Accepted Manuscript Evaluation of the relationship between mandibular condyle cortication and chronologic age with cone beam computed tomography Seval Bayrak, Sıddıka Halıcıoglu, Gülcan Kose, Koray Halıcıoglu PII:
S1752-928X(18)30030-1
DOI:
10.1016/j.jflm.2018.02.014
Reference:
YJFLM 1628
To appear in:
Journal of Forensic and Legal Medicine
Received Date: 2 November 2017 Revised Date:
7 February 2018
Accepted Date: 11 February 2018
Please cite this article as: Bayrak S, Halıcıoglu Sıı., Kose Gü., Halıcıoglu K, Evaluation of the relationship between mandibular condyle cortication and chronologic age with cone beam computed tomography, Journal of Forensic and Legal Medicine (2018), doi: 10.1016/j.jflm.2018.02.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Evaluation of the relationship between mandibular condyle cortication and chronologic age with cone beam computed tomography 1
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Seval Bayrak, 2Sıddıka Halıcıoglu, 3Gülcan Kose, 4Koray Halıcıoglu Assistant Proffessor, Abant Izzet Baysal University, Faculty of Dentistry, Department of
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Maxillofacial Radiology, Bolu, Turkey Assistant Proffessor, Abant Izzet Baysal University, Faculty of Medicine, Depaertment of
Radiology, Bolu, Turkey
Research Assistant, Abant Izzet Baysal University, Faculty of Dentistry, Department of
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Orthodontics, Bolu, Turkey
Associate Professor, Abant Izzet Baysal University, Faculty of Dentistry, Department of
Orthodontics, Bolu, Turkey
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Correspondence Author: Dr. Seval Bayrak
Golkoy, Bolu, Turkiye
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Adress: Abant Izzet Baysal University, Faculty of Dentistry, Maxillofacial Department,
E-mail Adress:
[email protected]
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Telephone Number: 90 374 254 8361
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Fax Number: 90 374 266 253 0066
ACCEPTED MANUSCRIPT Evaluation of the relationship between mandibular condyle cortication and chronologic age with cone beam computed tomography ABSTRACT Purpose: The aim of the present study is to evaluate the relationship between mandibular
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condyle cortication and chronologic age and gender via cone-beam computed tomography (CBCT) and to investigate the effectiveness of using the condylar cortication as a new method of age estimation.
Methods: CBCT images from 433 subjects aged 8 to 31 years were included in this study.
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The right and left condyle cortication were assessed on the sagittal plane separately for each individual by the same investigator via a new method that describes the cortication of the condyle. Type I: There is no cortication on the condyle. Type II: The bone that is on the
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superior surface of the condyle is seen less density than the structures around the condyle. Type III: The surface of the condyle is seen similar or higher density than the surrounding cortical areas.
Results: The type of the condyle cortication in the right and left mandible was similar for almost each subject and there was no statistically significant different between them
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(p=0.375). When we evaluated the results without including these patients for male, Type I cortication of the condyle was seen at 14.14 ± 2.3 years, Type II cortication of the condyle was seen at 16.11 ± 3.18 years and Type III cortication of the condyle was seen at 19.39 ± 3.96 years. For the female, Type I cortication of the condyle was seen at 13.01 ± 2.16 years,
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Type II cortication of the condyle was seen at 15.52 ± 2.71 years and Type III cortication of the condyle was seen at 17.95 ± 3.13 years. The minimum age of Type III cortication was 11
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and 15 years old for male and female, respectively. However, there are subjects, who are 30 year old man and 31 year old female, have no cortication as much as similar or higher than the surrounding the cortical areas. Conclusion: This study is the first investigation of the relationship between condyle cortication and chronologic age with CBCT in the Turkish population. The type of cortication in the right and left condyle may be different for the same individual. Chronologic age increased as the stages of the cortication process from Type I to Type III in male and female individuals, and all the stages of the cortication in the mandibular condyle of male occur later time according to female.
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Key Words: Age Estimation; Cone beam computed tomography; Cortication; Mandibular condyle
ACCEPTED MANUSCRIPT Introduction Forensic age estimation is needed to be done for identification of unidentified corpses and skeletons1. Phillip2 said that the most difficult issue to identify is human identification especially for determining age, gender, height, and ethnicity. On the other hand, age estimation is important for legal responsibilities of living individuals and identification3. The
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increase in migration movements in recent years has led to an increase in demand for estimating the age of living individuals1.
Numerous methods have been submitted for age estimation. The main components of the age estimation are history, physical examination, hand-wrist radiographs, panoramic
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image and if indicated, a thin-section computed tomography (CT) of medial clavicular epiphyses. It was purposed to specify or eliminate disorders that may affect growth and development while investigating the medical story and physical examination4. It is possible
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that age estimation can be done by using radiography of the hand. The clavicles ossify in five stages that are evaluated by thin-section CT5, 6. Radiological assessment of the degree of ossification of the medial clavicular epiphyseal cartilage is critical for age estimation of subjects who are adolescents and young adults if they have completed hand ossification5, 7. Alternatively, the ischium length is used and suitable to estimate the age for subjects who are
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at all the growth ages8. Teeth are the most everlasting part of the body and extensively used to evaluate maturity and estimate age9, 10. Schmeling et al.4 noted that various methods should be always used together so that optimal precision can be achieved. Forensic teams choose to use methods that based on osseous analysis11 and developing
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teeth are evaluated dependably in age estimation12. Different morphological and radiological techniques have been reported for dental age estimation.
The evaluation of attrition,
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secondary dentin, periodontal attachment, translucent apical zone, cementum apposition and root resorption are the most used morphological techniques13. Radiology has an essential role in human age estimation9 and this method is simple, quick, economic and non-invasive14-16. Additionally, it can be used for age estimation in dead as well as living persons15, 16. Kraus and Jordan17 studied that the early mineralization in deciduous teeth and the permanent first molar for prenatal, neonatal and postnatal age estimation9. The time that is the eruption of teeth and the calcification stage of teeth are evaluated for age estimation in children and adolescents15, 18. The data related to eruption and mineralization of third molar teeth are very important for age estimation19. Evaluation of third molar teeth may not be used if these teeth are congenital absence or individuals reach the threshold of 21 years of age20.
ACCEPTED MANUSCRIPT Age estimation in adults will be difficult when the development of dentition is completed9. In the systematic review by Marroquin et al.21 it was investigated different methods based on odontometric analysis for dental age estimation and suggested that the methods of pulp/tooth area ratio calculation and pulp/tooth length/with ratio calculation may be used for to identify the age.
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In mandible morphological changes related to size and remodeling take place to certain age22. Development of the mandibular condyle is closely related to the growth and development of the mandible. Secondary cartilage forms on the surface of the osseous condyle during the twelfth week of fetal development23-25. It was reported that there are
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differences in the mineralization of cortical bone between cortical regions in the mandibular condyle because of remodelling26. Lei et al.27 indicated that subchondral formation of the cortical bone was first seen in males aged 13 -14 years and in girls aged 12-13 years. The
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cartilage will not be replaced by osseous tissue until the age of 20–25 years23, 24. Arnett28 reported that cortication in the condyle occurs at 15-16 years of age and it is defined immature condyle if not having cortication. However, there is no study that includes any classification of the degree in the cortication of the condyle in the literature.
Conventional tomography, magnetic resonance imaging (MRI), arthrography and CT
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have been used for assessing temporomandibular joint (TMJ)29, 30. Three-dimensional imaging in dentistry offers many advantages with respect to diagnosis and treatment planning31. CBCT provides to take images that have the high resolution of the structures belong to the head and neck with low-dose32. The most important advantages of CBCT are the possibility of scanning
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the images in sagittal, axial and coronal planes, reconstruction without magnification, obtaining three dimensional images, and modeling using these images with software33. The
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images that are obtained via CBCT provide more reliability and truth than the other two dimensional imaging techniques34. The aim of this study is to investigate the relationship between mandibular condyle
cortication and chronologic age and gender via CBCT in the Turkish population and to investigate the effectiveness of using of condylar cortication as a new method of age estimation. Methods CBCT images of patients who underwent diagnosis (impacted tooth, skeletal malocclusion etc.) and control during treatment in Abant Izzet Baysal University, Faculty of
ACCEPTED MANUSCRIPT Dentistry, Department of Oral and Maxillofacial Radiology were used in this research. This study was approved by the Institutional Clinical Research and Ethics Committee of Abant Izzet Baysal University ( 2017/34). Subjects who have signs or symptoms of TMJ disorders (TMJDs) and bone mineral metabolism disorders were excluded and CBCT scans from 433 patients (260 female, 173 male), with age from 8 to 31 years, were examined in this study.
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While undergoing CBCT, the patients were in the sitting, with natural head position and in the maximum intercuspal position. CBCT (i-CAT: Imaging Sciences International, Hatfield, PA, USA) images were taken using the following parameters: 120 kVp, 5 mA, 0.3 mm voxel size, and field-of-view, 16 x 9 - 16 x13. The imaging software called i-CAT Vision was used to
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evaluate the images. The right and left condyle cortication were assessed on the sagittal plane separately for each individual by the same investigator.All evaluations were performed by an oral radiologist with ten years of experience (S.B) and one hundred radiographs were
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randomly selected after thirty days and assessed by the same investigator for the same investigator for the intra-examiner reliability.
All of the images were evaluated and classified according to the difference of the density between cortical bone surrounding the condyle and the other areas around the condyle. According to the new method that we formed has three stages which describe the
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cortication of the condyle: •
Type I: There is no cortication on the condyle (Fig. 1).
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Type II: The bone that is on the superior surface of the condyle is seen less density than the structures around the condyle (Fig. 2). Type III: The surface of the condyle is seen similar or higher density than the
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•
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surrounding cortical areas (Fig. 3).
Statistical Analysis
The weighted cappa coefficient was calculated for validating intra-examiner reliability. The sign test was performed to compare the type of cortication in the right and left condyle. Independent samples t-test was used to compare gender and mean chronologic for each the type of cortication in the right and left condyle. Pearson chi-square test was done to evaluate the relationship between the type of cortication and gender. The difference between the type of cortication and gender according to chronologic age was investigated by using one-way
ACCEPTED MANUSCRIPT ANOVA. The statistical analysis software used was SPSS (version 18.), and p < 0.05 was considered statistically significant. Results One hundred images were randomly selected after thirty days, and evaluated again by the same observer. The weighted cappa coefficient was 0.0886 and it is indicated good intra-
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examiner reliability.
In the evaluation of the right condyle, 188 subjects (43.4 %) had Type I cortication, 105 subjects (24.2 %) had Type II cortication and 140 subjects (32.3 %) had Type III cortication. In the evaluation of the left condyle, 188 subjects (43.4 %) had Type I cortication,
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108 subjects (24.9 %) had Type II cortication and 137 subjects (31.6 %) had Type III cortication (Table 1).
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There were five patients who have different types of the cortication in the right and left condyle and all of the patients are female. The type of the condyle cortication in the right and left mandible was similar for almost each subject and there was no statistically significant different between them (Table 1) (p=0.375).
As seen in Table 2 and 3, the distribution of chronologic age in the types of cortication
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in the right and left condyle was variable. The mean age (14.14 ± 2.3 years for the right and left condyle) of Type I cortication of male subjects was older than that of female subjects (13.06 ± 2.19 years for the right condyle and 13.01 ± 2.15 years for the left condyle) and the difference was statistically significant (p=0.001). The mean age of Type II cortication in the
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right and left condyle was similar in all of the subjects (p=0.286 for the right condyle and p=0.410 for the left condyle). The mean age of Type II cortication was 16.11 ± 3.18 years for
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the right and left condyle for male, and 15.48 ± 2.7 years for the right condyle, and 15.63 ± 2.67 years for the female. The mean age (19.39 ± 3.96 years for the right and left condyle) of Type III cortication of male subjects was older than that of female subjects (17.94 ± 3.08 years for the right condyle and 17.95 ± 3.13 years for the left condyle) and the difference was statistically significant (p=0.033 and p=0.037, respectively). Chronologic age increased as the stages of the cortication process from Type I to Type III in both genders (Fig 4 and 5). Secondly, we evaluated the results after the patients, have different types of the cortication in the right and left condyle, were excluded in the study. There was no significant difference between the mean age and gender of the subjects (p=0.717) and the distribution of the types of cortication of 428 patients according to gender Females who have Type III
ACCEPTED MANUSCRIPT cortication of the condyle are significantly more than males and males who have Type I cortication of the condyle are significantly more than female (p=0.0001) . Type II cortication of the condyle was seen similarly in both genders. The mean age according to the types of the cortication for male and female was presented Table 4. For the male, Type I cortication of the condyle was seen at 14.14 ± 2.3
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years, Type II cortication of the condyle was seen at 16.11 ± 3.18 years and Type III cortication of the condyle was seen at 19.39 ± 3.96 years (Fig. 6). The minimum age of males who have Type I cortication was 8 years and the maximum age of males who have Type III cortication was 31 years. For the female, Type I cortication of the condyle was seen at 13.01 ±
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2.16 years, Type II cortication of the condyle was seen at 15.52 ± 2.71 years and Type III cortication of the condyle was seen at 17.95 ± 3.13 years (Fig. 7). The minimum age of females who have Type I cortication was 10 years and the maximum age of females who have
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Type III cortication was 31 years. There are subjects, who are 30 year old man and 31 year old female, have no cortication as much as similar or higher than the surrounding the cortical areas.
It was extrapolated that the average age of Type I cortication of the condyle was the
of the condyle.
Discussion
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lowest and the highest average age was detected in the subjects who had Type III cortication
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Age estimation is one of the indicators that are used to identify human in forensic cases and it may be needed for civil rights or social benefits of living individuals35.
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Development of teeth are used to assess to estimate age10. It was stated that the methods of dental age estimation frequently require to extraction and preparation of microscopic sections of at least one tooth and these methods are not suitable for living individuals15,
16
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Radiological methods have advantages among the various methods used for age estimation . At the same time, it was indicated that age estimation in adults is difficult, especially if noninvasive methods are needed and there are different methods that can be used for age estimation by teeth21. The formation of secondary dentine processes and the root canal width narrows with age, and these signs can be measured in radiographs and tomography and used for age estimation in adults36. We taken into consideration all of these situations and the
ACCEPTED MANUSCRIPT necessity of non-invasive methods for age estimation in adults, we aimed to evaluate the relationship between mandibular condyle cortication and chronologic age. Condylar chondrogenesis starts with endochondral ossification in the fetal period and occurs slowly with regard to endochondral ossification and the condyle cartilage is thinner 2325
. After the maturation of the condyle has completed, endochondral ossification is
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progressively interrupted and a continuous, compact subchondral bone plate reveals37. It was stated that development of the condyle is related to the growth and development of the mandible23-25. Because of that, we decided to investigate whether there is a relationship between the condyle cortication and chronologic age.
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Morimoto et al.38 also stated that the maturity of the condyle in children may be assessed via MRI with evaluating the presence of structures which indicate active ossification
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on the superior surface of the condyles. Liu et al.39 assessed TMJ maturity by using panoramic radiographs. In addition to this CBCT is a radiographic technique that is used especially for cases needing the evaluation of the relationship of the anatomy of the maxillofacial skeleton and the structures surrounding it40. It was indicated that CBCT provides precise and reliable linear measurements for reconstruction and imaging of dental and maxillofacial structures and has ideal results for imaging TMJ41-43. The dimension, shape, position and joint space of the
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condyle head can be evaluated via CBCT44. In our study, we used CBCT images to evaluate clearly the cortication of condyle for via three-dimensional images. We used CBCT images of 433 patients (260 female, 173 male), with age from 8 to 31
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years for our investigation with excluding subjects have signs or symptoms of TMJDs and bone mineral metabolism disorders. We tried to keep the age range of the subjects included in this study as wide as possible considering the knowledge that cortication in the condyle
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occurs at 15-16 years of age by Arnett28. Renderes et al.26 indicated that the anterior, superior and lateral surfaces of the
mandibular condyle have the different degree in the mineralization of cortical bone with remodeling. We considered that the knowledge and created a new classification related to the cortication around the superior area of the condyle. According to this method, Type I cortication is no seen cortication on the condyle and immature. Type II cortication is seen less density than the structures around the condyle and Type III cortication is seen similar or higher density than the structures around the condyle and mature.
ACCEPTED MANUSCRIPT Lei et al.27 investigated the subchondral formation of cortical bone in the condyles of 1438 subjects aged 10-30 years with using CBCT images. The cortical formation of the condyle was classified in three categories: Complete formation of cortical bone, the partial formation of cortical bone and no cortical bone. Subchondral formation of cortical bone was reported to be seen in male aged 13-14 years old and female aged 12-13 years. Lei et al.39
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evaluated the panoramic images belong to 54 patients and indicated that the cortical bone at the periphery of the condyle was infrequent at the ages of 12-14 years. Westesson et al.45 also reported that the presence of cortical bone in the condyle on MRI was not seen before 13 years and there is no cortical bone around the superior surface of the condyle on panoramic
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radiographs before 15 years. In our study, the minimum age of Type I cortication was 8 and 10 years for male and female, respectively. According to the findings of our study, we acquired the information that no cortical bone seen around the right and left condyle until 14
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years for men and almost 13 years for female, similar to the results of the other investigations27. At the same time male was older than female among the individuals of Type I cortication in the right and left condyle, and the difference was statistically significant (Table 2, 3 and 4).
Complete formation of cortical bone was stated after 22 years for men and 21 years for
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the female in the investigation by Lei et al.27. Ingerwall et al.46 examined TME specimens of 22 subjects aged 1 month to 23 years and used micro radiograms for assessment. They reported that a bone layer around the periphery of the condyle did not grow before about 20 years of age. We obtained the information that the maximum age of Type I and III cortication
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was 31 years for all the subjects. In our study, it was reported that the cortication of the condyle was similar or higher density than the surrounding cortical areas after 19 years for
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male and almost 18 years for the female. However, there are subjects, who are 30 year old man and 31 year old female, have no cortication as much as similar or higher than the surrounding the cortical areas. Male was older than female among the individuals of Type III cortication in the right and left condyle, and the difference was statistically significant (Table 2, 3 and 6). The time that cortication occurred was different among the studies in the literature and we think that it was ingenerated by the difference in the number of samples included and the population in the study. In spite of this difference, the results that cortical bone formation takes place for the male one year earlier than female was the same for both two investigations. When we take into account all the data we obtained, it can be stated that for all the subjects who have or not have same or different stages in the right or left condyle, the mean
ACCEPTED MANUSCRIPT age of Type I cortication in the condyle was minimum and the mean age of Type III cortication in the condyle was maximum. Chronologic age increased as the stages of the cortication process from Type I to Type III in male and female individuals. Lei et al.27 reported that 90% of male and 93% female had the same stage in their condyles and these results support our findings. In our study CBCT images were assessed for
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the right and left condyle separately for each individual. The only five subjects had different types of the cortication in the right and left condyle and there was no statistically significant different between them ( Table 1). It was stated that female who are in procreative age have high prevalence of TMJDs47. Female are affected than male by TMJDs48 and it is assumed
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that female sex hormones and especially estrogen are related to these TMJDs49. We think that it is an expected result which the five patients are female. On the other hand, there were subjects who were older than 19 or 18 years and did not Type III cortication in the condyle. It
affect cortication of the condyle.
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may be contributed that it was due to genetic, developmental or iatrogenic factors that may
This study was realized in the Turkish population and it is both limitation and prilivage of our investigation. It is known that different populations are under the influence of various ethnic, environmental and genetic factors. We think that; it would be useful to
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perform the evaluation of our study in different populations and to make the comparison in
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order to achieve a global result when these factors ate taken into consideration.
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Si K. Does the relaxin, estrogen and matrix metalloproteinase axis contribute to
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degradation of TMJ fibrocartilage? J Musculoskel Neuron Interact. 2003;3(4):401-5.
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ACCEPTED MANUSCRIPT Table Legends: Table 1. The distribution of the types of cortication in the right and left condyle Table 2. The distribution of gender and chronologic age in the right condyle in male Table 3. The distribution of gender and chronologic age in the left condyle in female
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Table 4. Descriptive values of chronologic age according to the types of the cortication in
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both gender
ACCEPTED MANUSCRIPT Figure Legends: Figure 1. CBCT scans showing Tip I cortication of the condyle Figure 2. CBCT scans showing Tip II cortication of the condyle. Figure 3. CBCT scans showing Tip III cortication of the condyle.
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Figure 4. Scatter plot depicting mean chronologic age in the types of cortication in the right condyle for male and female.
Figure 5. Scatter plot depicting mean chronologic age in the types of cortication in the left condyle in the individuals.
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Figure 6. The histogram of the chronologic age according to the types of the cortication in male.
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Figure 7. The histogram of the chronologic age according to the types of the cortication in
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ACCEPTED MANUSCRIPT Table 1. The distribution of the types of cortication in the right and left condyle (n: Number of patients). Left Condyle
Total
Type II
Type III
Type I
n
187
1
0
Type II
n
1
104
0
Type III
n
0
3
137
188
188
108
137
Right Condyle
105 140 433
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188
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ACCEPTED MANUSCRIPT Table 2. The distribution of gender and chronologic age in the right condyle in male (n: Number of patients, sd: Standard deviation). Type I n Male
Mean
sd
Type II p
104 14.14 2.30
Chronologic age
n Mean
sd
n
Mean
sd
31
19.39 3.96
0.286 67 15.48 2.70
p 0.033
109 17.94 3.08
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84 13.06 2.19
p
38 16.11 3.18 0.001
Female
Type III
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Male
Mean
sd
p
104 14.14 2.30
Chronologic age
n Mean
sd
n
Mean
sd
70 15.63 2.67
0.037 106 17.95 3.13
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31 19.39 3.96 0.410
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84 13.01 2.15
p
38 16.11 3.18 0.001
Female
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Female p
Type I 104
Max
sd
n
Mean
c
8
19
2.30
83
13.01
66 106
16.11
b
12
30
3.18
31
19.39
a
11
31
3.96
0.0001
Min
Max
sd
c
10
20
2.16
15.52
b
12
31
2.71 0.0001
17.95
a
15
31
3.13
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p
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ACCEPTED MANUSCRIPT Main Points The relationship between condyle cortication and chronologic age was investigated.
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The cortication of the condyle was described by a new method.
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The stages of cortication may be used to assess for age estimation.
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There are subjects who have no cortication in adult individuals.
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The stages of cortication in male occur later time compared to female.
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