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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 185-190

Magnetic resonance imaging assessment of temporomandibular joint disorders


1 Department of Radio-Diagnosis, Department of General Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
2 Department of Maxillofacial Unit, Department of General Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt

Date of Submission19-Sep-2019
Date of Decision23-Sep-2019
Date of Acceptance16-Oct-2019
Date of Web Publication16-May-2020

Correspondence Address:
Abeer M Salah
Department of Radio-Diagnosis, Assiut University Hospitals, Faculty of Medicine, Assiut University, Assiut
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCMRP.JCMRP_132_19

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  Abstract 


Background
This prospective study aimed to detect the temporomandibular joint (TMJ) disk position in patients with TMJ dysfunction and asymptomatic patients using MRI.
Results
Out of 40 joints clinically diagnosed as internal derangement, MRI showed anterior disk displacement without reduction in five (12.5%) joints, anterior disk displacement with reduction in 12 (30%) joints while 23 joints showed no disk displacement (57.5%). MRI results of 20 asymptomatic joints showed ADDWR in two (10%) joints and no dis displacement in the remaining 18 (90%) joints. The associations of clinical diagnosis with MRI scan findings in both symptomatic and asymptomatic groups were statistically highly significant (P < 0.001).
Conclusion
From our study, we could conclude that in most of asymptomatic normal TMJs, the disk will be in the normal position with few exceptions. Among displaced disks, ADDWR is the most frequent MRI diagnosis in patients with internal derangement.

Keywords: temporomandibular joint dysfunction, MRI, disc displacement, osteoarthritis, internal dearragment


How to cite this article:
Meggaly HI, Haseib A, Osman MH, Salah AM. Magnetic resonance imaging assessment of temporomandibular joint disorders. J Curr Med Res Pract 2020;5:185-90

How to cite this URL:
Meggaly HI, Haseib A, Osman MH, Salah AM. Magnetic resonance imaging assessment of temporomandibular joint disorders. J Curr Med Res Pract [serial online] 2020 [cited 2020 Jul 10];5:185-90. Available from: http://www.jcmrp.eg.net/text.asp?2020/5/2/185/284390




  Introduction Top


The temporomandibular joint (TMJ) is a synovial joint located at the skull base in front of the ear and connects the mandible with the temporal bone. Anatomically, the most important TMJ structure is the articular disk (meniscus). This is a biconcave fibrocartilaginous structure which divides the TMJ into superior and inferior compartments. The presence of the articular disk between the temporal bone and mandibular condyle prevents articular damage in the closed-mouth and open-mouth positions[1].

According to some studies, TMJ dysfunction affects up to 28% of the population, although these studies did not show adequate imaging findings. The most frequent cause of TMJ dysfunction, or TMJ disorder, is internal derangement (ID), which is defined as an abnormal relationship of the disk to the condyle[2],[3].

Recently, MRI has been considered as the imaging modality of choice in the evaluation of TMJ dysfunction. The technique of MRI in this entity uses dual surface coils, sagittal oblique, and coronal thin sections of 3 mm or less, and proton-density-weighted and T2-weighted sequences in both closed-mouth and open-mouth positions. Furthermore, a dynamic study can be performed during progressive mouth opening with cine MRI[4],[5].

Together with the progress of MRI, there have been significant improvements in both hardware and software that currently allow better visualization of small structures such as the retrodiscal layers or the lateral pterygoid muscle (LPM) attachments[6].

Accurate localization of the disk is very important in the diagnosis of TMJ ID and can easily be achieved with MRI. Anterior disk displacement has been seen in up to 34% of asymptomatic volunteers[7],[8]) and a normal disk position has been depicted in 16–23% of symptomatic patients[9]. These findings have led the investigators to question if anterior disk displacement is the precursor of clinical ID or merely an anatomic variant[10].


  Aim Top


The aim of this study was to detect the TMJ disk position in patients with TMJ dysfunction and asymptomatic patients using MRI.


  Patients and Methods Top


Patients

This study was conducted at the Maxillofacial Surgery Unit and Diagnostic Radiology Department of Assiut University hospitals in the period from April 2016 to February 2017. A total of 35 cases were selected for the study (25 patients and 10 control healthy volunteers). The study was based on 40 joints of 25 symptomatic patients with various temporomandibular dysfunction (TMD) (study group; where 15 patients complained of both TMJs and 10 patients complained of one TMJ) and 20 joints of 10 asymptomatic volunteers (control group). The patients mean ± SD age was 29.36 ± 7.09 years. The ethics committee approval was obtained and all selected patients and controls filled a written consent form.

All patients were assessed using the Research Diagnostic Criteria for TMD[11]. Asymptomatic (control) individuals were included for our study after fulfilling the following evaluation:

  1. A clinical questionnaire to exclude the presence of jaw pain, joint noise, locking, and history of TMD.
  2. Clinical TMJ and dental examination for symptoms and signs usually associated with ID.
  3. A detailed medical and dental history to exclude the presence of any nonfunctional habits and systemic diseases.


Inclusion criteria for the study group were based on the presence of the following clinical findings:

  1. Restricted mouth opening.
  2. Deviated opening and/or closing of the mandible.
  3. TMJ pain during mandibular movement.
  4. Tenderness of masticatory muscles on palpation.
  5. Crepitation/clicking during mouth opening and/or closing movement.


The exclusion criteria for both groups (study and control) were as follows:

  1. Claustrophobic and uncooperative patients.
  2. Patients with a cardiac pacemaker, metallic prosthesis heart valves, cerebral aneurysm clip, or ferromagnetic foreign bodies.
  3. Patients with obvious skeletal jaw deformity, history of traumatic extraction, history or undergoing orthodontic treatment.


Methods

MRI examination

All MRI examinations were performed on a 1.5 T MRI system (Achieva; Philips Medical Systems, Best, The Netherlands).

For optimal imaging of the TMJ, small bilateral surface coils with a small field of view were used to achieve a higher signal-to-noise ratio and simultaneous bilateral acquisition. Coronal and axial T1 sequences were done in the closed mouth to evaluate the overall anatomy and bone marrow as well as the adjacent soft tissues to exclude other adjacent pathologies.

In our study, axial T1 was obtained as a localizer. Bilateral closed-mouth and open-mouth T2, proton density, and dynamic sequences are obtained in an oblique sagittal plane. Dynamic MRIs were obtained as a rapid acquisition of static images using a single-shot fast spin echo proton density sequence during progressive opening and closing of the mouth. These images were then displayed sequentially as a cine loop [Table 1].
Table 1: MRI protocol for temporomandibular joint imaging

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To maintain an open-mouth position, a rubber bite block was used. We did not use mouth opening devices as passive mouth opening with a device might not reproduce the physiological conditions occurring during mouth opening with the possible role of the LPM that keeps disk stabilization during mouth opening.

Image interpretation

The criterion used to interpret the disk position in closed as well as the open mouth was the intermediate zone (IZ) criterion[12].

The condition of each joint was categorized according to the following diagnosis:

  1. No disk displacement (NDD).
  2. Anterior disk displacement with reduction (ADDWR).
  3. Anterior disk displacement without reduction (ADDWOR).


The position of the disk in the closed mouth [Figure 1]a, [Figure 2]a was considered normal (NDD), when IZ was located between the anterior–superior aspect of the condyle and posterior–inferior aspect of articular eminence in middle or above a line that joined the centers of two imaginary circles fitted to these structures. In the open mouth [Figure 1]b, [Figure 2]b, disk position was considered normal (NDD), if IZ of the disk was located between the condyle and articular eminence in the middle of a line that joined the centers of two imaginary circles fitted to these structures[13]. In both positions, the circles were drawn to closely approximate condyle and eminence outlines. The upper limit of eminence circle was set to be within the bone boundary to the cranial cavity [Figure 1].
Figure 1: Normal disk position in (a) closed. and (b) open-mouth position.

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Figure 2: Sagittal oblique PDW images of the right TMJ in closed (a) and open (b) mouth positions showing normal disk position with no disk displacement (NDD). TMJ, temporomandibular joint.

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Diagnosis of ADDWR was considered when a displaced disk in the closed-mouth position assumed the normal position in the open mouth [Figure 3] and [Figure 4]. ADDWOR was considered when the displaced disk in the closed-mouth position has not achieved a normal position in the open mouth [Figure 5].
Figure 3: Sagittal oblique STIR closed-mouth (a) and proton density open mouth (b) showing anterior disk displacement with reduction (ADDWR). The disk is arrowed.

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Figure 4: Sagittal oblique proton density closed and open mouth of the right TMJ (a and b) showing anterior disk displacement with reduction (ADDWR). Sagittal oblique proton density closed and open mouth of the left TMJ of the same patient (c and d) also showing ADDWR. The disk is arrowed. TMJ, temporomandibular joint.

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Figure 5: Sagittal oblique STIR and proton density closed-mouth (a and b) and sagittal oblique proton density open mouth (c) showing anterior disk displacement without reduction (ADDWOR). The disk is arrowed.

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Consensus on interobserver diagnosis was taken from two different radiologists who were blinded to each other's MRI analysis and clinical diagnosis. The values obtained from two observers were compared to assess the agreement among them regarding MRI diagnoses.


  Results Top


Among the study group, joint tenderness was the most frequent and joint noise was the least common clinical finding. Thirty (75%) joints were tender, 22 (55%) showed restricted opening, 18 (45%) showed muscle tenderness, 16 (40%) showed joint deviation while 14 (35%) showed joint noise [Figure 6].
Figure 6: Clinical presentation among the study group.

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As regards clinical diagnosis in the study group, 15 (37.5%) joints were diagnosed as ADDWR, six (15%) joints were ADDWOR, five (12.5%) were myositis, and two (5%) were osteoarthritis. The remaining 12 (30%) joints were diagnosed as free of NDD [Figure 7].
Figure 7: Clinical diagnosis among the study group.

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MRI diagnosis: out of 40 joints of the study group, five were diagnosed as ADDWOR, 12 were diagnosed as ADDWR while the remaining 23 joints did not show any disk displacement; so were diagnosed as NDD. As regards 20 joints of the control group, MRI revealed NDD in 18 (90%) of them while two (10%) joints were diagnosed as ADDWR [Table 2].
Table 2: Comparison of clinical diagnosis and MRI diagnosis in symptomatic and asymptomatic groups

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Comparing the clinical and MRI diagnosis of disk position, out of the six joints clinically diagnosed as ADDWOR, MRI confirmed the diagnosis in five (83.3%) while one joint was diagnosed as NDD. Out of the 15 joints clinically diagnosed as ADDWR, MRI confirmed the diagnosis in 11 (73.3%) while four joints were diagnosed as NDD. Out of the 12 joints clinically diagnosed as NDD, MRI confirmed the diagnosis in 11 (91.7%) while one joint was diagnosed as ADDWR [Table 2].

The associations of clinical diagnosis with MRI findings in both symptomatic and asymptomatic groups were statistically highly significant (P < 0.001).


  Discussion Top


TMJ disk displacement occurs when the articular disk located between the condyle and the mandibular fossa moves out from these two structures so that the mandible and temporal bone contact is made on tissues other than the articular disk. This is usually very painful because unlike these adjacent tissues, the central portion of the disk contains no sensory innervations[14]. This could be the reason for the occurrence of joint tenderness as the most common clinical symptom among symptomatic patients in our study. Many authors mentioned joint tenderness as the most frequent presenting symptom among their study groups[13],[14],[15].

Using MRI analysis obtained with sagittal oblique projections, the disk position within the TMJ is considered normal when the posterior band of the disk is seen located at ‘12 o'clock’ where the posterior disk band is positioned over the upper portion of the mandibular condyle (i.e. closed-mouth and dental contact)[16],[17]. Nevertheless, many studies have shown that such ‘12 o'clock position’ of the disk is not observed in ~30% of asymptomatic patients[18],[19]. Thus, this condition raises a question about the definition of the normal position of the disk.

The present study included 20 joints of an asymptomatic 10 volunteers (control group). MRI scan showed two of the (10%) joints as ADDWR and the remaining 18 did not show any disk displacement. Kircos et al.[8] and Kishor Kanneppady et al.[14] also found a small percentage of disk displacement in asymptomatic volunteers (10 and 5%, respectively). In a study by Tallents et al.[15] which involved MRI analysis of disk position in asymptomatic volunteers and symptomatic patients, the researchers observed up to 33% of disk displacement in asymptomatic volunteers. In another study by Uchida, et al [20]. Disk displacement was present in 37% of asymptomatic patients. The occurrence of such silent displacement of articular disks in asymptomatic, normal joints could be just a variant of joint anatomy or it may be an alarming sign of future TMD.

ADDWR is caused by an articular disk that has been displaced from its position on top of the condyle due to elongation or tearing of the restraining ligaments[14]. Multiple etiological factors of DDWR are partially attributed to abnormal biomechanical forces applied to the mandibular condyle, which alter the shape and function of the articular tissues causing articular noise during mouth opening and closing. Dental clenching, stress, mandible trauma, excessive mastication, shape alterations of the articular tubercle and articular surfaces, lack of lubrication, disk modifications, degenerative articular disorder, hyperactivity of the LPM, ligament sprains, abnormal dental occlusion, mandible hypoplasia, loss of posterior teeth, deflective dental occlusion, hypermobility, and, occasionally, whiplash injury, are also considered as possible risk factors for DDWR[17],[18],[21].

Disk displacement with reduction is common in the general population, and clicking or popping joint is of little clinical significance unless it is accompanied by pain, loss of function, and/or intermittent locking[14].

In the present study on 40 joints diagnosed clinically as ID, MRI confirmed ID in 17 joints, 12 (70.6%) of them were ADDWR and five (29.4%) were ADDWOR. The remaining 23 joints did not show any disk displacement by MRI. Among the displaced disks, ADDWR was the most common MRI finding in our study. This is similar to Hassan, et al.[22]) who also found ADDWR as the most common representing 60.7% of displaced disks. In another large study by Marpaung et al.[23] performed on 1562 patients, ADDWR was the most common, encountered in about 34% of patients. Lalue-Sanc hes et al.[24] concluded that anterior and anterior–lateral DDWR are the most common TMJ disk displacements.


  Limitation Top


The data obtained by our study need confirmation by other study series with a larger number of cases.


  Conclusion Top


From our study, we could conclude that in most of asymptomatic normal TMJs, the disk will be in the normal position with few exceptions. Among patients with TMJ ID, joint tenderness is the most common clinical presentation. Among displaced disks, ADDWR is the most frequent MRI diagnosis in patients with ID.

Acknowledgements

Abeer M. Salah carried out the collection of patients and volunteers, filled their complete clinical sheets, and was concerned till they have performed MRI examination. M.H. Osman carried out full clinical assessment of the patients. Abolhasan Haseib carried out reading MRI of the cases and performed the statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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

  [Table 1], [Table 2]



 

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Abstract
Introduction
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Patients and Methods
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