Classification of Temporomandibular Joint Osteoarthrosis and Internal Derangement. Part I: Diagnostic Significance of Clinical and Radiographic Symptoms and Signs

In the clinical setting, diagnosis primarily depends on the history and present status of the patient, and on the examiner's expertise in physical examination and interpretation of conventional radiographs. In order to evaluate the diagnostic significance of clinical and radiographic variables, the authors used magnetic resonance imaging as the ‘golden standard’ for articular disk position. A total of 90 temporomandibular joints (TMJs) were available for the study. Group I (representing ‘normal’ disk position) comprised eight joints (8.9%); group II (representing reducing disk), 34 joints (37.8%); and group III (non-reducing disk), 48 joints (53.3%). Nine anamnestic, 15 clinical, and three radiographic variables obeyed pre-defined univariate selection criteria. Relatively high sensitivities were found for clicking-related variables in MR-group II, and for variables related to movement restriction in MR-group III. None of the symptoms or signs appeared to be pathognomonic for either one of the diagnostic groups. Principal component analysis revealed 13 factors that could be grouped into three major categories, representing impairment of joint mechanics, joint pain and tenderness, and radiographically detectable degenerative changes, respectively. Discriminant analyses showed that symptom combinations, which included clinical variables related to joint mechanics, appeared to provide the most useful diagnostic information. It is concluded that reducing and permanent disk displacement can be distinguished in many cases using clinical and radiographic variables. However, there is considerable variability within these groups. To establish a specific clinical diagnosis, a more detailed classification of osteoarthrosis and internal derangement is desirable.     

Axial Condyle Morphology and Horizontal Condylar Angle in Patients with Internal Derangement Compared to Asymptomatic Volunteers

The purpose of this study was to evaluate the possible structural variations of axial condyle morphology and horizontal condylar angle between patients with internal derangement and asymptomatic volunteers. Forty-five symptomatic patients and 31 asymptomatic volunteers (AV) were included in this study. All subjects had bilateral high-resolution magnetic resonance imaging scans. Axial condyle morphology was evaluated using these images and classified into four diagnostic groups: convex, flat, and concave anterior surfaces, and tapered form. The angulation between the condylar long axis and the transversal plane was then measured. A Wilcoxon-Whitney-Mann-U-test demonstrated no significant differences in the horizontal angulation of the patients with disk displacement with reduction (DDR) (24.35 ± 9.31) as compared to patients with displacement without reduction (DDN) (25.61 ± 10.11) and asymptomatic volunteers (25.68 ± 9.31) (AV). Eighty percent of the flat type condyles and 73.3% of the tapered type condyles belonged to the symptomatic patients with disk displacement with reduction (DDR) and without reduction (DDN). Chi-square test demonstrated significant differences between the diagnostic groups of condyle types (p<0.01). A comparison of the angular difference of right and left joints of asymptomatic volunteers and patients using the Wilcoxon-Whitney-Mann-U test showed that the results of the asymptomatic volunteers were significantly lower (p = 0.05). The conclusion that an increase in the horizontal condylar angle is a predisposing factor for the development of internal derangement or that the derangement develops during the prognosis of the disorder could not be clearly stated based on the results of this study. It is proposed that the difference between condyle morphology in patients with disk displacement and asymptomatic volunteers may be a result of the remodeling or degeneration caused by the disorder.     

Arthrocentesis in TMJ Internal Derangement: A Prospective Study

Objectives of the Study  

To evaluate improvement in symptoms following arthrocentesis: Pain, Maximum Mouth Opening, Clicking/Crepitation.     

Bradykinin Expression in Synovial Tissues and Synovial Fluids Obtained from Patients with Internal Derangement of the Temporomandibular Joint

Bradykinin has been implicated in the pathogenesis of inflammatory arthritis by virtue of the potent pro-inflammatory properties. The purpose of this study is to investigate the expression of bradykinin in patients with internal derangement of the temporomandibular joint (TMJ). We examined 33 TMJ synovial biopsy specimens from 31 patients with internal derangement of the TMJ by an immunohistochemical technique using specific antibodies. We also determined the concentration of bradykinin in 20 synovial fluids from 18 patients with TMJ internal derangement by enzyme-linked immunosorbent assay. These data were compared with those of the control subjects. Bradykinin was predominantly localized in the synovial lining cell layer of TMJ samples obtained from patients with TMJ internal derangement. Bradykinin was also detected in 19 patients' TMJ synovial fluids and the average of bradykinin concentration in the synovial fluids of patients was higher than that of the healthy controls. Although a statistically significant correlation was not observed, these findings support the hypothesis that bradykinin may also be involved in the pathogenesis of TMJ pain and synovitis.     

Diagnostic Accuracy of TMJ Vibration Analysis for Internal Derangement and/or Degenerative Joint Disease

Lower joint arthrography and videofluoroscopy were used to diagnose 297 joints from temporomandibular disorders (TMD) patients. The surface vibrations of the temporomandibular joints (TMJs) were recorded by electrovibratography and a parameter set was derived through frequency analysis. Total vibration energies were used as the primary separating threshold for abnormal joints. The following conditions were statistically discriminated by multi-variate analyses: I) meniscal displacement with reduction; II) meniscal displacement with a partial disk reduction; III) meniscal displacement without reduction; and IV) degenerative joint disease and/or perforation of the disk. Using the total vibration energy as a threshold, the diagnostic sensitivity for the abnormal joints was 82%, while the diagnostic specificity for the joints with no evidence of internal derangement was 75%. Discriminant analysis for the above-mentioned four conditions revealed a diagnostic sensitivity of 79.0%, 85.7%, 77.1% and 76.3% for conditions I, II, III and IV, respectively. The diagnostic specificity was 76.2%, 79.9%, 59.0% and 77.9% for conditions I, II, III and IV, respectively. It was concluded that vibration analysis of the TMJ could be clinically useful as a screening examination for TMD patients.     

TMD患者咬合接触情况与牙弓宽度的测量分析

目的：通过测量和比较正常人群与TMD患者在牙尖交错位时的咬合接触情况及牙弓宽度情况,探讨这2个解剖特征与TMD发病的相关性。方法：收集120个临床病例分为2组,A组TMD患者50例,B组正常人群（对照组）70例,通过对2组人群的咬合接触情况、牙弓宽度进行测量分析,探讨这2个解剖特征与TMD发病的相关性。结果：牙尖交错位时,TMD患者的无咬合接触牙齿数高于正常人群;牙弓宽度较正常人群窄（P﹤0.05）。结论：TMD发病与咬合接触少,牙弓宽度窄这2个解剖特征有关。     

右侧偏侧咀嚼患者单侧咀嚼运动的功能性磁共振成像研究

目的:探讨右侧偏侧咀嚼患者单侧交替咀嚼运动时大脑皮层的激活特点.方法:选取7例右侧偏侧咀嚼患者,采用时段设计方法,采集偏侧咀嚼患者单侧交替咀嚼运动时全脑血氧水平依赖对比的功能性磁共振成像(functional magnetic resonance imaging,fMRI)扫描数据,以SPM2软件包进行数据分析.结果:排除过度头动的干扰因素后,7例患者中仅有5例可以采用.个例分析结果显示:右侧偏侧咀嚼患者在右侧单侧咀嚼时不同脑区BOLD信号的激活比左侧单侧咀嚼时更加广泛.5例偏侧咀嚼患者中有4例在左、右侧单侧咀嚼运动时,右侧中央前回 ( primary motor cortex,M1) 的激活均强于左侧.结论:右侧偏侧咀嚼患者在左、右侧单侧咀嚼时大脑皮层的激活特点不同.右侧偏侧咀嚼患者M1对单侧咀嚼运动的调控可能具有同侧半球优势.     

Internal derangement in the temporomandibular joint of juveniles with clinical signs of TMD

Aim

The aim of this study was to investigate possible correlation of specific skeletal or dental class in children and adolescents with clinical signs of temporomandibular dysfunction (TMD) with the severity of internal derangement (ID) of the temporomandibular joint.

Materials and methods

Based on MRI images, the ID of 232 juvenile temporomandibular joints in 116 patients were retrospectively recorded. The distribution of the ID stages within the skeletal and dental classes was compared by means of the χ ² test.

Results

Excluding the comparison between skeletal Class I (S I) and skeletal Class II (S II; p < 0.05), no statistically significant differences in the distribution of the ID stages were found between the skeletal classes (p > 0.05). No statistically significant differences were found when comparing the distribution of the ID stages between the dental classes (p > 0.05).

Conclusion

According to these findings, there is no skeletal or dental class that is related to higher degrees of internal derangement in the TMJs of children and adolescents presenting clinical signs of TMD. Therefore, it is not possible to draw conclusions about the severity of the ID in relation to the dental and skeletal class in symptomatic juvenile TMJs.

     

Clinical and MRI Evaluation of Orthodontic Mini-Screws for Disc Repositioning in Internal Derangement of TMJ: A Prospective Study

Purpose

The purpose of this study was to assess the efficacy of orthodontic mini-screws as a modified suture anchor for disc repositioning in cases of internal derangement of the temporomandibular joint.

Patients and Methods

A prospective evaluation of ten patients was undertaken for a period of 6 months using this modified approach from Jan 2014 to Jun 2016. Symptomatic patients with clinical and MRI features suggestive of internal derangement of TMJ and willing to undergo surgical repositioning of articular disc to alleviate symptoms of temporomandibular dysfunction were taken up for the study. Post-operatively, functional outcomes were assessed in terms of reduction in pain, joint movement and absence of joint noise and clicking sounds. Post-operative MRI was used to assess the disc position and morphological changes in the disc and arthritic changes in the condyle.

Results

All patients underwent a surgical repositioning of the anteriorly displaced disc by the modified orthodontic suture anchor. Patients were post-surgically followed up at intervals of 1, 3 and 6 months. Immediate complications in terms of pain, restriction of functional motion and transient facial nerve palsy were noted. Late complications include temporal nerve palsy in one case. All patients experienced significant improvement with good functional outcomes and stable repositioning of disc was noticed at the end of 6 months.

Conclusion

The modified disc repositioning using an orthodontic screw via a mini preauricular approach provided a good functional outcome in all patients as assessed over a period of 6 months. However, the long-term functional sequel of the procedure and changes in the articular disc needs to be assessed.

     

Internal Derangement of Temporomandibular Joint: An Evaluation of Effect of Corticosteroid Injection Compared with Injection of Sodium Hyaluronate after Arthrocentesis

Aims and Objectives

Internal derangements are the commonest disorders of temporomandibular joint (TMJ). Different treatment modalities including conservative and surgical methods have been proposed to treat the same. Arthrocentesis is gaining popularity in the treatment of internal derangement of TMJ. Being minimally invasive it does not have the demerits of surgical approaches and at the same time is producing better results than conservative approaches. This study evaluates and compares corticosteroid and sodium hyaluronate after arthrocentesis in the treatment of internal derangement of TMJ.

Materials and Methods

Sixteen patients with internal derangement were randomly selected and divided into 2 groups (8 in each group). Arthrocentesis of the upper joint space was then performed using Ringer lactate under local anaesthesia followed by injection of either betamethasone or sodium hyaluronate into the joint. Clinical data was collected in the form of pain (visual analog scale), maximum mouth opening, joint sound and deviation before and after treatment up to 6 months.

Results

Both groups of patients were benefited from the treatment at the 6 month follow up and there was slightly less intensity of pain in sodium hyaluronate group compared with corticosteroid group. Maximum mouth opening was also increased in both groups. A decrease in clicking and deviation were seen in both groups. There was no statistically significant difference between betamethasone and sodium hyaluronate.

Conclusion

Intra articular injection of corticosteroid or sodium hyaluronate after arthrocentesis had considerable effect on the TMJ. Both betamethasone and sodium hyaluronate can be used after arthrocentesis with similar results.     

Differences in Lip Support with and without Labial Flanges in a Maxillary Edentulous Population. Part 1: Objective Analysis

Purpose

To study the objective differences in lip support using common facial soft tissue markers, when evaluating patients wearing a maxillary denture with a labial flange in comparison to an experimental flangeless denture.

Materials and Methods

A total of 31 maxillary edentulous patients who were esthetically satisfied with their existing maxillary denture were recruited in this clinical study. The maxillary denture was then duplicated in clear acrylic resin. Two standardized full‐face digital photographs (frontal and profile) were made with the duplicate denture in the mouth. The labial flange of the duplicate denture was then removed from first premolar to first premolar region, to create the experimental flangeless denture. It was returned to the oral cavity, and 2 additional full‐face digital photographs were made. The differences between these images were studied using 5 facial anatomic markers (subnasale, labrale superior, stomion, nasolabial angle, lip thickness). A paired sample t‐test was used to compare differences in measurements for various anatomic markers using an alpha value of 0.05.

Results

For profile images, there were no statistically significant differences between photographs with and without a labial flange for anatomic markers‐ labrale superior and stomion (p < 0.05). There was a statistically significant difference for subnasale as well as the nasolabial angle but the magnitude of the difference was too small to be clinically significant (p < 0.05). For frontal images, there was no statistically significant difference in lip thickness between photographs with and without a labial flange. Additionally, there was no association between differences in measurements and patient‐related factors such as gender and prior years of edentulism.

Conclusions

Removal of a labial flange in a maxillary denture resulted in minimal and clinically insignificant anatomic differences in lip support between flange and flangeless dentures, when analyzed in frontal and profile images.     

Temporomandibular Joint Internal Derangement and Osteoarthrosis: Are Effusion and Bone Marrow Edema Prognostic Indicators for Arthrocentesis and Hydraulic Distention?

PURPOSE: Arthrocentesis and hydraulic distention of the temporomandibular joint (TMJ) has proven to be an effective modality in treating patients exhibiting clinical findings consistent with the diagnosis of disc displacement without reduction. The purpose of this study was to investigate whether the magnetic resonance imaging (MRI) variables of effusion and/or bone marrow edema may predict treatment outcomes of arthrocentesis and hydraulic distention of the TMJ. PATIENTS AND METHODS: The study group comprised 37 consecutive patients with TMJ pain, who were assigned a unilateral clinical TMJ disorder of TMJ pain associated with an internal derangement (ID) type III (disc displacement without reduction) and a TMJ pain side-related MRI diagnosis of disc displacement without reduction associated with osteoarthrosis (OA). Bilateral sagittal and coronal MRI images were obtained immediately before the operation to establish the presence or absence of ID, OA, TMJ effusion, and bone marrow edema. Pain level and mandibular range of motion (ROM) were assessed preoperatively and compared with the respective 2-month follow-up findings. Outcome criteria for success were a ROM >or=35 mm and pain reduction >50%. A logistic regression analysis was used to compute the odds ratio for TMJ effusion and bone marrow edema for successful outcomes (n = 21) versus unsuccessful (n = 16) outcomes. RESULTS: At the 2-month follow-up, clinical evaluation showed a significant reduction in TMJ pain during function (P = .000), a significant reduction in clinical diagnoses of TMJ disorders (P = .016), and a significant increase in ROM (P = .000). A significant increase in the risk of an unsuccessful outcome of ROM <35 mm and/or pain reduction >or=50% occurred with MRI findings of effusion (odds ratio 1:10.8 = 0.09; P = .007). CONCLUSIONS: TMJ effusion may prove to be an important prognostic determinant of successful arthrocentesis. However, the data re-emphasize the concept that the prediction of a specific outcome is not a matter of simple linearity, in which the presence of 1 factor may equate with predictive ability, but rather is a function of a complex interaction among different biological variables.