Superior Joint Space Research Articles

Comparative Study of Inferior Joint Space and Superior Joint Space Injection of Sodium Hyaluronate in Patients With Anterior Disc Displacement Without Reduction of the Temporomandibular Joint

In the past decade, there has been an explosion in the use of psychotropic medicines for both psychiatric and non-psychiatric conditions. Many new agents have been developed with multiple applications across a wide range of human conditions. We will review all classes of psychiatric medicines, including sub-classes, mechanisms of action, disease state indication and purported other uses. We will examine how these medicines may affect the Oral and Maxillofacial surgeon in terms of how psychotropic agents may contribute to oral disease, the potential for drug interactions with anesthetic agents and pain medications, and in terms of what the surgeon may expect from patients with conditions that require these treatments.

Comparative Study of Inferior Versus Superior Joint Space Injection of Sodium Hyaluronate in Patients With Anterior Disc Displacement Without Reduction of the Temporomandibular Joint: A Randomized Controlled Trial

Comparative Study of Inferior Versus Superior Joint Space Injection of Sodium Hyaluronate in Patients With Anterior Disc Displacement Without Reduction of the Temporomandibular Joint: A Randomized Controlled Trial

A new proposal for the radiographic evaluation of cartilage wasting in osteoarthritic hip joints

The aim of the present study was to analyze the distinct locations of minimum joint space width (mJSW) across the articular surface among osteoarthritic (OA) hip joints and to correlate the radiographic signs of cartilage wasting with clinical measures of hip function. Forty patients (mean age 67.6 years, range 50–82 years) with 80 hips showing varying degrees of OA were included in this study. For each hip, the Lequesne Index and the passive range of hip motion were evaluated and the mJSW was localized and measured in a.p. radiographs. Independent of the mJSW localization, the lateral, superior, and axial joint space width (JSW) were additionally measured in radiographs. Radiographic and clinical data were analysed and correlated with each other. mJSW was found in the superiolateral and axial parts of the OA hip joint in 90% of the cases. A significant correlation was found among almost all variables; however, the highest correlation (P < 0.01) existed between all functional variables and the sum of lateral, superior, and axial JSW (lsaJSW). As compared to the traditional mJSW, the results strongly recommend the measurement of lsaJSW, since this radiographic parameter represents well the weight-bearing areas of cartilage and shows a superior correlation with clinical evidences of hip disability.

Image-Guided Minimally Invasive Surgical Access to the Temporomandibular Joint: A Preliminary Report

To establish a protocol for image-guided minimally invasive surgical access to the temporomandibular joint (TMJ). This study involved 2 patients with TMJ pain and mandibular motion dysfunction. Axial magnetic resonance imaging (MRI) of the TMJ was obtained and loaded into an intra-operative navigation system to guide joint space injection. With a navigated syringe, 1 mL synvisc Hylan G-F 20 was directly injected into the superior and inferior joint spaces under navigation guidance. With the assistance of an intraoperative navigational system, the TMJ MRI images were visualized in 3 dimensions and enabled guiding a needle into the superior and inferior joint spaces for therapeutic injection. The treatment outcome for both patients was satisfactory with improvement in pain score and mandibular motion. A protocol for image-guided minimally invasive surgical access to the TMJ was established. This could provide the technical basis for evaluation of accurate joint space intervention as a form of treatment of appropriate TMJ disorders.

Image-guided puncture technique for the superior temporomandibular joint space: value of cone beam computed tomography (CBCT)

Temporomandibular joint (TMJ) disk perforation or adhesion requires arthrographic examination. However, puncture of the TMJ may result in damaging penetration of the middle cranial fossa. We investigated the effectiveness of penetrating the superior TMJ space using a safe image-guided puncture technique (IGPT). Fifty-two patients underwent cone beam computed tomography (CBCT) examination. Optimum angles and distances from the puncture site to the thinnest point of the glenoid fossa to penetrate the superior joint space were measured using three-directional images. Puncturing the superior articular cavity was immediately successful in 50 cases. Image measurements gave an average horizontal angle of 8.0 degrees (standard deviation [SD]: 9.2), an average coronal angle of 16 degrees (SD: 11.3), and an average distance of 27 mm (SD: 2.8). Variation in puncture angle among individuals indicated that CBCT examination is necessary preceding TMJ puncture. Preliminary clinical application has demonstrated the safety of IGPT using CBCT.

Histological Evaluation of Full Thickness Skin as an Interpositional Graft in the Rabbit Craniomandibular Joint

The purpose of this study is to determine the histological fate of the full thickness skin graft when placed into the temporomandibular joint using a rabbit model. Fourteen New Zealand white rabbits were used and divided into 3 groups. Two rabbits were used as controls (Group A) whereby a sham operation was undertaken with an incision made and immediately repaired without breaching the joint space of the left craniomandibular joint (CMJ). In 6 rabbits (Group B), the joint capsule of the left CMJ was surgically breached but the articular disc was preserved and the wound was repaired. The remaining 6 rabbits (Group C) also had the left CMJ surgically exposed with preservation of the articular disc and the interpositional placement of a full thickness skin graft that was taken from the skin of their necks. All grafts were placed above the articular disc and head of condyle in the superior joint space and firmly secured to the surrounding tissues with nonresorbable sutures. The rabbits were sacrificed at 1, 3, and 5 months after surgery and the left CMJs were histologically prepared and examined under light microscopy. The condylar head in the regions where the disc was present appeared to closely resemble that of the control rabbits. However, where the disc was breached by inadvertent surgical trauma (Group B), the underlying condyle showed an irregular outline with increased fibrosis and a marked reduction in mature cartilage. In the subarticular bone there was increased osteoblast and osteoclast activity reflecting high bone activity indicative of a remodeling rather than a degenerative process. The interpositional skin grafts in all experimental animals (Group C) were found adjacent to the condyle on the lateral aspect rather than above the condylar head where it was originally sutured in place. Significant atrophy and reduction in the number and size of the skin appendages such as sweat glands and hair follicles was found within the grafted skin of all experimental animals (Group C) compared with normal skin. All the grafts showed evidence of epidermoid inclusion cysts. The full thickness skin graft is not a suitable interpositional material for the TMJ because of the high risk of epidermoid cyst formation and the propensity for lateral displacement of the graft even when sutured into the appropriate intra-articular position.

Synovial chondromatosis of the temporomandibular joint with condylar extension

Synovial chondromatosis is a benign disease that rarely affects the temporomandibular joint (TMJ). It can be seen commonly in the superior joint space and presents with various signs and symptoms according to the stage of progression. Sometimes it presents as a large swelling in the preauricular area with or without cranial extension, and the clinical and radiographic findings may be misdiagnosed as other benign or malignant diseases of TMJ. Therefore, we report an uncommon case of synovial chondromatosis presenting as a large preauricular mass arising from the inferior joint space of the TMJ with bony resorption of the mandibular condyle, which mimicked osteochondroma.

Acetabular development after bipolar hemiarthroplasty for osteosarcoma in children

A retrospective analysis was performed of eight patients with an open triradiate cartilage, who underwent resection for osteosarcoma and reconstruction of the proximal femur with a hemiarthroplasty, in order to identify changes of acetabular development. An analysis of the centre-edge angle, teardrop-to-medial prosthesis distance, superior joint space, teardrop-to-superior prosthesis distance, degree of lateral translation, and arthritic changes, was performed on serial radiographs. The median age at the time of the initial surgery was 11 years (5 to 14). All patients developed progressive superior and lateral migration of the prosthetic femoral head. Following hemiarthroplasty in the immature acetabulum, the normal deepening and enlargement of the acetabulum is arrested. The degree of superior and lateral migration of the prosthetic head depends on the age at diagnosis and the length of follow-up.

Embryological study of the development of the rat temporomandibular joint: highlighting the development of the glenoid fossa

Basic embryological findings on the development of the temporomandibular joint have yet to be elucidated sufficiently. This experiment, was undertaken to find the standard time course of the development of the temporomandibular joint in rat fetuses. Serial frontal and sagittal sections of rat fetal heads (between 13.5 and 20.5 days post-conception [p.c.]) were examined microscopically. The condyle was recognized as a mesenchymal condensation at 14.5 days p.c., while the glenoid fossa was recognized at 15.5 days p.c. The mesenchymal condensation of the condyle had differentiated into chondrocytes by 16.5 days p.c., and endochondral ossification was recognized at 17.5 days p.c. The intramembranous ossification of the glenoid fossa was already recognized by 16.5 days p.c.; this started in the posterior region and progressed anteriorly between the zygomatic arch and the squamous part of the temporal bone. Ossification of the condyle had not been completed by 20.5 days p.c., a mass of hypertrophic chondrocytes remained in the center of the condylar head. The glenoid fossa was almost completely ossified by 19.5 days p.c. A coarse region of cells, reminiscent of apoptosis, was recognized in the region of the prospective superior joint space at 17.5 days p.c., and an actual joint space had formed by 18.5 days p.c. The inferior joint space was recognized at 19.5 days p.c. as a fissural cavity, but it was much narrower than its superior counterpart. The prospective meniscus was distinguished on the condylar surface at 17.5 days p.c. by the difference in the shape of its constituent cells. The results obtained here seem to be useful for further experiments and molecular biological studies.

A Comparison of Synovial Fluid Pressure After Immediate Versus Gradual Mandibular Advancement in the Miniature Pig

Mandibular advancement is a commonly performed surgical procedure for the treatment of mandibular hypoplasia. With the increased use of rigid fixation, there has been a decrease in the amount of relapse but an increase in the amount of force transmitted to the condyles. Gradual advancement of the mandible by distraction osteogenesis slowly overcomes the soft-tissue envelope and may decrease the amount of force exerted on the condyles. The purpose of this study was to develop an animal model to measure the magnitude of pressure associated with immediate versus gradual mandibular advancement. A 2.0-mm pressure transducer was placed in the superior joint space in 2 miniature pigs. In the first animal, immediate advancement of the mandible with rigid fixation was performed. The synovial fluid hydrostatic pressures were measured prior to surgery and postoperatively. A second animal underwent gradual advancement with distraction osteogenesis. The synovial fluid hydrostatic pressures were measured prior to and after each activation of the distraction device. The condyles were examined radiographically and microscopically. The superior joint space fluid pressures increased and remained elevated over a 5-week period after immediate advancement. In the gradually advanced mandible, the pressures were elevated but returned to near baseline prior to the activation the following day. This animal model is useful to directly measure the pressure that is exerted on the condyle. This will allow further studies to compare methods for mandibular advancement. It is likely that gradual advancement of the mandible by distraction osteogenesis produces less force and causes less condylar resorption than large mandibular advancement stabilized with rigid fixation.

Tomographic evaluation of TMJ in adolescents with temporomandibular disorders

This study evaluated the TMJ images of normal subjects and of those who presented TMD (temporomandibular disorders) using linear tomography at rest position. Craniomandibular Index (CMI) and a questionnaire on subjective symptoms were used to assess 217 subjects aged 12 to 18 years. Those with the highest and the lowest scores were divided into Control (n = 20) and TMD groups (n = 20), respectively. Corrected tomography was used to measure the narrowest anterior, superior and posterior joint spaces, to determine the condyle position in all 40 subjects. The distance means did not correlate with CMI scores (p > 0.05). The number of posteriorly positioned condyles was significantly higher in TMD patients (p = 0.05), especially in females. It was concluded that condyle position in linear tomography at rest position cannot yield TMD diagnosis.

Comparison of cytokine level in synovial fluid between successful and unsuccessful cases in arthrocentesis of the temporomandibular joint

Purpose The aim of this study was to compare proinflammatory cytokine levels between successful cases and unsuccessful cases of arthrocentesis in patients with internal derangement of the temporomandibular joint (TMJ). Patients and methods This study involved 73 joints judged as successful and 30 judged as unsuccessful of 103 joints in 100 patients diagnosed with internal derangement of the TMJ and who underwent arthrocentesis. The diluted synovial fluid before undergoing arthrocentesis was aspirated from the superior joint space. The concentrations of interleukin (IL)-1β, tumor necrosis factor-α, IL-6, and IL-8 were measured using an enzyme-linked immunosorbent assay. The differences in the detection rate and concentration of each cytokine between successful cases and unsuccessful cases were analyzed statistically. Results There was a statistically significant difference between successful cases (72.2%) and unsuccessful cases (95.5%) in the detection ratio of IL-6 ( P < .05). There was a statistically significant difference between successful cases (0.017 pg/100 μg protein) and unsuccessful cases (0.046 pg/100 μg protein) in the concentration of IL-1β ( P < .05). Conclusion It has been shown that the presence of IL-1β and IL-6 in synovial fluid may be indicators of possible unsuccessful treatment following arthrocentesis for internal derangement of the TMJ.

Effects of a single arthrocentesis and a COX-2 inhibitor on disorders of temporomandibular joints: A preliminary clinical study

Our aim was to examine the short-term effect of combined treatment with single arthrocentesis and a COX-2 inhibitor on 26 patients with severe symptoms of temporomandibular joint (TMJ) disorders. The severity of the disorders was graded according to the degree of restriction of mouth opening and pain score on a visual analogue scale. Synovial fluid was collected from the superior joint space of the affected TMJ, and arthrocentesis was done with isotonic saline, 200 ml. Subsequently, etodolac, 400 mg/day, was given for 2 weeks. At 14 days, patients were re-examined and further specimens of synovial fluid were collected. Patients generally lost their symptoms and the severity of the disorders improved significantly ( P<0.01). The concentrations of total protein and albumin in synovial fluid decreased with no statistical significance. However, the concentration of matrix metalloproteinase-3 and its ratios to total protein and albumin did decrease significantly ( P<0.05). Our results suggest that a larger controlled study is necessary to clarify the contributory effect of arthrocentesis and etodolac for patients with severe symptoms of TMJ disorders.

Analysis of inflammatory mediators in TMJ synovial fluid lavage samples of symptomatic patients and asymptomatic controls

Arthroscopy is a minimally invasive surgical approach to the diagnosis and treatment of patients with persistent, recalcitrant symptoms related to temporomandibular joint (TMJ) pathology. Synovial fluid analysis combined with arthroscopy has provided a research model designed to identify pathogenic mechanisms of TMJ disease. It is our purpose to study IgA, IgG, and beta-glucuronidase levels in order to find a correlation between biochemical markers and joint pathology which will allow us to better understand intra-articular pathology. Our working hypothesis was that those joints with the highest levels of osteoarthritis and synovitis, would have elevated levels of inflammatory by products in the synovial fluid. Our patient population included 20 patients (18 female, 2 male) with severe pain and limitation of mandibular movement that failed to improve with at least 3 months of a full course of nonsurgical therapy. Arthroscopic surgery was performed on 29 temporomandibular joints in these 20 patients. Immediately prior to the arthroscopic procedure, a synovial fluid aspirate was obtained by injecting then aspirating 2 mL of 0.9% saline from the superior joint space. Synovial fluid aspirates of TMJs from 13 control subjects (6 female and 7 males), with no history of TMJ pain/dysfunction, were obtained. These subjects underwent flexible fiberoptic arthroscopy through a No. 15 gauge needle and a 0.86 mm flexible endoscope and were recruited for the study with full IRB approval. Arthroscopic examination of the patient and control groups involved classification of joints for osteoarthritis (OA) and synovitis (syn) using a visual grading system. All synovial fluid samples were analyzed for beta-glucuronidase, IgA, and IgG using fluorometric assay and ELISA. The results in the symptomatic group revealed the following arthroscopic findings: non-OA in 11 joints, OA grade I in 7 joints, and OA grade II in 11 joints. In the asymptomatic control group, all 13 joints showed non-OA (P < .05 nonparametric variance). The symptomatic group demonstrated the following: non-syn in 1 joint, syn grade 1 in 1 joint, syn grade 2 in 11 joints, syn grade 3 in 13 joints, and syn grade 4 in 3 joints. The asymptomatic control group demonstrated non-syn in 8 joints, syn grade 1 in 2 joints, and syn grade 2 in 3 joints (P < .05, nonparametric variance). Beta-glucuronidase was significantly elevated (P < .05, t test) in the patient group when compared to the control group (4.13 plus minus 8.30 versus 0.9 ±0.83) (mean ± standard deviation). The difference in the IgG level was also statistically significant (31,638 ± 70,714 versus 4,407 ± 1,324; P < .05, t test). IgA level showed a similar trend between the patient and the control group (6,315 ± 19,037 versus 425 ± 192; P =.10, t test).

Prospective study of posttreatment changes in the temporomandibular joint

The purpose of this follow-up prospective longitudinal study was to determine what changes occurred in the condyle/fossa relationship after treatment. Orthodontic posttreatment records, including corrected tomograms of 106 white patients (58 Class I and 48 Class II Division 1), from a pretreatment sample of 232 patients, were analyzed. The average pretreatment age was 13.6 ± 3.0 years. The average length of treatment was 2.3 ± 0.6 years for the Class I group and 2.8 ± 0.9 years for the Class II Division 1 group. With orthodontic treatment, the condyle became more concentrically positioned, and a significant (P <.05) decrease in left and right anterior, posterior, and superior joint spaces was observed in most subjects. There was no statistically significant correlation between changes in the condyle/fossa relationship based on age, gender, skeletal or dental variables, signs or symptoms of temporomandibular disorder, headgear use, type of elastics, or nonextraction vs extraction treatment. (Am J Orthod Dentofacial Orthop 2002;122:486-90)

Tomographic assessment of temporomandibular joint osseous articular surface contour and spatial relationships associated with disc displacement and disc length

The objective of this retrospective study was to determine whether associations exist between osseous temporomandibular joint (TMJ) characteristics and TMJ internal derangement (disc position and deformation) in an adolescent population. Magnetic resonance imaging (MRI) was used to quantitatively determine disc position and length in 335 TMJs in 175 subjects (106 female and 69 male) between the ages of 7.27 and 20.0 years (mean age, 13.08 years). Nine tomographic variables were measured from pretreatment tomograms. Tomographic data were cross-referenced with MRI data. Male and female samples were evaluated separately. Stepwise linear regression identified associations between disc displacement and reduced superior joint space, increased posterior joint space, increased anterior joint space, and reduced articular eminence convexity (male R2 value, 0.41; female R2 value, 0.38). Associations between reduced disc length and condylar position and eminence flattening were weaker (male R2 value, 0.16; female R2 value, 0.32). This study demonstrates that TMJ internal derangement is associated with functional osseous adaptation within the joint. (Am J Orthod Dentofacial Orthop 2002;121:152-61)

Morphological and positional asymmetries of young children with functional unilateral posterior crossbite.

This prospective clinical study evaluated the morphological and positional mandibular asymmetry of young patients with functional unilateral posterior crossbite. The sample included 9 girls and 6 boys (8.8 +/- 1.0 years of age), evaluated at the initiation of treatment and approximately 6 months after the retention phase (1.1 +/- 0.2 years after initiation of treatment). Each patient had a complete unilateral posterior crossbite involving 3 or more posterior teeth, a functional shift from centric relation-intercuspal position, and no signs or symptoms of temporomandibular disorder. A bonded palatal expansion appliance was used to rapidly expand the maxilla (1 month) and retain the treatment changes (6 months). Zonograms were used to assess articular joint spaces, and submental vertex radiographs were used to assess morphological and positional asymmetry. The results showed that the mandible was significantly longer on the noncrossbite side than it was on the crossbite side. The asymmetry was most evident for the ramus and involved both the condylar and the coronoid processes. The posterior and superior joint spaces were larger on the noncrossbite side than they were on the crossbite side. After treatment and retention, the mandible showed no significant morphological asymmetries. Mandibular growth was greater on the crossbite side than it was on the noncrossbite side, and the mandible had been repositioned; the crossbite side had rotated forward and medially toward the noncrossbite side. We concluded that unilateral posterior crossbites produce morphological and positional asymmetries of the mandible in young children, and that these asymmetries can be largely eliminated with early expansion therapy.

Multifactorial analysis of differences in temporomandibular joint hard tissue anatomic relationships between disk displacement with and without reduction in women

Statement of problem. Without multifactorial models, it is difficult to resolve whether hard tissue tomographic relationships can distinguish differences between temporomandibular joint (TMJ) internal derangement diagnoses. Purpose. The purpose of this study was to use multifactorial models to examine whether there are hard tissue anatomic and orthopedic characteristics that distinguish temporomandibular joints with disk displacement with reduction from disk displacement without reduction. Material and methods. TMJ tomograms from female patients who had unilateral disk displacement diagnosed with (n = 84) or without (n = 78) reduction were compared with the use of 14 linear and angular measurements and 8 ratios. A representative classification tree model was tested for fit with sensitivity, specificity, accuracy, and likelihood accountability, and the results were compared with a multiple stepwise logistic regression model and univariate analysis. Results. Disk displacement without reduction joints had longer mean postglenoid fossa heights (P<.0005), greater mean fossa depth (P<.017), and narrower mean absolute superior joint spaces (P<.041) than disk displacement with reduction joints (univariate t test). The classification tree had 4 terminal nodes; to differentiate the joints, it used the eminence radius and the absolute superior joint space to anterior joint space ratio subordinate to the postglenoid process height. The tree model accounted for 31.4% of the likelihood (Rescaled Cox and Snell R2) with 73.5% accuracy (sensitivity 82.6% and specificity 65.4%). Disk displacement without reduction joints had either deeper posterior fossa walls or posterior walls of average length combined with a superior-to-anterior joint space ratio of less than 0.83; this suggests a more open-wedge-shaped anterior joint space combined with a less-rounded articular eminence. In contrast, most disk displacement with reduction joints had shorter posterior fossa wall height combined with more equal or larger superior-to-anterior joint spaces. The logistic regression model was less accurate than the classification tree model (sensitivity 60.9%, specificity 66.7%) and accounted for only 9.9% of the likelihood (Rescaled Cox and Snell R2) and 63.6% accuracy. The postglenoid process height was the strongest differentiating factor in all models. Conclusion. Hard tissue relationships revealed by central tomogram sections were able to model notable differences between disk displacement with and without reduction joints when examined as contingency-based multifactorial systems. (J Prosthet Dent 2001;86:407-19.)

Correlation of radiographic and arthroscopic findings with rotator cuff tears and degenerative joint disease

The purpose of this study was to identify early signs of rotator cuff tear and glenohumeral articular cartilage degeneration by using conventional radiography. A non-weighted anteroposterior oblique and a weighted active abduction view were evaluated for superior humeral migration and matching degenerative changes at the inferolateral acromion and superior aspect of the greater tuberosity in 40 patients who underwent shoulder arthroscopy. Measurements of the glenohumeral distance were performed. Surgical reports were reviewed to determine rotator cuff and glenohumeral articular cartilage status. Matching degenerative changes correlate with complete rotator cuff tear (P =.04); superior migration does not. Severe glenohumeral cartilage loss correlates with narrowing of the superior joint space on the anteroposterior oblique radiograph (P =.02) and with narrowing of the mid joint space on the active abduction view (P =.05). Both glenohumeral articular cartilage degenerative change and rotator cuff injury, before formation of typical sequelae of chronic rotator cuff tear, can be detected with the use of conventional radiography. (J Shoulder Elbow Surg 2001;10:428-33.)

Changes in the TMJ disc-condyle-fossa relationship following functional treatment of skeletal Class II Division 1 malocclusion: A magnetic resonance imaging study

A detailed clinical examination of the parts of the temporomandibular joint can be carried out by means of magnetic resonance imaging. The aim of this study was to examine, with the use of magnetic resonance imaging, the mandibular condyle-disc-fossa relationship in subjects with Class II Division 1 malocclusions who were treated with the Andresen activator. The sample consisted of 18 subjects with Class II Division 1 malocclusion, 9 treated with the Andresen activator and 9 control subjects. Unilateral magnetic resonance images, lateral cephalograms, and hand-wrist films were taken for each subject at the beginning and end of the treatment or observation period. The anterior, posterior, and superior joint spaces were measured on the magnetic resonance images, and the posterior, medial, and anterior disc angles were measured for the determination of the disc position. The changes that occurred during the treatment and observation periods were examined by means of a paired t test and an analysis of variance. The condyle was found to be located anteriorly. However, the changes in the disc position were found to be statistically insignificant. (Am J Orthod Dentofacial Orthop 2001;119:316-9)