The value of arthrography in the decision-making process regarding surgery for internal derangement of the temporomandibular joint

Disc derangements of the temporomandibular joint

Disc-related derangement of the temporomandibular joint is common and epidemiological research has found that about 20% of the population may be affected. Although very few of these people have the more prominent symptoms, recent data indicate that the numbers who need treatment is increasing. The two clinical variants of disc derangement, reciprocal clicking and closed lock, have long been recognized, but the association between them and their aetiology and pathogenesis is still unclear. As a consequence, there is still uncertainty on how to treat the conditions, and this is even more evident when surgery is involved. This paper describes new tissue research related to disc derangement. A simplified scheme is presented and implications for surgical treatment are discussed.

Internal derangement of the temporomandibular joint: correlation of arthrographic imaging with surgical findings

Sixty-seven patients, who were surgically treated for internal derangement of the temporomandibular joint (TMJ), were retrospectively examined. The patients were evaluated preoperatively by clinical and arthrographic examinations and these results were compared with findings at surgery. Partial or complete dislocation of the disc was detected by arthrographic examination in 65 joints. Actual disc displacement was demonstrated at surgery in 57 TMJs, giving arthrography a positive predictive value of 88% for detecting disc dislocation. Arthrographic diagnosis of disc perforation was unreliable, as both false positive and false negative observations were recorded. Arthrography was found to have a positive predictive value of only 53% for assessing disc perforation. Based upon its proven inaccuracy, invasiveness and discomfort to the patient, it is recommended to replace arthrography by magnetic resonance imaging.

Evidence-based evaluation of three imaging methods for the temporomandibular disc

OBJECTIVES

To review the literature and evaluate the evidence for the diagnostic outcome of arthrography, computed tomography (CT) and magnetic resonance imaging (MRI) in the assessment of temporomandibular joint (TMJ) disc position.

METHODS

A literature search from 1978 to 1994 was conducted. Data on sensitivity, specificity, predictive values and likelihood ratios were collected and, if not available, calculated for each imaging method. Measures of observer performance were also recorded.

RESULTS

In total, more than 400 publications were retrieved on imaging of TMJ disc position, 219 on arthrography, 99 on CT and 147 on MRI, with a marked decrease in recent years. The majority of the publications (54%) presented series of patients. The diagnostic outcome cold be obtained from only 7% of the studies and the observer performance from only two of these. Arthrography had the highest diagnostic outcome for the diagnosis of anterior disc position; sensitivity 0.90, specificity 0.80, positive predictive value 0.88 and negative predictive value 0.82. Corresponding figures for CT were 0.66, 0.68, 0.66 and 0.74 and for MRI 0.86, 0.63, 0.67 and 0.83. The diagnostic outcomes expressed as the likelihood ratios for positive test outcome were 4.5 for arthrography, 2.3 for MRI and 2.1 for CT. The outcomes in diagnosing sideways and rotational displacements were higher for MRI (sensitivity 0.81, specificity 0.87, positive predictive value 0.82, negative predictive value 0.88) than for arthrography (0.64, 0.83, 0.70, 0.79). The likelihood ratios were 6.2 for MRI and 3.8 for arthrography. The interobserver performance ranged between moderate to substantial for arthrography and was almost perfect for MRI.

CONCLUSIONS

Based on current evidence on the diagnostic outcome, MRI seems to be the method of choice for diagnosing TMJ disc position. Arthrography has a higher diagnostic outcome for anterior disc position but the disadvantage of being an invasive method. We suggest that the quality of the evidence should be improved and that an analysis of the impact of the imaging methods on patient treatment should be performed.

Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint

This prospective 1-year follow-up investigated the efficacy of temporomandibular joint lysis and lavage in relation to arthroscopic diagnoses. The study comprised 42 patients. Clinical evaluation was performed before surgery and at regular intervals up to 1 year postoperatively. Diagnostic arthroscopy and immediately subsequent lysis and lavage were performed under local anesthesia in all patients. Only unilateral upper compartment arthroscopies were executed. The results were evaluated according to the 1984 criteria of the American Association of Oral and Maxillofacial Surgeons. Osteoarthrosis was diagnosed arthroscopically in 30 joints (71%), 21 of which (70%) had more pronounced changes. Synovitis, mainly of a mild, localized type, was diagnosed in 39 joints (93%). More pronounced synovitis was found arthroscopically in 12 (31%). Adhesions were found in 20 joints (48%) and were significantly correlated with joints displaying osteoarthrosis (P < 0.001). The overall success rate for arthroscopic lysis and lavage was 50% (21/42 joints). The best response to lysis and lavage was in joints with arthroscopic diagnosis of pronounced synovitis (8/12 joints; 67%). All 21 joints regarded as unsuccessful were operated with diskectomy without implants. The success rate at 1-year follow-up was 18 joints (86%).

The shape of the condyle and position of the meniscus in temporomandibular joint dysfunction

The position of the meniscus seems to be significant in the natural history of temporomandibular joint dysfunction. It can be identified on MRI and arthrography but generally its displacement is referred to only in the sagittal plane. Little consideration is given to the shape and size of the condyle which could have great influence upon the position which the meniscus takes up. This paper reports the findings in 105 TM joints which have had arthrotomy for meniscoplasty (meniscopexy) and menisectomy over an 8-year period. Only 30% of the condyles had a normal size and shape; 24% were excavated on the medial side, 15% had lost the anterior surface of the condyle and were oblique in shape, 15% were small and round, while 12.5% were flattened, two having no discernable condyle at all. The meniscus was found to be displaced anteromedially most commonly, with the anterior position, to which reference is so frequently made, being rare; the medial position was more common. The significance of these findings is discussed with particular reference to imaging.

Comparison of arthrotomographic and magnetic resonance images of 50 temporomandibular joints with operative findings

Arthrotomography and magnetic resonance imaging (MRI) were carried out on 50 temporomandibular joints (TMJs) in 48 patients who were being considered for surgery for clinically diagnosed internal derangement. The patients presented over a 4-year period with pain and dysfunction which had failed to respond to conservative management. Open surgery was carried out on all TMJs and operative findings compared with the results of imaging. The clinical diagnosis of internal derangement was confirmed in every case by imaging and at surgery. Arthrotomography over-diagnosed non-reducibility of an anteriorly displaced meniscus and perforation. MRI over-diagnosed non-reducibility to a lesser extent and under-diagnosed perforation. MRI demonstrated neither bony changes nor adhesions. Dynamic arthrotomography produced the best images of meniscal derangement in function and the pre-arthrogram tomograms were the best indicator of osseous abnormality. Arthrotomography was the preferred imaging technique.

The effect of the stabilization splint on the TMJ closed lock

The mandibular manipulation technique and anterior repositioning splint are considered acceptable conservative therapies for an acute temporomandibular joint (TMJ) closed lock. However, an anterior repositioning splint will result in a corresponding change in occlusion, such as posterior open-bite. Furthermore, invasive treatments such as surgery have many complications. This article describes the effect of the stabilization splint with more conservative therapies, including the manipulation technique, wherein the complications are minimal. In this study, the authors used the stabilization splint instead of the anterior repositioning splint. They obtained acceptable results, including the increase of interincisal distance, a decrease in Fricton's craniomandibular index, and a decrease in Helkimo's clinical dysfunction index. Therefore, the treatment method that is composed of a stabilization splint, manipulation, moist heat, and exercise should be considered as the first choice of treatment for TMJ closed lock, as opposed to a repositioning splint.

Closed lock. A survey of 400 cases

Four hundred consecutive classic closed lock cases were examined. Of these, 301 were treated. Mandibular range of motion was restored by condylar distraction during jaw opening, anterior, and lateral movements. Mandibular appliances were used to prevent complete closure during healing. Of the 45 males and 355 females examined, almost all reported jaw restrictions, but 38% reported little or no pain. Secondary disorders of temporomandibular joint inflammation, muscle spasm, trigger points, and cervical dysfunction were seen on patients with temporomandibular joint pain. Of the 301 conservatively treated patients, 209 were successfully treated, 55 were moderately successful, and 37 failed. Occlusal factors did not appear as primary etiologic factors. Because all locks were preceded by clicking, treatment is recommended for clicking temporomandibular joint's that lock, however briefly, to prevent future locking. Conservative closed lock treatment is successful in many cases.

Accuracy of clinical diagnosis for TMJ internal derangement and arthrosis

This study investigated the accuracy of clinical examination in determining the status of the temporomandibular joint with respect to internal derangement and arthrosis. A series of 110 patients was given standard clinical examinations followed by bilateral imaging with arthrography and/or magnetic resonance imaging. There was agreement between the clinical diagnosis and the imaging finding in 95 joints (43%). In the other 125 joints (57%), the clinical diagnosis did not agree with imaging findings. There were false-positive clinical diagnoses in 39 joints and false-negative clinical diagnoses in 31 joints. In the other 55 joints the clinical diagnosis correctly indicated that the joint was abnormal but was incorrect about the stage of abnormality. On the basis of the overall diagnostic accuracy of 43%, it was concluded that a clinical examination is not reliable for determining the status of the joint in patients with signs and symptoms of temporomandibular joint internal derangement.