h~t. .L Oral Maxillofac. Surg. 1999; 28." 253 257 Printed in Denmark. All rights reserved

Copyright �9 Munksgaard 1999

Oral & 7 Maxillofacial Surfer )

ISSN 0901.-5027

Aesthetic and reconstructive surgery

Disc position and morphology in patients with nonreducing disc displacement treated by injection of sodium hyalur0nate

Shuichi Sato 1, Maya Sakamoto 2, Hiroshi Kawamura 1, Katsutoshi MotegP Departments of 1Oral and Maxillofacial Surgery I; 2Oral Diagnosis and Radiology, Tohoku University SchooJ of Dentistry, Sendai, Japan

S. Sato, 31. Sakamoto, H. Kawamura, K. Motegi. Disc position and morphology in patients with nonreducing disc displacement treated by injection o f sodium hyaluronate. Int. J. Oral Maxillofac. Surg. 1999; 28: 253-257. �9 Munksgaard, 1999

Abstract. 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.

Key words: temporomandibutar joint; disc displacement; sodium hyaluronate; disc position and morphology.

Accepted for publication 30 January 1999

Many treatment options have been sug- gested for the management of nonre- ducing disc displacement of the tem- poromandibular joint (TMJ) such as medication, physical therapy 9, occlusal splints with or without manual repo- sitioning 234, surgery 12,3~ and arthro- centesis 13. However, it has been re- ported that injection of the superior joint space with sodium hyaluronate is effective 1,II. In a previous study 21, this fact was confirmed. These studies, how- ever, did not examine disc position and morphology in the subsequent period.

The purpose of the present study was to examine the disc position and mor- phology of the articular disc in patients with nonreducing disc displacement who were treated by injection of the su- perior joint space with sodium hyalu- ronate.

Material and methods This study was based on 21 patients (22

" joints) (3 men and I9 women; mean age 33.6 years; range 17 to 74 years). Forty-five pa-

tients diagnosed as having nonreducing disc displacement of the TMJ underwent injec- tion of sodium hyaruronate, and changes in their signs and symptoms were examined for at least 12 months. Twenty-one of the 45 pa-

Table 1. Clinical findings

Clinical signs and symptoms

Patients (n=21)

At beginning At Controls of this study follow-up (n= 15)

Range of motion at maximal mouth opening (mm) Protrusion (mm) Lateral excursion to the affected side (mm)

Lateral excursion to the unaffected side (ram)

Patients with TMJ tenderness Patients with TMJ noise (crepitus) Patients with tenderness of masticatory muscles

27.9_+5.56 41.2_+6.21 51.6_+5.08 4.9_+1.99 7.6_+2.33 7,7+2.26 7.0_+2.35 8.0_+2.05 9.0_+2.32

(left side) 6.1+_2.34 8.3_+1.91 8.4+_2.76

(right side) 19 (90.4) 0 (0) 0 (0) 3 (14.3) 3 (14.3) 0 (0) 2 (9.5) o (0) o (o)

Per cent frequencies are shown in parentheses.

254 Sa to et al.

Fig. 1. Arthrograms of patient's right TMJ at initial visit. Anterior disc displacement of the TMJ in the closed mouth position (A) does not reduce to normal at mouth opening (B).

Fig. 2. MR images (FLASH) of right TMJ in the sagittal plane in control subject. Disc is situated superiorly on condyle in both closed (A) and open (B) positions. The disc has bicon- cave configuration.

tients agreed to have their affected TMJ examined by magnetic resonance imaging (MRI) at more than 12 months posttreat- ment and thus, 21 patients were enrolled in the study. Nonreducing disc displacement is clinically characterized by a history of click- ing followed by limitation of opening ability without clicking. In all patients, nonreduc- ing disc displacement was confirmed by arthrography at initial visit. After a 22-gauge needle was inserted into the superior joint space of the TMJ, 1 ml of 1% xylocaine was

injected and withdrawn several times through the needle and 1 mI of sodium hyaluronate (Artz | Seikagaku Kogyo Co., Tokyo, Japan) was then injected following aspiration of most of the synovial fluid. This therapy was repeated once a week for five weeks. None of the patients with limited mouth opening had increased opening immediately after the last injection. The disc position and configur- ation were examined at a mean follow-up in- terval of 17.8 months (range 12 to 29 months), using MRI.

As a control, 30 joints in 15 persons (8 men and 7 women; mean age 29.3 years; range 24 to 47 years) who had no current or previous TMJ symptoms were studied. The disc posi- tion and configuration were examined only once using MRI. Clinical findings in patients and controls are shown in Table 1.

Axial images were first obtained to select the settings for sagittal imaging perpendicu- lar to the long axis of the condyle. Sagittal images were obtained in the closed as well as in the open mouth position. The degree of mouth opening was fixed with a bite block, available in various sizes. All MRIs were per- formed with a 1.5 Tesla System (Magnetom Vision, Siemens-Asahi, Tokyo, Japan) using dual-surface coils. Proton density weighted images were acquired with a fast, low-angle shot (FLASH: a repetition time (TR) of 450 ms, an echo time (TE) of 11 ms, a flip angle 30 ~ field-of-view of 150 mm, and a scanning matrix of 256• mm) or fast spin echo (FSE: TR of 1100 ms, TE of 12 ms, an echo train length 3, a field-of-view of 150 ram, and a scanning matrix of 256• mm) pulse se- quences as described previously TM. The slice thickness was 3 mm without interslice gap.

Normal disc position in the sagittal plane was defined as the posterior band of the disc being located at the superior, or 12 o'clock, position relative to the condyle as described by KATZBERG and KATZBERG et al. 6'7. Disc configuration was evaluated in the closed mouth position and was classified into five types: biconcave, enlargement of the pos- terior band, even thickness, convex, and folded 27,29.

Table 2. The disc position of the TMJ on MRI

ADD without reduction Normal

Patient TMJ 22 (100) 0 (0) (,,=22)

Control TMJ 0 (0) 30 (100) (n = 30)

Per cent frequencies are shown in parentheses. ADD: anterior disc displacement.

Table 3. The disc configuration of the TMJ on MRI

Patient Control TMJ TMJ

(n=22) (n-30)

Biconcave 0 (0) 30 (100) Enlargement of posterior band 0 (0) 0 (0) Even thickness 8 (36.4) 0 (0) Convex 8 (36.4) 0 (0) Folded 5 (22.7) 0 (0) Obscure 1 (4.5) 0 (0)

Per cent frequencies are shown in paren- theses.

Fig. 3. MR images (FLASH) of left TMJ in sagittal plane in 26-year-old female patient at follow-up. Anterior disc displacement at mouth closing (A) does not reduce to normal at mouth opening (B). The disc has even thickness.

Disc position and morphology 255

1/23 (4.5%) at follow-up (Figs. 3, 4, and 5) (Table 3).

Discussion

In previous studies, it has been ob- served that in some patients with nonre- ducing disc displacement of the TMJ, clinical signs and symptoms improved without any treatment 19'2~ and that in such patients disc displacement was persistent and disc deformity was still common on MR122. It was, however, also shown that the frequency of im- provement of clinical signs and symp- toms in patients who received injection of the superior joint space with sodium hyaluronate was significantly higher than that in a group without any treat- ment, though clinical signs and symp- toms improved in both patient groups 21.

In this study, the patients' clinical symptoms improved and the range of motion for maximal mouth opening in- creased during the follow-up period, al- though the disc displacement was per- sistent and disc deformity was still com- mon. This suggests that injection of the superior joint space with sodium hyalu- ronate does not necessarily improve dis- placement and deformity of the disc, but that symptoms can be resolved and the range of motion for maximal mouth opening can increase, even if disc dis- placement and disc deformity are still present.

Pain is generally caused by the effects of trauma. Injury produces an inflam- matory reaction with release of pain mediators such as bradykinin, hista- mine, substance P etc. These mediators attach to and stimulate nerve-endings. In the TMJ, it seems reasonable that the pain originates from pressure and trac- tion on the disc attachments. In joints

Fig. 4. MR images (FLASH) of right TMJ in sagittal plane in 19-year-old female patient at follow-up. Anterior disc displacement at mouth closing (A) does not reduce to normal at mouth opening (B). The disc has convex configuration.

between the condyle and temporal bone during mouth opening at follow-up (Fig. 1) (Table 2).

In all 30 control TMJs, the disc had a biconcave shape (Fig. 2). In the pa- tients, the disc was of an even thickness in 8/23 (36.4%), convex in 8/23 (36.4%), folded in 5/23 (22.7%), and obscure in

Results

In all the controls, the disc was situated normally on the condyle in both the closed mouth and open mouth position. In the patients, the disc was still dis- placed anteriorly on mouth closing and did not reduce into a normal relation

with anterior disc displacement, the loose tissue in the posterior attachment is displaced between the condyle and fossa and could be compressed or stretched during function 25. Mediators produced here might stimulate nerve- endings in the TMJ. QUINN & BAZAN 15

identified prostaglandin E2 and leuko- triene B4 in the synovial fluid from pa- tients with painful dysfunctional TMJ joints, and they observed a strong cor- relation between the levels of these chemical mediators of pain and in- flammation and an index of clinical joint pathology. They suggested that prostaglandin E2 and leukotriene B4 are among the factors which evoke TMJ

256 Sa to et al.

and disc deformity is still common at follow-up, even though clinical signs and symptoms have improved.

Fig. 5. MR images (FSE) of left TMJ in sagittal plane in 44-year-old female patient at follow- up. Anterior disc displacement at mouth closing (A) does not reduce to normal at mouth opening (B). The disc shows folded configuration.

pain. In our patients, the aspiration of synovial fluid of the superior joint space might have excluded these chemical me- diators. Hyaluronic acid is a major natural component of synovial fluid that plays an important role in lubri- cation of synovial tissues 16. Sodium hy- aluronate has been reported to improve joint pain 3 and prevent intra-articular adhesions 4.

VV~ESTESSON 27 observed deformation of the disc in 83.1% of 77 TMJs with nonreducing disc displacement using double-space contrast arthrography at initial visit. Deformat ion of the disc was observed in 66.7% of 96 TMJs with nonreducing disc displacement by SE- GAMI et al. 24 using double-space con- trast arthrography, and in 77.3% of 67 TMJs by WAJIMA et al. 26 using double- space contrast ar thrography at initial visit.

VV'ESTESSON 27 also found that a convex shape was the most common disc con- figuration in the TMJs with nonreduc- ing disc displacement at initial visit, while WAJIMA ET AL. 26 cited enlargement of the posterior band as the most com- mon finding. These differences in re- sults might be due to differences in the patient populations studied. In this study, the most common disc configur- ation included even thickness and con- vexity. The disc condit ion at the begin- ning of the study in patients was exam- ined only by inferior joint space

arthrography. This method was not use- ful for detecting disc configuration, though it was useful for detecting pres- ence or absence of disc displacement. Therefore, it is not possible to state whether there were changes of disc pOsi- tion and configuration between the be- ginning of the study and at follow-up. Condylar mobili ty have increased be- tween the beginning of this study and follow-up. Because mouth opening in- creased, it is likely that the anteriorly dislocated disc moved even somewhat more anteriorly, followed by increased disc deformation.

Al though we did not observe disc displacement and deformity in any of the control subjects, some investi- gators 8'1~ have observed anterior disc displacement even in asymptomatic subjects without T M J dysfunction using M R I or arthrography, KIRCOS et al. 1~ found anterior disc displacement in 13 out of 42 asymptomatic joints using MRI . As in our study, KAPLAN et al. s did not find disc displacement in 31 asymptomatic volunteers without T M J dysfunction using arthrography. They, however, also found that the disc was concave in 32% of the joints and flat in 68%.

In conclusion, in the patients with nonreducing disc displacement of the T M J who underwent injection of the superior joint space with sodium hyalu- ronate, disc displacement is persistent

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Address: Shuichi Sato Department q f Oral and Maxillofacia[

Surgery I Tohoku University School of' Dentistw 4--1 Seiryo-machi, Aoba-ku Sendai 980~575 Japan Tel: +81 22 717 8350 Fax: +81 22 717 8354 e-mail: shuichi@maiL cc. tohoku.ac.jp