Ultrasonography of the temporomandibular joint: Comparison of findings in

patients with rheumatic diseases and temporomandibular disorders.

A preliminary report
Daniele Manfredini, DDS,a Francesco Tognini, DDS,b Daniela Melchiorre, MD,c Laura Bazzichi, MD,d
and Mario Bosco, MD, DDS,e Carrara, Italy
UNIVERSITY OF PISA

Objective. The objective of the study was to compare findings from ultrasonography (US) of the temporomandibular joint
(TMJ) in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and temporomandibular disorders (TMD).
Study design. US assessment of the temporomandibular joints was bilaterally performed in 68 patients (22 with RA, 11 with PsA,
and 35 with TMD). All the TMJs were assessed for the presence of disc displacement, effusion, and changes of the condylar
profile, and the prevalence of such abnormalities was compared across the 3 groups of patients. To confirm generalizability of
results, US findings were also compared with those of magnetic resonance (MR), taken as the standard of reference.
Results. Prevalence of disc displacement and changes in condylar profile were similar between patients with rheumatic diseases
and temporomandibular disorders, while effusion was significantly more present in TMJs of TMD patients. Sensitivity of US to
detect TMJ abnormalities was acceptable, while specificity was low for condylar alterations.
Conclusions. Temporomandibular joint involvement in patients with rheumatic diseases seems to be similar to that described
in subjects with temporomandibular disorders. Ultrasonography confirmed to be an accurate technique to detect disc
displacement and effusion within the temporomandibular joint, but not to detect condylar abnormalities.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:481-5)

The study of the temporomandibular joint (TMJ) is to compare TMJ involvement in a group of rheumatic
often neglected during the clinical evaluation of patients affected by rheumatoid arthritis (RA) or
rheumatic patients, even though TMJ involvement has psoriatic arthritis (PsA) with that in a group of subjects
been described for a number of rheumatic diseases.1-3 with temporomandibular disorders (TMD).
Clinical assessment still remains a basic step for the
study of the TMJ,4-7 but an instrumental evaluation is MATERIALS AND METHODS
sometimes requested to confirm clinical findings in Sample and study design
complex cases.8 Magnetic resonance (MR) represents Participants in the study were 22 subjects with RA
the standard of references in these cases,9-11 but ultra- diagnosed according to the American Rheumatology
sonography (US) has some potential advantages over Asssociation (ARA) criteria and complaining of TMJ
MR in terms of costs, avalaibility, and ease of use. pain, 11 subjects with PsA diagnosed according to ARA
As a consequence, US has been recently introduced in criteria and complaining of TMJ pain, and 35 subjects
the study of the TMJs, with good results for the de- with TMD diagnosed on the basis of the presence of at
tection of both disc displacement12-14 and intrarticular least one Research Diagnostic Criteria for Temporo-
effusion.15,16 It has been performed to evaluate the mandibular Disorders (RDC/TMD) diagnosis. Rheu-
TMJ of rheumatic patients as well.17 Considering these matic patients were recruited at the Operative Unit of
premises, US was used in the present investigation Rheumatology of the University of Pisa, Italy, while
TMD subjects were recruited at the Section of Prosthetic
Dentistry, Department of Neuroscience, University of
a
Resident, Section of Prosthetic Dentistry, Department of Neurosci- Pisa, Italy. Therefore, a total of 68 patients (45 females
ence, University of Pisa, Italy. and 23 males, mean age 43.4 years) were enrolled.
b
Resident, Section of Prosthetic Dentistry, Department of Neurosci- Differences between the 3 groups of patients regarding
ence, University of Pisa, Italy.
c
Resident, Department of Rheumatology, University of Pisa, Italy.
sex distribution and mean age were not significant. All
d
Resident, Department of Rheumatology, University of Pisa, Italy. patients underwent a bilateral assessment of the tempo-
e
Professor, Section of Prosthetic Dentistry, Department of Neurosci- romandibular joints by means of both US and MR.
ence, University of Pisa, Italy.
Received for publication Jul 29, 2004; returned for revision Feb 22, Ultrasonography
2005; accepted for publication Feb 25, 2005.
1079-2104/$ - see front matter
Ultrasonographic examination was carried out with
Ó 2005 Mosby, Inc. All rights reserved. a Toshiba Powervision 6000 instrument (Toshiba Inc.,
doi:10.1016/j.tripleo.2005.02.071 New York, NY) with 8- to 20-MHz high-frequency

481
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482 Manfredini et al October 2005

Fig 1. Drawing of an ultrasonographic image of a temporo-

mandibular joint (sagittal view) showing the condylar latero-
superior surface (C), the articular disk (D), the lateral surface
of the glenoid fossa (GF), and the articular eminence (AE).

Fig 3. Ultrasonography of a TMJ in a TMD patient at closed

mouth position. The articular disc is anteriorized and
hyperechogenic.

Fig 2. Ultrasonography of a TMJ in a rheumatic patient. The

increased capsular width (space between the X symbols) is an
indicator of effusion. The articular disc (located between
the 1 symbols) is anteriorized.

transducers. All the assessments were performed by the

same trained operator. The imaging protocol included
sagittal oblique and axial oblique scans to evaluate the
antero-superior joint compartment in a sagittal to frontal
plane. The probe was placed over the TMJ perpendic- Fig 4. Ultrasonography of a TMJ in a TMD patient at open
ular to the zygomatic arch and parallel to the mandibular mouth position. The articular disc is anteriorized (displace-
ramus and tilted out until the best visualization was ment without reduction) and some irregularities are evident on
achieved. Once a satisfactory visualization was ob- the condylar latero-superior surface.
tained, both static and dynamic evaluations were
performed. On the sonograms, the articular capsule
presented as a hyperechoic line running parallel to the irregularities suggested the possible presence of ero-
surface of the mandibular condyle and its width was sions or osseous remodelling (Fig 1).
measured as the distance between that line and condylar As for diagnostic criteria, the presence of joint
latero-superior surface with the subject in the closed- effusion was diagnosed as follows (Fig 2):
mouth position. d Articular capsule width of 2 or more mm and/or
The articular disc appeared as a hyperechoic line d Hypoechoic area within the articular space.
with a subtle hypoechoic halo, positioned above the
condylar hyperechoic line. The 2-mm value was chosen because an article demon-
The condylar latero-superior surface was evident strated it is the most accurate threshold to discriminate
with oblique sagittal scan as an hyperechoic line, whose between joint with and without MR effusion.15
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Volume 100, Number 4 Manfredini et al 483

Table I. Magnetic resonance findings. Prevalence Table II. Ultrasonographic diagnosis of TMJ effusion
of TMJ effusion (JE), disc displacement (DD), and (JE), disc displacement (DD), and condylar abnormal-
condylar abnormalities (CA) in patients with rheumatic ities (CA) in patients with rheumatic diseases (RD) and
diseases (RD) and temporomandibular disorders (TMDs) temporomandibular disorders (TMD)
RD TMD RD TMD
JE 18/33 (54.5%) 29/35 (82.8%) JE 16/33 (48.5%) 31/35 (88.6%)
DD 18/33 (54.5%) 12/35 (34.3%) DD 14/33 (42.4%) 13/35 (37.1%)
CA 18/33 (54.5%) 31/35 (88.6%) CA 23/33 (69.7%) 24/35 (68.6%)

Disc position was categorized as follows (Fig 3): Table III. Accuracy, sensitivity, specificity, PPV, and
NPV of ultrasonography for the diagnosis of TMJ
d Normal disc position (N): disc located above the condylar effusion (JE), disc displacement (DD), and condylar
head at closed-mouth position. abnormalities (CA)
d Disc displacement (DD): disc not located on the DD JE CA
condylar surface at closed-mouth position.
Accuracy 66.2 79.4 55.9
Changes of the condylar profile were diagnosed Sensitivity 56.7 85.1 67.3
when irregularities of the hyperechoic line representing Specificity 73.7 66.7 26.3
PPV 63 85.1 70.2
the condylar latero-superior surface were evident NPV 68.3 66.7 23.8
(Fig 4).

MR imaging
Changes of the condylar profile were diagnosed when
MR imaging (MRI) was carried out with a 1.5-T
abnormalities of the intensity of the cortical area and/or
(GE Signa Contour, GE Medical Systems, Buc, France)
morphological alterations were evident.
and dedicated, circular polarized transmit and receive
All the MR images were interpreted by the same
TMJ coil. The MRI protocol included oblique sagittal
trained radiologist.
and oblique coronal T1 GRE 2D weighted images (time
of repetition 340 ms; echo time 16 ms; flip angle = 30%)
Statistical analysis
with thin 3-mm slices. MRI was angulated according to
A comparison of the prevalence of disc displacement,
the horizontal angulation of the long axis of the condyle.
joint effusion, and condylar abnormalities within the 3
Each subject received a wooden intermaxillary device to
groups of patients was performed. Moreover, sensitivity,
obtain the different mouth-opening positions. We made
specificity, positive predictive value (PPV), and negative
sequential bilateral images with the subjects at closed-
predictive value (NPV) of US with respect to MR were
mouth and maximal open-mouth positions. Data were
evaluated for all diagnostic categories.
collected on a 256 3 192 matrix with a field of view of
15 mm. The articular disc was directly identified, in
RESULTS
sagittal oblique images, as an area of hypointensity with
Joint effusion was detected by MR in 18 of 33 patients
a biconcave shape above the condylar structure and
with rheumatic diseases (RA and PsA) and in 29 of 35
its position was categorized, according to literature
patients with TMD; US showed effusion in 16 patients
data,10,18,19 as follows:
with rheumatic diseases and in 31 patients with TMD.
d Superior (normal) disc position (N): posterior MR revealed disc displacement in 18 patients with
band of articular disc located above the apex of the rheumatic diseases and in 12 patients with TMD; US
condylar head in both intercuspal and maximum diagnosis of disc displacement was made in 14 patients
opening mouth positions; with rheumatic diseases and in 13 patients with TMD.
d Disc displacement (DD): posterior band of the disc Condylar abnormalities were detected by MR in 18
located anterior to the condylar head at the closed- patients with rheumatic diseases and in 31 with TMD,
mouth position; normal disc-condyle relationship and by US in 23 patients with rheumatic diseases and in
might reestablish in maximal opening position (re- 24 patients with TMD (Table I and Table II).
ducing disc displacement) or not (permanent disc The accuracy of US was assessed in the whole sample
displacement). of 68 patients. For the diagnosis of joint effusion, US
showed an accuracy of 79.4% (sensitivity 85.1%,
The presence of joint effusion was diagnosed when specificity 66.7%, PPV 85.1%, NPV 66.7%). In the
thin lines or areas of high signal intensity were depicted assessment of disc displacement, US had an accuracy of
within the articular space. 66.2% (sensitivity 56.7%, specificity 73.7%, PPV 63%,
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484 Manfredini et al October 2005

NPV 68.3%). An accuracy of 55.9% was recorded to myalgia and local myalgia of the temporomandibular system.
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