Disk and joint morphology variations on coronal and sagittal MRI in temporomandibular joint disorders

Objectives

This study aims to assess the disk morphology and the condyle position in subjects with temporomandibular (TMJ) disk displacements on sagittal and coronal magnetic resonance imaging (MRI).

Materials and methods

Seventy-four TMJs (from 37 patients) with positive clinical TMD symptoms according to the RDC/TMD axis I protocol were evaluated by 1.5 T MRI. Disk position, disk morphology, sagittal and coronal condyle position, joint effusion, joint space, and coronal condyle angulation were evaluated. Multivariate logistic regression was used to explore the relationship between disk displacement and MRI variables.

Results

Disk displacement with reduction (DDR) was found in 36.48 % and without reduction (DDwR), in 21.62 % of the joints. Disk displacement was anterior in 35.1 %, anterior-medial in 13.5 %, and anterior-lateral in 9.45 % of cases. The thickened posterior band (94.48 OR, p?=?0.001) and the posterior condyle position (4.57 OR, p?=?0.03) were more likely found on sagittal MRI in disk displacements. On coronal slices, the disk displacement was significantly associated with the distance from the most medial condyle point to the midplane (p?<?0.05).

Conclusions

Disk displacement is associated with changes of disk shape, disk dimension, and condyle position on sagittal MRI. A significant variation of the distance from the most medial condyle point to the midplane in disk displacement was found on coronal MRI.

Clinical relevance

Our study highlights the existence of changes on coronal MRI in TMD patients which should be assessed for better understanding of the clinical evolution of temporomandibular disorders.     

Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup of degenerative joint disease

Research is needed to assess the validity of the Clinical Diagnostic Criteria for Temporomandibular Disorders (CDC/TMD). The purpose of this study was to test the reliability of the clinical diagnosis of temporomandibular joint (TMJ) degenerative joint disease (DJD) as compared with the magnetic resonance imaging (MRI) 'gold standard'. The TMJ DJD group comprised 48 joints in 24 consecutive patients who were assigned a clinical bilateral diagnosis of TMJ DJD. The TMJ non-DJD group consisted of 82 joints in 41 consecutive patients without a TMJ-related diagnosis of TMD. Bilateral sagittal and coronal MR images were obtained subsequently to establish the corresponding diagnosis of degenerative joint changes. An MRI diagnosis of osteoarthrosis (OA) was defined by the presence of flattening, subchondral sclerosis, surface irregularities, and erosion of the condyle or presence of condylar deformities associated with flattening, subchondral sclerosis, surface irregularities, erosion and osteophyte. For the CDC/TMD interpretations, the positive predictive of DJD for OA was 67%, and for the presence of degenerative joint changes 88%. The overall diagnostic agreement for DJD was 44.6% with a corresponding K-value of 0.01. Most of the disagreement was due to false-negative interpretations of asymptomatic joints. The results suggest CDC/TMD to be predictive for degenerative joint changes but insufficient for determination of OA. Patients assigned a clinical TMJ-related diagnosis of DJD may need to be supplemented by evidence from MRI to determine the presence or absence of OA.     

Orthodontic finishing after TMJ disk manipulation and recapture

Orthodontic treatment has as its goal in most patients to achieve a cosmetic and functional result. There are functional goals for all orthodontic treatment and in some few cases the functional outweigh the cosmetic; an example would be a cleft-palate case. Orthodontic finishing to a specific condylar position is not routinely a goal of orthodontic care. The reason for this is that only patients who have pain, dysfunction and a negative change in quality of life from their temporomandibular apparatus need this tangential type of treatment. Research has shown that most patients suffering from a temporomandibular disorder (TMD) have displacement of the temporomandibular disk(s). Research has shown that when the mandibular condyle is repositioned to the Gelb 4/7 position that the temporomandibular joint disk is recaptured to a normal position between 85% and 96% of the time. The Gelb 4/7 position has been equated to the physiologic position of the mandibular condyle in the glenoid fossa. TMJ condyle repositioning to the physiologic position has been correlated to disk recapture proven by magnetic resonance imaging (MRI). A case is shown in which a displacement without reduction is manipulated into reduction and maintained with orthodontic correction. TMJ disk displacement without reduction is usually preceded by TMJ disk displacement with reduction. Pumping of the upper joint compartment can assist in reducing the TMJ disk displacement without reduction. Magnetic resonance imaging before and after the manipulation and after orthodontic treatment are shown. A detailed method of orthodontic finishing that maintains a specific condylar position and TMJ disk recapture is shown.     

髁突运动中心大张口轨迹与关节窝形态的关系及临床应用探讨

目的　探讨髁突运动中心大张口轨迹与关节窝形态的关系 ,对TMD患者髁突运动中心轨迹特征进行初步研究。方法　利用自行开发的髁突运动中心轨迹显示分析系统 ,分别以运动中心、终末绞链轴点作为参考点 ,观察 10名健康人和 7例临床检查怀疑盘前移位的TMD患者大张口轨迹 ,与磁共振成像得到的相应关节窝形态及关节盘位置诊断结果进行比较。结果　健康人左右侧运动中心轨迹与关节窝形态曲线重合率分别为 80 % (8/ 10 )和 90 % (9/ 10 ) ;终末绞链轴点轨迹与关节窝形态重合率均为 0 (0 / 10 )。TMD患者中 ,11侧盘前移位关节 ,除 1侧可复性盘前移位关节外 ,髁突运动中心轨迹均与正常的轨迹明显不同 ,出现各种改变 ;3侧正常盘位关节 ,髁突运动中心轨迹均与健康人的轨迹相似。结论　运动中心轨迹较终末绞链轴点个体稳定 ,可认为是较理想的研究髁突运动轨迹的参考点     

颞下颌关节紊乱病关节盘与髁突改变的MRI表现及相关性研究现状

正常的关节盘–髁突关系对于颞下颌关节的健康十分重要，它的改变在临床上具有重要意义。磁共振成像（MRI）被认为是颞下颌关节盘–髁突关系紊乱及软组织形态成像的金标准，被广泛地用于颞下颌关节特征的评估、协助诊断以及治疗方式的选择中。目前多数研究表明颞下颌关节紊乱病（TMD）早期阶段可能表现为关节盘的前外侧移位、双凹形态的改变。关节盘形态、位置的改变进一步导致髁突长度、高度及旋转角度等发生变化，使疾病向更严重的阶段发展。TMD患者关节盘的位置和形态改变、髁突的解剖学变化与关节盘移位具有相关性，被认为引起是TMD最常见的原因。     

Condyle position as a predictor of temporomandibular joint internal derangement.

STATEMENT OF PROBLEM: The significance of the position of the mandibular condyle in the glenoid fossa remains a controversial subject. PURPOSE: This study evaluated the relationship between condyle position and disk displacement. MATERIAL AND METHODS: Fifty-two asymptomatic volunteers and 130 symptomatic patients underwent linear tomography and bilateral temporomandibular joint magnetic resonance scans. RESULTS: There was a higher prevalence of distal condyles in symptomatic patients with disk displacement compared with asymptomatic volunteers (P <.05). Distally positioned condyles identified joints with disk displacement with reduction, disk displacement without reduction, or a symptomatic normal joint with a sensitivity of 0.64, 0.56, and 0.33, respectively. Distally positioned condyles identified joints with disk displacement with reduction, disk displacement without reduction, or a symptomatic normal joint with a specificity of 0.56, 0.65, and 0.55, respectively. CONCLUSION: There were more distal condyles in symptomatic subjects with disk displacement, but the reliability of a distal condyle to predict the presence or absence of disk displacement was low.     

Analysis of magnetic resonance imaging characteristics and pain in temporomandibular joints with and without degenerative changes of the condyle

The aim of this study was to investigate temporomandibular joint (TMJ) pain and magnetic resonance imaging characteristics in 104 TMJs with and 58 without degenerative changes of the condyle, such as osteophytes, erosion, avascular necrosis, subcondral cyst and intra-articular loose bodies. TMJ images were also assessed for flattening, retropositioning and hypomobility of condyle and disc displacement. Comparison of the TMJ side-related data showed a significant relationship between disc displacement without reduction (DDwoR) and the presence of degenerative bony changes (p=0.00). Flattening, retropositioning and hypomobility of condyle showed no significant difference in relation to the presence or absence of degenerative bony changes. Retropositioning of the condyle was significantly associated to disc displacement with reduction (DDwR) (p=0.00), while condylar hypomobility was significantly more frequent in TMJ with DDwoR (p<0.05). Independent of the presence or type of DD, TMJ pain was more frequent in the presence of degenerative bony changes. When considering only DDwR, TMJ pain was significantly associated to a degenerative condition (p=0.03). When there were no degenerative bony changes, TMJ pain was significantly more frequent in DDwoR (p=0.04). Despite the present findings, the absence of symptoms in some patients with condylar bony changes suggests that the diagnosis of osteoarthritis should be established by evaluation of magnetic resonance images in association with clinical examination.     

Relationships between disk displacement,joint effusion,and degenerative changes of the TMJ in TMD patients based on MRI findings

This study was performed to investigate the relationships between disk displacement, joint effusion, and degenerative changes in patients with temporomandibular disorders using MRI. Randomly selected MRIs of 508 temporomandibular joints of 254 patients (92 males and 162 females, mean age was 30.5 ± 12.0 years) were reviewed retrospectively. Seventy-eight percent (198 out of 254) of the patients complained of joint pain. Compared with joints with a normal disk position, the joints with anterior disk displacement with reduction showed a 2.01 odds ratio (P < 0.01) of degenerative changes and a 2.85 odds ratio (P < 0.001) of joint effusions. The joints with anterior disk displacement without reduction showed a 4.43 odds ratio (P < 0.001) of degenerative changes and a 4.61 odds ratio (P < 0.001) of joint effusions. These results clearly show that the risk of degenerative changes and joint effusions increase with displacement of the disk position in patients with temporomandibular disorders. Although all disk displacement situations do not progress to painful joints and/or degenerative joint diseases, the possibility of an increased risk of progression by a breakdown in the balance between a patient’s adaptive capacity and functional loading of the TMJ should be assessed in each and every patient through comprehensive evaluation of various contributing factors.     

Histopathological changes in rabbit craniomandibular joint associated with experimentally induced anterior disk displacement (ADD)

Several studies have shown that anterior disk displacement (ADD) of human temporomandibular joint (TMJ) can lead to cellular and extracellular alterations in the disk proper, bilaminar zone (BZ), condyle, articular eminence and synovial membrane. Due to lack of an animal model for this disease, it is not known whether the mechanical displacement of the disk could lead to the observed histopathological changes. The purpose of this experiment was to investigate the histopathological changes that occur in the rabbit craniomandibular joint (CMJ) following surgical induction of ADD. The right CMJ was exposed surgically and the discal attachments were severed except for the BZ attachments. Then the disk was displaced anteriorly and sutured to the zygomatic arch. The left joint served as surgical control. The CMJs were removed after 24 h, 1 week, 2 weeks or 6 weeks and stained with H&E or modified Masson stain. The results showed neovascularization, cell clustering and fibrillation of the displaced disk. The BZ showed marked fibrosis. The condyle showed subchondral hemorrhage and fibrosis followed by osteoarthritic changes in the articular cartilage. The articular eminence showed chondrocytic clustering and an increase in the amount of chon-droid bone. Synovial membrane exhibited marked hyperplasia. We concluded that surgical induction of ADD in the rabbit CMJ leads to cellular and extracellular alterations in the disk proper, BZ, condyle, articular eminence and synovial membrane similar to those described previously in human ADD. It appears that the mechanical trauma resulting from ADD could lead to a cascade of reparative and degenerative changes of the affected joints similar to those described for osteoarthritis.     

髁突位置与颞下颌关节盘移位关系的研究

在颞下颌关节内紊乱（TMJID）的患者中髁突位置和关节盘移位之间的关系一直是研究者所关注的问题,许多学者从不同的角度进行了探索,但对TMJID患者髁突在关节窝中的位置及其临床意义存在争议。本文就TMJID概况、髁突位置与关节盘移位的关系及其在TMJID诊断中的意义作一综述。     

颞下颔关节磁共振FIESTA动态成像的诊断价值

目的:探讨颞下颌关节(TMJ)磁共振FIESTA动态成像的诊断价值.方法:对40例患者80侧TMJ进行常规静态磁共振扫描和斜矢状位FIESTA动态磁共振扫描.由2名医师分别对每侧TMJ FIESTA动态扫描时关节盘的位置、髁突的骨质改变和关节腔积液情况进行诊断,并与常规静态磁共振扫描诊断结果进行比较.结果:80侧TMJ磁共振FIESTA动态图像中,对关节盘移位的诊断,72侧与静态磁共振扫描结果相符,准确率为90％;对髁突骨质改变和关节腔积液的诊断,所有病例与静态磁共振结果完全相符,准确率达100％.结论:TMJ磁共振FIESTA动态图像诊断颞下颌关节内紊乱(TMJID)具有一定价值,但单凭动态检查结果不够全面,必须与常规静态磁共振扫描相结合.     

Condylar and disk position and signs and symptoms of temporomandibular disorders in stress-free subjects

BACKGROUND: The authors conducted a study in subjects who tested free of psychological stress to determine the position of the condyle and whether that position was related to signs and symptoms of temporomandibular disorders (TMDs). METHODS: Forty subjects underwent psychological evaluation to ensure freedom from psychological stress. The authors evaluated tenderness of the masticatory muscles and temporomandibular joints (TMJs) by means of bimanual digital palpation, and they determined the positions of the condyle and disk by using magnetic resonance imaging. RESULTS: A total of 23.75 percent of the condyles were displaced away from the centric position either anteriorly (3.75 percent) or posteriorly (20.00 percent). chi(2) analysis showed a relationship between the position of the condyle and displacement of the disk, as well as a relationship between the position of the condyle and tenderness of the TMJs. CONCLUSION: Although these relationships proved significant, it cannot be assumed that displacement of the condyle away from the centric position is predictive of TMD. CLINICAL IMPLICATIONS: Only two subjects were judged to have had TMJ internal derangement. Thus, the absence of psychological stress seems to have played a role in this finding.     

MR grading of temporomandibular joint fluid: association with disk displacement categories, condyle marrow abnormalities and pain

The purpose of this study was to investigate temporomandibular joint (TMJ) effusion on magnetic resonance (MR) images, and its association with specific categories of disk displacement, bone marrow abnormalities and pain. From a series of 523 consecutive TMJ MR imaging studies of patients referred to imaging because of pain and dysfunction, those with TMJ effusion, defined as an amount of fluid that exceeded the maximum amount seen in a control group of asymptomatic volunteers, were analysed. The selected patients were reassessed and the amount of TMJ fluid was graded bilaterally according to a set of reference films. Other parameters recorded included disk displacement categories and condyle marrow abnormalities. Pain self-records were obtained from the patients immediately before MR imaging. The association between the recorded parameters and TMJ pain was analysed with t-tests and regression analysis. Of the 523 patients, 70 (13%) had TMJ effusion, which was unilateral in 61%. Only 9% of the 70 patients had effusion bilaterally, whereas bilateral disk displacement was found in 80%. In the 76 joints with effusion, 83% showed two specific categories of disk displacement at closed mouth. Condyle marrow abnormalities were found in 31% of the 70 patients, mostly on one side, and in 24% of the 76 joints. An in-patient regression analysis of the side difference in TMJ pain showed that effusion and condyle marrow abnormalities were significant pain-increasing factors. In conclusion, patients with TMJ effusion represent a subgroup with pain and dysfunction with more severe intra-articular pathology than those with disk displacement but no other joint abnormalities.     

Temporomandibular joint condyle changes after surgically induced non-reducing disk displacement in rabbits: a macroscopic and microscopic study

Experimentally induced displacement of the temporomandibular joint (TMJ) disk has previously been shown to induce shortening of the mandibular ramus on the ipsilateral side. The aim of this investigation was to reveal whether this shortening develops due to primary influence on condyle growth or by secondary loss of condyle mass due to degenerative tissue breakdown. Disk displacement was created in the right TMJ in seven 3-month-old rabbits, the posterior disk attachment kept intact. Seven rabbits underwent surgical opening of the TMJ without disk intervention. Seven additional animals served as references. After a 3-month experimental period, the animals were sacrificed. Previous analysis revealed shortening of mandibular height and length caused by ipsilateral TMJ disk displacement. The condyles were examined macroscopically and by histologic sectioning or scanning electron microscopy. All condyles were covered with smooth articulating soft tissue and without visible signs of degenerative changes. Four condyles from joints with disk displacement demonstrated substantial regressive remodeling resulting in a change of condyle shape with forward/downward rotation of an enlarged articulating surface. It was concluded that TMJ disk displacement in a growing individual can induce reduction of mandibular height and length before a stage where visible osteoarthrotic changes develop. It implies a primary adverse effect on condyle growth.     

Evaluation of the correlation between disc displacements and degenerative bone changes of the temporomandibular joint by means of magnetic resonance images

The aim was to evaluate the correlation between disc displacements and degenerative bone changes in magnetic resonance images (MRI) of 112 patients of both genders, with signs and symptoms of temporomandibular disorder. For this purpose, a calibrated examiner evaluated 224 MRI by assigning scores for the displacement of the disc and degenerative bone changes. Disc displacement was found in 58.42% of the temporomandibular joints (TMJs) evaluated. Anterior displacement of the disc with reduction was the most common, occurring in 67.18% cases of joints with disc displacement. Degenerative bone changes were observed in 53.94% of the TMJs analysed. There was significant correlation between disc displacement with reduction and condylar flattening, disc displacement without reduction and condylar flattening, disc displacement without reduction, and associated degenerative bone changes (flattening and erosion, flattening, osteophyte and erosion; flattening and osteophytes, erosion and sclerosis, flattening and sclerosis, flattening, osteophytes and sclerosis). The correlation between advanced cases of disc displacement and the occurrence of degenerative bone changes emphasises the importance of MRI for an accurate diagnosis and development of an appropriate treatment plan and in cases in which clinical examination is not sufficient for these purposes.     

Prevalence of missing posterior teeth and intraarticular temporomandibular disorders.

STATEMENT OF PROBLEM: The association between missing mandibular posterior teeth and the development of intraarticular temporomandibular disorders (TMDs) remains unclear. PURPOSE: The purpose of this study was to evaluate the prevalence of missing mandibular posterior teeth and intraarticular TMDs in a mixed population of asymptomatic subjects and symptomatic TMD patients. MATERIAL AND METHODS: Eighty-two asymptomatic volunteers and 263 symptomatic TMD patients were included in this study. Asymptomatic volunteers completed a subjective questionnaire and underwent clinical examination to document the absence of TMD signs and symptoms. All symptomatic subjects had localized jaw joint pain and pain on movement or when eating. The number of missing mandibular bicuspid and molar teeth (excluding third molars) in each subject was recorded, and magnetic resonance images were made to document the presence or absence of disk displacement in the temporomandibular joints. Subjects were divided into 4 groups: group 1 = asymptomatic, normal magnetic resonance imaging result; group 2 = asymptomatic, disk displacement; group 3 = symptomatic, normal magnetic resonance imaging result; and group 4 = symptomatic, disk displacement. Collected data were analyzed with chi-square tests (P<.05) with no adjustment for multiple comparisons. RESULTS: A positive association between missing mandibular posterior teeth and the presence of disk displacement was found. CONCLUSION: The literature does not suggest that replacement of missing posterior teeth prevents the development of TMDs. However, missing mandibular posterior teeth may accelerate the development of degenerative joint disease.     

Correlation of different MRI characteristics of anterior disc displacement with reduction and without reduction

The aim of this study was to evaluate the correlations between magnetic resonance imaging (MRI) findings in anterior displacement with reduction (ADDR) and anterior displacement without reduction (ADDWR). Two hundred patients with temporomandibular disorder (TMD) symptoms were examined clinically by a clinician experienced with this disorder. There were 130 joints with ADDR and 45 joints with ADDWR; 88 patients were identified according to the clinical and MRI diagnoses of both observers. The MRI characteristics such as position, signal intensity, morphology of disc, degenerative changes, effusion, scar tissue, avascular necrosis, and condylar hypermobility were evaluated in the individual with ADDR and ADDWR. The Chi-square test was used to determine the correlation between MRI characteristics in the ADDR and the ADDWR. There were significant relationships between degenerative changes and increased signal intensity, degenerative changes and side-way displacement, effusion and the deformation of the disc, effusion and subluxation, increased signal intensity and subluxation, elongation deformation and increased signal intensity, and elongation deformation and side-way displacement in ADDR. There were significant relationships between degenerative changes and effusion, degenerative changes and decreased signal intensity, scar tissue and avascular necrosis, deformation of disc and increased signal intensity, as well as deformation of disc and decreased signal intensity in ADDWR. These MRI findings also correlated with the clinical findings, however, this correlation appears to be a synergistic pattern rather than a set of clear-cut relationships. The correlations between these MRIs and different clinical findings such as pain and dysfunction also must be evaluated. Existing correlations must be considered in the diagnosis and treatment planning of TMD, and signs and symptoms of TMD should be monitored after treatment.     

Multifactorial comparison of disk displacement with and without reduction to normals according to temporomandibular joint hard tissue anatomic relationships

STATEMENT OF PROBLEM: There is disagreement about the predictive value of temporomandibular joint tomographic anatomy in the diagnosis of internal derangements. PURPOSE: This study aimed to identify multifactorial temporomandibular hard tissue relationships that differentiate disk displacement with reduction and disk displacement without reduction from normals. MATERIAL AND METHODS: Temporomandibular joint tomograms from females diagnosed with unilateral disk displacement with (n=84) or without (n=78) reduction were compared to 42 asymptomatic normal joints with the use of 14 linear and angular measurements and 8 ratios. A validated classification tree model was tested for accuracy with sensitivity, specificity, goodness of fit, and the amount of log likelihood accounted for. The tree model was compared with a multiple logistic regression model and univariate testing. RESULTS: The disk displacement with reduction tree model consisted of 3 disease and 2 normal pathways with interactions between fossa width to depth ratio, condyle position, and linear posterior joint space. This class was characterized by either a much wider- and shallower-than-average fossa shape and/or by a moderately posterior condyle position when the fossa shape was average to deeper and/or narrower. The logistic regression and univariate models also suggested wider and/or shallower fossae, as well as longer eminence length. The disk displacement without reduction tree model consisted of 2 disease pathways and 1 normal pathway. Interactions characterized this class by either a posterior to very posterior condyle position or by a much deeper than average fossa depth when the condyle position was concentric to anterior. The logistic regression model emphasized greater fossa depth and width versus normals. The tree models conservatively predicted the disease classes: Rescaled Cox and Snell R(2) 37.0%, sensitivity 70.2%, and specificity 90.5% for disk displacement with reduction; R(2) 28.8%, sensitivity 66.7%, and specificity 85.7% for disk displacement without reduction. CONCLUSION: Within the limitations of this study, hard tissue relationships revealed by central tomogram sections were able to model notable differences between disk displacement with reduction and disk displacement without reduction versus asymptomatic normals when temporomandibular joints were examined as a multifactorial system typified by interactions of fossa width to depth proportions and condyle position. While substantial, the hard tissue predicted only part of the biology. The model could be broadened by additional factors and interactions.     

Temporomandibular joint: surgically created disk displacement causes arthrosis in the rabbit.

To document a causal relationship between temporomandibular joint disk displacement and arthrosis, the disk was surgically displaced in one temporomandibular joint in each of three rabbits. The rabbits were sacrificed after 4 weeks and the mandibular condyles were studied radiographically and histologically. All three joints that underwent disk displacement had radiographic and histologic evidence of arthrosis, which included erosion of the bone, irregularity and fissure formation of the articular soft tissue cover, disruption of the subchondral layer of cartilage cells, and chondrocyte proliferation. No radiographic or histologic changes occurred in the joints that were untouched. The results suggest that surgically created disk displacement can cause arthrosis in the temporomandibular joint of the rabbit.     

A retrospective study on the relationship between aging and tomographic findings in 174 patients with TMD

The purpose of this study was to examine age-related changes in the tomographic characteristics of the temporomandibular joints (TMJ) of patients with temporomandibular dysfunction (TMD). 174 patietns with TMD from 12–76 years old were divided into six groups by age. Bilateral TMJs of the patients were examined by TMJ tomography, and 91 joints were also performed with arthrography. The frequencies of abnormal condylar shape and osseous changes (including osteosclerosis, flattening, bone erosion and osteophytes) increased with age (P<0.01), less osseous changes were observed in the younger patients (<30 years) with anterior disk displacement with reduction than in the older ones (≥30 years) (P<0.05). No statistically significant difference in the frequency of condylar displacement was found among the groups. It was concluded that the frequencies of abnormal condylar shape and some osseous changes might increase with aging, which might be due to remodeling in TMJ and low adaptive ability of the TMJs in elderly people.