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A dynamic approach to evaluation of the temporomandibular joint is described. By combining videofluoroscopy with arthrography, the authors were able to demonstrate anterior displacement with capture by the condyle, anterior dislocation, perforation of the meniscus, and fibrosis. This technique provides clinical information about the position of the meniscus and its integrity with minimal patient discomfort.
A case of synovial chondromatosis of the temporomandibular joint in a 48-year-old woman is presented. Computed tomography and magnetic resonance imaging contributed to a clear understanding of the extent of the lesion and were helpful in both surgical treatment planning and follow-up.
The spectrum of disease that affects the temporomandibular joint (TMJ) can be varied. To differentiate among the diseases that cause pain and dysfunction, an intimate knowledge of the anatomy, physiology, and pathology of this region is necessary. Due to the joint's complex anatomy and relationship to the skin, it has been difficult to image in the past. Magnetic resonance imaging is ideally suited for visualizing TMJ because of its superb contrast resolution when imaging soft tissues. Magnetic resonance imaging allows simultaneous bilateral visualization of both joints. The ability to noninvasively resolve anatomic detail can be performed easily and quickly using magnetic resonance imaging. The development of magnetic resonance imaging has greatly aided the diagnosis of TMJ disorders. An understanding of TMJ anatomy and pathogenesis of TMJ pain is crucial for interpretation of magnetic resonance imaging and subsequent treatment.
Trauma is the major cause for temporomandibular joint (TMJ) ankylosis. 20 patients with posttraumatic TMJ ankylosis were surgically treated with interposition of lyophilized homologous cartilage between the newly-formed condylar head and the articular fossa. The follow-up of all patients revealed a correct function of the TMJ. A meticulously performed surgical exposure is decisive for the prevention of facial nerve paresis.
Clinical signs and symptoms of temporomandibular joint arthropathy were evaluated by comparison of clinical findings with arthroscopic findings in 62 temporomandibular joints of 55 patients. The arthroscopic frequency of osteoarthritis was high and was often combined with a mild localized synovitis.
A 34-year-old woman with known rheumatic disease (psoriatic arthritis) in joints other than the temporomandibular joint (TMJ) developed condylar posterosuperior destruction and anterior disk displacement of the right symptomatic TMJ during a 7-month period, as revealed by magnetic resonance imaging. A theory is proposed that destruction of the posterior attachment by pannus was the main reason for the disk displacement, although the pannus formation itself could not be depicted. Follow-up studies also indicated the potential of magnetic resonance imaging to demonstrate fluctuation of inflammatory changes in the TMJ.
Four cases of psoriatic arthritis of the temporomandibular joint are presented. Three patients suffered from polyarthritis, but in one the disease was monoarticular. Clinically, the affection of the TMJ was associated with symptoms and signs characteristic of chronic arthritis. Radiologic examination, including arthrography, demonstrated signs of erosive arthritis in three patients. The TMJ affections were treated by physiatrics and by correction of oral function.
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In this study, lavage fluid was fractionated from the superior joint space in patients with temporomandibular joint (TMJ) dysfunction. A hide powder azure protease assay was used to assess protease activity in lavage fluid. No correlation between a patient's pain and the level of protease activity was demonstrated. Latent as well as active proteases were detected in the sample lavage fluid. Latent matrix metalloproteinases (MMPs) were activated using trypsin. Stromelysin-1 was detected in an active form in lavage fluid by immunozymography. The presence of high molecular weight species with protease activity was also demonstrated. This study validates the presence of stromelysin-1 as well as other MMPs in TMJ lavage fluid and proposes a mechanism for their physiologic activation.
Eight patients with previously placed silicone temporomandibular joint (TMJ) implants were operated on again. Excised tissues from in and around the joint were histologically evaluated. In one case, a parotid lymph node was also examined. All specimens revealed fragmented, amorphous, refractile, but nonbirefringent, irregularly spherical foreign material consistent with fragmented silicone. Granulomatous inflammation and multinucleated giant cells were associated with the silicone material. These findings demonstrated that silicone may not be a totally inert material and that its biomechanical properties are not ideal for use in the TMJ.
The normal temporomandibular joint (TMJ) was evaluated using magnetic resonance (MR) imaging with a surface coil in five subjects and compared with the abnormal joint in 37 patients (aged 14-59 years; total joints studied, 76). Multisection 3-mm-thick sagittal, coronal, and axial images were obtained with a 1.5-T MR system and 6.5-cm-diameter surface coil using both partial saturation and spin-echo sequences (TR = 1,000 msec, TE = 20 or 25 msec). A comparison with arthrography (n = 13 joints), computed tomography (CT) (n = 11), and surgical (n = 5) findings demonstrated that MR imaging with a surface coil provided an accurate depiction of both normal and abnormal TMJs. MR provided information about meniscal position, morphology, and histology that was not available with either arthrography or CT alone. The imaging potential of MR and its noninvasive characteristics warrant priority for further examination of MR as a useful modality in the diagnosis of TMJ pain and dysfunction.
Magnetic resonance (MR) imaging of the temporomandibular joint (TMJ) has now been established as a procedure of choice in the evaluation of TMJ disorders. In this study, we evaluated the dynamics of TMJ motion on MR imaging, which resembles arthrography. Sixty-eight TMJs in 38 symptomatic patients and one healthy volunteer were examined using pseudodynamic images with gradient echo sequences using a 0.5 Tesla MR unit and 8 cm circular planar surface coil. For depiction of each compartment of the meniscus, the optimum sequence was 200/15/2 (TR/TE/excitations) with 50 degrees or 60 degrees flip angle in gradient refocused acquisition in steady-state (GRASS) sequences. Three contiguous slices on sagittal MR images were routinely obtained at 14-18 different phases of the opening cycle and displayed in closed-loop cine fashion. Internal derangement was observed in 57% of 68 joints. The most common type was anterior meniscal displacement without reduction. Sideway and rotational displacements, observed in 10% each, were noted on both sagittal multislice images and axial reference images. As a pseudodynamic MR technique, jaw movement specifically designed to check bite procedure to adjust splints is useful for detecting the exact time of meniscal redisplacement on the second click. After conservative therapy for arthrosis, pseudodynamic MR provided information on changes in the meniscus and condylar relationship. Pseudodynamic MR with multiple phases is suitable for evaluating subtle motion abnormality of the meniscus and for post-therapeutic monitoring.
PURPOSE: The amount of friction in the temporomandibular joint (TMJ) is dependent on the joint components, including the synovial fluid, disc, and articular surface cartilage. As friction in the TMJ is less than in other (discless) joints, we hypothesized that this is caused by the presence of the disc. MATERIALS AND METHODS: The frictional coefficient of the TMJ was first measured in the intact porcine joint (n = 10). After the disc was removed the measurement of frictional coefficient was conducted again. Furthermore, the subsequent effects of loading duration and the application of hyaluronic acid (HA) were examined. RESULTS: The mean frictional coefficient in the intact joint was 0.0177 (SD 0.0021). After disc resection it became 0.0361 (SD 0.0063). The frictional coefficient increased with the length of the preceding loading duration and exceeded 0.0635 (SD 0.0085) after 30 minutes. Subsequent application of HA resulted in a slight decrease of the frictional coefficient. CONCLUSIONS: The presence of the disc reduces the amount of friction in the TMJ. This reduction is likely due to the role of the disc in reducing the amount of incongruity between the articular surfaces and in increasing synovial fluid lubrication.
To gain further knowledge on temporomandibular joint disturbance syndrome (TMJDS), the synovial membranes of 7 patients and 3 cadavers were examined with light microscope and transmission electron microscope. The results showed that the synoviocytes degenerated or disappeared in TMJDS. The cytoplasm contained numerous fibrils, while the organelles diminished in number. The surface of the synovial membrane was covered with a fibrinoid material. The surface of the synovial membrane was covered with a fibrinoid material. The authors consider that these pathological changes reduce or eliminate the normal functions of the synovial membrane, which may lead to damage to the articular cartilage. The articular adhesion found sometimes in TMJDS may be related to the changes in the synovial membrane.
The management of refractory temporomandibular joint (TMJ) pain is both challenging and controversial. A number of simple, noninvasive approaches have been used in the management of this condition with variable success. In patients who fail to respond to conventional conservative measures, in a joint that is not deemed to be grossly mechanically deranged, we advocate the use of TMJ arthrocentesis. In our practice, this is followed by intra-articular morphine infusion in an attempt to give long-term pain relief. Arthrocentesis is a simple technique with minimal morbidity that can be tried instead of more invasive procedures. To date we have used arthrocentesis of the upper joint space, with intra-articular morphine injection in over 500 TMJs. Approximately 90% of patients have found the procedure beneficial, with pain often being reduced 1 year after the procedure. We recommend arthrocentesis as an effective, minimally invasive technique in patients with continuing pain in the TMJ that is unresponsive to conservative management. We additionally advocate the use of intra-articular morphine as a long acting analgesic in these patients. Although arthrocentesis is a well documented technique and there have been many studies published in relation to the use of intra-articular morphine in orthopedic surgery, further research is required, to delineate its use in the TMJ more fully.
OBJECTIVE: To investigate the anatomic attachments to the lateral aspect of the anterior band of the human temporomandibular joint articular disk. MATERIAL AND METHODS: Sixteen human cadaver half-heads were dissected and examined macroscopically. RESULTS: No direct attachment was observed between the deep masseter muscle and the temporomandibular joint articular disk. In one specimen, a small band of the anterior temporalis muscle was directly attached to the lateral aspect of the temporomandibular joint disk; whereas, on the same specimen, the attachment of the superior belly of the lateral pterygoid muscle was a comparatively large band. In another specimen, the lateral pterygoid muscle passed in an anterolateral direction. CONCLUSIONS: The masseter muscle has no functional significance in the biomechanics of temporomandibular joint disk displacement. The anterior temporalis muscle may have functional significance when it is accompanied by an anterolaterally divergent lateral pterygoid muscle.
Referring to the temporomandibular joint (TMJ) of the human mandibular locomotor system, it has been asserted that displacement of the TMJ disc and inflammation of TMJ tissues are the results of acute and indirect trauma to the TMJ; on occasion this is allegedly experienced in motor vehicle accidents and commonly known as a TMJ whiplash injury. It is postulated that the TMJ whiplash injury is released in the occupant or occupants of a target vehicle when its rear end is impacted by the front end of a bullet vehicle. On the basis of detailed analyses of TMJ trauma/pain histories and TMJ magnetic resonance images, presented as circumstantial evidence in favour of the postulated TMJ whiplash injury, and detailed analyses of the mathematical biophysics of the mandibular locomotor system as well as direct experimental evidence, it is concluded that the postulated TMJ whiplash injury does not exist as a single and independent disease entity caused by motor vehicle accidents. If TMJ disc displacement and inflammation are present, they are expressions of an insidious and progressive pre-existing (pre-accident) disease entity that is comprised of TMJ synovitis/osteoarthritis (phase of inflammation with presence of immune system cells), TMJ internal derangement (phase of disc displacement and deformation with presence of proteinases), and TMJ osteoarthrosis (phase of degeneration with absence of immune system cells). For the asserted TMJ whiplash manoeuvre and ensuing injury to occur as postulated, the laws of physics and biology would have to be suspended.
A method for reconstruction of temporomandibular joint is proposed using an intermediary prosthesis and non-sealed cupula. This prosthesis respects the cranial articular slope and provides twofold mobility at the cupular level, which approaches physiological conditions and allows reproduction of buccal opening and closing movements as well as lateralization. A strict surgical procedure is essential when inserting the prosthesis, particular care being necessary in the approach to the facial nerve and control of its temporofacial contingent until above the zygomatic arch. Indications for this procedure are discussed in relation to injuries and tumoral, degenerative and malformatory lesions.