Year : 2010 | Volume
: 21 | Issue : 2 | Page : 189--194
Assessment of diagnostic accuracy of high-resolution ultrasonography in determination of temporomandibular joint internal derangement
Sujata M Byahatti, BR Ramamurthy, M Mubeen, PG Agnihothri
Department of Oral Medicine and Radiology, Government Dental College, Bangalore Shrinivasa Ultrasound and Scanning Center, Shankarmath Road, Bangalore, India
Sujata M Byahatti
Department of Oral Medicine and Radiology, Government Dental College, Bangalore Shrinivasa Ultrasound and Scanning Center, Shankarmath Road, Bangalore
Aim : The aim of this study was to determine the value of dynamic high-resolution ultrasonography (HR-US) in the evaluation of internal derangements of a temporomandibular joint (TMJ) in the open and closed mouth position.
Settings and Design : The study designed to collect the sample from the Outpatient Department of Oral Medicine and Radiology at GDC, Bangalore. Patients with pain, clicking, deviation, and tenderness were included in the study as a symptomatic group. The asymptomatic group was free of any symptoms.
Materials and Methods : Maximum mandibular range of motion (Open and Closed) was performed during HR-US of TMJ in 100 consecutive patients, (50 symptomatic and 50 asymptomatic cases, a total of 400 joints, with 200 joints in the right and left closed and open mouth position;36 males and 64 females; age range, 16 - 50 years; mean age 27.56 years). Subsequently, the entire group, after clinical diagnosis, went for HR-US. Sonography confirmed the diagnosis by showing internal derangement in 34 (68%) of the symptomatic group and the remaining 16 (32%) patients failed to show any derangement. In the asymptomatic group 40 patients did not show any pathology associated with TMJ, whereas, 10 patients showed internal derangement. The data obtained was analyzed statistically.
Results : HR-US performed during the maximal range of motion (Open and Closed) helped to detect 34 instances (68 joints) of internal derangement, which were true positive cases, whereas, 16 patients (32 joints) showed a false positive finding for internal derangement (ID). The results obtained showed a sensitivity of 64%, specificity of 88%, positive predictive value of 84%, and a negative predictive value of 71%, with an accuracy of 76%.
Conclusions : Dynamic HR-US being non-invasive can provide valuable information about internal derangement of the TMJ in mandibular closed mouth than open mouth position.
|How to cite this article:|
Byahatti SM, Ramamurthy B R, Mubeen M, Agnihothri P G. Assessment of diagnostic accuracy of high-resolution ultrasonography in determination of temporomandibular joint internal derangement.Indian J Dent Res 2010;21:189-194
|How to cite this URL:|
Byahatti SM, Ramamurthy B R, Mubeen M, Agnihothri P G. Assessment of diagnostic accuracy of high-resolution ultrasonography in determination of temporomandibular joint internal derangement. Indian J Dent Res [serial online] 2010 [cited 2021 May 8 ];21:189-194
Available from: https://www.ijdr.in/text.asp?2010/21/2/189/66634
The term 'Internal derangement' is generally used to describe an abnormal relationship between the articular disk, the mandibular condyle, and the fossa, including the articular eminence. 
Internal derangement occurs in up to 28% of the adult population. Despite the prevalence of these disorders, it has been poorly understood and investigated until recently. 
The most frequent joint abnormality that has been found in patients with TMJ disorders is the anterior position of the articular disk. 
The purpose of this study is to describe the technique of high-resolution sonography in the evaluation of an internal derangement and to discuss the reliability and accuracy of the ultrasonographic findings.
Materials and Methods
This study was carried out between October 2002 and July 2004, in the Department of Oral Medicine and Radiology, Government Dental College, Bangalore.
A total of 100 consecutive patients (Symptomatic-50, Asymptomatic-50) were examined clinically (A proforma designed by the Research Diagnostic Criteria published by Dworkin and LeResche in 1992, was used for symptomatic cases) between the age group of 16 and 50 years. The age and sex of both the groups were matched. Later these groups underwent HR-US imaging. There were 64 females and 36 males, whose ages ranged from 16 to 50 years (mean age 27.56 years), underwent sonography. The findings were statistically analyzed [Figure 1].
Sonography was performed using a 12-MHZ linear array transducer on an HDI 5000 scanner (Advanced Technology Lab. Bothell, WA). The patient was made to lie down comfortably with the joint to be observed closer to the scanner and gel was applied to the surface of the skin near the joint and a transducer probe was placed over this with proper orientation. The procedure was performed in both open and closed mouth positions for both the right and left joints [Figure 2] and [Figure 3]. Once the images obtained were displayed on the monitor these images were 'FREEZED' and interpreted by an Ultrasonologist.
On the sonogram, the disk was visualized as a thin homogenous, hypo-to-isoechoic band. The bony landmark of the mandibular condyle and the articular eminence were visualized as hyperdense lines [Figure 4]. In evaluating the findings of the closed mouth position, the position of the disk was considered to be normal if the intermediate zone of the disk was located between the anterosuperior aspect of the mandibular condyle and the posteroinferior aspect of the articular eminence. Disks with the intermediate zone located anterior to this position were considered to be displaced in the anterior direction (internal derangement).
In evaluating the findings of the open mouth, the position of the disk was considered to be normal if the intermediate zone of the disk was located between the condyle and the articular eminence. If the disk was displaced in anterior direction then it was considered to be an internal derangement. Apart from the disk position, the condylar movements and deformity of the condylar surface were also detected.
It has been proved that ultrasonography can be used in human being as it remains a noninvasive technique. Ethically it is proven to be a safer measure to be used in human being.
The following methods of statistical analysis have been used in this study. Data was entered in a Microsoft Excel Sheet and the analysis was carried out using an SPSS package. Sensitivity was calculated as the number of true positive / false negative + number of true positive. Specificity was calculated as the number of true negative / false positive + number of true negative; and accuracy as the number of true positive + number of true negative / n (total no. of patients).
Observation and Results
High-resolution ultrasonography of 100 patients (Symptomatic - 50, Asymptomatic - 50), revealed that on the right side 34 cases (68 Joints) were true-positive and 16 (32 joints) cases showed false-negative findings for internal derangement. On the left side 32 (64 joints) cases were true-positive and 18 (36 joints) cases showed false-negative results. In the asymptomatic group 40 (80 joints) on the right and left side showed true negative findings. The other 10 cases (20 joints) showed false-positive findings [Figure 1], [Table 1] and [Table 2].
[Figure 5] shows 72% of the individuals had bilateral symptoms where as 16% of the individuals had symptoms on the right side and 12% of the individuals had symptoms on the left side.
[Figure 6], [Table 3] shows, among a total of 50 symptomatic patients, in the right closed and open mouth position, a sensitivity of 77.3%, specificity of 80%, positive predictive value of 68%, and a negative predictive value of 71.4%, with an accuracy of 74%.
In the left closed and open mouth position, HR-US showed a sensitivity of 64%, specificity of 88%, positive predictive value of 84%, and a negative predictive value of 71%, with accuracy of 76%.
[Table 4] and [Table 5] shows that the overall results showed a sensitivity of 80%, specificity of 76%, PPV of 76.9%, and NPV of 79.2, with an accuracy of 78% in assessing the internal derangement in the closed mouth position using HR-US. In the open mouth position; a sensitivity of 76%, specificity of 76%, PPV of 76%, NPV of 76%, and accuracy of 76% was achieved using HR-US.
The above-mentioned findings showed that internal derangement was better visualized in the closed mouth position than in the open mouth position.
The dynamic HR-US of the symptomatic group showed restricted condylar movements in 38 patients (76 joints) on the right side and 36 patients (72 joints) on the left side. The rest did not have any restriction.
The appearance of the condylar head on the ultrasonography was as follows. In a static state, HR-US observed a normal round surface in 16 condyles in the right closed, 14 condyles in the right open, 20 condyles in the left closed, and 18 condyles in the left open mouth positions. Flat condylar surfaces were observed in 18 condyles in the right closed, 14 condyles in the right open, 10 condyles in the left closed, and 10 condyles in the left open mouth positions. Angulated condylar heads were observed in 16 condyles in the right closed, 20 condyles in the right open, 14 condyles in the left closed, and 14 condyles in the left open mouth positions. Condylar heads were not appreciated in two condyles in the right closed, four condyles in the right open, four condyles in the left closed, and six condyles in the left open mouth positions. The condylar movements and condylar head surface were additional factors in this study.
The purpose of TMJ imaging is to evaluate the integrity and relationship of the hard and soft tissues, to confirm the extent or state of progression of a known disease, and to evaluate the effect of treatment.  The most frequent abnormalities that are imaged in TMJ patients are degenerative changes of bone and disk displacement.  Diagnostic imaging  of the temporomandibular joint has undergone revolutionary development during the last two decades. With advanced modalities we have been able to differentiate between different articular entities in patients with temporomandibular joint disorders.
Displacement of the articular disk of the TMJ from its normal position was recognized as a clinical problem over 100 years ago. Since these early reports, several others have been associated with joint pain, limited mandibular movements, and joint sounds, with displacement of the articular disk of the TMJ. 
During the last two decades there has been a dramatic development in the potential of diagnostic imaging that has led to a significant increase in our understanding of temporomandibular joint disorders. The close association between symptoms of TMJ internal derangement and disk displacement has been emphasized in the previous literature. Authors  have suggested that ultrasonography (US) can be used as a diagnostic aid with a sensitivity and specificity of up to 95%.
In the second half of the 1970s and throughout most of the 1980s, arthrography  was the leading imaging modality for soft tissue examination of the TMJ. During the second half of the 1980s and in the 1990s, magnetic resonance (MR) imaging has gradually, but rapidly emerged as the prime imaging modality for TMJ diagnosis. During the 1980s computed tomography (CT) was also used in evaluating TMJ disorders, but inferior soft tissue resolution now makes CT the method of choice only when osseous TMJ abnormalities are of prime concern.
Similar to MRI, US  is used for the imaging and diagnosis of internal derangements of the TMJ in closed mouth and open mouth positions. It is suggested that US is a noninvasive and dynamic imaging technique, which may help in the confirmation of the disk position in patients presenting with symptoms of TMJ internal derangements. However, an ultrasound examiner's experience is very important for the use of US. With an experienced radiologist, images obtained by US will be interpreted more accurately. US will also help in the identification of disk position in subjects with signs and symptoms of TMJ internal derangement.
Various studies ,,,,,,,,,,,,, have suggested that US is a noninvasive, static, and dynamic imaging technique that provides an insight into the dynamics of the TMJ. It has been used widely in assessing TMJ pathology, disk displacement, to study joint spaces and condylar position, and to study the distance between the articular capsule and the lateral surface of the mandibular condyle, joint anatomy.
A majority of symptomatic TMJ disk displacement cases  have been reported in the second decade of life where the gender distributions are 4:1, 6:1, and 3.3:1 for females and males, which are in accordance with our study, wherein, the number of females were more affected than males (3:5.3). In the present study, a 12-MHz scanner was used. This imports high resolution quality and an improvement in tissue differentiation, which have reduced the proportion of false positive results.
HR-US allowed greatly improved diagnostic efficacy during repeated motions at the respective open-mouth positions, which probably made the structures involved more clearly distinguishable. There was a difference in diagnostic accuracy between HR-US evaluation performed at the closed and maximum mouth opening positions. False negative errors outnumbered false positives, which could have resulted from the misinterpretation of a deformed condyle or an incorrect beam angle of the TMJ, degeneration or a partial rupture of the disk. Another reason for a false negative result may be a completely deranged disk. ,
HR-US, despite its limitations, may provide valuable information about disk displacement of the TMJ, with instant results and low cost. Regarding diagnosis and treatment, several techniques have been advocated for the management of TMJ disorders, with diagnostic accuracies ranging between 43 and 90%. ,,,,,,
As the treatment of TMJ disorders carries benefits and risks, it may be important to avoid treatment of asymptomatic subjects due to incorrect (false positive) diagnoses. ,, Therefore, high sensitivity and specificity are necessary before HR-US is considered for use as a sole screening test. Further studies are necessary to reduce the false positive HR-US interpretations, in particular, to avoid unnecessary treatment of patients. ,,
It can be concluded from this study that, HR-US with the added benefit of reduced cost, remains another effective, noninvasive technique, to define the disk, its position, and the presence of TMJ internal derangements. However, further studies including a large sample would support and make available the widespread use of HR-US in the diagnosis of Internal Derangements in the forthcoming FUTURE.
|1||Jank S, Rudisch A, Bodner G, Brandlmaier I, Gerhard S, Emshoff R. High resolution ultrasonography of the TMJ: Helpful diagnostic approach for patients with TMJ disorders. J Craniomaxillofac Surg 2001;29:366-71.|
|2||Kaplan PA, Helms CA. Current status of TMJ imaging for the diagnosis of internal derangements. AJR Am J Roentgenol 1989;152:697-705.|
|3||Larheim TA. Current trends in TMJ imaging. Oral Path Oral Med Oral Surg 1995;80:555-76.|
|4||White, Pharaoh, editors. Oral Radiology principals and Interpretation. 5th ed. Mosby Elsevier Publication; 2004. p. 336.|
|5||Greenberg, Lick, editors. Berket's Oral medicine diagnosis and treatment. 10 th ed. Haricourt (India) Private Limited Publication; 2003. p. 271.|
|6||Fonseca RJ, editors. A textbook of oral and maxillofacial surgery. 4 th vol. W.B. Saunders Company; 2000. p. 39-46.|
|7||Gateno J, Miloro M, Hendler B. The use of ultrasound to determine the position of the mandibular condyle. Oral Path Oral Med Oral Surg 1993;51:1081-6.|
|8||Uysal S, Kansu H, Akhan O, Kansu Φ. Comparison of Ultrasonography with MRI imaging in the diagnosis of TMJ internal derangements: A preliminary investigation. Oral Path Oral Med Oral Surg 2002;94:115-21.|
|9||Emshoff R, Bertram S, Rudisch A, Gassner R. The diagnostic value of ultrasonography to determine the temporomandibular joint disc position. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:688-96.|
|10||Isberg A, Hagglund M, Paesani D. The effect of age and gender on the onset of symptomatic TMJ disk displacement. Oral Path Oral Med Oral Surg 1998;85:252-7.|
|11||Nabeih YB, Speculand B. Ultrasonography as a diagnostic aid in temperomandibular joint dysfunction: A preliminary investigation. Int J Oral Maxillofac Surg 1991;20:182-6.|
|12||Stefanoff V, Hausamen JE, van den Berghe P. Ultrasound imaging of the TMJ disc in asymptomatic volunteers. J Craniomaxillofac Surg 1992;20:337-40.|
|13||Fredini DM, Tognini F, Melechiorre, Zampa V, Bosco M. Research ultrasound assessment of increased capsular width as a predictor of TMJ effusion. DMFR 2003;32:359-64.|
|14||Emshoff R, Jank S, Bertram S, Rudisch A, Bodner G. Disk displacement of the TMJ sonography versus MR imaging. AJR Am J Roentgenol 2002;78:1557-62.|
|15||Shahidi S, Haghnegahdar AA, Falamaki MN, Khojastehpoor L. Clinical evaluation of internal joint derangement using sonography. Oral Radiol 2008;24:34-8.|
|16||Pereira LJ, Gaviγo MB, Bonjardim LR, Castelo PM. Ultrasound and tomographic evaluation of temporomandibular joints in adolescents with and without signs and symptoms of temporomandibular disorders: A pilot study. Dentomaxillofac Radiol 2007;36:402-8.|
|17||Melchiorre D, Calderazzi A, Maddali Bongi S, Cristofani R, Bazzichi L, et al. A comparison of ultrasonography and magnetic resonance imaging in the evaluation of temporomandibular joint involvement in rheumatoid arthritis and psoriatic arthritis. Rheumatology (Oxford) 2003;42:673-6.|
|18||Hayashi T, Ito J, Koyama J, Yamada K. The accuracy of sonography for evaluation of internal derangement of the temporomandibular joint in asymptomatic elementary school children: Comparison with MR and CT. AJNR Am J Neuroradiol 2001;22:728-34.|
|19||Sommer OJ, Aigner F, Rudisch A, Gruber H, Fritsch H, Millesi W, et al. Cross-sectional and functional imaging of the temporomandibular joint: Radiology, pathology, and basic biomechanics of the jaw. Radiographics 2003;23:e14.|
|20||Manfredini D, Tognini F, Melchiorre D, Zampa V, Bosco M. Ultrasound assessment of increased capsular width as a predictor of temporomandibular joint effusion. Dentomaxillofac Radiol 2003;32:359-64.|
|21||Paesani D, Westesson PL, Hatala MP, Tallents RH, Brooks SL. Accuracy of clinical diagnosis of TMJ internal derangement and arathrosis. Oral Surg Oral Med Oral Pathol 1992;73:360-3.|
|22||Mohl ND, Ohrbach R. Clinical decision making for temporomandibular disorders. J Dent Educ 1992;56:823-33.|
|23||Anderson GC, Schiffman EL, Schellhas KP, Fricton JR. Clinical Vs. arthrographic diagnosis of TMJ internal derangement. J Dent Res 1989;68:826-9.|
|24||Schiffman E, Anderson G, Fricton J, Burton K, Schellhas K. Diagnostic criteria for intraarticular TMJ disorders. Community Dent Oral Epidemiol 1989;17:252-7.|
|25||Roberts C, Katzberg RW, Tallents RH, Espeland MA, Handelman SL. The clinical predictability of internal derangements of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1991;66:32-6.|
|26||Marguelles-Bonnet RE, Carpentier P, Yung JP, Defrennes D, Pharaboz C. Clinical diagnosis compared with findings of magnetic resonance in 242 patients with internal derangements of the TMJ. J Orofac Pain 1995;9:244-53.|
|27||Parlett K, Paesani D, Tallents RH, Hatala MA. Temporomandibular joint axiography and MRI findings: A comparative study. J Prosthet Dent 1993;70:521-31.|
|28||Cebul RD, Hershey JC, Williams SV. Using multiple tests: Series and Parallel approaches. Clin Lab Med 1982;2:871-90.|
|29||Griner PF, Mayewski RJ, Mushlin AI, Greenland P. Selection and interpretation of diagnostic tests and procedures: Principles and applications. Ann Intern Med 1981;94:533-600.|
|30||Hershey JC, Cebul RD, Williams SV. Clinical guidelines for using two dichotomous tests. Med Decis Making 1988;66:68-78.|
|31||Widmer CG, Lund JP, Feine JS. Evaluation of diagnostic tests for TMD. J Calif Dent Assoc 1990;18:53-60.|
|32||Mohl ND. Reliability and validity of diagnostic tests for TMD. J Dent Res 1993;72:113-9.|