## 4 Discussion  
Based on our findings, no significant differences existed in the FD values for the ROIs in patients with and without bruxism of different sexes. This result showed that fractal analysis of panoramic radiographs cannot be useful in detecting patients with bruxism. Moreover, the findings of this study showed that, in different age ranges, there were significant differences in the right condyle and gonial region and left gonial and alveolar region, and the FD values were significantly higher in 60-69 year old individuals compared to 70-79 year old individuals in these ROIs. Moreover, the results of this study showed that the maximum and minimum mean FD values in both sides were obtained for the condylar and alveolar regions, respectively. No consensus exists regarding the diagnosis of bruxism due to its subjective and unspecific nature [18]. Several methods have been suggested for diagnosing bruxism, including polysomnography, questionnaires, clinical examination, and electromyography [12, 19]. However, based on existing literature, a combination of polysomnography, clinical evidence of flat facets in the teeth, and a history of clenching and grinding was used in this study to confirm bruxism [20]. While the application of image enhancement techniques to medical images is a crucial stage in many diagnostic processes and leads to better diagnosis in oral radiographs, such as in evaluating the periapical region [9], for visual recognition of changes in bone structures in radiographs, a minimum change of 30% is needed [21]. One technique that has the potential to improve the diagnostic accuracy of radiographs, even when the changes are below 30%, is fractal analysis, which employs mathematical morphology for evaluation of bone trabecular structures [22]. Various studies have been carried out using fractal analysis as a tool for evaluating bone structure. According to a study by [PERSON] et al. from 2021, FD levels decrease in moderate and severe periodontitis [6]. In [PERSON] et al. 's study, 45 digital bitewing radiographs were taken obtained individuals. Afterward, the FD values of four different ROIs (maximlary and mandibular premolar and molar regions) were determined. This study found that FD values were affected by the dimensions of ROIs more than their gray level values [23]. Thus, in the current study, for ROI selection in the condyle and alveolar area, 50 \(\times\) 50 pixel regions of trabecular bone without teeth, periodontitis, or cortical bone were selected for fractal analysis. Moreover, for applying fractal analysis in the gonial regions, 100 \(\times\) 100 pixel ROIs were selected from the trabecular bone of the mandible, excluding the cortical bone because of its effect on FD values. In a study performed by [PERSON] et al. in 2021 with 212 individuals, three bilateral regions of interest (ROIs) were selected: the mandibular condyle, the mandibular angle, and the area between the apical regions of the mandibular second premolar and the first molar teeth. It was determined that FD values were lower in the right condyle in \begin{table}
\begin{tabular}{c c c c c c} \hline
**ROI** & **50–59** & **60–69** & **70–79** & **80–89** & \(p\) **Value** \\ \hline Right condyle & 1.42 \(\pm\) 0.14 & 1.43 \(\pm\) 0.13 & 1.38 \(\pm\) 0.08 & 1.40 \(\pm\) 0.08 & 0.030 \\ \hline Left condyle & 1.42 \(\pm\) 0.12 & 1.42 \(\pm\) 0.14 & 1.41 \(\pm\) 0.08 & 1.38 \(\pm\) 0.11 & 0.200 \\ \hline Right gonial region & 1.40 \(\pm\) 0.13 & 1.42 \(\pm\) 0.15 & 1.34 \(\pm\) 0.09 & 1.47 \(\pm\) 0.11 & 0.001 \\ \hline Left gonial region & 1.42 \(\pm\) 0.15 & 1.42 \(\pm\) 0.15 & 1.35 \(\pm\) 0.08 & 1.39 \(\pm\) 0.09 & 0.002 \\ \hline Right alveolar region & 1.38 \(\pm\) 0.17 & 1.41 \(\pm\) 0.13 & 1.32 \(\pm\) 0.12 & 1.36 \(\pm\) 0.14 & \textless{}0.001 \\ \hline Left alveolar region & 1.37 \(\pm\) 0.16 & 1.38 \(\pm\) 0.15 & 1.35 \(\pm\) 0.09 & 1.33 \(\pm\) 0.15 & 0.542 \\ \hline \end{tabular}
\end{table} 
Table 5: Mean FDs \(\pm\) standard deviation for different ROIs in different age ranges.