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\begin{document}

\title{Diagnostic Properties of RDC/TMD Criteria for TMJ Internal Derangement
versus MRI Gold Standard.}



\author[1]{Li Feng}%
\author[2]{Zhao Yang}%
\author[2]{Shiyue Chen}%
\author[3]{Jianghua Wan}%
\author[4]{Sanjay Rastogi}%
\author[4]{Rupshikha Choudhury}%
\affil[1]{Chengdu First People’s Hospital}%
\affil[2]{First Affiliated Hospital of Naval Military Medical University}%
\affil[3]{The First Affiliated Hospital of Hainan Medical University}%
\affil[4]{Regional Dental College}%


\vspace{-1em}



  
  \date{May 29, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective: To correlate the clinical RDC/TMD findings with Magnetic
resonance imaging (MRI) as a diagnostic aid in the internal derangement
of TMJ. Methods: The present study consists of a total sample size of 14
subjects clinically diagnosed with the internal derangement of TMJ.
According to the set criteria by Research Diagnostic Criteria for
Temporomandibular disorders (RDC/TMD), the subjects were subjected to
MRI after a thorough evaluation. The diagnostic findings were compared
with MRI. The data obtained were statistically analyzed using the
specificity, sensitivity, and kappa coefficient. Results: Twenty-five
percent of sensitivity and fifty-seven percent of specificity were
observed for RDC/TMD diagnosis regarding MRI in the total sample. Kappa
value was found to be in the moderate range. Conclusion: The clinical
findings based on RDC/TMD alone were not sufficient for the diagnosis of
TMJ, and MRI's internal derangement still a ``golden standard'' among
the other modalities.%
\end{abstract}%



\sloppy


Diagnostic Properties of RDC/TMD Criteria for TMJ Internal Derangement
versus MRI Gold Standard

\textbf{Objective:} To correlate the clinical RDC/TMD findings with
Magnetic resonance imaging (MRI) as a diagnostic aid in the internal
derangement of TMJ.

\textbf{Methods:} The present study consists of a total sample size of
14 subjects clinically diagnosed with the internal derangement of TMJ.
According to the set criteria by Research Diagnostic Criteria for
Temporomandibular disorders (RDC/TMD), the subjects were subjected to
MRI after a thorough evaluation. The diagnostic findings were compared
with MRI. The data obtained were statistically analyzed using the
specificity, sensitivity, and kappa coefficient.

\textbf{Results:} Twenty-five percent of sensitivity and fifty-seven
percent of specificity were observed for RDC/TMD diagnosis regarding MRI
in the total sample. Kappa value was found to be in the moderate range.

\textbf{Conclusion:} The clinical findings based on RDC/TMD alone were
not sufficient for the diagnosis of TMJ, and MRI's internal derangement
still a ``golden standard'' among the other modalities.

KEYWORDS: Internal Derangement of TMJ; MRI; RDC/TMD.

What is already Known?

Internal Derangement of Temporomandibular joint is a recurrent problem
in the pre-auricular region. Often misdiagnosed and leads to
mistreatment. Contemporary literature shows that Research Diagnostic
criteria of Temporomandibular Disorders (RDC/TMD) are commonly used
among the physicians for the diagnosis of the same problem.

What's New?

The results of this study suggest that RDC/TMD criteria for internal
derangement alone are not sufficient, and it may be supplemented by the
use of MRI so that a proper treatment protocol can be generated for the
patient.

\textbf{Introduction}

Internal derangement of the Temporomandibular Joint (TMJ) is an organic
disease, and attempts have been made to identify TMJ disc displacement's
clinical symptoms. Several studies were done to identify clinical signs
and symptoms that were predictive of the joint's status. Various
diagnostic imaging techniques were performed, which contributed to the
proper diagnosis of TMJ disorders. The most standard and most
well-established technique for examining the TMJ radiographically is the
transcranial projection. Even more precise depictions of the osseous
changes were gained from tomography than from transcranial radiography.
With the advent of newer advanced modalities like CT and MRI, both soft
and hard tissues can now be viewed in nearly any desired plane of
reference with considerable accuracy\textsuperscript{1-3}.

All imaging techniques are not equally effective for each of the
different condition that affects the TMJ. The efficacy of any imaging
examination rests not just with its technical adequacy but also with its
diagnostic accuracy, a complex interaction between the images and the
person interpreting it. Besides, the increasing sophistication of
imaging techniques does not guarantee a better diagnosis of the
patient\textsuperscript{4,5}.

The accuracy of clinical examination for diagnosing the exact status of
TMJ internal derangements has been investigated in several previous
studies\textsuperscript{6-9}, which have reported the clinical
examination's overall accuracy as 43\% to 95\%.

False-positives diagnoses are related to over-classification of the
disease, which might lead to over-treatment, while false negative
diagnoses are related to under-classification and consequently
under-treatment\textsuperscript{8}. Now the question arises, how to
establish an accurate diagnosis for the internal derangement of the TMJ?
Despite various advances in the field of clinical diagnosis of
temporomandibular disorders and imaging modalities, i.e., various
modifications done in the RDC/TMD since its advent by various societies
on temporomandibular joint and imaging technologies, the question
remains the same about the best diagnostic criteria and imaging module
in order to diagnose the internal derangement of the
TMJ.\textsuperscript{2-4}

In order to resolve the confusion regarding the diagnosis and management
of the TMD, it was felt necessary to study and compare the efficacy of
RDC/TMD diagnostic criteria and MRI as a diagnostic aid in the internal
derangement of TMJ. Furthermore, to find out whether RDC/TMD criteria
alone is enough for diagnosing the internal derangement of TMJ or its
combination with MRI is required whenever seeing the patient with
internal derangement. A study was planned to compare the efficacy of
RDC/TMD alone or in combination with MRI to diagnose the internal
derangement of TMJ.

The study's specific focus was to correlate the findings of RDC/TMD with
advanced imaging techniques like MRI as a diagnostic aid in the
Temporomandibular joint's internal derangement (TMJ).

\textbf{Materials and Methods:}

This prospective study was conducted at the Department of Oral and
Maxillofacial Radiology, performed from October 2016 to October 2019.
The Institutional Review Board and the local ethical committee have
approved the study after registration with the Research Center (protocol
HMU \# RC/IRB/2016/1040). This study followed the criteria as declared
by Helsinki. All participants signed provided written informed consent
after a full explanation of the process's procedure and safety.
According to the set criteria, those who were not ready or failed to
report were excluded from the study.

In this study, adult patients without any systemic complications, who
strictly met the inclusion criteria, were included. The subjects'
clinical inclusion criteria were assessed on the following five clinical
characteristics that were/are the modification of those described
initially by Okeson\textsuperscript{10}. The inclusion criteria were;
Limited mouth opening; Deflection of the mandible to the affected side
at the maximal mouth opening, TMJ pain at the pre-auricular region
during mandibular movement; Limitation of condylar translation to the
maximal mouth opening; Crepitation during mouth opening and/or closing
movement. The exclusion criteria were patients with cerebral aneurysm
clip, cardiac pacemaker, skeletal jaw deformity, undergoing orthodontic
treatment, history of traumatic extraction, claustrophobic and
uncooperative, pregnant patient, and metallic prosthesis heart valves,
ferromagnetic foreign bodies in a critical location like the eye.

Each patient was subjected to the clinical diagnostic process. In accord
with the Research Diagnostic Criteria (RDC/TMD) \textsuperscript{11},
the diagnostic process used a standardized clinical head and neck
examination that included palpation of the TMJ and muscles of
mastication for pain, palpation of joint sounds, and measurement of the
range of motion\textsuperscript{3}.

According to the RDC/TMD criteria, a total of 14 symptomatic patients
with clinically diagnosed internal derangement of TMJ according to the
RDC/TMD criteria were included in this study group. All volunteers were
examined and were accepted for the study after completing the following
evaluation-

A subjective questionnaire to document the absence of jaw pain, joint
noise, locking and history of TMD.

Clinical TMJ and dental examination for signs and symptoms usually
associated with internal derangement.

The symptomatic patients were selected from 14 consecutive subjects who
were evaluated at the Department of Oral Medicine, Diagnosis, and
Radiology.

Bilateral TMJ magnetic resonance images were obtained of all 14 patients
employing Higher 1.5 Tesla magnet (General Electric). Pulse sequences
were obtained from all patients in closed-mouth position and maximal
mouth opening positions on corrected sagittal and coronal T1 weighted;
proton density (PD) and T2 weighted images.\textsuperscript{3}

MRI images were prescribed graphically perpendicular (sagittal images)
and parallel (coronal images) to the condyle's horizontal long axis. The
maximum intercuspation position was used for closed mouth images and
maximum mouth opening for open mouth images.

The disc's position was analyzed and grouped into one of the categories
described by Tasaki et al. \textsuperscript{12}. Disc function was
analyzed as usual, displaced with reduction or without reduction, or
indeterminate. The normal function was noted when a disc in the superior
position in the closed mouth position interposed between the condyle and
the articular eminence in the open mouth position. The reduction was
noted when a displaced disc in the closed mouth position assumed a
position interposed between the condyle and the articular eminence in
the open mouth position. No reduction was noted when the displaced disc
in the closed mouth position did not achieve a position between the
condyle and the articular eminence in the open mouth position.

Indeterminate disc function was noted when the disc could not be
identified because of the artifact or post-surgical
scaring\textsuperscript{13}. Osseous components were classified as
normal or abnormal.

The TMJs were classified according to the following MR
criteria\textsuperscript{8}-

\textbf{Normal state} (No Disc Displacement; NDD) - in the sagittal
plane of imaging, the disc had a biconcave shape (an anterior band; an
intermediate zone, the thinnest portion; a posterior band, the thickest
portion). In a closed-mouth position, the posterior band's junction with
the bilaminar zone was located above the apex of the condylar head (12
o'clock position). When the jaw opens, the condyle rotates under the
disc, and the disc-condyle complex translates inferiorly under the
temporal tubercle. The disc remains interposed between the osseous
component and moves anteriorly in a synchronized fashion. The disc has
an arc-shaped configuration in the coronal plane of imaging due to its
insertions at the condylar pole. The disc is perfectly centered on the
condylar head in an open and closed-mouth position.

(Figure 1).

\textbf{Anterior disc displacement with reduction (ADDWR):-} In the
closed position, the disc's posterior band is anterior to the condylar
head in all the sagittal sections. When the jaw is opened, the disc is
recaptured by the condyle, and the disc condyle relation appears normal.
Figure 2

\textbf{Anterior disc displacement without reduction (ADDWOR):-} In
close and open mouth position, the disc's posterior band is anterior to
the condylar head's superior aspect in all sagittal sections. When the
jaw is opened, the disc is anteriorly compressed, whether its shape is
modified or not. Figure 2

\textbf{Sideways displacement (medial or lateral):-} Sideways
displacements of the disc are well documented in the coronal plane. The
disc crosses over one of the sagittal plane tangents to one of the
condylar poles. Figure 3

Rotational displacement was present when the disc was anteriorly
displaced in all sagittal sections, together with a sideway component
(medial or lateral), whether it is reduced or not, according to the
definition of Katz berg.

\textbf{Stuck disc or disc adhesion:-} During jaw movement, the disc
remains in the same place in relation to the mandibular fossa or the
articular tubercle. The stuck disc may be fixed in a normal or displaced
position and may or may not be associated with the condyle's normal
mobility.

\textbf{Degenerative changes:} Flattening, erosion, changes in the shape
of the articular surfaces, anterior osteophytes, and/or subchondral
lacunas were classified as a degenerative joint disease (osteoarthritic
joint). The sharpness of the cortical limits was not considered:
chemical shifting may produce artifacts in the MR images.

\textbf{Restricted condylar translation:} Limitation of translation was
identified when the condylar head did not reach the apex of the
articular tubercle of the temporal bone during the opening, with or
without the disc -- condyle complex dislocation.

All radiograph s and images were evaluated for a set criterion to
determine osseous and soft tissue changes in the TMJ.

\textbf{Statistical Analysis} .

Data were subjected to statistical analysis using SPSS 22.0 (SPSS, Inc.,
Chicago, IL). Statistical tests used for analyzing data were mean and
standard deviation and unpaired t-test.

Statistical analyses were undertaken to correlate the
radiography/imaging findings to the clinical signs and symptoms in the
internal derangement according to RDC/TMD criteria. Data were subjected
to statistical analysis using SPSS 22.0 (SPSS, Inc., Chicago, IL).
Statistical tests used for analyzing data were sensitivity\&specificity
tests and inter-observer reliability correlation through the Kappa test.

\textbf{RESULTS}

Joint tenderness was the most frequent clinical finding (18 out of 28
joints) (64\% ), followed by joint noise (16 out of 28 joints) (57\%),
muscle tenderness (10 out of 28 joints) (36\%), and deflection/deviation
was found only in 9 out of 28 joints (32\%) and was the least frequent
clinical finding in the present study. Thirty-six percent (36\%) of the
patients showed limited mouth opening (5 out of 14 patients).

14 joints were clinically diagnosed as ADDWR (50\%) out of a total of 28
joints and were the most prevalent in RDC diagnostic subgroups, whereas
3 joints were clinically diagnosed to be ADDWOR (11\%) and were least
prevalent among the RDC diagnostic subgroups. 13 joints were diagnosed
as No disc displacement (NDD) (39\%).

Out of 28 TM, joints-13 were diagnosed by MRI as No Disc Displacement
(NDD) (46.4\%), MRI diagnosed 11 as ADDWR (39.3\%), 2 were diagnosed by
MRI as ADDWOR (7.1\%), and 2 joints were categorized as others (7.1 \%)
\{Others-Disc was not seen in MRI\}.

Out of 28 TMJ joints (14 patients), 11 were diagnosed normal with
RDC/TMD criteria; among these 11 normal TMJ joints, 4 were confirmed as
normal by MRI (the remaining 7 joints were diagnosed as ADDWR). Out of
28 TMJ joints (14 patients), 14 were diagnosed ADDWR with RDC criteria;
among these 14, 3 were confirmed as ADDWR by MRI (out of the remaining
joints, 8 joints were diagnosed as NDD and 2 as ADDWOR). Out of 28 TMJ
joints (14 patients), 3 were diagnosed ADDWOR with RDC criteria; among
these 3 TMJ joints, MRI has shown 1 ADDWR, 1 NDD and 1 as others.

RDC/TMD diagnosis's sensitivity and specificity concerning MRI findings
were (36.4\%) of sensitivity and (63.6\%) of specificity of RDC
diagnosis was found for NDD. (21.4\%) of sensitivity and (57.4\%) of
specificity of RDC diagnosis was observed for ADDWR. (0\%) of
sensitivity and (33\%) of specificity of RDC diagnosis was observed for
ADDWOR. Twenty-five percent (25\%) of sensitivity and Fifty-seven point
one percent (57.1\%) of specificity were observed for RDC diagnosis with
respect to MRI in the total sample.

A comparison of clinical examination findings with MRI diagnosis is
summarized in Table 1.

Consensus inter-observer diagnosis was taken from the three different
observers, who interpreted the MRI findings individually. Each observer
was blind to each other's MRI analysis and the RDC clinical diagnosis.

For left TMJ, Kappa values were analyzed between observer 2 and observer
1 and were found to be 0.421. (Moderate). Kappa values were analyzed
between observer 2 and observer 3 and were found to be 0.413 (Moderate).

For Right TMJ, Kappa values were analyzed between observer 2 and
observer 1 and were found to be 0.407. (Fair). Kappa values were
analyzed between observer 2 and observer 3 and were found to be 0.412.
(Moderate). Table 2-5

\textbf{DISCUSSION}

The present study investigated the accuracy of clinical findings in
determining the presence or absence of internal derangement of TMJ
according to the set criteria by RDC/TMD and the superior diagnostic
imaging modality like magnetic resonance imaging (MRI).

For this study, 14 patients between 11 to 40 years of age were selected.
The control group of 5 healthy volunteers without any sign \& symptoms
of TMD showed a different age distribution; they were between 20 to 30
years.

Out of a total of 14 patients, the study consisted of 9 female \& 5 male
patients. The ratio of female to male in this group of patients with
TMDs was 1.8:1. The results of this study show that the prevalence of
TMDs was higher in women than in men. Several related studies have
reported comparable results\textsuperscript{10,14}.

In the present study, the author has investigated the accuracy of five
clinical parameters for determining the presence or absence of anterior
disc displacement. The MRI findings obtained from 28 joints with TMDs
were compared with their initial visits' clinical findings. The
sensitivity values of the clinical parameters were considerably low, in
contrast with their high specificity. It means that false--negative
diagnoses were made more frequently than false-positive
diagnosis\textsuperscript{7}. It was in accordance with the study
carried out by Yatani et.al\textsuperscript{15}. Thus results obtained
from these studies indicate that it is challenging to predict disc
derangement based on clinical symptoms alone. In other words, not all
joints commonly present characteristic clinical signs and symptoms of
disc derangement\textsuperscript{2,7,8,16}.

The most common clinical sign in this study group was tenderness in the
pre-auricular region (18 out of 28 joints, i.e., 64\%), the cause being
unclear. Okeson et al. \textsuperscript{10} reported that disc
displacement of TMJ is the crucial cause of facial and TMJ pain. Based
on these observations, pain/tenderness in the preauricular region could
be associated with alteration of retrodiscal tissue\textsuperscript{17}.

A study carried out by Kobs G et al. \textsuperscript{9}, concluded that
although clicking is a predictor of anterior disc displacement with
reduction, it was not present in his entire study population. In the
present study, joint noise was found in 16 out of 28 joints (57\%), thus
indicating that TMJ clicking might occur as a consequence of frictional
incompatibility between the disc and the eminence when the posterior
band of the disc moves anteriorly or posteriorly beyond the apex of the
articular eminence. Other causes may be a deviation in the condylar form
(remodeling), adhesion, or muscular
incordination\textsuperscript{18-22}.

Muscle tenderness and limited mouth opening were found in Thirty-six
percent in the present study. Deflection/deviation was found in 9 joints
out of 28 joints (Thirty-two percent) and was the least among all the
clinical symptoms\textsuperscript{7}.

In anticipation of osseous changes in the long-standing internal
derangement of TMJ and to rule out other TMJ organic pathologies, the
authors could have chosen the various radiographic and imaging
modalities to determine the status of the disc. However, none of the
modalities (conventional radiograph, specialized radiograph, and CT-
axial and coronal view) could substantiate and locate the disc
position\textsuperscript{23,24,25}.

The predictive value of the clinical diagnosis of ADDWR was 0.65 in a
study by Barclay et al. \textsuperscript{2}. The present study showed a
7 non-symptomatic joint with ADDWR on MRI. 2 joints clinically diagnosed
ADDWR showed anterior disc displacement without reduction with MRI. 1
joint clinically diagnosed as anterior disc displacement without
reduction did reduce on opening. 1 joint clinically diagnosed as
anterior disc displacement without reduction appeared normal on MRI.
Whereas 1 joint clinically diagnosed as anterior disc displacement
without reduction could not be interpreted in MRI, 3 joints clinically
diagnosed as MRI correctly diagnosed ADDWR, and 4 joints clinically
diagnosed as NDD was confirmed by MRI\textsuperscript{2, 19, 20, 21,
22}.

There was a low agreement (33\% to 70\%) between clinical diagnosis and
MRI diagnosis in symptomatic \& asymptomatic joints\textsuperscript{2,
6, 7-9}. The present study showed only 36\% (4/11) of the asymptomatic
joints had a normal disc position, detected by MRI. The prevalence of
disc displacement in asymptomatic subjects is between 16\% and
33\%\textsuperscript{2}.

A previous study has shown that contralateral non-symptomatic joints in
subjects with internal derangement in the other TMJ frequently have disc
displacement\textsuperscript{10, 14}; the present study findings also
correlate with this study (7/11 ADDWR).

In accordance with the available literature, posterior disc displacement
is exceptionally uncommon, and it was not observed in the present
study\textsuperscript{12}. Superior disc position is commonly used to
refer to normal disc positioning in the sagittal oblique closed mouth
view. The method used to judge disc position in this study was the
closed mouth sagittal view assessment of the posterior band's position
relative to the top of condyle as a superior disc position. It was
considered normal if the posterior band of the disc is at
position\textsuperscript{17}.

In the current study, the medial displacement proportion was more
significant than lateral displacement (4 joints were medial; 2 joints
lateral). These findings are in accordance with the existing
literature\textsuperscript{18,} which suggests that medial displacement
occurs more frequently than lateral displacement and can be attributed
to the force of muscles attached to the disc. It has been speculated
that one reason for medial disc displacement is muscle spasm of the
superior belly of the lateral pterygoid muscle\textsuperscript{3}.

Most clinical studies on anteroposterior arthrography and sagittal \&
coronal MRI have shown that the displacement's medial component is more
frequent than the lateral component. The percentage of medial
displacement was more significant in anterior disc displacement without
reduction, and sideways displacement was also most frequent in anterior
disc displacement without reduction\textsuperscript{8}.

The anterior disc displacement without reduction is the most common
internal displacement depicted among TMJ derangement, but the present
study showed that the NDD was most common in the study population
diagnosed by MRI. (13 NDD; 11ADDWR and 2 anterior disc displacement
without reduction). The limited protrusive movement was the most
accurate clinical sign used for diagnosing anterior disc displacement
without reduction\textsuperscript{8}. However, this study did not
support it as only 1 patient had limited mouth opening out of 2 patients
diagnosed anterior disc displacement without reduction with
MRI\textsuperscript{18}. It could be due to contradicting views in
clinical parameters based on protrusive movements/deflection and no
single specific criteria in diagnosing specific TMJ disc
displacement\textsuperscript{19-25}.

The overall diagnostic agreement of 88.25\% (15/17) between specific
RDC- diagnosis, and MRI in the current study is in accordance with
various contemporary studies\textsuperscript{9,13}. Several authors have
investigated the reliability of the clinical diagnosis of ID using MRI
as a 'gold standard'. The reported percent agreement ranged from 59\% to
90\%. A positive RDC examination is predictive for internal derangement
but not reliable with regard to the type of disc displacement. The
clinical examination is of limited value in determining the TMJ disc's
true position and its functional movement. When accurate information
about the TMJ disc position is clinically essential, MRI should be
performed; the clinical examination alone cannot provide sufficient
information\textsuperscript{2,7,9,16,} \textsuperscript{18-20}.

The combinations of TMJ radiographs are useful only in long-standing
pathology, leading to visible changes in the osseous structures.
However, these are still relevant in ruling out and eliminating osseous
pathology for a confirmed diagnosis of soft tissue pathology of TMJ.

Based on the results of this study, the main strength is that the
RDC/TMD criteria are not alone sufficient for the diagnosis of the
internal derangement, and perhaps, it should be supported by the MRI to
reach a confirmatory diagnosis so that a comprehensive approach can be
initiated towards the management of the internal derangement of the TMJ
by the clinicians. However, this study's major drawback was a small
sample size before reaching a definitive conclusion. A further study
examining a group of volunteers with or without a history of TMD and
using the same diagnostic criteria as set by RDC/TMD, MRI with larger
sample size, multi-center trials needs to be conducted.

\textbf{Conclusion:}

The results of this study suggest that RDC/TMD criteria for internal
derangement alone are not sufficient, and it may be supplemented by the
use of MRI so that a proper treatment protocol can be generated for the
patient. However, it needs to validate through multi-center trials
before coming to a definitive conclusion.

\textbf{Abbreviations: NDD: Normal Disc Displacement; ADDWR: Anterior
disc displacement with reduction; ADDWOR: Anterior disc displacement
without reduction.}

\textbf{Declarations:}

Ethics approval and consent to participate:

All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or
national research committee of the The First

Affiliated Hospital of Hainan Medical University, First Affiliated
Hospital of Naval Military

Medical University, and Chengdu First People's Hospital. And comply with
the 1964

Helsinki Declaration and its later amendments or comparable ethical
standards. The written informed consent was taken from all the patients.

Consent to publish: Not Applicable

Availability of data and materials: The datasets used and/or analyzed
during the current study available from the corresponding author on
reasonable request.

Competing interests: The authors declare that they have no competing
interests

Author's Contribution: LF has designed the concept; ZY Data acquisition;
SC drafted the manuscript; JW and SR Final proof reading and editing.

Conflict of interest: The authors declare that they have no conflict of
interest.

Funding: No Funding received.

Informed consent: It was obtained from all individual participants
included in the study.

\textbf{ACKNOWLEDGEMENTS:} Not Applicable

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\end{enumerate}

\textbf{FIGURE LEGENDS:}

Figure 1: Depicts No Disc Displacement (NDD)

Figure 2: Illustrates Anterior Disc Displacement with Reduction (ADDWR)
and Anterior Disc Displacement without Reduction (ADDWOR).

Figure 3: Shows Medial Disc Displacement (MDD)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-NDD-1/Figure-1-NDD-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2-ADDWR-1/Figure-2-ADDWR-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3-MDD-1/Figure-3-MDD-1}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`Tables for OMR.docx`  available at \url{https://authorea.com/users/730281/articles/710090-diagnostic-properties-of-rdc-tmd-criteria-for-tmj-internal-derangement-versus-mri-gold-standard}

\selectlanguage{english}
\FloatBarrier
\end{document}

