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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 28  |  Issue : 4  |  Page : 351-357

Assessment and comparison of the capsular width of temporomandibular joint on ultrasonography and magnetic resonance imaging


1 Centre for Advanced Biomedical Imaging, University College London, London, United Kingdom
2 Department of Oral Medicine and Radiology, Mahatma Gandhi Vidyamandir's Karmaveer Bhausaheb Hiray Dental College and Hospital, Nashik, Maharashtra, India
3 Private Practice, Nashik, Maharashtra, India

Date of Submission30-Jan-2016
Date of Acceptance20-Jan-2017
Date of Web Publication21-Feb-2017

Correspondence Address:
Priyanka U Sakhavalkar
868/5A, Atharv, Deepali Nagar, Nashik - 422 009, Maharashtra
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_15_16

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   Abstract 

Aims and Objectives: Purpose of this study was to evaluate the reliability and clinical usefulness of ultrasonography (USG) and magnetic resonance imaging (MRI) in temporomandibular joint (TMJ) imaging. Materials and Methods: By USG and MRI the distance between the most lateral point of the articular capsule and the most lateral point of the mandibular condyle (lateral capsule-condyle distance) was measured, and both the values were compared in normal asymptomatic volunteers as well as in patients with temporomandibular disorders (TMDs) in both open and closed mouth positions. A total of 40 joints were analysed in which 19 were asymptomatic and 21 were joints with TMD. Capsular width of TMJ was measured and compared in normal and joints with TMD joints using unpaired t test. Widths were also compared in images obtained with MRI and USG. Karl Pearson's correlation coefficient was calculated to find out if there exists any relationship between the capsular width measured with MRI and USG. Results: Results show that both the modalities viz. MRI as well as USG are effective in differentiating the capsular width of normal joints to that of joints with TMD joints. Although capsular widths obtained with MRI and USG are not equal, they are positively correlated. Conclusion: USG can be used for the preliminary investigation of patients with TMD.

Keywords: Capsular width assessment, magnetic resonance imaging and ultrasonography comparison, temporomandibular disorders, temporomandibular disorders magnetic resonance imaging, temporomandibular disorders ultrasound, temporomandibular joint imaging


How to cite this article:
Sakhavalkar PU, Bhoosreddy AR, Kotwal HJ. Assessment and comparison of the capsular width of temporomandibular joint on ultrasonography and magnetic resonance imaging. J Indian Acad Oral Med Radiol 2016;28:351-7

How to cite this URL:
Sakhavalkar PU, Bhoosreddy AR, Kotwal HJ. Assessment and comparison of the capsular width of temporomandibular joint on ultrasonography and magnetic resonance imaging. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2017 Sep 26];28:351-7. Available from: http://www.jiaomr.in/text.asp?2016/28/4/351/200621


   Introduction Top


The temporomandibular joint (TMJ) is a vital joint that joins the mandible to the skull and controls mandibular movement. Temporomandibular joint disorders (TMDs) are a collection of musculoskeletal disorders influencing the TMJ and related structures. TMD is a broad term used for various diseases that have distinctive causes but may have similar symptoms and signs. They relate to a group of debilitating diseases concerning the field of oral medicine and are sufficiently predominant to constitute a general public health concern.[1] Nonetheless, while Carlsson has reported that about 93% of the population may have a sign and/or symptom of TMD in their lifetime, just 5–13% show clinically significant symptoms like pain or serious dysfunction.[2] TMD is an aggregate term involving various clinical issues, including the masticatory muscles, the TMJ or both.[3] Studies have demonstrated that physical examination alone is insufficient in deciding the status of TMJ. The exact clinical diagnosis, in particular, the status of joint based only on physical examination may be accurate in just 50–60% of cases.[4] TMJ imaging may be important to supplement data acquired from the clinical examination.

Magnetic resonance imaging (MRI) permits good delineation of the TMJ anatomy and variations from the normal as a result of its innate tissue contrast and high resolution. MRI has turned into an examination of decision-making in assessing the TMJ. Data available regarding the TMJ from MRI incorporates the area of the disc in both open and closed mouth positions at different levels through the joint. Mediolateral and rotational displacements can be identified, as well as the straight anterior displacements.[5] MRI is considered the “gold-standard” technique to evaluate the TMJ capsule.[4] However, MRI cannot be done in a few patients such as those with pacemakers and claustrophobics, and its utilization is restricted by its cost and the time it takes. Furthermore, it is not accessible in all places. A need has arisen for a minimal effort, quick, noninvasive and safe option that has significant accuracy and dependability.

Ultrasonography (USG) is persistently developing since its first use in the medical field. These days, USG systems with high-frequency transducers provide a speedy and exact appraisal of the little joints encompassing delicate tissues. USG of the TMJ is generally agreeable to the patient, with minimal effort and high accessibility, providing data regarding degenerative changes, vicinity of articular effusion and disc displacement. The USG can be utilized for diagnosing TMJ disc position irregularities in a reasonable manner as MRI at closed mouth position and also at open-mouth position.[6] The utilization of USG for contemplating the TMJ is not a regular clinical practice, despite the fact that there have been important discoveries in symptomatic concurrence with MRI for joint effusion and disc displacement.[6] It is hard to detect the disc in all the regular scans of USG. Hence, some specialists chose to utilize indirect USG signs to focus on the disc positions.[6],[7]

Indirect signs, for example, lateral capsule–condyle distance and anterior capsule–condyle distances were utilized to imagine the disc position because these distances could be measured in all the examinations.[8] According to previously reported studies, the landmark lateral capsule–condyle distance, which is the distance between the most lateral point of the articular capsule and the most lateral point of the mandibular condyle, seen in transverse section is presumably augmented in the instances of lateral disc displacements and joint effusions. Consequently, the disc is discovered to be thicker in patients with TMD.[9] Purpose of this study was to evaluate the reliability and clinical usefulness of USG and MRI in the TMJ imaging. In this study, the distance between the most lateral point of the articular capsule and the most lateral point of the mandibular condyle was measured as capsular width.


   Aims and Objectives Top


The present study was devised for assessing the capsular width of TMJ using MRI and USG in normal individuals and patients having TMD on clinical examination. This study also aimed to evaluate the reliability and clinical usefulness of USG and MRI in patients with TMD. The present study was performed to compare the capsular width in open and closed mouth position obtained using MRI to that using USG, as well as to compare the capsular width of asymptomatic patients to that of the patients suffering from temporomandibular dysfunction.


   Materials and Methods Top


This study was carried out at Department of Oral Medicine and Radiology, Mahatma Gandhi Vidyamandir's Karmaveer Bhausaheb Hiray Dental College and Hospital, Nashik, India during year 2011 to year 2013. This study included (n = 20) participants (40 joints) presenting with signs and symptoms (10 patients) or without signs and symptoms (10 volunteers). Their age and genders are seen in [Table 1]. This study was approved by the institutional ethical committee. The participants were informed about the study procedure and their consent was obtained.
Table 1: Distribution of participants by age and gender

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Inclusion criteria

All the joints were classified into two groups depending upon the signs and symptoms they present. Group 1 consisted of the joints having TMD according to Research Diagnostic Criteria (RDC)/TMD,[10] whereas Group 2 consisted of the joints with no sign or symptom of TMD.

Exclusion criteria

Patients with previous TMJ surgery, history of orthodontic treatment and conditions contraindicating MRI acquisition such as claustrophobia and cardiac stent were excluded.

Detailed case history was obtained. It included chief complaint, past and present histories, history of pain, joint noise, trauma, or locking of the joint. Furthermore, the time, duration of pain, as well as aggravating and relieving factors were noted along with the history of treatment if any. Clinical examination was done for the presence or absence of joint sounds and pain, palpation of intraoral and extraoral masticatory muscles, and mandibular motion. USG and MRI examination was performed in open and closed mouth position in both TMJs. The distance between the most lateral point of the articular capsule and the most lateral point of the mandibular condyle was measured as capsular width. All the examinations were performed by a single observer.

In the patients who had unilateral TMD as per any of presenting symptom according to RDC/TMD, contralateral healthy joint showing no symptoms of TMD were considered to be normal. After clinical examination, 21 joints (20 joints in 10 normal volunteers and 1 normal joint in 1 patient with unilateral TMD) were found to be normal, and 19 joints (18 joints with TMD in 9 patients with bilateral TMD and 1 joint in 1 patient with unilateral TMD) were affected (joints with TMD) with either by clicking, pain, deviation, deflection or disc derangement.

Machine specifications of magnetic resonance imaging

The MRI examination was done at Sun Scan Centre, Nashik, Maharashtra, India, using a 1.5 Tesla scanner (Magnetom Essenza, SIEMENS, Germany) Tim (25 × 8) with bilateral brain coil. Sagittal and coronal plane proton density (TR 3000, TE 36) images were obtained at closed and maximum-opening mouth positions. Data were composed of voxel size: 0.8 × 0.6 × 3.0 mm field of view, 3 mm slice thickness, and 0 mm slice distance. MR scans were performed in the supine position in both closed and open mouth position using brain coil [Figure 1].
Figure 1: Brain coil used

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Bite block was used for stability in the open mouth position. Images were analyzed in sagittal section using software Syngo FastView, build VX57F24 (Siemens AG, Berlin and Munchen 2004-2006) [Figure 2]. Then, the most appropriate slice was selected and capsular width was measured from the highest point on the head of the condyle to the superior capsular border. Finally, these measurements were obtained in both open and closed mouth position in right and left TMJs [Figure 3]a and [Figure 3]b.
Figure 2: Acquired image

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Figure 3: Capsular width measured with MRI in (a) closed mouth position and (b) open mouth position

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Machine specifications for ultrasonography

USG was performed using Philips HD 15 at Kotwal Diagnostic Centre, Nashik, Maharashtra, India. All images were acquired using linear high resolution probe [Figure 4] (Frequency L12–3 MHz). All examinations were conducted in a dark room with the patient lying in a lateral position (right or left). Gel was applied over the TMJ area. Transducer was placed parallel to the ala tragus line over the TMJ area. The transducer was positioned over the TMJ perpendicular to the zygomatic arch in a transverse plane and tilted out until the best visualization was achieved [Figure 5]a and [Figure 5]b. Thus, the articular capsule was identified as a hyperechoic line running parallel to the surface of the mandibular condyle. Capsular width was the distance between that hyperechoic line and the condylar laterosuperior surface with the patient in closed and open mouth position [Figure 6]a and [Figure 6]b. Measurements of the right and left TMJs were obtained in open and closed mouth position. A same mouth block which was used for MRI examination was also used for USG assessment in open mouth position. Thus, capsular widths were measured with both MRI and USG. Results were tabulated and statistically analyzed.
Figure 4: Transducer

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Figure 5: Patient positioning for USG examination for (a) closed mouth position and (b) open mouth position

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Figure 6: Capsular width measured with USG in (a) closed mouth position and (b) open mouth position

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Statistical analysis

Results were analyzed using the software Microsoft excel 2010 (Microsoft Office 2010, India). Independent sample t-test was applied at 38° of freedom and 95% confidence level to compare capsular widths between MRI and USG, as well as in normal joint and joints with TMD. Independent sample t-test was also applied separately for open and closed mouth positions.


   Results Top


[Table 1] shows the distribution of patients by age and sex. The participants' ages ranged from 15 to 75 years. The mean age was 27.5 years. The largest number of participants were in the age group of 15–25 years, i.e., 14 participants, while 4 were in the age group of 26–35 years, and 1 was in the group of 46–55 and 66–75 years each. [Figure 7] and [Figure 8] show the comparison of capsular width measured on MRI and USG using t-test in closed and open mouth positions respectively. According to [Figure 7], mean capsular width obtained with MRI was 2.9 and with that of USG was 1.5 in closed mouth position. The P value obtained between MRI and USG in closed mouth positions with two-tailed unpaired t-test was <0.5 showing significant difference. [Figure 8] shows that mean capsular width obtained with MRI was 2.2 and with that of USG was 1.0 in open mouth position. The P value obtained with two-tailed unpaired t-test was <0.5 showing significant difference.
Figure 7: Comparison of capsular width measured on MRI and USG using t-test in closed mouth positions

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Figure 8: Comparison of capsular width measured on MRI and USG using t-test in open mouth positions

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[Table 2] shows the comparison of capsular width in closed mouth position in normal joints vs. joints with TMD as measured on MRI analyzed by t-test; two-sample assuming equal variances (closed mouth position). Mean capsular width obtained with MRI was 2.4 in normal joints and was 3.4 in joints with TMD. Out of all the TMJs examined, 21 were normal and 19 were joints with TMD. P value obtained with two-tailed unpaired t-test was <0.5 showing significant difference. [Table 2] also shows the comparison of capsular width in open mouth position in normal joints vs. joints with TMD as measured on MRI analyzed by t-test; two-sample assuming equal variances (open mouth position). Mean capsular width obtained with MRI was 1.8 in normal joints and was 2.7 in joints with TMD. Out of all the TMJs examined, 21 were normal and 19 were joints with TMD. P value obtained with two-tailed unpaired t-test was <0.5.
Table 2: Comparison of capsular width (mm) measured with MRI and USG in open and closed mouth positions in normal joints and joints with TMD

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[Table 2] shows the comparison of the capsular width in closed mouth position in normal joints and joints with TMD as measured on USG (closed mouth position) by using t-test; two-sample assuming equal variances. Mean capsular width obtained with USG was 1.3 in normal joints and was 1.7 in joints with TMD. Out of all the TMJs examined, 21 were normal and 19 were joints with TMD. P value obtained with two tailed unpaired t-test was <0.5 showing significant difference. Also in [Table 2], comparison of the capsular width in normal joints and joints with TMD is shown as measured on USG in open mouth position by using t-test; two-sample assuming equal variances. Mean capsular width obtained with USG was 0.84 in normal joints and was 1.3 in joints with TMD in open mouth position. Out of all the TMJs examined, 21 were normal and 19 were joints with TMD. The P value obtained with two-tailed unpaired t-test was <0.5 showing significant difference.

[Table 2] shows a comparison of capsular width measured with MRI and USG in open and closed mouth positions. Mean capsular width obtained with MRI was 2.4 in closed mouth position in normal joints and it was 3.4 in joints with TMD. Mean capsular width obtained with USG was 1.3 in closed mouth position in normal joints and was 1.7 in joints with TMD. Mean capsular width obtained with MRI was 1.8 in open mouth position in normal joints and it was 2.7 in joints with TMD. Mean capsular width obtained with USG was 0.84 in open mouth position in normal joints and it was 1.3 in joints with TMD. The P value obtained was <0.5 showing significant differences in all other values. Percentage difference obtained was 40.17 in MRI closed mouth position 43.30 in MRI open mouth position, 32.34 in USG open mouth position, and it was 55.81 in USG open mouth position.


   Discussion Top


The present study was carried out to assess the capsular width of TMJ in patients with or without TMD using MRI and USG. A total of 20 participants (40 joints) were evaluated in open and closed mouth positions using clinical examination, MRI and USG. Age range of the participants was 15–75 years, and mean age was 27.5 years [Table 1]. Capsular width measured in open and closed mouth positions on MRI and USG is given in master chart. The study was aimed to compare two imaging modalities, i.e., MRI and USG with respect to the capsular width. This capsular width was measured in cases and controls in both open and closed mouth positions. To compare the mean capsular width obtained using MRI and USG, the unpaired t-test was applied at 38° of freedom and 95% confidence level. The results obtained are shown in [Table 2].

It can be observed that, in both closed and open mouth position, there was a significant difference between the mean capsular width measured using MRI (closed 2.9 and open 2.2) and USG (closed 1.5 and open 1.0). In both the cases, the percentage difference between mean measurements was approximately 50%. This was contrary to a similar study performed by Lee et al.[11] According to their results, there was no statistically significant difference between the capsular width obtained by MRI and USG.

The study also aimed to compare the capsular width of TMJ in normal joints to that of joints with TMD. Brucu et al.[12] showed that painful joints are more likely to demonstrate high grades of joint effusion in MRI and increased capsular width in USG. In the present study, 20 patients were examined clinically. Out of all 40 joints assessed, 19 were found to have TMD and 21 joints were normal on clinical examination according to RDC/TMD [13] clinical guidelines. For each of these joints, capsular width was measured in closed and open mouth positions with each MRI and USG. The unpaired t-test was applied to compare these measurements at 38° of freedom and 95% confidence level separately for open and closed mouth positions, as shown in [Table 2]. Mean capsular width obtained with MRI was 2.4 in closed mouth position in normal joints and was 3.4 in joints with TMD; USG was 1.3 in closed mouth position in normal joints and it was 1.7 in joints with TMD.

Mean capsular width obtained with MRI was 1.8 in open mouth position in normal joints and 2.7 in joints with TMD. Mean capsular width obtained with USG was 0.84 in open mouth position in normal joints and 1.3 in joints with TMD. The P value obtained was 0.000 in MRI closed and open mouth positions, 0.006 in USG closed mouth position, while it was 0.004 in open mouth position. Thus, the difference is statistically significant. Percentage difference obtained was 40.17 in MRI closed mouth position, 43.30 in MRI open mouth position, 32.34 in USG open mouth position, and 55.81 in USG open mouth position. Thus, our analysis shows that both the techniques significantly show the difference between mean capsular width in normal joint and joints with TMD. This was in accordance with the study by Wang et al.[9] that showed that TMJ discs are thicker in joints with TMD than those with normal joints.

Overall, it can be stated that both the modalities viz. MRI as well as USG are effective in differentiating the capsular width of normal joints to that of joints with TMD. In a study performed by Manfredini et al.,[7] where the authors assessed increased capsular width on USG with effusion seen on MRI. The study concluded that USG is a promising technique in the study of TMJ effusion with capsular distension as an indirect sign. They also analyzed receiver operating characteristic (ROC) curve and revealed the critical area of approximately 2 mm for TMJ capsular width. In another study, Burcu et al.[12] performed a similar analysis and found the critical area to be around the value of 1.65 mm. They also stated that the difference between these two results is due to the difficulty in standardization of the examination. One of the major shortcomings of USG is that accuracy mainly depends on the operator's training. These findings need to be refined by further studies assessing the smallest detectable difference in capsular width.

Studies by Hayashi et al.,[14] Jank et al.,[15] Uysal et al.,[16] and Lee [11] also showed that USG can be considered as a reliable diagnostic imaging modality in TMD though it may not be as accurate as MRI. USG should be used for the preliminary investigation. However, findings reported by Dopuy-Bonafe et al.[17] do not support the recommendation of USG as a conclusive diagnostic tool for internal derangement of TMJ. Thus, USG is a less expensive and easily available modality as compared to MRI and can be used for the preliminary diagnosis of patients with TMD. MRI can be considered to be the standard of choice for a detailed examination of TMJ.


   Conclusion Top


From the present study, it can be concluded that both MRI and USG are effective in assessment of capsular width patients with TMJ. However, in comparison with normal joints, joints with TMD have greater capsular width. Although capsular widths obtained with MRI and USG are not equal, they both show increased capsular width in patients with TMD. Thus, USG being easily available, economical, and less time consuming, can be used for the preliminary investigation of patients with TMD. For more accurate and detailed analysis of joint capsule and disk, MRI can be recommended.

Limitations and future scope

Present study analyzed TMD based on the assessment of capsular width. Comparison was made in capsular width measurements of normal joints and joints with TMD by single observer. More studies should be carried out with larger sample size to determine the width of TMJ capsule with MRI and USG in normal individuals. Determination of normal range of capsular width can aid in rapid screening of patients with TMD. Detailed analysis by ROC curve will establish the correlation between MRI and USG. Because ultrasonography is a technique sensitive imaging modality, studies must be carried out with two or more observers and a protocol should be established for standardization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
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Carlsson GE. Epidemiology and treatment need for temporomandibular disorders. J Orofac Pain 1999;13:232-7.  Back to cited text no. 2
    
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Auvenshine RC. Temporomandibular disorders: Associated features. Dent Clin N Am 2007;51:105-27.  Back to cited text no. 3
    
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Brooks SL, Brand JW, Gibbs SJ, Hollender C, Lurieet AG, Omnell KA, et al. Imaging of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:609-18.  Back to cited text no. 5
    
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Manfredini D, Guarda-Nardini L. Ultrasonography of the temporomandibular joint: A literature review. Int J Oral Maxillofac Surg 2009;38:1229-36.  Back to cited text no. 6
    
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Manfredini D, Tognini F, Melchiorre D, Zampa V, Bosco M. Ultrasound assessment of increased capsular width as a predictor of temporomandibular joint effusion. Dentomaxillofac Radiol 2003;32:359-64.  Back to cited text no. 7
    
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Elias FM, Birman EG, Matsuda CK, Olivera ERDS, Jorge WA. Ultrasonographic findings in normal temporomandibular joints. Braz Oral Res 2006;20:25-32.  Back to cited text no. 8
    
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Wang M, Cao H, Ge Y, Widmalm SE, Odont D. Magnetic resonance imaging on TMJ disc thickness in TMD patients: A pilot study. J Prosthet Dent 2009;102:89-93.  Back to cited text no. 9
    
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Hasanain F, Durham J, Moufti A, Steen IN, Wassel RW. Adapting the diagnostic definitions of the RDC/TMD to routine clinical practice: A feasibility study. J Dent 2009;37:955-62.  Back to cited text no. 10
    
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Lee TW, Yoo DS, Han WJ, Kim EK. Comparison of the capsular width measured on ultrasonograph and MR image of the temporomandibular joint. Korean J Oral Maxillofac Radiol 2006;36:41-8.  Back to cited text no. 11
    
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Brucu B, Yilmaz N, Gokce E, Akan H. Ultrasound assessment of increased capsular width in temporomandibular joint internal derangements: Relationship with joint pain and magnetic resonance grading of joint effusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:112-7.  Back to cited text no. 12
    
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Dworkin SF, Leresche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301-55.  Back to cited text no. 13
    
14.
Hayashi T, Ito J, Koyama J, Yamada K. The accuracy of sonography for evaluation of internal derangement of the temporomandibular joint in asymptomatic elementary school children: Comparison with MR and CT. Am J Neuroradiol 2001;22:728-34.  Back to cited text no. 14
    
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Jank S, Rudisch A, Bodner G, Brandlmaier I, Gerhard S, Emshoff R. High-resolution ultrasonography of the TMJ: Helpful diagnostic approach for patients with TMJ disorders? J Craniomaxillofac Surg 2001;29:367-71.  Back to cited text no. 15
    
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Uysal S, Kansu H, Akhan O, Kansu O. Comparison of ultrasonography with magnetic resonance imaging in the diagnosis of temporomandibular joint internal derangements: A preliminary investigation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:115-21.  Back to cited text no. 16
    
17.
Dupuy-Bonafé I1, Picot MC, Maldonado IL, Lachiche V, Granier I, Bonafé A. Internal derangement of the temporomandibular joint: Is there still a place for ultrasound? Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:832-40.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2]



 

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