Temporomandibular joint osteoarthrosis diagnosed with high resolution ultrasonography versus magnetic resonance imaging: how reliable is high resolution ultrasonography?

Diagnostic ultrasound assessment of temporomandibular joints: a systematic review and meta-analysis

OBJECTIVES:

The purpose of this systematic review was to determine the diagnostic capability of ultrasound to assess TMJ alterations as disc displacement (DD), joint effusion (JE) and condylar changes (CC) using 3D imaging modalities as reference standard.

METHODS:

Studies were gathered by searching several electronic databases and partial grey literature up to January eighth, 2018 without restrictions of language and time. The risk of bias was evaluated using the second version of Quality Assessment Tool for Diagnostic of Accuracy Studies-2 (QUADAS-2). The grading of Recommendation, Assessment, Development and Evaluation (GRADEpro system) instrument was applied to assess the level of evidence across the studies.

RESULTS:

After applying the eligibility criteria, 28 studies were identified and synthesized. All studies were methodologically acceptable presenting low applicability concerns, although none of them fulfilled all QUADAS-2 criteria. The quantitative analysis included 22 studies, 2829 joints in total. The quality of the evidence evaluated by GRADE system suggested moderate confidence in estimating the outcomes.

CONCLUSION:

This systematic review demonstrated the ultrasound has acceptable capability to screen for DD and JE in TMD patients. For screening of condylar changes, ultrasound needs further studies using CT or CBCT as reference standard to support its use. More advanced imaging such as MRI can thereafter be used to confirm the diagnosis if deemed necessary.

Ultrasound versus magnetic resonance imaging of the temporomandibular joint in juvenile idiopathic arthritis: a systematic review

A systematic review of published articles on ultrasound (US) and magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ) in juvenile idiopathic arthritis (JIA) was performed to answer the question "What is the sensitivity and specificity of US as compared to MRI in diagnosing acute and chronic joint changes in patients with JIA?" The most recent evidence was sought in published articles via a search of the PubMed, Ovid, and Embase databases. Article appraisal was performed by two reviewers. Nineteen articles reporting prospective or ambispective studies comparing US to MRI in TMJ imaging were found. Six of these articles were specific to JIA patients. The heterogeneity of these articles made comparison difficult. Of the acute and chronic changes assessed (disk displacement, joint effusion, bony deformity), only joint effusion was appropriately assessed by multiple authors, with US having a sensitivity of 0-72% and specificity of 70-83% as compared to MRI. There was a paucity of studies specific to JIA, with many studying adult, non-rheumatic patients. This systematic review found that dynamic imaging with high-resolution US improves sensitivity and specificity compared to static, low-resolution US. Additionally, there is evidence to suggest that US imaging following a baseline MRI can increase US sensitivity and specificity and may have a future role in disease surveillance.

Is high-resolution ultrasonography suitable for the detection of temporomandibular joint involvement in children with juvenile idiopathic arthritis?

OBJECTIVES

The purpose of this study was to determine the potential of high-resolution ultrasonography for the detection of temporomandibular joint (TMJ) changes in children with juvenile idiopathic arthritis (JIA).

METHODS

We investigated prospectively 20 children (17 female and 3 male; mean age 11.06 years, standard deviation 3.43 years) with TMJ disorders caused by JIA, over a period of 16 months. Using a 12 MHz array transducer, four images in each TMJ (160 images) were acquired. Each image was analysed with regard to five different aspects (condylar erosion, thickness of the condylar disc, synovial thickness, joint effusion and enlargement of the intra-articular space).

RESULTS

Diagnosis of JIA was ensured for every child and involvement of the TMJ was proven by MRI. Overall 287 changes (35.9%) were detected by using high-resolution ultrasonography. On 124 images (77.5%) condylar erosions were diagnosed; on 55 images (34.4%) synovial thickness was abnormal; on 48 images (30%) we could see higher thickness of the condylar disc; on 40 images (25%) irregularities of the bony surface were detected; and on 20 images (12.5%) we found joint effusion.

CONCLUSION

High-resolution ultrasonography could be a sufficient diagnostic method, especially for the detection of condylar involvement in children with JIA, even if not all parts of the TMJ are visible for ultrasonography. High-resolution ultrasonography is a valuable tool in particular situations: (i) when MRI examination is not available; (ii) when children fear MRI examination; (iii) in more advanced stages of JIA; and (iv) for monitoring the progression of TMJ involvement and response of therapy.

Ultrasonography of the temporomandibular joint: a literature review

This review summarizes knowledge on the accuracy and clinical usefulness of ultrasonography (US) for the diagnosis of temporomandibular joint (TMJ) disorders. A systematic search in the National Library of Medicine's Database was performed to identify all peer-reviewed papers in the English literature that assessed the accuracy of US with respect to magnetic resonance (MR), computerized tomography (CT), clinical assessment or autopsy specimens for the diagnosis of TMJ disk displacement, effusion and osteoarthrosis. The combined search words "ultrasonography" and "temporomandibular joint", "temporomandibular disorders", "effusion", "disk displacement", "condyle", yielded 20 papers. Most studies (N=17) focused on detecting disk displacement, with less emphasis on assessing joint effusion (N=6) and osteoarthrosis (N=7). US accuracy was 54-100% for diagnosing disk displacement, 72-95% for joint effusion and 56-93% for osteoarthrosis. US is operator-dependent. Better standardization of the technique is required and normal parameters must be set. Standardization is also required for the taxonomic aspects of pathologies. Despite these limitations, US remains potentially useful as an alternative imaging technique for monitoring TMJ disorders, particularly the presence of intrarticular effusion.

Evaluation of the severity of temporomandibular joint osteoarthritic changes related to age using cone beam computed tomography

OBJECTIVES

The aim of this study is to evaluate and correlate with age the severity of temporomandibular joint (TMJ) osteoarthritic changes using cone beam CT (CBCT).

METHODS

The images of 71 patients with findings of degenerative arthritis were retrieved from the computer data base. All patients had been examined with CBCT (NewTom 9000 QR-DVT). Left and right TMJs were evaluated independently for each patient. TMJ evaluation included: (a) bony changes of the condyle (flattening, erosion, sclerosis, osteophytes, resorption); (b) joint space (normal, increased, reduced, bony contact between the condyle and the mandibular fossa); and (c) bony changes of mandibular fossa (normal, sclerosis, erosion, resorption). The radiographic findings were statistically analysed.

RESULTS

Significant differences in the mean age were found: (a) between absent and moderate erosion (P = 0.019), as well as between absent and extensive erosion (P = 0.048); (b) between absent and extensive formation of osteophyte (P = 0.003), as well as between slight and extensive formation of osteophyte (P = 0.025); (c) between normal joint space and bony contact (P = 0.0002), as well as between reduced joint space and bony contact (P = 0.001).

CONCLUSIONS

Degenerative arthritis is an age-related disease. The progression and severity of osseous changes in the condylar head and mandibular fossa are increased with age. In older age groups, patients are expected to have more frequent and severe progressive degenerative bony changes due to the development of TMJ osteoarthritis than patients in younger age groups.

Ultrasound and tomographic evaluation of temporomandibular joints in adolescents with and without signs and symptoms of temporomandibular disorders: a pilot study

OBJECTIVES

Condylar position in the glenoid fossa has been linked to temporomandibular disorders (TMDs); however its importance in TMD aetiology is still unclear. The purpose of this study was to determine joint spaces and condylar position in adolescents with TMDs using ultrasound static images and linear corrected tomograms at the mandibular rest position.

METHODS

Craniomandibular index (CMI) and a symptom questionnaire were assessed in 217 subjects aged 12-18 years. Those with the lowest and the highest scores were divided into control (n=20) and SSTMD (presence of signs and symptoms of TMD) groups (n=20). Ultrasound images and tomography were used to measure the distance between the capsule and the lateral surface of the condyle and to determine the condyle location at the mandibular resting position, respectively.

RESULTS

The mean distances obtained from ultrasound images did not correlate with CMI scores and they did not differ between the two groups (P>0.05). Posterior positioned condyles were determined on tomograms, and they were more prevalent both in the SSTMD group (P=0.05) and in girls (P<0.05).

CONCLUSIONS

Even though there was a significant difference in condyle position between the control and SSTMD groups, determined by axially corrected tomograms, it cannot be inferred that posteriorly positioned condyles can predict TMDs. In addition, there was no association between the articular capsule and the lateral condyle surface distances measured by ultrasound using a 10 MHz linear transducer and the clinical diagnosis of TMD. Further studies in diagnostic imaging of TMJs with ultrasound should be encouraged, since it has some useful diagnostic applications and does not require special facilities.

Sonographic evaluation of the ranges of condylar translation and of temporomandibular joint space as well as first comparison with symptomatic joints

AIM

To assess the normal ranges of condylar translation and width of the lateral temporomandibular joint (TMJ) of a healthy population by sonography and permit comparison of findings made in individual patients using this norm.

PATIENTS AND METHOD

Fifty non-orthodontically treated, asymptomatic volunteers (100 joints) were subdivided by Angle classes (I = 20, II = 15, III = 15) and evaluated. Reliability was assessed in 15 of those volunteers. The validity was checked in 8 more patients with temporomandibular dysfunction (TMD), all class II with disc dislocation diagnosed by means of MRI. Sonographic assessment of condylar translation from centric occlusion to maximum opening and during protrusion and mediotrusion was performed with a probe positioned parallel to the zygomatic arch.

RESULTS

Translation during opening was 12.7+/-3.2 mm in class I, 12.9+/-3.3 mm in class II and 10.9+/-3.6 mm in class III. Protrusive translation was 7.4+/-2.5 mm/10.3+/-4.4 mm/6.8+/-2.1mm, respectively; and mediotrusive translation was 7.9+/-2.6 mm/10.8+/-3.4 mm/6.7+/-2.4 mm, respectively. Class II had longer and class III shorter condylar translations. The lateral joint space in occlusion and protrusion was wider in class II than in classes I and III. Symptomatic patients had shorter condylar translations than asymptomatic volunteers.

CONCLUSION

Patients with class II had a more anteroposterior mobility, class III shorter translation. Significant sonographic differences of condylar translation from the norm did not correspond with clinical findings. This demonstrates the higher sensitivity of sonography for the evaluation of individual condylar translation. It is a sensitive tool for assessing joint function.

ULTRASONOGRAPHIC ANATOMY OF THE TEMPOROMANDIBULAR JOINT IN HEALTHY PURE-BRED SPANISH HORSES

The objective was to describe the normal ultrasonographic appearance of the soft tissue and bony structures of the temporomandibular joint in Pure-Bred Spanish horses using frozen and plastinated sections performed as anatomical references. The temporomandibular joint of five healthy Pure-Bred Spanish horses and the head specimens from 12 Pure-Bred Spanish cadavers that were subjected to euthanasia for reasons other than temporomandibular joint problems were studied sonographically and anatomically. An 11 MHz linear-array transducer was used to obtain longitudinal ultrasonographic images of the temporomandibular joint from rostral, lateral, and caudal approaches. For anatomic study, a gross dissection was performed on six temporomandibular joints. The other six head specimens were first frozen at -30 degrees C for 48h and then, at -70 degrees C for a week. Three millimeter thick anatomic sections were collected in the same plane as the sonographic planes. These sections were plastinated, photographed, and compared with the corresponding ultrasonographic images. The articular surfaces, the articular cartilage, the disc, the intra-articular fat tissue, the joint capsule, and other structures were clearly visualized sonographically. Structures identified on the ultrasonographic images were in accordance with those identified on the corresponding anatomic sections. We confirmed the appearance of structures of the equine temporomandibular joint that have been described previously but we also identified the caudal fibrous expansion of the disc, the caudal compartment of the dorsal synovial pouch, and the lateral ligament. Our results define a reference that will aid in sonographic evaluation of the equine temporomandibular joint region.

Temporomandibular joint arthritis in juvenile idiopathic arthritis: the forgotten joint

PURPOSE OF REVIEW

This review explores the prevalence, clinical and radiographic signs, and treatment of temporomandibular joint arthritis in children with juvenile idiopathic arthritis.

RECENT FINDINGS

Temporomandibular joint arthritis seems to be a more frequent manifestation in patients with juvenile idiopathic arthritis than previously believed, in part due to the paucity of clinical symptoms and poor sensitivity of conventional radiographs used for diagnosis. Antinuclear antibody positivity, early onset of disease, and presence of systemic or polyarticular disease are all risk factors for temporomandibular joint arthritis but may underpredict temporomandibular joint involvement in juvenile idiopathic arthritis. Magnetic resonance imaging enhanced with gadolinium is currently the gold standard in detection of temporomandibular joint arthritis, and treatment with intra-articular corticosteroids has been shown to be effective and safe, with minimal side effects.

SUMMARY

Given the paucity of clinical symptoms in temporomandibular joint arthritis, detection of temporomandibular joint inflammation using contrast-enhanced magnetic resonance imaging is essential for instituting appropriate therapy in a timely fashion. The use of intra-articular corticosteroids holds promise for control of temporomandibular joint inflammation and prevention of associated morbidities.

3-D sonography for diagnosis of osteoarthrosis and disk degeneration of the temporomandibular joint, compared with MRI

This study determined the value of three-dimensional (3-D) sonography for the assessment of osteoarthrosis and disk degeneration of the temporomandibular joint (TMJ). Sixty-eight patients (136 TMJ) with clinical dysfunction were examined by 272 sonographic 3-D scans. An 8- to 12.5-MHz motor-angulated transducer positioned inferior-parallel to the zygomatic arch scanned the region-of-interest. 3-D condylar morphology was compared with subsequent magnetic resonance imaging (MRI). Fifty-three datasets were complete, i.e., 106 TMJ, 212 examinations. 3-D sonographic examination took 5 min and attained 70% sensitivity/76% specificity/75% accuracy; positive predictive value was 44%%; negative predictive value was 90%. Disk degeneration was diagnosed synonymously with 64%/73%/71%/42%/ 87%. 3-D sonography proved to be reliable for exclusion of osteoarthrosis as disk degeneration compared with MRI, whereas the presence of osteoarthrosis and disk dislocation cannot be reliably diagnosed. Prospective use will include routine screening, using more sophisticated equipment with higher frequency in real-time 3-D viewing.

Pathologic-sonographic correlation in temporomandibular joint pathology

The accuracy of high-resolution ultrasonography (HR-US) in detecting disk displacement and condylar erosion of the temporomandibular joint (TMJ) was evaluated, using corresponding cryosections as a "gold standard". HR-US of the TMJ was performed with a high frequency 12 MHz transducer on 30 preserved autopsy specimens. Succeeding sonography, the autopsy specimens were deep-frozen and cut in paracoronal planes corresponding to the sonographic images. HR-US diagnoses were compared with cryosectional findings in a blinded fashion. HR-US detected 19 (95%) of 20 instances of condylar erosion and 16 (73%) of 22 instances of disk displacement. There were one false-positive finding for condylar erosion and two false-positive findings for disk displacement. The accuracy of HR-US evaluating condylar erosion and disk displacement rated 93% and 73%, respectively. In conclusion, condylar erosion was reliably assessed by HR-US, but the evaluation of disk position was less accurate.