- Email: [email protected]
Temporomandibular joint axiography and MRI findings: A comparative study
Temporomandibular comparative study
joint
K. Parlett, DDS,a D. Paesani, DDS,b M. A. Hatala, DDSb Eastman Dental Center, Rochester, N. Y.
axiography R. H. Tallents,
DDS,C
and MRI
findings:
A
and
Axiography may be useful in the evaluation of condyle motion and the effects of internal derangements on this motion. Fifty-one patients were selected by one investigator (RHT) to provide a representative sample of asymptomatic and symptomatic subjects for the following categories: (1) normal disk position, (2) disk displacement with reduction, (3) disk displacement without reduction and (4) disk displacement without reduction associated with degenerative joint disease. Axiography was performed by a separate investigator (KGP) in a blinded fashion. The diagnosis of the presence of internal derangement was based on the tracings only. All subjects had bilateral magnetic resonance imaging scans to evaluate for the presence or absence of internal derangement. The diagnostic sensitivity was 0.64, which indicated that axiography is marginal at identifying disease when present. The negative predictive value was 0.78, which indicated that axiography is accurate in the detection of normal disk condyle relationship. (J PROSTHET DENT 1993;70:521-31.)
I
nterest in the etiology, diagnosis, and treatment of the temporomandibular dysfunction (TMD) has increased in the past two decades. Diagnosis poses a particularly difficult problem because there is no consistent agreement on the definition of a TMD problem. Internal derangements have been evaluated with imaging techniques such as magnetic resonance imaging (MRI), computed tomography (CT), and arthrography. These diagnostic modalities pose a problem in clinical availability and health care economics. There is no infallible diagnostic method for the detection and diagnosis of the pathologic conditions associated with internal derangements of the temporomandibular joint (TMJ). It has been reported that MRI has an accuracy for disk position of 85 % , disk shape of 77 % , and bony abnormalities of 100% .l More recently Tasaki and Westesson2 demonstrated an accuracy of 95 % when the coronal and sagittal images were combined to evaluate disk position. Arthrography permits a more dynamic evaluation of the disk/condyle assembly compared with the static evaluation by MRI or CT and has a diagnostic accuracy of 83 % when combined with videofluroscopy.3 MRI and arthrography have been used to evaluate aPrivate Practice, Bracebridge, Ontario, Canada. bTemporomandibular Joint Resident, Department of Orthodontics. “Senior Clinical Associate, Department of Prosthodontics; and Clinical Associate, Department of Orthodontics. Copyright @ 1993 by The Editorial Council of THE JOURNAL OF PROSTHETIC DENTISTRY. 0022-3913/93/$1.00 +.10.
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asymptomatic volunteers, and anterior disk position has been found in 15 % to 32 % of joints studied.4-6 Westesson et a1.6 described internal derangement as a localized mechanical fault that interferes with the smooth action of the joint. He also suggested that a displaced disk not causing a functional disturbance might be described as a variation of normal. Axiographic recordings may prove to be a reliable diagnostic aid for detection of the presence or absence of intracapsular abnormalities. Previous studies using axiography have described joint pathology, but lacked suitable controls. A systematic comparison between imaging and axiographic findings is necessary.
REVIEW
OF THE
LITERATURE
McCollum7 used the pantograph to study the paths of condylar movement. Protrusive and lateral movements were graphically represented as horizontal projections. A condylographic study of 50 patients whose temporomandibular joints were considered normal on the basis of clinical examination revealed that (1) condylar movements vary widely in direction and size; (2) the angle of the eminence varies from 15 to 66 degrees (average 35 degrees), and (3) right and left eminences rarely have the same slanL8 Shields et a1.g studied 46 patients with clinical diagnoses of TMD and found that pantographic tracings corroborated the diagnoses. He suggested that a diagnosis of TMD may require the use of several diagnostic modalities, such as subjective response, clinical examination, imaging, and
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Fig. 1. Geometric Table
1.
Age and sex distribution GIWUP classification
Asym~plomatic volunteers, normal pit:7 h
.~s~mptomatic volunteers, abnormal jointti Symptomatir pat.ients
of the studied
representation
movement.
individuals
Number subjects
of
24
(48 joints) 6 (12 joints) "1
(40 joints)
graphic projections of condylar movement. Farrar”’ and Farrar and McCarty” correlated specific condylar path characteristics with types of internal derangements of the TMJ. Van Willingen’? compared the condylar movements 01’ live patients with clinically normal joints and five patients wit,h unilateral or bilateral clicking joints. The group with clicking joints showed perceivable deviations from the movement pat,tern found in the clinically normal group. Lundeen’,’ recorded an average condylar path of 45 degrees in I63 subjects, with the majority (80%) in the range of 30 i-o 60 degrees. Mongini I4 demonstrated a significant relationship between the shape of the TMJ (condyle and articular fossaj and the axiographic tracings of mandibular movement,s in 30 patients with TMD. Simonet and Clayton’” compared subjects with clinical signs of TMD with subjects in a control group and found more Bennett movement in the TMD group. Mongini and Capurso’” studied 12 men and 38 women (l;? to 60 years of age) with signs of TMJ pain and concluded that internal derangements with condyle disk incoordination can lead to deviations in pantographic rracings. Hates et al.‘; described a method of determining the condyle position necessary to keep the disk in place during splint fabrication. He suggested the use of a simplified axis recorder to obtain diagnostic information and compare tracings before and after treatment. Mauderli and Lundeen’s reported that simplified condylar movement
:; 9 L’
of condylar
ET AL
SEX
Mean
age
10 Females 14 Males 5 Females 1 Male 20 Females 1 Male
(years)
Age
range
(years)
30
24
33
24
to 41 to 49 to 36
27
20
25 31 14
10 to 46
recorders could analyze TMJ derangements. Later, Mauderli et al.lg described several irregular patterns that correlate with intracapsular derangements. The patterns were not corroborated with MRI or arthrograms and a specific diagnosis could not be made. Slavicek20-2” has suggested that computer-aided axiography may be useful in the early detection of subclinical diskopathies. He also related tracing shape with condylar movements in several diagnostic conditions; however, these studies did not have adequate controls. Alsawaff et a1.“4 used computerized axiography to compare clicking joints with nonclicking control joints and demonstrated that condylar path inclination may not be a predictive factor in TMD. Clayton and Beard25 used electronic computerized pantography to evaluate uncoordinated TMJ movements to calculate muscle dysfunction scores and to grade the relative severity of TMD. A review of the pantographic literature from 1902 to the present has suggested correlation between flat condyles and flat tracings, roundish condyles and concave tracings, and clicking sounds and disk inversion of the tracings.16 This study compared axiographic recordings with MRI findings in asymptomatic volunteers and patients with temporomandibular disorders.
MATERIAL
AND
METHODS
Fifty-one subjects participated included 21 symptomatic patients years, 24 asymptomatic volunteers
in this study, which with a mean age of 30 with normal TMJs and
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Fig. 2. A, Tracings represent right and left sagittal paths of asymptomatic volunteer with normal joints as diagnosed by magnetic resonance imaging. Smooth convex path starts and ends at same reference position. B, Tracings represent right and left velocity curves from Fig. 2, A. C, These tracings represent right and left horizontal axis tracings from subject in Fig. 2, A.
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C Fig. 3. A, Left tracing represents symptomatic patient with diagnosis of disk displacement with reduction. B, Representation of horizontal axis tracing of patient in Fig. 3, A. C, Representation of velocity tracing for subject in Fig. 3, A. a mean age of 22 years, and six asymptomatic volunteers with a mean age of 27 years, who demonstrated abnormal ‘I’M,Js. Table I shows the age and sex distribution of asymptomatic volunteers and symptomatic subjects in the st,udy. izll participants were imaged with bilateral TMJ MRI in t.he sagittal (open and closed) and coronal (closed) planes as described.“” Participants were studied with computerized axiogra-
5’1
phy, and the tracings were interpreted by one of the investigators (KP) without knowledge of the MRI diagnosis. This investigator was not allowed to ask the subject any questions or evaluate the clinical records. The tracing procedure was explained to each of the participants and a signed consent form was obtained from each. The SAMT axiograph (SAM Prazisionstechnik, Munich, Germany. U.S. distributor: Great Lakes Orthodontics Inc., Buffalo,
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N. Y.) recorded the predetermined mandibular movements. A customized occlusal clutch was used for all recordings. Protemp2 temporary crown and bridge material (ESPE Protemp II, Fabrik Pharmazeutischer Praparate GMBH & Co. KG D-8031 Seefeld/Oberba, Vienna) was placed on the inner arms of the paraocclusal brass clutch and seated over the buccal surface of the mandibular teeth. The patients held the teeth in the centric occlusal position until the material was fully set. The clutch was then adjusted to avoid occlusal interferences. The mandibular teeth were dried and the custom clutch was cemented with cyanoacrylate cement. The mandibular kinematic arch was attached to the clutch. The upper bow was placed over the patient’s head as described previously.24The recording plates were positioned over the TMJ in front of the ears almost in contact with the skin. Intercondylar distance and a third reference pointer (orbitale) were recorded for each subject. The hinge axis and the recording arms were adjusted to the axis point. Mai* and Reuschz7 described axiography as axial pantography. The geometry of the system allows the reduction of the axiographic tracings to mathematical terms. As the condyle translates, the styli on the dial gauge translate a distance S (Fig. 1). Any movement of the working condyle toward the orbiting side creates a compression of the styli and activates the dial gauge a distance @N). Given S, AN and intercondylar distance, the Bennett angle (63)can be calculated. The predetermined mandibular movements recorded with the computer-aided axiograph, (CADIAX), were open, close, protrusive, mediotrusive, and medioretrusive. The computerized version allows the recording and storage of a record for repeated visualization of dynamic mandibular movements at a later time. One of the investigators (KP) interpreted the tracings at a later date and subjects were placed in one of the four predesignated diagnostic groups. Before the collection of the data, four diagnostic categories were established for axiography based on the four most common radiographic diagnoses. These include normal disk position, disk displacement with reduction, disk displacement without reduction, and disk displacement without reduction associated with degenerative joint disease.28 The diagnosis of normal disk position was made when the length of tracing was more than 9 mm and concave. The tracings in Fig. 2 are from an asymptomatic volunteer with normal TMJs as diagnosed by MRI. The sagittal tracing (Fig. 2, A) starts and ends at a reference point with open/ close jaw movements. The horizontal axis tracings (Fig. 2, B) demonstrate minimal deviation from the midline with no abrupt changes in the condylar path movement. The velocity curves (Fig. 2, C) demonstrate a spiking symmetric wave with a sharp peak from acceleration at the beginning of opening, slowing down at maximal opening, accel-
*Mai M. Personal communication,
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erating as closing starts and slowing down again near the centric occlusal position (measured in millimeters per second). During the initial phase of closing on the left side there was an inversion, which probably represents the condyle slowing down as it passed over the articular eminence. The diagnosis of disk displacement with reduction was made when the tracing showed an inversion integral at different points of the open/close pathway. This may occur on either sagittal, horizontal, or time curve recordings (Fig. 3). The inversion during the sagittal opening path (at X = 4 and Z = 7) represents the condyle passing under the deformed posterior band of the disk (Fig. 3, A). The late closing click can be seen at 2 = 3. This represents the condyle slipping posterior to the posterior band of the artitular disk. This has been described by Isberg-Holm and Westesson2g in a study of cadaver specimens. From the horizontal axis tracing (Fig. 3, B) of the patient in Fig. 3, A, a change in direction of the opening path can be seen. This represents an abrupt change in opening direction about the Y (mediolateral) axis. The velocity tracing for this subject is seen in Fig. 3, C. The rapid reversal of the curve from positive to negative and then to positive again as the disk reduction takes place represents a rapid deceleration of the condyle. The inversion of the velocity wave during opening or closing is characteristic of a reduction event. This usually shows a velocity change of 50 to 100 mm/second. A change of velocity that is smaller can be seen on closing as the disk falls anterior to the condyle. The diagnosis of disk displacement without reduction was made when the concave curvature was absent or the tracing was a straight line (Fig. 4, A). The straight, limited condylar path is approximately 4 to 5 mm. The horizontal axes tracing in Fig. 4, B, demonstrates an abrupt right movement on opening. This is the disk reduction on the right side. The left velocity tracing (Fig. 4, C) from the subject in Fig. 4, A, demonstrates an erratic, irregular velocity with no development of the spiking symmetric wave as seen in Fig. 1, C. One unpublished study* and a study by Harper30 evaluated asymptomatic volunteers and were used for baseline interpretation of the quality and character of normal axiographic tracings. Results of the MRI scans were classified as normal, disk displacement with reduction (DDR), or disk displacement without reduction with or without degenerative joint disease as described.26, 28 RESULTS The subjects were divided into three diagnostic categories as described in Table I: (1) asymptomatic volunteers with normal TMJs and no history of TMJ pain, locking, joint noises, dysfunction, or restriction of mandibular movements; (2) asymptomatic volunteers with anterior *Stroud L. Personal Communication, Vienna (Interdisciplinary Study Group), Petaluma, Calif., 1990.
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Fig. 4. A, Representation of left joint with disk displacement without reduction and degenerative joint disease. B, Horizontal axis tracing (Y axis) of left side shows rapid deviation to right side (small arrow), representing disk reduction on right side. C, Left velocity tracing from subject in Fig. 4, A.
disk position with no history of TMJ pain, locking, joint noises, dysfunction, or restriction of mandibular movements, and (3) symptomatic patients with a history of localized TMJ pain and dysfunction. Table II illustrates the joint diagnosis by MRI and the tracing diagnosis determined by axiography. Twenty-four asymptomatic volun-
x3;
teers (48 joints) had bilaterally normal TMJs (diagnostic category 1). Six asymptomatic volunteers (12 joints) had one or two abnormal joints (diagnostic category 2). There were 21 symptomatic patients (40 joints) with one or two abnormal joints (diagnostic category 3). There were 61 joints diagnosed as normal (true negative examinations)
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+z
B
Fig. 5. A, The left sagittal tracing of asymptomatic normal volunteer. B, Horizontal axis tracings from volunteer in Fig. 5, A, shows quantity and smoothness of translation.
Table
II.
Diagnostic studies of TMJ Axiographic
Diagnostic
category 1 2
3
MRI
diagnosis
1
diagnosis
2
1 1 2 3 4 1 2 3
48 TN 4TN 6FN 1 FN 9TN 9FN 2FN
13 TP 5TP
4
-
-
3
1 TP
-
-
-
1 TP
4 1 TP
Diagnostic category: 1, asymptomatic with normal TMJs; 2, asymptomatic with abnormal TMJs; and 3, symptomatic TMJs. MRI diagnosis within each category: 1, normal disk position; 2, disk displacement with reduction; 3, disk displacement without reduction; and 4, disk displacement without reduction with degenerative joint disease. Tracing (axiographic) diagnosis: 1, normal disk position; 2, disk displacement with reduction; 3, disk displacement without reduction; and 4, disk displacement without reduction with degenerative joint disease. Examination results: TN, true negative; FN, false negative; and TP, true positive.
with axiography (48 + 4 + 9) and found to have normal disk position with MRI. Eighteen joints were diagnosed normal with axiography (6 + 1 + 9 + 2) and found to have anterior disk position (false negative examination results) with MRI. Twenty-one joints had a diagnosis of anterior
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disk position with axiography (1 + 13 + 5 + 1 + 1) and were found to have anterior disk position with MRI (true positive examination results). There were no false positive examination results. Table III summarizes positive and negative diagnostic comparisons from Table II.
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Fig. 6. A and B, Right and left sagittal tracings of symptomatic patient with disk displacement without reduction on right side and disk displacement with reduction on left side. Velocity curve on right side appears normal in Fig. 6, B, compared with Fig. 2, B. C, Horizontal axis tracings appear normal with only slight deviation at maximal opening.
52x
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Fig.
7. A, Left tracing
from asymptomatic
volunteer
with diagnosis
of disk displacement
with reduction. B, Left velocity tracing of the volunteer in Fig. 7, A. C, Velocity curve on right side appears normal, compared with Fig. 2, C. The diagnostic
sensitivity
in this study was 0.64. Twen-
ty-one joints were called abnormal with axiography (true positive) and 18 were called normal, but were abnormal (false negative) (TP/‘I’P + FN; 21/21 + 18). The diagnostic specificity predictive
(TN/TN + FP; 61/61 + 0) was 1.0. The negative value was 0.78 (TN/TN + FN) (61/61 + 18).
There were 61 true negative examination results and 18 false negative examination results. The positive predictive value (TP/TP + FP; 21/21 + 0) was 1.0. Two joints were not used because of artifact with the tracing device.
Table
III.
Summary of diagnostic comparisons
Test results positive
Disease present
Disease
True positive
False positive
21 Test results negative
False negative 18
absent
0 True negative 61
True positive, diagnostic test result is positive end diseaseis present; false positive, diagnostic test result is positive but diseaseabsent; false negative, diagnostic test result is negative but diseaseis present, and true negative, diagnostic test result is negative and disease is absent.
DISCUSSION Although further research is needed, axiography may have some use as a screening procedure for the staging of TMJ internal derangements. The axiographic tracings for subjects with normal TMJ were never interpreted as
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abnormal (false positive) as evidenced by the diagnostic specificity of 1.0. The diagnostic sensitivity (0.64) is still suspect. The right and left sagittal tracings of an asymptomatic
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volunteer wit.h normal TMJs are demonstrated in Fig. 5, A. The sagittal path is short and flat (5 to 7 mm), which suggest.s disk displacement without reduction and degenerative joint disease. This volunteer’ TMJs were called normal because the horizontal axis tracings (Fig. 5, B) and the velocity tracings were normal. This emphasizes that more than one axis should be used for analysis to avoid false positive examination resulm. False negative examination results were common in the asymptomatic abnormal volunteers and the symptomatic subjects. The left tracing in Fig. 6, A, represents tracings from an asymptomatic volunteer with disk displacement, with reduction and the right tracing disk displacement without reduction. The path on the right side is smooth; minor deflections on the left side were considered electronic artifact. It is important to note that this patient has normal range of motion. The horizontal axis tracings appear normal with only slight deviation at maximal opening (Fig. 6, R). The velocity tracing on the left side (Fig. 6, C) indicates a small inversion pattern typical of disk displacement.. but because the sagittal and horizontal axis appeared normal, t,he joint was called normal by axiography. The sagittal, horizontal, and velocity curves on the right side were considered normal. This was a bilateral falsenegative examination result. Another false-negative examination result is demonstrated in Fig. 7. There is a slight inversion in the sagittal opening path but. no inversion with closing. The horizontal axis and velocity tracings were normal and the axiographic diagnosis was called normal. (The left tracing does not begin or end at, 0). If the subject was positioning the mandible forward to avoid the disk reduction it would be possible t.o produce this type of tracing and miss the appropriate diagnosis, The left velocity curve of the volunteer is demonstrated ir! 7, t” In t.he velocity curve in Fig. 7, C, there are no inversions as in Fig. 3. C’.even though the joint was diagnosed by MRI as disk displacement with reduction. This represents a false negative diagnosis. By contrast, the left tracing in Fig. 3, A, in a patient, with sufficient disk deformity to cause a depression in the tracing, indicates a reducing disk displaced. Clinically there must be audible joint noise, sudden jerky movements, or deviation during opening to suggest disk interference with condyle translation. The tracing in Fig. 4 represents a straight, short condylar path. If clicking, locking, or crepitation are in the history of a nonreducing disk displacement, association with degenerative joint disease should be suspected. In Fig. 5 the tracing is flat and short. The velocity curves and limited horizontal axis movement in Fig. 4 all suggest some impairment to condyle motion. The suggestion has been made that axiography may be helpful in t,he recognition of “subclinical” TMD. There were eight joints in the asymptomatic volunteers with anterior disk position. Only one of the eight (12.5%) was pre-
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dicted with axiography. This subgroup of asymptomatic abnormal findings warrants further study.
SUMMARY The significance of axiography lies in its potential as an office aid for diagnosis and treatment. Advantages may include detection and documentation of internal derangements before dental treatment at less cost than MRI. Disadvantages include its inability to aid correct diagnosis for all joints (producing false negative examination results). The sensitivity of this examination is still suspect. The equipment and learning curve necessary to gain expertise require time for the clinician to master. Axiography has limited ability to reveal shape and character of the TMJ disk that may be helpful in prognosis of treatment, but this article should further interest and research in the potential uses and diagnostic capabilities of axiography. This study did not cause any patient to be “overdiagnosed.” Some abnormal TMJs produced normal tracings and thus were functionally normal. The results show that there is diagnostic validity to condylar tracings and suggest that their use in TMJ diagnostics and treatment should be evaluated carefully. REFERENCES 1. Hansson LG, Westesson PL, Katsberg RW, et al. MR imaging of the temporomandibular joint: comparison of images of autopsy specimens made at, 0.3 and 1.5T with anatomic cryosections. AJR 1989;152: 1241-4. 2. Tasaki MM, Westesson PL. MR imaging of the temporomandibular joint: diagnostic accuracy with sagittal and coronal images. Radiology 1993;186:‘723-9. 3. Westesson PL, Bronstein SL. Temporomandibular joint: comparison of single- and double-contrast arthrography. Radiology 1987;164:65-70. 4. Kircos LT, Ortendahl DA, Mark AS, Arakawa MS. Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg 1987;45:852-4. 5. Hatala MP, Westesson P-L, Tallents RH, Katzberg RW. Disc displacement in asymptomatic volunteers using magnetic resonance imaging. J Dent Res 1991;70(Special issue):278 6. Westesson PL, Eriksson L, Kurta K. Reliability of a negative clinical examination: prevalence of disk displacement in asymptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol 1989;68:551-4. 7. McCollum BB. Fundamentals involved in prescribing restorative dental remedies. Dent Items Interest 1939;61:852-63. 8. Au11 A. Condylar determinants of occlusal patterns. J PROSTHET DENT 1965;15:826-49. 9. Shields J, Clayton J, Sindledecker L. Using pantographic tracings to detect TMD and muscle dysfunctions. J PROSTHET DENT 1978;39:80-7. 10. Farrar W. Characteristic of the condylar path in internal derangements of the TMJ. J PROSTHET DENT 1978;39:319-33. 11. Farrar WB, McCarty WL Jr. Inferior joint space arthrography and characteristics of condylar paths in internal derangements of the TMJ. J PROSTHET DENT 1979;41:548-55. 12. Van Willigen J. The sagittal condylar movements of the clicking TMJ. J Oral Rehabil 1979;6:167-175. 13. Lundeen H. Mandibular movement recordings and articular adjustments simplified. Dent Clin North Am 1979;23:231-41. 14. Mongini F. Relationship between the temporomandibular joint and pantographic tracings of mandibular movements. J PROSTHET DENT 1980:43:331-7. 15. Simonet P, Clayton J. Influence of temporomandibular dysfunction on Bennett movement as recorded by a modified pantograph. Part 3: progress report on the clinical study. J PROSTHET DENT 1981;46:652-61.
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16. Mongini F, Capurso U. Factors influencing the pantographic tracings of mandibular border movements. J PROSTHET DENT 1982;48:585-98. 17. Bates RE, Welscb BB, Stewart CM. Temporomandibular joint disk position as determined by a simple recorder. J PROSTHET DENT 1986; 56221-4. 18. Mauderli A, Lundeen H. Simplified condylar movement recorders for analyzing TMJ derangements. J Craniomandib Pratt 1986;4:208-12. 19. Mauderli A, Lundeen H, Loughner B. Condylar movement recordings for analyzing TMJ derangements. J Craniomand Disord Facial Oral Pain 1988;3:119-27. 20. Slavicek R. Clinical and instrumental functional analysis for diagnosis and treatment planing. Part 5: axiography. J Clin Orthod 1988;22:65667. 21. Slav&k R. Clinical and instrumental functional analysis for diagnosis and treatment planning. Part 6: computer aided diagnosis and treatment planning system. J Clin Orthod 1988;22:718-29. 22. Slav&k R. Clinical and instrumental functional analysis for diagnosis and treatment planning. Part ‘7: computer aided axiography. J Clin Orthod 1988;22:776-87. 23. Slavicek R. Clinical and instrumental functional analysis for diagnosis and treatment planning. Part 8: case studied in CADIAX. J Clin Orthod 1989;23:42-7. 24. Alsawaf M, Garlapo DA, Gale EN, Carter MJ. The relationship between condylar guidance and temporomandibular joint clicking. J PROSTHET DENT 1989;61:349-54. 25. Clayton JA, Beard CC. An electronic, computerized pantographic reproducibility index for diagnosing temporomandibular joint dysfunction. J PROSTHET DENT 1986;55:500-5.
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26. Katzberg RW, Bessette RW, Tallents RH, et al. Normal and abnormal temporomandibular joint: MR Imaging with surface coil. Radiology 1986;158:183-89. 27. Reusch D. In Rekonstruktion van Kouftachen and Frontzahnan 1990. Westerburger Kontakte, Westerburg. 28. Katzberg RW. Temporomandibular joint imaging. Radio1 1989;170:297307. 29. Isberg-Holm AM, Westesson P-L. Movement of disk and condyle in temporomandibular joints with clicking. An arthrographic and cineradiographic study on autopsy specimens. Acta Odontol Stand 1982; 40~151.64. 30. Harper R. Analysis of temporomandibular joint function after orthognathic surgery using condylar path tracings. Am J Orthod Dentofacial Orthop 1990;97:480-88. Reprint
requests
to:
Ross H. TALLENTS 1333 LAKE AVENUE ROCHESTER, NY 14613
Contributing R. W. Katzberg,
Author MD, Assistant
University of California, mento, Calif.
Davis
Professor of Radiology, Medical Center, Sacra-
531
joint
K. Parlett, DDS,a D. Paesani, DDS,b M. A. Hatala, DDSb Eastman Dental Center, Rochester, N. Y.
axiography R. H. Tallents,
DDS,C
and MRI
findings:
A
and
Axiography may be useful in the evaluation of condyle motion and the effects of internal derangements on this motion. Fifty-one patients were selected by one investigator (RHT) to provide a representative sample of asymptomatic and symptomatic subjects for the following categories: (1) normal disk position, (2) disk displacement with reduction, (3) disk displacement without reduction and (4) disk displacement without reduction associated with degenerative joint disease. Axiography was performed by a separate investigator (KGP) in a blinded fashion. The diagnosis of the presence of internal derangement was based on the tracings only. All subjects had bilateral magnetic resonance imaging scans to evaluate for the presence or absence of internal derangement. The diagnostic sensitivity was 0.64, which indicated that axiography is marginal at identifying disease when present. The negative predictive value was 0.78, which indicated that axiography is accurate in the detection of normal disk condyle relationship. (J PROSTHET DENT 1993;70:521-31.)
I
nterest in the etiology, diagnosis, and treatment of the temporomandibular dysfunction (TMD) has increased in the past two decades. Diagnosis poses a particularly difficult problem because there is no consistent agreement on the definition of a TMD problem. Internal derangements have been evaluated with imaging techniques such as magnetic resonance imaging (MRI), computed tomography (CT), and arthrography. These diagnostic modalities pose a problem in clinical availability and health care economics. There is no infallible diagnostic method for the detection and diagnosis of the pathologic conditions associated with internal derangements of the temporomandibular joint (TMJ). It has been reported that MRI has an accuracy for disk position of 85 % , disk shape of 77 % , and bony abnormalities of 100% .l More recently Tasaki and Westesson2 demonstrated an accuracy of 95 % when the coronal and sagittal images were combined to evaluate disk position. Arthrography permits a more dynamic evaluation of the disk/condyle assembly compared with the static evaluation by MRI or CT and has a diagnostic accuracy of 83 % when combined with videofluroscopy.3 MRI and arthrography have been used to evaluate aPrivate Practice, Bracebridge, Ontario, Canada. bTemporomandibular Joint Resident, Department of Orthodontics. “Senior Clinical Associate, Department of Prosthodontics; and Clinical Associate, Department of Orthodontics. Copyright @ 1993 by The Editorial Council of THE JOURNAL OF PROSTHETIC DENTISTRY. 0022-3913/93/$1.00 +.10.
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asymptomatic volunteers, and anterior disk position has been found in 15 % to 32 % of joints studied.4-6 Westesson et a1.6 described internal derangement as a localized mechanical fault that interferes with the smooth action of the joint. He also suggested that a displaced disk not causing a functional disturbance might be described as a variation of normal. Axiographic recordings may prove to be a reliable diagnostic aid for detection of the presence or absence of intracapsular abnormalities. Previous studies using axiography have described joint pathology, but lacked suitable controls. A systematic comparison between imaging and axiographic findings is necessary.
REVIEW
OF THE
LITERATURE
McCollum7 used the pantograph to study the paths of condylar movement. Protrusive and lateral movements were graphically represented as horizontal projections. A condylographic study of 50 patients whose temporomandibular joints were considered normal on the basis of clinical examination revealed that (1) condylar movements vary widely in direction and size; (2) the angle of the eminence varies from 15 to 66 degrees (average 35 degrees), and (3) right and left eminences rarely have the same slanL8 Shields et a1.g studied 46 patients with clinical diagnoses of TMD and found that pantographic tracings corroborated the diagnoses. He suggested that a diagnosis of TMD may require the use of several diagnostic modalities, such as subjective response, clinical examination, imaging, and
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Fig. 1. Geometric Table
1.
Age and sex distribution GIWUP classification
Asym~plomatic volunteers, normal pit:7 h
.~s~mptomatic volunteers, abnormal jointti Symptomatir pat.ients
of the studied
representation
movement.
individuals
Number subjects
of
24
(48 joints) 6 (12 joints) "1
(40 joints)
graphic projections of condylar movement. Farrar”’ and Farrar and McCarty” correlated specific condylar path characteristics with types of internal derangements of the TMJ. Van Willingen’? compared the condylar movements 01’ live patients with clinically normal joints and five patients wit,h unilateral or bilateral clicking joints. The group with clicking joints showed perceivable deviations from the movement pat,tern found in the clinically normal group. Lundeen’,’ recorded an average condylar path of 45 degrees in I63 subjects, with the majority (80%) in the range of 30 i-o 60 degrees. Mongini I4 demonstrated a significant relationship between the shape of the TMJ (condyle and articular fossaj and the axiographic tracings of mandibular movement,s in 30 patients with TMD. Simonet and Clayton’” compared subjects with clinical signs of TMD with subjects in a control group and found more Bennett movement in the TMD group. Mongini and Capurso’” studied 12 men and 38 women (l;? to 60 years of age) with signs of TMJ pain and concluded that internal derangements with condyle disk incoordination can lead to deviations in pantographic rracings. Hates et al.‘; described a method of determining the condyle position necessary to keep the disk in place during splint fabrication. He suggested the use of a simplified axis recorder to obtain diagnostic information and compare tracings before and after treatment. Mauderli and Lundeen’s reported that simplified condylar movement
:; 9 L’
of condylar
ET AL
SEX
Mean
age
10 Females 14 Males 5 Females 1 Male 20 Females 1 Male
(years)
Age
range
(years)
30
24
33
24
to 41 to 49 to 36
27
20
25 31 14
10 to 46
recorders could analyze TMJ derangements. Later, Mauderli et al.lg described several irregular patterns that correlate with intracapsular derangements. The patterns were not corroborated with MRI or arthrograms and a specific diagnosis could not be made. Slavicek20-2” has suggested that computer-aided axiography may be useful in the early detection of subclinical diskopathies. He also related tracing shape with condylar movements in several diagnostic conditions; however, these studies did not have adequate controls. Alsawaff et a1.“4 used computerized axiography to compare clicking joints with nonclicking control joints and demonstrated that condylar path inclination may not be a predictive factor in TMD. Clayton and Beard25 used electronic computerized pantography to evaluate uncoordinated TMJ movements to calculate muscle dysfunction scores and to grade the relative severity of TMD. A review of the pantographic literature from 1902 to the present has suggested correlation between flat condyles and flat tracings, roundish condyles and concave tracings, and clicking sounds and disk inversion of the tracings.16 This study compared axiographic recordings with MRI findings in asymptomatic volunteers and patients with temporomandibular disorders.
MATERIAL
AND
METHODS
Fifty-one subjects participated included 21 symptomatic patients years, 24 asymptomatic volunteers
in this study, which with a mean age of 30 with normal TMJs and
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ocmn/closs
-1
;t
.
2
.
‘3
.
4
.
8
.
5
.
1
8
.
9
.
.i 1
’
Fig. 2. A, Tracings represent right and left sagittal paths of asymptomatic volunteer with normal joints as diagnosed by magnetic resonance imaging. Smooth convex path starts and ends at same reference position. B, Tracings represent right and left velocity curves from Fig. 2, A. C, These tracings represent right and left horizontal axis tracings from subject in Fig. 2, A.
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HCI
*
*
~ .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. --4 --5 --6 --7 --a --9 -- 10
V B
C Fig. 3. A, Left tracing represents symptomatic patient with diagnosis of disk displacement with reduction. B, Representation of horizontal axis tracing of patient in Fig. 3, A. C, Representation of velocity tracing for subject in Fig. 3, A. a mean age of 22 years, and six asymptomatic volunteers with a mean age of 27 years, who demonstrated abnormal ‘I’M,Js. Table I shows the age and sex distribution of asymptomatic volunteers and symptomatic subjects in the st,udy. izll participants were imaged with bilateral TMJ MRI in t.he sagittal (open and closed) and coronal (closed) planes as described.“” Participants were studied with computerized axiogra-
5’1
phy, and the tracings were interpreted by one of the investigators (KP) without knowledge of the MRI diagnosis. This investigator was not allowed to ask the subject any questions or evaluate the clinical records. The tracing procedure was explained to each of the participants and a signed consent form was obtained from each. The SAMT axiograph (SAM Prazisionstechnik, Munich, Germany. U.S. distributor: Great Lakes Orthodontics Inc., Buffalo,
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N. Y.) recorded the predetermined mandibular movements. A customized occlusal clutch was used for all recordings. Protemp2 temporary crown and bridge material (ESPE Protemp II, Fabrik Pharmazeutischer Praparate GMBH & Co. KG D-8031 Seefeld/Oberba, Vienna) was placed on the inner arms of the paraocclusal brass clutch and seated over the buccal surface of the mandibular teeth. The patients held the teeth in the centric occlusal position until the material was fully set. The clutch was then adjusted to avoid occlusal interferences. The mandibular teeth were dried and the custom clutch was cemented with cyanoacrylate cement. The mandibular kinematic arch was attached to the clutch. The upper bow was placed over the patient’s head as described previously.24The recording plates were positioned over the TMJ in front of the ears almost in contact with the skin. Intercondylar distance and a third reference pointer (orbitale) were recorded for each subject. The hinge axis and the recording arms were adjusted to the axis point. Mai* and Reuschz7 described axiography as axial pantography. The geometry of the system allows the reduction of the axiographic tracings to mathematical terms. As the condyle translates, the styli on the dial gauge translate a distance S (Fig. 1). Any movement of the working condyle toward the orbiting side creates a compression of the styli and activates the dial gauge a distance @N). Given S, AN and intercondylar distance, the Bennett angle (63)can be calculated. The predetermined mandibular movements recorded with the computer-aided axiograph, (CADIAX), were open, close, protrusive, mediotrusive, and medioretrusive. The computerized version allows the recording and storage of a record for repeated visualization of dynamic mandibular movements at a later time. One of the investigators (KP) interpreted the tracings at a later date and subjects were placed in one of the four predesignated diagnostic groups. Before the collection of the data, four diagnostic categories were established for axiography based on the four most common radiographic diagnoses. These include normal disk position, disk displacement with reduction, disk displacement without reduction, and disk displacement without reduction associated with degenerative joint disease.28 The diagnosis of normal disk position was made when the length of tracing was more than 9 mm and concave. The tracings in Fig. 2 are from an asymptomatic volunteer with normal TMJs as diagnosed by MRI. The sagittal tracing (Fig. 2, A) starts and ends at a reference point with open/ close jaw movements. The horizontal axis tracings (Fig. 2, B) demonstrate minimal deviation from the midline with no abrupt changes in the condylar path movement. The velocity curves (Fig. 2, C) demonstrate a spiking symmetric wave with a sharp peak from acceleration at the beginning of opening, slowing down at maximal opening, accel-
*Mai M. Personal communication,
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1991; A-1232 Wien, Austria.
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erating as closing starts and slowing down again near the centric occlusal position (measured in millimeters per second). During the initial phase of closing on the left side there was an inversion, which probably represents the condyle slowing down as it passed over the articular eminence. The diagnosis of disk displacement with reduction was made when the tracing showed an inversion integral at different points of the open/close pathway. This may occur on either sagittal, horizontal, or time curve recordings (Fig. 3). The inversion during the sagittal opening path (at X = 4 and Z = 7) represents the condyle passing under the deformed posterior band of the disk (Fig. 3, A). The late closing click can be seen at 2 = 3. This represents the condyle slipping posterior to the posterior band of the artitular disk. This has been described by Isberg-Holm and Westesson2g in a study of cadaver specimens. From the horizontal axis tracing (Fig. 3, B) of the patient in Fig. 3, A, a change in direction of the opening path can be seen. This represents an abrupt change in opening direction about the Y (mediolateral) axis. The velocity tracing for this subject is seen in Fig. 3, C. The rapid reversal of the curve from positive to negative and then to positive again as the disk reduction takes place represents a rapid deceleration of the condyle. The inversion of the velocity wave during opening or closing is characteristic of a reduction event. This usually shows a velocity change of 50 to 100 mm/second. A change of velocity that is smaller can be seen on closing as the disk falls anterior to the condyle. The diagnosis of disk displacement without reduction was made when the concave curvature was absent or the tracing was a straight line (Fig. 4, A). The straight, limited condylar path is approximately 4 to 5 mm. The horizontal axes tracing in Fig. 4, B, demonstrates an abrupt right movement on opening. This is the disk reduction on the right side. The left velocity tracing (Fig. 4, C) from the subject in Fig. 4, A, demonstrates an erratic, irregular velocity with no development of the spiking symmetric wave as seen in Fig. 1, C. One unpublished study* and a study by Harper30 evaluated asymptomatic volunteers and were used for baseline interpretation of the quality and character of normal axiographic tracings. Results of the MRI scans were classified as normal, disk displacement with reduction (DDR), or disk displacement without reduction with or without degenerative joint disease as described.26, 28 RESULTS The subjects were divided into three diagnostic categories as described in Table I: (1) asymptomatic volunteers with normal TMJs and no history of TMJ pain, locking, joint noises, dysfunction, or restriction of mandibular movements; (2) asymptomatic volunteers with anterior *Stroud L. Personal Communication, Vienna (Interdisciplinary Study Group), Petaluma, Calif., 1990.
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HCI
"9 xc:
6
7
6
5
4
3
2
I
i-i
.
1-2
.
-3
.
--4
’
--5
.
--6
.
--7
.
:
*
.
t
.
t
.... 6
.
.
”
.
--6
--9
--10
A
+z B
.
X’
OPEN
CLOSE
-25 -50 t t
Fig. 4. A, Representation of left joint with disk displacement without reduction and degenerative joint disease. B, Horizontal axis tracing (Y axis) of left side shows rapid deviation to right side (small arrow), representing disk reduction on right side. C, Left velocity tracing from subject in Fig. 4, A.
disk position with no history of TMJ pain, locking, joint noises, dysfunction, or restriction of mandibular movements, and (3) symptomatic patients with a history of localized TMJ pain and dysfunction. Table II illustrates the joint diagnosis by MRI and the tracing diagnosis determined by axiography. Twenty-four asymptomatic volun-
x3;
teers (48 joints) had bilaterally normal TMJs (diagnostic category 1). Six asymptomatic volunteers (12 joints) had one or two abnormal joints (diagnostic category 2). There were 21 symptomatic patients (40 joints) with one or two abnormal joints (diagnostic category 3). There were 61 joints diagnosed as normal (true negative examinations)
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.
A
+z
B
Fig. 5. A, The left sagittal tracing of asymptomatic normal volunteer. B, Horizontal axis tracings from volunteer in Fig. 5, A, shows quantity and smoothness of translation.
Table
II.
Diagnostic studies of TMJ Axiographic
Diagnostic
category 1 2
3
MRI
diagnosis
1
diagnosis
2
1 1 2 3 4 1 2 3
48 TN 4TN 6FN 1 FN 9TN 9FN 2FN
13 TP 5TP
4
-
-
3
1 TP
-
-
-
1 TP
4 1 TP
Diagnostic category: 1, asymptomatic with normal TMJs; 2, asymptomatic with abnormal TMJs; and 3, symptomatic TMJs. MRI diagnosis within each category: 1, normal disk position; 2, disk displacement with reduction; 3, disk displacement without reduction; and 4, disk displacement without reduction with degenerative joint disease. Tracing (axiographic) diagnosis: 1, normal disk position; 2, disk displacement with reduction; 3, disk displacement without reduction; and 4, disk displacement without reduction with degenerative joint disease. Examination results: TN, true negative; FN, false negative; and TP, true positive.
with axiography (48 + 4 + 9) and found to have normal disk position with MRI. Eighteen joints were diagnosed normal with axiography (6 + 1 + 9 + 2) and found to have anterior disk position (false negative examination results) with MRI. Twenty-one joints had a diagnosis of anterior
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disk position with axiography (1 + 13 + 5 + 1 + 1) and were found to have anterior disk position with MRI (true positive examination results). There were no false positive examination results. Table III summarizes positive and negative diagnostic comparisons from Table II.
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. . . . . . . . . . . .
. . * . . .
. . . . . .
. . . , . . .
. . . . . . .
. . . . . . . . . . . . . . . . . open/c
.
7
. . . . . . .
. . . . . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
ET AL
. . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
lose
+z
“‘6
.
--7
.
6
1
VIQ X’
Fig. 6. A and B, Right and left sagittal tracings of symptomatic patient with disk displacement without reduction on right side and disk displacement with reduction on left side. Velocity curve on right side appears normal in Fig. 6, B, compared with Fig. 2, B. C, Horizontal axis tracings appear normal with only slight deviation at maximal opening.
52x
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1’
\
2
lo
9
0
7
6
5
4
3
2
i
X<::::::::” -2 5
-3 -4
0
-5 -6
7
-7
0
-6 #
-9 -- 10
11 ;
v
X’
B
CLOSE 1
Fig.
7. A, Left tracing
from asymptomatic
volunteer
with diagnosis
of disk displacement
with reduction. B, Left velocity tracing of the volunteer in Fig. 7, A. C, Velocity curve on right side appears normal, compared with Fig. 2, C. The diagnostic
sensitivity
in this study was 0.64. Twen-
ty-one joints were called abnormal with axiography (true positive) and 18 were called normal, but were abnormal (false negative) (TP/‘I’P + FN; 21/21 + 18). The diagnostic specificity predictive
(TN/TN + FP; 61/61 + 0) was 1.0. The negative value was 0.78 (TN/TN + FN) (61/61 + 18).
There were 61 true negative examination results and 18 false negative examination results. The positive predictive value (TP/TP + FP; 21/21 + 0) was 1.0. Two joints were not used because of artifact with the tracing device.
Table
III.
Summary of diagnostic comparisons
Test results positive
Disease present
Disease
True positive
False positive
21 Test results negative
False negative 18
absent
0 True negative 61
True positive, diagnostic test result is positive end diseaseis present; false positive, diagnostic test result is positive but diseaseabsent; false negative, diagnostic test result is negative but diseaseis present, and true negative, diagnostic test result is negative and disease is absent.
DISCUSSION Although further research is needed, axiography may have some use as a screening procedure for the staging of TMJ internal derangements. The axiographic tracings for subjects with normal TMJ were never interpreted as
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abnormal (false positive) as evidenced by the diagnostic specificity of 1.0. The diagnostic sensitivity (0.64) is still suspect. The right and left sagittal tracings of an asymptomatic
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volunteer wit.h normal TMJs are demonstrated in Fig. 5, A. The sagittal path is short and flat (5 to 7 mm), which suggest.s disk displacement without reduction and degenerative joint disease. This volunteer’ TMJs were called normal because the horizontal axis tracings (Fig. 5, B) and the velocity tracings were normal. This emphasizes that more than one axis should be used for analysis to avoid false positive examination resulm. False negative examination results were common in the asymptomatic abnormal volunteers and the symptomatic subjects. The left tracing in Fig. 6, A, represents tracings from an asymptomatic volunteer with disk displacement, with reduction and the right tracing disk displacement without reduction. The path on the right side is smooth; minor deflections on the left side were considered electronic artifact. It is important to note that this patient has normal range of motion. The horizontal axis tracings appear normal with only slight deviation at maximal opening (Fig. 6, R). The velocity tracing on the left side (Fig. 6, C) indicates a small inversion pattern typical of disk displacement.. but because the sagittal and horizontal axis appeared normal, t,he joint was called normal by axiography. The sagittal, horizontal, and velocity curves on the right side were considered normal. This was a bilateral falsenegative examination result. Another false-negative examination result is demonstrated in Fig. 7. There is a slight inversion in the sagittal opening path but. no inversion with closing. The horizontal axis and velocity tracings were normal and the axiographic diagnosis was called normal. (The left tracing does not begin or end at, 0). If the subject was positioning the mandible forward to avoid the disk reduction it would be possible t.o produce this type of tracing and miss the appropriate diagnosis, The left velocity curve of the volunteer is demonstrated ir! 7, t” In t.he velocity curve in Fig. 7, C, there are no inversions as in Fig. 3. C’.even though the joint was diagnosed by MRI as disk displacement with reduction. This represents a false negative diagnosis. By contrast, the left tracing in Fig. 3, A, in a patient, with sufficient disk deformity to cause a depression in the tracing, indicates a reducing disk displaced. Clinically there must be audible joint noise, sudden jerky movements, or deviation during opening to suggest disk interference with condyle translation. The tracing in Fig. 4 represents a straight, short condylar path. If clicking, locking, or crepitation are in the history of a nonreducing disk displacement, association with degenerative joint disease should be suspected. In Fig. 5 the tracing is flat and short. The velocity curves and limited horizontal axis movement in Fig. 4 all suggest some impairment to condyle motion. The suggestion has been made that axiography may be helpful in t,he recognition of “subclinical” TMD. There were eight joints in the asymptomatic volunteers with anterior disk position. Only one of the eight (12.5%) was pre-
PARLETT
ET AL
dicted with axiography. This subgroup of asymptomatic abnormal findings warrants further study.
SUMMARY The significance of axiography lies in its potential as an office aid for diagnosis and treatment. Advantages may include detection and documentation of internal derangements before dental treatment at less cost than MRI. Disadvantages include its inability to aid correct diagnosis for all joints (producing false negative examination results). The sensitivity of this examination is still suspect. The equipment and learning curve necessary to gain expertise require time for the clinician to master. Axiography has limited ability to reveal shape and character of the TMJ disk that may be helpful in prognosis of treatment, but this article should further interest and research in the potential uses and diagnostic capabilities of axiography. This study did not cause any patient to be “overdiagnosed.” Some abnormal TMJs produced normal tracings and thus were functionally normal. The results show that there is diagnostic validity to condylar tracings and suggest that their use in TMJ diagnostics and treatment should be evaluated carefully. REFERENCES 1. Hansson LG, Westesson PL, Katsberg RW, et al. MR imaging of the temporomandibular joint: comparison of images of autopsy specimens made at, 0.3 and 1.5T with anatomic cryosections. AJR 1989;152: 1241-4. 2. Tasaki MM, Westesson PL. MR imaging of the temporomandibular joint: diagnostic accuracy with sagittal and coronal images. Radiology 1993;186:‘723-9. 3. Westesson PL, Bronstein SL. Temporomandibular joint: comparison of single- and double-contrast arthrography. Radiology 1987;164:65-70. 4. Kircos LT, Ortendahl DA, Mark AS, Arakawa MS. Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg 1987;45:852-4. 5. Hatala MP, Westesson P-L, Tallents RH, Katzberg RW. Disc displacement in asymptomatic volunteers using magnetic resonance imaging. J Dent Res 1991;70(Special issue):278 6. Westesson PL, Eriksson L, Kurta K. Reliability of a negative clinical examination: prevalence of disk displacement in asymptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol 1989;68:551-4. 7. McCollum BB. Fundamentals involved in prescribing restorative dental remedies. Dent Items Interest 1939;61:852-63. 8. Au11 A. Condylar determinants of occlusal patterns. J PROSTHET DENT 1965;15:826-49. 9. Shields J, Clayton J, Sindledecker L. Using pantographic tracings to detect TMD and muscle dysfunctions. J PROSTHET DENT 1978;39:80-7. 10. Farrar W. Characteristic of the condylar path in internal derangements of the TMJ. J PROSTHET DENT 1978;39:319-33. 11. Farrar WB, McCarty WL Jr. Inferior joint space arthrography and characteristics of condylar paths in internal derangements of the TMJ. J PROSTHET DENT 1979;41:548-55. 12. Van Willigen J. The sagittal condylar movements of the clicking TMJ. J Oral Rehabil 1979;6:167-175. 13. Lundeen H. Mandibular movement recordings and articular adjustments simplified. Dent Clin North Am 1979;23:231-41. 14. Mongini F. Relationship between the temporomandibular joint and pantographic tracings of mandibular movements. J PROSTHET DENT 1980:43:331-7. 15. Simonet P, Clayton J. Influence of temporomandibular dysfunction on Bennett movement as recorded by a modified pantograph. Part 3: progress report on the clinical study. J PROSTHET DENT 1981;46:652-61.
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16. Mongini F, Capurso U. Factors influencing the pantographic tracings of mandibular border movements. J PROSTHET DENT 1982;48:585-98. 17. Bates RE, Welscb BB, Stewart CM. Temporomandibular joint disk position as determined by a simple recorder. J PROSTHET DENT 1986; 56221-4. 18. Mauderli A, Lundeen H. Simplified condylar movement recorders for analyzing TMJ derangements. J Craniomandib Pratt 1986;4:208-12. 19. Mauderli A, Lundeen H, Loughner B. Condylar movement recordings for analyzing TMJ derangements. J Craniomand Disord Facial Oral Pain 1988;3:119-27. 20. Slavicek R. Clinical and instrumental functional analysis for diagnosis and treatment planing. Part 5: axiography. J Clin Orthod 1988;22:65667. 21. Slav&k R. Clinical and instrumental functional analysis for diagnosis and treatment planning. Part 6: computer aided diagnosis and treatment planning system. J Clin Orthod 1988;22:718-29. 22. Slav&k R. Clinical and instrumental functional analysis for diagnosis and treatment planning. Part ‘7: computer aided axiography. J Clin Orthod 1988;22:776-87. 23. Slavicek R. Clinical and instrumental functional analysis for diagnosis and treatment planning. Part 8: case studied in CADIAX. J Clin Orthod 1989;23:42-7. 24. Alsawaf M, Garlapo DA, Gale EN, Carter MJ. The relationship between condylar guidance and temporomandibular joint clicking. J PROSTHET DENT 1989;61:349-54. 25. Clayton JA, Beard CC. An electronic, computerized pantographic reproducibility index for diagnosing temporomandibular joint dysfunction. J PROSTHET DENT 1986;55:500-5.
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26. Katzberg RW, Bessette RW, Tallents RH, et al. Normal and abnormal temporomandibular joint: MR Imaging with surface coil. Radiology 1986;158:183-89. 27. Reusch D. In Rekonstruktion van Kouftachen and Frontzahnan 1990. Westerburger Kontakte, Westerburg. 28. Katzberg RW. Temporomandibular joint imaging. Radio1 1989;170:297307. 29. Isberg-Holm AM, Westesson P-L. Movement of disk and condyle in temporomandibular joints with clicking. An arthrographic and cineradiographic study on autopsy specimens. Acta Odontol Stand 1982; 40~151.64. 30. Harper R. Analysis of temporomandibular joint function after orthognathic surgery using condylar path tracings. Am J Orthod Dentofacial Orthop 1990;97:480-88. Reprint
requests
to:
Ross H. TALLENTS 1333 LAKE AVENUE ROCHESTER, NY 14613
Contributing R. W. Katzberg,
Author MD, Assistant
University of California, mento, Calif.
Davis
Professor of Radiology, Medical Center, Sacra-
531