SUMMARY
Objectives: to assess the sensitivity and specificity of ARCUSdigma in diagnosing temporomandibular
joint (TMJ) pathology (TMD).
Methods. 102 TMJs were exmined with ARCUSdigma and “Cadiax Diagnostic” electronic
axiography system. Free opening, free protrusion and mediotrusion were recorded with
both devices. Guided opening and guided protrusion were examined with “Cadiax Diagnostic”.
Using free opening and free protrusion diagnosis was established.
Results. Sensitivity of ARCUSdigma was found to be 84,21% and 92,86% for the right and
left TMJ respectively. Specificity – 93,75% and 95,65% for the right and left TMJ. The 95%
confidence interval for sensitivity and specificity was calculated.
Conclusions. Within the limitations of this study, ARCUSdigma appeared to be a valuable
supplement to clinical findings in diagnosing TMDs.
Key words: temporomandibular joint disorders; axiography; sensitivity; specificity.
*Institute of Dentistry, Faculty of Medicine, Vilnius University,
Lithuania
Giedre Kobs* – DDS, PhD
Asta Didziulyte* – clinical intern
Robertas Kirlys* – clinical intern
Mindaugas Stacevicius* – student
Address correspondence to Robertas Kirlys, Institute of Dentistry,
Zalgirio 115, Vilnius, Lithuania.
E-mail: rkirlys@gmail.com
INTRODUCTION
Internal derangement of the temporomandibular
joint (TMJ) has been defined as an abnormal positional
relationship of the disc relative to the mandibular
condyle, fossa and/or articular eminence, and is a
major cause of jaw pain, clicking and/or crepitation
as well as limitation of opening [1]. Systematic examination
of TMJ pathology is of utmost importance
[2] and the primary goal is to determine the status of
the stomatognathic system in the most non-invasive
way possible, then to document the situation and plan
a therapy, appropriate to the findings.
The increasingly progressive development of
medical diagnostic processes has opened new possibilities
in the compilation of findings for mandibular
disorders.
Magnetic-resonance-tomography (MRT) provides
a non-invasive procedure for imaging both the
osseous- and soft-tissue structures with a high degree
of resolution [3, 4]. Although MRT cannot be
considered a routine procedure, due to cost considerations,
it is still currently regarded as the best possible
diagnostic standard [5, 6, 7, 8].
Diverse instrumental registration techniques of
TMJ, based on electro-mechanic, opto-electronic, ultrasound
and magnetic principles also exist. According
to Meyer [9, 10], there are remote, near-TMJ
and TMJ-oriented methods to evaluate lower jaw
movements.
Computerized axiography is a noninvasive diagnostic
method, wich enables to record jaw movements
in three dimensions. After localizing the geometric
hinge axis, it is possible to record movements free
from distortion, wich are combined of rotation and
translation. However, despite refinements and expanded
possibilities for registration, the actual significance
of instrumental functional analysis in mandibular
joint diagnostics is still not conclusively clear. The
possibilities for error involved in extraoral registration
of functional movements have been discussed
elsewhere [10].
Electronic axiograph “Cadiax Diagnostic”, which
was considered as a reference method in this study,
utilizes exactly determined hinge axis - orbital reference
plane [11]. ARCUSdigma is a near-TMJ working
ultrasonic diagnostic device, that was put on the
market 3 years ago. ARCUSdigma is technically sim
4 8 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
pler and cheaper than electronic
axiograph, however
there are no studies to support
its use in clinical work
as a diagnostic tool.
The American Academy
of Orofacial Pain (AAOP)
even discourages using instrumental
functional analysis
for the purpose of diagnosing
orofacial pain because
of lack of scientific evidence
[12].
On the other hand, the
German Society for Dentistry
and Orofacial Medicine attributes
at least as much
weight to instrumental functional
analysis as to clinical
findings [13, 14].
Having in mind the variance
of opinion in the scientific
literature, the objective
of this study was to assess
the ability of ARCUSdigma
to describe the kinematics of
diseased TMJs and determine
which movement patterns
is associated with a
clinically (or by other methods)
diagnosed joint pathology
[15].
MATERIAL AND
METHODS
From a group of patients
attending consultations at
Vilnius University Hospital
“Zalgirio clinics” 56 subjects
(8 males and 48 females)
were selected for this investigation.
The age of subjects
ranged from 15 to 76 years
old, with a mean age of 31,98.
This comprised 102 temporomandibular
joints.
All subjects underwent
computerized axiography using
“Cadiax Diagnostic” device
and also temporomandibular
joint examination using
ultrasonic device
ARCUSdigma (KaVo®) after
proper history taking and
assessment of clinical symptoms.
The data obtained using
“Cadiax Diagnostic” and
Fig. 1. Computerized axiography adjusted to head of patient
Fig. 3. A – left: Overlap of colour-coded axiograms of healthy joints; B – right: Opening/
closing cycle on the right joint shows anterior disk displacement with early reposition
(typical "figure eight") in the beginning of the movement
A
B
SCIENTIFIC ARTICLES
ARCUSdigma were independently
assessed by four
diagnosticians. “Cadiax Diagnostic”
was considered a
standard in this study.
Interclass correlation
coeficient (ICC) was calculated
to validate the use of
“Cadiax Diagnostic” as a
standard. Sensitivity and
specificity of ARCUSdigma
in diagnosing temporomandibular
joint pathology was
evaluated by k (kappa)
koefficient. Better visualisation
of results was done by
graphics.
Electronic axiography
diagnosis
The registration of TMJ
tracings was made with the
double face-bow “Cadiax
Diagnostic” system (Gamma,
Wien). Three-dimensionally
adjustable lower bow is used
to transmit hinge-axis movement
of the mandible to the
upper face bow (Fig 1).
In all cases the axiographic
findings were recorded
and assessed for both
joints. One of the folowing
diagnoses was made separately
for left and right temporomandibular
joints:
• no appreciable disease
• disk displacement
with early reposition
• disk displacement
with late reposition
• disk displacement
without reposition
• non classifiable
pathological change
Determination of the
jaw-tracking curvature degree
[11, 16]
For the evaluation of
pathological changes in the
following interpretation, the
curvature, especially from
opening/closing cycle and
free protrusion cycle (X-and
Z-axis), was a crucial factor.
Convex curves were defined
as definitely pathologic and
their characteristics were not
further analysed.
Fig. 2. Diagrammed determination of the of curvature coefficient on example of opening/closing
cycle. Legend: d – Distance between the beginning and the finish point of movement recording
(continuous red line); a – maximal deviation of the excursion or incursion curve from constructed
straight line between the beginning and the finish point (see double red arrow)
Fig. 4. A – left: Mediotrusive movement on the right joint shows typical "figure eight" creation
of the late disk reposition at the end of the movement. Red arrow shows the repositioning time;
B – right: Opening/closing cycle on the right joint is characterised as anteriorly convex, on the
left joint as straight line cycle. In both TMJ there is strong suspicion of DDWR
A
B
5 0 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
In the case of a concave
curve it was necessary, to define
it clearly from straight
jaw-tracking in consideration
to the curvature degree. Figure
2 shows determination of
coefficient for the quantification
of the flexion performance
on opening/closing
cycle recording.
For evaluation of maximal
deviation the constructed
straight line (red line between
beginning and finish point of
the movement recording)
was displaced parallel downward
(increasing Z-value),
until it was tangent to the farthest
point of movement recording
(minor Z-value).
From the distance between
both straight lines (a) as well
as from the length between
beginning and finish point of
movement recording (d) we
get the curvature coefficient
K as follows:
In the present examination
we defined a limiting
value of K = 0,05 (that is
equivalent to a proportion of
).
In the case that the
curvature coefficient lies
around the limiting value
(0,04 £ K £ 0,06), no evidence
could be made due to
the curvature in terms of
pathological change. The
outcomes of this are the following
intervals:
K < 0,04
– straight line
0,04 £ K £ 0,06
– limit interval
K > 0,06
– curved track
Decision making in diagnosis
Due to the interpretation
of the jaw-tracking devices
the following suspecting diagnoses
were made:
a) “No appreciable
disease” described following
criteria (Figure 3: a) left):
K = a
d
= 1
20
a
d
Fig. 5. a) left: disk displacement without reduction (right joint): Opening/closing cycle underflows
mediotrusive und protrusive line (red circle); b) right: Both TMJs were signed with non-classifiable
pathological change
Fig. 6. Ultrasonic device ARCUSdigma adjusted to head of patient
A
B
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2 5 1
G. Kobs al. SCIENTIFIC ARTICLES
b) “Disk displacement with early reposition”
defined following criteria (Figure 3: b) right):
• typical „figure eight“ creation from excursive
and incursive cycles at the beginning area of coordinate
system;
• partial deviation of excursive from the
incursive line in the first 2 mm area of X- and Z-axis;
• negative value in the X-Axis at the and of
intrusion movement.
c) “Disk displacement with late reposition”
defined typical „figure eight“ creation in the terminal
phase of excursive und der incursive cycles (Figure
4: a) left).
• harmonically, reproducible, congruent cycles
with anterior concavity;
• mediotrusive line is slightly longer than protrusive
line and in the first 6-8 mm forms no Fischer
angle;
• free and managed Bennett movements are
ever positive and continuous;
• an average protrusive tracking length is about
8-10 mm, opening movement 10-12 mm and
mediotrusive movement 12-14 mm;
• In the first 8 mm protrusive-, opening-, and
mediotrusive cycles are normally coincident. Afterwards
the opening line runs usually above.
Fig. 7. "No appreciable disease" Fig. 8. "Disk displacement with early reposition"
Fig. 9. "Disk displacement without reposition" Fig. 10. "Non-classifiable pathological change"
5 2 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
d) In the evaluation of diagnosis
„disk displacement without reposition“
the focal point was the interpretation
of the opening/closing cycles (Figure
4: b) right). In case of convex or straight
line cycles (curvature coefficient K <
0,04) disk displacement without reposition
(DDWR) was suspected diagnosis.
In case of a concave cycle with a
curvature coefficient K on a limit interval
(0,04 £ K £ 0,06), it was necessary
to check coincidence of the opening/closing
movement with those of the
mediotrusive and protrusive tracks. In
case of the opening/closing cycle
underflowing the mediotrusive und protrusive
movements, it was typical characteristic
of disk displacement without
reduction (Figure 5: a) left).
The concave cycle (K > 0,06) was
characterized as physiological.
e) Cycles, where due to the interpretation
criteria no clear diagnosis could
be made, get the identification „nonclassifiable
pathological change“
(Figure 5: b) right). At this point it has to
be noted, that the most “struck disks“ hide
under that coding. The typical characteristics
of the cycles are limited, slightly
concave, congruent curves.
Diagnosis using ultrasonic device
ARCUSdigma
The registration of TMJ tracings was
also made with the ARCUSdigma ultrasonic
device (KaVo, Germany). Ultrasonic
sender and receiver parts are used.
First the position of the upper jaw is recorded.
To register the lower jaw movements,
the sender is fixed on the vestibular
surfaces of lower anteriors with a
paraocclusal aid (Fig. 6).
In all cases both joints were examined
with ARCUSdigma. One of the
folowing diagnoses was made separately
for left and right temporomandibular joints:
• no appreciable disease
• disk displacement with early reposition
• disk displacement with late reposition
• disk displacement without reposition
• not classifiable pathological
change
Determination of the jaw-tracking
curvature degree
Since ARCUSdigma also provides
graphical representation of the condylar
movements in the form of curves, it was
Fig. 11. Distribution of diagnoses for right TMJ based on "Cadiax Diagnostic"
data
Fig. 12. Distribution of diagnoses for left TMJ based on "Cadiax Diagnostic"
data
Fig. 13. Distribution of diagnoses for right TMJ based on ARCUSdigma data
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2 5 3
G. Kobs al. SCIENTIFIC ARTICLES
and left temporomandibular joints respectively.
As it is seen from the graphs, dominant
diagnosis using data from “Cadiax
Diagnostic” was disk displacement with
early reposition. Pathology occuring in
right temporomandibular joint was more
comonly observed than in the left temporomandibular
joint.
The distribution of diagnoses made
with ARCUSdigma is shown in Figs. 13
and 14 for the right and left temporomandibular
joints respectively.
For the right TMJ ARCUSdigma
showed much less number of joints that
could be asssigned to “no appreciable
disease” group, only 32,14% compared
to 42,86% “no appreciable disease” joints
using “Cadiax Diagnostic” data. The
number of TMJs diagnosed with “disk
displacement with early reposition” was
comparable showing values of 41,07%
and 44,64% for “Cadiax Diagnostic” and
ARCUSdigma respectively. ARCUSdigma
was unable to detect joints having
disk displacement with late reposition.
The number of joints under “disk displacement
with no reposition” diagnosis was
higher with ARCUSdigma (14,29%) than
with “Cadiax Diagnostic” (12,5%). Diagnosis
of “non-classifiable pathological
condition” was also more often made
with ARCUSdigma (8,93%) than with
“Cadiax Diagnostic” (1,79%).
For the left TMJ the number of joints
with no appreciable pathology was equal
with both devices reaching 55,36%. Disk
displacement with early reposition was
more commonly diagnosed with
ARCUSdigma (26,79%) than with
“Cadiax Diagnostic” (23,21%). There was no “disk
displacement with late reposition” group using
ARCUSdigma on the left side. The absence of this
group was observed on the right side too. Using ultrasonic
device some disk displacements without reposition
were left undetected, the numbers reaching
16,07% and 10,71% with “Cadiax Diagnostic” and
ARCUSdigma respectively. However a diagnosis of
non-classifiable pathologic change could be reached
more often using ARCUSdigma (7,14%) than “Cadiax
Diagnostic” (1,79%).
Sensitivity and specificity values (including 95%
confidence intervals) of ARCUSdigma were calculated,
equivalence of two diagnostic devices was
evaluated by k (kappa) coeficient. The results are
shown in Fig.15.
High sensitivity and specificity values shown in
the graph above were for differentiating between “no
appreciable disease” and any pathologic condition in
possible to use the same curvature coefficient K and
similar criteria of decision making in diagnosis as described
above for “Cadiax Diagnostic”.
Decision making in diagnosis
Bellow typical examples of ARCUSdigma tracings
are shown for each diagnostic group:
“No appreciable disease” (Fig. 7),
“Disk displacement with early reposition”
(Fig. 8.),
“Disk displacement with late reposition”
There was not a single case with this diagnosis
working with ARCUSdigma.
“Disk displacement without reposition“(Fig. 9),
“Non-classifiable pathological change“(Fig. 10)
RESULTS
The distribution of diagnoses made with “Cadiax
Diagnostic” is shown in Figs. 11 and 12 for the right
Fig. 14. Distribution of diagnoses for left TMJ based on ARCUSdigma data
Fig. 15. Sensitivity, specificity values and kappa coeficient for ARCUSdigma
5 4 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
the joint. High kappa coeficient of 79% and 88% for
the right and left temporomandibular joints respectively
were also calculated when differentiating
“healthy” from diseased. According to the kappa
coeficient equivalence of two diagnostic devices in
differentiating “healthy” from “diseased” TMJs was
deemed excellent.
DISCUSSION
Patients were selected for the study on the basis
of previous or present clinical symptoms, such as pain
in TMJ, clicking and/or crepitation, limited opening.
All subjects underwent computerized axiography using
“Cadiax Diagnostic” device and also temporomandibular
joint examination using ultrasonic device
ARCUSdigma after proper history taking and assessment
of clinical symptoms. A total number of 128
TMJs were examined. 102 pairs of TMJ tracings were
left for final examination. Each pair of tracings was
recorded during the same visit. First examination was
performed with “Cadiax Diagnostic”, second one with
ARCUSdigma. Tracings of 26 TMJs were discarded,
because patients had no clinical symptoms and instrumental
examination was performed only to obtain
data for fully adjustable articulators. Electronic
axiograph “Cadiax Diagnostic” can record more
movements than ARCUSdigma (including speech,
bruxing, MPI and guided movements), so only the
movements that both devices can record were chosen.
Calibration of four examiners was performed
using tracings of 40 TMJs (29 diseased, 11 no appreciable
disease). Common percent of coincidence of
93% (kappa 81%, 82%, 83%, 83%) was found.
Electronic axiograph “Cadiax Diagnostic” is considered
a valuable and reliable tool to aid in making
diagnosis and comparable to MRI according to literature,
so it was chosen as a reference in this study.
In a study by Kobs G. [11] electronic axiograph was
compared to MRI, which has high sensitivity of 67-
100% according to autopsy studies. Sensitivity of
“Cadiax Diagnostic” was 75,8% and 80,7% for left
and right TMJ respectively and specificity 90,7% and
82,8% for left and right TMJ respectively. It is proven
that electronic axiography is better at differential diagnosis
of dynamic dysfunction than MRI [17, 18].
Interclass correlation was calculated to check the
reliability of “Cadiax diagnostic” data. The result approximately
being equal to 1, “Cadiax Diagnostic” was
considered reliable.
Writing this article we had only six studies [19,
20, 21, 22, 23, 24] available where ARCUSdigma was
used. In three of them the device was only used as
an adjunctive tool and was not a subject of study itself.
In other three studies ARCUSdigma was used
as an additional patient examination tool besides medical
and dental history taking, clinical examination and
radiological examination. However in none of those
studies available to us sensitivity and specificity of
the device was determined. Also the reliability of
ARCUSdigma data was not determined using autopsy
or MRI data, which best represent joint anatomy. The
only study were reliability of ARCUSdigma data was
evaluated was performed not in clinical setting but
using predetermined values on articulators that were
measured with ARCUSdigma.
Same measurements can be performed using
both devices. Hinge axis – orbital reference plane is
used by “Cadiax Diagnostic”and camper horizontal
by ARCUSdigma. However it does not affect the
diagnosis.
ARCUSdigma was shown to be highly specific
and sensitive in differentiating between healthy and
diseased joints, however it performed worse when
used for differential diagnosis. These results conform
with Kiss G. et al. [19], who conclude that
ARCUSdigma is a good additional tool to examine
patients with TMJ dysfunction however it cannot replace
ordinary diagnostic methods, and with Kobs G.,
Bernhardt O., Meyer G. [25].
Piehslinger [26] and Gsellmann et al. [27] see a
special significance for axiography in the visual presentation
of dysfunctional dynamics and the strength
of MRT in the diagnosis of morphologic alterations.
They suggest combining the two methods, in order to
obtain a comprehensive evaluation of functional disorders
in the stomatognathic system
However the results presented offer some contradictions
to Lückerath et al. [28], Rammelsberg et
al. [29] and Rozencweig [30], who were the first to
show that tentative diagnoses, based on axiography
often did not correspond with findings from MRT.
Also, Bumann and Groot-Landeweer [31] could determine
correspondence between the two methods
in only 42% of the cases, whereby posterior discus
displacement and discus adhesions did not correspond
in any of the cases studied. Anterior discus dislocation
without repositioning was correctly diagnosed in
43% of the cases and non-pathologic findings were
correctly diagnosed in 35% of the cases.
Mohl et al. [32] and Türp [33] also doubted the
diagnostic value of mandibular movement registration
(because of the contradictory data in the literature).
Lund et al. [34] pointed out, that registrations of
active mandibular joint movements, irregardless of the
device, were so non-specific, that neither the registration,
nor the attempt at interpreting the tracks, was
meaningful for differential therapy. His opinion was
that these systems could still be useful, however, for
scientific problem-solving in isolated cases.
CONCLUSION
Ultrasonic axiograph registrations of mandibular
movements, in the framework of instrumental functional
diagnostics of the masticatory organ, appeared
to be a valuable supplement to clinical findings. HowStomatologija,
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G. Kobs al. SCIENTIFIC ARTICLES
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Res 1995;74:1133-43.
Received: 17 04 2007
Accepted for publishing: 17 07 2007
ever it should not be solely relied on in making differential
diagnosis and the direct assessment of
axiography tracks should be concerned less with
wanting to obtain definite indications whether the
patient being examined is functionally healthy or sick,
but rather with determining which movement pattern
is associated with a clinically (or by other methods)
diagnosed joint pathology [24].
Objectives: to assess the sensitivity and specificity of ARCUSdigma in diagnosing temporomandibular
joint (TMJ) pathology (TMD).
Methods. 102 TMJs were exmined with ARCUSdigma and “Cadiax Diagnostic” electronic
axiography system. Free opening, free protrusion and mediotrusion were recorded with
both devices. Guided opening and guided protrusion were examined with “Cadiax Diagnostic”.
Using free opening and free protrusion diagnosis was established.
Results. Sensitivity of ARCUSdigma was found to be 84,21% and 92,86% for the right and
left TMJ respectively. Specificity – 93,75% and 95,65% for the right and left TMJ. The 95%
confidence interval for sensitivity and specificity was calculated.
Conclusions. Within the limitations of this study, ARCUSdigma appeared to be a valuable
supplement to clinical findings in diagnosing TMDs.
Key words: temporomandibular joint disorders; axiography; sensitivity; specificity.
*Institute of Dentistry, Faculty of Medicine, Vilnius University,
Lithuania
Giedre Kobs* – DDS, PhD
Asta Didziulyte* – clinical intern
Robertas Kirlys* – clinical intern
Mindaugas Stacevicius* – student
Address correspondence to Robertas Kirlys, Institute of Dentistry,
Zalgirio 115, Vilnius, Lithuania.
E-mail: rkirlys@gmail.com
INTRODUCTION
Internal derangement of the temporomandibular
joint (TMJ) has been defined as an abnormal positional
relationship of the disc relative to the mandibular
condyle, fossa and/or articular eminence, and is a
major cause of jaw pain, clicking and/or crepitation
as well as limitation of opening [1]. Systematic examination
of TMJ pathology is of utmost importance
[2] and the primary goal is to determine the status of
the stomatognathic system in the most non-invasive
way possible, then to document the situation and plan
a therapy, appropriate to the findings.
The increasingly progressive development of
medical diagnostic processes has opened new possibilities
in the compilation of findings for mandibular
disorders.
Magnetic-resonance-tomography (MRT) provides
a non-invasive procedure for imaging both the
osseous- and soft-tissue structures with a high degree
of resolution [3, 4]. Although MRT cannot be
considered a routine procedure, due to cost considerations,
it is still currently regarded as the best possible
diagnostic standard [5, 6, 7, 8].
Diverse instrumental registration techniques of
TMJ, based on electro-mechanic, opto-electronic, ultrasound
and magnetic principles also exist. According
to Meyer [9, 10], there are remote, near-TMJ
and TMJ-oriented methods to evaluate lower jaw
movements.
Computerized axiography is a noninvasive diagnostic
method, wich enables to record jaw movements
in three dimensions. After localizing the geometric
hinge axis, it is possible to record movements free
from distortion, wich are combined of rotation and
translation. However, despite refinements and expanded
possibilities for registration, the actual significance
of instrumental functional analysis in mandibular
joint diagnostics is still not conclusively clear. The
possibilities for error involved in extraoral registration
of functional movements have been discussed
elsewhere [10].
Electronic axiograph “Cadiax Diagnostic”, which
was considered as a reference method in this study,
utilizes exactly determined hinge axis - orbital reference
plane [11]. ARCUSdigma is a near-TMJ working
ultrasonic diagnostic device, that was put on the
market 3 years ago. ARCUSdigma is technically sim
4 8 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
pler and cheaper than electronic
axiograph, however
there are no studies to support
its use in clinical work
as a diagnostic tool.
The American Academy
of Orofacial Pain (AAOP)
even discourages using instrumental
functional analysis
for the purpose of diagnosing
orofacial pain because
of lack of scientific evidence
[12].
On the other hand, the
German Society for Dentistry
and Orofacial Medicine attributes
at least as much
weight to instrumental functional
analysis as to clinical
findings [13, 14].
Having in mind the variance
of opinion in the scientific
literature, the objective
of this study was to assess
the ability of ARCUSdigma
to describe the kinematics of
diseased TMJs and determine
which movement patterns
is associated with a
clinically (or by other methods)
diagnosed joint pathology
[15].
MATERIAL AND
METHODS
From a group of patients
attending consultations at
Vilnius University Hospital
“Zalgirio clinics” 56 subjects
(8 males and 48 females)
were selected for this investigation.
The age of subjects
ranged from 15 to 76 years
old, with a mean age of 31,98.
This comprised 102 temporomandibular
joints.
All subjects underwent
computerized axiography using
“Cadiax Diagnostic” device
and also temporomandibular
joint examination using
ultrasonic device
proper history taking and
assessment of clinical symptoms.
The data obtained using
“Cadiax Diagnostic” and
Fig. 1. Computerized axiography adjusted to head of patient
Fig. 3. A – left: Overlap of colour-coded axiograms of healthy joints; B – right: Opening/
closing cycle on the right joint shows anterior disk displacement with early reposition
(typical "figure eight") in the beginning of the movement
A
B
SCIENTIFIC ARTICLES
ARCUSdigma were independently
assessed by four
diagnosticians. “Cadiax Diagnostic”
was considered a
standard in this study.
Interclass correlation
coeficient (ICC) was calculated
to validate the use of
“Cadiax Diagnostic” as a
standard. Sensitivity and
specificity of ARCUSdigma
in diagnosing temporomandibular
joint pathology was
evaluated by k (kappa)
koefficient. Better visualisation
of results was done by
graphics.
Electronic axiography
diagnosis
The registration of TMJ
tracings was made with the
double face-bow “Cadiax
Diagnostic” system (Gamma,
Wien). Three-dimensionally
adjustable lower bow is used
to transmit hinge-axis movement
of the mandible to the
upper face bow (Fig 1).
In all cases the axiographic
findings were recorded
and assessed for both
joints. One of the folowing
diagnoses was made separately
for left and right temporomandibular
joints:
• no appreciable disease
• disk displacement
with early reposition
• disk displacement
with late reposition
• disk displacement
without reposition
• non classifiable
pathological change
Determination of the
jaw-tracking curvature degree
[11, 16]
For the evaluation of
pathological changes in the
following interpretation, the
curvature, especially from
opening/closing cycle and
free protrusion cycle (X-and
Z-axis), was a crucial factor.
Convex curves were defined
as definitely pathologic and
their characteristics were not
further analysed.
Fig. 2. Diagrammed determination of the of curvature coefficient on example of opening/closing
cycle. Legend: d – Distance between the beginning and the finish point of movement recording
(continuous red line); a – maximal deviation of the excursion or incursion curve from constructed
straight line between the beginning and the finish point (see double red arrow)
Fig. 4. A – left: Mediotrusive movement on the right joint shows typical "figure eight" creation
of the late disk reposition at the end of the movement. Red arrow shows the repositioning time;
B – right: Opening/closing cycle on the right joint is characterised as anteriorly convex, on the
left joint as straight line cycle. In both TMJ there is strong suspicion of DDWR
A
B
5 0 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
In the case of a concave
curve it was necessary, to define
it clearly from straight
jaw-tracking in consideration
to the curvature degree. Figure
2 shows determination of
coefficient for the quantification
of the flexion performance
on opening/closing
cycle recording.
For evaluation of maximal
deviation the constructed
straight line (red line between
beginning and finish point of
the movement recording)
was displaced parallel downward
(increasing Z-value),
until it was tangent to the farthest
point of movement recording
(minor Z-value).
From the distance between
both straight lines (a) as well
as from the length between
beginning and finish point of
movement recording (d) we
get the curvature coefficient
K as follows:
In the present examination
we defined a limiting
value of K = 0,05 (that is
equivalent to a proportion of
).
In the case that the
curvature coefficient lies
around the limiting value
(0,04 £ K £ 0,06), no evidence
could be made due to
the curvature in terms of
pathological change. The
outcomes of this are the following
intervals:
K < 0,04
– straight line
0,04 £ K £ 0,06
– limit interval
K > 0,06
– curved track
Decision making in diagnosis
Due to the interpretation
of the jaw-tracking devices
the following suspecting diagnoses
were made:
a) “No appreciable
disease” described following
criteria (Figure 3: a) left):
K = a
d
= 1
20
a
d
Fig. 5. a) left: disk displacement without reduction (right joint): Opening/closing cycle underflows
mediotrusive und protrusive line (red circle); b) right: Both TMJs were signed with non-classifiable
pathological change
Fig. 6. Ultrasonic device ARCUSdigma adjusted to head of patient
A
B
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2 5 1
G. Kobs al. SCIENTIFIC ARTICLES
b) “Disk displacement with early reposition”
defined following criteria (Figure 3: b) right):
• typical „figure eight“ creation from excursive
and incursive cycles at the beginning area of coordinate
system;
• partial deviation of excursive from the
incursive line in the first 2 mm area of X- and Z-axis;
• negative value in the X-Axis at the and of
intrusion movement.
c) “Disk displacement with late reposition”
defined typical „figure eight“ creation in the terminal
phase of excursive und der incursive cycles (Figure
4: a) left).
• harmonically, reproducible, congruent cycles
with anterior concavity;
• mediotrusive line is slightly longer than protrusive
line and in the first 6-8 mm forms no Fischer
angle;
• free and managed Bennett movements are
ever positive and continuous;
• an average protrusive tracking length is about
8-10 mm, opening movement 10-12 mm and
mediotrusive movement 12-14 mm;
• In the first 8 mm protrusive-, opening-, and
mediotrusive cycles are normally coincident. Afterwards
the opening line runs usually above.
Fig. 7. "No appreciable disease" Fig. 8. "Disk displacement with early reposition"
Fig. 9. "Disk displacement without reposition" Fig. 10. "Non-classifiable pathological change"
5 2 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
d) In the evaluation of diagnosis
„disk displacement without reposition“
the focal point was the interpretation
of the opening/closing cycles (Figure
4: b) right). In case of convex or straight
line cycles (curvature coefficient K <
0,04) disk displacement without reposition
(DDWR) was suspected diagnosis.
In case of a concave cycle with a
curvature coefficient K on a limit interval
(0,04 £ K £ 0,06), it was necessary
to check coincidence of the opening/closing
movement with those of the
mediotrusive and protrusive tracks. In
case of the opening/closing cycle
underflowing the mediotrusive und protrusive
movements, it was typical characteristic
of disk displacement without
reduction (Figure 5: a) left).
The concave cycle (K > 0,06) was
characterized as physiological.
e) Cycles, where due to the interpretation
criteria no clear diagnosis could
be made, get the identification „nonclassifiable
pathological change“
(Figure 5: b) right). At this point it has to
be noted, that the most “struck disks“ hide
under that coding. The typical characteristics
of the cycles are limited, slightly
concave, congruent curves.
Diagnosis using ultrasonic device
ARCUSdigma
The registration of TMJ tracings was
also made with the ARCUSdigma ultrasonic
device (KaVo, Germany). Ultrasonic
sender and receiver parts are used.
First the position of the upper jaw is recorded.
To register the lower jaw movements,
the sender is fixed on the vestibular
surfaces of lower anteriors with a
paraocclusal aid (Fig. 6).
In all cases both joints were examined
with ARCUSdigma. One of the
folowing diagnoses was made separately
for left and right temporomandibular joints:
• no appreciable disease
• disk displacement with early reposition
• disk displacement with late reposition
• disk displacement without reposition
• not classifiable pathological
change
Determination of the jaw-tracking
curvature degree
Since ARCUSdigma also provides
graphical representation of the condylar
movements in the form of curves, it was
Fig. 11. Distribution of diagnoses for right TMJ based on "Cadiax Diagnostic"
data
Fig. 12. Distribution of diagnoses for left TMJ based on "Cadiax Diagnostic"
data
Fig. 13. Distribution of diagnoses for right TMJ based on ARCUSdigma data
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2 5 3
G. Kobs al. SCIENTIFIC ARTICLES
and left temporomandibular joints respectively.
As it is seen from the graphs, dominant
diagnosis using data from “Cadiax
Diagnostic” was disk displacement with
early reposition. Pathology occuring in
right temporomandibular joint was more
comonly observed than in the left temporomandibular
joint.
The distribution of diagnoses made
with ARCUSdigma is shown in Figs. 13
and 14 for the right and left temporomandibular
joints respectively.
For the right TMJ ARCUSdigma
showed much less number of joints that
could be asssigned to “no appreciable
disease” group, only 32,14% compared
to 42,86% “no appreciable disease” joints
using “Cadiax Diagnostic” data. The
number of TMJs diagnosed with “disk
displacement with early reposition” was
comparable showing values of 41,07%
and 44,64% for “Cadiax Diagnostic” and
ARCUSdigma respectively. ARCUSdigma
was unable to detect joints having
disk displacement with late reposition.
The number of joints under “disk displacement
with no reposition” diagnosis was
higher with ARCUSdigma (14,29%) than
with “Cadiax Diagnostic” (12,5%). Diagnosis
of “non-classifiable pathological
condition” was also more often made
with ARCUSdigma (8,93%) than with
“Cadiax Diagnostic” (1,79%).
For the left TMJ the number of joints
with no appreciable pathology was equal
with both devices reaching 55,36%. Disk
displacement with early reposition was
more commonly diagnosed with
ARCUSdigma (26,79%) than with
“Cadiax Diagnostic” (23,21%). There was no “disk
displacement with late reposition” group using
ARCUSdigma on the left side. The absence of this
group was observed on the right side too. Using ultrasonic
device some disk displacements without reposition
were left undetected, the numbers reaching
16,07% and 10,71% with “Cadiax Diagnostic” and
ARCUSdigma respectively. However a diagnosis of
non-classifiable pathologic change could be reached
more often using ARCUSdigma (7,14%) than “Cadiax
Diagnostic” (1,79%).
Sensitivity and specificity values (including 95%
confidence intervals) of ARCUSdigma were calculated,
equivalence of two diagnostic devices was
evaluated by k (kappa) coeficient. The results are
shown in Fig.15.
High sensitivity and specificity values shown in
the graph above were for differentiating between “no
appreciable disease” and any pathologic condition in
possible to use the same curvature coefficient K and
similar criteria of decision making in diagnosis as described
above for “Cadiax Diagnostic”.
Decision making in diagnosis
Bellow typical examples of ARCUSdigma tracings
are shown for each diagnostic group:
“No appreciable disease” (Fig. 7),
“Disk displacement with early reposition”
(Fig. 8.),
“Disk displacement with late reposition”
There was not a single case with this diagnosis
working with ARCUSdigma.
“Disk displacement without reposition“(Fig. 9),
“Non-classifiable pathological change“(Fig. 10)
RESULTS
The distribution of diagnoses made with “Cadiax
Diagnostic” is shown in Figs. 11 and 12 for the right
Fig. 14. Distribution of diagnoses for left TMJ based on ARCUSdigma data
Fig. 15. Sensitivity, specificity values and kappa coeficient for ARCUSdigma
5 4 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2
SCIENTIFIC ARTICLES G. Kobs al.
the joint. High kappa coeficient of 79% and 88% for
the right and left temporomandibular joints respectively
were also calculated when differentiating
“healthy” from diseased. According to the kappa
coeficient equivalence of two diagnostic devices in
differentiating “healthy” from “diseased” TMJs was
deemed excellent.
DISCUSSION
Patients were selected for the study on the basis
of previous or present clinical symptoms, such as pain
in TMJ, clicking and/or crepitation, limited opening.
All subjects underwent computerized axiography using
“Cadiax Diagnostic” device and also temporomandibular
joint examination using ultrasonic device
ARCUSdigma after proper history taking and assessment
of clinical symptoms. A total number of 128
TMJs were examined. 102 pairs of TMJ tracings were
left for final examination. Each pair of tracings was
recorded during the same visit. First examination was
performed with “Cadiax Diagnostic”, second one with
ARCUSdigma. Tracings of 26 TMJs were discarded,
because patients had no clinical symptoms and instrumental
examination was performed only to obtain
data for fully adjustable articulators. Electronic
axiograph “Cadiax Diagnostic” can record more
movements than ARCUSdigma (including speech,
bruxing, MPI and guided movements), so only the
movements that both devices can record were chosen.
Calibration of four examiners was performed
using tracings of 40 TMJs (29 diseased, 11 no appreciable
disease). Common percent of coincidence of
93% (kappa 81%, 82%, 83%, 83%) was found.
Electronic axiograph “Cadiax Diagnostic” is considered
a valuable and reliable tool to aid in making
diagnosis and comparable to MRI according to literature,
so it was chosen as a reference in this study.
In a study by Kobs G. [11] electronic axiograph was
compared to MRI, which has high sensitivity of 67-
100% according to autopsy studies. Sensitivity of
“Cadiax Diagnostic” was 75,8% and 80,7% for left
and right TMJ respectively and specificity 90,7% and
82,8% for left and right TMJ respectively. It is proven
that electronic axiography is better at differential diagnosis
of dynamic dysfunction than MRI [17, 18].
Interclass correlation was calculated to check the
reliability of “Cadiax diagnostic” data. The result approximately
being equal to 1, “Cadiax Diagnostic” was
considered reliable.
Writing this article we had only six studies [19,
20, 21, 22, 23, 24] available where ARCUSdigma was
used. In three of them the device was only used as
an adjunctive tool and was not a subject of study itself.
In other three studies ARCUSdigma was used
as an additional patient examination tool besides medical
and dental history taking, clinical examination and
radiological examination. However in none of those
studies available to us sensitivity and specificity of
the device was determined. Also the reliability of
ARCUSdigma data was not determined using autopsy
or MRI data, which best represent joint anatomy. The
only study were reliability of ARCUSdigma data was
evaluated was performed not in clinical setting but
using predetermined values on articulators that were
measured with ARCUSdigma.
Same measurements can be performed using
both devices. Hinge axis – orbital reference plane is
used by “Cadiax Diagnostic”and camper horizontal
by ARCUSdigma. However it does not affect the
diagnosis.
ARCUSdigma was shown to be highly specific
and sensitive in differentiating between healthy and
diseased joints, however it performed worse when
used for differential diagnosis. These results conform
with Kiss G. et al. [19], who conclude that
ARCUSdigma is a good additional tool to examine
patients with TMJ dysfunction however it cannot replace
ordinary diagnostic methods, and with Kobs G.,
Bernhardt O., Meyer G. [25].
Piehslinger [26] and Gsellmann et al. [27] see a
special significance for axiography in the visual presentation
of dysfunctional dynamics and the strength
of MRT in the diagnosis of morphologic alterations.
They suggest combining the two methods, in order to
obtain a comprehensive evaluation of functional disorders
in the stomatognathic system
However the results presented offer some contradictions
to Lückerath et al. [28], Rammelsberg et
al. [29] and Rozencweig [30], who were the first to
show that tentative diagnoses, based on axiography
often did not correspond with findings from MRT.
Also, Bumann and Groot-Landeweer [31] could determine
correspondence between the two methods
in only 42% of the cases, whereby posterior discus
displacement and discus adhesions did not correspond
in any of the cases studied. Anterior discus dislocation
without repositioning was correctly diagnosed in
43% of the cases and non-pathologic findings were
correctly diagnosed in 35% of the cases.
Mohl et al. [32] and Türp [33] also doubted the
diagnostic value of mandibular movement registration
(because of the contradictory data in the literature).
Lund et al. [34] pointed out, that registrations of
active mandibular joint movements, irregardless of the
device, were so non-specific, that neither the registration,
nor the attempt at interpreting the tracks, was
meaningful for differential therapy. His opinion was
that these systems could still be useful, however, for
scientific problem-solving in isolated cases.
CONCLUSION
Ultrasonic axiograph registrations of mandibular
movements, in the framework of instrumental functional
diagnostics of the masticatory organ, appeared
to be a valuable supplement to clinical findings. HowStomatologija,
Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2 5 5
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 2 5 5
G. Kobs al. SCIENTIFIC ARTICLES
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Received: 17 04 2007
Accepted for publishing: 17 07 2007
ever it should not be solely relied on in making differential
diagnosis and the direct assessment of
axiography tracks should be concerned less with
wanting to obtain definite indications whether the
patient being examined is functionally healthy or sick,
but rather with determining which movement pattern
is associated with a clinically (or by other methods)
diagnosed joint pathology [24].
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