Bone marrow edema of the mandibular condyle related to internal derangement, osteoarthrosis, and joint effusion

Could temporomandibular joint arthroscopic discopexy with resorbable pins or disc mobilisation influence mandibular condyle marrow?

The aim of this study was to evaluate the relationship between arthroscopic discopexy with resorbable pins or disc mobilisation and its effect on the bone marrow of the mandibular condyle. An observational analytical retrospective cohort study was conducted. The inclusion criteria comprised adult patients with Wilkes IV and V with MRI in T2 sequence undergoing TMJ arthroscopy. The first group included subjects who received discopexy with pins (Level III Arthroscopy), and the second included subjects who underwent disc mobilisation without any fixation (Level IIb Arthroscopy). Variables studied were maximum interincisal opening (MIO), pain, and Signal Intensity Ratio (SIR) index. Data were analysed using the chi-squared test, Fisher's exact test, the Mann Whitney U test, and the Shapiro-Wilk test. To establish the relationship between the variables and SIR ≥ 2, a multivariate analysis was performed using unconditional logistic regression. A total of 50 joints were divided in two groups. In the multivariate logistic regression analysis, discopexy surgery with pins (Odds Ratio OR = 0.03, 95% [CI] 0.02 to 0.69, p = 0.027) was identified as an independent predictor for the non-development of a high SIR score (≥2.0) after adjusting preoperative covariates. This study shows changes in the medullary signal in patients undergoing discopexy with resorbable pins. However, more studies are required that correlate quantitative measures.

Assessment of temporomandibular joint bone changes associated with anterior disc displacement: An MRI cross-sectional study

OBJECTIVE

This cross-sectional study aimed to evaluate the presence of bone changes on magnetic resonance imaging (MRI) scans of patients with temporomandibular joint (TMJ) anterior disc displacement (ADD) with reduction (ADDWR) and without reduction (ADDWoR).

METHODS

TMJ-MRI scans were screened for the presence of ADD. 285 scans presented ADD, being further divided into ADDWR (n = 188) and ADDWoR (n = 97). Bone changes on the mandibular condyle and articular eminence were also assessed and computed. The chi-square test compared the association of these bone changes with the presence of ADDWR and ADDWoR, with a significance level of 5 %. Also, the prevalence ratio (PR) was calculated.

RESULTS

In the mandibular condyle, subchondral cyst (p = 0.035, PR = 1.08) and bone edema (p = 0.044, PR = 2.40), more prevalent on ADDWR, and generalized sclerosis (p = 0.015, PR = 1.04), more prevalent on ADDWoR, presented significant association with ADD. On the articular eminence, generalized sclerosis (p = 0.015, PR = 1.04) and articular surface flattening (p = 0.003, PR = 1.19) presented significant association with ADD, both more prevalent on ADDWoR.

CONCLUSION

Bone changes are usual findings in TMJ with ADD diagnosis. The real influence of ADD is not fully clear, although clinicians should be aware of patients with this condition, to provide an early diagnosis and improve patient´s prognosis.

Reconstructed magnetic resonance image-based effusion volume assessment for temporomandibular joint arthralgia

BACKGROUND

Joint effusion is often noticed in magnetic resonance image (MRI) and its diagnostic value for arthralgia of the temporomandibular joint (TMJ) remains obscure.

OBJECTIVE

To develop a method for quantitatively evaluating the joint effusion revealed in MRI and its diagnostic value for arthralgia of the TMJ.

METHODS

Two-hundreds and twenty-eight TMJs, 101 with arthralgia (Group P) and 105 without (Group NP) from 103 patients, and 22 TMJs (Group CON) from 11 asymptomatic volunteers were examined by using MRI. The effusion volume was measured after constructing a three-dimensional structure of the joint effusion revealed in MRI by using the ITK-SNAP software. The diagnostic capabilities of the effusion volume on arthralgia were evaluated with receiver operating characteristic (ROC) curve analysis.

RESULTS

Totally 146 joints showed MRI signs of joint effusion, including nine joints from Group CON. However, the medium volume was greater in Group P (66.65 mm3 ), but was much similar in Group CON (18.33 mm3 ) to Group NP (27.12 mm3 ). The effusion volume larger than 38.20 mm3 was validated to discriminate Group P from Group NP. The AUC value was 0.801 (95% CI 0.728 to 0.874), with a sensitivity of 75% and specificity of 78.9%. The median volume of the joint effusion was larger in those with than without bone marrow oedema, osteoarthritis, Type-III disc configurations, disc displacement and higher signal intensity of the retrodiscal tissue (all, p < .05).

CONCLUSION

The present method for evaluate joint effusion volume well discriminated painful TMJs from non-pain ones.

Diagnostic Value of High-Resolution Ultrasound for the Evaluation of Capsular Width in Temporomandibular Joint Effusion

Aim: The aim of this study was to evaluate if the increased temporomandibular joint (TMJ) capsular thickness, measured by ultrasound (US), is associated with the presence of effusion, diagnosed using MRI imaging. Materials and Methods: 102 patients with signs and symptoms of temporomandibular disorders were included in the study. Each patient underwent US and MRI examinations, 1 to 5 days following clinical examination. The US was performed with an 8−40 MHz linear transducer operating at 20 MHz. The MRI was performed using a 1.5 T MRI device. The ROC curve was analyzed to identify the optimal cut-off value for capsular distention, which can be interpreted as an indirect sign of TMJ effusion. Results: The capsular width values were found to be between 0.7 and 3.6 mm. The best cut-off value was 2.05 mm with a sensitivity of 55.9% and a specificity of 94.7%. The next optimal cut-off value was 1.75 mm with a sensitivity of 67.6% and a specificity of 82.4%. The area under the ROC curve was 0.78 (95% CI 0.68, 0.87, p < 0.05). Conclusions: Ultrasound-measured capsular width can be interpreted as an indirect sign of TMJ effusion. The critical cut-off for capsular width was 2 mm.

Histopathology of the temporomandibular joint disc: Findings in 30 samples from joints with degenerative disease

Aim

The aim of this study is to show the anatomical and histological features of the displaced temporomandibular joint (TMJ) disc in joints with degenerative disease.

Methods

This study was performed on a total of 30 TMJ discs extracted from 22 patients, who underwent surgical discectomy after failure of conservative non‐surgical treatment regimens to control pain and/or limited range of motion. All joints had imaging signs of an anteriorized disc position and degenerative joint disease. Samples of the extracted discs were stored in formalin, cut into 3 micron‐thick sections imbedded in paraffin and processed with hematoxylin‐eosin.

Result

All the samples present irreversible morphologic and histological alterations. The macroscopical evaluation showed that 14 discs were worn and fragmented in several parts, and one disc was perforated. Morphological alterations with deformation and degenerative signs were shown in all discs, which were all severely worn and compromised. Histologically, various alterations were found, such as pre‐fibrous sclerosis with myxoid degeneration and collagen deposits (N = 25), an increase in fibro‐hyaline and fibrous tissues, with loss of elasticity (N = 25), scattered calcifications (N = 15), and synovial inflammation with microvascular proliferation and increased cellularity, presence of lymphocytes, histiocytes and plasma cells (N = 18). After the intervention, all patients reported decreased pain levels and showed improved function at 6 months.

Conclusion

These observations suggest that degenerative joint disease is accompanied by a anteriorized discs featuring abnormal macroscopical and histological changes. From a clinical viewpoint, this may suggest that, when treatment escalation leads to consider TMJ surgery, total discectomy is the most reasonable approach.

Synthetic magnetic resonance imaging for quantitative parameter evaluation of temporomandibular joint disorders

OBJECTIVE

This study investigated the usefulness of quantitative parameters [longitudinal relaxation (T1), transverse relaxation (T2), and proton density (PD)] obtained with synthetic magnetic resonance imaging (MRI) in assessing the progression of temporomandibular joint (TMJ) disorders.

METHODS

For individual TMJ disorder diagnoses, the presence of disc displacement in MRI and the osseous change in cone-beam CT were investigated. Joints were classified into three stages: (1) silent stage, no disc displacement or osseous change; (2) incipient stage, presence of disc displacement and absence of osseous change; and (3) progressed stage, both disc displacement and osseous change. In synthetic MRI, the T1, T2, and PD values of the condyle bone marrow were measured simultaneously. The median T1, T2, and PD values were analyzed according to disc displacement, osseous changes, and joint stage.

RESULTS

Significant differences were observed in the T1 and PD values of joints with disc displacement or condylar osseous change compared to normal joints. The T1 and PD values also differed between the silent and progressed stages. The PD value differed between the silent and incipient groups, while the T2 value did not differ significantly among the three groups.

CONCLUSION

The PD and T1 values of condylar bone marrow obtained from synthetic MRI can be used as sensitive indicators of TMJ disorder progression. The PD value of the bone marrow showed potential as a useful biomarker for recognizing the initial stages of TMJ disorders. Synthetic MRI is useful for the simultaneous acquisition of effective MRI parameters for evaluating TMJ disorders.

Assessment of bone marrow fat fractions in the mandibular condyle head using the iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL-IQ) method

The prevalence of temporomandibular joint disorder (TMD) is gradually increasing, and magnetic resonance imaging (MRI) is becoming increasingly common as a modality used to diagnose TMD. Edema and osteonecrosis in the bone marrow of the mandibular condyle have been considered to be precursors of osteoarthritis, but these changes are not evaluated accurately and quantitatively on routine MRI. The iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL-IQ) method, as a cutting-edge MRI technique, can separate fat and water using three asymmetric echo times and the three-point Dixon method. The purpose of this study was to analyze the quantitative fat fraction (FF) in the mandibular condyle head using the IDEAL-IQ method. Seventy-nine people who underwent MRI using IDEAL-IQ were investigated and divided into 1) the control group, without TMD symptoms, and 2) the TMD group, with unilateral temporomandibular joint (TMJ) pain. In both groups, the FF of the condyle head in the TMJ was analyzed by two oral and maxillofacial radiologists. In the TMD group, 29 people underwent cone-beam computed tomography (CBCT) and the presence or absence of bony changes in the condylar head was evaluated. The FF measurements of the condyle head using IDEAL-IQ showed excellent inter-observer and intra-observer agreement. The average FF of the TMD group was significantly lower than that of the control group (p < 0.05). In the TMD group, the average FF values of joints with pain and joints with bony changes were significantly lower than those of joints without pain or bony changes, respectively (p < 0.05). The FF using IDEAL-IQ in the TMJ can be helpful for the quantitative diagnosis of TMD.

Evaluating the mandibular condyles of patients with osteoarthritis for bone marrow abnormalities using magnetic resonance T2 mapping

OBJECTIVES

This study investigated whether erosion and osteophyte correlates with condyle bone marrow abnormalities (BMA), as detected with quantitative T2 mapping.

METHODS

Fifty-six joints (in 44 patients) that demonstrated evidence of bony erosion (ER) or osteophytes (OS) related to disc displacement without reduction were studied with MR images. A control group of 50 joints (in 50 patients) was included. The subjects were divided into five groups; noAR (control), noBMA-ER, BMA-ER, noBMA-OS, and BMA-OS. T2 mapping was performed and the regions of interest were placed over the bone marrow at the top of the condyle. The mean T2 values of the bone marrow of the mandibular condyle were calculated for all mapping images. After assessing age-related changes in T2 values of noAR group using Pearson's product-moment, differences in median T2 values of five groups were analyzed using Kruskal-Wallis test, and Steel-Dwass test (p < 0.05).

RESULTS

There was no significant correlation between age and T2 value in noAR group. The median T2 values of noBMA-ER and BMA-ER groups were significantly higher than those of noAR, noBMA-OS and BMA-OS groups. Those of noBMA-OS and BMA-OS groups were significantly lower than those of noAR, noBMA-ER and BMA-ER groups. There was no significant difference between noBMA and BMA groups.

CONCLUSIONS

It is suggested that erosion and osteophyte of the condyle may correlate with bone marrow abnormalities. T2 mapping could be show slight marrow changes of the arthritic condyle.

Changes in disc status in the reducing and nonreducing anterior disc displacement of temporomandibular joint: a longitudinal retrospective study

Treatment procedures for anterior disc displacement (ADD) of temporomandibular joint (TMJ) are far from reaching a consensus. The aim of the study was to evaluate disc status changes of anterior disc displacement with reduction (ADDWR) and without reduction (ADDWoR) comparatively, to get a better understanding of the disease progress without intervention. This longitudinal retrospective study included 217 joints in 165 patients, which were divided into ADDWR group and ADDWoR group based on magnetic resonance imaging (MRI) examination. The joints were assessed quantitatively for disc length and displacement distance at initial and follow-up visits. Disc morphology, which was classified in 5 types, was also evaluated. Paired t-test and Wilcoxon signed rank test were used to assess intra-group differences and independent t-test for inter-group differences. Moreover, analysis of covariance was applied to analyze influential factors for changes in disc length and displacement distance. According to our results, discs tended to become shorter, move further forward and distort more seriously in ADDWoR group than in ADDWR group after follow-up. Moreover, discs were prone to become shorter and more anteriorly displaced in teenagers, type I and III morphologies, advanced Wilkes stages, or those with joint effusion. Follow-up period seemed to be not critical.

Does condylar height decrease more in temporomandibular joint nonreducing disc displacement than reducing disc displacement?: A magnetic resonance imaging retrospective study

The aim of the study was to compare condylar height changes of anterior disc displacement with reduction (ADDwR) and anterior disc displacement without reduction (ADDwoR) in temporomandibular joint (TMJ) quantitatively, to get a better understanding of the changes in condylar height of patients with anterior disc displacement who had received no treatment, and to provide useful information for treatment protocol. This longitudinal retrospective study enrolled 206 joints in 156 patients, which were divided into ADDWR group and ADDwoR group based on magnetic resonance imaging examination. The joints were assessed quantitatively for condylar height at initial and follow-up visits. Also, both groups were further divided into 3 subgroups according to age: <15 years group, 15 to 21 years group, and 22 to 35 years group. Paired t test and independent t test were used to assess intra- and intergroup differences. The average age of the ADDwR group was 19.65 years with a mean of 9.47 months' follow-up. The follow-up interval of the patients with ADDwoR was 7.96 months, with a mean age of 18.51 years. Condylar height in ADDwoR tended to decrease more than those in ADDwR, especially during the pubertal growth spurt and with the presence of osteoarthrosis, meaning ADDwoR could cause a severe disturbance in mandibular development. Thus, an early disc repositioning was suggested to avoid decrease in condylar height.

Association of bone marrow edema with temporomandibular joint (TMJ) osteoarthritis and internal derangements

PURPOSE

This study reviewed the dental literature in order to determine the association of bone marrow edema with osteoarthritis and temporomandibular joint (TMJ) internal derangement disorders.

METHODS

A literature search was performed using electronic databases PubMed/Medline (National Library of Medicine, Bethesda, Maryland) and Cochrane for articles published during the last 15 years (January 2000-December 2014). A predetermined inclusion and exclusion criteria were used for filtering the scientific papers. Research articles fulfilling the basic inclusion criteria were included in the review.

RESULTS

The reviewed studies showed that bone marrow edema is found in painful joints with osteoarthritis in a majority of cases. A few cases with no pain or significant degenerative changes are reported to have a bone marrow edema pattern as well.

CONCLUSIONS

Bone marrow edema, increased fluid level, and pain are associated with osteoarthritis in the majority of patients reporting TMJ arthritis. Degenerative and disc displacement conditions are multifactorial and require further investigations. Magnetic resonance imaging can be employed to detect bone marrow edema even in the absence of pain and clinical symptoms in the patients of internal derangements.

Evaluation of the TMJ by means of clinical TMD examination and MRI diagnostics in patients with rheumatoid arthritis

This study included 30 patients with diagnosed rheumatoid arthritis (RA) and 30 test subjects without RA (control group). The objective of the study was to examine both groups for the presence of temporomandibular disorders (TMD) and morphological changes of the temporomandibular joint (TMJ). All individuals were examined using a systematic detailed clinical TMD examination as well as magnetic resonance imaging (MRI). The clinical TMD examination yielded significant differences between the RA patients and the control group concerning crepitus of the TMJ, and palpation tenderness of the masticatory muscles as well as the unassisted mandibular opening. The evaluation of the MRI images for the RA group showed significantly more frequent deformations of the condyle, osteophyte formations and erosions in the condylar compacta, and degenerative changes in the spongiosa. Increased intra-articular accumulation of synovial liquid and signs of inflammatory changes of the spongiosa were only found in the RA group. Statistical analysis showed a significant correlation between crepitus and specific osteoarthrotic changes (MRI), respectively, and between crepitus and a complete anterior disk displacement without reduction (MRI). The duration of the RA disease correlated neither with the anamnestic and clinical dysfunction index by Helkimo nor with RA-specific MRI findings.

Magnetic resonance imaging evaluation of mandibular condyle bone marrow and temporomandibular joint disc signal intensity in anaemia patients

OBJECTIVES

To compare the signal intensity (SI) of mandibular condyle bone marrow (MCBM) and the temporomandibular joint (TMJ) disc in patients with chronic anaemia and healthy subjects, and to investigate the relationships between bone marrow changes, age, types of anaemia and severity of anaemia.

METHODS

MRIs of 18 patients with chronic anaemia were compared with those of 12 healthy subjects. The SI of MCBM and the TMJ disc were quantitatively evaluated. The SI of the grey matter (GM), white matter (WM) and the lateral pterygoid muscle were also investigated. Relationships between age, MCBM and TMJ disc signal-intensities and anaemia severity, and correlations between the groups, were analysed.

RESULTS

The mean MCBM SI was lower in anaemia patients (including both subgroups and also separately) than in healthy subjects (P < 0.05). No statistical significance was found for GM, WM and the muscle SI between the anaemia patients and healthy patient group (P > 0.05). No statistical significance was found between the groups with respect to the anterior band, whereas the mean SI value of the posterior band in the study group was significantly lower than in healthy subjects (P < 0.05). There were no correlations between age and MCBM SI, or between anaemia severity and MCBM SI.

CONCLUSIONS

Anaemia may cause bone marrow alterations without any internal derangement. Patients with chronic anaemia exhibit lower mandibular condyle bone marrow and posterior band SI than healthy subjects.

Magnetic resonance imaging in the evaluation of temporomandibular joint disc displacement--a review of 144 cases

One hundred and forty four patients underwent magnetic resonance imaging (MRI) for evaluation of suspected internal derangement (ID) of the temporomandibular joint (TMJ). All scans were performed on a state-of-the-art scanner by highly experienced technologists and evaluated by a single Head and Neck/Maxillofacial radiologist. Seventy-nine percent of patients were female and 21% male. Age distribution of the cases was bi-modal with first peak at 20-30 years of age and second peak at 50-60 years of age. Of the 82.5% of cases with disc displacement, 59.5% demonstrated reduction with opening and 40.5% did not reduce. Anterior disc displacement is common (44%) and sideways displacement rare (4%). Antero-lateral displacement was the second commonest type of displacement (29%) probably related to the weakness of the lateral disc attachment.

Temporomandibular joint internal derangement: relationship between joint pain and MR grading of effusion and total protein concentration in the joint fluid

OBJECTIVES

The objective of this study was to determine whether there is any association between the protein concentration in the synovial fluid and (i) the amount of articular hydrops, as graded in magnetic resonance (MR) images, and (ii) joint pain in temporomandibular joints (TMJs) with and without displacement of the disc.

PATIENTS AND METHODS

This study involved 16 joints in 16 patients referred to our clinic with the complaint of pain and limited mouth opening. The control group consisted of 15 joints in 15 patients with unilaterally normal disc and condyle relationship and no pain while the opposite side had a non-painful joint with disc displacement without reduction (DDwoR). The subjects and controls were different individuals and only a single joint was used for each. Pain and dysfunction were evaluated by visual analogue scale. Bilateral proton density and T2 weighted images of the TMJs of the 31 subjects were analysed for fluid and condyle bony changes as well as disc position. The amount of fluid, identified as an area of high signal intensity in the region of the upper and lower joint spaces, was characterized as none, minimal, moderate or marked. Arthrocentesis was performed both for synovial fluid analysis of total protein concentration and the treatment of the joints with DDwoR. Total protein concentration was measured by using protein dye binding on spectrophotometry.

RESULTS

All patients experienced a significant (P<0.01) increase in maximal mouth opening immediately post-arthrocentesis. In the study group, the disc was displaced most frequently in an anteriormedial direction (75%) and deformation of disc form was seen in 13 joints. Condylar bony changes were seen in 27% of joints in the control group and in 81% of joints in the study group. A statistically significant association was found between joints with disc displacement, disc form and condylar bony changes (P<0.05). In the control group, only one joint, which had an osteophyte, showed joint effusion (JE) with moderate fluid. In the study group, only four joints had no fluid (25%). JE was found in 10 (63%) joints with disc displacement on anteromedial direction, in 10 (63%) joints with disc deformation and in 10 (63%) joints with osteophytes and erosion. Mean total protein concentration was 16.87+/-7.9 (range 7.4-34.1 mg dl-1) in control joints, 55.08+/-35.16 (range 21.5-153.9 mg dl-1) in study joints. There were significant differences in the mean total protein concentration between the control and study groups (P<0.01). Significant positive correlation was found between the total protein concentration and JE (r=0.65, P<0.01). No significant correlation was found between the level of pain and dysfunction and JE and total protein concentration in either control or study groups (P>0.05).

CONCLUSION

Pain in the TMJ was not related to MR findings of effusion in internal derangement and synovial fluid aspirate findings of total protein concentration. However, total protein concentration was related to the amount of JE in DDwoR joints and painful joints were more likely to demonstrate the JE.