Effects of four treatment strategies for temporomandibular joint closed lock.

A previous randomized controlled trial (RCT) by Schiffman et al. (2007)(15) compared four treatments strategies for temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock). In this parallel group RCT, 106 patients with magnetic resonance imaging (MRI)-confirmed TMJ closed lock were randomized between medical management, non-surgical rehabilitation, arthroscopic surgery, and arthroplasty. Surgical groups also received rehabilitation post-surgically. The current paper reassesses the effectiveness of these four treatment strategies using outcome measures recommended by the International Association of Oral and Maxillofacial Surgeons (IAOMS). Clinical assessments at baseline and at follow-up (3, 6, 12, 18, 24, and 60 months) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing. TMJ MRIs were performed at baseline and 24 months, and TMJ tomograms at baseline, 24 and 60 months. Most IAOMS recommended outcome measures improved significantly over time (P≤0.0003). There was no difference between treatment strategies relative to any treatment outcome at any follow-up (P≥0.16). Patient self-assessment of treatment success correlated with their ability to eat, with pain-free opening ≥35mm, and with reduced pain intensity. Given no difference between treatment strategies, non-surgical treatment should be employed for TMJ closed lock before considering surgery.

Pressure-pain thresholds and MRI effusions in TMJ arthralgia.

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

Condylar position as a predictor of temporomandibular joint internal derangement.

Scout tomograms and arthrograms of 243 patients were separated and numbered. The location of the condyle within the fossa in the closed-mouth position was assessed by means of three evaluation techniques. Later, the arthrograms were interpreted and matched with the corresponding tomograms to evaluate the relationship between posterior displacement of the condyle and anterior displacement of the articular disk. The position of the disk within the fossa was found to be extremely variable whether disk position was normal or abnormal.

The effects of temporomandibular joint internal derangement and degenerative joint disease on tomographic and arthrotomographic images.

In a blind study, 243 arthrograms were interpreted as showing normal disk position, anterior disk displacement with reduction, or anterior disk displacement without reduction. The presence or absence of a perforation of the posterior attachment or disk was recorded. Later, tomograms of the same patient were interpreted. The presence or absence of evidence of temporomandibular degenerative joint disease (TMDJD) was recorded. The condyle-to-fossa relationship was characterized as retropositioned or not retropositioned. O the 106 cases with tomographic evidence of TMDJD, 100 (94%) had arthrographic evidence of internal derangement (p less than 0.0001), whereas 47% of the cases with internal derangement (211) had evidence of TMDJD. Perforations were seen in 29 (27%) of the cases with degenerative joint disease and in none (0%) of the cases without TMDJD (p less than 0.001). In cases without TMDJD, 90% of the cases with internal derangement revealed condylar retropositioning (p less than 0.0001). With tomographic evidence of TMDJD present, the relationship between condylar position and disk position was not significant.

Pathologic evaluation of disc dysfunction and osseous abnormalities of the temporomandibular joint.

The arthrographic findings in 141 patients with TMJ symptoms were compared with the linear tomographic evaluation to assess the incidence and severity of associated osseous abnormalities. Thirty-nine temporomandibular joints (28%) had significant osseous abnormalities compatible with degenerative joint disease. The incidence and severity of the degenerative changes compared favorably with the arthrographic assessment of the degree of soft-tissue injury. A cause-and-effect relationship between TMJ disc damage and dysfunction and degenerative arthritis is suggested.

Loose bodies of the temporomandibular joint: arthrographic diagnosis.

We report a series of four patients presenting with symptoms of temporomandibular joint pain and dysfunction, and manifesting calcified loose bodies within the temporomandibular joint. Tomographic and arthrotomographic findings are described. Surgical confirmation was obtained in two patients and the histopathology in one demonstrated that the loose body was calcified cartilage surrounded by synovial tissue. The synovial tissue of the joint space was normal in all four cases by arthrotomography and at surgery in two patients. The findings suggest that these cases may be examples of osteochondrosis dissecans.

Dislocation of jaws.

Pluri-directional tomographic and arthrotomographic findings are described in six patients with dislocation of the jaw severe enough to require medical assistance. A grooved defect along the posterior aspect of the condylar head was noted in two of the six patients. The arthrotomographic findings that were obtained in one patient that was dislocated at the time of the arthrogram did not suggest a meniscocondyle incoordination as a mechanism. However, arthrotomographic findings in the six reported cases suggest that significant intra-articular soft tissue damage may result.