MRI evidence of high signal intensity and temporomandibular arthralgia and relating pain. Does the high signal correlate to the pain?

The Role of Ultrasound in Temporomandibular Joint Disorders: An Update and Future Perspectives

Temporomandibular joint (TMJ) disorder is the second most common chronic pain condition affecting the general population after back pain. It encompasses a complex set of conditions, manifesting with jaw pain and limitation in mouth opening, influencing chewing, eating, speaking, and facial expression. TMJ dysfunction could be related to mechanical abnormalities or underlying inflammatory arthropathies, such as rheumatoid arthritis (RA) or juvenile idiopathic arthritis (JIA). TMJ exhibits a complex anatomy, and thus a thorough investigation is required to detect the TMJ abnormalities. Importantly, TMJ involvement can be completely asymptomatic during the early stages of the disease, showing no clinically detectable signs, exposing patients to delayed diagnosis, and progressive irreversible condylar damage. For the prevention of JIA complications, early diagnosis is therefore essential. Currently, magnetic resonance imaging (MRI) is described in the literature as the gold standard method to evaluate TMJ. However, it is a high-cost procedure, not available in all centers, and requires a long time for image acquisition, which could represent a problem notably in the pediatric population. It also suffers restricted usage in patients with claustrophobia. Ultrasonography (US) has emerged in recent years as an alternative diagnostic method, as it is less expensive, not invasive, and does not demand special facilities. In this narrative review, we will investigate the power of US in TMJ disorders based on the most relevant literature data, from an early screening of TMJ changes to differential diagnosis and monitoring. We then propose a potential algorithm to optimize the management of TMJ pathology, questioning what would be the role of ultrasonographic study.

Correlation of arthroscopic findings with clinical-radiological signs and symptoms of temporomandibular joint dysfunction: retrospective study of 829 joints

Temporomandibular joint (TMJ) arthroscopic findings are difficult to predict based on clinical criteria. Few studies have attempted to correlate signs, symptoms, and characteristics of patients with the final arthroscopic findings. The aim of this study was to assess the correlation between clinical-radiological signs and symptoms and arthroscopic findings in patients with TMJ dysfunction undergoing arthroscopy. A retrospective study was performed involving 487 patients (829 joints) with TMJ dysfunction who underwent TMJ arthroscopy between 2000 and 2019. The clinical-radiological variables recorded were pain, maximum mouth opening, joint noises, Wilkes classification, and disc displacement. The arthroscopic findings evaluated were synovitis, chondromalacia, adhesions, disc perforation, disc displacement, and roofing. Pain symptoms were significantly associated with the intensity of synovitis (P = 0.005) and disc displacement evaluated arthroscopically (P < 0.001). A statistically significant relationship was observed between Wilkes stage and the level of synovitis (P < 0.001) and chondromalacia (P < 0.001). Mouth opening was negatively correlated with adhesions (P < 0.001). Based on this study, pain symptomatology was associated with the intensity of synovitis and disc displacement evaluated arthroscopically, the Wilkes stage was a good predictor of the severity of synovitis and chondromalacia, and mouth opening was negatively correlated with adhesions.

Analysis of three-dimensional imaging findings and clinical symptoms in patients with temporomandibular joint disorders

Background

The purpose of this study was to analyze cone-beam computed tomography (CBCT) and magnetic resonance imaging (MRI) findings in temporomandibular joint disorder (TMD) patients and to comprehensively assess the relationships between these imaging findings and clinical symptoms.

Methods

A total of 754 temporomandibular joints (TMJs) in 377 patients with clinical symptoms of TMD who underwent both CBCT and MRI examinations were retrospectively reviewed. Clinical symptoms included TMJ pain, TMJ sound, and limitation of mouth opening. Oral radiologists evaluated osseous changes of the condylar head on CBCT, as well as the disc configuration, internal derangement, and joint effusion on MRI. The frequency of CBCT and MRI findings and the mean and standard deviation of age were analyzed. Logistic regression analysis was used to identify associations between these imaging findings and clinical symptoms using SPSS version 25.0 for Windows (IBM Corp., Armonk, NY, USA). The model fit was evaluated using the Hosmer and Lemeshow test.

Results

TMD patients consisted of 294 females and 83 males, and the age group of 20-39 accounted for 47.2% of the patients. Normal findings regarding osseous changes of the condylar head on CBCT were found in 65.1% of the patients. On MRI, a change in disc configuration was found in 54.9% of the patients, internal derangement in 62.6%, and joint effusion in 46.0%. TMJ pain was significantly associated with sclerosis [odds ratio (OR): 3.81], disc displacement without reduction (DDWOR) (OR: 3.22), grade 2 joint effusion (OR: 2.33), and grade 3 joint effusion (OR: 5.54). TMJ sound was significantly associated with disc displacement with reduction (DDWR) (OR: 3.04), DDWOR (OR: 2.50), grade 2 joint effusion (OR: 2.37), and grade 3 joint effusion (OR: 3.23). Limitation of mouth opening was significantly associated with flattened disc configuration (OR: 2.08), folded disc configuration (OR: 2.30), and grade 3 joint effusion (OR: 2.85).

Conclusions

CBCT findings had little to do with clinical symptoms. In contrast, MRI findings, including disc configuration, internal derangement, and joint effusion, were associated with clinical symptoms. These results suggest that MRI should be recommended over CBCT for the proper diagnosis of TMD patients.

Does clinical findings correlate with magnetic resonance imaging (MRI) findings in patients with temporomandibular joint (TMJ) pain? A cross sectional study

Background

Although magnetic resonance imaging (MRI) helps to clearly visualize the disorders in temporomandibular joint (TMJ), the relationship between cross-sectional and clinical findings has not been precisely established. The aim of this study was to evaluate the relationship between clinical symptoms and MRI findings in individuals with TMJ pain.

Material and Methods

This cross-sectional study, conducted on the clinical and MRI findings of the patients, who applied to Uşak University, Oral and Maxillofacial Surgery Clinic with TMJ pain between the years 2016-2019. The primary predictor variables were MRI findings; disc position (normal, disc displacement with reduction (DDWR), disc displacement without reduction (DDWOR)), disc structural distortion (normal, folded, lengthened, round, biconvex, thick), condyle degeneration type (normal, moderate, severe) and joint effusion (JE) (absent, present). The primary outcome variable was pain, recorded on a visual analog scale (VAS) (numbered between 0-10). The other variables were demographic variables (age/gender). The relationship between clinical and MRI findings were statistically evaluated. The data were analysed by Kruskal Wallis and Mann Whitney U test. Chi-square (x2) test was used for categorical variable comparisons. P values < .05 were considered to indicate statistical significance.

Results

Clinical and MRI records of 700 TMJ, from 350 patients with the mean age of the 31 (12-65) were evaluated in this study. Statistically significant differences were found between; disc position and pain, disc position and JE; JE and pain; disc structural distortion and pain; and disc structural distortion and disc position. JE was seen more common in DDWOR group. The most common disc distortion, seen in patients with JE, is the folded type.

Conclusions

The present study can infer that pain is associated with disc position, JE, disc structural distortion, and DDWOR is associated with JE. Folded type disc is the most common disc type in TMJ with JE.

Key words:Internal derangement, TMJ, MRI evaluation, disc morphology, disc position, condyle degeneration, joint effusion.

A nomogram for classification of temporomandibular joint disk perforation based on magnetic resonance imaging

OBJECTIVE

The aim of this study was to analyze risk factors and establish a prediction model for temporomandibular joint (TMJ) disk perforation by constructing a nomogram.

STUDY DESIGN

The study included a total of 282 joints in 274 patients. All patients underwent open TMJ surgery after obtaining magnetic resonance imaging (MRI), from 2005 to 2015. The presence or absence of disk perforation was confirmed during the operation. Patients were classified into 2 groups: perforation and nonperforation groups. We investigated demographic data and the characteristics of the disk, joint space, and bone on MRI. A logistic regression analysis was performed to analyze risk factors. A nomogram was constructed and validated internally and externally.

RESULTS

Risk factors for disk perforation were increased age, disk shape (eyeglass or amorphous), low bone marrow signal, abnormal joint space, and 2 or more bony changes in the condyle and fossa. The area under the receiver operating characteristic curve of the nomogram was 0.908 (95% confidence interval [CI] 0.869-0.946) in the internal validation and 0.889 (95% CI 0.804-0.973) in the external validation with good suitability.

CONCLUSIONS

We were able to predict the probability of disk perforation with analyzed risk factors and constructed a nomogram, which may be helpful in proper diagnosis and treatment.

Internal derangement as a predictor of provoked pain on mouth opening: A magnetic resonance imaging study

Purpose

This study investigated the relationship between pain and internal derangement in temporomandibular disorder (TMD) patients using magnetic resonance imaging (MRI).

Materials and Methods

This study analyzed 356 TMD patients (712 temporomandibular joints [TMJs]). The inclusion criteria were the presence of spontaneous or provoked pain on one or both TMJs and having undergone MRI. The patients with provoked pain were divided into 3 groups: pain on palpation, pain on mouth opening, and pain on mastication. MRI was performed using a 1.5-T scanner. T1- and T2-weighted parasagittal and paracoronal images were obtained. According to the findings on the T1-weighted images, another 3 groups were created based on internal derangement: normal, disc displacement with reduction, and disc displacement without reduction. The MRI findings were independently interpreted by 2 experienced oral and maxillofacial radiologists at 2 different times. Statistical analysis was performed by the chi-square test using SPSS (version 12.0; SPSS Inc., Chicago, IL, USA).

Results

Provoked pain on mouth opening was found to be correlated with internal derangement in TMD patients (P<.05). However, spontaneous pain and provoked pain on palpation or mastication were not associated with internal derangement (P>.05).

Conclusion

These results suggest that internal derangement was a significant predictor of provoked pain on mouth opening.

The usefulness of diagnostic imaging for the assessment of pain symptoms in temporomandibular disorders

The causes of pain symptoms in the temporomandibular joint (TMJ) and masticatory muscle (MM) regions may not be determined by clinical examination alone. In this review, we document that pain symptoms of the TMJ and MM regions in patients with temporomandibular disorders (TMDs) are associated with computed tomography and magnetic resonance (MR) findings of internal derangement, joint effusion, osteoarthritis, and bone marrow edema. However, it is emphasized that these imaging findings must not be regarded as the unique and dominant factors in defining TMJ pain. High signal intensity and prominent enhancement of the posterior disk attachment on fat saturation T2-weighted imaging and dynamic MR imaging with contrast material are closely correlated with the severity of TMJ pain. Magnetic transfer contrast, MR spectroscopy, diffusion tensor imaging, and ultrasonography findings have helped identify intramuscular edema and contracture as one of the causes of MM pain and fatigue. Recently, changes in brain as detected by functional MR neuroimaging have been associated with changes in the TMJ and MM regions. The thalamus, the primary somatosensory cortex, the insula, and the anterior and mid-cinglate cortices are most frequently associated with TMD pain.

A Longitudinal Study of Magnetic Resonance (MR) Evidence of Temporomandibular Joint (TMJ) Fluid in Patients with TMJ Disorders

It has been reported that joint effusion, the excessive accumulation of joint fluid in and around the joint, is related to temporomandibular joint (TMJ) disorders such as pain and disk displacement. However, there have been no longitudinal studies of this phenomenon. We performed a longitudinal study on the relationship between joint fluid and various pathological disk conditions. The subjects were 17 patients who visited our facility for orthodontic treatment and were diagnosed using MRI as having internal derangement of one or both TMJs (three males and 14 females; age 12-31 years; mean age 20.5 years). MRI was performed before, during, or after treatment for their disorders. We evaluated the relationship between changes in joint fluid in the joint space and the state of the disk, as well as the presence or absence of pain. Joint fluid was evaluated by classifying the extent of high-signal areas in the upper and lower articular cavities on T2-weighted images. The extent of high-signal areas was classified into five levels. Disk displacement and the extent of displacement were evaluated using proton density-weighted images. Statistical analysis was performed using the chi-square test, and differences in the distribution among the groups were examined. Effusion was noted on the first MRI in nine of the eleven joints (81.8%) in which joint fluid decreased on the second MRI (p<0.01). Displacement remained unchanged or worsened in 18 of the 21 joints (85.7%) that showed joint fluid on the first MRI (p<0.01). Pain was alleviated or absent in all joints in which the fluid decreased. These results suggest that joint fluid may be a factor in the outcome of disk recapture treatment as well as in the evaluation of pain.

Relationship between anterior disc displacement with/without reduction and effusion in temporomandibular disorder patients using magnetic resonance imaging

PURPOSE

This study was performed to evaluate the relationship between anterior disc displacement and effusion in temporomandibular disorder (TMD) patients using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

The study subjects included 253 TMD patients. MRI examinations were performed using a 1.5 T MRI scanner. T1- and T2-weighted images with para-sagittal and para-coronal images were obtained. According to the MRI findings, temporomandibular joint (TMJ) disc positions were divided into 3 subgroups: normal, anterior disc displacement with reduction (DWR), and anterior disc displacement without reduction (DWOR). The cases of effusion were divided into 4 groups: normal, mild (E1), moderate (E2), and marked effusion (E3). Statistical analysis was made by the Fisher's exact test using SPSS (version 12.0, SPSS Inc., Chicago, IL, USA).

RESULTS

The subjects consisted of 62 males and 191 females with a mean age of 28.5 years. Of the 253 patients, T1- and T2-weighted images revealed 34 (13.4%) normal, DWR in 103 (40.7%), and DWOR in 116 (45.9%) on the right side and 37 (14.6%) normal, DWR in 94 (37.2%), and DWOR in 122 (48.2%) joints on the left side. Also, T2-images revealed 82 (32.4%) normal, 78 (30.8%) E1, 51 (20.2%) E2, and 42 (16.6%) E3 joints on the right side and 79 (31.2%) normal, 85 (33.6%) E1, 57 (22.5%) E2, and 32 (12.7%) E3 on the left side. There was no difference between the right and left side.

CONCLUSION

Anterior disc displacement was not related to the MRI findings of effusion in TMD patients (P>0.05).

Interexaminer reliability of T2-weighted magnetic resonance imaging for lumbar bright facet sign

OBJECTIVE

The aims of this study were to characterize the bright facet response within the lumbar spine, to identify a constellation of findings associated with the response, and to quantify the interexaminer agreement on the previous objectives.

METHODS

A retrospective study of lumbar magnetic resonance images obtained on 105 (N = 105) adult subjects (62 men and 43 women; age range, 18-84 years; mean age, 46.51 +/- 16.01 years) were reviewed by 2 musculoskeletal radiologists for the presence of high signal within the facet articulations (bright facet response) on fast spin echo T2-weighted images.

RESULTS

Of the 630 lumbar facet articulations imaged (L3/L4 through L5/S1), 340 (54%) and 346 (55%) respectively, per examiner, did show a bright facet response. Interexaminer agreement with respect to the level and grading of a bright facet response was almost perfect with kappa ranging from 0.85 to 0.91 (SE, 0.06). Prevalence of bright facet responses averaged 40.5% at L5/S1, 56.5% at L3/L4, and 66.5% at the L4/L5 level. There was an association with degenerative facet and disk changes.

CONCLUSION

The bright facet response was a common phenomenon on T2-weighted magnetic resonance imaging of the lumbar spine in these cases. There was sufficient agreement with respect to the presence and extent of the bright facet response to conclude that the examiners' determinations were not made by random chance. There exist sufficient repeatability and reliability that a single descriptive term can be applied to unify the bright facet response, the bright facet sign.

Hard and Soft Tissue Stability of Orthognathic Surgery

Objective: To test the hypothesis that there is no difference in the stability of the hard and soft tissue changes following a surgical mandibular setback using a sagittal split ramus osteotomy or an intraoral vertical ramus osteotomy.

Materials and Methods: The samples consisted of 45 female patients with mandibular prognathism, who were divided into two groups. Twenty-three underwent a sagittal split ramus osteotomy (SSRO) with rigid fixation by titanium mini-screws and maxillomandibular fixation (MMF) for 14.0 ± 0.7 days. Twenty-two underwent intraoral vertical ramus osteotomy (IVRO) without rigid fixation, and MMF was released 21.5 ± 3.3 days after surgery. Data were collected from standardized cephalometric radiographs taken at the start of preoperative orthodontic treatment (T1), immediately after surgery (MMF, T2), and the completion of postoperative treatment (T3). Angular measurements were compared on each of T1, T2, and T3.

Results: There were no significant differences in the pretreatment hard and soft tissue morphology between the SSRO and IVRO. However, when fixation was released, the mandible was posteriorly positioned in the IVRO group. In the soft tissue profile, the mental region was located backward in the IVRO group at postoperative stage (T3).

Conclusions: The hypothesis is rejected. The soft tissue profile of the IVRO group especially showed a retromandibular position after postoperative treatment in comparison with the SSRO group. This tendency of the IVRO group would contribute to the database for treatment planning and prediction.

The relationship between MRI findings and the relative signal intensity of retrodiscal tissue in patients with temporomandibular joint disorders

OBJECTIVE

The purpose of this study was to evaluate the relationship between magnetic resonance imaging (MRI) findings and the relative signal intensity (RSI) of retrodiscal tissue in patients with temporomandibular joint disorders (TMDs) and to determine the usefulness of RSI as a diagnostic marker.

STUDY DESIGN

One hundred and thirty-two temporomandibular joints in 66 TMD patients were analyzed. The signal intensities of regions of interest (ROIs) in retrodiscal tissues were measured using T2-weighted MRI. The RSIs of retrodiscal tissues were referenced to the signal intensities of the ROIs of brain gray matter. The relationships between the RSI of retrodiscal tissue and condylar degenerative change (Wilcoxon rank sum test), joint effusion (Wilcoxon rank sum test), disc position (Kruskal-Wallis test), pain (Wilcoxon rank sum test), and limited mouth opening (Wilcoxon rank sum test) were determined.

RESULTS

A strong association was seen between retrodiscal-tissue RSI and disc displacement, joint effusion, condylar degenerative change, and joint pain. Limited mouth opening did not significantly correlate with retrodiscal-tissue RSI.

CONCLUSION

The retrodiscal-tissue RSI for T2-weighted MRI is a valuable noninvasive tool for monitoring the progression of TMD. Additional clinical studies are warranted.

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.

Magnetic resonance imaging characteristics of temporomandibular joint pain during opening and biting in patients with disc displacement

OBJECTIVE

The purpose of this study was to evaluate the magnetic resonance (MR) imaging characteristic of temporomandibular joint (TMJ) pain during opening and biting in patients with disk displacement.

STUDY DESIGN

MR images of 1252 TMJs in 640 patients with disk displacement were studied retrospectively. The relationship between TMJ pain and age, sex, and MR imaging findings, such as disk displacement with or without reduction, TMJ fluid, and osteoarthrosis, was analyzed using logistic regression analysis.

RESULTS

The resultant data showed a significant relationship between TMJ pain during maximum jaw opening and disk displacement without reduction (OR = 2.36). The resultant data also showed a significant relationship between TMJ pain during maximum biting and TMJ fluid (OR = 1.85).

CONCLUSION

The results suggest that TMJ pain during opening and biting is related to disk displacement without reduction and TMJ fluid on MR images.

Cross-cultural adaptation of the JPF-Questionnaire for German-speaking patients with functional temporomandibular joint disorders

OBJECTIVES

Clinical research related to the management of the syndrome of temporomandibular joint pain and dysfunction would be facilitated enormously between researchers in different locations around the world if a small number of patient-oriented questionnaires were to achieve wide acceptance. It would make comparison of therapeutic results possible. For this reason, a cross-cultural version of the Jaw Pain and Function (JPF)-Questionnaire was developed and validated for use in German-speaking patients with functional temporomandibular disorders.

MATERIAL AND METHODS

The scale was translated from the English into the German language and translated back into English again, pretested and reviewed by a committee. The German version of the JPF-Questionnaire was tested on 137 patients with temporomandibular disorders. Reliability and concurrent construct validity were assessed using Pearson's correlation coefficients.

RESULTS

The concurrent validity was assessed by evaluating the relation of the questionnaire's summary score (the internal criterion) to data on maximum interincisal distance (the external criterion). Spearman's and correlation coefficients were statistically significant for the comparison of the summary score with maximal mouth opening (r=-0.213; p=0.036). Test-retest reliability for the JPF-Questionnaire was also assessed by Spearman's correlation coefficients: at first admission at the clinic (time a, mean=20.23+/-16.42, median=16), then at the time of administration 1 day later at home (time b, mean=17.98+/-16.29, median=13), and 7 days later at home (time c, mean=17.90+/-15.77, median=13). They were r=0.91 (p=0.0001) for the initial administration with the repetition 1 day later, r=0.90 (p=0.0001) for the initial administration with the repetition 1 week later, and r=0.93 (p=0.0001) for the correlation between the two repetitions. Test - retest reliability measured by mean-against-difference graphs was not satisfactory for time (a) versus time (b) and time (a) versus time (c) but there was a good test-retest reliability for time (b) versus time (c).

CONCLUSION

The use of this instrument can be recommended in future clinical trials, as the German version of the JPF-Questionnaire seems to be valid and--under the same test-retest conditions--reliable for the assessment of temporomandibular joint disorders.

Open versus arthroscopic surgery for internal derangement of the temporomandibular joint: A retrospective study comparing two centres’ results using the Jaw Pain and Function Questionnaire

OBJECTIVES

Surgical procedures currently used for treating of internal derangement of the temporomandibular joint vary widely. Although different studies present favourable results following open or arthroscopic TMJ surgery, the criteria for a successful treatment outcome are not always defined identically. In a retrospective study, two groups of patients who underwent either open or arthroscopic surgery for internal derangement (stages III-V according to Wilkes' classification) were investigated using the so-called JPF-Questionnaire.

PATIENTS AND METHODS

The Kyoto collective (group 1) consisted of 28 patients, 2 men and 26 women, who underwent arthroscopic surgery. At the time of surgery, age ranged from 13 to 77 years (mean 32.8 y). The postoperative follow-up period ranged from 4 years and 4 months to 5 years and 9 months. Twelve of the 28 patients were classified as stage III, 10 as stage IV and 6 were classified as stage V (according to Wilkes) at the time of surgery. The Vienna collective (group 2) also consisted of 28 patients, 2 men and 26 women, who underwent open meniscoplasty or discectomy. At the time of surgery age ranged from 17 to 55 years (mean 31.6 years). The postoperative follow-up ranged from 5 to 6 years and 9 months. Fourteen of the 28 patients were classified as stage III, 11 as stage IV and 3 were classified as stage V (according to Wilkes) at the time of surgery. The results of the JPF-Questionnaire of the two groups were compared by Wilcoxon 2-sample tests. The Japanese version was applied, while in Austria the German version of this questionnaire was applied.

RESULTS

At a level of significance alpha=0.05 no significant difference was found when comparing the subgroups (Wilkes stages III, IV and V) or both groups of patients 5 years after temporomandibular joint surgery.

CONCLUSION

There cannot be any clear indication for only one of the treatment modalities as similar results were noted following open or arthroscopic temporomandibular joint surgery. Nevertheless, arthroscopic surgery is a minimally invasive procedure resulting in a shorter or no time of hospitalization when compared with open surgery and therefore is preferred by many surgeons nowadays.

Magnetic resonance imaging findings of internal derangement, osteoarthrosis, effusion, and bone marrow edema before and after performance of arthrocentesis and hydraulic distension of the temporomandibular joint

OBJECTIVES

To investigate whether temporomandibular joint (TMJ) internal derangement type III and capsulitis/synovitis are related to magnetic resonance imaging (MRI) diagnoses of internal derangement, osteoarthrosis (OA), effusion, and/or bone marrow edema (BME), and whether arthrocentesis is associated with changes in diagnoses of internal derangement, OA, effusion, and/or BME.

STUDY DESIGN

The study comprised 28 patients with a clinical unilateral TMJ disorder of internal derangement type III and capsulitis/synovitis. Bilateral MRI was immediately performed preoperatively and at a 2-month follow-up.

RESULTS

There was a significant relationship between TMJ internal derangement type III and capsulitis/synovitis and TMJ internal derangement (P = .000), effusion (P = .036), and BME (P = .002). MRI showed a significant decrease in diagnoses of TMJ BME ((P = .018).

CONCLUSIONS

MRI variables of internal derangement, effusion, and BME were related to TMJ internal derangement type III and capsulitis/synovitis; however, arthrocentesis was only associated with a significant change in diagnoses of TMJ BME.

Parameters for Diffusion Weighted Magnetic Resonance Imaging for Temporomandibular Joint

The purpose of this study was to determine optimum diffusion parameters for diffusion weighted imaging (DWI) techniques, including echo planer imaging (EPI), single-shot fast spin echo (SSFSE), and steady-state free precession (SSFP) in Magnetic Resonance Imaging (MRI) of the Temporomandibular Joint (TMJ). A polyethylene tube with distilled water was individually positioned at the external acoustic meatus foramen in each of three volunteers with normal healthy TMJs. Images were obtained using three types of DWI at differing diffusion parameters, b-factors, and diffusion moment. Signal intensity and imaging ability for various anatomical structures, including the distilled water, were evaluated from each image. The details of the anatomical structures of the TMJ were unidentifiable in the images produced with EPI and SSFSE, but were identifiable on the SSFP images. A diffusion moment value from 100 mT/m(*)msec to 150 mT/m(*)msec for SSFP, in particular, restrained the signal intensity of the water, thereby protecting the comparably high image quality of the TMJ structure. In conclusion, only SSFP is capable of allowing interpretation of emerging pathologic conditions in the TMJ region, when used with a diffusion moment set at between from approximately 100 mT/m(*)msec to 150 mT/m(*)msec.

Role of Magnetic Resonance Imaging in the Clinical Diagnosis of the Temporomandibular Joint

Temporomandibular joint (TMJ) abnormalities cannot be reliably assessed by a clinical examination. Magnetic resonance imaging (MRI) may depict joint abnormalities not seen with any other imaging method and thus is the best method to make a diagnostic assessment of the TMJ status. In patients with temporomandibular joint disorder (TMD) referred for diagnostic imaging the predominant TMJ finding is internal derangement related to disc displacement. This finding is significantly more frequent than in asymptomatic volunteers, and occurs in up to 80% of patients consecutively referred for TMJ imaging. Moreover, certain types of disc displacement seem to occur almost exclusively in TMD patients, namely complete disc displacements that do not reduce on mouth opening. Other intra-articular abnormalities may additionally be associated with the disc displacement, predominantly joint effusion (which means more fluid than seen in any asymptomatic volunteer) and mandibular condyle marrow abnormalities (which are not seen in volunteers). These conditions seem to be closely related. Nearly 15% of TMD patients consecutively referred for TMJ MRI will have joint effusion, of whom about 30% will show bone marrow abnormalities. In a surgically selected material of joints with histologically documented bone marrow abnormalities nearly 40% showed joint effusion. Disc displacement is mostly bilateral, but joint effusion seems to be unilateral or with a lesser amount of fluid in the contralateral joint. Abnormal bone marrow is also mostly unilateral. Many patients have unilateral pain or more pain on one side. In a regression analysis the self-reported in-patient TMJ pain side difference was positively dependent on TMJ effusion and condyle marrow abnormalities, but negatively dependent on cortical bone abnormalities. Of the joints with effusion only one fourth showed osteoarthritis. Thus, there seems to be a subgroup of TMD patients showing more severe intra-articular pathology than disc displacement alone, and mostly without osteoarthritis. It should, however, be emphasized that patients with TMJ effusion and/or abnormal bone marrow in the mandibular condyle seem to constitute only a minor portion (less than one fourth) of consecutive TMD patients referred for diagnostic TMJ imaging. The majority of patients have internal derangement related to disc displacement, but without accompanying joint abnormalities. In patients with rheumatoid arthritis and other arthritides TMJ involvement may mimick the more common TMDs. Using MRI it is possible, in most cases, to distinguish these patients from those without synovial proliferation.

Temporomandibular joint internal derangement: relationship between joint pain and MR grading of effusion and total protein concentration in the joint fluid

OBJECTIVES

The objective of this study was to determine whether there is any association between the protein concentration in the synovial fluid and (i) the amount of articular hydrops, as graded in magnetic resonance (MR) images, and (ii) joint pain in temporomandibular joints (TMJs) with and without displacement of the disc.

PATIENTS AND METHODS

This study involved 16 joints in 16 patients referred to our clinic with the complaint of pain and limited mouth opening. The control group consisted of 15 joints in 15 patients with unilaterally normal disc and condyle relationship and no pain while the opposite side had a non-painful joint with disc displacement without reduction (DDwoR). The subjects and controls were different individuals and only a single joint was used for each. Pain and dysfunction were evaluated by visual analogue scale. Bilateral proton density and T2 weighted images of the TMJs of the 31 subjects were analysed for fluid and condyle bony changes as well as disc position. The amount of fluid, identified as an area of high signal intensity in the region of the upper and lower joint spaces, was characterized as none, minimal, moderate or marked. Arthrocentesis was performed both for synovial fluid analysis of total protein concentration and the treatment of the joints with DDwoR. Total protein concentration was measured by using protein dye binding on spectrophotometry.

RESULTS

All patients experienced a significant (P<0.01) increase in maximal mouth opening immediately post-arthrocentesis. In the study group, the disc was displaced most frequently in an anteriormedial direction (75%) and deformation of disc form was seen in 13 joints. Condylar bony changes were seen in 27% of joints in the control group and in 81% of joints in the study group. A statistically significant association was found between joints with disc displacement, disc form and condylar bony changes (P<0.05). In the control group, only one joint, which had an osteophyte, showed joint effusion (JE) with moderate fluid. In the study group, only four joints had no fluid (25%). JE was found in 10 (63%) joints with disc displacement on anteromedial direction, in 10 (63%) joints with disc deformation and in 10 (63%) joints with osteophytes and erosion. Mean total protein concentration was 16.87+/-7.9 (range 7.4-34.1 mg dl-1) in control joints, 55.08+/-35.16 (range 21.5-153.9 mg dl-1) in study joints. There were significant differences in the mean total protein concentration between the control and study groups (P<0.01). Significant positive correlation was found between the total protein concentration and JE (r=0.65, P<0.01). No significant correlation was found between the level of pain and dysfunction and JE and total protein concentration in either control or study groups (P>0.05).

CONCLUSION

Pain in the TMJ was not related to MR findings of effusion in internal derangement and synovial fluid aspirate findings of total protein concentration. However, total protein concentration was related to the amount of JE in DDwoR joints and painful joints were more likely to demonstrate the JE.

Transitional joint effusion in the mandibular prognathic surgery patient: intraoral vertical ramus osteotomy versus sagittal split ramus osteotomy

PURPOSE

The purpose of this study was to examine the cause of joint effusion (JE) appearing postoperatively in the temporomandibular joint (TMJ) of patients with mandibular prognathism on T2-weighted magnetic resonance (MR) images.

PATIENTS AND METHODS

MR imaging was performed before and after surgery in 30 TMJs of 15 subjects with mandibular prognathism who underwent intraoral vertical ramus osteotomy (IVRO) and in 20 TMJs of 10 subjects with mandibular prognathism who underwent sagittal split ramus osteotomy (SSRO). The preoperative MR imaging was performed 1 month before surgery, and postoperative MR imaging was performed during maxillomandibular fixation.

RESULTS

Preoperatively, none of SSRO and IVRO groups had JE. Postoperatively, 12 TMJs (40%) of the IVRO group and only 1 TMJ (5%) of the SSRO group had JE. As for the TMJs in the IVRO group, on MR imaging, the degree of downward movement of the condyle after surgery was larger in TMJs with JE (3.8 +/- 2.3 mm) than in TMJs without JE (1.8 +/- 1.6 mm). JE diminished within about 4 months after removal of the maxillomandibular fixation.

CONCLUSION

JE appearing postoperatively in the TMJ of patients with mandibular prognathism might be relation to the degree of downward movement of the condyle.

Usefulness of proton density and T2-weighted vs. T1-weighted MRI in diagnoses of TMJ disk status

The aim of this study was to test the hypothesis that proton density and T2-weighted magnetic resonance (MR) images are more useful than T1-weighted MR images in the diagnoses of disk displacement, disk reduction, and disk shape. The subject group consisted of 92 patients referred for bilateral MRI imaging because of diagnosed signs of temporomandibular disorders (TMD). In the experimental group (52 patients), both T2-weighted and proton density images were made. In the control group (40 patients), only T1-weighted images were taken. The images were evaluated by two oral radiologists relative to their usefulness as a diagnostic aid and rated as either good or fair in each diagnostic category. The percentages of ratings that were good were higher (p < 0.01) for T2-weighted and proton density images than for T1-weighted images in all three types of diagnoses (Fisher's Exact test). In conclusion, T2-weighted and proton density-weighted images were found to be more useful than T1-weighted images in the diagnoses of disk status.

Predictive value of clinical findings for temporomandibular joint effusion

OBJECTIVE

The aim of this work was to evaluate the predictive value of clinical symptoms for magnetic resonance imaging (MRI) findings of temporomandibular joint (TMJ) effusion.

STUDY DESIGN

Sixty-one patients with TMJ pain were assessed by means of a standardized clinical examination and MRI. A calibrated investigator evaluated the presence of 8 clinical indicators (predictors) of TMJ effusion (outcome variable). A logistic regression analysis was performed to detect significant associations between clinical symptoms and MRI findings of TMJ effusion. The accuracy of the final logit to predict effusion was compared with that derived from univariate analysis.

RESULTS

A clinical examination based upon the assessment of pain in the TMJ with lateral palpation, with posterior palpation, during motion, and during maximum assisted opening, and the presence of click and crepitus sounds has an accuracy of 78.7% to predict TMJ effusion. Among the single clinical symptoms, the most reliable predictor of TMJ effusion is the presence of pain with lateral palpation (accuracy 76.2%; K =.525).

CONCLUSION

The use of a multiple regression approach demonstrated that an extensive clinical assessment which considers 6 main indicators consents to predict accurately the presence of MRI TMJ effusion. Based on these findings, MRI assessment should be reserved for patients in which the exact disc-condyle relationship needs to be evaluated.

Magnetic Resonance Evidence of Joint Fluid with Temporomandibular Joint Disorders

OBJECTIVES

The relationship between temporomandibular joint (TMJ) effusion and TMJ disorders is controversial. The frequency of TMJ effusion has varied as shown in previous studies. Furthermore, though some authors have suggested a correlation between TMJ effusion and pain, others question the relationship. In order to clarify the relationship, it is necessary to quantify the degree of effusion and thoroughly investigate its relationship to other factors. The purpose of this study was to analyze the amount of TMJ fluid present in joints with TMJ disorders and to see how TMJ effusion is related to TMJ status and pain.

METHODS

We studied 577 joints in 293 patients referred to us for magnetic resonance imaging. The joints were divided into painful and nonpainful categories and also classified according to Westesson's criteria for the status of the TMJ. The grading system of Larheim et al was used for categorizing the amount of fluid. Statistical methods were used for analyzing the relationship between TMJ fluid and TMJ status and pain.

RESULTS

TMJs with disk displacement without reduction showed the largest amount of fluid while TMJs with normal superior disk position showed the least fluid (Kruskal-Wallis test, P<0.001; Scheffe test, P<0.001). There was a significant difference in the amount of the fluid between painful and nonpainful joints in the group of disk displacement without reduction (Wilcoxon rank sum test, P<0.001). No significant differences were found between other groups.

CONCLUSIONS

Joint effusion is likely to appear in painful TMJs with disk displacement without reduction. Joint effusion may be an abnormal entity just suited to joints with disk displacement without reduction.

Does joint effusion on T2 magnetic resonance images reflect synovitis? Part 3. Comparison of histologic findings of arthroscopically obtained synovium in internal derangements of the temporomandibular joint

OBJECTIVES

To evaluate the relationship between the volume of joint effusion (JE), determined by T2-weighted magnetic resonance imaging (MRI), and microscopic findings of synovial inflammation in internal derangement of the temporomandibular joint (TMJ).

STUDY DESIGN

Magnetic resonance images of 53 symptomatic TMJs (53 patients) associated with painful hypomobility were taken to evaluate the degree of JE on a scale of 0 to 3. Within 2 months after MRI, biopsy specimens obtained by arthroscopy were quantitatively assessed, on the basis of Gynther's grading system, for severity of hyperplasia of synovial lining cell layers, vascularity, and the presence of inflammatory cells. Each synovitis score was compared among the 4 JE grades, as well as between 2 groups-effusion present (grades 2 and 3) and effusion absent (grades 0 and 1)-by using the Spearman correlation coefficiency and the Mann-Whitney U test.

RESULTS

The distribution of JE was as follows: 14 joints had grade 0, 9 joints had grade 1, 19 joints had grade 2, and 11 joints had grade 3. Significant relationships were found between the grades of JE and scores of synovial lining cell layers (P =.0012) as well as between the grades of JE and scores of presence of inflammatory cells (P =.0064). The joints with effusion had significantly higher scores for synovial lining cell layers (2.0 +/- 0.2) than the joints without effusion (1.3 +/- 0.2) (P =.029). There was no statistically significant correlation between the scores of vascularity and JE (P =.394).

CONCLUSIONS

The evidence of JE on MRI might correlate with synovial inflammatory activity. It confirms the common consensus that JE probably reflects synovitis, especially when synovial hyperplasia has a key role in the pathogenesis of JE.

Magnetic resonance imaging predictors of temporomandibular joint pain

BACKGROUND

The authors conducted a study to evaluate whether temporomandibular joint, or TMJ, disorder subgroups are related to magnetic resonance imaging, or MRI, diagnoses of TMJ internal derangement, or ID; osteoarthrosis, or OA; effusion; and bone marrow edema.

METHODS

The TMJ disorder group was composed of 118 subjects with TMJ pain who were assigned a clinical unilateral single diagnosis of a specific TMJ disorder. The control group consisted of 46 subjects who did not have TMJ pain. Sagittal and coronal magnetic resonance images were obtained to establish the prevalence of ID, OA, effusion and bone marrow edema. The authors used a multiple logistic regression analysis to compute the odds ratios, or OR, for MRI features for control subjects versus four groups of subjects who had TMJ pain: ID type I (n = 35), ID type III (n = 39), capsulitis/synovitis (n = 26) and degenerative joint disease, or DJD, (n = 18).

RESULTS

MRI diagnoses that did not contribute to the risk of TMJ pain included disk displacement, or DD, with reduction and effusion. Significant increases in the risk of experiencing TMJ pain occurred selectively with DD without reduction (OR = 10.2:1; P = .007) and bone marrow edema (OR = 15.6:1, P = .003) for the ID type III group and with DD without reduction (OR = 11.7:1, P = .054) for the DJD group. Subjects in the group with ID type I were less likely to be associated with an MRI finding of OA than were control subjects (OR = 1:5.6).

CONCLUSIONS

While the contribution of MRI variables to the TMJ pain subgroups was not zero, most of the variation in each TMJ pain population was not explained by MRI parameters. Thus, MRI diagnoses may not be considered the unique or dominant factor in defining TMJ disorder populations.

CLINICAL IMPLICATIONS

Therapy for subjects with TMJ based on the evaluation of concomitant morphological abnormalities, whether prophylactically or as treatment for TMJ disorders, may be unwarranted.

Magnetic resonance imaging of temporomandibular joint synovial fluid collection and disk morphology

OBJECTIVE

The purpose of this study was to determine the features of synovial fluid, the shape of the disk, and the presence of disk displacement without reduction (DDsR) of the temporomandibular joint.

STUDY DESIGN

A total of 612 bilateral temporomandibular magnetic resonance images of 306 patients were reviewed. The status of the joint was categorized as follows: normal disk position, disk displacement with reduction, acute DDsR, subacute DDsR, and chronic DDsR. The disk shape was characterized as one of following: biconcave, cap-shaped, cup-shaped, flattened, eyeglass-shaped, amorphous, or discontinuous. The amount of synovial fluid was divided into 4 categories: not observed, small, moderate, or large.

RESULTS

Synovial fluid collection was observed more frequently with subacute DDsR and when the disk was a folded shape.

CONCLUSION

Synovial fluid collection, which was observed on T2-weighted magnetic resonance images, is more frequent in the early stage of DDsR. In addition, high signal intensity within the disk space should be considered a simple matter of fluid collection.

Risk factors for temporomandibular joint pain in patients with disc displacement without reduction - a magnetic resonance imaging study

The purpose of this study was to evaluate whether the magnetic resonance (MR) imaging variables of temporomandibular joint (TMJ) internal derangement, osteoarthrosis and/or effusion may predict the presence of pain in patients with a clinical disorder of an internal derangement type (ID)-III. The relationship between TMJ ID-III pain and TMJ internal derangement, osteoarthrosis and effusion was analysed in MR images of 84 TMJs in 42 patients with a clinical unilateral diagnosis of TMJ ID-III pain. Criteria for including a TMJ ID-III pain patient were report of orofacial pain referred to the TMJ, with the presence of unilateral TMJ pain during palpation, function and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ internal derangement, osteoarthrosis and effusion. Using chi-square analysis for pair-wise comparison, the data showed a significant relationship between the MR imaging findings of TMJ ID-III pain and those of internal derangement (P=0.01) and effusion (P=0.00). Of the MR imaging variables considered simultaneously in the multiple logistic regression analysis, osteoarthrosis (P=0.82) and effusion (P=0.08) dropped out as non-significant in the diagnostic TMJ pain group when compared with the TMJ non-pain group. The odds ratio that a TMJ with an internal derangement type of disk displacement without reduction might belong to the pain group was strong (2.7:1) and highly significant (P=0.00). Significant increases in risk of TMJ pain occurred with 'disk displacement without reduction in combination with osteoarthrosis' (5.2:1) (P=0.00) and/or 'disk displacement without reduction in combination with osteoarthrosis and effusion' (6.6:1) (P=0.00). The results suggest that TMJ pain is related to internal derangement, osteoarthrosis and effusion. However, the data re-emphasize the aspect that these MR imaging variables may not be regarded as the unique and dominant factors in defining TMJ pain instances.

Expression of interleukin 6 in synovial tissues in patients with internal derangement of the temporomandibular joint

Using an immunohistochemical technique, we examined synovial tissue from 46 temporomandibular joints (TMJ) with internal derangement in 44 patients. As controls, we examined synovial tissue specimens from 7 joints with habitual dislocation without pain. In synovial tissues from 21 of the 46 joints with internal derangement, interleukin 6 (IL-6) was expressed in the synovial lining cells and in the mononuclear cells infiltrating the periphery of the blood vessels. The density of IL-6-stained cells in specimens with internal derangement correlated significantly with the grade of joint effusion shown by magnetic resonance imaging (P=0.01, r=0.32).

Relative odds of temporomandibular joint pain as a function of magnetic resonance imaging findings of internal derangement, osteoarthrosis, effusion, and bone marrow edema

OBJECTIVE

The purpose of this study was to evaluate whether common magnetic resonance (MR) imaging variables such as temporomandibular joint (TMJ) internal derangement, osteoarthrosis, effusion, and bone marrow edema are predictive of the presence of TMJ pain.

STUDY DESIGN

The relationship between TMJ pain and TMJ internal derangement, osteoarthrosis, effusion, and bone marrow edema was analyzed in MR images of 338 TMJs in 169 patients with a clinical diagnosis of TMJ pain and dysfunction. Criteria for including a patient with TMJ pain were a report of orofacial pain referred to the TMJ, with the presence of unilateral or bilateral TMJ pain during palpation, function, or unassisted or assisted mandibular opening. The criteria for including a patient with no pain were the absence of TMJ pain during palpation, function, and unassisted or assisted mandibular opening. Application of the criteria resulted in a study group of 129 patients with unilateral TMJ pain, 18 with bilateral TMJ pain, and 22 without TMJ pain. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ internal derangement, osteoarthrosis, effusion, and bone marrow edema. Logistic regression analysis was used to compute the odds ratios for internal derangement, osteoarthrosis, effusion, and bone marrow edema for nonpainful TMJs (n = 173) versus painful TMJs (n = 165).

RESULTS

For pairwise comparison, the chi(2) test was used; the resultant data showed a significant relationship between the clinical findings of TMJ pain and the MR imaging diagnoses of internal derangement (P =.000), osteoarthrosis (P =.015), effusion (P =.002), and bone marrow edema (P =.016). Of the MR imaging variables considered simultaneously in multiple logistic regression analysis, osteoarthrosis (P =.405), effusion (P =.131), and bone marrow edema (P =.231) dropped out as nonsignificant in the diagnostic TMJ pain group in comparison with the TMJ no-pain group. Significant increases in risk of TMJ pain occurred with disk displacement without reduction in combination with osteoarthrosis and bone marrow edema (3.7:1 odds ratio; P =.000) and with disk displacement without reduction in combination with osteoarthrosis and effusion (2.8:1 odds ratio; P =.000).

CONCLUSIONS

The results suggest that TMJ pain is related to internal derangement, osteoarthrosis, effusion, and bone marrow edema. However, the data reemphasize that these MR imaging variables may not be regarded as the unique and dominant factors in defining TMJ pain occurrence.

Relation between the expression of vascular endothelial growth factor in synovial tissues and the extent of joint effusion seen on magnetic resonance imaging in patients with internal derangement of the temporomandibular joint

The aim of this study is to elucidate the relation between the expression of vascular endothelial growth factor (VEGF) in synovial tissues and the extent of joint effusion seen on magnetic resonance imaging (MRI) in patients with internal derangement of the temporomandibular joint (TMJ). Using an immunohistochemical technique, we examined specimens of synovial tissues from 41 joints in 40 patients with internal derangement. Specimens from 36 of the 41 joints stained for VEGF. There was a significant correlation between the percentage of the VEGF-stained cells and the grade of joint effusion seen on MRI (P=0.0002, r=0.62). The correlation between the two was also significant on multiple logistic regression analysis (P=0.003, odds ratio=1.75). These results suggest that VEGF may have an important role in the genesis of joint effusion.

Magnetic resonance imaging findings of osteoarthrosis and effusion in patients with unilateral temporomandibular joint pain

The purpose of this study was to investigate the relationship between the presence of temporomandibular joint (TMJ) pain and the magnetic resonance (MR) imaging findings of osteoarthrosis (OA), and effusion. The study comprised 112 consecutive TMJ pain patients. Criteria for including a patient were report of unilateral pain near the TMJ, with the presence of unilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ OA, and/or effusion. Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ OA (P=0.000), and TMJ effusion (P=0.000). Further, there was a significant relationship between the MR imaging diagnosis of TMJ OA and TMJ effusion (P=0.000). Use of the Kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of TMJ OA (K=0.22), TMJ effusion (K=0.29), and TMJ 'OA and effusion' (K=0.30). The study's findings suggest that while clinical pain is correlated to TMJ-related MR imaging findings, clinical pain in and of itself, is not reliable for predicting the presence of TMJ OA and/or effusion. Validation of MR imaging diagnoses would involve the investigation of cross-sectional and longitudinal evidence to assess decisive differences in terms of prognosis and/or treatment outcome.

Does joint effusion on T2 magnetic resonance images reflect synovitis? Part 2. Comparison of concentration levels of proinflammatory cytokines and total protein in synovial fluid of the temporomandibular joint with internal derangements and osteoarthrosis

OBJECTIVE

We sought to clarify the nature of joint effusion (JE) on T2-weighted magnetic resonance images of the temporomandibular joint (TMJ) by analysis of the synovial fluid in the superior compartment of patients with internal derangement and osteoarthrosis.

STUDY DESIGN

One hundred symptomatic TMJs (100 patients) with 65 internal derangements and 35 osteoarthroses were scanned by means of magnetic resonance imaging, and, the synovial fluid was sampled on the same day. The amount of JE was evaluated on a scale of 0 to 3. Grades 0 and 1 indicated absence of JE or a negligible amount of JE, respectively, and grades 2 and 3 indicated the presence of JE. Correlation was evaluated among the amount of JE and the concentrations of the total protein and interleukin-1beta(IL-1beta), IL-6, IL-8, and tumor necrosis factor-alpha in the synovial fluid.

RESULTS

Magnetic resonance imaging revealed the absence of JE in 40 joints (grade 0, 17 joints; grade 1, 23 joints) and the presence of JE in 60 joints (grade 2, 31 joints; grade 3, 29 joints). The joints with JE had, on average, significantly higher concentrations of total protein (1,675 microg vs 714 microg; P = .0001) and IL-6 (42.9 pg vs 10.6 pg; P = .009) than did the joints without JE. Furthermore, there were significant correlations between the JE grade and the concentrations of the total protein (P = .0001), IL-6 (P = .001), and IL-8 (P = .004). The detection ratio of cytokines among the presence-absence groups of JE showed a significant difference in tumor necrosis factor-alpha (68.3% vs 47.5%; P = .037) and IL-6 (86.7% vs 67.5%; P = .012). Conclusions. JE may contain the released products when there is pronounced synovitis. It is probably composed of high concentrations of total protein with inflammatory cytokines. Furthermore, IL-6 and IL-8 seem to have an important role in the pathogenesis of JE in TMJ disorders.

Importance of the changes in joint effusion shown by magnetic resonance imaging before and after arthroscopic lysis and lavage of the temporomandibular joint

We investigated the changes in the amount of joint effusion estimated from T2-weighted magnetic resonance imaging (MRI) before and after arthroscopic lysis and lavage of the temporomandibular joint (TMJ). We studied 29 consecutive patients, each with internal derangement and osteoarthritis in one TMJ. Before operation, the MRI showed joint effusions in 22 of the patients (76%). After operation, the amount of the effusion decreased in 16 and increased in 2 patients. Effusions developed postoperatively in four of the seven patients who had no effusion before operation. In four of the six patients in whom the effusion increased, the symptoms had almost resolved by the time the MRI was taken. There was no significant correlation between changes in the amount of joint effusion and the clinical condition of the patients before and after the operation. In conclusion, changes in the amount of joint effusion in the TMJ are not related to the patient's clinical condition.

Magnetic resonance imaging findings of internal derangement and effusion in patients with unilateral temporomandibular joint pain

OBJECTIVES

The purpose of this study was to investigate the relationship between the presence of temporomandibular joint (TMJ) pain and the magnetic resonance (MR) imaging findings of internal derangement (ID) and effusion.

STUDY DESIGN

The study was comprised of 41 consecutive patients with TMJ pain. Criteria for including a patient were report of unilateral pain near the TMJ, with the presence of unilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening, and the absence of a specific clinical TMJ-related diagnosis of disk displacement with or without reduction. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ ID or effusion, or both.

RESULTS

Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ ID (P =.001), and TMJ effusion (P =.004). Furthermore, there was a significant relationship between the MR imaging diagnosis of TMJ ID and TMJ effusion (P =.000). Use of the kappa statistic test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of TMJ ID (kappa = 0.34), TMJ effusion (kappa = 0.32), and TMJ ID and effusion (kappa = 0.27).

CONCLUSIONS

The study's findings suggest that although clinical pain is correlated with TMJ-related MR imaging findings, clinical pain in and of itself is not reliable for predicting the presence of TMJ ID or effusion, or both. Therefore, MR imaging appears to be a warranted and necessary supplement to the clinical findings.

Pressure-pain thresholds and MRI effusions in TMJ arthralgia

It has been suggested that MRI-depicted effusions identify patients with TMJ arthralgia. The Research Diagnostic Criteria (RDC) propose a pressure-pain threshold (PPT) of 1 pound for the identification of TMJ arthralgia. The hypotheses in this study were that: (1) there is no association between MRI-depicted effusions and TMJ arthralgia, and (2) a PPT of 1 pound does not discriminate between subjects with and those without arthralgia. Thirty females with TMJ disc displacement with reduction were divided into two groups based on the presence or absence of the self-report of TMJ pain. Bilateral TMJ PPTs and MRIs were obtained. Increasing palpation pressure from 1 to 3 pounds increased the sensitivity for identifying arthralgia from 22% to 100%, with a corresponding decrease in the specificity from 100% to 81%. The sensitivity and specificity of effusions for identifying arthralgia were 85% and 28%, respectively. These results suggest that the use of palpation pressures greater than 1 pound is a valid test for TMJ arthralgia. However, TMJ effusions lack adequate specificity for identifying TMJ arthralgia and were not associated with pain.

Does joint effusion on T2 magnetic resonance images reflect synovitis? Comparison of arthroscopic findings in internal derangements of the temporomandibular joint

OBJECTIVE

The purpose of this study was to clarify the characteristics of joint effusion (JE) in the temporomandibular joint by comparing T2-weighted magnetic resonance (MR) images with arthroscopic findings.

STUDY DESIGN

MR images of 47 symptomatic temporomandibular joints (47 patients) with internal derangement associated with painful hypomobility were taken to evaluate the degree of JE on a scale of 0 to 3. Within 2 months after MR images, arthroscopic findings with respect to the severity of synovitis, adhesion, and degenerative change in the superior compartment were each quantitatively assessed on a scale of 0 to 10. The arthroscopic scores were compared among the 4 JE grades, as well as between 2 groups, effusion-present (grades 2 and 3) and effusion-absent (grades 0 and 1), by using the Spearman correlation coefficient and the Mann-Whitney U test.

RESULTS

The distribution of JE was as follows: 10 joints had grade 0, 5 joints had grade 1, 19 joints had grade 2, and 13 joints had grade 3. The synovitis score had a significant relationship to the degree of effusion (P =.0012) and was higher in the effusion-present group (6.4 +/- 2.0) than in the effusion-absent group (4.2 +/- 1.6) (P =.0005) On the other hand, there was no statistically significant correlation between either adhesion or degenerative change and effusion.

CONCLUSIONS

JE may reflect synovitis; however, the nature of JE itself needs to be further elucidated by additional studies.