Degenerative disease in the temporomandibular, metatarsophalangeal and sternoclavicular joints. An autopsy study

Medial clavicular osteophyte: a novel cause of paget-schroetter syndrome

Paget-Schroetter syndrome is a form of upper limb deep venous thrombosis usually seen in younger patients in association with repetitive activities of the affected limb. When occurring in more elderly patients or in those where it is difficult to appreciate a causative mechanism, other aetiologies should be considered. We present a case in which degenerative osteoarthritis of the sternoclavicular joint with osteophyte development impinged on the subclavian vein, leading to extensive upper limb thrombosis. The difficulties in identifying and managing this unusual cause of Paget-Schroetter are presented and discussed.

Macroscopic and microscopic features of the mandibular condyle in autopsied elderly individuals

Many studies have attempted to classify the macroscopic shapes of the mandibular condyle in humans; however, no consensus has yet been reached because the shapes vary. One problem is that classification of macroscopic morphological changes of the condylar surface has been largely based on bones from ancient people, with few bones from modern people covering many different age groups. In this study, 144 condyles from 78 cadavers (40 men, 38 women; age at death: >70 years) were investigated. The macroscopic shapes of the condyles were classified from posterior and lateral views into four types: convex, flattened, angled, and irregular. Of the 144 condyles, 25 were investigated microscopically. On macroscopic examination, in both posterior and lateral views, convex-type condyles were most frequently observed. Most posterior convex-type condyles were also categorized as the lateral convex type. On histological examination, we observed an increase in cartilage cells (7 condyles, 28%), a decrease in cartilage cells (3 condyles, 12%). Increases in cartilage cells were seen only in angled and irregular types (P = 0.001), whereas decreases in cartilage cells were only observed in the flattened type (P = 0.01). A convex macroscopic form appears to be standard for human mandibular condyles, even in the elderly. The histological findings suggest that mandibular condyles tend to not only undergo flattening, but also undergo progressive changes toward protrusion with age due to increased numbers of cartilage cells. In other words, this study suggests that there is potential for progressive alterations in mandibular condyles in the elderly.

Synovial apoptosis in temporomandibular joint disc displacement without reduction

OBJECTIVE

Our hypothesis is that increased apoptosis in synovium might contribute to temporomandibular joint (TMJ) degeneration. To investigate this, we measured soluble Fas (sFas) and nuclear matrix protein (NMP) levels in TMJ synovial fluid from patients with disc displacement without reduction as indicators of apoptosis in the synovium.

PATIENTS AND METHODS

Synovial fluid was obtained from 17 joints in 17 patients (11 female, 6 male; mean age, 31.5 +/- 11.9 years; range, 19 to 55). Patients were referred to our clinic because of limited mouth opening, joint sounds, or TMJ pain. Synovial fluid obtained by arthrocentesis for therapeutic reasons was analyzed by enzyme-linked immunosorbent assays for APO-1/Fas and cell death detection (NMP).

RESULTS

We studied 12 left (71%) and 5 right (29%) joints with disc displacement without reduction. The chief complaint was pain on the affected side and limited mouth opening. Only 2 patients had a click in the affected joint, whereas 14 reported pain and 17 had the limited mouth opening. All patients experienced a significant (P < .01) increase in maximal mouth opening immediately after arthrocentesis. Mean sFas and NMP levels were 484.9 +/- 466.7 pg/mL (range, 17 to 1501) and 29.2 +/- 13.7 U/mL (range, 8 to 52.8) respectively.

CONCLUSION

Considering reports that increased sFas blocks apoptosis by inhibiting binding of FasL to Fas on the cell membrane, low level of sFas in our patients' synovial fluid (compared with amounts reported in joint inflammation or degeneration) suggests vulnerability to apoptosis in patients with internal derangement.

Changes in urinary bone resorption markers (pyridinoline, deoxypyridinoline) resulting from experimentally-induced osteoarthritis in the temporomandibular joint of rats

The purpose of this study was to quantify the urinary bone resorption markers, pyridinoline (Pyr) and deoxypyridinoline (Dpyr), excreted from experimentally-induced osteoarthritis (OA) in the temporomandibular joint (TMJ) of rats. Osteoarthritic lesions were induced by intra-articular injection of collagenase into the right TMJs of 16-week-old male rats. The whole day's urine was collected from each animal one day before the injection and 5, 7, 11 and 14 days after the injection. Urine samples were analyzed by high-perfomance liquid chromatography and fluorescence spectroscopy. Histological changes in condyle were examined by using paraffin sections with toluidine blue staining. Degenerative changes were observed in the articular cartilage of the experimental group on day 7 and day 14 after the injection of collagenase. The concentration of Pyr was remarkably high in the experimental group, and consequently the Pyr to Dpyr ratio was significantly higher (p<0.05) in the experimental group than in the control group from 7-14 days after the injection. These findings suggest that a urinary Pyr/Dpyr ratio would be available for the detection of degenerative changes in condyle relevant to temporomandibular joint osteoarthritis (TMJ OA).

Factors affecting degeneration in human temporomandibular joints as assessed histologically

The influence of sex, age, tooth loss, and articular disc position on temporomandibular joint (TMJ) degeneration was evaluated in specimens collected at autopsy from 15 women and 38 men ranging in age from 15 to 92 yr. The position of the articular discs was classified as normal or abnormal, tooth loss was both counted and categorized. Degenerative changes of the articular tissues were assessed histologically and quantified, taking into account both the severity of structural alterations and their extension along the articular surface. This was recorded separately in the condyle, disc, and temporal component, three latero-medial joint regions, and putative load-bearing and non-load-bearing surfaces. Analysis of covariance with repeated measures served for testing contributing factors. It showed that the effects of sex and the number of missing teeth were insignificant, whereas age up to about 55-60 yr and reduction of dental arch length proved to be the most important factors. Load-bearing seemed to play a significant role mainly at younger ages, and the effect of disc position was significant, when internal derangement was combined with reduction of dental arch length. Thus, rising severity of TMJ degenerative changes appears to be associated primarily with increasing age. In addition, it may also depend on mechanical factors, in particular loss of molar support and, to a minor degree, abnormal disc position.

Pathogenesis of degenerative joint disease in the human temporomandibular joint

The wide range of disease prevalences reported in epidemiological studies of temporomandibular degenerative joint disease reflects the fact that diagnoses are frequently guided by the presence or absence of non-specific signs and symptoms. Treatment is aimed at alleviating the disease symptoms rather than being guided by an understanding of the underlying disease processes. Much of our current understanding of disease processes in the temporomandibular joint is based on the study of other articular joints. Although it is likely that the molecular basis of pathogenesis is similar to that of other joints, additional study of the temporomandibular joint is required due to its unique structure and function. This review summarizes the unique structural and molecular features of the temporomandibular joint and the epidemiology of degenerative temporomandibular joint disease. As is discussed in this review, recent research has provided a better understanding of the molecular basis of degenerative joint disease processes, including insights into: the regulation of cytokine expression and activation, arachidonic acid metabolism, neural contributions to inflammation, mechanisms of extracellular matrix degradation, modulation of cell adhesion in inflammatory states, and the roles of free radicals and heat shock proteins in degenerative joint disease. Finally, the multiple cellular and molecular mechanisms involved in disease initiation and progression, along with factors that may modify the adaptive capacity of the joint, are presented as the basis for the rational design of new and more effective therapy.

Radiographic signs in the TMJ and finger joints in elderly people

Radiographic signs in the temporomandibular joints (TMJs) and finger joints were investigated in a series of 139 residents of elderly people's homes using panoramic tomographs and dorso-volar radiographs. Radiographic signs in TMJs were found in 14% of the subjects, whereas all subjects had signs in at least one finger joint. The TMJs of men and women were equally affected, whereas signs in finger joints were more severe in women. No correlation was found between radiographic signs in TMJs and finger joints, suggesting that most signs in TMJs are probably due to local factors.

Degenerative joint disease. Part I: Diagnosis and management considerations

Degenerative joint disease, primarily in the form of osteoarthrosis, affects the temporomandibular joints (TMJs) with symptoms similar to those found in other body joints. These symptoms include stiffness, pain, restriction of movement, inflammation, crepitus and radiographic changes. Symptoms can occur in both males and females at any age, starting with pre-adolescent, but most often occur in females age 30 and over. Most symptoms will last nine to 18 months (followed by remission) and are managed using anti-inflammatory medications, physical therapy, occlusal splints and dietary changes. Major areas for consideration in this article include epidemiology, signs and symptoms, radiography, etiopathology and symptom management.

Temporomandibular joint osteoarthrosis: clinical and radiographic characteristics 30 years after nonsurgical treatment: a preliminary report

Thirty years after being treated nonsurgically for osteoarthrosis and internal derangement, 14 women and seven men were re-examined clinically and radiographically. The results of this examination were compared with those recorded before and after treatment 30 years ago, and with those of a matched control group. The number and degree of subjective and objective signs and symptoms decreased, and was comparable to that of the controls. However, the patients reported significantly more pain and difficulty on opening the mouth wide. This was reflected in the radiographically assessed joint mobility, which increased significantly over the years, but was still significantly less than that of the controls. The occurrence and extent of radiographically visible osteoarthrotic alterations increased over the years, and differed significantly from those of the controls. Therefore, the authors conclude that few symptoms and clinical signs of osteoarthrosis are found many years after treatment, although radiographic alterations may be extensive.

Radiographic signs in the temporomandibular and hand joints in patients with psoriatic arthritis

The temporomandibular (TMJ) and hand joints of 64 patients with psoriatic arthritis (PA) were examined radiographically with panoramic tomography and dorsovolar projection. The associations between radiographic signs in the condyle of the TMJ and finger joints were analyzed with Pearson's product-moment correlation coefficient. Twenty-six patients (41%) had radiographic signs in their TMJs. Arthritic signs were seen in 14 (22%) and degenerative signs in 12 (19%) patients. Fifty-five patients (86%) had radiographic signs in their hands; 33 patients (52%) had arthritic and 22 (34%) degenerative signs. In the TMJ statistically significant correlations were found among erosion, flattening, and cortical sclerosis and also between osteophyte and cortical sclerosis. In the finger joints erosion correlated significantly with dislocation and loss of space. Erosion in the condyle of the TMJ was the only sign that correlated with changes in the finger joints such as erosion, dislocation, and ankylosis. Erosion in the TMJ also correlated with erosion in the metacarpophalangeal joint and wrist.

Reflected light microscopy of the human mandibular condyle--a study of a post-mortem material

The surface characteristics of the articulating surfaces of 11 human mandibular condyles removed post-mortem were determined by the use of reflected light dark-field microscopy. Good agreement was obtained between macroscopical grading of degenerative change and appearance as observed by microscopy. Microscopical appearances believed to correspond to normal surface, fibrillation and degenerative changes are described.

Prenatal developmental process of human temporomandibular joint

The prenatal development of 20 human TMJs from the fourteenth gestational week to full term was studied and the following observations were made. Radiologic findings: at the sixteenth gestational week, the outline of the TMJ as radioopaque structures appeared. Curvature of the articular eminence of the temporal components was observed at gestational week 33, and convexity of the condylar head of the condylar process was observed at the thirty-first week. Histologic findings: at the fifteenth gestational week, thin intramembranous ossification of the temporal components and endochondral ossification of the condylar process were observed, and secondary cartilage occupied the whole condylar process. The articular disk was distinguishable and was composed of fine collagen fibers. At the seventeenth gestational week, endochondral ossification of the condylar process appeared, the formation of joint cavities was fairly completed, and synovial tissues were easily observed. From gestational week 17 through 21, endochondral ossification of the condylar process developed rapidly and the layer structures, which consisted of a fibrous covering layer, transitional cell layer, hypertrophic layer, and erosive layer, were observed. At the twenty-first gestational week, Meckel's cartilage disappeared and hematopoietic foci appeared in the temporal components and the condylar process. Week 21 seemed to be the greatest turning point of the prenatal development of the human TMJ. Secondary cartilage of the condylar process diminished gradually throughout fetal life, but was vestigial at full term.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteoarthritis and internal derangement of the temporomandibular joint: a light microscopic study

To describe osteoarthritic changes of the temporomandibular joint (TMJ) and their relation to internal derangements, 22 randomly selected TMJ autopsy specimens were dissected and studied by light microscopy. Normal disc position was seen in eight joints, partial anterior displacement of the discs in eight joints, and complete anterior displacement of the discs in five joints; one joint had a perforated disc. Degenerative changes, such as horizontal splitting, clustering of chondrocytes, bone marrow fibrosis, sclerosis, erosion, cyst formation, and reduction in TMJ size, were found in 11 of the 14 joints with displacement or perforation of the disc and in four of the eight joints with normal disc position. Internal derangement appeared to be associated with osteoarthritis. The relations between remodeling, aging, internal derangement, and osteoarthritis are discussed.

The effects of immobilization on the rabbit temporomandibular joint

While the effects of immobilization of joints covered with hyaline cartilage have been widely studied, the effects on the fibrous tissue-covered temporomandibular joint have not been studied as extensively. This study was designed to determine the short-term effects of immobilization on the rabbit temporomandibular joint. Nineteen rabbits were placed in maxillomandibular fixation. The temporomandibular joints were studied histologically after periods of from ten to 28 days. Significant thinning was observed as early as after ten days, as was degeneration of the cartilage. Degeneration became progressively more severe as the duration of the immobilization increased. Reparative events began appearing after 28 days. These findings suggest that although initially immobilization produces destructive changes, the changes may well be reversible.

Bilateral degenerative changes and deviation in form of temporomandibular joints. An autopsy study of elderly individuals

The right and left temporomandibular joints were removed as blocks from the skulls of 22 individuals in the 60-89-year-old age group at autopsy. The skulls were examined to determine the number and position of teeth and dentures. The articular surfaces of the joints were examined macroscopically for topographical distribution and degree of degenerative changes and topographical distribution of deviation in form. Indices of degenerative changes and of deviation in form were proposed. Correlations were found between the right and left joints with respect to both indices for degenerative changes and deviation in form. The indices were also correlated with each other within the same joint. A sex difference was found for degenerative changes and deviation in form, with the most advanced changes in the joints of women. It was concluded that degenerative changes and deviation in form in this age group were correlated between right and left joints and within the same joint.

Dental attrition and degenerative arthritis of the temporomandibular joint

The extent and rate of occlusal attrition in relation to degenerative arthritis of the temporomandibular joint were studied in 101 skulls representing early Aboriginal man in Australia. Joint degenerations affected 40% of the specimens and were associated with both the rate and extent of tooth attrition. Age, unaccompanied by tooth wear, was not significant in the progress of the disease. Degenerations affected the temporal joint surface more frequently than the condyle, particularly in the lateral and central regions of the articular eminence. Patterns of degenerative joint disease in the Aboriginals illustrated a break-down in the physiological adaptability of the masticatory system resulting from increased occlusal stress consequent upon progressive tooth wear. Under these conditions, the teeth and the temporomandibular joints enter a 'wear-out' phase of occlusal function which usually commences in early adult life and becomes more severe as the conditions continue.

Experimental analysis of temporomandibular joint reaction force in macaques

Mandibular bone strain in the region immediately below the temporomandibular ligament was analyzed in adult and sub-adult Macaca fascicularis and Macaca mulatta. Following recovery from the general anesthetic, the monkeys were presented food objects, a wooden rod, or a specially designed bite-force transducer. Bone strain was recorded during incisal biting and mastication of food, and also during isometric biting of the rod and/or the transducer. The bone strain data suggest the following: The macaque TMJ is loaded by a compressive reaction force during the power stroke of mastication and incision of food, and during isometric molar and incisor biting. TMJ reaction forces are larger on the contralateral side during both mastication and isometric molar biting. Patterns of ipsilateral TMJ reaction force in macaques during isometric biting vary markedly in response to the position of the bite point. During biting along the premolars or first two molars a compressive reaction force acts about the ipsilateral TMJ; however, when the bite point is positioned along the M3, the ipsilateral TMJ has either very little compressive stress, no stress, or it is loaded in tension.

Clinical findings in temporomandibular joint osteoarthrosis

The clinical findings in 20 patients with TMJ-crepitation (E1-group) and 19 patients with TMJ palpatory tenderness (E2-group) have been compared with the findings in 29 other patients with mandibular dysfunction (R-group). The patients underwent a clinical examination of the masticatory system and of the second distal interphalangeal joints (DIP II joints). No statistically significant differences could be found between groups with respect to clinical signs, occlusal interferences, or dental attrition. Loss of molar support was found to be significantly more frequent in the E1-group than in the R-group. The frequency of tenderness to palpation or pain on movement of DIP II joints was significantly higher in the E2-group than in the R-group. Periarticular bony swelling of DIP II joints was significantly correlated with TMJ-crepitation. The patients with TMJ-crepitation were considered to have TMJ-osteoarthrosis. The results of the present study indicate that patients with TMJ-OZ have a similar clinical picture to other patients with mandibular dysfunction and that molar loss plays a role in the etiology of TMJ-OA.