Magnetic Resonance Imaging of Temporomandibular Joints in Children With Arthritis

doi:10.1016/j.joms.2010.12.058

Journal of Oral and Maxillofacial Surgery

Volume 69, Issue 9, September 2011, Pages 2321-2328

https://doi.org/10.1016/j.joms.2010.12.058 Get rights and content

Purpose

The aim of the present study was to describe the gadolinium-enhanced magnetic resonance imaging (MRI) features of temporomandibular joints (TMJs) in children with arthritis. These findings would facilitate the early diagnosis of disease and/or relapse.

Materials and Methods

In the present retrospective study, 2 pediatric radiologists reviewed consecutive MRI scans of the TMJs of children with a definitive diagnosis of juvenile idiopathic arthritis (JIA), including oligoarthritis, polyarthritis, and juvenile psoriatic arthritis. For each MRI scan, specific criteria were evaluated, including the condylar head, condylar fossa, articular eminence, disk shape and position, joint effusion, synovium, intra-articular space, and jaw motion.

Results

A total of 48 patients with mean age of 11.2 years who had been diagnosed with JIA were reviewed. The most common abnormal findings (in order of frequency) were erosion of the condylar head (n = 38), synovial enhancement (n = 35), articular surface flattening (n = 20), abnormalities in jaw motion (n = 26), intra-articular space enhancement (n = 20), subchondral sclerosis of articular eminence (n = 12), joint effusion (n = 9), deformed/displaced disk in the open or closed position (n = 9), bone marrow edema (n = 8), sclerosis of fossa (n = 3), sclerosis of head (n = 3), and the presence of osteophytes (n = 1). Comparing each category of MRI findings, no significant gender differences were found.

Conclusions

Children with JIA who have undergone MRI of their TMJs typically present with more than 1 abnormal radiographic finding consistent with synovitis. Although the presence or absence of each MRI finding did not differ among the arthritis types, bilateral synovial enhancement and bilateral condylar head articular surface flattening were more common in JIA than in juvenile psoriatic arthritis. These findings suggest that MRI should play an important role in the diagnosis and assessment of TMJ involvement in children with JIA.

Section snippets

Materials and Methods

The institutional review board approved the present study (institutional review board no. M09-12-0041). A review of the radiology department database from Children's Hospital Boston identified all MRI scans of TMJs. The exclusion criteria included MRI scans of TMJs that had been obtained for reasons other than arthritis (eg, chronic dislocation, ankylosis), MRI scans that were obtained without contrast (ie, secondary to kidney disease), MRI scans of patients with other facial abnormalities that

Patient Information

A review of the radiology department database from Children's Hospital Boston during a 4-year period (January 2005 to December 2009) identified 219 patients who had undergone MRI of the TMJs. The exclusion criteria were MRI of the TMJs without arthritis (eg, chronic dislocation, ankylosis), MRI of the TMJs without contrast (ie, secondary to kidney disease), previous intra-TMJ treatment or jaw surgery, the presence of other facial abnormalities that could have affected development of the TMJ

Discussion

Juvenile chronic arthritis is a condition of unknown etiology, recently reclassified by the International League of Associations for Rheumatology as juvenile idiopathic arthritis (JIA).⁹ This was done in hopes of defining clinically homogenous subsets of arthritis and thus enhancing worldwide communication among members of the pediatric rheumatology community. JIA is the most commonly diagnosed rheumatologic condition in children, with about 300,000 affected children in the United States.¹⁷ It

Acknowledgments

The authors would like to thank Steven Whalen for assistance with gathering data for this project.

References (28)

H.J. Smith et al.
Rheumatic and nonrheumatic disease in the temporomandibular joint: Gadolinium-enhanced MR imaging
Radiology
(1992)
T.A. Larheim et al.
MR grading of temporomandibular joint fluid: Association with disk displacement categories, condyle marrow abnormalities and pain
Int J Oral Maxillofac Surg
(2001)
T.A. Larheim et al.
MR evidence of temporomandibular joint fluid and condyle marrow alterations: Occurrence in asymptomatic volunteers and symptomatic patients
Int J Oral Maxillofac Surg
(2001)
S. Lamer et al.
MRI and ultrasound in children with juvenile chronic arthritis
Eur J Radiol
(2000)
C.A. Helms et al.
Temporomandibular joint: Morphology and signal intensity characteristics of the disk at MR imaging
Radiology
(1989)
X. Tomas et al.
MR imaging of temporomandibular joint dysfunction: A pictorial review
RadioGraphics
(2006)
A. Küseler et al.
Contrast enhanced magnetic resonance imaging as a method to diagnose early inflammatory changes in the temporomandibular joint in children with juvenile chronic arthritis
J Rheumatol
(1998)
E.Y. Lee et al.
MRI findings of juvenile psoriatic arthritis
Skeletal Radiol
(2008)
M. Twilt et al.
Facioskeletal changes in children with juvenile idiopathic arthritis
Ann Rheum Dis
(2006)
S. Ringold et al.
The temporomandibular joint in juvenile idiopathic arthritis: Frequently used and frequently arthritic
Pediatr Rheumatol
(2009)

T.K. Pedersen et al.

A prospective study of magnetic resonance and radiographic imaging in relation to symptoms and clinical findings of the temporomandibular joint in children with juvenile idiopathic arthritis

J Rheumatol

(2008)

R.E. Petty et al.

International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: Second revision, Edmonton, 2001

J Rheumatol

(2004)

J.E. Drace et al.

Defining the normal temporomandibular joint: Closed-, partially open-, and open-mouth MR imaging of asymptomatic subjects

Radiology

(1990)

P.L. Westesson et al.

Temporomandibular joint: Relationship between MR evidence of effusion and the presence of pain and disk displacement

AJR Am J Roentgenol

(1992)

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The temporomandibular joint (TMJ) is commonly involved in children with juvenile idiopathic arthritis. The diagnosis and evaluation of the disease progression is dependent on medical imaging. The precision of this imaging is under debate. Several scoring systems have been proposed but transparent testing of the precision of the constituents of the scoring systems is lacking. The present study aims to test the precision of 25 imaging features based on magnetic resonance imaging (MRI).
Clinical data and imaging were obtained from the Norwegian juvenile idiopathic arthritis study, The NorJIA study. Twenty-five imaging features of the TMJ in MRI datasets from 86 study participants were evaluated by two experienced radiologists for inter- and intraobserver agreement. Agreement of ordinal variables was measured with Cohen´s linear or weighted Kappa as appropriate. Agreement of continuous measurements was assessed with 95% limit of agreement according to Bland-Altman.
In the osteochondral domain, the ordinal imaging variables “loss of condylar volume,” “condylar shape,” “condylar irregularities,” “shape of the eminence/fossa,” “disk abnormalities,” and “condylar inclination” showed inter- and intraobserver agreement above Kappa 0.5. In the inflammatory domain, the ordinal imaging variables “joint fluid,” “overall impression of inflammation,” “synovial enhancement” and “bone marrow oedema” showed inter- and intraobserver agreement above Kappa 0.5. Continuous measurements performed poorly with wide limits of agreement.
A precise MRI-based scoring system for assessment of TMJ in JIA is proposed consisting of seven variables in the osteochondral domain and four variables in the inflammatory domain. Further testing of the clinical validity of the variables is needed.
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We present a retrospective study to report the outcomes of total temporomandibular joint (TMJ TJR) replacement with alloplastic devices in patients suffering from systemic inflammatory arthropathies.
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Citation Excerpt :
A multidisciplinary approach and the evaluation of radiologic and laboratory abnormalities is often necessary for the diagnosis of JIA.7 Patients with JIA have at least two of the following clinical features for more than 6 weeks: joint swelling, pain/tenderness with motion, limitation of joint motion, and calor overlying the joint.6 Limited maximal incisal opening (MIO) and deviation of the jaw with opening has a high sensitivity and specificity for synovitis.1
Imaging of the Temporomandibular Joint in Juvenile Idiopathic Arthritis: How Does Quantitative Compare to Semiquantitative MRI Scoring?
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Contrast-enhanced magnetic resonance imaging (MRI) is commonly used to evaluate temporomandibular joint (TMJ) disease in patients with juvenile idiopathic arthritis (JIA). However, MRI assessments have been limited by qualitative reporting, the presence of enhancement in normal joints, and a lack of standardized protocols. The purpose of the present study was to compare a quantitative MRI analysis using an enhancement ratio (ER) to a new semiquantitative system developed by Outcome Measures in Rheumatology and Clinical Trials (OMERACT).
We performed a retrospective cross-sectional study of children with JIA who had undergone TMJ MRI with gadolinium enhancement at Boston Children's Hospital. The predictor variables were demographic data (sex, age at MRI) and disease-related findings (JIA subtype and arthritis medication at MRI). The outcome variables were OMERACT scores and ER (ratio of TMJ synovium and longus capitis muscle pixel intensities). The ER was compared with the OMERACT total, inflammatory, and damage scores using Pearson's correlation analysis and multivariable linear regression. Statistical significance was evaluated using the Student t test and analysis of variance with significance set at P < .05. Inter- and intraexaminer reliability were evaluated using intraclass correlation coefficients (ICCs).
The sample included 50 subjects (84% female) with a mean age of 12.7 ± 3.9 years and 124 MRI scans. The mean ER was 2.5 ± 0.9 (normal, <1.55). The mean OMERACT total was 4.9 ± 3.3. Controlling for age, sex, JIA subtype, and medication, for every 1-U increase in ER, the OMERACT increased by 3.11 for the total (P < .001), 1.01 for the inflammatory (P < .001), and 0.86 for the damage (P < .001) scores. The intra- and interrater consistency was better for the ER (ICC, 0.83 and 0.96, respectively) than for OMERACT (ICC, 0.77 and 0.35, respectively).
Quantitative evaluation of TMJ synovial enhancement using the ER is easier to score and has superior intra- and interrater agreement; however, it can only assess inflammation. Semiquantitative assessment of TMJ using the OMERACT adds data about chronic changes. Using both systems might provide the most accurate assessment of JIA status.

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Anesthesia/facial painMagnetic Resonance Imaging of Temporomandibular Joints in Children With Arthritis

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Patient Information

Discussion

Acknowledgments

Radiology

Int J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Eur J Radiol

Temporomandibular joint: Morphology and signal intensity characteristics of the disk at MR imaging

Radiology

MR imaging of temporomandibular joint dysfunction: A pictorial review

RadioGraphics

Contrast enhanced magnetic resonance imaging as a method to diagnose early inflammatory changes in the temporomandibular joint in children with juvenile chronic arthritis

J Rheumatol

MRI findings of juvenile psoriatic arthritis

Skeletal Radiol

Facioskeletal changes in children with juvenile idiopathic arthritis

Ann Rheum Dis

The temporomandibular joint in juvenile idiopathic arthritis: Frequently used and frequently arthritic

Pediatr Rheumatol

A prospective study of magnetic resonance and radiographic imaging in relation to symptoms and clinical findings of the temporomandibular joint in children with juvenile idiopathic arthritis

J Rheumatol

International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: Second revision, Edmonton, 2001

J Rheumatol

Defining the normal temporomandibular joint: Closed-, partially open-, and open-mouth MR imaging of asymptomatic subjects

Radiology

Temporomandibular joint: Relationship between MR evidence of effusion and the presence of pain and disk displacement

AJR Am J Roentgenol

Anesthesia/facial pain
Magnetic Resonance Imaging of Temporomandibular Joints in Children With Arthritis