Introduction
Temporomandibular disorders (TMDs) affect the temporomandibular joint (TMJ), masticatory muscles, and associated structures [
1]. According to researchers, approximately 65–85% of U. S citizens experience certain TMD symptoms in their lives [
2]. An estimated 2% of people with TMD reported to have a limitation in jaw opening, usually referred to as “jaw locking” [
3]. Patients may experience prolonged pain and disability, which causes chronic symptoms to become more refractory to traditional medical treatment approaches [
4].
Patients with a TMJ closed lock may require additional imaging to determine the nature, location, and extension of the osseous changes, and to detect any associated disk displacements [
5,
6]. Currently, magnetic resonance imaging (MRI) is the technique of choice for assessing the pathological conditions of the TMJ [
7,
8].
TMJ osteoarthritis (OA) is an inflammatory joint disease that is characterized by deterioration of the articular surfaces and simultaneous remodeling of the underlying bone [
9,
10]. Condylar erosion (CE) of the TMJ represents changes in the articular cartilage and the adjacent cortical and subcortical bone [
10,
11], which are regarded as a sign of progressive OA [
11,
12] and have been associated with characteristic clinical findings, such as pain, joint sounds, and irregular or deviating jaw function [
12,
13]. Furthermore, CE is associated with MRI findings of disk displacement [
14,
15] and should be adequately addressed in terms of diagnostic and therapeutic management to prevent changes in dentofacial morphology or limited mandibular growth [
16].
To the best of the authors’ knowledge, there are no MRI studies available addressing the imaging parameters of TMJ CE and types of internal derangement (ID), i.e., disk displacement with (DDR) and without reduction (DDNR), with a multivariate design in patients with painful TMJ closed lock. Thus, the aim of the present paired design study was to assess whether the MRI findings of CE are predictive of specific clinical diagnosis of painful closed lock of the TMJ, and to determine the strength of the association between the MRI items of CE and types of ID, thereby controlling for confounding variables such as age, sex, time since pain onset, pain intensity, and type of ID.
Discussion
The results of the present MRI study indicate that TMJs with a clinical RDC/TMD diagnosis of ‘AR and DDwoR/wLO’ are significantly associated with MRI findings of DDNR at a prevalence rate of 71%. This observation compares favorably with those of other authors reporting prevalences of TMJ DDNR in TMJ closed lock instances accounting for 73 to 84% [
24,
26‐
29], while the reported prevalence rates of contralateral asymptomatic TMJs in patients with unilateral TMJ pain have ranged from 19 to 40% [
26,
30‐
34]. These findings may support the concept that nonreducing disks are significantly involved in the clinical presentation of TMJ closed lock. However, considerable attention should be given to the point that other underlying factors may be etiologic in the production of these commonly observed ‘nonreducing disk’ findings, i.e., DDNR may be a highly questionable diagnostic criterion in managing patients with TMJ closed lock, especially for considerations involving surgical procedures.
Concerning the observed MRI prevalence rates of CE (60%) and “DDNR and CE” (57%) in the clinical ‘arthralgia and DDwoR/wLO’ subgroup, the findings may correspond to those of previous research reports describing the prevalences of cone beam computed tomography findings of CE in specific RDC/TMD subgroups of TMJ DDwoR as 25% [
35], in TMJ arthralgia as 60% [
13], and in TMJ arthritis as 94% [
36]; the frequencies in asymptomatic TMJs have been reported to be 6% [
21,
35], 22% [
37], and 26% [
13]. However, in these studies confounding variables were not considered to calculate the respective associations with clinical parameters, i.e., studies failed to take into account variations in the time since pain onset, pain intensity, and MRI findings regarding the ID type.
To the best of our knowledge, this is the first study to provide relative odds for the estimation of painful closed lock of the TMJ in a multivariate design using logistic regression techniques for analysis. This investigation provides a perspective on the contribution of MRI items of CE and ID type to the occurrence of a clinical RDC/TMD diagnosis of ‘AR and DDwoR/wLO’. While the ID types of DDR (0.7:1) and DDNR (2.1:1) did not contribute to the change in risk, a clear definition of the ‘AR and DDwoR/wLO’ group was evident for the MRI variable of CE (3.1:1). Therefore, based on this study, CE may be considered a dominant factor in the definition of painful closed lock of the TMJ. Considering the aspect of arthritic TMJ locking as an underlying mechanism in the etiology of TMJ closed lock, further investigations are indicated to clarify which additional specific OA variables may be associated with an elevated risk for signs and symptoms defining specific groups of TMJ closed lock.
The prevalence of the MRI finding of DDNR in TMJs with CE was 92%, and it carried an increased OR for the TMJ CE group (OR = 43.9:1). Although no data were reported on CE prevalence rates, these observations may compare favorably with the results of another MRI study describing the MRI items of TMJ DDNR and CE as closely related entities (OR = 3.5:1); that is, the TMJs with DDNR appeared to be 3.5 times more likely to have CE than the TMJs without DDNR [
21]. However, these results may not be directly comparable, since the latter study failed to use specific TMD subgroups and to adjust for confounding variables such as age, sex, time since pain onset, pain intensity, and type of ID. Further, it must be emphasized that the pathophysiology of CE is unclear and the question whether CE is a sign of progressive OA or an entity related specifically to the onset of DDNR remains unresolved.
The present study asserts that the MRI features of CE may be an essential factor in defining TMJ closed lock patients. Assessing the risk of developing CE should include general and local biochemical factors [
9,
11,
38]. Several general factors that have the potential to influence the risk of CE development. They include age, sex, systemic arthritis, and hormonal factors [
39,
40]. Mechanical factors comprise of occlusion, disk displacement, trauma, increased friction at the joint, and functional overloading [
41‐
43]. Assessing the additional variables may be considered crucial in defining patients with CE. Unlike a case-control study, a well-controlled cohort study is capable of establishing how specific factors contribute to CE.
Regarding the aspect of prevention and therapy, it is essential not to overemphasize the role of MRI findings of CE and DDNR in order to avoid overlooking other etiological factors that are potentially involved in the production of signs and symptoms characteristic of the clinical ‘AR and DDwoR/wLO’ subgroup. It may be hypothesized that the tendency for TMJs to develop CE in the ‘AR and DDwoR/wLO’ subject group is a consequence of and secondary to mechanical disturbances that may produce an imbalance between anabolic and catabolic processes, progressive degradation of cartilage, and secondary inflammatory components [
9,
11]. Moreover, overloading is the main cause of disorders in any synovial joint, including the TMJ [
44,
45] and this potentially contributes to the generation of various phenomena, such as adhesive forces, increased friction and shear stress [
46,
47]. When lubrication is compromised, various levels of friction are generated between the articular surfaces. Mild friction over a long period of time may contribute to the nonreducing disk process [
48], and the articular surface may degenerate due to severe friction, which may also trigger the onset of OA and arthritic TMJ locking [
49‐
51]. From a clinical point of view, therefore, the temporal aspects of pain and dysfunction assessment (i.e., onset, duration, and changes since onset) may become indicative of potential high-risk issues such as the risk of nonreducing disks and/or progressive OA alterations.
The results of this study may suggest the preventive use of MRI in symptomatic cases to differentiate subtypes of degenerative TMJ diseases [
16]. These include progressive conditions such as idiopathic condylar resorption (ICR) or juvenile idiopathic arthritis (JIA) [
52,
53]. MRI enables the accurate evaluation of TMJ ID and OA changes [
8], thereby allowing the detection of CE indicating acute or active alterations. To successfully control these destructive inflammatory conditions and to differentiate between ICR and JIA and erosive TMJ disease [
54,
55], early MRI diagnosis of DDNR and associated erosive condylar destruction may become an important factor in terms of prevention and early treatment to prevent changes in dentofacial morphology or limited mandibular growth, leading to facial deformity [
16,
52,
55,
56]. Considering that etiology, prognostic aspects, and treatment implications are the main criteria for the utility of diagnostic classifications [
57], ongoing research is necessary to determine how well specific findings of CE may demonstrate differences in pathogenesis, treatment, and prognosis.
It is noteworthy that the gold-standard MRI criterion (the 12 o’ clock reference) was used to define normal disk position in the present study [
58,
59], and the odds ratios of ID types for predicting a clinical diagnosis of ‘AR and DDwoR/wLO’ established by this criterion were determined. However, disk displacement according to this criterion (the presence of the posterior band of the disk anterior to the 12 o’ clock position) was found in normal aymptomatic volunteers, posing the question of what should be considered an abnormal disk position [
8,
60]. More accurate diagnostic operational criteria may be necessary in terms of ‘disease classification’ to identify TMJ disk displacement that is closely linked to the clinical signs and symptoms of particular TMDs, to prevent over- and undertreatment and to achieve a more cost-effective outcome.
The present study may suffer from the lack of evaluation of all aspects of degenerative bony alterations that may affect the articular surfaces of the TMJ. MRI enables the accurate assessment of TMJ OA changes such as flattening, erosion, osteophytes, subchondral bone sclerosis and pseudocysts [
16]. The application of MRI in individuals with and without TMJ pain and dysfunction permits the identification, localization, and quantification of these osseous changes, including those that affect the fossa or articular eminence [
23]. Ongoing investigations are necessary to determine how well specific TMJ OA changes may show differences in pathogenesis, treatment, and prognosis.
A limitation of this study concerns the aspect that most clinical experience is commonly limited by observer variations, which tend to have a significant impact on the diagnostic process. The possibility of rater bias from the radiologist who assessed the MRI variables must also be considered. Observer performance can be affected by various factors such as training, image quality, and the specific criteria for interpretation. This study used well-defined criteria in the interpretation of MRI variables, and the MR images used were of high quality. The MR images of the TMJ were reported based on intraobserver reliability that was within the accepted limits for a diagnostic study. In contrast, no measurement of interobserver reliability was performed. As a result, overrating may have caused some of the variations in disk displacement and CE reported in this study. Consequently, overestimation of the relevance of these factors to the described disorder groups may have occurred. With regard to the diagnosis of CE, the radiologist may have been influenced by the state of the disk and the other joint components. The most effective way to control for this type of error is to blind the rater in some way. In addition, observer training in the use of specific instruments and the development of specific grading criteria may be considered crucial in protecting observers against rater bias.
Clear directives for diagnosis and treatment of TMJ IDs are often elusive, despite the fact that much research has been done to validate current classification systems, such as the Wilkes Staging System [
61], the RDC/TMD [
17], and the Diagnostic Criteria (DC) for TMD [
62]. Deciding on the terminology that one may use to designate TMJ disorders, it’s up to the clinician to decide wether the diagnostic terminology should be based on clinical manifestations or on structural alterations. The RDC/TMD diagnostic subgroups of ‘arthralgia’ and ‘disk displacement’ represent non-specific clinical manifestations of underlying disease processes, which in fact may be somewhat misleading, because evidence for aetiologic factors is lacking. Basic pathologies encompass inflammation and degeneration in arthritic disorders, and may clinically manifest as pain and biomechanical dysfunction, ie, clicking, intermittent locking, and locking [
11,
63]. As diagnosis-making algorithms should provide a basis for effective treatment modalities, and current treatment approaches mainly focus on influencing the pathologic changes without addressing positional changes of the disk [
63], the RDC/DC terminology used in the ‘disk displacement’ domain may confuse diagnosis and ultimately treatment and management of these patients.
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