International Journal of Oral and Maxillofacial Diseases

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1 Original Research Surface wise and section wise evaluation of Flattening, Osteophyte, Erosion and Sclerosis of Temporomandibular Joint on Computed Tomography in a patient with Rheumatoid arthritis (RA) and Localised Osteoarthritis (LOA) Kshar Avinash, 1 Patil Abhijeet, 2 Umarji Hemant 3 1 Professor and Head, Department of Oral Medicine and Radiology, Vasantdada Patil Dental College and Hospital, Sangli, Maharashtra. 2 Senior Lecturer, Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune. Maharashtra, 3 Professor and Head, Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra. Corresponding Author: Dr. Abhijeet Patil Senior Lecturer, Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune. abhijeet.p86@gmail.com Mobile: Visit our website: How to site this article: Kshar A.., Patil A., Umarji H., Surface wise and section wise evaluation of Flattening, Osteophyte, Erosion and Sclerosis of Temporomandibular Joint on Computed Tomography in a patient with Rheumatoid arthritis (RA) and Localized Osteoarthritis (LOA). Int J Ora Max Dis; 1(1); 2016:5-13. Abstract: Objectives: The aim of this study is to evaluate 1) Cortical and subcortical changes in the head of condyle, glenoid fossa and articular eminence in axial, coronal and sagittal planes on Computed tomography 2) To correlate clinical and radiographic findings. 3) To ascertain a relationship if any between type of arthritis and bony changes Materials and methods: The study comprised of 25 patients who reported to our institute with chief complaint of TMJ pain and 5 patients with established diagnosis of Rheumatoid arthritis referred from orthopedic OPD of other city medical hospitals. Those patients who presented with evidence of TMJ arthritis on conventional radiography were included in the study and subjected to CT scan. CT scan of the right and left TMJ was taken with Siemens Somatom Plus 4 (spiral CT).The study comprised of 25 patients of Localized Osteoarthritis (LOA) and 5 patients of Rheumatoid Arthritis (RA) (i.e. totally 60 TMJ).Each TMJ was subjected to CT scan using axial section, coronal section, and sagittal reconstruction. Obtained CT scan was evaluated for a) Flattening b) Osteophyte c) Erosion and d) Sclerosis of TMJ. Results: In case of Localized osteoarthritis(loa) a) Changes in head of the condyle flattening (P = 0.049); osteophyte(p =0.016); erosion(p =0.018); sclerosis (P=0.001) b) Changes in articular eminence flattening (P = 0.019); erosion (P =0.015) c) Changes in glenoid fossa- flattening (P = 0.042); osteophyte (P =0.016); erosion (P =0.001); sclerosis (P=0.001). In case of Rheumatoid arthritis (RA) a) Changes In head of the condyle flattening (100%); osteophyte (100%); erosion(60%); sclerosis (20%) b) Changes in articular eminence flattening (80%); erosion (20%) c) Changes in glenoid fossa- osteophyte (60%); flattening (40%); erosion (20%); sclerosis (20%) Conclusions: In both LOA and RA involvement Head of the condyle was common finding. The most common change affecting the HOC was flattening, followed by erosion and osteophyte. In RA the common changes affecting TMJ components were flattening and erosion. Keywords: Temporo-mandibular joint; CT scan TMJ; TMJ CT in Rheumatoid arthritis; TMJ CT in Localized Osteoarthritis; TMJ CT in arthritis, TMJ arthritis. Introduction Pain and dysfunction of TMJ is quite commonly manifested in the day to day clinical practice. It is well established that conventional radiography fails to reveal the detailed changes taking place in the TMJ because of drawbacks of unwanted and excessive superimposition. CT scan on the other hand provides inherent high resolution power, excellent clarity and facility for bone window, therefore it is possible to study any bone pathology in the minutes detail thus helps in making early diagnosis and treatment possible. Computed tomography is the best method for delineating the osseous details of arthritic joints. This being so it was considered worthwhile employing this unique method to study and record the variation in the radiographic pattern of TMJ arthritis viz. in localized TMJ Osteoarthritis and Rheumatoid arthritis. Methodology The study comprised of 25 patients who reported with the chief complaint of TMJ pain and 5 patients with established diagnosis of Rheumatoid arthritis. All the patients were subjected to conventional TMJ radiography on OPG machine, only those patients who had radiographic evidence of TMJ arthritis were included in the study. 5

2 All examinations were performed by the same operator using Siemens Somatom Plus 4 spiral CT scan (Germany) machine. CT scan of the TMJ was done in two sections i) direct axial ii) direct coronal and sagittal reconstruction was done later on, using direct axial section. Using high resolution algorithm (HRCT) with high KV (140) and ma (146), time of acquisition 1 second, 1 mm thin contiguous sections were taken. The CT scans obtained were scrutinized in great detail for both the normal and affected joints by two experienced oral radiologists. Each joint was viewed and changes such as flattening, osteophyte, sclerosis and erosion involving the condyle, articular eminence and glenoid fossa were recorded on a specific evaluation sheet. All images were viewed on the same monitor under the same conditions. The two observers were asked to evaluate the following imaging characteristics: Osseous changes in TMJ components: (1) Flattening (F), defined as a flat bony contour deviating from the convex form; (2) Erosion(E), defined as an area of decreased density of the cortical bone and the adjacent subcortical bone; (3) Osteophytes (O): defined as marginal bony outgrowths on the condyle; (4) Sclerosis (S), defined as an area of increased density of cortical bone extending into the bone marrow. A four point rating scale (0-3) is used in order to define severity of osseous changes in TMJ components (i.e. Head of condyle, Articular eminence and Glenoid fossa): Flattening Absence 1. Mild: - flattening involving less than one third of TMJ component. 2. Moderate: - flattening involving more than one third and less than two third of TMJ component. 3. Severe: - flattening involving more than two third of TMJ component. Erosion Absence 1. Mild: - erosion within the cortical layer of TMJ component. 2. Moderate: - erosion slightly deeper than cortical layer of TMJ component. 3. Severe: - erosion causing destruction of more than two third of TMJ component. Sclerosis Absence 1. Mild: - sclerosis just beneath the cortical layer of TMJ component. 2. Moderate: - sclerosis extending more than one third and less than two third of TMJ component. 3. Severe: - sclerosis extending into more than two third of TMJ components. Osteophyte formation Absence 1. Mild: slight, when marginal bony outgrowth on TMJ component was less than 1 mm 2. Moderate: when marginal bony outgrowth on TMJ component was 1-2 mm 3. Severe: when marginal bony outgrowth on TMJ component was more than 2 mm. Statistics Radiographic findings were statistically analyzed with ANOVA using the Statistica 6.0 for Windows software (StatSoft Inc., Tulsa, OK) with Pearson correlation test. The results obtained in our study were compared with similar studies in literature and objective conclusions drawn. Result Table I shows the various osseous changes seen in the TMJ components in patients with localized osteoarthritis and rheumatoid arthritis. Changes in LOA involving TMJ:- 1. Changes in condyle: In LOA of TMJ the most common radiographic change observed was flattening of condyle followed by erosion and osteophyte formation. Flattening (P = 0.049) osteophyte (P =0.016); erosion (P =0.018); sclerosis (P=0.001) 2. Changes in articular eminence: Most common radiographic change observed was flattening. Flattening (P = 0.019), erosion (P =0.015) 3. Changes in glenoid fossa: most common radiographic change observed was flattening followed by erosion and osteophyte formation. Flattening (P = 0.042), Osteophyte (P =0.016); Erosion (P =0.001); Sclerosis (P=0.001) Changes in Rheumatoid arthritis involving TMJ:- 1. Changes in condyles: The most common radiographic change observed was flattening and erosion followed by osteophyte formation and sclerosis. 2) Changes in articular eminence:-most common radiographic change observed was flattening followed by erosion 3) Changes in glenoid fossa: most common radiographic change observed was erosion followed by flattening, sclerosis and osteophyte. Table II shows co-relation between flattening of TMJ components as seen on different sections of CT scan in LOA as well as RA. The flattening of head of condyle in LOA can be appreciated equally on all the three sections of CT scan i.e. axial, coronal and sagittal reconstruction whereas in case of RA flattening of head of condyle (HOC) is recorded highest on sagittal reconstruction followed by coronal section and axial section. Flattening of articular eminence is recorded predominantly on sagittal reconstruction followed by axial section and coronal section. In localized osteoarthritis, glenoid fossa equally shows flattening on coronal section and sagittal reconstruction followed by axial section.where as in RA flattening of glenoid fossa seen only in axial section 6

3 Figure 1: Axial section, flattening of left HOC anteriorly Figure 2: Axial section, flattening of right HOC laterally Figure 3: Coronal section, severe flattening of right & left HOC superiorly Figure 4: Sagittal reconstruction, severe flattening of left HOC anterosuperiorly and articular eminence posteroinferiorly Figure 4: Sagittal reconstruction, severe flattening of left HOC anterosuperiorly and articular eminence posteroinferiorly Figure 5: Sagittal reconstruction, severe flattening of right HOC superiorly Figure 6: Coronal section, erosion of left HOC superiorly Figure 9: Sagittal reconstruction, flattening of left HOC anterosuperiorly and AE inferiorly Figure 7: Axial section, osteophyte in the centre of left glenoid fossa Figure 8: Coronal section flattening of left articular eminence laterally 7

4 Figure 10: Axial section severe erosion & flattening of right and left HOC anteriorly Figure 11: Coronal section, erosion & flattening of right HOC superiorly (arrowwhite) & erosion of glenoid fossa (arrow - black). Figure 12: Axial section osteophyte (arrow) and erosion of left HOC anteriorly. Figure 13: Axial section, erosion of left HOC anteriorly Figure 14: Axial section, erosion of right HOC laterally Figure 15: Coronal section, erosion of left HOC superiorly Figure 16: Sagittal reconstruction, erosion of right HOC superiorly Table III shows section-wise appearance of osteophyte on head of condyle, articular eminence and glenoid fossa in localized osteoarthritis as well as in rheumatoid arthritis on CT scan. Both in LOA or in RA the osteophyte of head of condyle was predominantly recorded on sagittal reconstruction followed by coronal section, axial section. Osteophyte of glenoid fossa was best visualized on coronal section and followed by axial section and sagittal reconstruction equally. Table IV shows section wise appearance of sclerosis of head of condyle, articular eminence and glenoid fossa in localized osteoarthritis as well as in rheumatoid arthritis on CT scan. In localized osteoarthritis sclerosis was not common finding. In the rheumatoid arthritis sclerosis of head of condyle was equally appreciable on axial section, coronal section and sagittal reconstruction. Sclerosis of glenoid fossa was seen only on sagittal reconstruction. 8

5 Table V shows section wise appearance of erosion of head of condyle, articular eminence and glenoid fossa in localised osteoarthritis as well as rheumatoid arthritis in CT scan. Erosion of head of condyle predominantly seen on coronal section. In RA erosion of articular eminence seen only on sagittal reconstruction. Erosion of glenoid fossa is equally seen on axial and coronal sections Table VI shows Out of 60 joints 45 joints were symptomatic. Out of 45 symptomatic joints 42 joints showed CT scan findings and 3 joints did not show any findings on the CT scan. Total number of asymptomatic joints were 15. Out of 15 asymptomatic joints 14 showed positive CT scan findings whereas only one joint did not show CT scan changes. Table VII shows surface wise various osseous changes seen in TMJ on CT scan section in patients with localized osteoarthritis. On axial sections, flattening of head of condyle is recorded highest on lateral and anterolateral surface followed by anterior surface. In same way flattening of articular eminence recorded maximum on lateral and anterolateral surface followed by posterior and posterolateral surfaces. Axial section is best to visualize osteophyte involving lateral and anterolateral surface and erosion involving anterior surface of head of condyle. Coronal section is best to visualize flattening of the head of condyle involving superior and superolateral surfaces, Osteophyte involving the medial surface and erosion involving the superior and superolateral surfaces. Coronal section is best to visualize flattening of articular eminence involving the lateral surface. Sagittal reconstruction is best to visualize flattening of head of condyle anterosuperiorly, osteophyte involving anteriorly and erosion involving superiorly. Sagittal reconstruction is best to visualize flattening of articular eminence posteroinferiorly followed by inferiorly. Table VIII shows surface wise (various) osseous changes seen in the TMJ on CT scan section in patients with RA. On axial section flattening of head of condyle was seen on anterior surface (3 joints) followed by lateral surface, osteophyte on superior surface, sclerosis of posterior surface and erosion on anterior surface. On axial section flattening of glenoid fossa seen on anterior surface (1joint) erosion on anterior and superior surface. Articular eminence did not show any CT scan finding. On coronal section, flattening is recorded maximum on superior surface, osteophyte medially, sclerosis and erosion superiorly. Glenoid fossa shows maximum changes on superior surface, AE didn t sho any change. On sagittal reconstruction flattening of HOC is recorded maximum on anterosuperior and superior surface, osteophyte superiorly, sclerosis anterosuperiorly and erosion superiorly.ae showed maximum flattening posteroinferiorly and posteriorly and erosion anteriorly.gf showed maximum flattening superiorly, osteophyte superiorly, sclerosis anteriorly and erosion superiorly able IX shows age wise and sex wise distribution of TMJ arthritis. In our study, most commonly affected age group by TMJ arthritis is years followed by years and males are more affected than females. Discussion Larheim 1 (1984) studied osseous components of TMJ by using high resolution CT and found condylar erosion in 77% of his cases (10 out of 13), as compared to their study our study showed condylar erosions in 40% (10out of 25) of cases. Goran W. Gynther 2 (1996) in his study which utilized sagittal tomography in patients of generalized osteoarthritis, found osteophyte and flattening of head of condyle in 55% and 40% respectively and sclerosis of the eminence in 35% of cases. These findings are consistent with our study findings. Goran W. Gynther 3 (1996) in his study which utilized sagittal tomography in patients of generalized osteoarthritis, found osteophyte and flattening of head of condyle in 55% and 40% respectively and sclerosis of the eminence in 35% of cases. He also concluded that flattening of the eminence as well as osteophytes have been most common in osteoarthritis. These findings are consistent with our study findings. According to GW Gynther and G. Tronje 4 (1997), a tomographic evaluation of TMJ in generalized osteoarthritis, concluded that flattening and osteophyte of head of condyle and sclerosis of the eminence were common findings. In the study by P.A.Toller 5 (1973) which involved conventional radiography of mandibular condyle in osteoarthritic patients found erosion in 93.5% and osteophyte in 21% of cases. Our study also recorded the similar findings. In the study by Reny de Leew, Geert Boering 6 (1995) on osteoarthritis of TMJ observed that erosion is regarded as a sign of the progressive stage, whereas flattening and sclerosis are thought to reflect repair. In the study done by P. Goupille et al 7 (1992) which involved direct coronal CT of TMJ in RA found that Table I: Shows the various osseous changes seen in the TMJ components in patients with LOA and RA Abbreviations : N normal, F- flattening, O osteophyte, E- erosion, HOC head of condyle, AE- articular eminence, GF Glenoid fossa 9

6 Table II: shows co-relation between flattening of TMJ components as seen on different sections of CT scan in LOA as well as RA Table III: shows section wise appearance of osteophyte on head of condyle, articular eminence and GF in Localized Osteoarthritis as well as in Rheumatoid arthritis on CT scan. Table IV: shows section wise appearance of sclerosis of head of condyle, articular eminence and GF in localized osteoarthritis as well as in rheumatoid arthritis on CT scan. Table V: shows section wise appearance of erosion of head of condyle, articular eminence and GF in localized osteoarthritis as well as rheumatoid arthritis in CT scan. Table VI: shows total number of symptomatic and asymptomatic TMJ and their co-relation with CT scan findings. Table VII: shows surface wise various osseous changes seen in TMJ on CT scan section in patients with LOA[ joint wise (50 joints)] 10

7 Table IX: Showing age wise and sex wise distribution of TMJ arthritis. Table VIII: shows surface wise (various) osseous changes seen in the TMJ on CT scan section in patients with RA [ joint wise (10 joints)] erosion (36 out of 52) and osteophyte (13 out of 52) of head of condyle were common finding followed by erosion of glenoid fossa (18 out of 52) and flattening of articular eminence (30 out of 52). In our study, patients with RA were subjected to conventional TMJ view (on OPG machine) and only those patients who showed positive radiographic signs were further subjected to CT scan. This may explain the high percentage of positive osseous changes on CT scan in our study. In the study of Yunn-Sheng Hu 8 (1995) which involved CT scan for TMJ in Juvenile Rheumatoid Arthritis (JRA) and concluded that the predominant finding was erosion of head of condyle. Celiker et al 9 (1995) studied TMJ involvement in RA on CT scan, found most frequent pathological signs were osteophyte formation, erosion of the mandibular condyle in (40%) of the cases. They also concluded that TMJ involvement may be detected even in asymptomatic patients with RA and there is positive co-relation between the severity of disease and involvement of TMJ. In the study done by Goupille P et al 10 (1993) which involved clinical and sagittal plane tomographic examination of TMJ in RA patients found that incidence of erosion and cyst of mandibular condyle are significantly higher in patients with R.A. Iand they also concluded that there is no co-relation between the clinical and tomographic findings of the TMJ in RA and the intensity of the destructive lesions of the TMJ on tomography in RA is well correlated to the severity of the disease. In study of Scutellari PN et al 11 (1993) which involved tomographic examination of TMJ in RA patients found erosion (68.2%), osteophyte (31.8%), sclerosis (28.6%) were common findings. They also concluded that in RA abnormalities are bilateral and symmetric, whereas in sero-negative patients it is unilateral. In studies done by GW Gynther and G. Tronje (1996) 2 and which involved tomography, observed that in RA the predominant radiographic changes were erosion of condyle (11 out of 21 TMJ), sclerosis of condyle (6 out of 21 TMJ) and articular eminence (6 out of 21 TMJ). They also concluded that the erosion were more severe in young RA patients which may indicate a more aggressive form of the disease. In our study erosion and flattening of the head of the condyle were the predominant findings, followed by erosion and flattening of the glenoid fossa and articular eminence. Sclerosis was less common finding. The most common TMJ component involved in localized osteoarthritis is head of condyle followed by articular eminence and the most common CT finding was flattening. In case of RA again head of the condyle is most commonly affected and the osseous changes were flattening and erosion. Flattening was also noticed in articular eminence. In case of LOA in 68% of cases, glenoid fossa appeared to be normal. Flattening of the TMJ components is a very common finding in TMJ arthritis according to Goran W. Gynther 12 (1996), GW Gynther and G. Tronje 23 (1997), Bjoor Wiberg and Anders Wanman 14 (1998), Reny de Leeuw 24 (1995), P. Goupille et al 1 (1992) our findings are in general agreement with their studies. In our study either in LOA or in RA the osteophyte of head of condyle was predominantly recorded on sagittal reconstruction followed by coronal section, axial section. According to H. Sato and T.Fuji 13 (1992), GW Gynther and G.Tronje 2 (1996), BjoorWiberg and Anders Wanman 14 (1998), Reny de Leeuw 24 (1995), P. Goupille et 11

8 al 1,P. Goupille et al 1 (1992) our findings are in general agreement with their studies. In our study either in LOA or in RA the osteophyte of head of condyle was predominantly recorded on sagittal reconstruction followed by coronal section, axial section. According to H. Sato and T.Fuji 13 (1992), GW Gynther and G.Tronje 2 (1996), BjoorWiberg and Anders Wanman 13 (1998), P. Goupille, B.Fouquet 7 (1992), Scutellari PN, Orzincolo C. et al 5 (1993), P.A. Toller 11 (1973), osteophyte of TMJ components is a very common finding in TMJ arthritis and the findings of our study coincides with theirs. According to GW Gynther 14 (1997),Goran W. Gynther and G.Tronje 2 (1996), BjoorWiberg 13 (1998), Scutellari PN 11 (1993), Lambert G.M., D.E. Bont (1986), Reny de Leeuw 6 (1998), sclerosis of TMJ components is common finding in TMJ arthritis in their studies and in our study sclerosis was observed in RA cases. According to T.A.Larheim(1984), H.Sato, T.Fuji 13 (1992), G.W.Gynther and G.Tronje ( and ), BjoorWiberg 14 (1998), P.A.Toller 11 (1993), Lambert GM DE Bont(1986), Reny de Leeuw 24 (1995), P.Goupille 1 (1992), Yunn-sheng Hu 2 (1995), Celiker R and et al 3 (1995), P.Goupille 4 (1993), Scutellari-PN 5 (1993), S.M.Surjanen 6 (1985), erosion of TMJ components is common finding in their studies in TMJ arthritic patients. Our findings are similar. According to the study done by Sharon Brookes, Lars Eriksson 15 (1992), on tomography out of 34 asymptomatic patients they found flattening of head of condyle and articular eminence in 12 patients (35%). No joint in this series showed more advanced changes such as erosion, osteophytes or sclerosis. According to T.A.Larheim 8 (1984) axial scanning appeared to be most useful method for demonstrating osseous defects of TMJ e.g. erosion, sclerosis and osteophytes. According to Eckerdal O and Lundberg 16 M (1979) (autopsy study on tomogram) pathological changes such as sclerosis, erosion, osteophytes occurred exclusively in medial and central parts. Oberg et al 36 reported lesions of TMJ laterally and centrally. Baur 36 found the highest frequency of osteophytes in the central part of the joint. According to P.A.Toller 5 (1973) erosion of head of condyle most commonly found on anterior surface followed by superior surface and posterior surface. The findings of our study roughly coincides with those of the above workers. Anterior and anterosuperior surfaces of HOC were commonly affected surfaces by arthritic changes, in this study it seen logical to suppose that maximum stress born by these surfaces predispose them to the above changes. According to P. Goupilleet al 8 (1992)RA, coronal scanning is an accurate technique for evaluation of bone changes in TMJ. According to Yunn-Sheng Hu 8 (1995), erosion was commonly observed in the lateral aspect of the condyle and also concluded that axial scan is not ideal for revealing deformities in the superior aspect of articular surface, lesion in this area may have gone undetected. Our study findings are in harmony with studies mentioned above. According to study done by K E Alexiou, HC Stamatakis, K Tsiklakis on CBCT 17 degenerative arthritis is an agerelated disease. The progression and severity of osseous changes in condylar head and mandibular fossa are increased with age. In older age groups, patients are expected to have more frequent and severe progressive degenerative bony changes due to the development of TMJ osteoar thritis, than patients in younger age groups. As opposed to generalized osteoarthritis where changes are visualized to weight bearing joint in elderly group of patients, the TMJ involvement seen in younger age group TMJ changes may be associated with Para functional habits rather than age changes. Conclusion In conclusion, from this study we found increased incidence of condylar involvement in patients with localized TMJ osteoarthritis as well as in rheumatoid arthritis. In localized TMJ osteoarthritis the most common change affecting head of the condyle was flattening, followed by erosion and osteophyte [ to glenoid fossa: - flattening followed by erosion and to articular eminence flattening only]. Not a single case showed sclerosis. In rheumatoid arthritis the common changes affecting TMJ components were flattening and erosion. Flattening and osteophyte of head of condyle and articular eminence was best visualized on sagittal reconstruction and that of the glenoid fossa was best appreciated on coronal section. Sclerosis of head of condyle and glenoid fossa was best seen on sagittal reconstruction. Erosion of head of condyle and glenoid fossa was depicted well on the coronal section In this study the most common surfaces involvement Head of condyle: a) Anterosuperior b) Superior ii) Articular eminence: a) Posteroinferior b) Inferior No association between radiographic change and the type of arthritis could be established. As some of the asymptomatic joints in this study showed radiographic evidence of arthritis it can be concluded that positive CT scan findings may be present in the absence of the clinical signs and symptoms. In this study the common age group affected was 21 to 30 years and males were affected more than females. Reference 1. T. A. 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9 3. Ambarkar Priti Library Dissertation, Magnetic resonance Imaging Govt. Dental College & Hospital. 4. Gynther GW et al, Comparison of arthroscopy & radiography in patients with TMJ symptoms &generalised arthritis. Dentomaxfac.Radiol 1998, 27, Toller P.A., Osteoarthritis of mandibular condyle, BDJ march 20, 134:223, Reny De-Leeuw et al., Radiographic signs of TMJ osteoarthritis & internal derange. 7. Goupille P et al Direct coronal CT of TMJ in patients with rheumatoid arthritis. British J. Radiol 1992 vol. 65 no. 779, Hu Y S et al, Temporomandibular joint in rheumatoid arthritis CT findings, Pediatric Dentistry 17: 14, Celiker R et. al., TMJ involvement in rheumatoid arthritis relationship with disease activity, Scand J Rheumatol 1995, 24 (1), Goupille P et al TMJ in rheumatoid arthritis correlation between clinical & tomographic features J Dent 1993 Jun 21 (3): Scutellari PN et al TMJ in pathologic conditions: rheumatoid arthritis &seronegativespondyloarthritis. Radiol Med-Torino 1993 Oct 86 (4) BjoorWiberg et al Signs of osteoarthritis of the TMJ in young patients Oral Med Oral Surg Oral Pathol 1998, 86: Sato H, Fuji T The contribution of frontal tomography to the diagnosis of TMJ osteoarthritis DentomaxfacRadiol 1992, 21: Gynther GW et al Comparison of arthroscopy & radiography in patients with TMJ symptoms &generalised arthritis. Dentomaxfac.Radiol 1998, 27, Brooks SL et al Prevalence of osseous changes in the TMJ of asymptomatic persons without internal derangement Oral Med Oral Surg Oral Pathol 1992, 73: Eckerdal O et al TMJ relation as revealed by conventional radiographic technique. A comparision with the morphology & Tomographic images DentomaxfacRadiol 1979, 18: K E Alexiou, HC Stamatakis, K Tsiklakis Evaluation of the severity of temporomandibular joint osteoarthritic changesrelated to age using cone beam computed tomography DMFR (2009) 38, Conflict of interest: Nil Source of fund: Self 13