UNIVERSIDADE ESTADUAL DE CAMPINAS DORA ZULEMA … · Biologia Buco-Dental, na área de Anatomia....

UNIVERSIDADE ESTADUAL DE CAMPINAS

FACULDADE DE ODONTOLOGIA DE PIRACICABA

DORA ZULEMA ROMERO DIAZ

ESTUDO ULTRASSONOGRÁFICO DE ESTRUTURAS ANATÔMICAS DA

ARTICULAÇÃO TEMPOROMANDIBULAR EM INDIVÍDUOS COM E SEM

DISFUNÇÃO TEMPOROMANDIBULAR

ULTRASONOGRAPHIC STUDY OF ANATOMICAL STRUCTURES OF

TEMPOROMANDIBULAR JOINT IN INDIVIDUALS WITH AND WITHOUT

TEMPOROMANDIBULAR DISORDERS

Piracicaba

2017

DORA ZULEMA ROMERO DIAZ

ESTUDO ULTRASSONOGRÁFICO DE ESTRUTURAS ANATÔMICAS DA

ARTICULAÇÃO TEMPOROMANDIBULAR EM INDIVÍDUOS COM E SEM

DISFUNÇÃO TEMPOROMANDIBULAR




Piracicaba

2017

Dissertação apresentada à Faculdade de Odontologia de

Piracicaba da Universidade Estadual de Campinas, como parte

dos requisitos exigidos para a obtenção do titulo de Mestra em

Biologia Buco-Dental, na área de Anatomia.

Dissertation presented to the Piracicaba Dental School of the

University of Campinas in partial fulfillment of the requirements

for the degree of Master in Oral Biology, in Anatomy area.

Orientadora: Profa. Dra. Maria Beatriz Duarte Gavião

Este exemplar corresponde à versão final da dissertação

defendida pela aluna Dora Zulema Romero Diaz e

orientada pela Profa. Dra. Maria Beatriz Duarte Gavião.

Agência(s) de fomento e nº(s) de processo(s): CAPES

Ficha catalográfica

Universidade Estadual de Campinas Biblioteca da

Faculdade de Odontologia de Piracicaba Marilene

Girello - CRB 8/6159

Diaz, Dora Zulema Romero, 1987-

D543e Estudo ultrassonográfico de estruturas anatômicas da articulação

temporomandibular em indivíduos com e sem disfunção temporomandibular / Dora

Zulema Romero Diaz. – Piracicaba, SP : [s.n.], 2017.

Orientador: Maria Beatriz Duarte Gavião.

Dissertação (mestrado) – Universidade Estadual de Campinas, Faculdade de

Odontologia de Piracicaba.

1. Ultrassonografia. 2. Articulação temporomandibular. 3. Anatomia. I.

Gavião, Maria Beatriz Duarte,1955-. II. Universidade Estadual de Campinas.

Faculdade de Odontologia de Piracicaba. III. Título.

Informações para Biblioteca Digital

Título em outro idioma: Ultrasonographyc study of anatomical structures of

temporomandibular joint in individuals with and without temporomandibular disorders

Palavras-chave em inglês:

Ultrasonography

Temporomandibular joint

Anatomy

Área de concentração: Anatomia

Titulação: Mestra em Biologia Buco-Dental

Banca examinadora:

Maria Beatriz Duarte Gavião [Orientador]

Polliane Morais de Carvalho

Ana Cláudia Rossi

Data de defesa: 04-08-2017

Programa de Pós-Graduação: Biologia Buco-Dental

UNIVERSIDADE ESTADUAL DE CAMPINAS

Faculdade de Odontologia de Piracicaba

A Comissão Julgadora dos trabalhos de Defesa de Dissertação de Mestrado, em sessão

pública realizada em 04 de Agosto de 2017, considerou a candidata DORA ZULEMA

ROMERO DIAZ aprovada.

PROFa. DR

a. MARIA BEATRIZ DUARTE GAVIÃO

PROFa. DR

a. POLLIANE MORAIS DE CARVALHO

PROFa. DR

a. ANA CLÁUDIA ROSSI

A Ata de defesa com as respectivas assinaturas dos membros encontra-se no processo

de vida acadêmica do aluno.

DEDICATÓRIA

Dedico este trabalho a:

DEUS, meu Pai, que foi minha fortaleza nos momentos mais difíceis, por

NUNCA ter me deixado mesmo nas horas de angústia e solidão. Por ter me abençoado

com a dádiva da vida, a coragem de aproveitar as oportunidades que ele me apresentou

e pela felicidade de realizar todos os meus sonhos.

María Zulema Díaz, minha mãe, que mesmo não compreendendo a natureza

do meu trabalho, sempre me apoiou de forma INCONDICIONAL e me moldou no que

hoje sou.

A eles sou imensamente grata!

AGRADECIMENTOS

Agradeço acima de tudo a DEUS, pela vida e pela benção concedida de

terminar o meu mestrado.

À Universidade Estadual de Campinas, na pessoa do Magnifico Reitor Prof.

Dr. Marcelo Knobel.

À Faculdade de Odontologia de Piracicaba, na pessoa do senhor Diretor,

Prof. Dr. Guilherme Elias Pessanha Henriques.

À Coordenadoria de Pós-graduação, na pessoa da Senhora Coordenadora

Profa. Dra. Cinthia Pereira Machado Tabchoury.

Ao Programa de Pós-graduação em Biologia Buco-Dental, na pessoa da

Coordenadora Profa. Dra. Maria Beatriz Duarte Gavião.

A minha orientadora Profa. Dra. Maria Beatriz Duarte Gavião, por ter me

ajudado e apoiado em todos os momentos, mesmo diante de toda dificuldade, agradeço

imensamente pela participação ativa e direta neste passo gigantesco a caminho da

construção de minha carreira profissional, muito obrigada!

À Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES

pela da bolsa de estudos concedida.

Ao Prof. Dr. Luciano José Pereira, pelo treinamento com o ultrassom.

Ao Prof. Dr. Yuri Martins Costa, por ter compartilhado o seu conhecimento

durante o treinamento para o preenchimento do índice DC/TMD.

Ao Prof. Paulo Henrique Caria, pelos seus ensinamentos, conselhos e

criticas nos seminários, que me modelaram na minha formação acadêmica.

À Profa. Dra. Ana Claudia Rossi, pelos ensinamentos durante o programa

de estágio docente os quais me permitiram desenvolver uma das minhas paixões,

ensinar.

A Florence Cuadra, pela amizade que me motiva ser uma pessoa melhor,

que me inspira ser boa profissional. Sou grata pela ajuda incondicional: você foi o anjo

que Deus colocou na minha vida.

A todos os voluntários que dispuseram do seu tempo, história e

sintomatologia para o desenvolvimento científico deste trabalho.

A Cristina Emöke Erika Müller, pela amizade, ajuda fundamental e peça

imprescindível para a realização desta obra.

A Mariana Fernandes dos Santos, pela sua amizade e pelo carinho que me

deu desde que nós conhecemos, pelas nossas conversas e pelos conselhos.

A Sra. Leni Aparecida Garcia de Brito e ao Sr. Valdir Francisco de Brito,

meus pais em Piracicaba, muito obrigada pela sua ajuda e apoio, os senhores foram uma

benção na minha vida.

Agradeço a Deus por ter colocado aos meus amigos “estrangeiros” na minha

vida, sou muito grata por todos os momentos que passamos juntos sempre estarão

guardados comigo, mesmo que o tempo passe e a distância seja grande; vocês fizeram

minha estadia mais leve e me apoiaram quando necessitei!

RESUMO

O objetivo desse estudo foi descrever estruturas anatômicas da articulação

temporomandibular (ATM) pela ultrassonografia. O estudo caracterizou-se como

observacional-descritivo de tipo transversal e comparativo. Participaram 32 indivíduos

(17 do sexo feminino e 15 do sexo masculino) na faixa etária de 19 a 39 anos.

Aplicaram-se os critérios diagnósticos para disfunção temporomandibular (DC/TMD),

dividindo os voluntários em grupo DTM com 20 voluntários e grupo assintomático com

12 voluntários. Portanto, foram avaliadas 64 articulações temporomandibulares pela

ultrassonografia de alta resolução do lado direito e esquerdo na posição de boca-fechada

(BF) e boca-aberta (BA), por um único examinador treinado e calibrado (Kappa=0,7).

As estruturas avaliadas foram a cabeça da mandíbula, o disco articular, o espaço supra e

infradiscal e a cápsula articular. Além disso, mensurou-se a distância entre o ponto mais

lateral da cápsula articular e o ponto mais lateral da cabeça da mandíbula (distância

lateral cápsula-cabeça da mandíbula) nas posições de BF e BA. As respectivas medidas

foram comparadas entre os grupos, aplicando-se os testes t de Student pareado e não

pareado (α=0,05). As imagens ultrassonográficas possibilitaram visualizar o polo lateral

da cabeça da mandíbula como uma imagem hiperecóica; o disco articular como uma

imagem hiperecogênica central rodeada por uma imagem linear superior e inferior

hipoecoica, o espaço supra e infradiscal respectivamente; a borda superior da cápsula

articular como uma imagem linear hiperecóica. As médias da distância lateral cápsula-

cabeça da mandíbula no lado direito no grupo DTM foram 0,69±0,19 mm em BF e

0,61±0,15 mm em BA e no grupo assintomático 0,71±0,16 mm e 0,63±0,16 mm,

respectivamente. No lado esquerdo, as medidas em BF para o grupo DTM foi 0,68±0,15

mm e no grupo assintomático 0,70±0,14 e em BA 0,64±0,15 mm para o grupo DTM e

no grupo assintomático 0,66±0,15. Perante os resultados encontrados, pode-se

considerar a Ultrassonografia como uma ferramenta promissora e viável para avaliação

da ATM. As mensurações da distancia cápsula-cabeça da mandíbula não diferiu entre o

grupo TMD e o grupo assintomático.

Palavras-chaves: Ultrassonografia, Articulação temporomandibular, Anatomia.

ABSTRACT

The purpose of this study was to describe anatomic structures of the

temporomandibular joint (TMJ) by high-resolution ultrasonography. The study was

characterized as observational-descriptive, cross-sectional and comparative. Participants

were 32 volunteers (17 females and 15 males) in the age of 19 to 39 years. Diagnostic

criteria for temporomandibular dysfunction (CD/TMD) were applied, and the volunteers

were divided in two groups, TMD group of 20 volunteers and an asymptomatic group of

12 volunteers. Therefore, 64 temporomandibular joints were evaluated by high-

resolution ultrasonography on the right and left side in the closed- mouth (CM) and

open-mouth (OM) positions, by a single trained and calibrated examiner (Kappa = 0.7).

The evaluated structures were the mandibular condyle, the articular disc, the supra and

infradiscal spaces and the upper edge of the articular capsule. In addition, the distances

between the most lateral point of the articular capsule and the most lateral point of the

mandibular condyle (lateral capsule-condyle distance) at the CM and OM positions

were measured. The respective measurements were compared between the groups,

applying paired and unpaired Student t tests (α = 0.05). Ultrasound imaging made it

possible to visualize the articular surface of the mandibular condyle as a hyperechoic

image; the articular disc as a central hyperechogenic image surrounded by a hypoechoic

linear image; the upper border of the articular capsule as a linear hyperechoic image.

The averages of lateral capsule-mandibular condyle distance on the right side in the

TMD group were 0.69±0.19 mm in CM and 0.61±0.15 mm in OM and in the

asymptomatic group 0.71±0.16 mm and 0.63±0.16 mm, respectively. On the left side,

the CM measurements for the TMD group were 0.68±0.15 mm and in the asymptomatic

group 0.70±0.14 and in the OM 0.64±0.15 mm for the TMD group and in the

asymptomatic group 0.66±0.15. Given the results found, Ultrasonography can be

considered as a promising and feasible tool for the assessment of TMJ. The distance

from the most lateral point of the articular capsule to the most lateral point of the

mandibular condyle (lateral capsule-condyle distance), measured on the

ultrasonographic scans, did not differ between TMD group and asymptomatic group.

Keywords: ultrasonography, temporomandibular joint, anatomy.

LISTA DE ILUSTRAÇÕES

Figura 1 - Transducer positioned against the patient’s face, perpendicular

to the Frankfort horizontal plane and parallel to the mandibular

ramus

Figura 2 - Flow chart

Figura 3 - Ultrasonography scan of the left temporomandibular joint in

closed- mouth position in transversal/axial slice of a volunteer

of the TMD group

Figura 4 - Ultrasonography scan of the right temporomandibular joint in

open-mouth position in transversal/axial slice of a volunteer of

the TMD group

Figura 5 - Measurement of the distance between the most lateral point of

the articular capsule and the most lateral point of the

mandibular condyle (lateral capsule-condyle distance) in

ultrasonographic scan of the right temporomandibular joint in

closed-mouth of a volunteer of the TMD group

Figura 6 - Measurement of the distance between the most lateral point of

the articular capsule and the most lateral point of the

mandibular condyle (lateral capsule-condyle distance) in

ultrasonographic scan of the right temporomandibular joint in

open-mouth of a volunteer of the TMD group

LISTA DE TABELAS

Tabela 1 – Sample distribution according to sex and DC/TMD

Tabela 2 – Measurement of the distance between the most lateral point of the

articular capsule and the most lateral point of the mandibular

condyle (lateral capsule-condyle distance) in the

Temporomandibular disorders group and asymptomatic group

(mm)

Tabela 3 – Measurement of the distance between the most lateral point of the

articular capsule and the most lateral point of the mandibular

condyle (lateral capsule-condyle distance) in the volunteers with

intra-articular disorders and asymptomatic group (mm)

LISTA DE ABREVIATURAS E SIGLAS

DTM - Disfunção Temporomandibular

US - Ultrassonografia / Ultrasonography

DC/TMD - Diagnostic Criteria for Temporomandibular Disorders

TMD - Temporomandibular Disorders

ATM - Articulação temporomandibular

ATMs - Articulações temporomandibulares

TMJ - Temporomandibular joint

MHz - Megahertz

mm - Milímetros

SUMÁRIO

1 INTRODUÇÃO ................................................................................................. 14

2 ARTIGO Ultrasonography of anatomical structures of

temporomandibular joint in individual with and without

temporomandibular disorders ……………………………...

17

3 CONCLUSÃO .................................................................................................. 35

REFERÊNCIAS

APÊNDICES

Apêndice 1 Ficha de avaliação

Apêndice 2 Ficha de avaliação dos dados ultrassonográficos

ANEXOS

Anexo 1 Certificado do Comitê de Ética em Pesquisa com seres

humanos da FOP - UNICAMP

Anexo 2 DC/TMD

14

1 INTRODUÇÃO

A Articulação temporomandibular (ATM) é uma das articulações sinoviais mais

complexas do corpo humano e apresenta como componentes ósseos a fossa mandibular na

porção petrosa do osso temporal e a cabeça da mandíbula. Possui um disco articular de

fibrocartilagem localizado entre ambas as estruturas ósseas permitindo melhor adaptação

entre elas, fixando-se nos polo medial e lateral da cabeça da mandíbula para acompanha-la

durante os movimentos; divide o espaço articular em dois compartimentos: o espaço

supradiscal e infradiscal. A cápsula articular estende-se dos limites da superfície articular

craniana em direção inferior para o colo da mandíbula, circundando assim toda a ATM.

Também apresenta ligamentos extracapsulares que restringem os movimentos mandibulares

para evitar possíveis danos nas estruturas (Alomar et al., 2007).

Quando a cavidade bucal se encontra fechada, a cabeça da mandíbula deve estar

situada na região central da fossa mandibular; a posição do disco articular é considerada

normal quando a porção posterior e se localiza entre 12 e 13 horas na superfície articular, a

porção central do disco posiciona-se na face anterior superior da superfície articular da cabeça

da mandíbula (Mello-Júnior et al., 2011).

Hábitos parafuncionais como ranger e/ou apertar os dentes podem alterar as relações

de normalidade das estruturas anatômicas e, consequentemente, gerar disfunções na

articulação temporomandibular (DTM) com o passar do tempo.

A DTM refere-se a um conjunto complexo de condições que podem se manifestar com

dor na região das articulações e limitações nos movimentos normais de abertura e fechamento

da boca. De acordo com Schiffmanet et al. (2014), os principais sintomas incluem clique,

crepitação, redução ou dificuldade na capacidade de fazer os movimentos mandibulares, dor

na área da articulação e nos músculos da mastigação. Além disso, pode ocorrer posição

anormal do disco articular em relação à cabeça da mandíbula e da fossa mandibular gerando

deslocamento anormal durante os movimentos mandibulares (Emshoff et al., 2002,

Melchiorre et al., 2010, Mello-Júnior et al., 2011).

A abordagem dos pacientes que sofrem de DTM começa com o diagnóstico completo,

incluindo um minucioso exame clínico. O Diagnostic Criteria for Temporomandibular

15

Disorders (DC/TMD) é um dos protocolos mais indicado para o diagnóstico da DTM, pois é

um método de avaliação com critérios claramente definidos, simples de aplicar e de fácil

pontuação (Schiffman et al., 2014). As imagens das ATMs podem ser indicadas para

completar o diagnóstico da disfunção (Kundu et al., 2013). A finalidade das imagens da ATM

consiste em avaliar a integridade e a relação dos tecidos duros e moles, e observar o progresso

da alteração (Byahatti et al., 2010).

Os métodos mais usados para a obtenção das imagens da ATM incluem a ressonância

magnética, a tomografia computadorizada, a artrografia, a radiografia panorâmica e

ultrassonografia (US). O padrão ouro para a avaliação da articulação é a ressonância

magnética, porém a sua disponibilidade é relativamente baixa devido a seu elevado custo, uso

restrito em indivíduos com marcapassos, próteses e claustrofóbicos. Nas ultimas duas década,

autores como Hayashi et al. (2001), Emshoff et al. (2002), Pereira et al. (2007), Byahatti et al.

(2010) e Assaft et al. (2013), mostraram que a US pode ser uma ferramenta promissora e

viável na avaliação das estruturas anatômicas da ATM.

A imagem ultrassonográfica se forma quando um grupo de elementos piezoelétricos

localizados dentro do transdutor (emissor/receptor.), ao receber energia elétrica, vibram,

produzindo um pulso que gera milhares de ecos, os quais atingem os tecidos corporais, parte

deste eco é refletida de volta para os elementos piezoelétricos, os quais o transformam em

sinais que serão visualizados na tela do equipamento de ultrassom em diversas escalas de

cinza de acordo com a ecogenicidade do tecido. Parte das ondas remanescentes continuam seu

caminho, gerando ecos adicionais, até que a energia inicial seja totalmente dissipada. A

ecogenicidade do tecido depende das características estruturais como espessura, largura,

comprimento, quantidade de gordura e água presente; assim, os tecidos que geram ecos de

onda de alta freqüência aparecerão mais brilhantes – hiperecóicos (branco) - no monitor.

Aqueles que produzem poucos ecos de onda de baixa freqüência aparecerão hipoecóicos

(cinza). Os pulsos de frequência mais baixa podem caminhar mais facilmente e gerar ecos que

retornam mais facilmente ao transdutor gerando mais sinal do tecido, porém os detalhes da

imagem podem ser de baixa resolução. A idéia é usar a onda com frequência mais alta

possível que permite alcançar a área de interesse com sinal suficiente para visualizar maiores

detalhes do tecido, isto é, com alta resolução. A US permite visualizar o movimento das

estruturas por que os ecos gerados são rápidos, aproximadamente a 1540 m/seg nos tecidos

moles, o que permite visualizar a imagem 30 vezes por segundo (van Holsbeeck et al., 2001).

16

Sendo assim, a US como método de diagnóstico por imagem uma técnica não invasiva usada

no âmbito clinico por ser de rápida execução e de baixo custo, com a vantagem de permitir

avaliar as estruturas em “tempo real”.

Com o decorrer dos anos e o avanço da tecnologia, surgiram novos equipamentos de

ultrassonografia com transdutores de maior resolução, capazes de transmitir sinais mais claros

que possibilitam melhor visualização das estruturas anatômicas do corpo para prover ao

paciente um diagnóstico preciso. Para o aproveitamento dessas novas tecnologias se faz

necessário estudos que mostrem a sua utilidade na pratica clinica. Nesse sentido, o objetivo

desta pesquisa foi descrever estruturas anatômicas que compõem a articulação

temporomandibular, como a cabeça da mandíbula, o disco articular, o espaço supra e

infradiscal, e a cápsula articular, além disso, a mensuração da distância entre o ponto mais

lateral da cápsula articular e o ponto mais lateral da cabeça da mandíbula (distância lateral da

cápsula-cabeça da mandíbula) nas posições de boca fechada e boca aberta, pela

ultrassonografia de alta resolução em voluntários com sinais e sintomas de disfunção

temporomandibular, comparando-os com voluntários assintomáticos.

17

2 ARTIGO




Dora Zulema Romero Diaz1, Cristina Emöke Erika Müller

1, Maria Beatriz Duarte Gaviao*

2.

1Department of Morphology, Piracicaba Dental School, University of Campinas

2Department of Pediatric dentistry, Piracicaba Dental School, University of Campinas

*Correspondence to:

Prof. Maria Beatriz Duarte Gavião

Faculdade de Odontologia de Piracicaba, Universidade Estadual de Campinas

Address: Av. Limeira 901, Bairro Areião, CEP 13414-903, Piracicaba, SP, Brasil

E-mail: [email protected]

Artigo submetido ao periódico Dentomaxillofacial Radiology

18

Abstract

The purpose of this study was to describe anatomic structures of the

temporomandibular joint (TMJ) by high-resolution ultrasonography. The study was

characterized as observational-descriptive, cross-sectional and comparative. Participants were

32 volunteers (17 females and 15 males) in the age of 19 to 39 years. Diagnostic criteria for

temporomandibular dysfunction (DC/TMD) were applied, and the volunteers were divided in

two group, TMD group of 20 volunteers and asymptomatic group of 12 volunteers. Therefore,

64 temporomandibular joints were evaluated by high-resolution ultrasonography on the right

and left side in the closed-mouth (CM) and open-mouth (OM) positions, by a single trained

and calibrated examiner (Kappa = 0.7). The evaluated structures were the mandibular

condyle, the articular disc, the supra and infradiscal spaces and the articular capsule. In

addition, the distances between the most lateral point of the articular capsule and the most

lateral point of the mandibular condyle (lateral capsule-condyle distance) at the CM and OM

positions were measured. The respective measurements were compared between the groups,

applying paired and unpaired Student t tests (α = 0.05). Ultrasound imaging made it possible

to visualize the articular surface of the mandibular condyle as a hyperechoic image; the

articular disc as a central hyperechogenic image surrounded by a hypoechoic linear image; the

upper border of the articular capsule as a linear hyperechoic image. The averages of lateral

capsule-mandibular condyle distance on the right side in the TMD group were 0.69±0.19 mm

in CM and 0.61±0.15 mm in OM and in the asymptomatic group 0.71±0.16 mm and

0.63±0.16 mm, respectively. On the left side, the CM measurements for the TMD group were

0.68±0.15 mm and in the asymptomatic group 0.70±0.14 and in the OM 0.64±0.15 mm for

the TMD group and in the asymptomatic group 0.66±0.15. Given the results found,

Ultrasonography can be considered as a promising and feasible tool for the assessment of

TMJ, and the distance from the most lateral point of the articular capsule to the most lateral

point of the mandibular condyle (lateral capsule-condyle distance), measured on the


Keywords: Ultrasonography, temporomandibular joint, anatomy.

19

INTRODUCTION

One of the most important synovial joints in the human body is the

temporomandibular joint (TMJ), which acts with the muscles and teeth during mandibular

movements. The anatomical elements that form it are the mandibular fossa located in the

petrous portion of the temporal bone and the mandibular condyle. Between those bones there

is the articular disc, a fibrocartilage, which improves their adaptation and is attached to the

medial and lateral pole of the mandibular condyle to accompanying it during the mandibular

movements. The articular disc divides the joint space into two compartments: the supradiscal

and infradiscal space. The TMJ is surrounded by the articular capsule, and the extracapsular

ligaments restrict the mandibular movements avoiding possible damages in the structures

(Alomar et al., 2007). The proper position of the mandibular condyle relative to the

mandibular fossa; the position of the articular disc is considered normal when its posterior

portion is located between 12 and 13 o´clock on the articular surface and its central portion on

the upper anterior face of the articular surface of the mandibular condyle (Mello-Júnior et al.,

2011).

Adverse conditions affecting the masticatory musculature and TMJ can compromise

the relationship between the TMJ structures, and consequently to determine a negative effect

on functions, causing pain, noise and movement limitation. This condition is called

temporomandibular disorder (TMD).

The approach of individual suffering of TMD begins with a complete diagnosis,

follows by a detailed clinical examination. The Diagnostic Criteria for Temporomandibular

Disorders (DC/TMD) is an evaluation method with defined criteria, simple to apply and easy

to punctuate to obtain the diagnosis of dysfunction (Schiffman et al., 2014). Moreover, TMJ

images can be necessary to confirm the suspicion of the disorder (Kundu et al., 2013),

assessing the relationship of anatomical structures, and observing the progress of an alteration

(Byahatti et al., 2010).

The most common imaging methods are panoramic radiography, arthroscopy,

computed tomography scan, ultrasonography, and magnetic resonance imaging (MRI). The

MRI is considered the gold standard for the evaluation of the anatomic structures of the TMJ,

but its availability is relatively low due to high cost and restriction in some cases, such as

pacemaker use or claustrophobic individuals. Recently, ultrasound (US) has been considered a

20

promising and viable tool for the evaluation of the anatomical structures of the TMJ, and their

relationships during mandibular movements (Emshoff et al. (2002), Pereira et al. (2007),

Byahatti et al. (2010) and Assaft et al. (2013). US is a non-invasive technique that can be used

clinically because it is inexpensive and allow evaluating the structures in "real time".

In this context, the purpose of this study was to describe anatomical structures of TMJ

by high-resolution US, such as the mandibular condyle, the articular disc, the supra and

infradiscal space, and the articular capsule in individuals with and without TMD.

Furthermore, the measurement of the distance from the lateral point of the articular capsule to

the lateral point of the mandibular condyle was carried out to verify possible differences

between participants with articular disorders and the asymptomatic ones.

MATERIAL AND METHODS

Sample

The study was approved by the Ethics Committee in Research of Piracicaba Dental

School, University of Campinas (FOP-UNICAMP), with register number 051/2015 (Annex

1). It was cross-sectional observational study.

Young adults aged from 18-40 years, with or without clinical signs and symptoms of

TMD, were invited to participate. From August 2016 to February 2017, 37 individuals were

assessed for eligibility. The final sample was composed of 17 female and 15 male, in the age

range of 19 and 39 years (26.24 ± 4.63 years), who presented at the Ultrasound laboratory of

the FOP-UNICAMP. They were distributed in two groups accordingly the following inclusion

criterial:

TMD group (N=20): presence of clinical signs and symptoms of TMD during the last

six months or more, without treatment.

Asymptomatic group (N=12): absence of signs and symptoms suggestive of TMD.

The exclusion criteria for both groups were unable individuals to sign informed

consent, developmental disorders that directly or indirectly could affect the structures of head

and neck, radiotherapy and chemotherapy of head and neck, surgery of TMJ, use of

medication for pain, such as narcotics.

21

The examiner was trained by experts in the DC/TMD (Annex 2). Previously, the

participants were informed about the objectives and methodology to be used in a clear and

easily understandable way. Their written authorization was required, by sign the consent from

for participation in the survey. After that, the volunteers provide personnel information filling

a specific from (Appendix 1).

Diagnostic Criteria for Temporomandibular Disorders (DC/TMD)

The axis I of the DC/TMD (Gonzales et al. 2014), which corresponds to the clinical

evaluation, was applied. The volunteer remained sit down, with his back resting on the

backrest of a chair, head in natural position and feet on the floor. Moreover, they were asked

about TMD symptoms using a questionnaire. The exams were performed by a single

examiner (D.Z.R.D.).

The DC/TMD evaluate the following parameters: location of the pain and headache;

incisal relationships: horizontal and vertical incisal (mm); opening pattern: straight, corrected

or uncorrected deviation (mm); opening movements: pain free on opening, on maximum

unassisted and assisted opening (mm); lateral and protrusive movements (mm); TMJ noises

during open, closing, and lateral and protrusive movements; muscle (temporalis and masseter

muscle) and TMJ pain on palpation.

The DC/TMD diagnosis was obtained from the diagnostic decision tree, which has

three large branches, the first one is related to the pain diagnosis [Pain-Related TMD and

Headache] and two latter are to obtain the diagnosis of jaw joint disorders [Intra-articular

Joint Disorders e Degenerative Joint Disorders]. After that, the participants were located in

TMD and asymptomatic group.

Ultrasonography

Imaging Acquisition

Sonography was performed with a high-resolution linear array transducer of 38 mm

and 7-18 MHz [SSA-780A – APLIO MX (Toshiba Medical Systems Corporation, Japan)],

belonging of the Department of Pediatric Dentistry of the Piracicaba Dental School,

University of Campinas. The images were obtained by a single examiner (D.Z.R.D.), properly

trained. The 14 MHz was the best resolution achieved. After that, a pilot study was developed

with a sample of 10 healthy volunteers and the DC/TMD was applied twice with an interval

22

of seven days, at least. The intraexaminer agreement was determined using Cohen’s kappa

coefficient, obtained a value of 0.7.

In total, 64 joints of the 32 participants were evaluated accordingly with the following

parameters: visualization of the articular disc during mouth closing and opening, articular

surface of the mandibular condyle, upper edge of joint capsule and mensuration of the

distance capsule-mandibular condyle.

Ultrasound was performed in a room poor lighting, the participants remained sitting

with the back resting on the backrest of the chair, head in natural position and feet on the

floor; the transducer was placed over the TMJ, perpendicular and inferior to the zygomatic

arch and parallel to the mandible ramus for a axil view, as shown in figure 1.

Figure 1 – Transducer positioned against the patient’s face, perpendicular to the Frankfort horizontal plane

and parallel to the mandibular ramus

A static image of the right and left TMJ was obtained with the mandible in rest

position (without dental occlusion and slightly closed lips), and the transducer was tilted out

until an optimal view of the joint was obtained according to the participant´s face for axial

plan.

The disc was assessed during the static and dynamic examinations. Moreover, the

distance from the upper border of the joint capsule to the upper contour of the mandibular

condyle was measured in millimeters with the tools of the ultrasound equipment, in closed-

and open-mouth (Appendix 2).

23

The participants diagnosed with TMD were referred to specialized center for

treatment.

Statistical analysis

Descriptive statistics were applied consisting of means and standard deviations. The

values of the distance capsule-mandibular condyle were submitted to paired Student t test for

inter-groups comparisons and for intra-group comparisons referent to the right and left sides.

Bioestat 5.4 software package was used, adopting the significant level of 0.05.

RESULTS

Thirty-two young adults, mean age of 26.24 years ± 4.63 were examined clinically

using DC/TMD and ultrasonography. The volunteers included in this study was distributed in

two groups: TMD group n= 20 and Asymptomatic group n=12, as demonstrated in flow chart

(Figure 2).

Assessed for eligibility (n=37)

Convenience sample

Evaluated (n=32)

Consent form

Evaluation sheet

Ultrasonography

Excluded (n=5)

Did not attend the scheduled date

DTM Group

♀ (n=12)

♂ (n=8)

Asymptomatic Group

♀ (n=5)

♂ (n=7)

n=12 n=20

Fin

al g

rou

p

All

oca

tio

n

En

roll

men

t

Figure 2 – Flow chart

24

The sample distribution related to TMD according to DC/TMD is showed in Table 1.

Table 1 – Sample distribution according to sex and DC/TMD

Characteristic Female (%) Male (%)

Group

TMD group 12(37.5%) 8 (25%)

Asymptomatic group 5 (15.63%) 7 (21.87%)

TMD group

Only pain related TMD 3 (25%) 0

Myalgia 2 (16.66%) 0

Local myalgia 1 (8.34%) 0

Only intra-articular joint disorders 2 (16.66%) 7 (87.5%)

Disc displacement with reduction 1 (8.33%) 6 (75%)

Disc displacement without reduction, with limited opening 1 (8.33%) 0

Degenerative joint disease 0 1 (12.5%)

Pain related TMD + intra-articular joint disorders 7(58.33%) 1(12.5%)

Myalgia + Arthralgia+ DJD 0 1 (12.5%)

Headache attributed to TMD + DDR 4 (33.33%) 0

Myalgia + Arthralgia + DDR 2 (16.66%) 0

Myalgia + Arthralgia+ Headache attributed to TMD + DDR 1 (8.34%) 0

Total 12(100%) 8 (100%)

DJD: degenerative joint disease; DDR: disc displacement with reduction.

Along the US images of TMJ, the superior convexity of the mandibular condyle and

the articular disc were visualized as a hyperechoic. Moreover, the articular disc presented a

superior and inferior hypoechoic halo, corresponding to the supradiscal and infardiscal space,

respectively. The upper border of the joint capsule consisted of a linear hyperechoic image as

shown in Figure 3 and 4; there details were observed for all participants.

25

Figure 3 – Ultrasonographic scan of the left temporomandibular joint in closed-mouth

position in axial slice of a volunteer of the TMD group

The white triangles follow the upper contour of the mandibular condyle. The smaller arrow marks the articular disc. The

greater arrow points to the upper border of the articular capsule (typical anatomical structures).

Figure 4 – Ultrasonographic scan of the right temporomandibular joint in open-mouth

position in axial slice of a volunteer of the TMD group

The white triangles point the upper contour of the mandibular condyle. The arrow points the articular disc.

26

In Figure 5 and 6, the landmarks for measurement of the distance from articular capsule

to the upper point of the mandibular condyle were demonstrated.

Figure 5 – Measurement of the distance between the most lateral point of the articular capsule

and the most lateral point of the mandibular condyle (lateral capsule-condyle

distance) in ultrasonographic scan of the right temporomandibular joint in closed-

mouth of a volunteer of the TMD group

Figure 6 – Measurement of the distance between the most lateral point of the articular capsule

and the most lateral point of the mandibular condyle (lateral capsule-condyle

distance) in ultrasonographic scan of the right temporomandibular joint in open-

mouth of a volunteer of the TMD group

27

The measurements were performed in millimeters and the values are seen in Table 2

and Table 3, according to articular/pain and muscular disorders found in TMD Group and

mean values for Asymptomatic group. There was no difference between right and left side in

both groups (P>0.05). Moreover, the values did not differ between groups, as well as between

participants with intra-articular disorders with pain and those without pain.

Table 2 – Measurement of the distance between the most lateral point of the articular capsule and

the most lateral point of the mandibular condyle (lateral capsule-condyle distance) in

the Temporomandibular disorders group and asymptomatic group (mm)

Right US - CM Right US - OM Left US - CM Left US - OM

TMD group 0.69 ± 0.19 0.61 ±0 .15 0.68 ± 0.15 0.64 ± 0.15

Asymptomatic Group 0.71 ± 0.16 0.63 ± 0.16 0.7 ± 0.14 0.66 ± 0.15

*p>0,05 0.77 0.52 0.06 0.23

Right US - CM = Right ultrasound in a closed-mouth position / Right US - OM = Right ultrasound in open-mouth position / Left US -

CM = Left ultrasound in closed-mouth position / Left US - OM = Left ultrasound in open-mouth position

28

28

Table 3 – Measurement of the distance between the most lateral point of the articular capsule and the most lateral point of the

mandibular condyle (lateral capsule-condyle distance) in the volunteers with intra-articular disorders and

asymptomatic group (mm)

Interarticular Diagnosis Pain Diagnosis Sex Right US - CM Right US - OM Left US - CM Left US - OM

Degenerative joint disease right

Participant 1 None M 0.60 0.37 0.70 0.57

Degenerative joint disease right and left

Participant 2 Myalgia, artralgia right/ left M 0.57 0.57 0.50 0.47

Disc displacement without reduction, without limited opening

Participant 3 None F 0.95 0.77 0.90 0.93

Disc displacement with reduction left



Participant 6 Headache attributed to TMD F 1.23 0.87 0.83 0.97

Participant 7 Myalgia, arthralgia right/left F 0.60 0.47 0.53 0.43

Participant 8 Myalgia, arthralgia left F 0.60 0.60 0.63 0.63

Mean (SD) 0.85 (0.27) 0.63 (0.15) 0.67 (0.11) 0.65 (0.20)

Disc displacement with reduction right





Mean (SD) 0.64 (0.14) 0.58 (0.19) 0.60 (0.18) 0.59 (0.11)

SD - Standard Deviation

28

29

29

Table 3 continued

Intra-articular Diagnosis Pain Diagnosis Sex Right US - CM Right US - OM Left US - CM Left US - OM

Disc displacement with reduction right and left



Participant 15 None F 0.70 0.70 0.80 0.60


Participant 17 Myalgia, arthralgia right/left,

headache attributed to TMD F 0.63 0.53 0.47 0.57

Mean (SD) 0.64 (0.04) 0.67 (0.13) 0.72 (0.16) 0.68 (0.16)

Without articular disorders

Participant 18 Muscular pain on palpation 0.60 0.57 0.63 0.67



Mean (SD) 0.63 (0.22) 0.57 (0.17) 0.73 (0.20) 0.67 (0.13)

Intra-articular disorders and pain

(N=8) - 0.71 (0.22) 0.68 (0.16) 0.66 (0.16) 0.65 (0.19)

Intra-articular disorders no pain

(N=9)

- 0.70 (0.17) 0.56 (0.12) 0.67 (0.15) 0.64 (0.14)

TMD Group - 0.69 ± 0.19 0.61 ±0 .15 0.68 ± 0.15 0.64 ± 0.15

Asymptomatic Group - 0.71 (0.16) 0.63 (0.16) 0.70 (0.14) 0.66 (0.15)

SD - Standard Deviation

29

30

DISCUSSION

Temporomandibular disorders represent 5-12% of a chronic pain condition and are

becoming more frequent in young adults (NIDCR, 2017). In this study, 32 young adults were

evaluated, being 12 females (37.5%) and 8 males (25%) presenting signs and symptoms of

TMD as shown in Table 1. Those frequencies and sample size are similar to Mello-Júnior et

al. (2011), who evaluated by high-resolution US, 9 males and 29 females presenting intra-

capsular TMD; and Müller et al. (2009) who evaluated 16 females and 14 males with TMJ

arthritis using ultrasound (US) and MRI. All these study showed higher frequency in females

than in males.

The anatomic structures of the temporomandibular joint are visualized on

ultrasonography at different echogenicity scales. In the present study, along the closed and

open-mouth position, the articular disc was visualized as hyperechoic image with a superior

and inferior hypoechoic halo as shown in Figure 3. Similar image has been described by

Manfredini et al (2003) and Emshoff et al. (1997). Conversely, Byahatti et al. (2010) and Jank

et al. (2001) observed the articular disc as a hypo to isoechoic band.

The articular surface of the mandibular condyle showed a hyperechoic image, and the

upper border of the joint capsule was visualized as a hyperechoic image, as seen by Assaft et

al. (2013). These differences may be related to the resolution of the transducer, which has

been varied from 7.5 to 12 MHZ (Emshoff et al., 1997; Manfredini et al., 2003; Jank et al.

2001; Elias et al., 2006; Byahatti et al. 2010; Mello-Júnior et al., 2011; Assaf et al., 2013). In

the present study a transducer of 14 MHz was used that allowed images with anatomical

structures well defined. The sensitivity of US has been considered to be directly proportional

to the resolution of the transducer (Kundu et al., 2013), i.e., increasing in resolution,

increasing the sensitivity of US.

Fifteen participants of TMD Group presented disc displacement with reduction and

one without reduction, accordingly DC/TMD. Nevertheless, there was a great difficulty in

observing the disc position relative to the mandibular condyle along the US images. Thus, the

position of other anatomical structures could give signs of disk position (Landes et al., 2000;

Hayashi et al., 2001; Elias et al., 2006). In this way, the distance from the most lateral point of

the articular capsule and the most lateral point of the mandibular condyle (lateral capsule-

31

condyle distance) was selected in the present study, since this contour represents lateral

surface of mandibular condyle in an axial view. According to Hayashi et al. (2001) and

Mello-Júnior et al. (2011), these landmarks can be considered as indirect ultrasonographic

signs of the disc position, probably enlarged in cases of lateral disc displacement. In the

present study, the respective values in open- and closed-mouth ranged from 0.58 mm to 0.68

mm for participants with disk displacement with reduction, accordingly with DC/TMD,

values lesser than the cut-off stated by Hayashi et al. (2001) to separate joints with and

without anterolateral disc displacement. Besides, Mello-Júnior et al. (2006) found the distance

varying from 1.2 mm to 1.6 mm in TMD individuals without disc displacement. Thus, it is

possible to infer that the US images, in the present study, could not confirm the disk

displacement diagnosed clinically. A large sample with severe TMD is indicated to confirm

the findings.

Furthermore, the measurements of the distance capsule-mandibular condyle did not

differ significantly between the TMD and Asymptomatic Groups in both mouth positions.

These results were not expected, since in TMD Group 15 participants were clinically

diagnosed with disc displacement and two with degenerative joint disease. The enlargement

distance between the articular capsule and mandibular condyle could be an indicative of disc

displacement (Hayashi et al., 2001; Elias et al., 2006), as commented above. Moreover, for

Motoyoshi et al. (1998), irregularities of the soft tissues surrounding the TMJ could also point

out the disc displacement.

It was not observed also differences in images and distance the most lateral point of

the articular capsule and the most lateral point of the mandibular condyle (lateral capsule-

condyle distance) between individuals with intra-articular disorders and pain (N=8) and those

without pain (N=9). Probably, the number of individuals could have a determinant factor in

this result, as well as the pain intensity.

The different findings between this study and others, cited above can be attributed to

technique itself, and despite the methodological details have been precisely taken into

account, US images depend on the direction of the scanning and the mouth/head posture. The

position of the transducer may vary from horizontal (parallel to the zygomatic arc) to vertical

(parallel to the ramus of the mandible), thus giving a different image of the TMJ in a

transverse or a coronal / sagittal plane. In fact, the planes of the images are not truly

transverse, coronal or sagittal, but they are almost inclined, because the transducer is tilted

32

during the examination, in order to achieve a better visualization of the different components

of the TMJ (Kundu et al., 2013).

One limitation of the US is the correct visualization of the articular disc, as observed

during the rotation and translation of mandibular condyle in dynamic images as shown in

Figure 4, i.e., from the mouth-closed position to the mouth-open position; however, the

central portion of the disk was observed in all participants adjusting the position of the

transducer constantly. According to Kundu et al. (2013), only the lateral part of the TMJ can

be reached in the sonograms, while the medial part remains hidden by the structures,

consequently the medial displacements of the disc can remain overlooked.

CONCLUSION

Ultrasonography allowed visualization of the anatomical structures of the TMJ as

follows: the articular surface of the mandibular condyle was visualized as an hyperchoic

image; the articular disc as an hyperechoic image with a superior and inferior hypoechoic halo

(dividing the joint space into two compartments, superior and inferior, the supra and

infradiscal space, respectively); the upper border of the joint capsule was visualized as an

hyperchoic image.

The distance from the most lateral point of the articular capsule to the most lateral

point of the mandibular condyle (lateral capsule-condyle distance), measured on the


33

REFERENCES

Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, et al. Anatomy of The

Temporomandibular Joint. Semin ultrasound CT MR.2007;28(3):170-83.

Mello-Júnior CF, Saito Osmar C, Guimarães Filho HA. Avaliação ultrassonográfica dos

distúrbios intracapsulares temporomandibulares. Radiol Bras [internet]. 2011; [acesso

2017 Jul 27] 44(6):355-359. Disponível em:

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-

39842011000600005&lng=pt.

Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic for

Temporomandibular disorders (DC/TMD) for Clinical and Reserarch Applications:

Recommendations of the Internacional RDC/TMD Consortium Network and Oralfacial

Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28(1); 6-27.

Kundu H, Basavaraj P, Kote S, Singla A, Singh S. Assessment of TMJ Disorders Using

Ultrasonography as a Diagnostic Tool: A Review. J Clin Diagn Res. 2013

Dec;7(12):3116-20. doi: 10.7860/JCDR/2013/6678.3874.

Byahatti SM, Ramamurthy BR, Mubeen M, Agnihothri PG. Assessment of diagnostic

accuracy of high-resolution ultrasonography in determination of temporomandibular

joint internal derangement. Indian J Dent Res. 2010 Apr-Jun;21(2):189-94. doi:

10.4103/0970-9290.66634.

Emshoff R, Jank S, Bertram S, Rudisch A, Bodner G. Disk displacement of the

temporomandibular joint: sonography versus MR imaging. AJR Am J Roentgenol.

2002 Jun;178(6):1557-62.

Pereira LJ, Gavião MB, Bonjardim LR, Castelo PM. Ultrasound and tomographic evaluation

of temporomandibular joints in adolescents with and without signs and symptoms of

temporomandibular disorders: a pilot study. Dentomaxillofac Radiol. 2007

Oct;36(7):402-8.

Assaf AT, Kahl-Nieke B, Feddersen J, Habermann CR. Is high-resolution ultrasonography

suitable for the detection of temporomandibular joint involvement in children with

juvenile idiopathic arthritis? Dentomaxillofac Radiol. 2013;42(3):20110379. doi:

10.1259/dmfr.20110379.

Gonzalez Y, Chwirut J, List T, Ohrbach R. Diagnostic Criteria for Temporomandibular

Disorders Clinical Protocol and Assessment Instruments. MedEdPORTAL

Publications [internet]. 2014 Nov [acesso 2017 Jul 27];10:9946. Disponível em

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Disponível em:

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D.htm.

Müller L, Kellenberger CJ, Cannizzaro E, Ettlin D, Schraner T, Bolt IB, et al. Early diagnosis

of temporomandibular joint involvement in juvenile idiopathic arthritis: a pilot study

comparing clinical examination and ultrasound to magnetic resonance imaging.

Rheumatology (Oxford). 2009 Jun;48(6):680-5. doi: 10.1093/rheumatology/kep068.

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 Nov;32(6):359-64.

Emshoff R, Bertram S, Rudisch A, Gassner R. The diagnostic value of ultrasonography to

determine the temporomandibular joint disk position. Oral Surg Oral Med Oral Pathol

Oral Radiol Endod. 1997 Dec;84(6):688-96.

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 Dec;29(6):366-71.

Elias FM, Birman EG, Matsuda CK, Oliveira Ilka RS, Jorge WA. Ultrasonographic findings

in normal temporomandibular joints. Braz Oral Res. 2006;20(1): 25-32.

Landes C, Walendzik H, Klein C. Sonography of the temporomandibular joint from 60

examinations and comparison with MRI and axiography. J Craniomaxillofac Surg

2000;28(6):352-61.

Motoyoshi M, Kamijo K, Numata K, Namura S. Ultrasonic imaging of the

temporomandibular joint: a clinical trial for diagnosis of internal derangement. J Oral

Sci. 1998;40(2):89-94.

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https://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/FacialPain/PrevalenceTMJD.htm

35

3 CONCLUSÃO

A ultrassonografia possibilitou a visualização das estruturas anatômicas da articulação

temporomandibular como o polo lateral da cabeça da mandíbula em uma imagem linear

hiperecóica, o disco articular como uma imagem linear hiperecóica e como este divide o

espaço articular em dois compartimentos menores, um superior e outro inferior (espaço supra

e infradiscal, respectivamente) visualizados em uma imagem linear hipoecóica, e a borda

superior da cápsula articular como uma imagem linear hiperecóica.

A mensuração da distância entre o ponto mais lateral da cápsula articular e o ponto

mais lateral da cabeça da mandíbula (distância lateral da cápsula-cabeça da mandíbula) nas

posições de boca fechada e boca aberta não diferiu significativamente entre os participantes

com DTM e os participantes assintomáticos.

REFERÊNCIAS

Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, et al. Anatomy of The

Temporomandibular Joint. Semin ultrasound CT MR.2007;28(3):170-83.

Mello-Júnior CF, Saito Osmar C, Guimarães Filho HA. Avaliação ultrassonográfica dos

distúrbios intracapsulares temporomandibulares. Radiol Bras [internet]. 2011; [acesso

2017 Jul 27] 44(6):355-359. Disponível em:

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-

39842011000600005&lng=pt.

Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic for

Temporomandibular disorders (DC/TMD) for Clinical and Reserarch Applications:

Recommendations of the Internacional RDC/TMD Consortium Network and Oralfacial

Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28(1); 6-27.

Emshoff R, Jank S, Bertram S, Rudisch A, Bodner G. Disk displacement of the

temporomandibular joint: sonography versus MR imaging. AJR Am J Roentgenol.

2002 Jun;178(6):1557-62.

Melchiorre D, Falcini F, Kaloudi O, Bandinelli F, Nacci F, Matucci CM. Sonographic

evaluation of the temporomandibular joints in juvenile idiopathic arthritis. Journal of

Ultrasound. 2010; 13(1): 34–37. doi: 10.1016/j.jus.2009.09.008.

Kundu H, Basavaraj P, Kote S, Singla A, Singh S. Assessment of TMJ Disorders Using

Ultrasonography as a Diagnostic Tool: A Review. J Clin Diagn Res. 2013

Dec;7(12):3116-20. doi: 10.7860/JCDR/2013/6678.3874.

Byahatti SM, Ramamurthy BR, Mubeen M, Agnihothri PG. Assessment of diagnostic

accuracy of high-resolution ultrasonography in determination of temporomandibular

joint internal derangement. Indian J Dent Res. 2010 Apr-Jun;21(2):189-94. doi:

10.4103/0970-9290.66634.

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. AJNR Am J Neuroradiol.

2001;22(4):728-734.

Pereira LJ, Gavião MB, Bonjardim LR, Castelo PM. Ultrasound and tomographic evaluation

of temporomandibular joints in adolescents with and without signs and symptoms of

temporomandibular disorders: a pilot study. Dentomaxillofac Radiol. 2007

Oct;36(7):402-8.

Assaf AT, Kahl-Nieke B, Feddersen J, Habermann CR. Is high-resolution ultrasonography

suitable for the detection of temporomandibular joint involvement in children with

juvenile idiopathic arthritis? Dentomaxillofac Radiol. 2013;42(3):20110379. doi:

10.1259/dmfr.20110379.

van Holsbeeck M, Introcaso JH. Ultras-sonografia Musculoesquelética. Rio de Janeiro:

Editora Guanabara Koogansa; 2001.

APÊNDICE 1/APPENDIX 1

UNIVERSIDADE ESTUADUAL DE CAMPINAS

FACULDADE DE ODONTOLOGIA DE PIRACICABA

DEPARTAMENTO DE MORFOLOGIA

ÁREA DE ANATOMIA

FICHA DE AVALIAÇÃO

Data da avaliação: _____/ ______/ ________.

Nome Completo: _________________________________________________. Sexo:

Telefone: fixo _____________________________________/

celular____________________________.

Endereço: _________________________________________ N°:______

Bairro:____________________

Cidade___________________________________ Estado:__________________________________.

Horários d isponíveis:__________________________________________________________.

Profissão: ________________________________________.

1. Anamnese:______________________________________________________________________

2. Histórico

Familiar:_________________________________________________________________

3. Critérios de Inclusão:

Idade:______ anos. Peso: ______Kg. Altura: ________ cm. IMC: ____________

1.1. História de cinco meses ou más de sintomas como:

Indicação: marque com uma X sobreo a resposta que represente o seu sentir.

Ruídos próximos dos ouvidos .................................................... Sim Não

Restrição na capacidade de abrir e fechar a boca .................... Sim Não

Dor na área da articulação ........................................................ Sim Não

Dor no mús. da mastigação ....................................................... Sim Não

1.2. Você já recebeu tratamento prévio ou atual para seus sintomas: Sim Não

1.3. Ciclo menstrual: Regular Anticoncepcional

1.4. Data do último ciclo menstrual [1° dia] ______/______/_______.

2. Critérios de Exclusão:

Indicação: marque com uma X sobreo a resposta que represente o seu sentir.

Tratamento ortodôntico atual: Sim Não (se sim, a quantos anos_________________________)

Comprometimento sistêmico como febre reumática, endócrina ou autoimune: Sim Não .

Tratamento atual ou passado de radioterapia de cabeça e pescoço: Sim Não

Cirurgia da ATM: Sim Não

Trauma na mandíbula por acidentes: Sim Não

Dificuldade para se comunicar devido à barreira da língua e / ou incompetência mental: Sim Não

Gestante: Sim Não

O uso de medicação para a dor [narcóticos, relaxantes musculares, esteroides, antidepressivos e/ou

abuso de drogas: Sim Não

Pessoas comprometidas com transtornos de desenvolvimento que afetam direta ou indiretamente a

cavidade oral [qualquer tipo de síndrome diagnosticado clinica ou geneticamente]: Sim Não

F M

APÊNDICE 2/APPENDIX 2

FICHA DE AVALIAÇÃO DOS DADOS ULTRASSONOGRAFICOS

Data da avaliação: ______/_______/______.

Nome completo:________________________________________________________________

Nome do avaliador: _____________________________________________________________

Mensuração em milímetros do espaço do disco articular da ATM Direita

[A distância entre o polo lateral do côndilo e da parte lateral da cápsula articular].

Posição do

Paciente

Postura

mandibular Ultrassom

Media

Sentado

Boca

fechada [lábios levemente

encostados sem

contato oclusal]

Boca aberta [sem forçar, nem

dor].

Mensuração em milímetros do espaço do disco articular da ATM Esquerda

Posição do

Paciente

Postura

mandibular Ultrassom

Media

Sentado

Boca

fechada [lábios levemente

encostados sem

contato oclusal]

Boca aberta [sem forçar, nem

dor].

ANEXO 1/ANNEX 1

ANEXO 2 /ANNEX

UNIVERSIDADE ESTADUAL DE CAMPINAS DORA ZULEMA … · Biologia Buco-Dental, na área de Anatomia....

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