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The value of MRI in patients with temporomandibular joint dysfunction: Correlation of MRI and clinical findings
Accepted Manuscript Title: The value of MRI in patients with temporomandibular joint dysfunction: Correlation of MRI and clinical findings Author: Thomas J. Vogl Hans-Christoph Lauer Thomas Lehnert Nagy N.N. Naguib Peter Ottl Natalie Filmann Howard Soekamto Nour-Eldin A. Nour-Eldin PII: DOI: Reference:
S0720-048X(16)30028-6 http://dx.doi.org/doi:10.1016/j.ejrad.2016.02.001 EURR 7388
To appear in:
European Journal of Radiology
Received date: Revised date: Accepted date:
21-10-2015 17-1-2016 1-2-2016
Please cite this article as: Vogl Thomas J, Lauer Hans-Christoph, Lehnert Thomas, Naguib Nagy NN, Ottl Peter, Filmann Natalie, Soekamto Howard, NourEldin Nour-Eldin A.The value of MRI in patients with temporomandibular joint dysfunction: Correlation of MRI and clinical findings.European Journal of Radiology http://dx.doi.org/10.1016/j.ejrad.2016.02.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The value of MRI in patients with temporomandibular joint dysfunction: Correlation of MRI and clinical findings
Thomas J. Vogl1, Hans-Christoph Lauer², Thomas Lehnert1, Nagy N. N. Naguib1,3, Peter Ottl4, Natalie Filmann5, Howard Soekamto², Nour-Eldin A. Nour-Eldin1,6 1
Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany ²Department of Prosthodontics, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany 3
Department of Diagnostic and Interventional Radiology, Alexandria University, Alexandria, Egypt 4
Department of Prosthodontics, University Hospital Rostock, Hans Moral, University of Rostock, Rostock, Germany 5
Department of Biomedical Statistics, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany 6
Department of Diagnostic and Interventional Radiology, Cairo University, Cairo, Egypt
Corresponding author: Nour-Eldin A. Nour-Eldin , MD, PhD Institute for Diagnostic and Interventional Radiology Johann Wolfgang Goethe-University Frankfurt Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany Tel.: + 49 69-6301-7278 Fax.: + 49 69-6301-7258 E-mail: [email protected]
1
ABSTRACT Aim: To estimate the correlation between the MRI findings and clinical outcomes in patients with temporomandibular joint dysfunction (TMD). Methods and Materials: We included 546 female and 248 male patients who were clinically diagnosed with TMD (mean age 38.7 years) and examined by MRI (T1 and T2 weighted images, parasagittal and paracoronal slices). A questionnaire, radiological, and clinical findings were analysed for statistically significant correlations. The analysed parameters included gender, age, disk position, joint degeneration, arthralgia, mouth opening, condyle position and clinical progress. Results: Of all TMJ’s 62% showed physiological disc position, 35% anterior and 3% posterior disc position. Modification of therapy occurred in 20% and alteration of diagnosis was found in 32% of all cases. Anterior disc displacement with reduction showed a specificity of 88% and a sensitivity of 78%, whereas anterior disc displacement without reduction showed a specificity of 84% and a sensitivity of 73%. A significant correlation between disc length, condyle morphology and disc displacement was found. With the increase of intra-articular liquid as seen on MRI the level of arthralgia significantly rose as opposed to mouth opening. Conclusion: Specificity and sensitivity, for anterior disc displacement and osseous changes in TMJ were highly acceptable. Results had confirmed the diagnostic capability of MRI 2
in diagnostic imaging of TMJ. Additionally MRI should be used primarily in severe, therapy-resistant cases and for surgical planning purposes.
Keywords: magnetic resonance imaging (MRI), temporomandibular joint disorder (TMD), internal derangement
INTRODUCTION Temporomandibular joint dysfunction (TMD) is characterized by clinical symptoms such as arthralgia, joint clicking, alteration of mandibular movement, and disc displacement (1-3). These disorders may be caused by deranged or degenerated intra-articular components. The commonest cause of
internal
derangement (ID) is an imbalance among condyle, temporal bone, and discus articularis. Anterior disc displacement is most frequently found compared to posterior, medial or lateral dislocation (4). On mouth opening disc displacement can be reduced (disc displacement with reduction, DDWR) or remain displaced (disc displacement without reduction, DDWOR). A disc displacement is often combined with joint clicking or crepitus. Moreover degenerated discs, joint effusion, and osseous changes of condyle and temporal bone are late stages in TMD. Out of all potential options, MRI is currently the gold standard (3,5-7) for evaluating TMD compared to conventional or computed tomography. The advantage of a non-invasive, radiation-free imaging technique combined with high tissue contrast and the ability to assess joint effusion is unmatched. However with growing number of patients, an effective and economical use of MRI is highly desirable in order to reduce costs and treatment time. However, how reliable are the clinical 3
examinations and clinical signs; is an important question that needs careful attention. A clinical study is required to determine the pros and cons of MRI in comparison to clinical appearances. The current study evaluates the validity and utility of MRI in TMD patients. Correlations between clinical symptoms and MRI findings as well as further clinical progress were analysed for specific conspicuous characteristics.
MATERIALS AND METHODS: Patients The study was approved by the Clinical Research Ethics Committee of the University Hospital. All patients signed consent prior to
the MRI examination
including the utility of clinical data for research purposes. The files of the Institute for Diagnostic and Interventional Radiology at a University Hospital were explored for patients who received MRI examination of their temporomandibular joint (TMJ) from January 2000 to December 2010. The inclusion criteria included all patients who were referred with a suspected diagnosis of TMD at any age. Indications for MRI examination were: change of disc position, arthralgia, joint sounds and osteoarthritis. Exclusion criteria for MRI were patients with general contraindications to MRI e.g. patients with cardiac pacemaker, known metallic foreign bodies not compatible to MRI. In addition patients who were claustrophobic with consequent early termination of the examination were also excluded. All Patients received a questionnaire in which they were asked to answer questions regarding their clinical symptoms and therapy. Unanswered questions were
4
considered missing and not included in the evaluation. The clinical symptoms described in the referring letter were recorded. MRI Technique All images were obtained by a 1.5 Tesla Symphony Quantum or Avanto MRI (Siemens Medical, Erlangen, Germany) with a bilateral 80 mm diameter TMJ coil and 3 mm thick sections with a 190 mm field of view and a 256 matrix. With the help of localizers; sagittal and coronal oblique planes were obtained. The following sequences were performed: T1-weighted images (200/11 TR/TE) to assess disc position, disc morphology and osseous changes. T2-weighted images (1500/20 TR/TE) to determine joint fluid and joint effusion. Both sequences were acquired in occlusion and maximum mouth opening. Maximum mouth opening was measured in millimetres. No motion artefacts were tolerated. All MR images were diagnosed by a head and neck / maxillofacial radiologist with over 25 years of experience. TMJ pairs were analysed separately. Image evaluation With the help of T1 weighted images in closed mouth position, the disc position was divided according to the classification by Vogl et al. (8) into: disc position was deemed as normal if the posterior band in relation to condyle was located between 11 and 12 o´clock. A disc displacement below 11 o´clock was considered as anterior displacement and disc displacement above 12 o´clock as posterior displacement. MR images of all three categories are presented in Fig. 1 to 3. Using T2 weighted MR; images possible joint effusion was assessed and classified into absent signal of fluid, low signal of fluid, and joint effusion (see Fig. 4 and 5). Reduction of the disc was assessed by comparing T1 weighted MR images in open 5
and closed mouth position (see Fig. 6 and 7) and classified as disc displacement with or without reduction. All patients were grouped into Internal Derangement Grade (810) based on their findings. The appearance of the condyle was divided into normal and degenerated (plane, sharpened, and flattened (8). The morphology of the disc in the T1 sagittal plane was classified according to Ottl et al. (11) and Taskaya-Yylmaz et
al.
(12)
as
biconcave/normal,
biplane/flat,
thickened,
biconvex,
fragmented/destroyed. Disc deformity was also classified as: no deformity (biconcave) and deformed (all other forms). Statistical analysis Main objective of this study was to determine the sensitivity and specificity of clinical examination in comparison to MRI in a high number of patients. Suspected diagnose of DDWR or DDWOR were compared to radiological findings. To make an objective determination of statistically significant correlations of the parameters: age, disc length, disc position, joint effusion, maximum mouth opening, morphology,
and
Internal
Derangement
Grade
in
each
condyle case the
Spearman correlation coefficient was determined. To assess whether gender of a patient could be relevant the Mann-Whitney U-test was determined for the parameters: age, disc length, disk position, and morphology of the condyle. All statistical tests were two-tailed and used a significance level of alpha =5% (p<0.05). All data were entered into Excel 2007 (Microsoft Corporation, Redmond, WA, USA) and statistical analysis was performed with PASW Statistics, Release Version 18.0.0 (SPSS, Inc., 2009, Chicago, IL, USA). Biometric analysis was accomplished under supervision and guidance by employees of the Department of Biostatistics at the University.
6
Results Clinical findings of patients Patients in this study included 546 women and 248 men with a mean age of 38.7 ±16 years (range 14-83 years); 69% were females and 31 % males. There was no significant correlation between gender and age (Mann-Whitney-U-Test p > 0.05). Forty-three percent of all cases were referred by Prosthodontics, 34% by maxillofacial surgeons, 17% by Orthodontics, 4% by Orthopaedists, and 2% by ENT specialists. Based on clinical records indications for MRI examination were: 34% disc displacement, 30% arthralgia, 13% arthrosis, 9% joint clicking, 7% limitation of mandibular movement, 4% joint effusion, 3% myofascial pain. By means of clinical records and a questionnaire a change in therapy could be shown for 20% which included change of splint therapy (relaxing, reposition, or distraction), additional orthodontics, maxillofacial surgery, change in treatment order, and no further therapy. Alteration of diagnosis (32%) was mostly additional information regarding osteoarthritis, capsulitis, disc position, and disc replacement. MRI findings A rough division for sagittal disc position in MRI indicated that 62 % of all TMJ’s showed normal disc position, 35 % anterior and 3 % showed posterior disc position. Using cross tabulation the sensitivity and sensibility for clinical examination of anterior disc displacement with and without replacement were obtained while MRI was considered as gold standard. Anterior disc displacement with reduction (DDWR) showed a specificity of 84% and a sensitivity of 73% whereas anterior disc displacement without reduction (DDWOR) showed a sensitivity of 73% and a sensibility of 84% (see Table 1 and 2). The results of all cases classified by Internal 7
Derangement Grade were: Grade I: 28 %, II: 21%, III: 26%, IV: 9%, V: 14%, VI: 2%. (8,9) Correlation between clinical and MRI findings In order to assess the usefulness of the Internal Derangement Grade classification we compared radiological findings with clinical parameters. Therefore each Spearman-Rho coefficient was calculated in order to make an exact statement. A significant correlation between deformation of a condyle and a limitation of mouth opening (p<0.005) could be shown (normal condyle: average of 37 mm vs. deformed condyle average of: 34 mm). Comparing destructed and normal condyles with the chance of JE our study revealed a connection between destructed condyles and JE (p<0.05). The less mouth opening could be registered the higher was the determined classification of Internal Derangement Grade (p < 0.001). In the same way the length of the disc decreased with a rising Internal Derangement Grade (p < 0.001). No correlation between mouth opening and disk length was significant (p > 0.05) and mouth opening and joint effusion correlated well with each other (p < 0.05). When signal of fluid was absent an average of 39 mm mouth opening was determined, while low signal of fluid (see Fig. 4) and JE showed (see Fig. 5) an average of 36 mm respectively 34 mm. By dividing the disc form into normal and degenerated groups a significant connection between JE and disc deformation could be shown (p < 0.01). JE was found with a higher probability in patients with DDWOR compared to DDWR or normal disc position (p < 0.001). In joints with normal disc position JE occurred in 7%, in 19% of cases with DDWR whilst 22% of DDWOR showed JE. Significant results could be shown for symptomatic (pain) and asymptomatic joints in relation to their disc displacement: out of all asymptomatic joints (139) 27% had no disc displacement, 38% had DDWR and 31% showed DDWOR and 3 % posterior disc 8
displacement. On the other hand symptomatic joints (285): 19% showed no disc displacement, 33% showed DDWR and 46% showed DDWOR and 1% posterior disc displacement. Cases with DDWR and DDWOR which showed joint clicking were almost even (66% vs. 69%), whereas the occurrence of both diagnoses in joints with clicking varied (33% vs. 47%, p<0.05). According to our study a correlation between clicking and joint pain could not be verified (p>0.05).
Discussion Since the prevalence of TMD is up to 21% (2,13,14), an effective and efficient therapy management is needed. A clinical examination of the TMJ should not be skipped since the acquired findings are an indication for further diagnostics. Imaging the TMJ has the goal to assess the integrity of hard and soft tissue components inside the TMJ, to confirm the stage of disease, and to evaluate the effects of treatment. (15) By comparing conventional and computed radiography, and MRI Petersson et al. (5) suggested MRI to be the method of choice. The advantage of a complete TMJ assessment including disc, condyle, fossa, and joint effusion is yet unmatched. Different studies underlined the status of MRI being the gold standard in TMJ assessment. Westesson et al. (16) compared disc positions in autopsy specimens and MRI which showed a sensitivity of 0.86 and specificity of 0.63. Tasaki et al. (17) and Katzberg et al. (18) also revealed high accuracy of MRI in explanted TMJ’s for disc position and osseous changes. Assessing disc position is an important aspect in evaluating a TMJ, as Maizlin et al. (19) showed that occurrence of disc displacement was statistically significant higher for symptomatic joints than for asymptomatic joints. 9
Change of disc position is important but only one part of this complex disease. That could be the reason why the majority of our patients (62%) showed normal disc position and were referred with TMD. Other symptoms should be beared in mind such as JE, mouth opening, muscle tenderness, and grinding. Usumez et al. (20) published results (72% DDWR, 81% DDWOR) are similar to our results and show a high sensitivity and specificity for clinical examination of anterior disc displacements. Accordance between clinical and radiological diagnosis has been published with a wide range from 59% up to 90%. (19,21-24) Possible reasons for a low level of correlation could be an imprecise clinical examination, variation in technical equipment, protocols and patient population which lead to varying results. Schmitter et al. (25) published that with high quality images a good interobserver agreement could be shown. Another reason for varying results could be that the progress from DDWR to DDWOR is a flowing transition and hard to distinguish for patient and practitioner. These problems are aggravated by additional difficulties of TMJ examinations such as different diagnosis schemes, different examination criteria, and low interobserver reliability. (25) The level of degeneration and displacement of the disc is an important indicator for possible TMD. Sutton et al. (26) reported that a normal disc position was more likely in the clinically silent group than in the group with discernible sounds. Chowdary et al. (27) found an agreement among clinical symptoms such as muscle tenderness, clicking and arthralgia which correlated with MRI findings of the disc. With the ongoing degeneration of the disc the severity of the disease grew. Assessing the disc´s position has a primary role in evaluating the status a TMJ and estimating the risk of possible TMD. But according to our findings with 63% of normal disc position in TMD related patients other extra-capsular risk factors - such as 10
grinding, malocclusion, muscle tenderness, and psychological stress- must be kept in mind. The current results showed that joints with normal disc position JE occurred in 7%, in 19% of cases with DDWR whilst 22% of DDWOR showed JE. Significant results could be shown for symptomatic (pain) and asymptomatic joints in relation to their disc displacement: out of all asymptomatic joints (139) 27% had no disc displacement, 38% had DDWR and 31% showed DDWOR and 3 % posterior disc displacement. Joint clicking as a clinical symptom did not correlate with radiological findings or arthralgia. The number of joints with DDWR and DDWOR that showed joint clicking was almost even (66 % vs. 69 %), whereas the occurrence of both diagnoses in joints with clicking varied (33 % vs. 47 %). These results agree with those published (28) whereas other studies (10,29) suggest that clicking is an accurate sign of DDWR. We assume joint sounds have multiple reasons (reduction, osseous changes, cartilaginous changes) and MRI can deliver precise information and thereby support therapy in uncertain cases. Nevertheless disagreement among studies may occur due to differences in patients’ cohort and data interpretation. However, the question whether disc displacement is a result, the cause, or an accompanying factor remains a point of controversy (22). Since results showed that prevalence of JE rose with the severity of disc displacement and destruction of condyle a connection among these components should be considered. Published data (19,24,30) align with our results comparing JE and deformation of disc and condyle which if treated in time might prevent highly associated joint pain. Change of treatment could be found in 20% and alteration of diagnosis in 32% of all cases. This seems to be a high amount, however in order to evaluate the results further analysis is needed. Regarding the 11
question whether MRI related alteration of diagnosis or change of treatment has a positive effect, further long-term prospective studies are necessary. This study was limited by being a monocenter study, clinical and MRI findings were compared in only symptomatic group, and data was surveyed retrospectively. All patients were referred because of TMD which included a wide range of symptoms; this may explain the high number of 62 % of patients with no disc displacement. This study contained only findings of TMD; other additional information regarding general disease such as arthritic changes, traumata, or duration of disease were not included. For both the patient and the clinician, it’s hard to distinguish the level of progression; because symptoms differ in perception, vary during the day, and general disease can affect TMD. Therefore, standardized MRI protocols and clinical TMJ examination should be applied as well as periodical adjustment between radiologist and clinician. Since TMD is a protracted disease, a long term prospective study with a large number of asymptomatic and symptomatic patients is needed for more information regarding MRI findings and clinical symptoms. Furthermore validity should be confirmed by multicentre studies. Because the aetiology of TMD is yet not fully understood and for a better therapy prognosis, clinical and MRI based findings should be analyzed in relation to their treatment outcome. Good values for specificity, sensitivity for anterior disc displacement in TMJ were found and comparing available alternatives the MRI is currently the gold standard in imaging TMJ. MRI adds important information regarding grade of destruction and interaction of intra-articular components. Indications for running MRI are severe pain, therapy-resistant cases, therapy monitoring and surgical planning purposes. (6) More data is necessary to understand the progress and prevalence of TMD in order to rethink and renew clinical treatment. The study's findings suggest 12
that using MRI supports clinical findings of TMJ and appears necessary in certain cases to establish the presence or absence of TMD.
References 1. Ahlers M, Freesmeyer W, Fussnegger M, Götz G, Jakstat H, Koeck B, Neff A, Ottl P, Reiber T. Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde [Internet]; Düsseldorf: Zur Therapie der funktionellen Erkrankungen des kraniomandibulären Systems: Wissenschaftliche Stellungnahme der Deutschen Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK): Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde
(DGZMK);
2005[cited
2012
Jun12].
Available
from:
http://www.dgfdt.de/fileadmin/docs/07_Stellungnahme_Erkrankung_kraniomandibula eres_System.pdf. 2. Al-Jundi MA, John MT, Setz JM, Szentpetery A, Kuss O. Meta-analysis of treatment need for temporomandibular disorders in adult nonpatients. J Orofac Pain 2008; 22(2):97–107. 3. Peroz I. Untersuchungen zur Diskusverlagerung ohne Reposition am Kiefergelenk [Habilitation]. Berlin: Zentrum für Zahnmedizin der Medizinischen Fakultät Charité der Humboldt-Universität; 2004.
13
4. Whyte AM, McNamara D, Rosenberg I, Whyte AW. Magnetic resonance imaging in the evaluation of temporomandibular joint disc displacement--a review of 144 cases. Int J Oral Maxillofac Surg 2006; 35(8):696–703. 5. Petersson A. What you can and cannot see in TMJ imaging - an overview related to the RDC/TMD diagnostic system. J Oral Rehabil 2010; 37(10):771–8. 6. Styles C, Whyte A. MRI in the assessment of internal derangement and pain within the temporomandibular joint: a pictorial essay. Br J Oral Maxillofac Surg 2002; 40(3):220–8. 7. Westesson PL. Reliability and validity of imaging diagnosis of temporomandibular joint disorder. Adv Dent Res 1993; 7(2):137–51. 8.
Vogl
T,
Eberhard
D.
MR-Tomographie
Temporomandibulargelenk:
Untersuchungstechnik, klinische Befunde, diagnostische Strategien. Stuttgart: Thieme; 1993. 9. Vogl TJ, Eberhard D, Randzio J, Schmid C, Lissner J. MR tomographic diagnosis of internal derangement of the temporomandibular joint. Radiologe 1991; 31(11):537–44. 10. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989; 115(4):469–77. 11. Ottl P, Hohmann A, Piwowarczyk A, Hardenacke F, Lauer H, Zanella F. Retrospective study on the evaluation of the TMJ by MRI using a newly developed standardized evaluation form. Cranio 2008; 26(1):33–43. 12. Taskaya-Yylmaz N, Ogutcen-Toller M. Clinical correlation of MRI findings of internal derangements of the temporomandibular joints. Br J Oral Maxillofac Surg 2002; 40(4):317–21. 14
13.
Bundezahnärztekammer
(BZÄK)
[Internet].
Berlin:
Leitlinien
der
Bundeszahnärztekammer: Psychosomatik in der Zahn-, Mund- und Kieferheilkunde; 2006
[cited
2012
Jun
1].
Available
from:
http://www.bzaek.de/fileadmin/PDFs/za/leitfaden_psychosomatik.pdf. 14. Kanter RJ de, Truin GJ, Burgersdijk RC, van Hof MA 't, Battistuzzi PG, Kalsbeek H et al. Prevalence in the Dutch adult population and a meta-analysis of signs and symptoms of temporomandibular disorder. J Dent Res 1993; 72(11):1509–18. 15. Im Dias, Coelho PR, Assis NM, Leite FP, Devito KL. Evaluation of the correlation between
disc
displacements
and
degenerative
bone
changes
of
the
temporomandibular joint by means of magnetic resonance images. Int J Oral Maxillofac Surg 2012. 16. Westesson PL, Katzberg RW, Tallents RH, Sanchez-Woodworth RE, Svensson SA. CT and MR of the temporomandibular joint: comparison with autopsy specimens. AJR Am J Roentgenol 1987; 148(6):1165–71. 17. Tasaki MM, Westesson PL. Temporomandibular joint: diagnostic accuracy with sagittal and coronal MR imaging. Radiology 1993; 186(3):723–9. 18. Katzberg RW, Westesson PL, Tallents RH, Anderson R, Kurita K, Manzione JV, JR et al. Temporomandibular joint: MR assessment of rotational and sideways disk displacements. Radiology 1988; 169(3):741–8. 19. Maizlin ZV, Nutiu N, Dent PB, Vos PM, Fenton DM, Kirby JM et al. Displacement of the temporomandibular joint disk: correlation between clinical findings and MRI characteristics. J Can Dent Assoc 2010; 76:a3. 20. Usumez S, Oz F, Guray E. Comparison of clinical and magnetic resonance imaging diagnoses in patients with TMD history. J Oral Rehabil 2004; 31(1):52–6. 15
21. Bertram S, Rudisch A, Innerhofer K, Pumpel E, Grubwieser G, Emshoff R. Diagnosing TMJ internal derangement and osteoarthritis with magnetic resonance imaging. J Am Dent Assoc 2001; 132(6):753–61. 22. Emshoff R, Innerhofer K, Rudisch A, Bertram S. Clinical versus magnetic resonance imaging findings with internal derangement of the temporomandibular joint: an evaluation of anterior disc displacement without reduction. J Oral Maxillofac Surg 2002; 60(1):36-41; discussion 42-3. 23.
Emshoff
R,
Rudisch
A.
Validity
of
clinical
diagnostic
criteria
for
temporomandibular disorders: clinical versus magnetic resonance imaging diagnosis of temporomandibular joint internal derangement and osteoarthrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91(1):50–5. 24. Park JW, Song HH, Roh HS, Kim YK, Lee JY. Correlation between clinical diagnosis based on RDC/TMD and MRI findings of TMJ internal derangement. Int J Oral Maxillofac Surg 2012; 41(1):103–8. 25. Schmitter M, Kress B, Hahnel S, Rammelsberg P. The effect of quality of temporomandibular joint MR images on interrater agreement. Dentomaxillofac Radiol 2004; 33(4):253–8. 26. Sutton DI, Sadowsky PL, Bernreuter WK, McCutcheon MJ, Lakshminarayanan AV. Temporomandibular joint sounds and condyle/disk relations on magnetic resonance images. Am J Orthod Dentofacial Orthop 1992; 101(1):70–8. 27. Chowdary UV, Rajesh P, Neelakandan RS, Nandagopal CM. Correlation of clinical and MRI findings of tempero-mandibular joint internal derangement. Indian J Dent Res 2006; 17(1):22–6.
16
28. Manfredini D, Basso D, Salmaso L, Guarda-Nardini L. Temporomandibular joint click sound and magnetic resonance-depicted disk position: which relationship? J Dent 2008; 36(4):256–60. 29. Eriksson L, Westesson PL, Rohlin M. Temporomandibular joint sounds in patients with disc displacement. Int J Oral Surg 1985; 14(5):428–36. 30. Westesson PL, Brooks SL. Temporomandibular joint: relationship between MR evidence of effusion and the presence of pain and disk displacement. AJR Am J Roentgenol 1992; 159(3):559–63.
17
Figure Legends:
Figure 1: MR imaging of central parts of a joint in parasagittal plane and closed mouth position. (A) The disk is biconcave and is located superior to the condyle (B). Indication for a MRI was a follow-up control during splint therapy. Physiological shape and position of condyle and disc could be verified.
18
Figure 2: MR imaging of TMJ in parasagittal plane with a rounded disc in anterior position (A) in relation to the condyle (B). The intra-articular space is empty (C). Indications for MRI were suspected anterior disc displacement with arthralgia which could be verified by MRI.
19
Figure 3: MR image of TMJ with a flattened disc in posterior position in relation to the condyle (B). Indications for running MR images were bruxism and joint clicking. Aftereffects bruxism could be the flattened shape of the disc.
20
Figure 4: MR image of TMJ (T2 weighted) with a rounded disc in an anterior position (A) and a low signal of intra-articular fluid (B). Indications for a MRI were occasional pain in TMJ region, which could be confirmed by MRI.
21
Figure 5: MR image (T2 weighted) with intense signs of joint effusion (A), a degenerated disc in anterior position (B) and degenerated condyle with osteophytes (C). Indication or running a MRI were severe pain and reduced mouth opening. Clinical symptoms correlated well with aquired MR images.
22
Figure 6: comparison of closed (left image) and open (right image) mouth MR sequences with normal disc position (A) located superior to the condyle (B). Normal mouth opening was achieved. Indication for MRI was a follow-up during splint therapy.
23
Figure 7: closed (left image) and open (right image) mouth MR sequences of a rounded and thickened disc with anterior disc position (A) in relation to condyle (B) without repositioning. Indication for a MRI arthralgia und limitation of mouth opening, which correspond the MRI findings.
24
Tables Table 1 Correlation between clinical examination and MRI findings for DDWR and DDWOR
diagnosis
n=
true-
true-
false-
false-
positive
negative
positive
negative
DDWR
713
137
473
65
38
DDWOR
875
278
418
76
103
Table 2 Sensitivity, Specifity, and predictive values of clinical examination compared to MRI
diagnosis
sensitivity
specificity
positive
negative
predictive
predictive
value
value
DDWR
78
88
0.68
0.93
DDWOR
73
84
0.79
0.8
25
S0720-048X(16)30028-6 http://dx.doi.org/doi:10.1016/j.ejrad.2016.02.001 EURR 7388
To appear in:
European Journal of Radiology
Received date: Revised date: Accepted date:
21-10-2015 17-1-2016 1-2-2016
Please cite this article as: Vogl Thomas J, Lauer Hans-Christoph, Lehnert Thomas, Naguib Nagy NN, Ottl Peter, Filmann Natalie, Soekamto Howard, NourEldin Nour-Eldin A.The value of MRI in patients with temporomandibular joint dysfunction: Correlation of MRI and clinical findings.European Journal of Radiology http://dx.doi.org/10.1016/j.ejrad.2016.02.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The value of MRI in patients with temporomandibular joint dysfunction: Correlation of MRI and clinical findings
Thomas J. Vogl1, Hans-Christoph Lauer², Thomas Lehnert1, Nagy N. N. Naguib1,3, Peter Ottl4, Natalie Filmann5, Howard Soekamto², Nour-Eldin A. Nour-Eldin1,6 1
Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany ²Department of Prosthodontics, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany 3
Department of Diagnostic and Interventional Radiology, Alexandria University, Alexandria, Egypt 4
Department of Prosthodontics, University Hospital Rostock, Hans Moral, University of Rostock, Rostock, Germany 5
Department of Biomedical Statistics, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt am Main, Germany 6
Department of Diagnostic and Interventional Radiology, Cairo University, Cairo, Egypt
Corresponding author: Nour-Eldin A. Nour-Eldin , MD, PhD Institute for Diagnostic and Interventional Radiology Johann Wolfgang Goethe-University Frankfurt Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany Tel.: + 49 69-6301-7278 Fax.: + 49 69-6301-7258 E-mail: [email protected]
1
ABSTRACT Aim: To estimate the correlation between the MRI findings and clinical outcomes in patients with temporomandibular joint dysfunction (TMD). Methods and Materials: We included 546 female and 248 male patients who were clinically diagnosed with TMD (mean age 38.7 years) and examined by MRI (T1 and T2 weighted images, parasagittal and paracoronal slices). A questionnaire, radiological, and clinical findings were analysed for statistically significant correlations. The analysed parameters included gender, age, disk position, joint degeneration, arthralgia, mouth opening, condyle position and clinical progress. Results: Of all TMJ’s 62% showed physiological disc position, 35% anterior and 3% posterior disc position. Modification of therapy occurred in 20% and alteration of diagnosis was found in 32% of all cases. Anterior disc displacement with reduction showed a specificity of 88% and a sensitivity of 78%, whereas anterior disc displacement without reduction showed a specificity of 84% and a sensitivity of 73%. A significant correlation between disc length, condyle morphology and disc displacement was found. With the increase of intra-articular liquid as seen on MRI the level of arthralgia significantly rose as opposed to mouth opening. Conclusion: Specificity and sensitivity, for anterior disc displacement and osseous changes in TMJ were highly acceptable. Results had confirmed the diagnostic capability of MRI 2
in diagnostic imaging of TMJ. Additionally MRI should be used primarily in severe, therapy-resistant cases and for surgical planning purposes.
Keywords: magnetic resonance imaging (MRI), temporomandibular joint disorder (TMD), internal derangement
INTRODUCTION Temporomandibular joint dysfunction (TMD) is characterized by clinical symptoms such as arthralgia, joint clicking, alteration of mandibular movement, and disc displacement (1-3). These disorders may be caused by deranged or degenerated intra-articular components. The commonest cause of
internal
derangement (ID) is an imbalance among condyle, temporal bone, and discus articularis. Anterior disc displacement is most frequently found compared to posterior, medial or lateral dislocation (4). On mouth opening disc displacement can be reduced (disc displacement with reduction, DDWR) or remain displaced (disc displacement without reduction, DDWOR). A disc displacement is often combined with joint clicking or crepitus. Moreover degenerated discs, joint effusion, and osseous changes of condyle and temporal bone are late stages in TMD. Out of all potential options, MRI is currently the gold standard (3,5-7) for evaluating TMD compared to conventional or computed tomography. The advantage of a non-invasive, radiation-free imaging technique combined with high tissue contrast and the ability to assess joint effusion is unmatched. However with growing number of patients, an effective and economical use of MRI is highly desirable in order to reduce costs and treatment time. However, how reliable are the clinical 3
examinations and clinical signs; is an important question that needs careful attention. A clinical study is required to determine the pros and cons of MRI in comparison to clinical appearances. The current study evaluates the validity and utility of MRI in TMD patients. Correlations between clinical symptoms and MRI findings as well as further clinical progress were analysed for specific conspicuous characteristics.
MATERIALS AND METHODS: Patients The study was approved by the Clinical Research Ethics Committee of the University Hospital. All patients signed consent prior to
the MRI examination
including the utility of clinical data for research purposes. The files of the Institute for Diagnostic and Interventional Radiology at a University Hospital were explored for patients who received MRI examination of their temporomandibular joint (TMJ) from January 2000 to December 2010. The inclusion criteria included all patients who were referred with a suspected diagnosis of TMD at any age. Indications for MRI examination were: change of disc position, arthralgia, joint sounds and osteoarthritis. Exclusion criteria for MRI were patients with general contraindications to MRI e.g. patients with cardiac pacemaker, known metallic foreign bodies not compatible to MRI. In addition patients who were claustrophobic with consequent early termination of the examination were also excluded. All Patients received a questionnaire in which they were asked to answer questions regarding their clinical symptoms and therapy. Unanswered questions were
4
considered missing and not included in the evaluation. The clinical symptoms described in the referring letter were recorded. MRI Technique All images were obtained by a 1.5 Tesla Symphony Quantum or Avanto MRI (Siemens Medical, Erlangen, Germany) with a bilateral 80 mm diameter TMJ coil and 3 mm thick sections with a 190 mm field of view and a 256 matrix. With the help of localizers; sagittal and coronal oblique planes were obtained. The following sequences were performed: T1-weighted images (200/11 TR/TE) to assess disc position, disc morphology and osseous changes. T2-weighted images (1500/20 TR/TE) to determine joint fluid and joint effusion. Both sequences were acquired in occlusion and maximum mouth opening. Maximum mouth opening was measured in millimetres. No motion artefacts were tolerated. All MR images were diagnosed by a head and neck / maxillofacial radiologist with over 25 years of experience. TMJ pairs were analysed separately. Image evaluation With the help of T1 weighted images in closed mouth position, the disc position was divided according to the classification by Vogl et al. (8) into: disc position was deemed as normal if the posterior band in relation to condyle was located between 11 and 12 o´clock. A disc displacement below 11 o´clock was considered as anterior displacement and disc displacement above 12 o´clock as posterior displacement. MR images of all three categories are presented in Fig. 1 to 3. Using T2 weighted MR; images possible joint effusion was assessed and classified into absent signal of fluid, low signal of fluid, and joint effusion (see Fig. 4 and 5). Reduction of the disc was assessed by comparing T1 weighted MR images in open 5
and closed mouth position (see Fig. 6 and 7) and classified as disc displacement with or without reduction. All patients were grouped into Internal Derangement Grade (810) based on their findings. The appearance of the condyle was divided into normal and degenerated (plane, sharpened, and flattened (8). The morphology of the disc in the T1 sagittal plane was classified according to Ottl et al. (11) and Taskaya-Yylmaz et
al.
(12)
as
biconcave/normal,
biplane/flat,
thickened,
biconvex,
fragmented/destroyed. Disc deformity was also classified as: no deformity (biconcave) and deformed (all other forms). Statistical analysis Main objective of this study was to determine the sensitivity and specificity of clinical examination in comparison to MRI in a high number of patients. Suspected diagnose of DDWR or DDWOR were compared to radiological findings. To make an objective determination of statistically significant correlations of the parameters: age, disc length, disc position, joint effusion, maximum mouth opening, morphology,
and
Internal
Derangement
Grade
in
each
condyle case the
Spearman correlation coefficient was determined. To assess whether gender of a patient could be relevant the Mann-Whitney U-test was determined for the parameters: age, disc length, disk position, and morphology of the condyle. All statistical tests were two-tailed and used a significance level of alpha =5% (p<0.05). All data were entered into Excel 2007 (Microsoft Corporation, Redmond, WA, USA) and statistical analysis was performed with PASW Statistics, Release Version 18.0.0 (SPSS, Inc., 2009, Chicago, IL, USA). Biometric analysis was accomplished under supervision and guidance by employees of the Department of Biostatistics at the University.
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Results Clinical findings of patients Patients in this study included 546 women and 248 men with a mean age of 38.7 ±16 years (range 14-83 years); 69% were females and 31 % males. There was no significant correlation between gender and age (Mann-Whitney-U-Test p > 0.05). Forty-three percent of all cases were referred by Prosthodontics, 34% by maxillofacial surgeons, 17% by Orthodontics, 4% by Orthopaedists, and 2% by ENT specialists. Based on clinical records indications for MRI examination were: 34% disc displacement, 30% arthralgia, 13% arthrosis, 9% joint clicking, 7% limitation of mandibular movement, 4% joint effusion, 3% myofascial pain. By means of clinical records and a questionnaire a change in therapy could be shown for 20% which included change of splint therapy (relaxing, reposition, or distraction), additional orthodontics, maxillofacial surgery, change in treatment order, and no further therapy. Alteration of diagnosis (32%) was mostly additional information regarding osteoarthritis, capsulitis, disc position, and disc replacement. MRI findings A rough division for sagittal disc position in MRI indicated that 62 % of all TMJ’s showed normal disc position, 35 % anterior and 3 % showed posterior disc position. Using cross tabulation the sensitivity and sensibility for clinical examination of anterior disc displacement with and without replacement were obtained while MRI was considered as gold standard. Anterior disc displacement with reduction (DDWR) showed a specificity of 84% and a sensitivity of 73% whereas anterior disc displacement without reduction (DDWOR) showed a sensitivity of 73% and a sensibility of 84% (see Table 1 and 2). The results of all cases classified by Internal 7
Derangement Grade were: Grade I: 28 %, II: 21%, III: 26%, IV: 9%, V: 14%, VI: 2%. (8,9) Correlation between clinical and MRI findings In order to assess the usefulness of the Internal Derangement Grade classification we compared radiological findings with clinical parameters. Therefore each Spearman-Rho coefficient was calculated in order to make an exact statement. A significant correlation between deformation of a condyle and a limitation of mouth opening (p<0.005) could be shown (normal condyle: average of 37 mm vs. deformed condyle average of: 34 mm). Comparing destructed and normal condyles with the chance of JE our study revealed a connection between destructed condyles and JE (p<0.05). The less mouth opening could be registered the higher was the determined classification of Internal Derangement Grade (p < 0.001). In the same way the length of the disc decreased with a rising Internal Derangement Grade (p < 0.001). No correlation between mouth opening and disk length was significant (p > 0.05) and mouth opening and joint effusion correlated well with each other (p < 0.05). When signal of fluid was absent an average of 39 mm mouth opening was determined, while low signal of fluid (see Fig. 4) and JE showed (see Fig. 5) an average of 36 mm respectively 34 mm. By dividing the disc form into normal and degenerated groups a significant connection between JE and disc deformation could be shown (p < 0.01). JE was found with a higher probability in patients with DDWOR compared to DDWR or normal disc position (p < 0.001). In joints with normal disc position JE occurred in 7%, in 19% of cases with DDWR whilst 22% of DDWOR showed JE. Significant results could be shown for symptomatic (pain) and asymptomatic joints in relation to their disc displacement: out of all asymptomatic joints (139) 27% had no disc displacement, 38% had DDWR and 31% showed DDWOR and 3 % posterior disc 8
displacement. On the other hand symptomatic joints (285): 19% showed no disc displacement, 33% showed DDWR and 46% showed DDWOR and 1% posterior disc displacement. Cases with DDWR and DDWOR which showed joint clicking were almost even (66% vs. 69%), whereas the occurrence of both diagnoses in joints with clicking varied (33% vs. 47%, p<0.05). According to our study a correlation between clicking and joint pain could not be verified (p>0.05).
Discussion Since the prevalence of TMD is up to 21% (2,13,14), an effective and efficient therapy management is needed. A clinical examination of the TMJ should not be skipped since the acquired findings are an indication for further diagnostics. Imaging the TMJ has the goal to assess the integrity of hard and soft tissue components inside the TMJ, to confirm the stage of disease, and to evaluate the effects of treatment. (15) By comparing conventional and computed radiography, and MRI Petersson et al. (5) suggested MRI to be the method of choice. The advantage of a complete TMJ assessment including disc, condyle, fossa, and joint effusion is yet unmatched. Different studies underlined the status of MRI being the gold standard in TMJ assessment. Westesson et al. (16) compared disc positions in autopsy specimens and MRI which showed a sensitivity of 0.86 and specificity of 0.63. Tasaki et al. (17) and Katzberg et al. (18) also revealed high accuracy of MRI in explanted TMJ’s for disc position and osseous changes. Assessing disc position is an important aspect in evaluating a TMJ, as Maizlin et al. (19) showed that occurrence of disc displacement was statistically significant higher for symptomatic joints than for asymptomatic joints. 9
Change of disc position is important but only one part of this complex disease. That could be the reason why the majority of our patients (62%) showed normal disc position and were referred with TMD. Other symptoms should be beared in mind such as JE, mouth opening, muscle tenderness, and grinding. Usumez et al. (20) published results (72% DDWR, 81% DDWOR) are similar to our results and show a high sensitivity and specificity for clinical examination of anterior disc displacements. Accordance between clinical and radiological diagnosis has been published with a wide range from 59% up to 90%. (19,21-24) Possible reasons for a low level of correlation could be an imprecise clinical examination, variation in technical equipment, protocols and patient population which lead to varying results. Schmitter et al. (25) published that with high quality images a good interobserver agreement could be shown. Another reason for varying results could be that the progress from DDWR to DDWOR is a flowing transition and hard to distinguish for patient and practitioner. These problems are aggravated by additional difficulties of TMJ examinations such as different diagnosis schemes, different examination criteria, and low interobserver reliability. (25) The level of degeneration and displacement of the disc is an important indicator for possible TMD. Sutton et al. (26) reported that a normal disc position was more likely in the clinically silent group than in the group with discernible sounds. Chowdary et al. (27) found an agreement among clinical symptoms such as muscle tenderness, clicking and arthralgia which correlated with MRI findings of the disc. With the ongoing degeneration of the disc the severity of the disease grew. Assessing the disc´s position has a primary role in evaluating the status a TMJ and estimating the risk of possible TMD. But according to our findings with 63% of normal disc position in TMD related patients other extra-capsular risk factors - such as 10
grinding, malocclusion, muscle tenderness, and psychological stress- must be kept in mind. The current results showed that joints with normal disc position JE occurred in 7%, in 19% of cases with DDWR whilst 22% of DDWOR showed JE. Significant results could be shown for symptomatic (pain) and asymptomatic joints in relation to their disc displacement: out of all asymptomatic joints (139) 27% had no disc displacement, 38% had DDWR and 31% showed DDWOR and 3 % posterior disc displacement. Joint clicking as a clinical symptom did not correlate with radiological findings or arthralgia. The number of joints with DDWR and DDWOR that showed joint clicking was almost even (66 % vs. 69 %), whereas the occurrence of both diagnoses in joints with clicking varied (33 % vs. 47 %). These results agree with those published (28) whereas other studies (10,29) suggest that clicking is an accurate sign of DDWR. We assume joint sounds have multiple reasons (reduction, osseous changes, cartilaginous changes) and MRI can deliver precise information and thereby support therapy in uncertain cases. Nevertheless disagreement among studies may occur due to differences in patients’ cohort and data interpretation. However, the question whether disc displacement is a result, the cause, or an accompanying factor remains a point of controversy (22). Since results showed that prevalence of JE rose with the severity of disc displacement and destruction of condyle a connection among these components should be considered. Published data (19,24,30) align with our results comparing JE and deformation of disc and condyle which if treated in time might prevent highly associated joint pain. Change of treatment could be found in 20% and alteration of diagnosis in 32% of all cases. This seems to be a high amount, however in order to evaluate the results further analysis is needed. Regarding the 11
question whether MRI related alteration of diagnosis or change of treatment has a positive effect, further long-term prospective studies are necessary. This study was limited by being a monocenter study, clinical and MRI findings were compared in only symptomatic group, and data was surveyed retrospectively. All patients were referred because of TMD which included a wide range of symptoms; this may explain the high number of 62 % of patients with no disc displacement. This study contained only findings of TMD; other additional information regarding general disease such as arthritic changes, traumata, or duration of disease were not included. For both the patient and the clinician, it’s hard to distinguish the level of progression; because symptoms differ in perception, vary during the day, and general disease can affect TMD. Therefore, standardized MRI protocols and clinical TMJ examination should be applied as well as periodical adjustment between radiologist and clinician. Since TMD is a protracted disease, a long term prospective study with a large number of asymptomatic and symptomatic patients is needed for more information regarding MRI findings and clinical symptoms. Furthermore validity should be confirmed by multicentre studies. Because the aetiology of TMD is yet not fully understood and for a better therapy prognosis, clinical and MRI based findings should be analyzed in relation to their treatment outcome. Good values for specificity, sensitivity for anterior disc displacement in TMJ were found and comparing available alternatives the MRI is currently the gold standard in imaging TMJ. MRI adds important information regarding grade of destruction and interaction of intra-articular components. Indications for running MRI are severe pain, therapy-resistant cases, therapy monitoring and surgical planning purposes. (6) More data is necessary to understand the progress and prevalence of TMD in order to rethink and renew clinical treatment. The study's findings suggest 12
that using MRI supports clinical findings of TMJ and appears necessary in certain cases to establish the presence or absence of TMD.
References 1. Ahlers M, Freesmeyer W, Fussnegger M, Götz G, Jakstat H, Koeck B, Neff A, Ottl P, Reiber T. Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde [Internet]; Düsseldorf: Zur Therapie der funktionellen Erkrankungen des kraniomandibulären Systems: Wissenschaftliche Stellungnahme der Deutschen Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK): Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde
(DGZMK);
2005[cited
2012
Jun12].
Available
from:
http://www.dgfdt.de/fileadmin/docs/07_Stellungnahme_Erkrankung_kraniomandibula eres_System.pdf. 2. Al-Jundi MA, John MT, Setz JM, Szentpetery A, Kuss O. Meta-analysis of treatment need for temporomandibular disorders in adult nonpatients. J Orofac Pain 2008; 22(2):97–107. 3. Peroz I. Untersuchungen zur Diskusverlagerung ohne Reposition am Kiefergelenk [Habilitation]. Berlin: Zentrum für Zahnmedizin der Medizinischen Fakultät Charité der Humboldt-Universität; 2004.
13
4. Whyte AM, McNamara D, Rosenberg I, Whyte AW. Magnetic resonance imaging in the evaluation of temporomandibular joint disc displacement--a review of 144 cases. Int J Oral Maxillofac Surg 2006; 35(8):696–703. 5. Petersson A. What you can and cannot see in TMJ imaging - an overview related to the RDC/TMD diagnostic system. J Oral Rehabil 2010; 37(10):771–8. 6. Styles C, Whyte A. MRI in the assessment of internal derangement and pain within the temporomandibular joint: a pictorial essay. Br J Oral Maxillofac Surg 2002; 40(3):220–8. 7. Westesson PL. Reliability and validity of imaging diagnosis of temporomandibular joint disorder. Adv Dent Res 1993; 7(2):137–51. 8.
Vogl
T,
Eberhard
D.
MR-Tomographie
Temporomandibulargelenk:
Untersuchungstechnik, klinische Befunde, diagnostische Strategien. Stuttgart: Thieme; 1993. 9. Vogl TJ, Eberhard D, Randzio J, Schmid C, Lissner J. MR tomographic diagnosis of internal derangement of the temporomandibular joint. Radiologe 1991; 31(11):537–44. 10. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989; 115(4):469–77. 11. Ottl P, Hohmann A, Piwowarczyk A, Hardenacke F, Lauer H, Zanella F. Retrospective study on the evaluation of the TMJ by MRI using a newly developed standardized evaluation form. Cranio 2008; 26(1):33–43. 12. Taskaya-Yylmaz N, Ogutcen-Toller M. Clinical correlation of MRI findings of internal derangements of the temporomandibular joints. Br J Oral Maxillofac Surg 2002; 40(4):317–21. 14
13.
Bundezahnärztekammer
(BZÄK)
[Internet].
Berlin:
Leitlinien
der
Bundeszahnärztekammer: Psychosomatik in der Zahn-, Mund- und Kieferheilkunde; 2006
[cited
2012
Jun
1].
Available
from:
http://www.bzaek.de/fileadmin/PDFs/za/leitfaden_psychosomatik.pdf. 14. Kanter RJ de, Truin GJ, Burgersdijk RC, van Hof MA 't, Battistuzzi PG, Kalsbeek H et al. Prevalence in the Dutch adult population and a meta-analysis of signs and symptoms of temporomandibular disorder. J Dent Res 1993; 72(11):1509–18. 15. Im Dias, Coelho PR, Assis NM, Leite FP, Devito KL. Evaluation of the correlation between
disc
displacements
and
degenerative
bone
changes
of
the
temporomandibular joint by means of magnetic resonance images. Int J Oral Maxillofac Surg 2012. 16. Westesson PL, Katzberg RW, Tallents RH, Sanchez-Woodworth RE, Svensson SA. CT and MR of the temporomandibular joint: comparison with autopsy specimens. AJR Am J Roentgenol 1987; 148(6):1165–71. 17. Tasaki MM, Westesson PL. Temporomandibular joint: diagnostic accuracy with sagittal and coronal MR imaging. Radiology 1993; 186(3):723–9. 18. Katzberg RW, Westesson PL, Tallents RH, Anderson R, Kurita K, Manzione JV, JR et al. Temporomandibular joint: MR assessment of rotational and sideways disk displacements. Radiology 1988; 169(3):741–8. 19. Maizlin ZV, Nutiu N, Dent PB, Vos PM, Fenton DM, Kirby JM et al. Displacement of the temporomandibular joint disk: correlation between clinical findings and MRI characteristics. J Can Dent Assoc 2010; 76:a3. 20. Usumez S, Oz F, Guray E. Comparison of clinical and magnetic resonance imaging diagnoses in patients with TMD history. J Oral Rehabil 2004; 31(1):52–6. 15
21. Bertram S, Rudisch A, Innerhofer K, Pumpel E, Grubwieser G, Emshoff R. Diagnosing TMJ internal derangement and osteoarthritis with magnetic resonance imaging. J Am Dent Assoc 2001; 132(6):753–61. 22. Emshoff R, Innerhofer K, Rudisch A, Bertram S. Clinical versus magnetic resonance imaging findings with internal derangement of the temporomandibular joint: an evaluation of anterior disc displacement without reduction. J Oral Maxillofac Surg 2002; 60(1):36-41; discussion 42-3. 23.
Emshoff
R,
Rudisch
A.
Validity
of
clinical
diagnostic
criteria
for
temporomandibular disorders: clinical versus magnetic resonance imaging diagnosis of temporomandibular joint internal derangement and osteoarthrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91(1):50–5. 24. Park JW, Song HH, Roh HS, Kim YK, Lee JY. Correlation between clinical diagnosis based on RDC/TMD and MRI findings of TMJ internal derangement. Int J Oral Maxillofac Surg 2012; 41(1):103–8. 25. Schmitter M, Kress B, Hahnel S, Rammelsberg P. The effect of quality of temporomandibular joint MR images on interrater agreement. Dentomaxillofac Radiol 2004; 33(4):253–8. 26. Sutton DI, Sadowsky PL, Bernreuter WK, McCutcheon MJ, Lakshminarayanan AV. Temporomandibular joint sounds and condyle/disk relations on magnetic resonance images. Am J Orthod Dentofacial Orthop 1992; 101(1):70–8. 27. Chowdary UV, Rajesh P, Neelakandan RS, Nandagopal CM. Correlation of clinical and MRI findings of tempero-mandibular joint internal derangement. Indian J Dent Res 2006; 17(1):22–6.
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28. Manfredini D, Basso D, Salmaso L, Guarda-Nardini L. Temporomandibular joint click sound and magnetic resonance-depicted disk position: which relationship? J Dent 2008; 36(4):256–60. 29. Eriksson L, Westesson PL, Rohlin M. Temporomandibular joint sounds in patients with disc displacement. Int J Oral Surg 1985; 14(5):428–36. 30. Westesson PL, Brooks SL. Temporomandibular joint: relationship between MR evidence of effusion and the presence of pain and disk displacement. AJR Am J Roentgenol 1992; 159(3):559–63.
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Figure Legends:
Figure 1: MR imaging of central parts of a joint in parasagittal plane and closed mouth position. (A) The disk is biconcave and is located superior to the condyle (B). Indication for a MRI was a follow-up control during splint therapy. Physiological shape and position of condyle and disc could be verified.
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Figure 2: MR imaging of TMJ in parasagittal plane with a rounded disc in anterior position (A) in relation to the condyle (B). The intra-articular space is empty (C). Indications for MRI were suspected anterior disc displacement with arthralgia which could be verified by MRI.
19
Figure 3: MR image of TMJ with a flattened disc in posterior position in relation to the condyle (B). Indications for running MR images were bruxism and joint clicking. Aftereffects bruxism could be the flattened shape of the disc.
20
Figure 4: MR image of TMJ (T2 weighted) with a rounded disc in an anterior position (A) and a low signal of intra-articular fluid (B). Indications for a MRI were occasional pain in TMJ region, which could be confirmed by MRI.
21
Figure 5: MR image (T2 weighted) with intense signs of joint effusion (A), a degenerated disc in anterior position (B) and degenerated condyle with osteophytes (C). Indication or running a MRI were severe pain and reduced mouth opening. Clinical symptoms correlated well with aquired MR images.
22
Figure 6: comparison of closed (left image) and open (right image) mouth MR sequences with normal disc position (A) located superior to the condyle (B). Normal mouth opening was achieved. Indication for MRI was a follow-up during splint therapy.
23
Figure 7: closed (left image) and open (right image) mouth MR sequences of a rounded and thickened disc with anterior disc position (A) in relation to condyle (B) without repositioning. Indication for a MRI arthralgia und limitation of mouth opening, which correspond the MRI findings.
24
Tables Table 1 Correlation between clinical examination and MRI findings for DDWR and DDWOR
diagnosis
n=
true-
true-
false-
false-
positive
negative
positive
negative
DDWR
713
137
473
65
38
DDWOR
875
278
418
76
103
Table 2 Sensitivity, Specifity, and predictive values of clinical examination compared to MRI
diagnosis
sensitivity
specificity
positive
negative
predictive
predictive
value
value
DDWR
78
88
0.68
0.93
DDWOR
73
84
0.79
0.8
25