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The possible role of nitric oxide in the physiopathology of pain associated with temporomandibular joint disorders.

Temporomandibular joint disorders (TMD) pose a significant challenge to the practice of oral and maxillofacial surgery. When painful, TMD are generally associated with hyperthermia of the overlying skin. It is hypothesized that this skin hyperthermia, caused by regional vasodilation, is induced by nitric oxide (NO) produced in the extravascular space of the joint. Extravascular NO can be produced by osteoblasts, chondrocytes and macrophages, or by stimulated neurons. It is suggested that this kind of pain is associated with NO-enhanced sensitivity of the peripheral nociceptors. Verification and clinical implications of the proposed mechanism are discussed.

Chondrocytes↗

Three-dimensional computed tomographic analysis of the normal temporomandibular joint.

Ten temporomandibular joints, obtained from three asymptomatic patients and two cadavers, were examined by three-dimensional computed tomography. The osseous components of the condylar process of the mandible and the glenoid fossa of the temporal bone were well visualized. The meniscus was visualized in both the closed- and the open-mouthed positions. Advantages and disadvantages of the technique are discussed.

Cartilage, Articular↗

Radiation dose in temporomandibular joint zonography.

Temporomandibular joint morphology and function can be evaluated by panoramic zonography. Thermoluminescent dosimetry was applied to evaluate the radiation dose to predetermined sites on a phantom eye, thyroid, pituitary, and parotid, and the dose distribution on the skin of the head and neck when the TMJ program of the Zonarc panoramic x-ray unit was used. Findings are discussed with reference to similar radiographic techniques.

Humans↗

The role of diagnostic arthroscopy in the management of temporomandibular joint dysfunction.

Temporomandibular joint (TMJ) dysfunction may manifest itself clinically by a variety of presentations ranging from headache, pre-auricular pain or tenderness, otalgia, to mandibular hypomobility. Some symptoms may mimic forms of facial pain such as: temporal arteritis, migraine, cluster headache, trigeminal or glossopharyngeal neuralgias, myofascial pain dysfunction, or muscle contraction (tension) headache. This article will focus on a relatively new diagnostic tool that may be used to examine the TMJ for intracapsular pathology which may be responsible for the presenting patients' symptoms.

Arthroscopy↗

The wrist pivot method, a novel technique for temporomandibular joint reduction.

Temporomandibular joint (TMJ) dislocation is an infrequent dislocation of the mandible. The usual technique of reduction, recommended by most Emergency Medicine textbooks, consists of downward forces applied to the mandible. In the authors' experience this is often painful and requires significant sedation. We present a patient in whom the usual manner of TMJ dislocation reduction was difficult. We describe a novel technique for TMJ dislocation reduction that uses the intrinsic biomechanical properties of the mandible.

Biomechanical Phenomena↗

Capsaicin receptor expression in the rat temporomandibular joint.

Experimentally, temporomandibular joint (TMJ) nerve units respond to capsaicin, which is used clinically to treat TMJ pain. However, the existence of capsaicin receptors in the TMJ has not previously been clearly demonstrated. Immunohistochemical analysis has revealed the presence of transient receptor potential vanilloid subtype 1 (TRPV1) expression in the nerves and synovial lining cells of the TMJ. TRPV1-immunoreactive nerves are distributed in the synovial membrane of the joint capsule and provide branches to the joint compartment. The disc periphery is supplied by TRPV1 nerves that are mostly associated with small arterioles, and occasional nerves penetrate to the synovial lining layer. Double immunofluorescence has shown that many TRPV1-immunoreactive nerves are labeled with neuropeptide calcitonin gene-related peptide, whereas few are labeled with IB4-lectin. The results provide evidence for the presence of TRPV1 in both nerves and synovial lining cells, which might thus be involved in the mechanism of nociception and inflammation in the TMJ.

Animals↗

Magnetic resonance image of internal derangement of the temporomandibular joint.

Sixteen temporomandibular joints (TMJ) were examined by a high resolution magnetic resonance (MR) imager. Multisection 3.5 mm thick sagittal and coronal images were obtained by 1.0-T MR system and spin-echo sequence (TR = 800 msec, TE = 20 msec). MR provided useful information about meniscal position, morphology and histology. In our study, the MR of the 16 TMJ showed normal finding in two cases and abnormal findings could be differentiated into anterior disc displacement with reduction (8 cases), anterior disc displacement without reduction (3 cases) and bony change (3 cases). MR imaging can produce high-quality tomographic images with good demonstration of the internal structures of TMJ. As it is a noninvasive technique involving no ionizing radiation, MR imaging has been shown to be a useful tool for the demonstration of internal changes in TMJ.

Adult↗

Evaluation of body posture in individuals with internal temporomandibular joint derangement.

Temporomandibular dysfunctions (TMD) comprise a great number of disruptions that may affect the temporomandibular joint (TMJ), the masticatory muscles, or both. TMJ internal derangement is a specific type of TMD, of which the etiology and physiopathology are broadly unknown, but have been suggested to be linked to head, neck, and body posture factors. This study aimed at verifying possible relationships between body posture and TMJ internal derangements (TMJ-id), by comparing 30 subjects presenting typical TMJ-id signs to 20 healthy subjects. Subjects' clinical evaluations included anamnesis, stomatognatic system evaluation, and plotting analysis on body posture photographs. No statistically significant differences were found between the groups. Results do not support the assertion that body posture plays a role in causing or enhancing TMD; however, these results should be cautiously considered because of the small number of subjects evaluated and the many posture variables submitted to statistical procedures that lead to high standard deviations.

Adolescent↗

A review of anaesthetic technique in 15 paediatric patients with temporomandibular joint ankylosis.

Temporomandibular joint ankylosis presents a serious problem for airway management. This relatively rare problem becomes even more difficult to manage in children because of their smaller mouth opening with near total trismus, and the need for general anaesthesia before making any attempts to secure the airway. A technique for securing the airway that combines local blocks for nerves of larynx and topical anaesthesia of upper airways for placement of these blocks, and minimal general anaesthesia for these manoeuvres, is described. For general anaesthesia, a combination of halothane and ether by spontaneous ventilation, using bilateral nasopharyngeal airways, was used. Because of the severe trismus, a tongue depressor or tip of a laryngoscope was used with a fibreoptic light source in the buccal sulcus to visualize the tracheal tube in the pharynx. Nasal forceps, with a smaller tip and narrower blade than Magill forceps was used to guide the tracheal tube towards the air bubbles coming out of larynx. No attempt was made to visualize the larynx, but its position was guessed from the direction of these air bubbles. We review the anaesthetic technique in 15 such cases of severe trismus managed successfully between 1986 and 1999.

Anesthesia, General↗

Clinical evaluation of amitriptyline for the control of chronic pain caused by temporomandibular joint disorders.

Temporomandibular disorder (TMD) is characterized by a combination of symptoms affecting the temporomandibular joint and/or chewing muscles. The two most common clinical TMD symptoms are pain and dysfunction. Pain is usually caused by dysfunction, and emergency therapy has focused on controlling it. Recent investigations into TMD have led to the recommendation of antidepressants as a supporting treatment against constant neuralgic pain. The aim of this double-blind study was to verify the efficiency of antidepressants (amitriptyline) as a support in the treatment of chronic TMD pain. Twelve female volunteers presenting chronic TMD pain were divided into two groups and treated for 14 days: Group 1 with 25 mg/day of amitriptyline and Group 2 with a placebo. The intensity of pain and discomfort was evaluated daily, using a visual analog scale (VAS), over a period of seven days preceding the treatment (baseline), during the 14-day treatment, and for seven days after the treatment. The results revealed a significant reduction of pain and discomfort in Group 1 (75%) compared to Group 2 (28%) during the three weeks beginning at baseline (p < 0.01). Amitriptyline proved to be an efficient alternative treatment for chronic pain in TMD patients.

Amitriptyline↗

Seeding techniques and scaffolding choice for tissue engineering of the temporomandibular joint disk.

Temporomandibular joint (TMJ) disk removal, or diskectomy, is a detrimental yet necessary surgery for patients with extremely displaced disks. Tissue engineering is an enticing methodology for improvement of the postoperative outcome of diskectomy. Unfortunately, the field of tissue engineering of the TMJ disk is only in the early stages of development. The initial objective of this investigation was to study the cellular response of TMJ disk cells in alginate culture. However, a marked decrease in cell population and the lack of detection of extracellular matrix (ECM) products did not support the use of alginate culture. The second objective was then to attempt TMJ disk cell culture in polyglycolic acid (PGA) nonwoven meshes. However, as suitable seeding methods for TMJ disk cells on PGA had not been determined, three techniques were selected for study: spinner flask, orbital shaker, and a novel pelleting technique. PGA constructs maintained cellularity throughout the culture period, and scaffolds seeded with the spinner flask produced about 35 microg of collagen per construct. Thus, as evidenced by the production of a major extracellular component, PGA nonwoven meshes seeded with TMJ disk cells, using a spinner flask, may be a first positive culturing step in tissue engineering the TMJ disk.

Alginates↗

Effect of lateral cranial base surgery on temporomandibular joint function.

Temporomandibular joint (TMJ) function in patients who experienced lateral cranial base tumor surgery was evaluated by a comparison of recordings of condylar movement in right and left parasagittal planes during opening and protrusive movements. The characteristic tracing and measurements of mandibular movements at the condyle of six patients after surgery were compared with a nonsurgical asymptomatic control group consisting of 16 subjects. Of the six surgical patients, three patients had the condyles disarticulated and rearticulated, and three patients had condyles surgically resected. The data gathered through computerized axiographic tracings of horizontal condylar inclinations at different intervals showed significant interaction effects among right and left sides within the groups (p 0.001). Medical histories and clinical examinations were used to diagnose or rule out the presence of TMJ disorders. Magnetic resonance imaging (MRI) and three-dimensional computerized tomograms (CT) imaging of the TMJs of these patients were investigated. MRI and CT scans illustrated the static detail and morphology of the TMJs. Computerized axiography revealed the dynamic detail and function of the TMJs in the various mandibular movements. The study of condylar pathways during opening and protrusive movements showed variations of mandibular deviation among patients having cranial base surgery. Increased mandibular deviation was found in patients who experienced resected condyles.

Adult↗

Subluxation of the temporomandibular joint.

The temporomandibular joint in actual function does not resemble other joints in the body in that the condyles leave their fossae with maximal opening and in some subjects with only a 35 mm. opening. The term subluxation, with its implication of abnormality, does not seem applicable to a normal movement. While significant problems, such as dislocation, locking, and loud clicking, can occur with such anterior-to-the-fossae movements, they are relatively rare. Most temporomandibular problems are associated with confinment of the condyles to their fossae with limited or no translatory condylar movement. A recognition of the normal range of condylar movement would lessen iatrogenic abuse of this area.

Humans↗

Incidence of systemic joint hypermobility and temporomandibular joint hypermobility in pregnancy.

The purpose of this study was to establish a possible correlation between systemic hypermobility and temporomandibular hypermobility during pregnancy. One hundred (100) healthy pregnant women were evaluated: 7% in the first trimester (1T), 38% in the second trimester (2T), and 55% in the third trimester (3T) of gestation. In the series, the authors analyzed systemic joint hypermobility (SJH), range of mandibular movement (MMR), head and shoulder posture, head lateralization, and the presence of noise, pain, and parafunction in the temporomandibular joint. They observed that pain is present to a mild degree mostly in the head and ears of all pregnant women who presented with pain. Most of the subjects had some type of parafunction, but only 42.8% had noises. Mild SJH was seen in 50% of the 2T and 3T subjects, and in 28.5% of 1T subjects. Mild mandibular hypermobility was found for jaw opening (46%) and lateralization to the right (44%) or to the left (46%). Most of the subjects had hypomobility for jaw protrusion and retraction. The subjects had head protrusion and anterior posture as a result of the change in their center of gravity brought about by pregnancy. The authors found no association between systemic joint hypermobility (SJH) and temporomandibular hypermobility, although hormonal changes and complex factors during pregnancy may represent a risk factor for both types of mobility change.

Adolescent↗

Long-term study of temporomandibular joint surgery with alloplastic implants compared with nonimplant surgery and nonsurgical rehabilitation for painful temporomandibular joint disc displacement.

PURPOSE: The purpose of this study was to determine the long-term objective and subjective outcomes of temporomandibular joint (TMJ) implant surgery for the treatment of painful TMJ disc displacement using temporary Silastic (Dow Corning Corporation, Midland, MI), permanent Silastic, or Proplast (Vitek, Houston, TX) implants to replace the disc. These cases were compared with other cases of the same diagnosis treated with either nonsurgical rehabilitation or nonimplant surgery involving discectomy or disc repair procedures. MATERIALS AND METHODS: A cross-sectional study was conducted among 466 patients who received treatment for unilateral or bilateral TMJ disc displacement before January 1, 1990. The 5 treatment groups noted above were compared for long-term outcomes. Objective outcome measurements for jaw function were performed using a calibrated examiner and the Craniomandibular Index (CMI). Subjective (self-reported) outcomes were obtained relative to jaw function (Mandibular Function Impairment Questionnaire [MFIQ]), symptom severity (Symptom Severity Index [SSI]), and the impact of pain (Global Pain Impact [GPI] scale). RESULTS: The results, adjusted for gender, baseline tomogram score, and baseline symptom scores, showed that the nonsurgical rehabilitation group (n = 159) and the group having TMJ surgery without implants (n = 149) had statistically better results than the group who underwent surgery with a Proplast implant (n = 94). These between-group differences included both objective signs (CMI), and subjective reports of jaw function (MFIQ), symptom severity (SSI), and global pain impact (GPI). The MFIQ score associated with the nonsurgical rehabilitation group was also statistically better than for the Silastic implant groups, including both the temporary (n = 31) and permanent (n = 33) implants. Clinical differences between groups were slight. CONCLUSION: This study suggests that the use of interpositional disc implants in TMJ surgery is not associated with improved outcomes when compared with nonimplant surgery or nonsurgical rehabilitation.

Adult↗

Utility of frequency-selective fat saturation T2-weighted MR images for the detection of joint effusion in the temporomandibular joint.

OBJECTIVES: To evaluate joint effusion in the temporomandibular joint (TMJ) using frequency-selective fat saturation (FS) T2-weighted images and assess this technique. To investigate whether bone marrow abnormalities and magnetic resonance imaging (MRI) findings of internal derangement may be linked to joint effusion in the TMJ in patients with pain. METHODS: TMJ effusion was sought on FS T2-weighted images and conventional T2-weighted images in 400 joints from 200 patients with TMJ-related pain. Self-reported pain records were obtained from patients immediately before MRI and images assessed by the amount of TMJ fluid graded bilaterally using reference films by two radiologists. Other parameters recorded included disk displacement categories and condyle marrow abnormalities. The association between the recorded parameters and TMJ effusion judged by FS-sequences or conventional sequences was analysed using chi-square and Kappa tests. RESULTS: The detection rate of TMJ effusion by FS-sequences was significantly greater than by conventional methods, and the results showed a significant relationship between MRI interpretation of TMJ effusion using FS-sequences or conventional methods and the presence of pain. The correlation between TMJ effusion on FS-sequences and pain was significantly stronger than the conventional method. Kappa test indicated good agreement between pain and MRI TMJ effusion by FS-sequences (kappa = 0.66), but not by conventional sequences (kappa = 0.56). The other parameters showed a similar trend for TMJ-related pain. CONCLUSIONS: FS T2-weighted imaging is useful for detection of TMJ effusion, without known causes and confirms the importance of TMJ effusion as an indicator in patients with TMJ-related pain, bone abnormalities, and disk displacement.

Adipose Tissue↗

Magnetic resonance evidence of joint effusion of the temporomandibular joint after fractures of the mandibular condyle: a preliminary report.

To investigate the clinical significance of magnetic resonance (MR) evidence of joint effusion of the temporomandibular joint after mandibular condylar fractures, magnetic resonance imaging (MRI) was performed on 18 joints in 15 patients with either unilateral or bilateral mandibular condylar fractures using a 1.5 Tesla MRI scanner (Signa, General Electric, Milwaukee, WI). MR evidence of joint effusion was evaluated and compared with the types and the positions of the fractures. MR evidence of joint effusion was observed in 11 of 18 TMJs, which was 61% of the condylar fractures. It appeared more frequently after fractures with dislocation than those without dislocation (p < 0.05). In addition, MR evidence of effusion appeared more frequently in TMJs after high condylar fractures (head to upper neck) than low condylar fractures (lower neck to subcondylar) (p < 0.05). These findings indicate that MR evidence of joint effusion may serve as a marker for the detection of severe intra-articular damage to the TMJ after mandibular condyle fractures.

Adolescent↗

Magnetic resonance imaging-based joint space measurements in temporomandibular joints with disk displacements and in controls.

OBJECTIVE: Previous studies have discussed a posterior displacement of the condyle as a possible risk factor for the development of disk displacements (DDs) of the temporomandibular joint (TMJ). The objective of this study was to compare the posterior and anterior joint spaces in healthy TMJs with those of patients who present different forms of DDs. STUDY DESIGN: The anterior and posterior joint spaces from 58 patients with unilateral or bilateral DD with reduction (DDR) or without reduction (DDNR) and from 30 healthy volunteers were measured with 3 sagittal magnetic resonance images (MRIs) from each TMJ in the maximum intercuspid position. RESULTS: Measurements of anterior and posterior joint spaces showed a good interexaminer reproducibility (rank correlation coefficients ranging from 0.88 to 0.95). Patients with bilateral DDR demonstrated a significantly more posterior position of the condyle, as compared with controls and patients with bilateral DDNR. DDNR presented a significant reduction of the anterior and the posterior joint spaces, leading to a mean concentric position of the condyle. Patients with unilateral DDR or DDNR demonstrated a greater variability of anterior and posterior joint spaces, compared with patients with a bilaterally identical type of DD. CONCLUSIONS: The data of this MRI-based clinical study indicate that different stages of disk displacements are associated with significant changes of condylar position. The variation of anterior and posterior joint spaces was influenced by the diagnosis of the contralateral joint.

Adolescent↗