Sklon sagitaâ lnõâ draâhycï elistnõâho kloubu Sagittal condylar path inclination

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1 Sklon sagitaâ lnõâ draâhycï elistnõâho kloubu Sagittal condylar path inclination *MUDr. Michal SÏ edivec, *MUDr. Petra HofmanovaÂ, **RNDr. Lucie Grajciarova *Stomatologicka klinikadeï tõâ adospeï lyâ ch, 2.le ka rïskaâ fakulta UK a Fakultnõ nemocnice Praha-Motol, *Clinic of Stomatology for Adults and Children, 2nd Medical Faculty of Charles University and University Hospital Praha-Motol, Prague **Vysoka sï kolachemicko-technologickaâ, Praha **Institute of Chemical Technology, Prague Souhrn CõÂlem teâ to studie je zjistit informace o kinetickyâ ch charakteristikaâ ch dolnõâ cï elisti a jejõâch kondyluê a urcï it, zda existujõâ zaâ vislosti mezi sklonem kloubnõâ draâ hy a vybranyâ mi skeletaâ lnõâmi a dentaâ lnõâmi parametry u vysï etrïenyâ ch pacientuê. Do souboru bylo vybraâ no 65 pacientuê. Pro zjisïteï nõâ sklonu kloubnõâ draâ hy bylo u teï chto pacientuê provedeno axiografickeâ vysï etrïenõâ kloubnõâch drah digitaâ lnõâm oblicï ejovyâ m obloukem ARCUS Ò digma. Nebyla nalezena statisticky vyâ znamnaâ korelace hodnoty sklonu kloubnõâ draâ hy s vertikaâ lnõâmi a sagitaâ lnõâmi charakteristikami oblicï ejoveâ ho skeletu, s hloubkou skusu a se sklonem dlouheâ osy hornõâch rïezaâ kuê (Ortodoncie 2014, 23, cï. 1, s ). Abstract The aim of the study is to collect information on kinetic features of the mandible and its condyles, and to determine dependency between the joint path inclination and selected skeletal and dental parameters. The sample included 65 patients. To determine condylar path inclination in the patients, axiographic evaluation of condylar paths was performed using the digital facial arch ARCUS Ò digma. We did not prove statistically significant correlation between condylar path inclination and vertical and sagittal features of facial bones, overbite, and upper incisors inclination (Ortodoncie 2014, 23, cï. 1, s ). KlõÂcÏ ovaâ slova: temporomandibulaâ rnõâ kloub, axiografie, kloubnõâ draâ ha Key words: temporomandibular joint, axiography, condylar path U vod V literaturïe muê zï eme naleâ zt dvaodlisï neâ naâ zory na problematiku pohybu kondylu [1]. Podle neï kteryâch autoruê [2] je draâ ha, po ktereâ se kloubnõâ hlavice pohybuje, urcï enamorfologiõâ kloubnõâho hrbolku auâ pony kloubnõâch ligament. PuÊ sobenõâ zïvyâkacõâch svalu beï hem pohybu v kloubu neustaâ le udrzï uje teï snyâ kontakt mezi kondylem a kloubnõâ jamkou. Jina teorie [3] rïõâkaâ, zï e kloubnõâ pouzdro umozï nï uje urcï itou volnost pohybuê kondylu apohyb dolnõâ cï elisti je rïõâzen prïedevsï õâm neuromuskulaâ rnõâm mechanismem. Dra ha, po ktereâ se pohybuje kondyl, muêzï e tedy byât mõârneï odlisïnaâ od morfologie svahu kloubnõâho hrbolku. Introduction There are two different views of condylar movement [1]. Some authors [2] believe that condylar path is determined by articular eminence morphology and by attachments of condylar ligaments. Masseter muscles movements facilitate close contact between condyle and articular socket. Another view [3] is that articular sheath allows for a free condylar movement to some degree, and that the mandible movement is controlled mainly by neuromuscular mechanism. Therefore, condylar path may differ to some extent from that of articular eminence morphology. 34

2 rocïnõâk23 Pro meï rïenõâ sklonu kloubnõâho hrbolku bylo navrzï eno neï kolik metod. NeÏ ktereâ studie vyuzï õâvaly prïõâmaâ kraniometrickaâ meï rïenõâ [4, 5]. Jine pak zobrazovacõâ metody jako naprïõâklad RTG - panoramatickyâ snõâmek, kefalogram [6]. DalsÏ õâ pak spojenõâ MRI a axiografie [7, 8, 9]. Axiografie je metoda, jezï umozïnï uje neprïõâmo urcïit sklon kloubnõâ draâ hy. BeÏ hem tohoto meï rïenõâ je pohyb dolnõâ cï elisti registrovaâ n mechanicky nebo pomocõâ ultrazvuku. Corbett et al. [2] ve sveâ studii udaâ vajõâ vysokyâ stupenï korelace mezi hodnotou sklonu kloubnõâ draâ hy zjisï teï nou axiograficky a sklonem kloubnõâho hrbolku, kteryâ byl odecï ten z kefalometrickeâ ho rtg snõâmku. K podobnyâ m vyâ sledkuê m dosï el i Widman [10]. Axiografie je metoda, kteraâ umozïnï uje s pomeï rneï vysokou prïesnostõâ [8, 11, 12] hodnocenõâ kinetiky mandibuly acï elistnõâho kloubu. UmozÏnÏ uje naâ m pomeï rneï jednoduchyâ m vysï etrïenõâm diagnostikovat kinetickeâ charakteristiky kondyluê. Vy sledkem teï chto meï rïenõâ je zjisï teï nõâ maximaâ lnõâho rozsahu pohybuê, hodnoty sklonu kloubnõâ draâ hy, rïezaâ koveâ ho vedenõâ avelikost Bennettovau hlu. CÏ astyâ m probleâ mem z hlediskavyuzï itõâ axiografie k diagnostice poruch cï elistnõâho kloubu je patologickaâ krïivkakloubnõâ draâ hy na axiogramu u pacientuê, kterïõâ vykazujõâ fyziologickyâ naâ lez prïi klinickeâ m vysï etrïenõâ ajsou bez obtõâzï õâ. Axiografie popisuje pouze deâ lku, sklon apravidelnost kloubnõâ draâ hy. Nepravidelnosti linie kloubnõâ draâ hy na axiogramu mohou, ale nemusõâ byât znaâ mkou dislokace kloubnõâho disku nebo artrotickeâ kloubnõâ deformace [9, 13]. CõÂlem teâ to studie je zjistit informace o kinetickyâch charakteristikaâ ch dolnõâ cï elisti ajejõâch kondyluê aurcï it, zda existujõâ asociace mezi teï mito velicï inami a vybranyâ mi kefalometrickyâ mi a neï kteryâ mi jinyâ mi hodnotami, ktereâ byly nameïrïeny u vysï etrïenyâch pacientuê. Bylo zjisï t'ovaâ no, zdavysï sï õâ hodnotu sklonu kloubnõâ draâ hy majõâ: 1. pacienti s brachycefalickyâ mi charakteristikami oblicï ejoveâ ho skeletu, 2. pacienti s tendencõâ ke druheâ skeletaâ lnõâ trïõâdeï, 3. pacienti s hlubokyâm skusem, 4. pacienti se strmyâm postavenõâm hornõâch rïezaâkuê. Materia l a metodika Do studie byli zarïazeni pacienti, kterïõâ absolvovali vstupnõâ vysï etrïenõâ naortodontickeâ m oddeï lenõâ DeÏ tskeâ stomatologickeâ kliniky Fakultnõ nemocnice v Motole. Vra mci tohoto vstupnõâho vysï etrïenõâ u nich bylo provedeno axiografickeâ vysï etrïenõâ kloubnõâch drah digitaâ lnõâm oblicï ejovyâm obloukem ARCUS Ò digma. VysÏ etrïovanyâ soubor obsahoval 65 pacientuê, z toho 43 zïeny a22 muzïuê. U pacientuê bylo provedeno standardnõâ ortodontickeâ vysï etrïenõâ. Bylazhotovenafotodokumentace, otisky zubuê, panoramatickyâ rentgenovyâ snõâmek adaâ lkovyâ To measure articular eminence inclination several techniques were suggested. Some authors use direct craniometric measurements [4,5], others prefer imaging techniques such as e.g. orthopantomogram, cephalogram [6]. Some authors employ MRI together with axiography [7,8,9]. Axiography is the method used for indirect determination of condylar path inclination. During the measurement the mandible movement is recorded either mechanically or by means of sonography. Corbett et al. [2] report the high degree of correlation between the value of condylar path inclination determined by means of axiography, and articular eminence inclination that was read from cephalogram. Similar results are given by Widman [10]. Axiography makes it possible to assess rather accurately kinetics of the mandible and temporomandibular joint [8,11,12]. Through a simple examination we can diagnose kinetic characteristics of condyles. The measurements give maximum extent of movements, condylar path inclination values, incisal guiding, and Bennett angle. The problem with axiography in diagnostics of TMJ derangements is represented by a pathological curve of articular path in axiograms of patients that show physiological findings in clinical examination, and do not report any discomfort. Axiography describes length, inclination and regularity of articular path. Irregular line of articular path in axiograms may, however do not need, indicate articular disk dislocation or arthrotic deformities [9, 13]. The aim of our study is to collect information on kinetic features of the mandible and its condyles, and determine whether there exists arelationship between these parameters and selected cephalometric and other values, that were measured in the patients examined. We sought the answers for the following: 1. Do patients with brachycephalic features of the face have higher values of articular path inclination? 2. Do patients with the tendency to Class II have higher values of articular path inclination? 3. Do patients with deep bite have higher values of articular path inclination? 4. Do patients with retrusion of upper incisors show higher values of articular path inclination? Material and method Patients who underwent entrance examination at the Department of Orthodontics of Clinic of Pediatric Stomatology, University Hospital in Motol, were included in the study. The examination included axiography of condylar paths with a digital facial arch AR- CUS Ò digma. The sample contained 65 patients - 43 women and 22 men. 35

3 Obr. 1. Axiogram, grafickeâ znaâ zorneï nõâ pruê beï hu kloubnõâ draâ hy, Bennettovau hlu arïezaâ koveâ ho vedenõâ. Fig. 1. Axiogram, graphic representation of a joint path, Bennett angle and incisor guiding snõâmek lebky. Na panoramatickeâ m snõâmku bylazjisï t'ovaâ na prïõâtomnost patologickyâ ch zmeï n temporomandibulaâ rnõâho kloubu (TMK) aprïi pozitivnõâm naâ lezu byli tito pacienti ze souboru vyrïazeni. VysÏ etrïenõâ cï elistnõâho kloubu se zameï rïovalo na prïõâtomnost prïõâznakuê temporomandibulaâ rnõâch poruch (TMP). Pro zarïazenõâ do souboru museli pacienti splnï ovat naâ sledujõâcõâ kriteâ ria: 1. zïaâ dnyâ z pacientuê zarïazenyâch do souboru nemeïl omezeneâ otevõâraâ nõâ pod hodnotu 40 mm interincizaâ lneï, 2. pacienti ze souboru nevykazovali bolest TMK, citlivost zïvyâkacõâch svaluê, 3. nebyly u nich prïõâtomny parafunkce nebo zvukoveâ fenomeâ ny TMK, 4. minimaâ lnõâ veï k 11 let, 5. staâ laâ dentice (prorïezaneâ druheâ molaâ ry nebyly podmõânkou). Instrumenta lnõâ vysï etrïenõâ cï elistnõâho kloubu apohybuê dolnõâ cï elisti bylo provaâdeïnoprïõâstrojem ARCUS Ò digma (KaVo Dental GmbH, Insy, Germany). Tento prïõâstroj umozïnï uje prïesneï zaznamenat trïõâdimenzionaâ lnõâ pohyby dolnõâ cï elisti. Tyto pohyby jsou zaznamenaâny sprïesnostõâ 0,1 mm v oblasti rïezaâkuê a0,2-0,3 mm v oblasti kondyluê [14]. BeÏ hem jednotlivyâch meï rïenõâ pacienti sedeï li vzprïõâmeneï bez opory hlavy a provaâ deï li seâ rii pohybuê dolnõâ cï elistõâ. Jednalo se o protruzi a lateropulzi postupneï na pravou a levou stranu. KazÏdy z pohybuê byl trïikraât zopakovaâ n apacienti byli instruovaâ ni, aby beï hem pohybuê udrzïovali kontakt mezi zuby hornõâ a dolnõâ cï elisti. Vy chozõâ akonecï neâ postavenõâ pro vsï echny exkurze dolnõâ cï elisti bylamaximaâ lnõâ interkuspidace. TõÂmto zpuêsobem bylapomocõâ digitaâ lnõâho oblicï ejoveâ ho oblouku zõâskaâ nahodnotasklonu kloubnõâ draâ hy (CPI - Condylar Obr. 2. Hornõ okluzaâ lnõâ a dolnõâ paraokluzaâ lnõâ kovovaâ vidlicï ka. Materia l pouzï ityâ k fixaci vidlicï ek: Sioplast BS, Fuji Ortho LC. Fig. 2. Upper occlusal and lower para-occlusal metal fork. Material used for fork fixation: Sioplast BS, Fuji Ortho LC. A standard orthodontic examination was performed, photographs, dental impressions, panoramic X- ray and cephalograms were made. In the panoramic picture we sought pathological changes in temporomandibular joint (TMJ) - patients with positive finding were eliminated from the sample. Examinations of temporomandibular joint focused on symptoms of temporomandibular derangements. The patients included in the sample had to meet the following criteria: 1. Unlimited opening of 40 mm and over interincisally 2. No pain of TMJ or sensitive masseter muscles 3. No parafunctions or sound phenomena of TMJ 4. Minimum age of 11 years 5. Permanent dentition (erupted second molars were not required) Instrumental function analysis of temporomandibular joint (TMJ) and the mandible movements was performed with the device ARCUS Ò digma (KaVo Dental GmbH, Insy, Germany). The device makes precise three-dimensional recording of mandibular movements possible. The movements are recorded with the accuracy of 0.1 mm in the area of incisors, and mm in the area of condyles [14]. During individual measurements the patients were sitting upright without support to their head, and they made movements of the mandible: protrusion and lateropulsion to the right and to the left. Each movement was repeated three times; the patients were told to keep contact between upper and lower teeth. Initial and final position of all excursions of the mandible was the maximum intercuspation. With digital facial arch the value of condylar path inclination (CPI) was determined. In the patients included in the sample, through analysis of cephalograms, and measurements performed in cast models, the following parameters 36

4 rocïnõâk23 Obr. 3. Kovova vidlicï kafixovanaâ nazuby. Dolnõ vidlicï kanesmõâ narusï ovat provedenõâ protruznõâch a lateropulznõâch pohybuê. Fig. 3. Metal fork attached to teeth. Lower fork should not interfere with protrusive and lateropulsive movements. Path Inclination). U pacientuê za rïazenyâ ch do souboru byly analyâzou kefalometrickyâch snõâmkuê ameïrïenõâm na saâ drovyâ ch modelech zõâskaâ ny naâ sledujõâcõâ velicï iny. HodnotaWITS, hloubkaskusu, pomeï r prïednõâ azadnõâ oblicï ejoveâ vyâsï ky, uâ hel osy hornõâch rïezaâ kuê k palatinaâ lnõâ rovineï, uâ hel ANB, dolnõâ goniovyâ uâ hel, uâ hel mandibulaâ rnõâ linie, goniovyâ uâ hel. NameÏ rïenaâ data byla zpracovaâ nametodou popisneâ statistiky. Ze zõâskanyâ ch velicï in byly propocï teny zaâ kladnõâ popisneâ charakteristiky - aritmetickyâ pruê meï r, mediaân, minimum, maximum, smeï rodatnaâ odchylka, rozptyl. Pomocõ Lillieforsovatestu bylaoveï rïovaâ nanormalita zõâskanyâ ch dat. Pro hodnotu CPI-pravy nebylatato normalita oveï rïena. Z tohoto duê vodu byl pouzï it WilcoxonuÊ v test pro oveï rïenõâ hypoteâ zy rovnosti distribucï nõâch funkcõâ CPI-levy acpi-pravyâ. ChybameÏ rïenõâ bylaurcï ena pomocõâ Dahlbergova vzorce. Stanovene hypoteâzy byly zkoumaâ ny pomocõâ testu nezaâ vislosti, kteryâ jezalozï en natzv. PearsonoveÏ vyâbeï roveâ m korelacï nõâm koeficientu. VsÏ echny testy byly provedeny nahladineï statistickeâ vyâznamnosti p < 0,05. Ke statistickeâ analyâze dat byly pouzï ity aplikace Excel 2007 a XLSTAT. Vy sledky Pro charakterizaci velikosti meï rïenyâ ch velicï in v celeâ m daneâ m souboru pacientuê jednõâm cï õâslem jsme pouzï ili mõâry polohy velicï in (pruêmeï r amediaâ n) (Tab. 1). Byla urcï enaminimaâ lnõâ amaximaâ lnõâ hodnotavelicï in (Tab. 1). Pro charakterizaci velicï in z hlediskavelikosti kolõâsaânõâ hodnot jsme pouzï ili mõâry variability velicï in (rozptyl, smeï rodatnaâ odchylka) (Tab. 1). Normalita zaâ kladnõâch souboruê bylaoveï rïenapomocõâ Lillieforsovatestu u vsï ech zkoumanyâ ch velicï in a zï na velicï inu CPI-pravy a 1+SpaSpp (Tab. 2). Pro oveï rïenõâ hypoteâ zy rovnosti distribucï nõâch funkcõâ CPI-levy acpi-pravyâ jsme pouzï ili WilcoxonuÊ v test oveï- Obr. 4. MeÏ rïenõâ pomocõâ oblicï ejoveâ ho oblouku ARCUSdigma. Kovova vidlicï kaje fixovaâ nanafrontaâ lnõâ zuby dolnõâ cï elisti abeï hem protruznõâch alaterotruznõâch pohybuê dolnõâ cï elisti probõâhaâ registrace draâhy teï chto pohybuê. Fig. 4. Measuring facial arch with ARCUSdigma. Metal fork is attached to anterior teeth of the mandible, and during protrusive and laterotrusive mandibular movements their paths is recorded. were determined: WITS, overbite, proportion of anterior and posterior facial height, angle between the maxillary incisors axes to palatal plane, ANB angle, lower gonion angle, mandibular line angle, gonion angle. The data measured were processed by means of descriptive statistics. The following principal descriptive characteristics were calculated: arithmetic mean, median, minimum, maximum, standard deviation, variance. Lilliefors normality test was used to verify the data obtained. For CPI-right the normality was not verified. Therefore, we used Wilcoxon test to verify hypothesis of equality of distribution functions CPI-left and CPIright. Measurement error was calculated according to Dahlberg formula. The hypotheses proposed were examined with the independence test which is based on the so-called Pearson sample correlation coefficient. All tests were performed on the level of statistical significance p < For statistical analysis of the data the applications Excel 2007 and XLSTAT were used. Results To characterize dimensions of parameters measured within the whole sample of patients with one number, we used extent of mean and median (Table 1). Minimum and maximum values of parameters were determined. To characterize the parameters measured from the viewpoint of value fluctuations we used the scale of variability (variance, standard deviation) (Table 1). Normality of basic samples was verified with Lilliefors test in all parameters, with the exception of CPIright and 1+SpaSpp (Table 2). 37

5 Tab. 1. MeÏrÏene velicï iny a variabilita v daneâ m souboru pacientuê Tab. 1. Measurements and variability CPI = sklon kloubnõâdraâ hy, Condylar Path Inclination, OB = hloubkaskusu, overbite, SGo/NMe = pomeï r zadnõâa prïednõâoblicï ejoveâ vyâsï ky, posterior/anterior facial height ratio, 1+SpaSpp = uâ hel osy hornõâch rïezaâkuê k palatinaâlnõâ rovineï,ngome = dolnõâ goniovyâ uâ hel, lower gonion angle, NS-ML = uâ hel mandibulaâ rnõâ linie, mandibular line angle, ArGoMe = goniovyâ uâ hel, gonion angle, S.D. = smeï rodatnaâ odchylka, standard deviation Tab. 2. LillieforsuÊ v test oveïrïujõâcõâ normaâ lnost rozdeï lenõâ pravdeï podobnosti zkoumanyâch velicïin Tab. 2. Lilliefors normality test CPI = sklon kloubnõâ draâ hy, Condylar Path Inclination Tab. 3. ChybameÏrÏenõ Tab. 3. Measurement error CPI = sklon kloubnõâ draâhy, Condylar Path Inclination, TEM = technickaâ chybameï rïenõâ, technical error of measurement, rtem = relativnõâ technickaâ chybameï rïenõâ, relative technical error of measurement, SEM = standardnõâ chyba meïrïenõâ, standard error of measurement Tab. 4. Test nezaâ vislosti (korelacï nõâ koeficienty) Tab. 4. Independence test (correlation coeficients) rïenõâ symetrickeâ ho rozlozï enõâ sledovaneâ naâ hodneâ velicï iny). VypocÏ tenaâ p hodnotarovna0,267 bylaveï tsï õâ nezï hladina vyâ znamnosti (0,05). DõÂky vyâ sledku tohoto testu ablõâzkosti strïednõâ hodnoty rozptylu velicï in CPI-levy acpi-pravyâ, muêzïeme pouzï õât pro popis velicï iny CPI pouze hodnoty CPI-levyÂ, ktereâ byly leâ pe nameïrïeny. ChybameÏ rïenõâ je vyjaâdrïenapomocõâ technickeâ chyby meï rïenõâ (technical error of measurement, TEM), relativnõâ technickeâ chyby meïrïenõâ (relative technical error of measurement, rtem), standardnõâ chyby meïrïenõâ (standart error of measurement - SEM). Velikost relativnõâ To verify the hypothesis of equal distribution functions CPI-right and CPI-left we used Wilcoxon test for verification of symmetric distribution of a randomly chosen parameter. The calculated p value = was higher than the level of significance (0.05). Due to the results of the test, and due to similar mean value of variance of parameters CPI-left and CPI-right, for the description of CPI parameter we can use only values of CPI-left, that were better measured. Measurement error is expressed by means of technical error of measurement (TEM), relative technical 38

6 rocïnõâk23 chyby meï rïenõâ byla0,18 % pro velicï inu CPI-pravy a0,19 % pro velicï inu CPI-levy (Tab. 3). Test nezaâ vislosti hodnocenyâ ch velicï in (Tab. 4) ukazuje, zïe v duê sledku nõâzkeâ hladiny spolehlivosti vyâsledkuê nelze vyvodit zaâveï ry potvrzujõâcõâ jednu z navrzïenyâ ch hypoteâ z. Nebyl nalezen statisticky signifikantnõâ vztah mezi sklonem kloubnõâ draâ hy se sagitaâ lnõâmi, vertikaâ lnõâmi adentaâ lnõâmi charakteristikami. Diskuse Tempora lnõâ komponentacï elistnõâho kloubu je tvorïena kloubnõâ jamkou a kloubnõâm hrbolkem. Tyto anatomickeâ struktury hrajõâ duê lezï itou roli ve funkci temporomandibulaâ rnõâho kloubu. PrÏi narozenõâ nenõâ kloubnõâ hrbolek vytvorïen. BeÏ hem prvnõâch meï sõâcuê zï ivotase mandibula muê zï e pohybovat anteriorneï alateraâ lneï bez jakeâ hokoliv pohybu kaudaâ lnõâm smeï rem [4]. Vrozena ageneze veï tve dolnõâ cï elisti maâ zanaâ sledek absenci kloubnõâho hrbolku. Jeho existence je tedy podmõâneï nafunkcõâ temporomandibulaâ rnõâho kloubu [4]. VeÏtsÏ inastudiõâ, [1, 4, 11, 16, 17] veï nujõâcõâch se meïrïenõâ sklonu kloubnõâ draâhy cï elistnõâho kloubu, se zameïrïilana vyâvoj hodnoty uâ hlu kloubnõâ draâ hy vzhledem k veïkupacientuê. Tato zaâ vislost nebylav nasï em meï rïenõâ hodnocena. Do souboru byli zarïazeni pacienti se staâlyâm chrupem, jejichzï minimaâ lnõâ veï k byl 11 let. PruÊ meï rnaâ hodnotasklonu kloubnõâ draâ hy pacientuê v nasï em souboru byla29,6 pro pravyâ a30,6 pro levyâ kondyl. Ve studii neï meckyâ ch autoruê [16] byl zjisï t'ovaâ n vyâ voj hodnoty sklonu kloubnõâ draâhyudeï tõâ mezi 6 a12 rokem. VyÂsledky ukazujõâ, zï e strïednõâ hodnotatohoto uâ hlu vzrostla ze 43 vsï esti letech, na50 ve dvanaâ cti letech adosaâhlatak prïiblizïneï 85% teâ to hodnoty v dospeï losti. Podobna studie [17] udaâvaâ hodnotu 32 v sï esti letech a41 u dvanaâ ctiletyâch deï tõâ. U kontrolnõâ skupiny dospeïlyâ ch jedincuê bylanameï rïenastrïednõâ hodnota49. VysÏ sï õâ hodnoty udaâvaâ studie Baqaiena et al. [1], a to 43 usïestiletyâ ch deï tõâ,49 u trïinaâ ctiletyâ ch a 59 u dospeï lyâ ch jedincuê. Katsavrias [18] udaâ vaâ, zï e morfologie glenoidaâ lnõâ fossy dosahuje dospeï lyâ ch dimenzõâ jizï prïed osmyâ m rokem veï ku. Nebyl nalezen statisticky vyâ znamnyâ rozdõâl ve sklonu kloubnõâ draâ hy mezi pohlavõâmi [1]. Znalost vyâ voje kloubnõâho hrbolku by mohlamõât vyâznam prïi terapii urcï ityâ ch ortodontickyâ ch anomaâ liõâ [19], naprïõâklad u druheâ skeletaâ lnõâ trïõâdy druheâ ho oddeïlenõâ. U teï chto anomaâ liõâ je popisovaâ n charakteristicky strmyâ avysokyâ kloubnõâ hrbolek [4, 20, 21, 22]. AvsÏ a k nenõâ prïesneï znaâ mo, jakeâ faktory se na vzniku morfologie hrbolku podõâlejõâ, jakou roli hraje hloubka skusu asklon hornõâch rïezaâkuê. Korekce okluze u druheâ trïõâdy druheâ ho oddeï lenõâ je cï asto velmi naâ rocïnaâ z pohledu stability dosazï eneâ ho vyâ sledku leâ cï by. JednõÂm z duê voduê mohou byât i naâ roky naremodelaci afunkcï nõâ adaptacï nõâ procesy temporomandibulaâ rnõâho kloubu, daneâ zcïaâ sti error of measurement (rtem), standard error of measurement (SEM). The value of relative error of measurement was 0.18% for CPI-right, and 0.19% for CPI-left (Table 3). Independence test of parameters evaluated (Table 4) shows that due to the low level of results reliability it is impossible to draw conclusions proving one of the proposed hypotheses. We did not find statistically significant relationship between articular path inclination and sagittal, vertical and dental characteristics. Discussion Temporal part of the jaw joint comprises articular socket and articular eminence. These anatomical structures play an important role in the functioning of temporomandibular joint. In a newborn eminence is not yet created. During the first months of life the mandible can move anteriorly and laterally without any movement in caudal direction [4]. Innate agenesis of the mandible ramus results in the absence of eminence. Its existence is thus given by the function of temporomandibular joint [4]. Most studies [1, 4, 11, 16, 17] dealing with TMJ path inclination focused on the angle values development related to the age of patients. This relationship was not assessed in our measurements. Our sample included patients with permanent dentition, the minimum age of 11 years. In our patients the mean value of condylar path inclination was 29.6 (right condyle) and 30.6 (left condyle). The German study [16] focused on the development of condylar path inclination in children between the age 6 and 12. The results show that the mean value increased from 43 (at the age of 6) to 50 (at the age of 12), and represented 85 % of the value in adults. The similar work [17] reported 32 at the age of 6, and 41 at the age of 12. The mean value of the control group of adult patients was 49. The study by Baqaien et al [1] gives higher values - 43 in children at the age of 6, 49 in children at the age of 13, and 59 in adults. Katsavrias [18] suggests that the glenoidal fossa morphology has the values of adult people as early as before the age of 8. No statistically significant difference in condylar path inclination between females and males was found [1]. To know the development of articular eminence may be important in the therapy of some orthodontic anomalies [19], e.g. in Class II, division 2. These malocclusions are characterized by steep and high articular eminence [4, 20, 21, 22]. However, the factors contributing to the development of eminence morphology are rather unclear; we do not know the role played by overbite and upper incisors inclination. Correction of bite in Class II, division 2 is often very demanding from the viewpoint of stability of the treatment result. One of 39

7 takeâ prïõâtomnostõâ strmeâ ho kloubnõâho hrbolku [20]. Podle neï kteryâch autoruê [20] by po vcï asneâ m zvyâsï enõâ skusu meï lo dochaâ zet k vyâvoji meâneï strmeâ ho kloubnõâho hrbolku, adõâky tomu dosazï enõâ stabilneï jsï õâho vyâ sledku leâ cï by. Studie neï meckyâ ch autoruê [21] zjisï t'ovala sklon kloubnõâho hrbolku u pacientuê s druhyâ m oddeï lenõâm druheâ skeletaâ lnõâ trïõâdy. PruÊ meï r sklonu kloubnõâ draâ hy byl u tohoto souboru o 7 vysïsï õâ v porovnaâ nõâ s kontrolnõâ skupinou, jezï meï laprvnõâ skeletaâ lnõâ trïõâdu. Vy sledky nasï eho meï rïenõâ nepotvrzujõâ vysï sï õâ hodnoty kloubnõâ draâhy u druheâ skeletaâ lnõâ trïõâdy. Nebyl takeâ nalezen statisticky vyâ znamnyâ vztah mezi sklonem hornõâch rïezaâ kuê, hloubkou skusu avelikostõâ uâ hlu kloubnõâ draâ hy. Objevujõ se naâ zory, zï e k remodelaci kloubnõâ jamky akloubnõâho hrbolku dochaâzõâpuê sobenõâm funkcï nõâch aparaâtuê prïedsouvajõâcõâch dolnõâ cï elist doprïedu. Tyto kostnõâ zmeï ny byly zdokumentovaâny prïi experimentech nalaboratornõâch zvõârïatech a neï kterïõâ autorïi je prïedpoklaâ dajõâ i u pacientuê, kterïõâ celodenneï nosõâ funkcï nõâ aparaâ ty [23]. Katsavrias et al. [24], kterïõâ hodnotili zmeï ny v morfologii fossa glenoidalis po terapii aktivaâ torem vsï ak remodelaci teâ to anatomickeâ struktury nezaznamenali. RÏ ada dalsï õâch studiõâ se zabyâ vala souvislostmi mezi morfologiõâ cï elistnõâho kloubu adentaâ lnõâmi askeletaâ lnõâmi charakteristikami [25, 5, 10, 26, 27, 28]. NaprÏõÂklad Widman [10] ve sveâ studii, kde hodnotil axiografickeâ meïrïenõâ u padesaâ ti pacientuê, uvaâ dõâ zjisï teï nyâ negativnõâ korelacï nõâ vztah mezi sklonem kloubnõâho hrbolku a uâ hlem mandibulaâ rnõâ linie. Tato zaâ vislost nebylanasï õâm meï rïenõâm potvrzena. U trïetõâ skeletaâ lnõâ trïõâdy bylanalezena pruê meï rneï spõâsï e meï lkaâ kloubnõâ jamka a nevyâ razneâ tuberculum articulare [29]. Tato morfologie by naznacïovala nizïsï õâ hodnotu uâ hlu kloubnõâ draâ hy. Ani tato hypoteâzavsï ak nebyla nasï imi vyâsledky potvrzena. Podle Slaviceka [22] se sklon kloubnõâch drah vytvaârïõâ v zaâ vislosti navyâmeï neï dentice, kdy prorïezaâ vajõâcõâ se staâ leâ rïezaâ ky tvorïõâ mechanickou prïekaâ zï ku dynamickeâ okluzi. Kondyly jsou v duê sledku teâtoprïekaâzï ky nuceny k pohybu kaudaâ lnõâm smeï rem. Adaptace zï vyâ kacõâch svaluê vede postupneï k morfologickyâ m zmeï naâ m na kloubnõâm hrbolku, kteryâ se staâvaâ strmeï jsï õâm. Stejny mechanismus autor popisuje takeâ u prorïezaâvaânõâ sï picï aâkuê apremolaâruê. Dle teâ to teorie by pacienti s hlubokyâm skusem meï li mõât strmeï jsï õâ sklon kloubnõâch hrbolkuê.vyâsledky nasï eho meïrïenõâ tuto zaâ vislost nepotvrdily. Velikost uâ hlu kloubnõâ draâhy maâ podle neï kteryâch autoruê [3, 6] takeâ vliv nafunkci komplexu disk-kondyl. PrÏi plocheâ m kloubnõâm hrbolku dochaâ zõâ pouze k minimaâ lnõâ rotaci disku na kondylu beï hem otevõâraâ nõâ. S tõâm, jak roste sklon kloubnõâho hrbolku, se zveï tsï uje rozsah vzaâ jemneâ ho pohybu mezi kondylem adiskem [3], cozï by mohlo veâ st k vysï sï õâmu riziku prodlouzï enõâ kloubnõâch vazuê a vzniku intrakapsulaâ rnõâch kloubnõâch poruch [6]. Na druhou stranu kolektiv japonskyâ ch autoruê [30] ne- the reasons may be the need for remodeling and functional adaptation of TMJ, partially due also to steep articular eminence [20]. Some authors [20] suggest that after early increase of bite, the less steep articular eminence develops, which is reflected in more stable treatment results. The German study [21] focused on articular eminence inclination in patients with Class II, division 2. The mean value of TMJ path inclination in their sample of patients was by 7 higher in comparison with the control group of Class I. Our measurements do not prove higher values of TMJ path inclination in Class II. There was found no statistically significant relationship between the inclination of upper incisors, overbite, and the value of TMJ path angle. Some authors believe that remodelling of articular socket and eminence is the result of functional appliances moving the mandible forward. The bone changes were described during experiments on laboratory animals, and some authors assume similar changes in patients wearing functional appliances all day long [23]. Katsavrias et al. [24] evaluated changes of fossa glenoidalis morphology after the therapy with activator, and did not find remodelling of this anatomical structure. A number of studies dealt with relationship between mandibular joint morphology, and dental and skeletal characteristics [25, 5, 10, 26, 27, 28]. Widman [10], for instance, performed the evaluation of axiography in fifty patients, and reports negative correlation between articular eminence inclination and the mandibular line angle. However, this was not proved by our measurements. In Class III we found rather shallow socket and virtually non-distinct tuberculum articulare [29]. The morphology suggests lower value of joint path angle. However, this hypothesis was not proved by our results either. According to Slavicek [22] condylar paths inclination development is associated with changing of dentition - erupting permanent incisors represent mechanical obstacle to dynamic occlusion. Condyles thus move caudally. Adaptation of masseter muscles leads to morphological changes of articular eminence that becomes steeper. The same mechanism is observed in erupting canines and premolars. This theory suggests that patients with deep bite should have also steeper inclination of articular eminence. However, our measurements did not prove that. The value of condylar path angle influences the function of the complex disk-condyle [3,6]. In case articular eminence is flat, disk rotates only slightly during opening. With steeper articular eminence inclination the extent of the movement between condyle and disk increases [3], which may result in higher risk of prolonged ligaments and intracapsular articulatory derange- 40

8 rocïnõâk23 nalezl zïaâ dnyâ vztah mezi sklonem kloubnõâho hrbolku avyâ skytem dislokace kloubnõâho disku. Tato souvislost bude pravdeï podobneï klinicky vyâ znamnaâ pouze v kombinaci s abnormaâ lnõâm funkcï nõâm zatõâzï enõâm kloubu. ZaÂveÏr CõÂlem teâ to praâ ce bylo zjistit, zdaexistujõâ zaâ vislosti mezi sklonem kloubnõâ draâ hy avybranyâ mi skeletaâ lnõâmi adentaâ l- nõâmi parametry u vysï etrïenyâ ch pacientuê. Byl hodnocen vztah sklonu kloubnõâ draâ hy s vertikaâ lnõâmi asagitaâ lnõâmi charakteristikami oblicï ejoveâ ho skeletu, s hloubkou skusu ase sklonem dlouheâ osy hornõâch rïezaâkuê.zï aâ dnaâ s teï chto z teï chto hledanyâch zaâ vislostõâ nebylaprokaâ zaâ nanastatisticky signifikantnõâ hladineï vyâ znamnosti. PrÏõÂpadne zaâ vislosti by mohly byât zjisïteïnynaveïtsïõâm souboru pacientuê. DalsÏ õâ zprïesneï nõâ vyâ sledkuê by mohlo prïineâst zarïazenõâ jedincuê stejneâho veï ku. Nadruhou stranu velkeâ rozdõâly v pruê meï rnyâ ch hodnotaâ ch sklonu kloubnõâ draâ hy zjisï teï neâ v publikovanyâ ch studiõâch mohou poukazovat na vysokou variabilitu teâ to velicï iny nebo navysokou neprïesnost pouzï ityâch metod. AutorÏi nemajõâ komercï nõâ, vlastnickeâ nebo financï nõâ zaâ jmy na produktech nebo spolecï nostech popsanyâ ch v tomto cïlaâ nku. ments [6]. On the other hand, Japanese authors [30] did not determine any relationship between articular eminence inclination and disk displacement. This relationship is probably clinically significant only together with abnormal functional load of the joint. Conclusion The work aimed to find out whether there is relationship between condylar path inclination and selected skeletal and dental parameters. We evaluated the relationship of condylar path inclination with vertical and sagittal characteristics of facial morphology, with overbite, and with the inclination of upper incisors. None of the suggested relationships was proved on the level of significance. Potential relationship may be found in a bigger sample of patients. Individuals of the same age may also contribute to more precise results. On the other hand, great differences in mean values of condylar path inclination reported in the studies published may suggest a high variability of the parameter, or inaccuracy of the methods used. Authors have no commercial, proprietary or financial interest in products or companies mentioned in the article. Literatura/References 1. Baqaien, M.A.; Barra, J.; Muessig, D.: Computerized axiographic evaluation of the changes in sagittal condylar path inclination with dental and physical development. Amer. J. Orthodont. dentofacial Orthop. 2009, 135, cï. 1, s Corbett, N.E.; DeVincenzo, J.P.; Huffer, R.A.; Shryock, E.F.: The relation of the condylar path to the articular eminence in mandibular protrusion. Angle Orthodont. 1971, 41, cï. 4. s Isberg, A.; Westesson, P.L.: Steepness of articular eminence and movement of the condyle and disk in asymptomatic temporomandibular joints. Oral. Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1998, 86, cï. 2, s Katsavrias, E.G.: Changes in articular eminence inclination during the craniofacial growth period. Angle Orthodont. 2002, 72, cï. 3, s Ikai, A.; Sugisaki, M.; Young-Sung, K.; Tanabe, H.: Morphologic study of the mandibular fossa and the eminence of the temporomandibular joint in relation to the facial structures. Amer. J. Orthodont. dentofacial Orthop. 1997, 112, cï. 6, s Ren, Y.F.; Isberg, A.; Westesson, P.L.: Steepness of the articular eminence in the temporomandibular joint. Tomographic comparison between asymptomatic volunteers with normal disk position and patients with disk displacement. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1995, 80, cï. 3, s Gallo, L.M.: Modeling of temporomandibular joint function using MRI and jaw-tracking technologies mechanics. Cells Tissues Organs 2005, 180, cï. 1, s Parlett, K.; Paesani, D.; Tallents, R.H.; Hatala, M.A.: Temporomandibular joint axiography and MRI findings: a comparative study. J. prosthet. Dent. 1993, 70, cï. 6, s Kimmel, F.P.; Athanasiou, A.E.; Melsen, B.: The evaluation of the function of the stomatognathic system using combination of 3-dimensional axiography, sirognathography, electromyography and photo-occlusion. Orthodont. F. 1986, 57, cï. 2, s Widman, D.J.: Functional and morphologic considerations of the articular eminence. Angle Orthodont. 1988, 58, cï. 3, s Reicheneder, C.; Proff, P.; Baumert, U.; Gedrange, T.: Comparison of maximum mouth-opening capacity and condylar path length in adults and children during the growth period. Ann. Anat. 2008, 190, cï. 4, s Uchida, T.; Sakai, J.; Okamoto, Y.; Watanabe, T.; Kitagawa, T.; Aida, M.; Saito, T.; Ito, T.: Studies evaluating measurement accuracy of CMS-JAW, a jaw motion tracking device with six degrees of freedom using an ultrasonic recording system. Nihon Hotetsu Shika Gakkai Zasshi 2008, 52, cï. 3, s Landes, C.; Walendzik, H.; Klein, C.: Sonography of the temporomandibular joint from 60 examinations and comparison with MRI and axiography. J. craniomaxillofac. Surg. 200, 28, cï. 6, s Kordass, B.; Hugger, A.; Bernhardt, O.: Correlation between computer-assisted measurements of mandibular opening and closing movements and clinical symptoms 41

9 of temporomandibular dysfunction. Int. J. Comput. Dent. 2012, 15, cï. 2, s Baqaien, M.A.; Barra, J.; Muessig, D.: Computerized axiographic evaluation of the changes in sagittal condylar path inclination with dental and physical development. Amer. J. Orthodont. dentofacial Orthop. 2009, 135, cï. 1, s Baqaien, M.A.; Al-Salti, F.M.; Muessig, D.: Changes in condylar path inclination during maximum protrusion between the ages of 6 and 12 years. J. Oral. Rehabil. 2007, 34, cï. 1, s Reicheneder, C.; Gedrange, T.: Baumert, U.: Faltermeier, A.; Proff, P: Variations in the inclination of the condylar path in children and adults. Angle Orthodont. 2009, 79, cï. 5, s Katsavrias, E.G.: Morphology of the temporomandibular joint in subjects with Class II Division 2 malocclusions. Amer. J. Orthodont. dentofacial Orthop. 2006, 129, cï. 4, s Mohl, N.D.: Reliability and validity of diagnostic modalities for temporomandibular disorders. Adv. Dent. Res. 1993, 7, cï. 2, s Anders, C.; Harzer, W.; Eckardt, L.: Axiographic evaluation of mandibular mobility in children with Angle Class- II/2 malocclusion (deep overbite) J. orofac. Orthop. 2000, 61, cï. 1, s Stamm, T.; Vehring, A.; Ehmer, U.; Bollmann, F.: Computer-aided axiography of asymptomatic individuals with Class II/2. J. orofac. Orthop. 1998, 59. cï. 4, s Slavicek R. Masticatory organ. Functions and dysfunction. Kloster Neuenburg: Gamma; Clark. W.J.: Twin Block Functional therapy: Applications in dentofacial orthopaedics. 2nd ed., London: Mosby, Katsavrias, E.G.; Voudouris, J.C.: The treatment effect of mandibular protrusive appliances on the glenoid fossa for Class II correction. Angle Orthodont. 2004, 74, cï. 1, s Katsavrias, E.G.: Morphology of the temporomandibular joint in subjects with Class II Division 2 malocclusions. Amer. J. Orthodont. dentofacial. Orthop. 2006, 129, cï. 4, s Ferna ndez, S.J.; Go mez,g.j.m.; del Hoyo, J.A.: Relationship between condylar position, dentofacial deformity and temporomandibular joint dysfunction: an MRI and CT prospective study. J. craniomaxillofac. Surg. 1998, 26, cï. 1, s Akahane. Y.; Deguchi, T.; Hunt, N.P.: Morphology of the temporomandibular joint in skeletal class III symmetrical and asymmetrical cases: a study by cephalometric laminography. J. Orthodont. 2001, 28, cï. 2, s Ueki. K.; Nakagawa, K.; Takatsuka, S.; Shimada, M.; Marukawa, K.; Takazakura, D.; Yamamoto, E.: Temporomandibular joint morphology and disc position in skeletal class III patients. J. craniomaxillofac. Surg. 2000, 28, cï. 6, s Katsavrias, E.G.; Halazonetis, D.J.: Condyle and fossa shape in Class II and Class III skeletal patterns: A morphometric tomographic study. Amer. J. Orthodont. dentofacial. Orthop. 2005, 128, cï.3, s Sato, S.; Kawamura, H.; Motegi, K.; Takahashi, K.: Morphology of the mandibular fossa and the articular eminence in temporomandibular joints with anterior disk displacement. Int. J. Oral maxillofac. Surg. 1996, 25, cï. 3, s MUDr. Michal SÏ edivec Stomatologicka klinika deï tõâ a dospeï lyâch 2. LF UK a FN Praha-Motol VU valu 84, Praha 5 3Dent s. r. o. porïaâdaâ 1) Doma cõâ akce: Datum ± MõÂsto: Praha Na zev: CertifikacÏ nõâ kurz ebrace/elock 3D customized lingual system Informace: 3Dent s. r. o., Ing. Ivan Hospoda r, MBA, Wolkrova 33, Bratislava, tel: , 2) ZahranicÏ nõâ akce: Datum 4.± MõÂsto: Bratislava Na zev: CertifikacÏny kurz ebrace/elock 3D customized lingual system (slovensky) Informace: 3Dent s. r. o., Ing. Ivan Hospoda r, MBA, website:

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