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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 31  |  Issue : 2  |  Page : 117-122

Assessment of disc position in clinically diagnosed patients of internal derangement of the temporomandibular joint through MRI


1 Department of Oral Medicine and Radiology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, India
2 Department of Oral Medicine and Radiology, Career Dental College, Lucknow, India
3 Department of Dentistry, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
4 Department of Oral Medicine and Radiology, Kantipur Dental College Teaching Hospital and Research Center, Kathmandu, Nepal

Date of Submission14-Jan-2019
Date of Acceptance04-Mar-2019
Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Haider Iqbal
Department of Oral Medicine and Radiology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Chaudhary Vihar, Rae-Bareilly Road, Lucknow, Uttar Pradesh - 226 025
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_13_19

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   Abstract 


Aims and Objectives: To study the efficacy of MRI in assessing the disk position in clinically diagnosed patients of TMJ, Disk Displacement with Reduction and Disk Displacement without Reduction, and also compare the MRI findings between a control group and patients with Disk Displacement. Materials and Methods: Magnetic Resonance Imaging (MRI) was performed on a total of 16 clinically diagnosed patients of Internal Derangement of the TMJ, 13 of whom were diagnosed with Disk Displacement with Reduction, and the remaining 3 were diagnosed with Disk Displacement without Reduction. 6 asymptomatic volunteers formed the Control Group. The selected patients were then made to undergo an MRI Scan of the TMJ using a 1.5 Tesla MRI Scanner. The MRI scans were evaluated by a radiologist who was unaware of the clinical findings of the patients who were being included in the study. Statistical Analysis Used: Chi square test. Result: Of the total of 3 diagnosed patients of ADDWOR, MRI detected it in 2 cases and thus detection of MRI being 66.7%. Similarly, of the total 13 patients diagnosed with ADDWR, MRI detected it in 10 and thus detection of MRI being 71.4%. Comparing the frequency of detection between the two procedures, χ2 test revealed similar detection between the two procedures (χ2 = 0.03, P =0.870). To test the reliability (reproducibility) of MRI findings, the findings were also performed on 6 controls. Comparing the frequency of MRI findings between the two groups, χ2 test revealed similar visualization in both groups {83.3% (in Control) vs. 70.6% (in patients), χ2 = 0.37, P = 0.541}. Conclusion: There is a high similarity between the Clinical and the Radiological Diagnosis by using MRI as the investigative modality, and thus MRI is considered one of the most efficient modality for assessing the articular disk in Temporomandibular Joints.

Keywords: Internal derangement, MRI, temporomandibular joint


How to cite this article:
Iqbal H, Sinha A, Agarwal N, Srivastava S, Giri D, Saha A. Assessment of disc position in clinically diagnosed patients of internal derangement of the temporomandibular joint through MRI. J Indian Acad Oral Med Radiol 2019;31:117-22

How to cite this URL:
Iqbal H, Sinha A, Agarwal N, Srivastava S, Giri D, Saha A. Assessment of disc position in clinically diagnosed patients of internal derangement of the temporomandibular joint through MRI. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2019 Jul 24];31:117-22. Available from: http://www.jiaomr.in/text.asp?2019/31/2/117/261079




   Introduction Top


The temporomandibular joints are two of the most frequently used joints in the body, but they probably receive the least amount of attention. Without these joints, we would be severely hindered when talking, eating, yawning, kissing, or sucking. In any examination of the head and neck, the temporomandibular joints should be included.

Temporomandibular disorders (TMDs) consist of several complex multifactorial ailments involving many interrelating factors including psychosocial issues. They comprise a number of clinical problems that can be clustered into the categories of muscle disorders, degenerative changes and intracapsular derangements of the temporomandibular joint (TMJ) components. They cause a wide-ranging and diverse clinical symptoms in the head and neck region. Headache, prosopalgia, movement disturbance, and joint noise develop in the Temporomandibular joint (TMJ), masticatory musculature and associated anatomical structures. It is generally reported that the occurrence rate of TMD begins to increase in the 2nd decade of life, unlike other joint diseases in the human body.

In several articles in the literature, we found that the classification, diagnosis and treatment of pain and dysfunction related to the Temporomandibular joint, or TMJ, were based on diagnoses of TMJ disk position.

Internal derangement (ID) of the Temporomandibular joint (TMJ) is accepted as the most common form of Temporomandibular Joint Disorder (TMD). Internal derangement is an intra-articular condition in which there is a disruption in the normal relationship of the articular disc of the TMJ to the articular eminence and the condyle when the joint is at rest or in function.

Internal derangement has been considered an underlying mechanism in the pathogenesis of TMJ dysfunction associated with clinical symptoms such as pain, joint sounds and abnormal jaw function and a main factor in the development of secondary osteoarthritis. It is one of the most common forms of TMD. It has been reported that 80% of patients with signs and symptoms of TMD have some form of Internal Derangement of the Temporomandibular joint.

Various Imaging modalities have been used for the assessment of disk position like Ultrasonography and Magnetic Resonance Imaging (MRI), however advanced studies have revealed that the MRI shows the direction of displaced disc position most accurately. Literature suggests that Magnetic Resonance (MR) has shown exquisite soft tissue contrast and provided a view of the structures of temporomandibular joint which cannot be differentiated by conventional radiography, conventional tomography and computerized tomography. MR of temporomandibular joint could distinguish internal anatomical features of the joint to a degree that no other imaging procedure can match. An image of the articular disk without contrast media as well an image of the posterior band has made the magnetic resonance the golden standard of temporomandibular joint imaging. The MRI demonstrates the internal anatomic structure of TMJ with great precision, excellent contrast resolution and surpass all known imaging methods in the diagnosis of TMJ disorders.

With the introduction of newer and more advanced imaging modalities, there is a dramatic change in the imaging of head and neck and their utilization which helps in more accurate diagnosis and proper treatment plan.


   Materials and Methods Top


A study was conducted in the department of Oral Medicine and Radiology of Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow. Over a period of 2 years, 47 patients were diagnosed with Internal Derangement—out of which 31 individuals were female and 16 were male. However, MRI was performed on total of 16 clinically diagnosed patients of Internal Derangement of the Temporomandibular joint, out of which 10 were male and 6 were female. 6 asymptomatic volunteers formed the Control Group; 3 of which were male and 3 were female. The mean age of the patients included in the study was 28 years and the mean age of the study group was 33 years. A total of 22 patients were included in the study.

The selected patients were then made to undergo an MRI Scan of the TMJ. The machine chosen was a 1.5 Tesla MRI Scanner of General Electrics Company (GE), Model Signa HDxt installed in the Department of Radiology, Ram Manohar Lohiya Hospital, Lucknow.

The selected 16 symptomatic patients that were included in the study were those that conformed to the clinical diagnostic process. In accord with the Research Diagnostic Criteria (RDC/TMD)[79], 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.

The diagnosis of anterior disk displacement with reduction was given to the patient after the following clinical signs were seen in the patient:

  1. Pain is precipitated by joint movement.
  2. Deviation during movement coinciding with a click.
  3. Reproducible joint noise, usually at variable positions during opening and closing of mandible.
  4. No restriction in mandibular movement (episodic and momentary catching of smooth jaw movements during mouth opening [<35 mm] that self-reduces with voluntary mandibular repositioning).


The diagnosis of anterior disk displacement without reduction was given to the patient after the following clinical signs were seen in the patient:

  1. Pain precipitated by function.
  2. Marked limited mandibular opening.
  3. History of clicking that ceases with the locking.
  4. Pain with palpation of the affected joint; ipsilateral hyperocclusion


Out of the 16 symptomatic patients, only 1 patient had clinically bilateral Internal Derangement, whereas all the rest of the patients had unilateral Internal Derangement. 6 asymptomatic volunteers formed the Control Group; thus a total of 22 patients were included in the study.


   Result Top


Of the total clinical diagnosis for ADDWOR, MRI detected it in 2 out of the 3 cases, and thus detection of MRI being 66.7%. Similarly, of total clinical diagnosis for ADDWR, MRI detected it in 10, and thus detection of MRI being 71.4%. Comparing the frequency of detection between the two procedures, χ2 test revealed similar detection between the two procedures (χ2 = 0.03, P = 0.870) [Table 1].
Table 1: Comparison between clinical diagnosis and MRI findings

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To test the reliability (reproducibility) of MRI findings, the findings were also confirmed on 6 controls (no internal derangement) and 17 cases, and summarized in [Table 2]. Comparing the frequency of MRI findings between the two groups, χ2 test revealed similar visualization in both groups (83.3% vs. 70.6%, χ2 = 0.37, P = 0.541) though it was 12.7% lower in cases.
Table 2: Distribution of MRI findings in controls and cases

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   Discussion Top


Temporomandibular disorders (TMD) are a collection of disorders involving the temporomandibular joint, the soft-tissue structures within the joint, and the muscles of mastication. These TMD conditions as a group are one of the more common chronic painful disorders of the face and jaws. For a number of years, considerable controversy has existed concerning the etiology of TMD, over the series of investigations required for the assessment and diagnosis of TMDs, and even greater controversy has existed regarding treatment approaches.

Most interest concerning Temporomandibular Joint Disorders has been laid down on the articular disc derangement of the TMJ. Internal Derangement is an organic disease and attempts have been made to identify clinical symptoms indicative of TMJ disc displacement. Many studies have been done to identify the exact clinical signs and symptoms that were predictive of the status of the joint. Various diagnostic imaging technique have been performed which contributed to the proper diagnosis of TMJ disorders. With the advent of newer advanced modalities like MRI, both soft tissues can now be viewed in nearly any desired plane of reference with considerable accuracy.

MRI is the preferred examination for soft tissue pathology. The studies reported that accuracy of MRI with respect to disc position is up to 97%. However, the diagnostic quality of disc examination can vary depending on the experience level of both the technologist and the radiologist who interpret the MRI examination, as well as the field strength of the magnet, surface coil and software of the MR imager itself.[1]

The accuracy of clinical examination for diagnosing the exact status of TMJ internal derangements has been investigated in several previous studies by Lorheim[2],[3] which have reported the overall accuracy of the clinical examination as 43% to 95%.

In the present study, the efficacy of MRI in the assessment of the Articular Disc position in clinically diagnosed patients of Internal Derangement was evaluated.

A total of 47 patients visiting the Department of Oral Medicine and Radiology over a period of 2 years with the condition of Internal Derangement were clinically diagnosed and shortlisted for the MRI Investigation. (MRI could however be performed only on 22 of the 47 patients) Out of the 47 patients, 31 (66%) were females and 16 (34%) were males. The prevalence of Internal Derangement being more in females than in males was found in agreement with most of the studies that have been done over the prevalence of TMD's in the past. Schellhas KP, 1989[4] in his study on the Internal Derangement of the Tempomandibular Joint; Radiologic staging with clinical, surgical, and pathological correlation reported that the prevalence of Internal Derangement was found to be 3-5 times more in females than in males. Similar findings were also reported by List T et al.[5] where they stated that the higher prevalence symptoms of TMD in girls and that the development of symptomatic TMD correlated with the onset of puberty.

The present study on MRI was done on 1.5 Tesla MRI Machine because of difficulty in localizing the discs on MRI machines of lower magnetic field strength [Figure 1]a and [Figure 1]b. This observation was found in agreement with Hannson et al.[6] performed a study on MRI of the temporomandibular joint in which he compared the Autopsy Specimen made at 0.3 and 1.5 T and compared the 2 image sequences. Imaging time and slice thickness were the same on scans made at each field strength. The purpose was to determine which field strength provides the best scans for imaging of the joint. The disk position, disk configuration, and bony abnormalities were correctly diagnosed in 85%, 77%, and 100%, respectively, on 1.5-TMR images compared with 46%, 41%, and 85%, respectively, on the 0.3-T images. Their results suggested that the diagnostic quality of MR images of the temporomandibular joint is better on scans made at 1.5 T than on those done at 0.3 T.
Figure 1: (a) Position of the patient in the MRI scanner with head coil in closed mouth position, (b) Position of the patient in the MRI scanner with head coil in open mouth position

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The primary importance in patients with Internal Derangement is assessing the disc position in relation to the condyle and the articular eminence. In the present study, amongst the normal subjects at closed mouth position, when the MRI Scans were evaluated, the posterior end of the disc was localized at its normal 11-12 o'clock position and at open mouth position in the normal subjects, the thin intermediate zone of the articular disk was found to be located between the articular eminence and the anterior portion of the condyle [Figure 2]a and [Figure 2]b.
Figure 2: (a) MRI scan image of the articular disc in a normal tmj in closed mouth position, (b) MRI scan image of the articular disc in a normal tmj in open mouth position

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This was in agreement with the findings of Wang et al.[7] who stated that on normal sagittal oblique closed-mouth images, a commonly cited standard for normal disc position on MRI is visualization of the posterior margin of the posterior band at an 11 o'clock position or more posterior clock face position above the mandibular condyle. Richard Wier Katzberg[8] in his paper on Temporomandibular Joint Imaging also stated that, at a closed-mouth position, in the sagittal plane, the disk had a biconcave-lens-like configuration with the posterior band lying at the 12 o'clock position relative to the condylar head when the jaw was opened the mid portion of the disc was remained interposed between the condyle and the tubercle.

In the present study, there were 16 patients that were evaluated and out of which only 1 patient had Internal Derangement diagnosed bilaterally. Therefore, there were a total of 17 joints that were being assessed. Out of the 17 joints, a clinical diagnosis of Anterior Disc Displacement without Reduction (ADDWR) was given to 14 joints (82.4%) whereas only 3 patients were given a diagnosis of Anterior Disc Displacement without Reduction (ADDWOR) (17.6%) [Figure 3]a and [Figure 3]b.
Figure 3: (a) Clinical Examination of Patient with Internal Derangement (b)Clinical Examination of the TMJ of patient with Internal Derangement

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Of the 3 patients suffering from ADDWOR, MRI detected 2 of the patients with Anterior Disc Displacement without Reduction, where as in one of the patients, the Disc appeared to reduce on opening of the mouth. Thus, the accuracy of the detection of the MRI was 66.7% [Figure 4]a and [Figure 4]b.
Figure 4: (a) MRI scan image of the anteriorly placed articular disc in a patient with anterior disc displacement without reduction in closed mouth position, (b) MRI scan image of the anteriorly placed articular disc in a patient with anterior disc displacement without reduction in open mouth position

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Out of the total of 14 joints diagnosed with Anterior Disc Displacement with Reduction (ADDWR), [Figure 5]a and [Figure 5]b. MRI was found in agreement with the clinical diagnosis in 10 of the joints and thus detection of MRI being 71.4%. Out of the remaining 4 joints, 2 joints appeared to have their disc in the normal position at the Open and Closed Mouths position, whereas in the remaining 2 joints, the Disc was not able to be visualized/ localized in the scan.
Figure 5: (a) MRI scan image of the anteriorly placed articular disc in a patient with anterior disc displacement with reduction in closed mouth position, (b) MRI scan image of the articular disc in a patient with anterior disc displacement with reduction in open mouth position

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Thus, MRI finding was found in agreement with that of the clinical diagnosis in 66.7% cases of Anterior Disc Displacement without Reduction, and the MRI finding was similar as the clinical diagnosis in 71.4% of the cases. Out of the 17 joints evaluated, the MRI findings were found to be dissimilar with the clinical diagnosis in about 17.64% of the cases, and the disc could not be visualized 11.76% of the patients.

Such a high percentage of agreement between the clinical diagnosis and the MRI finding was found in agreement with the studies conducted by El-Essawy et al.[9] who conducted a study on “MRI evaluation of TMJ derangement in symptomatic and asymptomatic patients”. This study was based on magnetic resonance images of 68 joints. They concluded that the MRI with the use of surface coils markedly improves the delineation of internal derangement of the TMJ; therefore, it enhanced the capability of detecting certain abnormalities, which proved to have a statistical significance in symptomatic patients. Yong-Suk Choi et al.,[10] made a study on “Analysis of Magnetic Resonance Images of Disk Positions and Deformities in 1,265 Patients with Temporomandibular Disorder”. This study was based on magnetic resonance images of 2,530 joints. He concluded that his study revealed a high correlation between clinical symptoms and MRI manifestations. Additional significant differences were observed between symptomatic and asymptomatic patients with respect to disk position and deformities. Zeev V. Maizlin 2010[11] conducted a study on “Correlation between Clinical Findings and MRI Characteristics in Clinically Diagnosed Patients of Internal Derangement and Asymptomatic Volunteers.” In their study, disk displacement was found in 45 (54%) of the 84 symptomatic joints and 13 (22%) of the 60 asymptomatic joints. A study done by Anelyssa D'Abreau[12] revealed a significant correlation between the clinical and imaging findings in the Internal Derangement of TMJ where the significance level was established as P< 0.05.

However, the findings in our study seemed to be contradictory with the findings conducted by Mahrokh Imanimoghaddam et al.[13] conducted a study on the MRI Findings in Patients with TMJ Click over a total of 26 patients with clinical symptoms of disk displacement with reduction (DDwR) according to RDC/TMD were compared to 14 normal subjects in terms of their MRI findings, including disk displacement, effusion, condylar osteoarthritic changes and disk deformities.

The result they obtained suggested that out of 80 joints in total (52 affected joints in 26 patients and 28 joints in control group), 48 were shown with normal disk position in MRI whereas 28 (35%) and 4 (5%) were categorized as DDWR and DDWOR, respectively. Similar finding was also reported Barclay et al.[14] whoconducted a study on comparison of the clinical and magnetic resonance imaging diagnoses in patients with disk displacement in the Temporomandibular joint. They conducted a clinical examination of 78 joints in 39 patients, each with disk displacement with reduction in at least one TMJ, and compared with the MRI diagnoses. The diagnostic agreement between RDC/TMD and MRI diagnoses for all joints examined was 53.8%. Most of the disagreement was due to false negative clinical diagnoses for asymptomatic joints.

They concluded that a positive RDC/TMD examination is predictive for internal derangement but not reliable with regard to the type of disk displacement; such examination is therefore of limited value in determining the true disk position and its functional movements.


   Conclusion Top


A wide variety of signs and symptoms are elicited in patients with Internal Derangement, most predominantly being joint pain/tenderness, clicking, deviation and reduction in mouth opening. In our present study, among normal subjects, in closed-mouth position, the posterior end of the Disc was localized at its normal 11-12 o'clock position and at open mouth position, the thin intermediate zone of the articular disk was found to be located between the articular eminence and the anterior portion of the condyle. Of the patients suffering from Anterior Disc Displacement without Reduction (ADDWOR), the accuracy of the detection on the MRI was found to be 66.7%. Of the patients suffering from Anterior Disc Displacement with Reduction (ADDWR), the accuracy of the detection on the MRI was found to be 71.4%.

There is a high similarity between the Clinical and the Radiological Diagnosis by using MRI as the investigative modality, and thus MRI is considered one of the most efficient modality for assessing the articular disk in Temporomandibular Joints. In our study, we could not arrive at a particular set of sequences of MRI for the detection of Disk position. Thus, multiple sets of sequences of MRI were run in order to localize the disk, and confirm the diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hansson LG, Westesson PL, Katzberg RW, Tallents RH, Kurita K, Holtås S, et al. MR imaging of the temporomandibular joint: Comparison of images of autopsy specimens made at 0.3 T and 1.5 T with anatomic cryosections. AJR Am J Roentgenol 1989; 153:1316.  Back to cited text no. 1
    
2.
Lorheim TA. Current trends in temporomandibular joint imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80:555-76.  Back to cited text no. 2
    
3.
White SC, Pharoah MJ. Oral Radiology, Principles and Interpretation. 4th ed. St. Louis: Mosby; 2000. p. 500-2.  Back to cited text no. 3
    
4.
Schellhas KP. Internal derangement of the temporomandibular joint; Radiologic staging with clinical, surgical, and pathological correlation. Magn Reson Imaging 1989; 7:495-515.  Back to cited text no. 4
    
5.
List T, Wahlund K, Wenneberg B, Dworkin SF. TMD in children and adolescents: Prevalence of pain, gender differences, and perceived treatment need. J Orofac Pain 1999; 13:9-20.  Back to cited text no. 5
    
6.
Hansson LG. MR imaging of the temporomandibular joint: Comparison of images of autopsy specimens made at 0.3 T and 1.5 T with anatomic cryosections. AJR Am J Roentgenol 1989; 152:1241-4.  Back to cited text no. 6
    
7.
Wang EY, Fleisher KA. MRI of temporomandibular joint disorders. J Appl Radiol 2008;37:17-25.  Back to cited text no. 7
    
8.
Katzberg RW. Temporomandibular joint imaging. Radiology 1989; 170:297-307.  Back to cited text no. 8
    
9.
El-Essawy MT, Al-Nakshabandi NA, Al-Boukai AA. Magnetic resonance imaging evaluation of temporomandibular joint derangement in symptomatic and symptomatic patients. Saudi Med J 2008; 29:1448-52.  Back to cited text no. 9
    
10.
Choi YS, Asaumi J, Hisatomi M, Unetsubo T, Yanagi Y, Matsuzaki H, et al. Analysis of Magnetic Resonance Images of disk positions and deformities in 1265 patients with temporomandibular disorder. Open Dent J 2009; 6:1-20.  Back to cited text no. 10
    
11.
Maizlin ZV, Nutiu N, Dent PB, Vos PM, Fenton DM, Kirby JM, et al. Displacement of the temporomandibular joint disk: Correlation between clinical findings and MRI characteristics. J Can Dent Assoc 2010; 76:a3.  Back to cited text no. 11
    
12.
Costa ALF, D'Abreu A, Cendes F. Temporomandibular joint internal derangement: Association with headache, joint effusion, bruxism, and joint pain. J Contempt Dent Pract 2008; 9:9-16.  Back to cited text no. 12
    
13.
Imanimoghaddam M, Madani AS, Mahmoudi Hashemi E. MRI findings in patients with TMJ click. J Dent Mater Tech 2014; 3:28-36.  Back to cited text no. 13
    
14.
Barclay P, Hollender LG, Maravilla KR, Truelove EL. Comparison of clinical and magnetic resonance imaging diagnosis in patients with disk displacement in the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88:37-43.  Back to cited text no. 14
    


    Figures

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

  [Table 1], [Table 2]



 

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