Disk displacement of the temporomandibular joint: correlation of magnetic resonance tomography and clinical findings

PURPOSE: To evaluate the value of magnetic resonance imaging (MRI) in symptomatic patients with different degrees of internal derangement. MATERIAL AND METHODS: We prospectively investigated 117 temporomandibular joints (TMJ) of 59 symptomatic patients and 31 asymptomatic volunteers and correlated this with clinical parameters. RESULTS: There was a positive correlation between the degree of internal derangement and deformity of the disc, maximal mouth opening, signal intensity of the posterior band, thickness of the bilaminar zone, proliferative bony changes, size of the condyle and reduced translation movement of the condyle, which in addition moved upward and backward. Patients most often complained of pain which was dependent on the degree of disc displacement and condylar changes. Clinical parameters were found to be inaccurate in predicting disc displacement. CONCLUSION: Patients with internal derangement of the temporomandibular joint may be asymptomatic. Patients history may give the only pointer to the disorder.     

The influence of observer calibration in temporomandibular joint magnetic resonance imaging diagnosis

OBJECTIVE: This study was undertaken to investigate the potential of reducing observer variation through a calibration program. STUDY DESIGN: The study was based on three sets of randomly selected temporomandibular joint magnetic resonance images. Each set consisted of bilateral images from 20 consecutive patients with temporomandibular disorders. As a baseline, three well-experienced noncalibrated investigators interpreted the images individually for disk position and disk configuration. After the initial interpretation, interobserver agreement was calculated as a kappa index and presented to the examiners. On the same occasion, the investigators analyzed agreement between them on the criteria to be used. RESULTS: Overall data in this study showed an increase in the frequency of interobserver agreement with regard to disk position after the calibration trials were instituted. With regard to disk configuration, substantial interindividual variations were observed even after the observers reached consensus as to the criteria to be used. CONCLUSIONS: These data suggest that after calibration trials, it is possible for three examiners to obtain reliable and reproducible results in reporting temporomandibular joint disk position on magnetic resonance images.     

Gas in the temporomandibular joint: computed tomography findings. Report of 3 cases

BACKGROUND: The advantages of pancreatogastrostomy over pancreatojejunostomy after pancreaticoduodenectomy are still debated. This study analyses the results of pancreatogastrostomy to identify factors that could influence immediate outcome. METHODS: During a 10-year period, 160 consecutive patients underwent a pancreatogastrostomy. There were 109 men (68 per cent) and 51 women (32 per cent) with a mean(s.d.) age of 59(10) (range 22-82) years; 27 patients were older than 70 years. The following parameters were assessed: mortality rate, morbidity, reasons for reoperation, length of hospital stay, duration of nasogastric tube and drainage. RESULTS: Hospital mortality rate was 3 per cent; overall morbidity rate was 30 per cent. The reoperation rate was 12 per cent, mainly because of bleeding at the pancreatic margin. Delayed gastric emptying occurred in 36 patients. The overall rate of pancreatic fistula was 2.5 per cent. Age, sex, indications for pancreatoduodenectomy, and the texture of the pancreatic remnant did not influence the occurrence of pancreatic fistula or delayed gastric emptying. CONCLUSION: This study confirmed that pancreatogastrostomy is a safe procedure with low mortality and morbidity rates.     

Epidural spinal infection. Variability of clinical and magnetic resonance imaging findings

STUDY DESIGN: This study evaluates the magnetic resonance characteristics of spinal epidural abscesses and their associated disc space infections. OBJECTIVES: The results were correlated with history, clinical, and laboratory findings to provide guidelines for early and appropriate diagnosis of epidural spinal infections. SUMMARY OF BACKGROUND DATA: Imaging signs of spinal infections have been reported before, but not with special attention to early clinical and imaging findings. METHODS: Thirteen patients (10 men, 3 women; age range, 32-64 years) with progressive sensorimotor deficit were studied. All patients had a neurologic examination after admission and a magnetic resonance imaging scan done within the first 48 hours. In all cases, T1-weighted images before and after administration of gadolinium were obtained. T2-weighted images were acquired in eight cases as well. Ten patients subsequently underwent open surgery; in three cases, a percutaneous biopsy and drainage was performed. RESULTS: Cervical discitis was found in five patients, and thoracic discitis was seen in another five cases. Three patients had an epidural infection without a concomitant discitis. Neurologic and clinical findings varied considerably. Despite clinical signs of spinal cord involvement, a spinal cord lesion was demonstrated only once. Signal change in T2-weighted images may be the first sign of disc space infection. Because a neurologic deficit may occur before any change is visible, follow-up examinations may be required if epidural infection is suspected on clinical grounds. CONCLUSIONS: Magnetic resonance imaging is the appropriate method for diagnostic work-up of progressive neurologic deficit resulting from epidural infection.     

Clinical and MRI findings of the temporomandibular joint in relation to occlusion in young adults

Although considerable evidence suggests that carcinogenic polycyclic aromatic hydrocarbons are immunosuppressive compounds, limited information is available regarding precise effects of these agents on immune cells. In the present report, the effect of subchronic exposure to benzo[a]pyrene (B[a]P) on immune cells in bone marrow, thymus and spleen of B6C3F1 mice was investigated. B[a]P treatment was found to reduce thymic cellularity and also to significantly alter normal thymocyte differentiation, as indicated by expression of CD4 and CD8 cell-surface antigens. Exposure to B[a]P also reduced cellularity of the bone marrow, including decreased percentage and absolute number of CD45R+ B-lineage lymphocytes. Further, B[a]P treatment dramatically increased the percentage of CD44hi cells in bone marrow, while proportionately reducing CD44lo cells. These results may indicate CD44lo bone marrow cells, including prolymphocytic cells, represent sensitive targets of B[a]P. The spleens of treated mice were found deficient in both Thy 1.2+ T lymphocytes and CD45R+ B lymphocytes, effects that correlate well with the chemical-induced alterations observed in thymus and bone marrow, respectively.     

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

Lymphatic regeneration following unilateral hindlimb autotransplantation was studied in 14 Lewis rats using Technetium-99 radiolabeled sulfur colloid (TC-99) lymphoscintigraphy and compared to the lymphatic pattern exhibited in four unoperated control rats. Control animals demonstrate a reproducible flow of lymph along the deep lymphatic system from the foot, draining into the ipsilateral inguinal nodes, and then up to the para-aortic nodes. Following replantation, lymphatic outflow from the replanted limb begins to occur within 3 to 6 days, reaching normal lymphatic clearance within 12 days. However, the pattern of lymphatic flow is ill-defined, relying on multiple small channels of the superficial lymphatic system. In contrast to controls, at 3 hr post TC-99 injection, lymphatic drainage in replanted rats is via the inguinal and axillary nodal regions bilaterally. This abnormal pattern persisted in the replanted animals for the duration of this study, 160 days. It is evident that lymphatic regeneration in this animal model is associated with a rapid return to normal levels of lymphatic clearance via collateral channels within the subcutaneous tissue. The rapidity with which lymphatic drainage is restored, and its localization within the subcutaneous tissue, can explain why replanted tissues and microvascular free flaps seldom develop lymphedema. In addition, the rat hindlimb replantation model may prove useful for studies of the general mechanisms and specific factors responsible for lymphangiogenesis.     

Synovitis in internal derangement of the temporomandibular joint: correlation between arthroscopic and histologic findings

PURPOSE: To define arthroscopic criteria for synovitis (SYN) reflecting specific histologic changes. Arthroscopic observations in the temporomandibular joint of patients with internal derangement were compared with histologic patterns in synovial biopsies obtained during arthroscopy. PATIENTS AND METHODS: Arthroscopic biopsies were obtained in 31 joints of 31 patients using an oriented semiblind technique. The histologic changes in the biopsies were compared with those in age-matched reference material obtained at autopsy. RESULTS: Microscopic examination of the reference material showed inflammation in three specimens (18%), whereas it showed inflammation in 22 patient specimens (71%). Biopsies from the patients also exhibited more pronounced inflammation. According to conventional criteria, arthroscopy showed mild SYN (increased vascularity) in 51%, moderate changes in 39%, and more pronounced changes in 10% of the joints. The presence of moderate or pronounced arthroscopic signs of SYN (capillary hyperemia and synovial hyperplasia), correlated well with the histologic diagnosis of SYN. This was in contrast to patients with mild arthroscopic SYN (increased vascularity). CONCLUSION: Increased vascularity seen during arthroscopy must be questioned as a sign of SYN. More reliable criteria seem to be capillary hyperemia and synovial hyperplasia.     

Uses of magnetic resonance imaging (MRI) in presurgical evaluation of internal derangement of temporomandibular joint (TMJ)

Nine cases of unilateral internal derangement of TMJ indicated for surgical intervention, were selected for this study. The affected joints were imaged by MRI presurgically. The non-affected joints were also imaged as controls. MRI findings were correlated with intraoperative surgical findings. The results were absolutely accurate as regards degenerative joint pathosis and capsular rupture, and with high degree of accuracy (85.7%) in detection of disc displacement. Two cases of disc perforation were not detected by MRI. The results were promising and encouraging the use of this noninvasive imaging technique as presurgical aid in TMJ disorders.     

Temporomandibular joint disorders and surgery of the temporomandibular joint

Surgery of the TMJ is a useful tool in Temporo Mandibular Disorders (TMD). After have been identified what is part of TMD and what isn't, this article lay stress upon the fact that surgery of the TMJ is the appropriate treatment only when the nonsurgically therapy had failed. Indications, danger and complications are discussed. Procedures of arthrotomy and arthroscopy are explained. Various surgical procedures and staging of TMD are discussed.     

Arthritic temporomandibular joint: correlation of macromolecular contrast-enhanced MR imaging parameters and histopathologic findings

PURPOSE: To assess the utility of macromolecular contrast material-enhanced magnetic resonance (MR) imaging parameters for determining the histopathologic severity of temporomandibular joint (TMJ) arthritis. MATERIALS AND METHODS: Ovalbumin was used to induce arthritis in the TMJs of 10 previously sensitized adult white rabbits. Five rabbits composed the sham-treated control group. Dynamic spin-echo imaging was performed immediately before and for 30 minutes after injection of macromolecular contrast medium. Histologic specimens of TMJ were assessed quantitatively for arthritis. Changes in MR signal intensity were derived from the synovial and subsynovial tissues of the TMJ, and plasma volume (PV) and permeability surface area product (PS) were calculated. These MR parameters and the arthritic scores were compared between sham-treated and antigen-challenged TMJs. The relationships between MR parameters and histopathologic indexes were also determined. RESULTS: Arthritic TMJs showed marked enhancement of the synovial and subsynovial tissues over the imaging period. PS and all histopathologic indexes of arthritis were significantly greater (P < .005) in antigen-challenged than in sham-treated TMJs. PS demonstrated strong positive relationships with all histologic parameters of arthritis, indicating its utility for assessing the severity of joint inflammation. CONCLUSION: Macromolecular contrast-enhanced MR imaging enables quantification of PS and PV in inflamed joints. This technique may provide insights into the pathogenesis of joint inflammation and noninvasive monitoring of disease severity and treatment response in arthritis.     

Cat scratch disease: magnetic resonance imaging findings

Cat scratch disease is an infectious lymphadenitis frequently occurring in children and adolescents. We present the magnetic resonance imaging findings of two patients with this disease. In both cases, lymphadenopathy was characterized by extensive stranding of the surrounding soft tissues, consistent with the inflammatory nature of this condition. Magnetic resonance imaging can be diagnostic and may obviate the need for invasive means of evaluation in patients suspected of having cat scratch disease.     

A case report. Chondromatosis of the temporomandibular joint

Synovial chondromatosis is a rare pathological condition that usually affects large joints but can affect the temporomandibular joint. The disease typically manifests itself with signs and symptoms similar to internal derangement. The disease is characterized by free-floating or attached cartilaginous bodies in the joint space. In this article, the authors present a case of synovial chondromatosis and discuss its pathological process. They also discuss diagnostic approaches and current treatment.     

Craniocerebral magnetic resonance imaging measurement and findings in Lesch-Nyhan syndrome

OBJECTIVE: To provide the first comprehensive magnetic resonance imaging (MRI) assessment of brain in a series of patients with Lesch-Nyhan syndrome (LNS), with emphasis on basal ganglia measurements. DESIGN: Routine readings of MRI studies, repeated reading in random order blinded to subject diagnosis, and 3-dimensional volumetric measures of basal ganglia regions. SETTING: The Johns Hopkins Hospital, Baltimore, Md. PATIENTS: Seven patients with LNS who have hypoxanthine guanine phosphoribosyltransferase levels less than 1.6% and characteristic clinical features of the disorder, which include hyperuricemia, cognitive impairment, and dystonic movement disorder, were compared with 7 age-matched control subjects. Five of the 7 patients demonstrated self-injurious behavior. MRI studies were performed using general anesthesia because of the severity of the movement disorder. MAIN OUTCOME MEASURES: Measurement of brain regions from MRI-obtained images. RESULTS: Routine readings described mild cerebral atrophy in 2 of 7 patients, but no caudate or putamen abnormalities were reported. However, on the directed blinded rereading, small caudates were suspected in 5 of 7 cases, and abnormalities in cerebral size and cranium were identified. Volumetric studies of the patients with LNS confirmed a 34% decrease in caudate volume (P<.001), a 17% decrease in total cerebral volume (P<.03), and a 12% decrease in putamen volume (P=.19). CONCLUSIONS: To our knowledge, this is the first demonstration of consistent neuroanatomic abnormalities in LNS. The findings of reduced basal ganglia volume are consistent with the dystonic movement disorder.     

Laser arthroscopy of the temporomandibular joint

Laser surgery is very different than traditional surgery. The clinician must be familiar with the physical properties of the laser to use this instrument safely and properly. Various lasers are available for use in oral and maxillofacial surgery and dentistry, namely the carbon dioxide laser, the neodymium:yttrium-aluminum-garnet laser, and the holmium: yttrium-aluminum-garnet laser (Ho:YAG). Only the Ho:YAG laser has been used with effectiveness in temporomandibular joint arthroscopic surgery.     

Kinesiotherapy and temporomandibular joint disorders

Physical therapy management is a part of the therapeutic treatment established in close relationship with the dentist or the maxillofacial surgery. The role of pain has always been an important evil, the psychological background has also to be taken into consideration. The sedative and calming role played by massage and relaxation can not occult the longterm improvement of functional rehabilitation. The aspect of physical therapy in relation to temporomandibular disorders is disregarded by the aspects because of its important role in functional treatment.     

Correlation of inflammatory cytokines with arthroscopic findings in patients with temporomandibular joint internal derangements

PURPOSE: The goal of this study was to evaluate the presence of the inflammatory cytokines interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) within the superior temporomandibular joint (TMJ) space in patients with internal derangements and to compare these values with the pathologic findings seen arthroscopically. PATIENTS AND METHODS: Thirty patients with symptomatic TMJ dysfunction and clinical and imaging evidence of internal derangements of the TMJ were evaluated. Before entering the superior joint space with the arthroscope, 2 mL sterile saline was injected and, after 30 seconds of equilibration, was aspirated for analysis. The surgeon then performed diagnostic arthroscopy. The degree of synovitis, degeneration, percent condylar roofing, and any pathologic changes, such as perforations, were recorded. The level of total protein in each sample was ascertained, as well as the levels of IL-1 beta, IL-6, and TNF-alpha. RESULTS: Of 30 samples tested, three were discarded because of failure to gain access into the superior joint space. Of the 27 remaining samples, IL-6 showed the closest correlation with the level of acute synovitis demonstrated arthroscopically. Two of the higher IL-6 levels (167 and 324 pg/microg protein) were seen with patients with a significant disc perforation. In patients with a high degree of vascularity, IL-6 was found to be between 0 to 581 pg/microg protein with an average of 80 pg/microg protein and a median value of 43 pg/mg. These values significantly correlated with the degree of vascularity (P < or = .02). This is in comparison with the 10 remaining patients, who showed significantly fewer vascular changes arthroscopically. In these patients, the range of IL-6 was 0 to 35 pg/microg protein, with an average of 19 pg/microg protein and a median value of 14.5 pg/microg. These values significantly correlated with the smaller degree of vascularity (P < or = .02). In seven patients, the role of nonsteroidal antiinflammatory drug (NSAID) use resulted in decreased levels of IL-6, which has been noted in previous studies. In patients with higher rated redundancy of the synovial tissue, the average IL-6 level was 92 pg/microg protein, whereas the median value was 44 pg/microg protein. In patients with little or no redundant synovial tissue, an average IL-6 level of 22 pg/microg protein was present. The median value in these same joints was 15 pg/microg protein. These IL-6 values significantly correlated with the degree of redundancy (P < or = .03). The degree of degenerative change (chondromalacia, fibrillation), disc displacement (roofing), and the presence or absence of adhesions did not significantly affect the levels of IL-6 within the patients studied. The presence of IL-1 beta and TNF-alpha was not found to correlate with the arthroscopic findings in the superior joint space. CONCLUSIONS: The presence of IL-6 correlated with the degree of acute synovitis. IL-1 beta and TNF-alpha were not found in significant levels within the superior joint space. These findings correlated with those reported by other investigators. The production of IL-6 by synovial cells and its role in TMJ disease warrants further investigation.