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ORIGINAL RESEARCH Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 1  |  Page : 22-26
Correlation of clinical and MRI findings of tempero mandibular joint internal derangement


Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Maduravoyal, Chennai, India

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   Abstract 

The most common clinical features of tempero-mandibular joint internal derangement are correlated with the MRI findings of shape of the disc in an attempt to find the etiology of tempero-mandibular joint internal derangement. In this study, the clinical parameters of pain, muscle tenderness, clicking with in the joint (like early, middle and late) are correlated with the MRI findings of disc shapes. (like biconcave, thick, lengthened, folded, adhesion). The study reveals any trauma that leads to muscle tenderness results in internal derangement of tempero-mandibular joint.

How to cite this article:
Chowdary U V, Rajesh P, Neelakandan R S, Nandagopal C M. Correlation of clinical and MRI findings of tempero mandibular joint internal derangement. Indian J Dent Res 2006;17:22-6

How to cite this URL:
Chowdary U V, Rajesh P, Neelakandan R S, Nandagopal C M. Correlation of clinical and MRI findings of tempero mandibular joint internal derangement. Indian J Dent Res [serial online] 2006 [cited 2020 Feb 22];17:22-6. Available from: http://www.ijdr.in/text.asp?2006/17/1/22/29896

   Introduction Top


The most common symptoms of internal derangements of tempero mandibular joint are pain, muscle tenderness a 'clicking' or 'popping' sensation with in the joint, headache, earache and limited ability to open the mouth [1],[2],[3]. Aural symptoms include subjective hearing loss, pain and sensation of blockage, vertigo and timiitus [4],[5],[6],[7],[8],[9],[10],[11]. A grading system for internal derangements has been proposed that grades the severity of internal derangements according to the morphology of the disc [12],[13]. An anteriorly displaced disc that maintains its normal bi­concave configuration is grade I (anterior disc displacement with reduction). An anteriorly displaced disc that does not have normal morphology is grade It (anterior disc displacement with out reduction).


   Patients and methods Top


We investigated 60 tempero mandibular joints in 30 patients (11 women, 19 men) with internal derangements by MRI in addition to clinical examination of musclet enderness and clicking.

Images were obtained by a 1.5 T MRI system (Gyro scan Intera Philips) using a transmit and receive head coil and 2mm thick section with a 150 ram field of view and 256 x 256 matrix. T2 PD/TSE images were obtained at coronal, axial, sagittal planes and kinematics using a transmit and receive head coil. Sequential bilateral images were taken with the subjects mouth closed and at the respective maximum open mouth positions.

The radiologist assessed the MRIs using established criteria for normal disc position versus disc displacement. The normal disc position in the posterior band of the disc located superior (12 0' Clock) to the condyle, where as disc displacement is the posterior, band of the disc being in anterior, antero-lateral, medial (or) lateral position, relative to the superior part of the condyle.

The parameters evaluated clinically were collaborated with MRI findings. Based on this disc condyle relationships were categorized as normal, disc displacement with reduction and disc displacement without reduction. The configuration of the disc in the sagittal plane was classified as biconcave-normal, thick posterior band, lengthened, biconvex, folded and rounded.


   Results and observation Top


Correlation of clinical findings of muscle tenderness, click with MR1 findings of disc deformity.

  1. Out of twenty six cases of biconcave disc, twenty had no symptoms (muscle tenderness and click); six had muscle tenderness without click,
  2. Out of thirteen cases of thickened disc, twelve had muscle tenderness and click; one had muscle tenderness without click
  3. Out of seventeen cases of lengthened disc, sixteen had muscle tenderness and click, but one had muscle tenderness without click
  4. Out of three cases of folded disc, two had muscle tenderness but no click; one had no symptoms (muscle tenderness and click).
  5. One had adhesion with muscle tenderness, but no click.



   Discussion Top


Helms et al [2] found that 17% of joints that had anteriorly displaced discs with reduction also had degenerative joint disease whereas 95% of joints with displaced discs without reduction had degenerative changes. Most of these joints had discs that were not repairable whereas virtually all of the joints in which disc repair was attempted had reduced discs. The AM can grade the severity of the hydration; in the posterior band, this is best seen as an intermediate signal on TI-weighed images and a high signal on T2 images [13]. Miller et al [16] reported that the discs were thickened and deformed in all cases of anterior disc displacement without reduction. Disc displacement without reduction was usually associated with an absence of joint sounds, the presence of TMJ pain and muscle spasms and a limitation of jaw opening with deviation to the affected side. On the other hand, Sutton et al [17] reported that the condyle-disc relation was more likely to be in the normal position (with the middle of the posterior band of the disc in the 12 O'clock position relative to the center of the head of the condyle) in the clinically silent group than in the group with clinically discernible sounds.

In an electromyographic study, Isberg et al [18] found that electromyo graphic activity of the temporalis and masseter muscles occurred when the condyle slid over the posterior band of the disc and could be interpreted as an arthrokinetic reflex caused by distraction. Continuous muscle activity could be provoked by displacement of the TMJ disc and ceased when the disc was returned to a normal position on opening mouth only to recur every time the disc became displaced on closure of mouth. Anterior disc displacement without reduction (closed lock) could cause spastic activity in the temporalis muscle on the affected side. Spastic activity of the masseter and temporalis muscles on the same side as a joint with anterior disc displacement hinders the condylar movement necessary to achieve reduction [18]. Sigaroudi and Knap [19] reported soreness of lateral pterygoid muscles and temporal muscles in 62% of the patients with internal derangements of the TMJ. It has been suggested that the click occurs because of in-coordination of the lateral pterygoid and temporal muscles, anterior displacement of the disc, posterior displacement of the condyle, folding or wrinkling of the disc, roughness of the joint surface and prolonged opening during dental procedures. However, our results were slightly different as the incidence of tenderness of medial pterygoid, masseter and temporalis muscles, was less than that of the lateral pterygoid muscle.

In arthrographic study combined with sound recordings, Eriksson et al [21] reported that joints with reciprocal clicking showed disc displacement with reduction and silent and crepitating joints showed disc displacement without reduction. All joint with clicking (and most silent joints) had nonarthritic articular surfaces, whereas crepitatinn was recorded in both arthritic and nonartheric joints, implying that crepitations are an unreliable sign of arthritis. They concluded that clicking can be considered to be an accurate sign of reduction of anteriorly displaced discs [17], [22],[23],[24]. However, Roberts et al [25] argued that all joint 'clicking' is not necessarily a sign of a reducing disc. Yatani et al [26] suggested that anterior disc displacement with reduction could be diagnosed with considerable accuracy by clinical examination alone, as the overall accuracy of the clicking test combined with the other tests was about 90%. However, they reported that the ability to predict the position of disc from the patient's history and clinical findings and to differentiate anterior disc displacement without reduction from other diagnoses was not high and that the overall accuracy of the clinical findings ranged from 71 to 81% [27] Wilkes [24] reported that the degree of clinical expression in any given case is proportional to the degree of the pathological condition present.


   Summary Top


Muscle tenderness is a common finding in all the cases even in discs with biconcave shape. But click was not associated with all the cases of muscle tenderness. Tenderness of the muscles of mastication is the initial symptom, if persists it causes lack of coordination between the disc and head of the condyle resulting in click, thus leading to in-coordination between both the joints.


   Conclusion Top


Systemic correlation of clinical signs and symptoms with results of MR1 reveals, muscle tenderness leads to internal derangement. Prevention of muscle tenderness can prevent internal derangement. Finding the cause of muscle tenderness can be the study for future.

 
   References Top

1.Katzberg RW anderson QN, Helms CA. Arthrography, [n: Helms CA, Katzberg R W, Doiwick MF, (Eds.),Internal derangements of the temporomandibular joint, San Francisco: Radiology Research and Education Foundation 85-134,1983.  Back to cited text no. 1    
2.Katzberg RW, Dolwick W, Helms CA, Hopens T, Bales DJ,Coggs GC; Arthrotomography of the temporomandibularjoint, Am J Radiol, 134: 995­1003,1980.  Back to cited text no. 2    
3.Farrar WB: Differentiation of temporomandibular joint dysfunction to simplify treatment, J Prosthet Dent, 28: 629-636,1972.  Back to cited text no. 3    
4.Costen JB: Diagnosis of mandibular joint neuralgia and its place in general head pain, Ann OtolRhinolLaryngo1,53:655-659,1944.  Back to cited text no. 4    
5.Myrhaug H: The incidence of ear symptoms in cases of malocclusion and temporomandibular joint disturbances, Br J Oral Sorg; 2: 28-32,1964.  Back to cited text no. 5    
6.Bernstein JM, Mohl ND, Spiller H: Temporomandibular joint dysfunction masquerading as disease of the ear, nose and throat, Trans Am Acad Ophtahnol Otolaryngol, 73:1208-1217,1969.  Back to cited text no. 6    
7.Brooks GB, Maw AR, Coleman MJ: Costens syndrome' correlation or coincidence: A review of 45 patients with temporomandibular joint dysfunction, otalgia and other aural symptoms, Clin Otolaryngol, 5:23-35,1980.  Back to cited text no. 7    
8.lonides CA, Hogland GA: The disco-malleolar ligament: a possible cause of subjective hearing loss in patients with temporomandibular joint dysfunction, J Craniomaxillofac Surg, 11: 227­231,1983.  Back to cited text no. 8    
9.Costen JB: Neuralgias and ear symptoms, J Am MedAssoc,107: 252,1936.  Back to cited text no. 9    
10.Costen JB: A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint, Ann Otol Rhinol Laryngo1,43:1-15,1934.  Back to cited text no. 10    
11.Ogtitcen-Toller M, Juniper RP: Audiological evaluation of the aural. symptoms in temporomandibular joint dysfunction, J Craniomaxillofac Sorg, 2: 2-8,1993.  Back to cited text no. 11    
12.Helms CA, Kahan L, McNeil C, Dotson T: Temporomandibular joint MR:morphology and signal characteristics of the disc. Radiology 172: 817-820,1989.  Back to cited text no. 12    
13.Helms CA, fritz RC: The temporomandibular joint. In: Higgins CB, HricakH. Helms CA, (Ed.) Magnetic resonance imaging of the body, (2nd ed.), NewYork,RavenPress,1207-1217,1992.   Back to cited text no. 13    
14.Drace JE, Enzmann DR: Defining the normal temporomandibular joint: Closed, partially open and open mouth MR imaging of asyrnptomatic subjects. Radiology, 177: 67-71,1990.  Back to cited text no. 14    
15.Murakami S, Takahashi A, Nishiyama H et al : Magnetic resonance evaluation of the TMJ disc position and configuration, Dentomaxillofac Radio1,22:205-207,1993.  Back to cited text no. 15    
16.Miller TL, Katzberg RW Tallents RH, Bessette RW, Hayakawa K: Temporomandibular joint clicking with nonreducing anterior displacement of themeniscus, Radiology, 154:121-124,1985.   Back to cited text no. 16    
17. Sutton DI, Sadowsky L, Bernreuter WK, McCutcheon MI. Lakshminarayanan AV: Temporomandibular joint sounds and condyle/disk relations on magnetic resonance images, Am J Orthod Dentufac Orthop, 101: 70­78,1992.  Back to cited text no. 17    
18.Isberg A, Widmalm SE, Ivarsson R: Clinical, radiographic and electromyographic study of patients with internal derangement of the temporomandibular joint, Am J Orthod, 88: 453­460,1985.  Back to cited text no. 18    
19.Sigaroudi K, Knap FJ: Analysis ofjaw movements in patients with temporomandibular joint click, J ProsthetDent, 50: 245-250,1983.  Back to cited text no. 19    
20.Malian PE, Kreutziger KL: Diagnosis and management of the temporomandibular joint pain, In: Alling CC, Malian PE, (Eds.) Facial pain, Philadelphia Lea and Febiger,201-211,1977.  Back to cited text no. 20    
21.Eriksson L, Westesson PL, Rohlin M: Temporomandibular joint sounds in patients with disc displacement, hit J Oral Sorg, 14: 428-436, 1985.  Back to cited text no. 21    
22.Farrar W13: Characteristics of the condylar path in internal derangements of the TMJ, J Prosthet Dent, 39:319-323,1978.  Back to cited text no. 22    
23.Schwartz HC, Kendrick RW: Internal derangements of the temporomandibular joint: description of clinical syndromes oral Surg Oral Med Oral Pathol Oral Radiol Endod, 58: 24-29, 1984.  Back to cited text no. 23    
24.Wilkes CH: Internal derangements of the temporomandibular joint arch Otolaryngol Head Neck Surg,115: 469-477, 1989.  Back to cited text no. 24    
25.Roberts CA, Tallents RH, Katzberg RW et al : Clinical and arthrographic evaluation of temporomandibular joint sounds. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 62: 373-376, 1986.  Back to cited text no. 25    
26.Yatani H, Sonoyama W, Kuboki T, Matsuka Y orsini MG, Yamashita A: The validity of clinical examination for diagnosing anterior disc displacement with reduction oral Surg Oral Med Oral Pathol Oral Radiol Endod, 85: 647- 653, 1998.  Back to cited text no. 26    
27.Yatani H, Suzuki K, Kuboki T, Matsuka Y, Maekawa K, YamashitaA: The validity of clinical examination for diagnosing anterior disc displacement without reduction oral Surg Oral Med Oral Pathol Oral Radiol Endod 85: 654-660, 1998.   Back to cited text no. 27    

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Correspondence Address:
U V Chowdary
Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Maduravoyal, Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.29896

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    Tables

[Table - 1], [Table - 2]

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