Internal derangements of the temporomandibular joint. Pathological variations

A retrospective analysis of 540 operated cases (740 joints) of internal derangements of the temporomandibular joint was carried out. Observations of this patient population provided the basis for describing pathological variations of internal derangements. Radiologic studies, including tomograms and arthrograms or magnetic resonance scans, and surgical/pathological findings were correlated with clinical data in each case. It was found that clinical manifestations varied in a characteristic way and were directly related to the degree of pathological change and time course. Various stages of internal derangements were identified. Pathophysiological mechanisms responsible for the observed changes, as well as clinical signs and symptoms and causal factors, were discussed. Internal derangements are organic lesions that appear to be progressive and are probably of traumatic origin. The view is given that internal derangements represent the basic pathological entity responsible for clinical manifestations of what has been known as the temporomandibular joint pain-dysfunction syndrome or similarly described conditions. Effective clinical management takes on new importance because progression to advanced degenerative states may occur.

Right-left asymmetry of maximum jaw opening

According to several studies on human populations, the mandible deviates on opening significantly more often to the left than to the right. An association between the asymmetry of opening and handedness has been suggested. The present study of 143 left-handed Finnish conscripts showed no significant difference from the asymmetry reported for populations unselected for handedness. It was concluded that the opening asymmetry and handedness are not associated. The asymmetry proved also to be unassociated with the side of first unilateral tooth contact on guided hinge closure, with the side of palpatory tenderness of the muscles of mastication, and with the side of temporomandibular joint sounds.

[The CT scanner and the temporomandibular joint. Anatomo-radiologic comparisons. Apropos of 14 cases of algodysfunctional of the manducator system]

Among 500 CT scan of temporomandibular joint (TMJ), examined since 1982 by bilateral direct sagittal method (Department of Radiology, Pr. A. TREHEUX, CHU Nancy-Brabois), the authors have retained 14 cases of patients with symptoms related to TMJ's dysfunction cured by surgery (Department of Maxillo Facial Surgery, Pr STRICKER, CHU Nancy). These cases were chosen among hundred patients annually examined by CT scan, for various diseases (TMJ's dysfunctions, traumatisms, infections, inflammatory diseases...). These correlations between radiology and surgery about 26 TMJ (2 patients underwent surgery only on one side) were: an accuracy with surgical findings for 19 cases (76%); in 6 cases (23%), a meniscus anteriorly displaced, non detected by CT scan was found by surgery; 2 cases of meniscus perforations (one in the frontal plane, the other sagittal) were surgical findings; in 1 case, a displacement was under-valued by CT scan; in 3 cases, arthrosic changes (1 case of Reiter syndrome), were characterized by CT scan. The authors emphasize the value and the limits of evaluation of the internal derangements of the TMJ with direct sagittal CT.

Dynamic magnetic resonance imaging of the temporomandibular joint using FLASH sequences

Magnetic resonance imaging (MRI) is a suitable modality for the visualization of the temporomandibular joint (TMJ) in both normal and pathologic conditions. Until recently, MRI had been unable to provide diagnostic dynamic images of the TMJ during opening. A series of 30 TMJ MRI examinations of 17 symptomatic patients and two normal volunteers (15 to 43 years old; 14 men and five women) was performed. Fast low angle shot (FLASH) sequences were used to provide a series of dynamic images of the TMJ in various phases of opening. In 30% of the joint examined, FLASH sequences contributed clinically significant information not available with standard T1-weighted sequences. These results suggest that FLASH images are particularly useful in distinguishing normal disc variants from pathologic conditions in which the disc is displaced anteriorly to a mild extent. The short imaging time of FLASH sequences decreases motion artifact in patients who have difficulty remaining still during the examination.

The recognition of craniomandibular disorders--a comparison between clinical, tomographical, and dental panoramic radiographical findings in thirty-one subjects

A comparison between clinical, tomographical, and dental panoramic radiographical findings was made in thirty-one female patients suffering from craniomandibular disorders (CMD). In general it was found that condylar sclerosis was more common in these patients than in earlier studies. After clinical separation of the material into two groups based upon the origin of pain, myogenous versus arthrogenous, no radiographical confirmation of the differential diagnostics could be made. Regarding vertical condylar asymmetry measured on the Orthopantomogram, it was found that 74% of the patients with CMD had more than the 3% of asymmetry regarded as within normal limits. It seems that with an increasing severity of the disorder the level of condylar asymmetry appears less. If the interpretation of the findings is correct its conclusion might lead to the recognition of a morphological factor which could contribute to the development of a craniomandibular disorder.

Systemic joint laxity (the hypermobile joint syndrome) is associated with temporomandibular joint dysfunction

A consecutive series of 37 individuals admitted to the hospital for elective temporomandibular joint (TMJ) reconstructive surgery and 3 seen as outpatients with TMJ disease were evaluated for rheumatic disease or for another etiologic factor that might account for this problem. These 40 patients were screened by history, physical examination, and laboratory study. We soon noticed that many patients had generalized joint laxity. Eighteen of the first 40 individuals satisfied established criteria for the hypermobile joint syndrome. An additional 3 were found to have Ehlers-Danlos syndrome or a forme fruste of this disorder. Many were markedly hypermobile and could perform a number of flexible maneuvers. Although excessive joint laxity is known to be associated with a variety of rheumatic conditions, TMJ disease has not been recognized as one of them. No patient in this series had a systemic inflammatory disorder or any other apparent etiologic factor for TMJ disease. We suggest that there is a cause-and-effect relationship between generalized joint laxity and TMJ disease.

Correlation of clinical parameters to the arthrographic depiction of temporomandibular joint internal derangements

This prospective clinical investigation of 188 patients with signs and symptoms of temporomandibular joint (TMJ) pain and dysfunction examines the correlation between clinical signs and symptoms versus the arthrographic characteristics of intracapsular disease related to displacement of the meniscus. An attempt has been made to establish which specific clinical signs and symptoms, as determined by arthrography, best predict the condition of the joint. Our findings suggest that most of the clinical signs and symptoms are not sufficiently reliable in themselves to permit prediction of the condition of the meniscus. Those clinical parameters that did show a strong correlation were tested in combinations using stepwise discriminant analysis to evaluate clinical tendencies. Thus, patients with normal meniscal position and function were often noted to have normal mandibular ranges of movement, no joint noises on opening and closing of the jaw, and no tomographic evidence of degenerative joint disease. Subjects with meniscal displacement with reduction were often found to have joint clicking, deviation of the jaw upon opening, and an absence of degenerative joint disease by multidirectional tomography. Patients who had meniscal displacement without reduction were often found to have limitation in jaw movement, crepitation on opening and closing of the jaw, and associated degenerative changes on multidirectional tomograms. If specific treatment plans are to be tailored for different stages of TMJ internal derangements, clinical findings alone or clinical findings in conjunction with plain radiographs of the TMJ are not consistently accurate.

[Characteristics of the topographic anatomical correlations of the chorda tympani, auriculotemporal nerve and anterior tympanic artery with the temporomandibular joint]

The aim of the investigation was to reveal the possibility to draw into the pathological process known as the "Costen syndrome" the formations mentioned in the title. The investigation performed by means of the craniometry method on 150 mature person skulls, that are rather evenly distributed according to their sex, age and form, and simultaneous investigation of 70 heads of corpses of persons of both sex, gave the data denying the possibility of mechanical damage of the chorda tympani, when the mandibular head is shifted backward or medially. This phenomenon can be observed at a loss of teeth and lowered bite. When the mandibular head is shifted backward, it does not involve the chorda tympani, since the nerve gets out of the osseous canal more medially to the spine of the sphenoid bone. The medial shift of the mandibular head also cannot damage the chorda tympani, since the nerve is separated from the joint by a marked osseous protrusion. At the same time the data are obtained on variations in topography of the chorda tympani at various form of the intratemporal fossa. It has been stated that when a pathological process occurs around the temporomandibular joint, the auriculotemporal nerve and the anterior tympanic artery can be involved into this process. This can produce appearance of the "Costen syndrome" components.

Intermittent open-mouth lower jaw locking in five dogs

Intermittent open-mouth lower jaw locking was documented in 5 dogs. In contrast to what has been reported in other cases, pronounced radiographic abnormalities in the temporomandibular joints were not observed. In 4 of the dogs, locking episodes started at a later age (35 to 83.5 months) than had been reported by others (6 to 22 months). Duration and frequency of locking were variable. Lateral shifting of the jaw and lack of neurologic deficits indicated a temporomandibular joint abnormality. Excision of the rostroventral portion of the involved zygomatic arch prevented locking in all cases. This syndrome involves variable severity of temporomandibular joint dysplasia, which could account for the variable age of onset and random frequency of locking episodes.