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Objective: Occlusal splints are commonly used in the management of temporomandibular joint disorders. However, it is unclear if it should be used after a second-line therapy like arthrocentesis. The evidence on the efficacy of post-arthrocentesis splint therapy in the management of temporomandibular joint disorders was systematically reviewed. Method and materials: PubMed, Embase, Scopus, Web of Science, CENTRAL, and Google Scholar were searched for studies published until 5 August 2024. The outcomes assessed were pain and maximal mouth opening. Results: Eight studies were included. Five studies reported data for the meta-analysis. The pooled analysis found that there was no statistically significant difference in pain scores in the arthrocentesis + splint group vs arthrocentesis group at 1 month (mean difference [MD] --0.01, 95% CI --0.46 to 0.44), 3 months (MS --0.02, 95% CI --0.67 to 0.63), and 6 months (MD 0.06, 95% CI --0.25 to 0.37). The pooled analysis also showed that splint therapy after arthrocentesis may not significantly improve maximal mouth opening as compared to no splint therapy at 1 month (MD 0.08, 95% CI --2.11 to 2.27), 3 months (MD 0.76, 95% CI --0.84 to 2.35), and 6 months (MD 0.56, 95% CI --0.65 to 1.78). Descriptive analysis of three studies showed that two supported the use of splints while one found no added improvement in outcomes. Conclusions: Limited evidence from low-quality studies shows that the use of splint therapy after arthrocentesis may not improve pain and maximal mouth opening in patients with temporomandibular joint disorders. High-quality randomized controlled trials are needed to improve evidence. [ABSTRACT FROM AUTHOR]

Objective: The aim of the current clinical study was to reveal whether harvesting of a temporalis fascia graft would be associated with a higher incidence of temporomandibular joint (TMJ) internal derangement. Methods: The study group involved 104 patients who had middle-ear operations, 67 of which involved harvesting of temporalis fascia and 37 that did not. The TMJs were clinically examined in each group. Results: The total incidence of internal derangement of the TMJ was significantly higher in the group that had temporalis fascia harvesting (79.1%), compared to the group that did not have temporalis fascia harvesting (29.7%), (p= 0.001). Conclusion: Harvesting of temporalis fascia probably alters mandibular kinematics and predisposes to internal derangement of the TMJs. [ABSTRACT FROM AUTHOR]

A Temporomandibular joint (TMJ) effusion is an accumulation of fluid components in the articular space. It represents an inflammatory process which can be associated with trauma, arthritis or internal derangement of TMJ such as disc displacement. In this study, we present the case of a 48-year-old patient presented with TMJ effusion, diagnosed as resulting from disc displacement without reduction and osteoarthrosis. The case report details the diagnostic and therapeutic strategies employed.

Background: Whether pain, jaw function and quality of life are correlated with disc positions is controversial, and similar studies evaluating disc positions by magnetic resonance imaging (MRI) are very limited. Objective: This study evaluated the pain, mandibular function and quality of life of the temporomandibular disorders (TMDs) patients with different disc positions according to MRI, and the relationship among them. Methods: Three hundred and thirty‐five participants were included. Patients completed questionnaires included the Numeric Rating Scale (NRS), Jaw Functional Limitation Scale 8‐item (JFLS‐8), the Generalised Anxiety Disorder 7‐item (GAD‐7), Patient Health Questionnaire 9‐item (PHQ‐9) and Oral Health Impact Profile for TMD (OHIP‐TMD). MRI was conducted to evaluate these diagnoses, resulting in the identification of three distinct categories: normal positioning (NP), disc displacement with reduction (DDwR) and disc displacement without reduction (DDwoR). Results: Participants had the mean age of 28.55 ± 11.10 years (80.90% women). DDwR and DDwoR had a higher percentage of females compared with NP. Significant differences existed among patients in all questionnaires. The DDwoR group had significantly the highest pain, functional limitation and the worst quality of life. Moreover, they experienced the most difficulties in chewing tough foods, yawning, experiencing pain and psychological discomfort. Moreover, the multivariate regression showed that age, female gender, diagnosis as DDwoR, GAD‐7 and PHQ‐9 were significantly linked to higher functional limitation. Worse quality of life was associated with age, diagnosis as DDwoR, GAD‐7 and PHQ‐9. Conclusions: Among patients with different disc positions, DDwoR showed the highest pain, functional limitation and the worst quality of life. Also, NP showed a proportion of chronic pain. Physical pain, psychological discomfort and chewing tough food were regarded as the most impaired. Women who experience anxiety and depression tended to have a higher propotion of dysfunction and a lower quality of life. [ABSTRACT FROM AUTHOR]

Objectives: Current studies on the treatment of adolescent patients with disc displacement without reduction (DDWOR) are limited by short follow-up periods and small sample sizes, and there are few comparative studies on the efficacy of conservative treatment with and without disc reduction for acute DDWOR. This study compared the therapeutic effects of two conservative treatment methods: physical therapy alone and physical therapy combined with non-surgical manual disc reduction and anterior repositioning splints (ARS), in adolescent patients with acute DDWOR. Materials and methods: This retrospective study included adolescent patients with DDWOR who underwent physical therapy at the Temporomandibular Joint Rehabilitation Department of the Shanghai Ninth People's Hospital from January 2018 to December 2021. Patient assessment data were collected before and after treatment. Patients were followed up through telephone and online questionnaires from March to August 2023. Results: The results indicate that compared to physical therapy alone, the combination of physical therapy and non-surgical manual disc reduction with ARS showed better short-term efficacy, improved mouth opening, and better long-term pain control. Also, it may be effective in preventing degenerative joint disease. Conclusions: This combination therapy is recommended for clinical application in adolescent patients with acute DDWOR. Clinical relevance: The present research demonstrates the superior efficacy of physical therapy and non-surgical manual disc reduction combined with anterior repositioning splint in adolescent patients with acute DDWOR. [ABSTRACT FROM AUTHOR]

Background and Objectives: Fibrillinopathies have different phenotypic expression: Marfan-like skeleton features, MLSF; mitral valve prolapse syndrome, MVPS; MASS phenotype, M = mitral valve prolapse, MVP, A = aortic root dilation, S = skeletal features, and the second S = (cutaneous) striae; Marfan Syndrome, MS. The study had the following main objectives: the correlation between disc displacement, DD (a major sign for temporomandibular joint dysfunction, TMDs) on magnetic resonance imaging, MRI, and aortic Z score (a major sign for aortic root dilation) on echocardiography; the predictive value of DD towards aortic Z score. DD had 2 types of severity: DD with reduction (the mild type, DDwR), and DD without reduction (the severe type, DDwoR). Materials and Methods: The type of fibrillinopathy was precised by clinical exam (systemic score), ophthalmic exam (for ectopia lentis), and echocardiography (aortic Z score, MVP). Medical treatment consisted of betablockers, BB (for patients with tachycardia), or angiotensin II receptor blockers, ARB. Surgical treatment was addressed to aortic root aneurysm, and severe mitral regurgitation, MR. DD benefited from dental conservatory treatment or surgical restoration. Results: DD-Z score had a powerful correlation in MASS (Rho = 0.787, p < 0.01), and in MS patients (Rho = 0.819, p < 0.01). For the entire sample, both DDwR-Z score and DDwoR-Z score had a moderate correlation (Rho = 0.469, and respectively 0.669). Furthermore, DD was an important predictor for Z score. DDwoR had a double power of prediction for the Z score compared with DDwR (B coefficient = 1.661 for DDwR and 3.281 for DDwoR). Conclusions: TMDs had a powerful correlation with aortic root dilation in MASS and MS patients from the sample. Likewise, TMDs was a major predictor for aortic root dilation, in the entire sample. In clinical practice, we can utilize an extracardiac finding, TMDs, obtained by a non-invasive technique, MRI, for cardiac severity stratification of fibrillinopathies. [ABSTRACT FROM AUTHOR]

Objective: To investigate the morphological and positional temporomandibular joint (TMJ) characteristics of different temporomandibular disorders (TMDs). Methods: One hundred forty-three TMD patients were divided into three groups: Group 1: Myalgia (M), Group 2: Disc displacement with reduction (DDWR), and Group 3: Disc displacement without reduction (DDWOR). Three-dimensional positional and dimensional parameters of the TMJ, including mandibular fossa, condyle, and TMJ spaces were evaluated using cone beam computed tomography (CBCT). The significance level was p < 0.05. Results: Mandibular condyles were significantly positioned in more vertical, posterior, and medial directions, with the reduced condylar width in the DD groups (p < 0.001). Anterior joint space was significantly higher in the DDWR group than the myalgia group; the superior joint spaces were more reduced in DD groups than the myalgia group. Conclusion: Patients diagnosed with disc displacement showed significantly different condylar positions and joint spaces compared to the myalgia group in a skeletally comparable sample. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the inter-examiner reliability of the Chinese version of the Axis I diagnoses of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and to compare the consistency between clinical diagnoses and magnetic resonance imaging (MRI). Methods: Sixty-seven individuals were evaluated by three TMD specialists, and 49 underwent MRI examination. Cohen's Kappa coefficient (κ) was used to evaluate the inter-examiner reliability and the consistency between clinical diagnoses and MRI manifestations. Results: Diagnostic agreement was good to excellent for pain and disc displacement with or without reduction (κ = 0.659–1.000). Agreement between clinical diagnoses and MRI findings was fair to good (κ = 0.400). Conclusion: Inter-examiner diagnostic reliability using the Chinese version of the DC/TMD Axis I instruments was excellent, especially for arthrogenic TMDs. [ABSTRACT FROM AUTHOR]

Background and Objectives: This research was aimed at constructing a complete automated temporomandibular joint disc position identification system that could assist with magnetic resonance imaging disc displacement diagnosis on oblique sagittal and oblique coronal images. Materials and Methods: The study included fifty subjects with magnetic resonance imaging scans of the temporomandibular joint. Oblique sagittal and coronal sections of the magnetic resonance imaging scans were analyzed. Investigations were performed on the right and left coronal images with a closed mouth, as well as right and left sagittal images with closed and open mouths. Three hundred sagittal and coronal images were employed to train the artificial intelligence algorithm. Results: The accuracy ratio of the completely computerized articular disc identification method was 81%. Conclusions: An automated and accurate evaluation of temporomandibular joint disc position was developed by using both oblique sagittal and oblique coronal magnetic resonance imaging images. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to investigate the relationship between types of disc displacement (DD) diagnosed by magnetic resonance imaging (MRI), and the risk (presence or absence) and severity of condylar erosion (CE) graded using cone‐beam computed tomography (CBCT) in adult Temporomandibular disorders (TMD) patients. Methods: A total of 353 TMD patients (283 females, 70 males) underwent MRI scans to categorise DD as normal (NA), anterior displacement with reduction (ADDR), or anterior displacement without reduction (ADDNR). CE severity was graded on a scale of 0–3 (absence, mild, moderate or severe) using CBCT. To establish the plausibility and cut‐off points for CE diagnosis, the severity of CE was then further divided into three classifications: Grade 0 versus 1 + 2 + 3; Grades 0 + 1 versus 2 + 3; Grades 0 + 1 + 2 versus 3. Logistic regression analysis was performed, adjusting for age, gender and joint correlation. Results: ADDNR significantly increased the risk of CE compared with NA (OR = 10.04, 95% CI: [6.41, 15.73]) and showed a significant increase in CE severity across all classifications (ORs = 10.04–18.95). The effects of ADDNR were significant in both genders (p <.001) and had a greater impact in females. ADDR was predominantly associated with mild CE. Conclusions: ADDNR significantly increased the risk and severity of CE independent of gender when compared to NA, whereas ADDR was mainly associated with mild CE. Slight cortical discontinuity may represent a subclinical diagnosis requiring further investigation. [ABSTRACT FROM AUTHOR]

To compare the comfort and anxiety levels of patients undergoing two different temporomandibular joint (TMJ) arthrocentesis techniques. Fifty female patients were randomly assigned into two groups of 25 based on the treatment modality: Group 1, single-puncture Type-1 arthrocentesis (SPA); Group 2, conventional double-puncture arthrocentesis (DPA). Preoperative and postoperative anxiety was scored with the State-Trait Anxiety Inventory-S (STAI-S) questionnaire. Blood pressure and heart rate were assessed preoperatively during the application of local anesthesia and at needle insertion into the joint cavity, the 5th and 10th minute of the procedure, and end of the procedure. STAI-S scores were lower postoperative than preoperative in both groups. Heart rate and mean arterial pressure were highest during anesthesia and needle insertion (p < 0.005). Changes in heart rate, mean arterial pressure, and STAI-S scores were statistically similar between the groups. DPA and SPA were tolerated similarly by the patients. [ABSTRACT FROM AUTHOR]

The temporomandibular joint (TMJ) is a complex synovial joint, vital for functions such as chewing, deglutition and speaking. Temporomandibular disorders (TMDs) affect a significant part of the population and are more prevalent in women. The articular disc is located between the mandibular condyle and the temporal bone fossa, avoiding direct contact between them, it has functions such as; cushion ad distribute loads, stabilize the joint, facilitate lubrication and nutrition of articular surfaces. Disc displacement without reduction is a condition where the disc remais in anteromedial position and does not return to normal position, causing pain, discomfort and limited mouth opening. This work aims to present a review of the literature on disc displacement joint of the TMJ without reduction analyzing from symptoms to diagnostic and treatment methods. It is concluded that the professional responsible for treating such dysfunction pays attention to the symptoms in order to reach a correct diagnosis and obtain positive treatment. [ABSTRACT FROM AUTHOR]

To assess jaw and neck function, pressure pain threshold (PPT), and the presence of trigger points (TrPs) in disc displacement with reduction (DDWR) subjects compared to healthy subjects. One hundred DDWR subjects and 100 matched controls were studied. Clinical evaluations included demographic data, range of motion, jaw and neck disability, PPT, and muscle TrPs. DDWR subjects have limited pain-free opening limitation (p < 0.001), jaw and neck disability limitation (p < 0.001), and higher presence of active and latent TrPs limitation (p < 0.001) compared to healthy subjects. DDWR subjects present a limited pain-free mouth opening, higher jaw and neck disability, lower PPT, and major presence of active and latent TrPs compared to healthy subjects. Cervical spine and TMJ evaluation and treatment should be considered in DDWR patients. [ABSTRACT FROM AUTHOR]

Abstract Background Disc perforation (DP) is a severe type of Temporomandibular Disorder (TMD). DP may induce changes in the internal stresses of the temporomandibular joint (TMJ). Herein, this study attempts to investigate the biomechanical effects of different positions and sizes of DP on the TMJ using a biomechanical approach, to explore the mechanical pathogenesis of TMD. Methods Eleven three-dimensional finite element (FE)models of the TMJ were constructed based on CBCT imaging files of a patient with DP on the left side. These models included the disc with anterior displacement and discs with different locations and sizes of perforations on the affected disc. FE methods were conducted on these models. Results Anterior displacement of the disc leads to a significant increase in the maxim von Mises stress (MVMS) in both TMJs, with the affected side exhibiting a more pronounced effect. DP occurring at the posterior band and the junction between the disc and the bilaminar region has a greater impact on the MVMS of both TMJs compared to perforations at other locations. As the size of the perforation increases, both sides of the TMJs exhibit an increase in the magnitude of MVMS. Conclusions Unilateral disc anterior displacement results in an increased stress on both TMJs. Unilateral DP further affects the stress on both sides of the TMJs. TMD is a progressive condition, and timely intervention is necessary in the early stages to prevent the worsening of the condition.

This study aims to determine if a large anterior and reduced posterior/superior joint space is highly predictable for disc displacement. From patients with temporomandibular disorders symptoms, fifty-two experimental joints and fourteen control joints were included. The cone beam computed tomography (CBCT) images were used to calculate posterior-to-anterior (P-A) and superior-to-anterior (S-A) joint space ratios, while disc position was determined using magnetic resonance imaging (MRI). One-way analysis of covariance test and receiver operating characteristics analysis were carried out. The results showed that among the 52 experimental joints, 45 were diagnosed as disc displacement and 7 as normal disc positions (N). All 14 control joints showed normal disc positions. The P-A ratio was 1.46 ± 0.21, 0.99 ± 0.23, and 0.86 ± 0.30 in the control, N, and DD groups, respectively (p < 0.001). The S-A ratio was 1.80 ± 0.27, 1.44 ± 0.33, and 1.08 ± 0.35 in the control, N, and DD groups, respectively (p < 0.001). When an altered P-A ratio and/or S-A ratio are observed on the CBCT, the diagnosis of disc displacement is quite predictable with high sensitivity and specificity. [ABSTRACT FROM AUTHOR]

Background and Objectives: This research was aimed at constructing a complete automated temporomandibular joint disc position identification system that could assist with magnetic resonance imaging disc displacement diagnosis on oblique sagittal and oblique coronal images. Materials and Methods: The study included fifty subjects with magnetic resonance imaging scans of the temporomandibular joint. Oblique sagittal and coronal sections of the magnetic resonance imaging scans were analyzed. Investigations were performed on the right and left coronal images with a closed mouth, as well as right and left sagittal images with closed and open mouths. Three hundred sagittal and coronal images were employed to train the artificial intelligence algorithm. Results: The accuracy ratio of the completely computerized articular disc identification method was 81%. Conclusions: An automated and accurate evaluation of temporomandibular joint disc position was developed by using both oblique sagittal and oblique coronal magnetic resonance imaging images.

Background: Disc perforation (DP) is a severe type of Temporomandibular Disorder (TMD). DP may induce changes in the internal stresses of the temporomandibular joint (TMJ). Herein, this study attempts to investigate the biomechanical effects of different positions and sizes of DP on the TMJ using a biomechanical approach, to explore the mechanical pathogenesis of TMD. Methods: Eleven three-dimensional finite element (FE)models of the TMJ were constructed based on CBCT imaging files of a patient with DP on the left side. These models included the disc with anterior displacement and discs with different locations and sizes of perforations on the affected disc. FE methods were conducted on these models. Results: Anterior displacement of the disc leads to a significant increase in the maxim von Mises stress (MVMS) in both TMJs, with the affected side exhibiting a more pronounced effect. DP occurring at the posterior band and the junction between the disc and the bilaminar region has a greater impact on the MVMS of both TMJs compared to perforations at other locations. As the size of the perforation increases, both sides of the TMJs exhibit an increase in the magnitude of MVMS. Conclusions: Unilateral disc anterior displacement results in an increased stress on both TMJs. Unilateral DP further affects the stress on both sides of the TMJs. TMD is a progressive condition, and timely intervention is necessary in the early stages to prevent the worsening of the condition. [ABSTRACT FROM AUTHOR]

Objective: This systematic review aimed to investigate and examine whether intra‐articular injections of platelet‐rich plasma (PRP) after arthrocentesis are beneficial for the treatment of temporomandibular disorders, when compared to other treatments, such as injections of hyaluronic acid (HA) or saline after arthrocentesis. Methods: An electronic search on PubMed was performed using combinations of the terms 'temporomandibular' and 'platelet rich plasma', to identify studies reported in English and published up until 2017. The initial screening identified 222 records, of which only seven fulfilled the inclusion criteria and were included in this review. Of these studies, three compared injection of PRP after arthrocentesis with the injection of HA after arthrocentesis, while two compared injection of PRP after arthrocentesis with Ringer's lactate after arthrocentesis and one compared injection of PRP after arthrocentesis to sodium chloride. Results: Five of the studies found that PRP injections have led to significant improvements in mandibular range of motion and pain intensity up to 12 months after treatment, while the remaining two studies found similar results for the different treatments. Conclusion: However, a standardized protocol for PRP preparation and application needs to be established. [ABSTRACT FROM AUTHOR]

Background: Anterior repositioning splint (ARS) is used to treat temporomandibular joint (TMJ) disc displacement with reduction (DDwR). However, high recurrence rate remains a problem especially in patients with unstable occlusions. Objective: This study optimised standard ARS therapy and proposed a step‐back ARS retraction (SAR) method in adult patients with DDwR. Methods: Dental examinations and magnetic resonance imaging of TMJ were obtained before treatment (T0), 1 to 3 months (T1), 3 to 6 months (T2) and 6 to 12 months (T3) during treatment in 48 adults (average age 27.1 ± 5.7 years). After 3 months of basic ARS wearing, personalised treatment for patients with normal disc–condyle relationship was prescribed depending on bilaminar zone adaptations and severity of molar openbite. SAR which required sequential ARS wearing was designed for patients with deep overbite/overjet until retrodiscal tissue adaptations and stable occlusions were achieved. Results: The maximum interincisal opening was increased from 44.3 ± 6.9 to 45.3 ± 6.3 mm (p <.01), and joint pain was alleviated after ARS treatment. The overall success rate of ARS wearing was 92.1% (58/63) featured by a recaptured disc. Fifteen patients who underwent SAR therapy all showed bilaminar zone adaptations in the end, and one patient had positive condylar bone remodelling. Conclusions: ARS treatment could improve mouth opening and joint symptoms in adult DDwR patients. SAR method was suitable for treating DDwR patients with deep overbite and overjet and improved retrodiscal tissue adaptations and condylar bone remodelling. [ABSTRACT FROM AUTHOR]

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Background: The temporomandibular joint (TMJ) is considered a complex joint. Temporomandibular disorders (TMDs) are a common cause of musculoskeletal pain. At least one TMD symptom is seen in 33% of the population and 3.6% to 7.0% of the population shows significant severity warranting treatment. Magnetic resonance imaging (MRI) is better for the evaluation of disc and adjacent soft-tissue structures compared to cone beam computed tomography. MRI allows articular disc assessment in open and closed mouth positions. MRI has 95% accuracy in the assessment of disc disorders and 93% accuracy for osseous changes. Materials and Methods: A cross-sectional study was performed with a sample size of 21 patients as per inclusion and exclusion criteria. MRI findings were noted and compared with clinical findings. Results: As per our study, the most common age group is between 20 and 35 years. Of 42 TMJ, 41 joints show disc displacement changes and one TMJ was normal. Disc displacement with reduction is less than disc displacement without reduction. Left TMJ is more affected as disc displacement without reduction, as compared to the right side. Two TMJ were with posterior DD. Four TMJ shows anteromedial and 4 TMJ shows anterolateral DD. Six joints have a subluxation. Conclusion: In our study, we found that MRI in TMDs is more reliable and accurate for the diagnosis of DD.

Purpose: This observational study aimed to elucidate the pathophysiology of subchondral cysts (SC) in the temporomandibular joint (TMJ) and examine the results of conservative therapy administered to patients with SCs in the TMJ. Methods: The study included 41 patients with SCs, extracted from 684 consecutive patients who underwent magnetic resonance imaging (MRI). The anatomical features of SCs and positional abnormalities of the articular disc were initially evaluated using MRI. A second MRI examination was performed for 28/41 patients at 40-107 months (mean, 66 months) after the first MRI. The joint space, anteroposterior width of the condylar head (WiC), articular eminence angle (AEA), and visual analog scale of jaw pain (VAS) were assessed alongside the MRI examinations. Results: Most SCs were present in the anterosuperior and central condyle. Disc displacement was observed in 100% of 42 TMJs with SCs. Of the 29 joints in 28 patients, SCs in 19 joints resolved with time, whereas SCs in 10 joints persisted. A significant increase in the WiC and a significant decrease in AEA and VAS scores were observed on the second MRI scan. Conclusions: SCs tended to form in the anterosuperior and central parts of the condyle, where mechanical loading was likely to be applied. SCs are strongly associated with articular disc displacement. Two-thirds of SCs resolved over time, accompanied by resorption and osteophytic deformation of the condyle. SC might not be an indicator for the start of surgical treatment, and nonsurgical treatment could improve the clinical symptoms of patients with SCs. [ABSTRACT FROM AUTHOR]

This study assessed the relationship between clinical symptoms and magnetic resonance imaging (MRI) findings in temporomandibular disorders (TMD). A total of 324 temporomandibular joints (TMJs) from 162 patients were included. The TMJs were divided into three groups based on disc positions on MRI: normal disc position, anterior disc displacement with reduction (ADDwR), and anterior disc displacement without reduction (ADDwoR). Clinical findings included TMJ pain, TMJ noise, and maximum mouth opening (MMO). The disc configuration, disc positions, condylar morphology, and joint effusion were evaluated in proton density-weighted and T2-weighted open and closed-mouth sagittal sections. Patients comprised 135 females and 27 males, with a mean age of 37.63 ± 13.86 years. The VAS score was significantly higher in ADDwoR than in ADDwR (p = 0.007). Condylar sclerosis (β coefficient: 1.449, 95% confidence interval (CI): 0.505-2.393, p = 0.003) and condylar flattening (β coefficient: 1.024, 95% CI: 0.209-1.840, p = 0.014) had higher VAS scores than the other MRI findings in multiple regression analyses. Limited mouth opening (MO) was independently associated with ADDwoR. ADDwoR had a higher risk of having limited MO than normal disc position (odds ratio: 5.268), while there were no associations between limited MO and other MRI findings. None of the MRI findings showed significant performance in predicting TMJ noise. The convex and folded disc configuration percentages, the frequencies of osteophyte formation, and grade 3 effusion were significantly higher in the ADDwoR group. More severe clinical symptoms and a higher degree of disc deformity, osteophyte formation, and high-grade effusion were shown to be associated with ADDwoR. [ABSTRACT FROM AUTHOR]

The present study evaluated the literature regarding the clinical outcomes after discopexy using suture bone anchors for repositioning disc displacement. A systematic review was conducted according to the PRISMA statement and applied for the PROSPERO platform. The database searches were performed in the PubMed, Scopus, Web of Science, EMBASE, The Cochrane Library, and LILACS for full articles published from no restrictions of the initial period time to April 2022. Selection criteria included clinical studies in humans comparing maximal inter-incisal opening (MIO), pain by visual analogue scale (VAS), and protrusive and lateral excursions before and after discopexy. The screening process was performed by two independent reviewers, and if they did not agree with each other, a third reviewer was consulted before proceeding. The meta-analysis was carried out by Comprehensive Meta-Analysis software. Eleven studies met the inclusion criteria. A total of 327 patients were diagnosed with disc displacement, and 142 patients were refractory to conservative and minimally surgical therapies. Preauricular and endaural approaches were performed to place suture bone anchors on the posterior area of the condyle. A significant difference was found in MIO, which ranged from 15.5 mm pre-opeatively to 41.6 mm post-operatively (p = 0.001). Pain scores using the VAS ranged from 7.42 to 0.28 indicating improvement post-operatively (p = 0.001). Mandibular excursions were underestimated. The available results have shown that discopexy using suture anchors seemed to decrease pain and improve mouth opening. Clinical studies are required in a larger sample and lower variability of follow-up time to predict actual benefits. [ABSTRACT FROM AUTHOR]

Abstract Background Magnetic resonance imaging (MRI) findings of temporomandibular joint (TMJ) in temporomandibular disorder (TMD) patients of different ages are still unclear. The aim of this study was to analyze and compare the characteristics of MRI features of TMJs in different age groups. Methods A total of 1760 TMJs from 880 patients were included in the study and divided into three groups: ≤ 18Y (n = 195, 14.89 ± 2.35Y); 19-30Y (n = 475, 24.09 ± 3.23Y); and > 30Y (n = 210, 41.73 ± 10.45Y). T2-weighted image (T2WI) of MRI was obtained to evaluate the relationship between age and disc morphology, the degree of disc displacement, joint effusion, joint movement and changes of condylar bone morphology. Data were analyzed by Pearson Chi square test and Spearman correlation coefficient. Results There was no statistical difference between left and right sides in all age groups. Except condylar morphology (χ2 = 0.943, P = 0.624), there were significant differences in the distribution of disc morphology, disc position, joint effusion and joint motion among different age groups (χ2 = 24.450, χ2 = 24.829, χ2 = 19.855, χ2 = 39.259, respectively). There were significant differences in the distribution of the degree of anterior disc displacement, condyle morphology and joint effusion in different types of disc morphology among the different age groups (except for joint effusion in > 30Y), among which the first two were significantly correlated with the disc morphology. Conclusions The morphology and position of the articular disc changed significantly with age, but the proportion of abnormal condylar bone remained about 50%. The greater the degree of disc folding, the more prone to bone abnormalities. Trial registration This study was retrospectively registered on 28/03/2022 and endorsed by the Ethics committee (LCYJ2022014).

The aim of this research was to assess possible relationships between petrotympanic fissure (PTF) characteristics, malleus position, and temporomandibular joint disorders (TMD). A retrospective study was performed, including patients with TMD. Magnetic resonance imaging (MRI) and cone-beam computed tomography (CBCT) examination were used to evaluate temporomandibular joint (TMJ) disc position and condylar bone changes. Fifty-eight TMJs from twenty-nine patients (23:6 females: males) were assessed. Erosive changes (DDR-disc displacement with a reduction of 6 (24%), DDwR-disc displacement without a reduction of 8 (61.5%) vs. normal disc position 3 (15%), p = 0.012) and condyle osteophytes production (DDR 6 (24%), DDwR 9 (69.2%) vs. normal condyle 7 (35%), p = 0.012) were more frequent in subjects with disc displacement compared to normal disc position; malleus was closer to PTF in cases with erosive changes (median 2.15 interquartile range: (1.85–2.75) vs. 2.75 (2.25–3.15), p = 0.029) as well as those with condylar osteophytosis (2.25 (1.91–2.75) vs. 2.75 (2.33–3.32), p = 0.015); the PTF length was higher in cases with condylar osteophytosis compared to those without (4.45 (3.50–4.77) vs. 3.67 (3.34–4.28), p = 0.039). The disc position and disc shape were not related to PTF or malleus position. Malleus position and PTF dimensions were not associated with the PTF type. In cases with erosive changes and condylar osteophytosis, malleus was closer to PTF.

Background: Temporomandibular joint disc displacement disorders are a group of temporomandibular disorders beside from other inflammatory disorders and growth related disorders of joint. The purpose of this analysis was to evaluate the efficacy of arthrocentesis procedure in comparison with stabilization splints used for disc displacement disorders without reduction. Materials and Methods: A systematic search was done in electronic databases (PubMed, Cochrane Central, Web of Science). In addition to this hand search of references and grey literatures was done. Qualities of randomized controlled clinical trials were assessed by Cochrane's tool for Systematic Reviews of Interventions and the Newcastle–Ottawa Scale was followed to assess the prospective and retrospective studies. Outcome variables pain (VAS) and maximum mouth opening were assessed by the software review manager 5.03. Results: A total of five studies were included in the review. Three studies showed greater improvement of symptoms in patients of arthrocentesis group in terms of maximum mouth opening, pain (VAS) value. Two other studies found no significant advantage of arthrocentesis over the other treatment protocol. The meta-analysis resulted in statistically significant difference between outcome variables favouring arthrocentesis group (VAS 1–10) (Mean Difference: 3.10; 95% CI 1.74, 4.45; P ≤.00001, Mean difference: 2.00; 95% CI 0.29, 3.71; P = 0.02). Conclusion: Arthrocentesis showed effective result in terms of increase in mouth opening and reduction of pain level compared to stabilization splint and other non-invasive approaches in patients with disc displacement disorders without reduction. Overall, results supported the rationale of using arthrocentesis in patients with disc displacement disorders without reduction. [ABSTRACT FROM AUTHOR]

Disc displacement (DD) appears in the majority of temporomandibular disorder (TMD) patients. The correlation between craniofacial morphology and different disc positions has been underlined, while the craniofacial morphological differences based on sex and sagittal skeletal pattern stratification have been insufficiently studied. In this study, 304 patients with TMD complaints were included and classified into normal position, disc displacement with reduction (DDwR) and disc displacement without reduction (DDwoR) groups according to magnetic resonance imaging. A total of 24 cephalometric measurements, covering the cranial base, vertical relationship, sagittal relationship, mandible position and morphology, and dental relationship, were assessed using lateral cephalograms. A stratified analysis was performed based on the sex and sagittal skeletal pattern. Overall, DD patients had distinctive craniofacial morphological features. The posterior cranial base length and mandibular arc angle were statistically different only in females, while the Y-axis angle, occlusal plane angle and sella nasion point A angle (SNA) might be unique features in males. Skeletal class II had the most statistically different measurements compared to the others. Differences in the Frankfort mandibular incisor angle (FMIA) and saddle angle were especially displayed in skeletal class III patients. The sex and skeletal sagittal pattern could affect the morphological differences in TMD patients with different disc positions. [ABSTRACT FROM AUTHOR]

Objectives: To predict temporomandibular joint (TMJ) anterior disc displacement with reduction (ADDWR) from condylar shape, position, and dimensions obtained from CBCT images. Methods: This cross-sectional study was performed on 17 patients suffering from temporomandibular disorders diagnosed by history taking according to the chart of the American Association of orthodontists, clinical examination according to the Helkimo index and MRI. CBCT and MRI examinations were performed within one-week interval. Disc position, diagnosed by MRI was used as the gold standard. TMJs with posterior disc displacement or anterior disc displacement without reduction were excluded. Qualitative and quantitative analyses were performed on CBCT images to find the correlation between condylar variables and ADDWR. A logistic regression model was created to estimate ADDWR from condylar dimensions (height, width and depth). Results: Condylar shape and condylar position in the glenoid fossa were significantly correlated with ADDWR (P < 0.05). Condylar width, height and depth were significantly smaller in condyles with ADDWR compared to condylar dimensions in normal disc position. Logistic regression analysis could be used to predict the probability of anterior disc displacement with reduction from condylar dimensions. Conclusion: Condylar shape, position, and dimensions assessed by CBCT are significantly correlated with ADDWR of the TMJ. Substituting the values of condylar width, height and depth in the equation suggests the probability of ADDWR. [ABSTRACT FROM AUTHOR]

Objective: The aim of the current clinical study was to reveal whether harvesting of a temporalis fascia graft would be associated with a higher incidence of temporomandibular joint (TMJ) internal derangement., Methods: The study group involved 104 patients who had middle-ear operations, 67 of which involved harvesting of temporalis fascia and 37 that did not. The TMJs were clinically examined in each group., Results: The total incidence of internal derangement of the TMJ was significantly higher in the group that had temporalis fascia harvesting (79.1%), compared to the group that did not have temporalis fascia harvesting (29.7%), ( p = 0.001)., Conclusion: Harvesting of temporalis fascia probably alters mandibular kinematics and predisposes to internal derangement of the TMJs.

Objectives: The purpose of this study was to propose a machine learning model and assess its ability to classify temporomandibular joint (TMJ) disc displacements on MR T1-weighted and proton density-weighted images., Methods: This retrospective cohort study included 180 TMJs from 90 patients with TMJ signs and symptoms. A radiomics platform was used to extract imaging features of disc displacements. Thereafter, different machine learning algorithms and logistic regression were implemented on radiomics features for feature selection, classification, and prediction. The radiomics features included first-order statistics, size- and shape-based features, and texture features. Six classifiers, including logistic regression, random forest, decision tree, k-nearest neighbours (KNN), XGBoost, and support vector machine were used for a model building which could predict the TMJ disc displacements. The performance of models was evaluated by sensitivity, specificity, and ROC curve., Results: KNN classifier was found to be the most optimal machine learning model for prediction of TMJ disc displacements. The AUC, sensitivity, and specificity for the training set were 0.944, 0.771, 0.918 for normal, anterior disc displacement with reduction (ADDwR) and anterior disc displacement without reduction (ADDwoR) while testing set were 0.913, 0.716, and 1 for normal, ADDwR, and ADDwoR. For TMJ disc displacements, skewness, root mean squared, kurtosis, minimum, large area low grey level emphasis, grey level non-uniformity, and long-run high grey level emphasis, were selected as optimal features., Conclusions: This study has proposed a machine learning model by KNN analysis on TMJ MR images, which can be used for TMJ disc displacements., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology and the International Association of Dentomaxillofacial Radiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Aim of the study: The study aims to assess the possible relationship between bruxism and TMJ sounds. Material and methods: The relationship between temporomandibular joint (TMJ) sounds and bruxism was evaluated in a sample composed of 62 females and 39 males varied in age from 21 to 56 years with a mean age of 40.0±1.07. The participants were informed about the purpose of this study, and they gave their consent. The main methods we used in registering TMJ sound were palpation and auscultation. A self-administered Bruxism Assessment Questionnaire assessed bruxism. Results: The prevalence of bruxism in study group was 60.39% (n = 61) – sleep bruxism (SB) and awake bruxism (AB) were 38.2% and 23.4%, respectively. A total of 53.47% (n = 54) of the sample exhibited some type of clicking joint sound. Chi-square test for independence (with Yates Continuity Correction) indicated significant association between bruxism and TMJ sounds, χ2 (1, n = 101) = 4.183, p = .046, phi = .28. Conclusions: Biomechanical factors seem to play a significant role in TMJ disk displacement development. Based on the research, it should be concluded that bruxism may be associated with joint pathologies, such as disc displacement and joint noises.

Background: Magnetic resonance imaging (MRI) findings of temporomandibular joint (TMJ) in temporomandibular disorder (TMD) patients of different ages are still unclear. The aim of this study was to analyze and compare the characteristics of MRI features of TMJs in different age groups. Methods: A total of 1760 TMJs from 880 patients were included in the study and divided into three groups: ≤ 18Y (n = 195, 14.89 ± 2.35Y); 19-30Y (n = 475, 24.09 ± 3.23Y); and > 30Y (n = 210, 41.73 ± 10.45Y). T2-weighted image (T2WI) of MRI was obtained to evaluate the relationship between age and disc morphology, the degree of disc displacement, joint effusion, joint movement and changes of condylar bone morphology. Data were analyzed by Pearson Chi square test and Spearman correlation coefficient. Results: There was no statistical difference between left and right sides in all age groups. Except condylar morphology (χ2 = 0.943, P = 0.624), there were significant differences in the distribution of disc morphology, disc position, joint effusion and joint motion among different age groups (χ2 = 24.450, χ2 = 24.829, χ2 = 19.855, χ2 = 39.259, respectively). There were significant differences in the distribution of the degree of anterior disc displacement, condyle morphology and joint effusion in different types of disc morphology among the different age groups (except for joint effusion in > 30Y), among which the first two were significantly correlated with the disc morphology. Conclusions: The morphology and position of the articular disc changed significantly with age, but the proportion of abnormal condylar bone remained about 50%. The greater the degree of disc folding, the more prone to bone abnormalities. Trial registration This study was retrospectively registered on 28/03/2022 and endorsed by the Ethics committee (LCYJ2022014). [ABSTRACT FROM AUTHOR]

Objective To observe the effect of comprehensive rehabilitation combined with soft and hard occlusion therapy for disc anchor surgery of anterior disc displacement with reduction. Methods A total of 60 patients with anterior disc displacement with reduction who underwent unilateral disc anchor surgery from January 2017 to April 2021 were treated in The Affiliated Hospital of Yunnan University. The position of the postoperative condyle was maintained by assisted occlusion therapy. The subjects were randomly divided into two groups: the experimental group was the soft occlusion therapy group ( n = 30 cases), and the control group was the hard occlusion therapy group (n = 30 cases). Comprehensive physical therapy and open-mouth training were performed 3 months after the operation, followed up 1, 3 and 6 months after the operation, and MRI was performed immediately, 3 and 6 months after the operation. Fricton index and MRI evaluation criteria were used to evaluate the reduction effect of joint disc, improvement degree of mouth opening, the comfort of patients wearing occlusion and visual analog scales. To study the efficacy of two occlusion therapy. Results Postoperative malocclusion occurred in all patients. The use of occlusion therapy for 3-6 months may decrease the proportion of malocclusion. The postoperative Friction index in both groups was significantly decreased compared with that before surgery. 1 month after surgery, CMI of the soft occlusion therapy group (0.149±0.054) was significantly lower than that of the hard occlusion therapy group (0.221±0.052) . Immediate postoperative MRI evaluation showed that the effective rate of soft and hard occlusion was 100% (30/30). MRI evaluation results at 3 and 6 months after surgery were the same, and the effective rate of soft and hard occlusion treatment was 97% (29/30). One month after surgery, the mouth opening degree in the soft occlusion therapy group was ( 2.73±0.27) mm better than that in the hard occlusion therapy group (2.07±0.39) mm, with statistical significance (P < 0.05). One month after surgery, the VAS of the soft occlusion therapy group ( 2.18±0.54) was significantly lower than that of the hard occlusion therapy group (3.03±0.29), with statistical significance (P < 0.05). The wear comfort survey of patients in the two groups one month after surgery showed that the comfort rate of 86.7% in the soft occlusion therapy group was significantly higher than that in the hard occlusion therapy group ( 73.3%), and the difference was statistically significant. Conclusions Soft occlusion and hard occlusion have similar effects, but the treatment effect of soft occlusion is significantly better than hard occlusion 1 month after surgery, and the patient’s comfort level is also significantly better than hard occlusion. Combined with the advantages and disadvantages of soft occlusion and hard occlusion, soft occlusion can be used immediately to 1 month after the operation, and hard occlusion can be used for treatment after 1-3 months after the patient's mouth opening significantly improves, or fixed orthodontics can be used for treatment according to specific malocclusion. [ABSTRACT FROM AUTHOR]

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The aim of this research was to assess possible relationships between petrotympanic fissure (PTF) characteristics, malleus position, and temporomandibular joint disorders (TMD). A retrospective study was performed, including patients with TMD. Magnetic resonance imaging (MRI) and cone-beam computed tomography (CBCT) examination were used to evaluate temporomandibular joint (TMJ) disc position and condylar bone changes. Fifty-eight TMJs from twenty-nine patients (23:6 females: males) were assessed. Erosive changes (DDR-disc displacement with a reduction of 6 (24%), DDwR-disc displacement without a reduction of 8 (61.5%) vs. normal disc position 3 (15%), p = 0.012) and condyle osteophytes production (DDR 6 (24%), DDwR 9 (69.2%) vs. normal condyle 7 (35%), p = 0.012) were more frequent in subjects with disc displacement compared to normal disc position; malleus was closer to PTF in cases with erosive changes (median 2.15 interquartile range: (1.85–2.75) vs. 2.75 (2.25–3.15), p = 0.029) as well as those with condylar osteophytosis (2.25 (1.91–2.75) vs. 2.75 (2.33–3.32), p = 0.015); the PTF length was higher in cases with condylar osteophytosis compared to those without (4.45 (3.50–4.77) vs. 3.67 (3.34–4.28), p = 0.039). The disc position and disc shape were not related to PTF or malleus position. Malleus position and PTF dimensions were not associated with the PTF type. In cases with erosive changes and condylar osteophytosis, malleus was closer to PTF. [ABSTRACT FROM AUTHOR]

Background/aim: To investigate morphological features of the mandibular condyle and its association with anterior temporomandibular disc displacement on sagittal oblique MRI plane. Materials and methods: One hundred and twenty patients with temporomandibular MRI examination were retrospectively involved in the study. Patients aged less than 18 years and those with severe osteoarthritis, posterior disk displacement, tumor, abscess, history of a rheumatic disease, facial trauma, and motion artifacts on images were excluded. Three radiologists evaluated all images in consensus. Temporomandibular disc locations were classified as normal, anteriorly displaced with reduction (ADr), and anteriorly displaced without reduction (ADwr) on sagittal oblique T1-weighted images. Condylar shapes were classified as flat, rounded, and angled, and condyle anteroposterior width (c-APW) was measured on these images in closed-mouth position. Results: Ninety six discs were in normal position (40%), 70 discs were ADr (29%), and 74 discs were ADwr (31%). Eighty-four condyles were flat (35%), 100 condyles were rounded (42%), and 56 condyles were angled (23%). Mean c-APW was 7 mm in normal joints, 5.9 mm in ADr, and 5.8 mm in ADwr joints, and it was smaller in joints with anterior disc displacement (p < 0.001). In normal joints, flat and rounded type condylar shape was more common and almost equally prevalent (44% and 43%); however, rounded type was more common among ADr (%47) and angled type was more common among ADwr joints (36%) (p = 0.008). Patients with anterior disc displacement were significantly younger from normal cases and anterior disc displacement was more common among female sex. Conclusion: Mandibular condyle shape alterations and condyle size on sagittal oblique MRI plane are associated with anterior disc displacement. Angled shape was more common among ADwr joints. Joints with anterior disc displacement had smaller c-APW than normal joints. [ABSTRACT FROM AUTHOR]

The aim of this systematic review was to analyze the effectiveness of exercise and manual therapy interventions in patients with disc displacement without reduction. The authors performed a systematic review of Medline, EMBASE, PEDro, CINAHL, and Google Scholar databases. Two independent reviewers conducted the eligibility and quality assessment of studies. Interventions based on exercise and manual therapy regarding pain intensity and maximum mouth opening as primary outcomes were examined. Ten articles were included, according to the inclusion criteria. Most of the interventions showed statistically significant improvements in the primary outcomes. Results show that interventions based on therapeutic exercise or manual therapy may be beneficial and play a role in the treatment of disc displacement without reduction. Limited evidence suggests that exercise significantly improves mouth opening in comparison to splints. Due to the heterogeneity of the included studies, these results should be interpreted with caution. [ABSTRACT FROM AUTHOR]

Modic changes (MCs) are known to be associated with low back pain (LBP). Literature contains conflicting reports about the prevalence of MCs and other spinal phenotypes among different populations with LBP patients. We aimed to evaluate the prevalence of MCs in the lumbar spine and associated features in Eastern Anatolian chronic LBP patients. The study sample comprised of 786 consecutive patients [(490 female, 296 male), (mean age 39.7; range 20–78)] with a history of low back pain for at least 3 months. Data about MCs involvement, Schmorl's nodes (SN), disc degeneration (DD), disc displacement, disc height and osteophytes were obtained via MRI. Patients' demographic characteristics, Oswestry disability index (ODI) and visual analog scale (VAS) scores were assessed using a questionnaire. MCs were present in 67.2% (528/786) of the patients. Of all evaluated lumbar-level changes, 86 (6.2%) were Type I, 991 (76.8%) were Type II, 11 (0.8%) were Type III, 47 (6.5%) were Type II/III, 89 (8.5%) were Type I/II, and 29 (1.2%) were Type I/II/III MCs. MCs were significantly associated with severe DD (p < 0.001), disc displacement (p < 0.001), SN (p < 0.001), and osteophytes (p < 0.001). In the multivariate regression analysis, BMI (for both ODI and VAS) and age (only for ODI) were the only independent predictors of clinical severity. The present study is the largest cross-sectional study of adult members of the Eastern Anatolian population with chronic LBP. Modic changes were detected in 67.2% of patients with chronic LBP and the prevalence of other phenotypic features differed significantly between MCs and non-MCs disc levels. Nevertheless, the results of the current study do not support a causal relationship of MCs or any MRI changes with clinical symptom severity. [ABSTRACT FROM AUTHOR]

Osteoarthritis (OA) is a debilitating disease. A number of treatments like conservative approach, minimally invasive procedures and surgical therapy have proved to be beneficial. However, there is no consensus regarding the use of a single modality of treatment. Our current study evaluates the role of intra articular injection iPRF along with arthrocentesis for the management of temporomandibular joint osteoarthritis (TMJ‐OA). A total of 130 patients were selected and divided into two groups, Group A (arthrocentesis only group) and Group B (arthrocentesis +i‐PRF). Patients were evaluated for pain scores and maximal mouth opening (MMO). After 1 year, mouth opening in arthrocentesis‐only group was 32.13 ± 1.46 mm compared with 36.48 ± 0.89 mm in the i‐PRF group (p‐value <0.0001). There was a significant reduction in mouth opening in Group A from 6 months to 1 year compared with Group B (p‐value <0.001).There was no statistical difference in mean VAS scores at the end of 6 months (p‐value 1.00). Addition of iPRF to arthrocentesis did not improve joint pain after 6 months. Nevertheless, repeated injections did have a beneficial effect in MMO. Within the limitations of the study repeated injections of iPRF in conjunction with arthrocentesis might be recommended for the treatment of mild TMJ‐OA. [ABSTRACT FROM AUTHOR]

To compare clinical and imaging results of two needles arthrocentesis (TNA) versus double-needle cannula arthrocentesis (DNCA) in the treatment of temporomandibular joint disc displacement (DD). Twenty patients with DD were randomly divided into two groups: TNA and DNCA. Clinical data (pain scores; maximal interincisal distance [MID], and protrusion and laterality movements) were evaluated before and 24 months after the arthrocentesis. Disc and condyle position and joint effusion (JE) were evaluated by magnetic resonance exams. Both groups presented improvement in the MID, including pain reduction, modifications in disc and condyle positions, and reduction of the presence of JE, without difference between groups (p > 0.05). The DNCA was performed significantly faster (p = 0.0001). Both TNA and DNCA are efficient in promoting improvement in the MID: reduction in pain, modifications in disc and condyle positions, and, in part, may account for less JE, without difference between techniques. [ABSTRACT FROM AUTHOR]

Background/purpose: Temporomandibular disorders (TMD) are common conditions that involve the temporomandibular joints (TMJs), jaw muscles, or both, and can cause alteration in the mandibular kinematics. The aim of this study was to assess the relationship between mandibular kinematics and temporomandibular joint disorders (TMJD) as a clinical tool for evaluation and diagnosis of these patients. Materials and methods: A retrospective study based on the analysis of the clinical findings from patients’ charts was carried out, with a sample size of 476 patients. Statistical analysis was made with chi-square test for qualitative variables and student t-test for quantitative variables. Then, odds ratio with its confidence interval were calculated. A p value