Received: 11 April 2023 | Revised: 28 April 2023 | Accepted: 6 May 2023

DOI: 10.1111/joor.13498

ORIGINAL ARTICLE

Relationship Between Temporomandibular Ankylosis And

Maximum Mouth Opening In Children

Kevser Kolçakoğlu1 | Salih Doğan1 | Gökmen Zararsız2,3 | Nükhet Kütük4 |

Zeynep Burçin Gönen5,6

1
Department of Pediatric Dentistry,
Erciyes University Faculty of Dentistry, Abstract
Kayseri, Turkey
Background: Pediatric dentists should have information regarding whether mouth
2
Faculty of Medicine, Department of
Biostatistics, Erciyes University, Kayseri,
opening is limited. In clinical practice, these professionals should collect and record
Turkey oral area measurements at the pediatric patient's first medical examination.
3
Erciyes University, Drug Application and Objectives: The study's aim developed the standard mouth opening measurement
Research Center (ERFARMA), Kayseri,
Turkey in children by using ordinary least squares regression to develop a clinical predic-
4
Department of Oral Maxillofacial tion model in children with Temporomandibular Joint Ankylosis before preoperative
Surgery, Bezmialem University Faculty of
surgery.
Dentistry, İstanbul, Turkey
5
Department of Oral Maxillofacial Surgery, Methods: All participants completed their age, gender, and calculated height, weight,
Erciyes University Faculty of Dentistry, body mass index, and birth weight. Pediatric dentist performed all mouth-­opening
Kayseri, Turkey
6 measurements. The oral-­maxillofacial surgeon marked subnasal and pogonion points
Genome and Stem Cell Center
(GENKOK), Erciyes University, Kayseri, for the lower facial length of soft tissue. It was measured using the distance between
Turkey
the subnasal and pogonion with a digital vernier caliper. The widths of the three fin-
Correspondence gers (index, middle, and ring fingers) and four fingers (index, middle, ring, and little
Kevser Kolçakoğlu, Department of
fingers) were also measured using a digital vernier caliper.
Pedodontics, Erciyes University Faculty
of Dentistry, 38039 Melikgazi, Kayseri, Results: Maximum mouth opening showed that three-­finger width (R2 = 0.566,
Turkey.
F = 185.479) and four-­finger width (R2 = 0.462, F = 122.209) had a significant influ-
Email: kevser.kolcakoglu@gmail.com.
ence on the Maximum mouth opening (MMO) (p < 0.001).
Conclusion: Pediatric dentists should collaborate with the treating maxillofacial sur-
geon to manage long-­term treatment needs for individuals with Temporomandibular
Joint Ankylosis.

KEYWORDS
Ankylosis of the Temporomandibular Joint (TMJ), Children, İnterincisal Distance, Mouth
opening, Vernier Caliper

1 | BAC KG RO U N D a fibrous, fibro-­osseous, or osseous mass that is fused to the base

of the skull. Various aetiologies, such as local or systemic infection,
Temporomandibular joint ankyloses (TMJa) are defined as the im- trauma, ankylosing spondylitis, rheumatoid arthritis, and psoriasis,
mobility of the temporomandibular joint (TMJ) and the growth of are common causes of TMJa; however, it is also possible for TMJa

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© 2023 The Authors. Journal of Oral Rehabilitation published by John Wiley & Sons Ltd.

940 | 
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KOLÇAKOĞLU et al.
to develop following surgery on the jaw joint.1,2 TMJa could stimu-
late oral dysfunction and, particularly during the formative stages of
growth, could result in abnormalities in both the mandible and the
maxilla.1,3 TMJa in pediatric patients is a complex and uncommon
problem managed by oral-­maxillofacial surgeons. Surgery of pediat-
ric patients with TMJa is challenging due to the technical aspects of
surgery and the difficulty of predicting any impact of the surgery on
the children's growth.4 Inadequate mouth opening in the postopera-
tive period in TMJa surgery, which causes limited mouth opening, is
5,6
one of the most common failures. To establish the postoperative
functionality of decreased mouth opening by TMJa, it is essential to
know the range of “normal” mouth opening for that population.7,8
TMJa is important not only for oral and maxillofacial surgery
but also for paediatric dentistry. Pediatric dentists should have in-
formation regarding whether mouth opening (MO) is limited.9 In
clinical practice, these professionals should collect and record oral
area measurements at the paediatric patient's first medical examina-
10
tion. Maximum mouth opening (MMO), one of these MO measure-
ments, is defined as the maximum painless linear distance between
the upper and lower incisal teeth.9 According to the voluntary or in-
voluntary nature of TMJ mobility, the MMO is categorized as active
11
(AMMO) or passive (PMMO) maximum mouth opening. AMMO,
which is defined as the maximum interincisal opening (MIO), can be
used to detect TMJa.10 Clinical measurement of the MMO is a di-
agnostic clinical entity that helps clinicians to examine the oral cav-
ity expediently and to recognize the early signs of reduced mouth
opening in children with TMJa. Therefore, the MMO is an essential
diagnostic tool for TMJa4,7,12.
The MMO is influenced by age, gender, ethnicity, face type,
8,10
and BMI. In the literature, these measurements have been
mostly evaluated in adults or participants belonging to a wide age
group.5,13,14 Although the MMO has clinical importance in a growing
number of individuals, limited data are available in the pediatric pop-
9
ulation. Therefore, this parameter has no reference in children for
determining whether a patient has limited MO capacity.5
The present study aims to determine the standard MMO mea-
surements in children by using ordinary least squares regression to
develop a clinical prediction model in children with TMJa before pre-
operative surgery.
2 | M E TH O D S
2.1 | Ethics and participants' criteria
The study received ethics approval from the Clinical Research
Committee of the University's Faculty of Medicine (No: 142.2023).
In addition, the parents of the patients received informed consent
forms following the Helsinki principles.
Data from all participants who presented at the university dental
clinic were collected.
A total of 288 children who fulfilled the following criteria were
included in this study: 1) children who had immobile and sound
|
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941
maxillary and mandibular central incisors, 2) children who had no in-
fluenced position of the central incisors and incisal edges, 3) healthy
children without systemic disease, and 4) children who had erupted
fully central incisors.
Patients were excluded if they disclosed any of the following: 1)
a history of TMJa; 2) a history of bruxism, paralysis, paresis, previ-
ous trauma, or cancer in the head or neck area; 3) a history of any
surgery that could have affected mandibular movement; 4) the pres-
ence of current orthodontic appliances; or 5) a history of any disease
affecting bone metabolism (leukaemia, lymphoma, osteoporosis,
etc.) 6) a history of the use of paediatric crown or restorative mate-
rial for incisors.
Participants, depending on dentition, were divided into three
groups.
2.2 | Demographic information
All 288 participants completed their age (in years), gender (female),
and calculated height (meters), weight (kg), body mass index (kg/m2),
and birth weight (g). In addition, weight and height were measured
with SECA Digital machine.
2.3 | Recorded measurements
A single examiner, an expert pediatric dentist, performed all MMO
measurements, thus preventing interexaminer variability. Children
rested their heads against a firm wall/surface upright on the chair.
Children were asked to open their mouths as wide as possible.
Additionally, the examiner measured the maximum distance from
the upper central incisor's edge to the lower central incisor's edge
at the midline. The MMO was measured using the distance between
the edges of the upper and lower incisal teeth with a digital vernier
caliper (JIAVARRY Digital Vernier Caliper) (Figure 1).
To increase the reproducibility and reliability of the MMO mea-
surement, the examiner made measurements three times with a dig-
ital vernier caliper to make the incisors rest at the same point on
different attempts (Figure 2). These three values were averaged for
the final MMO.
A single examiner, an expert maxillofacial surgeon, marked
subnasal and pogonion points for the soft tissue lower facial
length (STLFL). The STLFL was measured using the distance be-
tween the subnasal and pogonion with a digital vernier caliper
(Figure 3).
The widths of the three fingers (index, middle, and ring fingers)
and four fingers (index, middle, ring, and little fingers) were also
measured using a digital vernier caliper. Finally, the overbite that oc-
curred while the patient was in centric occlusion was measured with
a digital vernier caliper. To increase the reproducibility and reliability
of all measurements, the examiner made measurements three times
with a digital vernier caliper at the same point on different attempts.
These three values were averaged for the final measure.
 |
942
F I G U R E 1 Digital Vernier Caliper.
F I G U R E 2 Maximum opening distance measurement.
2.4 | Statistical Analysis
Histograms and q-­
q plots were constructed and Shapiro–­
Wilk's
test was conducted to assess the normality of the data. To compare
the clinical parameters between permanent, mixed, and milk teeth
groups, one-­way analysis of variance (ANOVA) and Kruskal–­Wallis-­H
tests were used for continuous variables. Pearson chi-­
square
analysis was used for categorical variables. Spearman correlation
coefficients were calculated to evaluate the relationship between
mouth opening (subnasal pogonion, interincisal distance) and age,
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KOLÇAKOĞLU et al.
F I G U R E 3 Subnasal and pogonion points for the soft tissue
lower facial length.
height, weight, body mass index, birth weight, overbite, three-­finger
width, and four-­finger width. Ordinary least squares linear regression
analyses were conducted to analyse the effect of age, three-­finger
width, and four-­
finger width on mouth opening measurements.
Analyses were conducted using the statistical software TURCOSA
(Turcosa Analytics Ltd. Co, Turkey, www.turco​sa.com.tr). A p value
less than 5% was considered statistically significant.
3 | R E S U LT S
A total of 288 participants aged 6.65 ± 2.19, with 150 females and
138 males, were included in the current study. Their height ranged
from 1.13 to 1.30 metres, their weight ranged from 19.0 to 28.0 kg,
their body mass index ranged from 14.4 to 17.6 kg/m2, and their
birth weight ranged from 2650 to 3250 g (Table 1).
All of the participants' STLFLs ranged from 68.25 to 83.18 mm.
Their maximum interincisal distance ranged from 37.91 to 41.19 mm;
The overbite of participants ranged from 0.00 to 2.00 mm; their
three-­finger width ranged from 35.52 to 38.92 mm, and their four-­
finger width ranged from 47.68 to 53.65 mm. In addition, there was a
statistically significant difference between recorded measurements
of the dentition groups (Table 2).
The correlation between recorded measurements in each teeth
group is shown in Table 3. A significant, weak, positive correlation
was observed between the STLFL and age (r = .325, p < 0.01), height
(r = .264, p < 0.01), three-­finger width (r=. 248, p < 0.05), and four-­
finger width (r = .327, p < 0.01) in the permanent dentition group. A
significant, weak, positive correlation was observed between the
MMO and age (r = .214, p < 0.05), height (r = .237, p < 0.05), three-­
finger width (r=. 369, p < 0.01), and four-­finger width (r = .291,
p < 0.01) in the permanent dentition group. In the mixed denti-
tion group, there was a significant, moderate, positive correlation
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KOLÇAKOĞLU et al. 943

TA B L E 1 Patient characteristics and comparison among teeth groups.

Teeth Groups

Variables Permanent (n = 96) Mixed (n = 96) Primary (n = 96) Total p

a b c
Age (year) 9.05 ± 1.82 6.15 ± 4.35 4.76 ± 1.15 6.65 ± 2.19 <0.001
Gender (female) 56(58.3) 49(51.0) 45(46.9) 150(52.1) 0.274
a b c
Height (meter) 1.34(1.28–­1.42) 1.19(1.13–­1.22) 1.12(1.07–­1.19) 1.20(1.13–­1.30) <0.001
Weight(kg) 30.0(25.6–­36.7)a 22.0(20.0–­24.7)b 19.0(17.0–­21.3)c 23.0(19.0–­28.0) <0.001
2 a b b
Body mass index (kg/m ) 16.9(15.0–­18.4) 15.9(14.2–­17.2) 15.0(13.6–­17.0) 15.9(14.4–­17.6) <0.001
Birth weight (g) 3113(2900-­3500)a 3000(2500-­3 000)b 3000(2656-­3150)b 3000(2650–­3250) <0.001

Data are summarized as n(%), mean ± standard deviation or median(1st-­3rd quartiles). Different superscripts in the same row indicate a statistical
significant difference among teeth groups. Significant results are shown in bold.

TA B L E 2 Comparison of dental measurements among teeth groups.

Teeth Groups

Variables Permanent (n = 96) Mixed (n = 96) Primary (n = 96) Total p

Mouth apertura subnasal 85.05(79.71–­90.41) 68.25(68.25–­68.25) 65.07(62.20–­73.40) 69.31(68.25–­83.18) <0.001

pogonion
Mouth apertura interincisal 41.67(39.22–­45.33) 40.86(40.86–­4 0.86) 36.85(33.29–­39.06) 40.86(37.91–­41.19) <0.001
distance
Overbite 2.00(.00–­2.00) 1.50(1.50–­1.50) .00(.00–­2.00) 1.50(.00–­2.00) <0.001
Three Fingers 39.53(37.04–­41.48) 38.86(38.86–­38.86) 35.01(32.54–­36.28) 38.86(35.52–­38.92) <0.001
Four Fingers 55.05(51.99–­58.78) 50.65(50.65–­50.65) 47.03(44.15–­48.34) 50.65(47.68–­53.65) <0.001

Data are summarized as median(1st-­3rd quartiles). Different superscripts in the same row indicate a statistical significant difference among teeth
groups. Significant results are shown in bold.

between the STLFL and age (r = .519, p < 0.05) as well as a significant,
weak, positive correlation between the STLFL and height (r = .519,
p < 0.05). A significant, moderate, negative correlation was observed
between the STLFL and overbite (r = −.524, p < 0.01) and three-­finger
width (r = −.550, p < 0.01) in the mixed dentition group. A significant,
weak, positive correlation was observed between the MMO and
four-­finger width (r = .331, p < 0.01) in the mixed dentition group. A
significant, moderate, positive correlation was observed between
the STLFL and age (r = .565, p < 0.01), height (r = .518, p < 0.01), birth
weight (r = .418, p < 0.01), three-­finger width (r = .596, p < 0.01), four-­
finger width (r=. 643, p < 0.01) in the primary dentition group. A
significant, weak, negative correlation was observed between the
STLFL and BMI (r = −.343, p < 0.01) in the primary dentition group.
A significant, moderate, positive correlation was observed between
the MMO and age (r = .489, p < 0.01), height (r = .472, p < 0.01), three-­
finger width (r = .665, p < 0.01), four-­finger width (r=. 553, p < 0.01) in
the primary dentition group. A significant, weak, positive correlation
was observed between the MMO and weight (r = .282, p < 0.01) in
the primary dentition group. A significant, weak, negative correla-
tion was observed between the MMO and BMI (r = −.224, p < 0.05)
in the primary dentition group.
Ordinary least squares regression analysis results, which indicate
the relationship between dental measurements and finger width,
are shown in Table 4. Regression analysis of the STLFL showed
finger width (R 2 = 0.555, F = 177.943) and four-­finger
that three-­
width (R 2 = 0.582, F = 198.989) had a significant influence on the
STLFL (p < 0.001). Regression analysis of the MMO showed that
three-­finger width (R 2 = 0.566, F = 185.479) and four-­finger width
(R 2 = 0.462, F = 122.209) had a significant influence on the MMO
(p < 0.001).
4 | D İ S CU S S I O N
Although the prevalence of TMJa in children has not been explicitly
given, the prevalence of TMD ranges from 7.3 to 30.4.15
Since children cannot truly describe their discomfort and pain,
localize their painful symptoms, or understand questions related to
their pain, TMJa can easily go undiagnosed.10 Thus, early diagnosis
and treatment of TMJ ankylosis in children (TMJa) are crucial for
both functional and aesthetic outcomes.16
Limited MO measurements are the clinical manifestations of
children with TMJa. These manifestations are affected by age, race,
BMI, and whether the ankylosis is unilateral or bilateral.11 Therefore,
limited MO should be well recognized by clinicians for detecting chil-
dren with TMJa.9 There are many different devices and techniques
for MMO measurements in the literature.9,10,17–­19 In these studies,
this parameter has been used for different landmarks, such as the
distance between the upper-­lower incisor, the distance of the alve-
olar crest, and the most excellent vertical mandibular opening.9,10,19
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944 KOLÇAKOĞLU et al.

TA B L E 3 Correlation between dental and clinical measurements in each teeth group.

Group and dental measurement Age Height Weight BMI Birth weight Overbite Three Fingers Four Fingers

Permanent
Mouth apertura subnasal pogonion .325** .264** .184 .068 .034 .096 .248* .327**
* * **
Mouth apertura interincisal distance .214 .237 .175 .069 −.056 −.050 .369 .291**
Mixed
Mouth apertura subnasal pogonion .519** .225* .009 −.148 .137 −.524** −.550** −.069
Mouth apertura interincisal distance −.034 −.160 .068 .166 −.108 .146 .174 .331**
Primary
Mouth apertura subnasal pogonion .565** .518** .233* −.343** .418** .121 .596** .643**
** ** ** * **
Mouth apertura interincisal distance .489 .472 .282 −.224 .184 .124 .665 .553**

* p < 0.05; ** p < 0.01.

Moreover, predicting post-­op facial profiles is a crucial aspect of
surgical procedures. Patients are concerned with their facial profile
and frontal appearance20 In addition, craniofacial evaluation based
on facial anthropometric measurements taken with a specific ruler
while soft tissue is displaced are valid and reliable. 21
In the present study, the MMO value was defined using soft tis-
sue subnasal-­pogonion length, distance between the upper-­lower
incisor, and three-­and four-­finger widths. The digital vernier calliper
is more accurate and precise.7,19 Therefore, it was used for all mea-
surements herein.
Head position is one of the critical factors affecting the deter-
mination of the MMO. The MMO can vary in the head's forwards,
neutral, and backwards position.5 Therefore, this study ensured that
all participants were relaxed to eliminate the effect of different head
positions on the MMO.
In this study, the presence of TMJa was investigated. Children
with any pain or restriction in terms of mandibular movement were
excluded. To minimize errors due to overbite, children with negative
overbite or crossbite were excluded.10 Children with TMJ sounds
who did not need to be treated22 or anything that could cause TMJ
discomfort were excluded, such as bruxism, using appliances, and re-
storative treatment. Healthy children without systemic disease were
included. Similar to Park et al., in the current study, only completely
erupted central incisors were included, avoiding bias due to incom-
10
plete eruption of central incisors. Similar to Visscher et al. and Park
et al., in the current study, all measurements were recorded upright
on a firm wall/surface on the chair to ensure the children's comfort
and compliance following DC/TMD.10,23
Growth partly continues to increase the mandibular length,
which geometrically influences the linear interincisal measure-
ments.10,13 Therefore, increases in both the MMO and STLFL with
age among children and adolescents could partly be explained by
mandibular growth.3,24 In relation to that, previous studies have also
13,17,25
highlighted that the MMO increases consistently with age.
Therefore, in support of previous studies, the authors found that the
MMO also increases with age in this study (p < 0.001).
The anatomical structures of the male head and face bones are
generally larger than those of females. Therefore, previous studies
have shown that the MMO of males is significantly greater than that
of females.5,25,26 Nonetheless, there is also a study in which no sta-
tistically significant differences were noted in the literature express-
ing a different opinion.17 The current study showed no significant
gender difference between the groups (p = 0.274).
The current study showed a weak correlation between the MMO
and height and weight. Similar results were acquired by other stud-
ies,17,19,27 which detected a slight correlation between the MMO and
weight and height. In addition, there was a weak, positive correlation
between the STLFL and height and weight in all dentition groups.
This is probably because children's growth is not continuous and
constant over the years. However, there are periods when the body
grows more slowly or rapidly. For this reason, as age increases, the
different parts of the body do not necessarily increase proportion-
ally. Therefore, it is reasonable that the STLFL and MMO are more
strongly correlated with age. Venkatraman et al. found a positive re-
lationship between BMI and the MMO in their study, which included
participants who were 18–­86 years old.8
Although age, weight, height, and BMI are predictors of the
MMO, condylar angle, mandibular length, and malocclusions could
have changed the variation in the MMO. However, these predictors
still need to be substantiated.8 In the current study, a negative rela-
tionship was found between BMI and the MMO only in the primary
dentition group.
Studies that selected different ethnic populations10,13 and per-
formed in several countries have shown wide variability across racial
groups.5 Ying et al. found that there was a positive correlation be-
tween the MMO and race. 28 Fatima et al. indicated that participants
who have different facial patterns have affected the MMO.7
When examining the studies in the literature, Park et al. ex-
amined the MMO in 438 Korean children aged 3–­15 years using a
metallic ruler. They found an MMO of 45.9 ± 7.6 mm in boys and
43.8 ± 6.00 mm in girls and stated that the MMO increased with
age and BMI.10 However, in their regression, Park et al. stated that
gender affected the mouth area.10 Using a plastic sliding calliper,
Chen et al. examined the MMO and its related factors in Taiwanese
children aged 3–­5 years. They found that the average MMO was
37.21 ± 3.99 mm, and they found that the MMO was weakly cor-
related with height and weight.17 Müller et al. examined maximum
mouth-­opening capacity (MOC) using a metallic calliper in the Zurich
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KOLÇAKOĞLU et al. 945

TA B L E 4 Ordinary least squares

Variables bi S(b i) BETA t p
regression analysis results displaying
the relationship between dental Mouth apertura subnasal pogonion
measurements and fingers width. Constant 39.782 4.063 -­ 9.791 <0.001
Age 3.355 0.252 0.662 13.312 <0.001
Three Fingers 0.329 0.130 0.126 2.538 0.012
s = 7.437, R2 = 0.555, (F = 177.943, p < 0.001)
Mouth apertura subnasal pogonion
Constant 28.624 4.338 -­ 6.599 <0.001
Age 2.596 0.299 0.512 8.696 <0.001
Four Fingers 0.562 0.111 0.298 5.058 <0.001
s = 7.204, R2 = 0.582, (F = 198.989, p < 0.001)
Mouth apertura interincisal distance
Constant 9.569 1.789 -­ 5.348 <0.001
Age 0.377 0.111 0.167 3.398 0.001
Three Fingers 0.741 0.057 0.639 13.000 <0.001
s = 3.275, R2 = 0.566, (F = 185.479, p < 0.001)
Mouth apertura interincisal distance
Constant 12.590 2.195 -­ 5.736 <0.001
Age 0.217 0.151 0.096 1.438 0.152
Four Fingers 0.507 0.056 0.603 9.023 <0.001
s = 3.64, R2 = 0.462, (F = 122.209, p < 0.001).

Significant results are shown in bold.

population. Their study of 366 children aged 4 years measured an
MOC of 40.1 mm in boys and 40.5 mm in girls. They said that MOC
increases with age but could be a wide range in children of the same
13
age. Similarly, Abou-­Atme et al. measured the MMO and the three-­
and four-­finger widths using gauges in 102 children aged 4–­15. They
determined the MMO to be 45.8 ± 0.6 mm, and their findings showed
a significant difference between the width of the right three fingers.
Additionally, Abou-­Atme et al. reported a weak correlation between
18
the MMO and height (r = 0.27). Al-­Hammad et al. investigated the
MMO and related factors such as age, sex, and BMI using an elec-
tronic digital calliper in the Saudi population. In their study, the mean
MMO for the male subjects, who were 5–­9 years old, was 43.5 mm,
and the mean MMO for the female subjects, who were 5–­9 years old,
was 50.0 mm. The mean MMO for all subjects, who were 6–­83 years
old, was 47.8 ± 6.9 mm. They stated that MMO showed a significant
correlation with gender, and MMO showed no significant correlation
with age, BMI, or TMD.19 In the current study, authors used a digital
Vernier calliper to measure the STLFL, MMO, and three-­and four-­
finger widths. They found an MMO of 36.85 mm in the primary den-
tition group, with a mean age of 4.76 ± 1.15. In the primary dentition,
the MMO showed a positive correlation with age, weight, height,
and the three-­and four-­finger widths (p < 0.01). However, it showed
a negative correlation with BMI (r = 0.224, p < 0.05).
The MMO could be expressed as the AMMO plus the overbite.
However, it has been said that the actual capacity of the MMO is
affected by overbite because of its effect on chewing and dental
treatments. Therefore, the authors have evaluated the relationship
between overbite and the MMO in this study. The authors think this
is because the overbite of participants is .00 mm (.00–­2.00) in the
primary dentition group.
Aliya et al. evaluated the MMO in Indian children who were
8–­10 years old using a digital vernier calliper.9 They found
41.77 ± 5.25 mm in girls and 44.5 ± 5.10 mm in boys. In addition,
they stated that the MMO was higher in males and increased with
age.9 In this study, the authors found a mean MMO of 40.86 mm in
children with mixed dentition. There was a significant positive cor-
relation between the MMO and the four-­f inger width. The STLFL
showed a significant positive correlation with age and height but a
significant negative correlation with overbite and the three-­f inger
width.
Al-­Dlaigan et al. examined the MMO using a calibrated fibre
ruler with a small light source in 14-­year-­old Saudi children. 29 They
found that the MMO was 43.5 ± 4.25 mm in boys and 35.5 ± 4.4 mm
in girls. 29 Sawair et al. measured the AMMO using the Willis Bite
Gauge in Saudi children who were 15–­19 years old. They found the
AMMO to be 47.9 mm in boys and 43.3 mm in girls. They stated that
there are significant, weak, positive correlations between weight
(r = 0.16, p = 0.00) and height (r = 0.21, p = 0.00) with the MMO.
Furthermore, they observed no significant relationship between
BMI and the MMO. Similarly, Al-­Hammad et al. found a significant,
weak, positive correlation between the MMO and height (r = 0.34,
p = 0.000) and weight (r = 0.20, p = 0.003).19 The current study found
the mean MMO to be 41.67 mm in the permanent dentition group.
In addition, the MMO showed a significant positive correlation with
 |
946
age (r = 0.489, p < 0.01), height (r = 0.472, p < 0.01), weight (r = 0.282,
p < 0.01), three-­finger width (r = 0.665, p < 0.01), and four-­finger
width (r = 0.553, p < 0.01). Moreover, the authors measured the
STLFL as 85.05 mm, showing a significant positive correlation with
age (r = 0.565, p < 0.01), height (r = 0.518, p < 0.01), weight (r = 0.233,
p < 0.05), three-­finger width (r = 0.596, p < 0.01), and four-­finger
width (r = 0.643, p < 0.01).
In the present study, there was no significant relationship be-
tween birth weight and MMO in all dentition groups. However, in
the primary dentition group, there was a positive correlation be-
tween birth weight and STLFL (r = 0.418, p < 0.01). This correlation is
a typical situation resulting from growth and development.
Restoring normal function is one of the major challenges in pa-
tients with TMJa. Many techniques have been described with ques-
tionable long-­term results. In particular, due to TMJA detection and
surgery technologies being high-­cost, treatment options for patients
with TMJ are suggested in the public health systems of underdevel-
oped countries. One of the aims of this study is to propose a clinically
applicable, multidisciplinary collaboration, low-­cost method for the
early detection of TMJA in children. In light of this approach, mea-
surement with fingers could be used as a secondary tool for measur-
8
ing the MMO and STLFL . This method of measurement could also
provide additional validation for the MMO.
Although the MMO and STLFL were weakly correlated with
age, height, and weight, the study's aim was to determine the
regression models that could be used to predict the MMO and
STLFL. Comparing the STLFL of Model 1 and Model 2, the authors
found that the correlation between four-­
f inger width and the
STLFL is more significant than that between three-­finger width
and the STLFL. Comparing the MMO of Model 3 and Model 4,
the authors found that the correlation between three-­f inger width
and the MMO is more significant than that between four-­finger
width and the MMO. These models indicated that to avoid long-­
term questionable results, both the MMO and STLFL should be
evaluated.
In this study, the authors suggested that TMJa operations in
children should be performed by paying attention to the three-­
finger width of the MMO and the four-­finger width of the STLFL.
Similarly, when paediatric dentists suspect TMJa, they could mea-
sure the MMO and STLFL by measuring the width of these fingers.
Additionally, referrals should be made to other health care providers,
including those with expertise in TMJa.
A limitation of this study is that participants were recruited from
people undergoing regular medical examinations in the author's de-
partment. Most of these participants came from surrounding cities.
The race of the participants was not questioned. Because the cur-
rent study was performed on healthy participants, radiographic and
magnetic resonance images of the TMJ were not collected. Factors
such as the mandibular length, angle of the condyle, and undiag-
nosed malocclusions could contribute to variability in the MMO
and STLFL. However, in the present study, these factors were not
evaluated.
13652842, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/joor.13498, Wiley Online Library on [14/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
KOLÇAKOĞLU et al.
5 | CO N C LU S I O N
Signs of TMJa could occur among children, and oral measurements
should be recorded. Pediatric dentists should collaborate with the
treating surgeon to manage long-­term treatment needs for individu-
als with TMJa.
AU T H O R C O N T R I B U T I O N S
Z.B.G. and N.K. and S.D. conceived the ideas; S.D. K.K. and Z.B.G.
collected the data; K.K. and G.Z. analysed the data; K.K. and N.K.
and Z.B.G. led the writing.
AC K N O​W L E D
​ G E ​M E N T S
Thanks to Professor Alper Alkan for his advice.
F U N D I N G I N FO R M AT I O N
No author has a financial or proprietary interest in any material or
method mentioned.
C O N FL I C T O F I N T E R E S T S TAT E M E N T
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request. The data are not
publicly available due to informed consent restrictions.
E T H I C S A P P R OVA L
The Clinical Research Committee of the Erciyes University‘s Faculty
of Medicine (No: 142.2023).
ORCID
Kevser Kolçakoğlu https://orcid.org/0000-0003-2596-8678
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How to cite this article: Kolçakoğlu K, Doğan S, Zararsız G,
Kütük N, Gönen ZB. Relationship Between
Temporomandibular Ankylosis And Maximum Mouth Opening
In Children. J Oral Rehabil. 2023;50:940-947. doi:10.1111/
joor.13498