Superior Joint Space Research Articles

Disc position and morphology in patients with nonreducing disc displacement treated by injection of sodium hyaluronate

Disc position and morphology were examined in 21 patients (22 joints) with nonreducing disc displacement of the temporomandibular joint (TMJ) at more than 12 months after undergoing injection of sodium hyaluronate into the superior joint space. The patients' clinical signs and symptoms improved during the follow-up period. In all patients, the disc was displaced anteriorly on mouth closure and did not reduce into the normal position during mouth opening at follow-up, whereas a normal disc position was found in all the controls. In the patients, the disc deviated from the normal biconcave configuration found in all of the controls on the follow-up magnetic resonance imaging (MRI). Disc displacement apparently is persistent and continued disc deformity common in patients, although the clinical signs and symptoms improved.

Disc position and morphology in patients with nonreducing disc displacement treated by injection of sodium hyaluronate

Disc position and morphology were examined in 21 patients (22 joints) with nonreducing disc displacement of the temporomandibular joint (TMJ) at more than 12 months after undergoing injection of sodium hyaluronate into the superior joint space. The patients’ clinical signs and symptoms improved during the follow-up period. In all patients, the disc was displaced anteriorly on mouth closure and did not reduce into the normal position during mouth opening at follow-up, whereas a normal disc position was found in all the controls. In the patients, the disc deviated from the normal biconcave configuration found in all of the controls on the follow-up magnetic resonance imaging (MRI). Disc displacement apparently is persistent and continued disc deformity common in patients, although the clinical signs and symptoms improved.

Mandibular asymmetry and condylar position in children with unilateral posterior crossbite

The purpose of this retrospective study was to determine if condylar position in children with functional unilateral crossbites was different from that found in children with Class I noncrossbite malocclusions and if there was a change in condylar position after correction of the crossbite by palatal expansion. Mandibular asymmetry in children with functional unilateral posterior crossbite was also compared to that of a Class I noncrossbite group. Thirty-one children aged 6 to 14 years (mean, 9.3 years; standard deviation, 2.2) with functional unilateral crossbites were compared to 31 children aged 9.5 to 14.1 years (mean, 11.9 years; standard deviation, 1.3) exhibiting Angle Class I noncrossbite malocclusions. Pretreatment submentovertex radiographs were used to study mandibular skeletal, dental, and positional asymmetries with reference to cranial floor and mandibular coordinate systems. In addition, the anterior, superior, and posterior joint spaces were measured to determine differences between the groups with the use of pretreatment and posttreatment horizontally corrected tomograms of the temporomandibular joints. Finally, the distances of the mesiobuccal cusp of the upper first molar relative to the buccal groove of the lower first molar were measured in both groups before treatment. Univariate analyses revealed that the mandibles of children in the functional unilateral posterior crossbite group exhibited asymmetry in both anteroposterior and transverse dimensions when compared with the Class I noncrossbite group ( P < .05). These asymmetries were the result of a functional deviation of the mandible that was present in all subjects in the crossbite group. This deviation was manifested occlusally by a Class II subdivision on the crossbite side as indicated from the study model analysis ( P < .05). Examination of condylar position as evidenced by horizontally corrected tomograms demonstrated a large standard deviation, resulting in an inability to detect any significant differences within or between groups at both T1 and T2 ( P > .05). This study raised the question of the appropriateness of measuring joint spaces for routine diagnostic purposes. (Am J Orthod Dentofacial Orthop 1999;115:569-75)

Reliability of radiographic assessment in hip and knee osteoarthritis

Objective: To evaluate the reproducibility of commonly used radiographic measures in hip and knee OA and to overcome certain limits of existing knowledge on their reliability from previous studies.Design: Three readers evaluated 100 hip joints (50 pelvic X-rays) and 100 antero-posterior and lateral knee films of a hospital-based sample of patients with radiographic OA at two time points 3 months apart. They retrospectively estimated the presence and severity of joint specific individual radiographic features (osteophyte formation and joint space narrowing at different sites, cysts, subchondral sclerosis, bony deformity and chondrocalcinosis) and two different overall scores. Within and between observer reproducibility was calculated by intra-class correlation coefficient.Results: At the hip joint excellent intra- as well as inter-observer reliability for superior joint space narrowing (JSN) and femoral head deformity could be demonstrated, while the assessment of medial JSN, osteophytes and acetabular sclerosis depends on the level of the investigator’s experience. At the knee joint, femorotibial and patellofemoral osteophytes showed a high intra- and inter-observer reliability. Grading of JSN is highly reader dependent; rating of subchondral sclerosis and chondrocalcinosis does not seem to be reproducible enough. The overall scores showed an excellent reproducibility both at hip and knee joints.Conclusion: A reliable radiographic severity grading of hip and knee OA is possible with the application of global scores and individual features, if joint specific items are selected and readers are trained enough.

TMJ Arthrocentesis and blunt sweeping of the superior joint space

TMJ Arthrocentesis and blunt sweeping of the superior joint space

Effect of intra-articular versus systemic anti-inflammatory drugs in a rabbit model of temporomandibular joint inflammation

Purpose: In an attempt to better understand the time course of inflammatory mediator production or release in inflammatory joint disease, a rabbit model of acute temporomandibular joint (TMJ) inflammation was established. This model was used to evaluate the effects of specific anti-inflammatory agents administered either systemically (intraperitoneal, IP) or locally (intra-articular, IA) on the modulation of in vivo tissue levels of two prototypic inflammatory mediators, prostaglandin E 2 (PGE 2) and bradykinin (BK). Materials and Methods: An experimental model of inflammation was created by administering carrageenan (carra) into one joint and an equivalent volume of saline (control) into the contralateral joint of 42 male New Zealand White rabbits. The development of hyperthermia was assessed by placement of a microthermister probe into the joint space. The inflammatory mediators, immunoreactive PGE 2 (iPGE 2) and BK (iBK), were recovered with microdialysis probes, and samples were assayed in conjunction with specific pharmacologic interventions. In the first part of the study, the time course for the release or production of iBK and iPGE 2 was determined. In the second part, the effects of IP versus IA administration of dexamethasone and a nonsteroidal anti-inflammatory drug, ketorolac tromethamine, were compared. Dexamethasone and ketorolac were administered at 3 hours and 1 hour, respectively, before the peak release of the inflammatory mediators. Results: The onset of IA hyperthermia, an index of inflammation, was evident by 90 minutes post-carra and reached a maximum of 1.2 °C above core temperature by 150 minutes post-carra. Intra-articular levels of iPGE 2 and iBK peaked at 240 minutes (3.35 ± 1.9 nmol/L) and 270 minutes (0.45 ± 0.29 nmol/L), respectively, after the induction of inflammation in the superior joint space. iBK levels within the superior joint space were significantly decreased by dexamethasone and ketorolac. Ketorolac (50 μg) decreased iBK and iPGE 2 levels when given IA or IP. With dexamethasone (3 mg), the levels of iBK were significantly reduced, and iPGE 2 levels were not changed. Conclusions: This study shows that the rabbit model of TMJ inflammation, with concurrent collection of iBK and iPGE 2 via microdialysis, is a reproducible and reliable method to investigate the time course of inflammatory mediator release and their modulation by either the local or systemic administration of anti-inflammatory medications.

Detection and preliminary characterization of matrix metalloproteinase activity in temporomandibular joint lavage fluid

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 patients'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.

Correlations between condylar characteristics and facial morphology in Class II preadolescent patients

The aim of this retrospective study was to determine correlations between condylar characteristics measured from preorthodontic tomograms of preadolescents and their facial morphologic characteristics. The sample consisted of 136 patients displaying a Class II malocclusion, a vertical or horizontal skeletal growth tendency, and ranging in age between 10 years 0 months and 12 years 6 months for males and 9 years 0 months and 11 years 6 months for females. Two groups were established: the vertical group had 68 patients, 36 males and 32 females, (average pretreatment age, 1l years 0 months); the horizontal group also had 68 patients, 29 males and 39 females, their average pretreatment age was 10 years 9 months. The central cut of axially corrected lateral tomograms of the left and right temporomandibular joints for each group was randomized, blinded, and traced for condyle/fossa measurements including: anterior, superior and posterior joint space; condylar head and posterior condylar ramus inclination; condylar neck width; and condylar shape and condylar surface area. A logistic discriminant analysis with significance values set at p < 0.05 was used to determine the most reliable condylar characteristics to predict facial morphology. A cluster analysis was completed on the significant variables to form three clusters. Numeric ranges separating these clusters were then calculated. Chi-square tests measures of association were computed for significant variables and tested for associations between facial morphologic characteristics. Condylar head inclination and superior joint space proved to be significantly correlated to facial morphology ( p values ranged from 0.010 to 0.018). Patients with vertical facial morphologic characteristics displayed decreased superior joint spaces and posteriorly angled condyles. Increased superior joint spaces and anteriorly angled condyles were significantly correlated to patients with a horizontal facial morphology. No significant correlations between the other condylar characteristics and facial morphology were determined. (Am J Orthod Dentofacial Orthop 1998;114:328-36.)

Correlation of inflammatory cytokines with arthroscopic findings in patients with temporomandibular joint internal derangements

Purpose: The goal of this study was to evaluate the presence of the inflammatory cytokines interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) within the superior temperomandibular joint (TMJ) space in patients with internal derangements and to compare these values with the pathologic findings seen arthroscopically. Patients and Methods: Thirty patients with symptomatic TMJ dysfunction and clinical and imaging evidence of internal derangements of the TMJ were evaluated. Before entering the superior joint space with the arthroscope, 2 mL sterile saline was injected and, after 30 seconds of equilibration, was aspirated for analysis. The surgeon then performed diagnostic arthroscopy. The degree of synovitis, degeneration, percent condylar roofing, and any pathologic changes, such as perforations, were recorded. The level of total protein in each sample was ascertained, as well as the levels of IL-1β, IL-6, and TNF-α. Results: Of 30 samples tested, three were discarded because of failure to gain access into the superior joint space. Of the 27 remaining samples, IL-6 showed the closest correlation with the level of acute synovitis demonstrated arthroscopically. Two of the higher IL-6 levels (167 and 324 pg/μg protein) were seen with patients with a significant disc perforation. In patients with a high degree of vascularity, IL-6 was found to be between 0 to 581 pg/μg protein with an average of 80 pg/μg protein and a median value of 43 pg/mg. These values significantly correlated with the degree of vascularity ( P ≤ .02). This is in comparison with the 10 remaining patients, who showed significantly fewer vascular changes arthroscopically. In these patients, the range of IL-6 was 0 to 35 pg/μg protein, with an average of 19 pg/μg protein and a median value of 14.5 pg/μg. These values significantly correlated with the smaller degree of vascularity ( P ≤ .02). In seven patients, the role of nonsteroidal antiinflammatory drug (NSAID) use resulted in decreased levels of IL-6, which has been noted in previous studies. In patients with higher rated redundancy of the synovial tissue, the average IL-6 level was 92 pg/μg protein, whereas the median value was 44 pg/μg protein. In patients with little or no redundant synovial tissue, an average IL-6 level of 22 pg/μg protein was present. The median value in these same joints was 15 pg/μg protein. These IL-6 values significantly correlated with the degree of redundancy P ≤ .03). The degree of degenerative change (chondromalacia, fibrilation), disc displacement (roofing), and the presence or absence of adhesions did not significantly affect the levels of IL-6 within the patients studied. The presence of IL-1β and TNF-α was not found to correlate with the arthroscopic findings in the superior joint space. Conclusions: The presence of IL-6 correlated with the degree of acute synovitis. IL-1β and TNF-α were not found in significant levels within the superior joint space. These findings correlated with those reported by other investigators. The production of IL-6 by synovial cells and its role in TMJ disease warrants further investigation.

Pre-auricular swelling and malocclusion.

A 58-year-old man was referred to the Head and Neck Clinic for the diagnosis and treatment of a painless swelling in the left pre-auricular region of approximately 18 months duration....

TMJ arthrocentesis and blunt sweeping of the superior joint space

TMJ arthrocentesis and blunt sweeping of the superior joint space

Presence of denatured hemoglobin deposits in diseased temporomandibular joints

Purpose: The purpose of this study was to test the hypotheses that hemoglobin recovered by arthrocentesis of the superior joint space of symptomatic human temporomandibular joints (TMJs) is “old” hemoglobin that was not iatrogenically introduced by the arthrocentesis procedure and that it exists primarily in a non-native or denatured conformation state that may be sufficient to catalyze a reaction leading to the formation of damaging free radicals. Patients and Methods: Twelve patients diagnosed with a unilateral articular disk displacement with TMJ arthralgia were included in this study. A superior joint space arthrocentesis was performed in the affected TMJ, and outflow lavage volumes were collected in serial 2-mL fractions. α-Hemoglobin/albumin ratios were determined for each collected fraction by densitometric analysis of sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). In addition, 3,3′,5,5′-tetramethylbenzidine (TMB) assays were used to determine the conformation state of the recovered hemoglobin. Results: High α-hemoglobin/albumin ratios relative to that of serum (at least 10 times greater) were observed in several collected fractions of TMJ lavage fluid in all subjects studied. Because the tissue half-life of hemoglobin is significantly longer than that of albumin, these findings indicate that much of the hemoglobin recovered by arthrocentesis of symptomatic TMJs represents “old” hemoglobin that was present in the joint before the procedure. Furthermore, based on reactivity in the TMB assay, we estimate that up to 89% of the α-hemoglobin present in TMJ lavage fluid samples exists in a denatured state. Conclusions: These results indicate that a significant amount of hemoglobin recovered by arthrocentesis of symptomatic TMJs exists in a denatured state and was present in the joint before arthrocentesis. Recent studies suggest that denatured hemoglobin may contribute redox active iron that can catalyze a reaction, leading to the formation of damaging free radicals. Such a process may represent one of the earliest molecular events involved in the pathogenesis of degenerative TMJ disease.

Condyle displacement associated with premolar extraction and nonextraction orthodontic treatment of Class I malocclusion

This study assessed condyle position change with premolar extraction and nonextraction orthodontic treatment in Class I malocclusions. Axially corrected pretreatment and posttreatment tomograms were obtained in 22 extraction and 13 nonextraction cases. Tomographic images were randomized and blinded for joint space measurement. A total of 27 linear anterior, superior, and posterior joint spaces were obtained from each tomogram and averaged. Comparisons of pretreatment and posttreatment joint spaces between groups were done by t test (pool variance estimate) with p < 0.05. Left and right anterior joint spaces were significantly increased during orthodontic treatment of the nonextraction group. No other significant changes in condyle position were determined in either group. There were no significant correlations between mean joint space changes with length of Class II elastic wear. There was no significant difference in condyle position change with extraction space closure using closing arch wires compared with alastic chain. (Am J Orthod Dentofac Orthop 1997;112:435-40.)

Effect of lavage with injection of sodium hyaluronate for patients with nonreducing disk displacement of the temporomandibular joint

Objective. The purpose of this study was to determine whether lavaging of the superior joint space with injection of sodium hyaluronate can be used as an alternative treatment method for nonreducing disk displacement of the temporomandibular joint. Study design. In 26 patients with nonreducing disk displacement of the temporomandibular joint, the superior joint space was rinsed with 1% yxlocaine, and then sodium hyaluronate was injected there (experimental group). As a control group, 50 patients with nonreducing disk displacement of the temporomandibular joint who received no treatment were used (control group). The frequency of the patients with successful clinical resolution was evaluated in each group during 6 months. Results. The frequency of the patients with successful clinical resolution in the experimental group (73.1%) was significantly higher than that in the control group (36.0%) at the 6-month follow-up (chi-squared test, p < 0.05). Conclusions. This therapy appears to represent an alternative treatment method for nonreducing disk displacement of the temporomandibular joint.

Elution of proteins by continuous temporomandibular joint arthrocentesis.

The purpose of this study was to determine whether specific proteins recovered from human temporomandibular joints (TMJs) by superior space arthrocentesis are eluted at different outflow volumes. Twenty subjects with unilateral TMJ pain and restricted mandibular range of motion underwent superior space arthrocentesis of the affected TMJ. Sixteen serial fractions of the arthrocentesis outflow volume were collected for analysis. The protein content of each fraction was determined by a BCA protein assay and analyzed by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). In addition, samples from each collected fraction were assayed for protease activity. The average amount of protein recovered in the total 32 mL of collected arthrocentesis fluid was 1.5 mg (0.72 to 2.1 mg). Significant differences (P = .03) in total protein recovered from arthrocentesis fluid were observed between males (0.824 +/- 0.43 mg/20 mL) and females (1.389 +/- 0.54 mg/20 mL). In general, protein concentration declined serially in collected TMJ lavage fluid fractions. Specific proteins and proteases detected in the lavage fluid were eluted at different outflow volumes. Although specific proteins are eluted from the TMJ at different outflow volumes during arthrocentesis, the procedure effectively reduces the protein concentration of the lavage fluid in a volume-dependent manner. Based on empirical assumptions, it is estimated that approximately 100 mL of total arthrocentesis volume is sufficient for a therapeutic lavage of the superior joint space of the human TMJ.

Changes in condylar position and occlusion associated with maxillary expansion for correction of functional unilateral posterior crossbite

The purpose of this study was to confirm that correction of functional posterior crossbite through maxillary expansion is associated with a change in condylar position and occlusal relationships, and to determine whether maxillary expansion is associated with autonomous increase in mandibular arch width. Pretreatment and posttreatment study models of 61 patients ages 4.1 to 12.0 years (mean 8.5 years, SD 1.5) were available after maxillary expansion with a Quad Helix or a Haas expander for correction of a functional posterior crossbite. Pretreatment and posttreatment tomograms were available for 22 of the patients. Tomographic evaluation revealed that the condyles moved posteriorly and superiorly on the noncrossbite side from before to after treatment (p < 0.05). No differences were observed on the crossbite side. Superior joint space was greatest on the noncrossbite side before treatment, whereas, conversely, it was greatest on the crossbite side after treatment (p < 0.05). Relative condylar position was more anterior on the noncrossbite side before treatment (p < 0.05), but similar on both sides after treatment. Molar and canine relationships were more Class II on the crossbite side before treatment (p < 0.01 and < 0.05, respectively) and similar on both sides after treatment. A significant reduction in midline deviation was seen from before to after treatment (p < 0.001). A small, but significant autonomous increase in mandibular intermolar width (p < 0.001) occurred concomitant with the maxillary expansion.

ウサギ顎関節における関節円板穿孔に関する実験的研究 第１報 免疫組織化学的検討

The articular disc and cartilage were studied immunohistochemically after experimentally induced disc perforation. Eighteen Japanese white rabbits were used in the present study. A round full-thickness perforation, measuring precisely 1.6 mm in diameter, was made in the left articular disc. Another joint, the right TMJ, was used as surgical control (sham operation); the superior joint space was entered but closed immediately, without perforation. Three rabbits served as non-surgical control. Assessments were performed 2, 4, 8, 12, and 24 weeks after the operation. Histopathological examination was performed after staining the specimens with H-E stain and toluidine blue stain. In addition, PCNA (proliferating cell nuclear antigen) immunohistochemical staining method was performed to count active cartilage cells.Two weeks after the operation, the proliferation of condylar cartilage was noted. After the 8 th week, the eminence and condyle were flat, with a decreased number of cartilage cells. At the 24th week, regeneration of the fibro-cartilage was seen. No healing of the disc perforation was seen during the observation period. The PCNA positive-cell rate was the highest at the 4 th week, when it was 14.3%. Subsequently, the positive-cell rate was 0.9%, which was slightly lower than the normal rate (2.0%). These results indicate that disc perforation induced degenerative changes in the articular cartilage, which showed no signs of normal healing. It was suggested that even a very small perforation in the articular disc may induce osteoarthritic changes in the osseous TMJ component in rabbits.

Total reconstruction of the temporomandibular joint with cryogenically preserved allograft mandibular condyle, meniscus, and fossa in the adult goat

The purpose of this study was to determine the feasibility of total temporomandibular joint reconstruction with the use of cryogenically preserved allograft mandibular condyle, disk, and fossa in the adult goat. This study consisted of an experimental group of 10 adult goats that underwent total resection of their temporomandibular joints. These animals were immediately reconstructed with cryogenically preserved mandibular condyles, disks, and fossa. These allograft were harvested from 10 donor animals matched to the recipient animal with respect to age, sex, and head dimensions. These grafts were harvested and stored at -185 degrees C for several months before implantation. At 2 years after surgery, the animals were killed. They were evaluated, clinically, radiographically, and histologically. Fifty percent of the eight surviving animals had a normal clinically functional joint with an intact superior joint space and viable articular surfaces. The authors conclude that this temporomandibular joint reconstruction technique is feasible in the adult goat model and is deserving of further research.

Dangerous angles and depths for middle ear and middle cranial fossa injury during arthroscopy of the temporomandibular joint

Purpose: Several reports have suggested a risk of injury to the middle cranial fossa and middle ear during arthroscopic procedures in the superior joint space of the temporomandibular joint (TMJ). However, there has been no anatomic study of directions and distances of the TMJ from the posterior portal in relation to the risk of mandibular fossa injury. In this study, the angles and depths at which the risk is greatest for injury to the deepest point of the mandibular fossa (DP) and to the middle ear during arthroscopy were analyzed. Materials and Methods: Three-dimensional measurements of 96 mandibular fossae in 48 dry skulls were made. Results: It was found that the distance from the lateral rim of the fossa to DP and Hugier's canal was 9.50 ± 2.07 mm and 17.04 ± 3.09 mm, respectively. The most dangerous angle for DP injury in the Frankfort horizontal plane (FH plane) was an inclination of the instrument base of −8° dorsad and 17 and 19° caudad in the frontal plane. The most dangerous angle for Hugier's canal injury was a tilting of the instrument base of 15° ventrad in the FH plane and −2° craniad in the frontal plane. However, these values showed a wide range. Conclusion: It was concluded that great care must be exercised in manipulation of instruments near the DP and Hugier's canal to avoid injury to the middle ear or penetration into the middle cranial fossa.

The MRI Study as a Diagnostic and Therapeutic Indicator in the Non-Surgical Management of Temporomandibular Joint Disorders: Phase I Management—A Case Report

The dental profession frequently points to occlusion, muscle disorders or psychological stress as principal causes of temporomandibular joint (TMJ) disorders. Diagnosis and management is confusing, and no general consensus exists. Recent advances in magnetic resonance imaging (MRI) have allowed a means of evaluating large numbers of patients for internal derangements in an objective non-invasive fashion. This has unequivocally confirmed prior arthrographic and surgical observation that partial or complete dislocation of the articular disk with condylar compression of sensitive superior posterior joint space neurovascular elements is the principal pathophysiologic mechanism of TMJ disorders. TMJ disorders have been shown to be a general progression of degenerative joint disease characterized by joint space compression with displacement and degeneration of articular hard and soft tissues, most commonly the result of trauma. This article illustrates how the author has combined several different dental and medical diagnostic procedures with clinical therapeutic measures to manage patients to improved function and remission of symptoms by controlling the position of the joint hard structures in an objective fashion.