormalities can affect the bony structures including the mandibular condyle, articular disc, ligaments and muscles. Görürgöz et al explained that the most common morphological changes are erosion, sclerosis and flattening in the mandibular condyle.32 Morphological alterations in the TMJ may be caused by bone remodelling due to the ageing process.33
We aim to generate the most comprehensive systematic review regarding the morphology of the TMJ and associated structures using three-dimensional imaging. This systematic review will follow JBI methodology for aetiology and risk systematic reviews, and the manuscript will adhere to the guidelines outlined in the PRISMA statement. The search will be conducted across a wide range of databases, including grey literature sources, with no language restrictions applied in the selection of the studies. However, the certainty of the evidence in this systematic review may be limited by the small number of available studies and the potential low quality of the individual studies.
This systematic review will help to provide a detailed overview of the morphological alterations in anatomic structures pertaining to the TMJ. The analysis of morphological alterations in the TMJ plays a crucial role in understanding the aetiology, diagnosis and treatment planning. This quantitative data will be of great value for tracking the progression of disorders, and conducting research in order to generate evidence-based practices and contribute to improved patient care and advancements in the field of oral and maxillofacial medicine.
Ethics and dissemination section
This systematic review does not involve the collection of new data from human participants. All data used in this review are obtained from previously published studies, which have presumably undergone their own ethical review and approval processes. As such, this review does not require additional ethical approval. The authors have adhered to ethical guidelines for conducting and reporting systematic reviews, ensuring transparency and integrity in the synthesis of existing research.
supplementary material
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2023-082396).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: Not applicable.
Data availability free text: As this is a review protocol, data sharing is not applicable.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Contributor Information
Sarika Kadekuzhi, Email: sarikaranjith9@gmail.com.
Vineetha Karuveettil, Email: kvineetha2016@gmail.com.
Rahul D Prabha, Email: rahuldp6@gmail.com.
Ajith Vallikat Velath, Email: ajithvv72@gmail.com.
Sapna Varma N K, Email: sapnavarmank@gmail.com.
Parvathy Ghosh, Email: parvathyghosh08@gmail.com.
Sangeeth Suresh, Email: drsangeethks@gmail.com.
Data availability statement
Data sharing not applicable as no data sets generated and/or analysed for this study.
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