Magnetic Resonance Imaging of Temporomandibular Joints of Children

Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children

After a thorough review of the history and presentation of a child's facial pain, a targeted head and neck examination is critical to the appropriate diagnosis of facial pain and temporomandibular joint disorders. It is critical to distinguish between the structural (trauma, degenerative disease, and tumor) and nonstructural (neurogenic, myogenic, and psychological) causes of pain, which will allow for incorporation of appropriate strategies of medical, psychological, dental, and surgical therapies.

Imaging of the Pediatric Temporomandibular Joint

Imaging of the temporomandibular joint in pediatric patients is a critical component in the evaluation and treatment of children with temporomandibular joint symptoms. MRI can provide detailed joint anatomy and identify inflammation, sometimes before symptom onset. Ultrasound scan is a convenient emerging modality to evaluate the joint and guide therapeutic injections. Radiography and computed tomography offer osseous detail to recognize early morphologic changes of the mandibular condyle and provide operative planning. Imaging promises to direct treatment to prevent future joint destruction and maintain function.

Normal magnetic resonance appearances of the temporomandibular joints in children and young adults aged 2-18 years

BACKGROUND

Knowledge of normal appearances of the temporomandibular joint (TMJ) is paramount when assessing the joint for disease in juvenile idiopathic arthritis. Reliable features defining normal TMJs in children are limited.

OBJECTIVE

To establish reliable normal standards for the TMJ at magnetic resonance imaging (MRI).

MATERIALS AND METHODS

We included children and young adults aged 2-18 years undergoing a head MRI for reasons not believed to affect the TMJs. We assessed TMJ anatomy and contrast enhancement using a high-resolution 3-D T1-weighted sequence. We noted joint fluid and bone marrow oedema based on a T2-weighted sequence. Three experienced radiologists read all examinations twice in consensus and defined intraobserver consensus agreement.

RESULTS

We evaluated the TMJs in 101 children and young adults (45 female), mean age 10.7 years (range 2-18 years). The intraobserver consensus agreement for the assessment of anterior condylar inclination in the sagittal/oblique plane was moderate to good (Cohen κ=0.7 for the right side). Cohen κ for intraobserver consensus agreement for condylar shape in the coronal plane on a 0-2 scale was 0.4 for the right and 0.6 for the left. Intraobserver agreement for measurement of joint space height and assessment of bone marrow oedema was poor. There was a statistically significant increase in anterior inclination by age in the sagittal plane on a 0-2 scale (P<0.0001). Eighty percent of the condyles showed a rounded shape in the coronal plane while 20% showed mild flattening. Thirty-five of 36 right TMJs showed contrast enhancement (mild enhancement in 32 joints, moderate in 3 joints).

CONCLUSION

Subjective assessment of the anterior condylar inclination in the sagittal/oblique plane and condylar flattening in the coronal plane can be considered precise features for describing TMJ anatomy in healthy children. There is an increasing anterior inclination by age. Mild contrast enhancement of the TMJs should be considered a normal finding.

Juvenile Idiopathic Arthritis Practice Patterns Among Oral and Maxillofacial Surgeons

PURPOSE

The purpose of this investigation is to assess the current clinical practices by oral and maxillofacial surgeons (OMSs) in the United States regarding diagnosis and treatment of temporomandibular joint (TMJ) involvement in children with juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

We implemented a cross-sectional survey of academic OMSs in the United States via an electronic survey. The survey included respondent demographic data, patient volumes, diagnostic methods, and management practices for children with JIA and TMJ involvement. The results of the survey were analyzed using descriptive statistics.

RESULTS

The study respondents were composed of 52 surgeons. Most respondents were men (n = 43, 87.8%), were aged 51 to 60 years (n = 20, 39.2%), were in full-time academics (n = 42, 84%), had more than 20 years of experience (n = 26, 50%), and were seeing 1 to 5 patients with JIA per month (n = 21, 46.7%). Most patients were aged 11 to 15 years (n = 22, 61.1%) and were managed with 1 to 2 systemic medications (n = 30, 81.1%). All OMSs reported evaluating TMJ involvement by reviewing patient history, clinical examination, and imaging. The most commonly used imaging modality was panoramic radiographs (n = 24, 63.2%) and magnetic resonance imaging (n = 22, 57.9%). OMSs decided to inject intra-articular medication based on history and symptoms (n = 36, 94.7%). Once in remission, patients were followed up at yearly (n = 12, 36.4%) or 6-month (n = 10, 30.3%) intervals.

CONCLUSIONS

Our study shows that, in general, there is consensus among US OMSs regarding diagnosis of TMJ involvement in children with JIA. There is less concordance among the respondents regarding treatment. Currently, management of TMJ involvement in children with JIA is mostly based on expert opinions and retrospective studies. This study further highlights the need for randomized clinical trials and multi-institution collaboration to allow for evidence-based diagnosis and treatment.