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J Am Dent Assoc, Vol 132, No 6, 753-761.
© 2001 American Dental Association
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RESEARCH

JADA Continuing Education

Diagnosing TMJ internal derangement and osteoarthritis with magnetic resonance imaging



STEFAN BERTRAM, M.D., D.M.D., ANSGAR RUDISCH, M.D., KATHARINA INNERHOFER, M.D., EDUARD PÜMPEL, M.D., D.M.D., GERT GRUB-WIESER, M.D., D.M.D. and RÜDIGER EMSHOFF, M.D., D.M.D.


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. The authors conducted a study to investigate the relationship between the presence of temporomandibular joint, or TMJ, pain and magnetic resonance imaging, or MRI, findings of internal derangement, or ID, and arthritis, or OA.

Methods. The authors studied 131 consecutively seen TMJ pain patients. Their criteria for including a patient in the study were report of unilateral orofacial pain referred to TMJ and the presence of unilateral TMJ pain during palpation, function, and unassisted or assisted mandibular opening. The authors took bilateral sagittal and coronal MRIs to establish the presence or absence of TMJ ID, OA or both.

Results. When the authors compared TMJ side–related data from all subjects, they found a significant relationship between the clinical findings of TMJ pain and the MRI diagnoses of TMJ ID (P = .000) and TMJ OA (P = .013). They also found a significant relationship between the MRI diagnosis of TMJ ID type and that of TMJ OA (P = .000). The authors used the {kappa} statistical test and found poor diagnostic agreement between the presence of TMJ pain and the MRI diagnosis of TMJ ID ({kappa} = 0.21), TMJ OA ({kappa} = 0.15), and TMJ ID and OA combined ({kappa} = 0.18).

Conclusions. The study’s findings suggest that while clinical pain is related to TMJ-related MRI findings, the presence of clinical pain is not a reliable predictor of TMJ ID, OA or both.

Clinical Implications. Using MRI to supplement clinical findings of TMJ pain appears warranted and necessary to establish the presence or absence of TMJ ID.

Patients with temporomandibular disorders, or TMDs, can have a cluster of joint and muscle disorders that are characterized primarily by pain, joint sounds, and irregular or deviating jaw function.1,2 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 position3,4 and TMJ osteoarthritis, or OA.5,6 Whether TMJ disk displacement, TMJ OA or both can be linked to the onset, progress or cessation of TMJ-related signs and symptoms, however, remains a point of controversy.7.8 Clinical trials suggested therapeutic approaches such as splint therapy,9,10 arthrocentesis,11.12 arthroscopic lysis and lavage,13.14 and arthrotomy.15,16 Yet in terms of diagnosis and therapy, we found only a few studies17–21 that addressed the evaluation of TMJ-related variable pain in relation to magnetic resonance imaging, or MRI, diagnoses of TMJ internal derangement, or ID, and TMJ OA. We conducted this study to investigate the relationship between the presence of TMJ pain and the MRI findings of ID and OA.

This study revealed a significant relationship between the presence of temporomandibular joint, or TMJ, pain and the magnetic resonance imaging diagnoses of TMJ internal derangement, or ID, and TMJ ID type.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Subjects. The study group of symptomatic consecutive TMJ pain patients comprised 112 females and 19 males, whose mean age was 36.4 years (range, 14–79 years). We informed the subjects about the study procedure and received informed consent from them. We included patients in the study if they met the following criteria: had a report of unilateral orofacial pain referred to the TMJ; unilateral TMJ pain was present during palpation, function, and unassisted or assisted mandibular opening; no signs and symptoms that characterized a diagnosis of myalgia; no history of trauma; and an absence of collagen vascular disease.

Methods. Clinical assessment. The clinical assessment consisted of a standardized evaluation of signs and symptoms of TMD, including mandibular range of motion, joint sounds, joint and muscle pain on palpation, and pain on unassisted or assisted mandibular opening.22

To evaluate the subjects’ mandibular ranges of motion, we measured the maximum opening from a central maxillary incisor to the opposing mandibular incisor, using a millimeter ruler. We then measured lateral movements relative to the maxillary midline with the teeth slightly separated. We also listened to the TMJs with a stethoscope as the subject performed three openings and three lateral and protrusive movements. Joint sounds were described as single and reciprocal clicks.

We used magnetic resonance images to analyze the diskcondyle relationship that depicted the disk, condyle, articular eminence and glenoid fossa.

We assessed patients’ TMJ pain on palpation through bilateral manual palpation of the lateral aspect of the condyle. TMJ pain during unassisted mandibular opening was assessed by asking patients to perform maximum voluntary jaw openings. We performed assisted mandibular openings by applying force to each patient’s lower and upper incisors with our middle fingers and thumbs. A positive pain score was recorded by the examiner (R.E.) if a patient experienced a distinctly painful sensation in the TMJ during the procedure.

Muscle pain was assessed using a bilateral manual palpation technique. We palpated the anterior, posterior and middle temporalis; the tendon of temporalis; the superficial and deep masseters; the lateral pterygoid; and the anterior and posterior digastric muscles. We diagnosed myalgia if palpation produced a clear reaction from the patient—that is, if the patient experienced a distinctly tender or painful sensation (pain score of 2 or higher on a 0 to 3 severity scale in which 3 is most pain) in two or more muscle sites.23

The study was single-blind; the clinical records and MRIs were interpreted by the clinician (R.E.) and medical radiologist (A.R.) independently without knowledge of the other’s results.

MRI. MRI was carried out with a 1.5 tesla MRI scanner and a dedicated, circular-polarized, transmit-and-receive TMJ coil. The data were collected on a 252 x 256 dots-per-inch matrix with a field of view of 145 mm, giving a pixel size of 0.60 x 0.57 mm.

With the patient in a supine position, we obtained 15 coronal slices and eight parasagittal slices of each TMJ using a turbo-spin-echo–proton-density sequence (time of reception, 2,800 milliseconds; echo time, 15 ms) with thin 3-mm slices. MRIs were corrected to the horizontal angulation of the long axis of the condyle. Each subject received a nonferromagnetic intermaxillary device to wear to help him or her obtain the different mouth opening positions required for this examination. We made sequential bilateral images with the subject’s mouth closed and at the maximum mouth opening positions.

Diagnosis. We selected those MRIs to analyze the disk-condyle relationship that depicted the disk, condyle, articular eminence and glenoid fossa. We defined normal disk position as the posterior band of the disk being located at the superior, or 12 o’clock, position relative to the condyle, whereas we defined disk displacement as the posterior band of the disk being in an anterior, anteromedial, anterolateral, medial or lateral position relative to the superior part of the condyle.

We categorized diagnosis of the TMJ disk-condyle relationship as no internal derangement, or NID; disk displacement with reduction, or DDR; and disk displacement without reduction, or DDNR. We based our categorizations on finding a closed-mouth–related diagnosis of absence or presence of disk displacement associated with or without an open-mouth–related interposition of the disk between the condyle and the articular eminence.3 We defined MRI diagnosis of TMJ OA as 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.24,25

Data analysis. We statistically assessed the TMJ-related MRI findings of ID and OA using {chi}2 analysis. We also evaluated the statistical significance of the diagnostic percentage agreement between the clinical findings and MRI diagnoses using the {kappa} statistical test. We set significance at P < .05 and used a statistical package (SPSS for Windows, Version 7.5.2G [1997], SPSS Inc.) for all statistical analysis.


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
An MRI diagnosis of TMJ ID was established in 176 of 262 TMJs (67.2 percent) (Table 1Go), while 74 TMJs (28.2 percent) were found to have a TMJ ID type of DDR, and 102 (38.9 percent) were found to have a TMJ ID type of DDNR (Table 2Go). Analysis of side-related data showed a significant relationship between the clinical finding of TMJ pain and the MRI diagnoses of TMJ ID (P = .000) and of TMJ ID type (P = .000) (Table 1Go and Table 2Go). In TMJs with pain, 69 of the 131 joints (52.7 percent) were characterized by the presence of DDNR, while in the TMJs without pain, only 33 of the 131 joints (25.2 percent) showed DDNR (Table 2Go).


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  		TABLE 1 RELATIONSHIP BETWEEN MRI* DIAGNOSIS OF TMJ{dagger} ID{ddagger} AND TMJ PAIN IN PATIENTS WITH UNILATERAL TMJ PAIN (N = 262).§

 

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  		TABLE 2 RELATIONSHIP BETWEEN MRI* DIAGNOSIS OF TMJ{dagger} ID{ddagger} TYPE AND TMJ PAIN IN PATIENTS WITH UNILATERAL TMJ PAIN (N = 262).§

 
Regarding the distribution of TMJ OA, 30 of 122 of such TMJs (24.6 percent) were associated with an MRI diagnosis of TMJ NID, and 24 (19.7 percent) and 68 (55.7 percent) were DDR and DDNR, respectively (Table 3Go). We found a significant relationship between the clinical finding of TMJ pain and the MRI diagnosis of TMJ OA (P = .013) (Table 4Go), and between the MRI diagnosis of TMJ ID type and that of TMJ OA (P = .000) (Table 3Go) (Figure 1Go). In TMJs with pain, 71 of the 131 joints (54.2 percent) were characterized by the presence of OA, while in the TMJs without pain, only 51 of the 131 joints (38.9 percent) showed OA (Table 4Go). A diagnosis of DDNR was more prevalent in TMJs with OA than those without OA (55.7 percent vs. 24.3 percent), whereas the diagnoses of NID (40.0 percent vs. 24.6 percent) and DDR (35.7 percent vs. 19.7 percent) were observed more frequently in TMJs without OA than those with OA (Table 3Go).


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  		TABLE 3 RELATIONSHIP BETWEEN MRI* DIAGNOSES OF TMJ{dagger} ID{ddagger} TYPE AND OA§ (N = 262).**

 

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  		TABLE 4 RELATIONSHIP BETWEEN MRI* DIAGNOSIS OF TMJ{dagger} OA{ddagger} AND TMJ PAIN IN PATIENTS WITH UNILATERAL TMJ PAIN (N = 262).§

 


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  		Figure 1. Bilateral closed-mouth–related magnetic resonance images, or MRIs, in a patient with right side–related temporomandibular joint, or TMJ, pain. A–B. Left TMJ that does not have internal derangement or osteoarthrosis, or OA. A. Sagittal MRI shows posterior band of the disk (arrows) superior to condyle. B. Coronal MRI shows disk superior to condyle (arrows). C–D. Right TMJ with OA and anterolateral disk displacement without reduction. C. Sagittal MRI shows disk (arrows) anterior to condyle, which is flattened and deformed. D. Coronal MRI showing lateral disk displacement (arrows) associated with condylar shape abnormalities.

 
Comparing the agreement between the presence of TMJ pain and the MRI diagnoses of ID and OA, the TMJ group {kappa}-values for ID, OA, and ID and OA combined were 0.21, 0.15 and 0.18, respectively, indicating poor agreement between the clinical and the MRI findings (Figure 2Go) (Table 5Go, page 759).



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  		Figure 2. Bilateral closed-mouth–related magnetic resonance images, or MRIs, in a patient with left-side–related temporomandibular joint, or TMJ, pain. A–B. Left TMJ with osteoarthritis, or OA, and anterior disk displacement without reduction, or DDNR. A. Sagittal MRI shows disk (arrows) anterior to condyle, which is flattened and deformed. B. Coronal MRI showing anterior disk displacement (arrows) associated with condylar shape abnormalities. C–D. Right TMJ with OA and anterolateral DDNR. C. Sagittal MRI shows disk (arrows) anterior to condyle, which is flattened and deformed. D. Coronal MRI showing anterolateral disk displacement (arrows) associated with abnormalities of condylar shape.

 

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  		TABLE 5 DIAGNOSTIC AGREEMENT BETWEEN CLINICAL FINDING OF TMJ* PAIN AND MRI{dagger} DIAGNOSES OF TMJ ID{ddagger} AND OA§ IN PATIENTS WITH UNILATERAL TMJ PAIN (N = 262).

 

   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
This study revealed a significant relationship between the presence of TMJ pain and the MRI diagnoses of TMJ ID and TMJ ID type. Our results are comparable with those of previous studies that reported that in patients with TMD pain and dysfunction the side affected with TMJ may be associated with high MRI-related prevalences of TMJ ID and the TMJ ID type of DDNR. Prevalence percentages reported in other studies have ranged from 69.5 to 100.0 percent for TMJ ID26–29 and from 47.5 to 100.0 percent for the TMJ ID type of DDNR.26–29 These findings may support the concept that TMJ ID is involved significantly in the production of TMJ pain and dysfunction. However, given the fact that TMJ ID alone is not always associated with pain and dysfunction and since several imaging studies also have demonstrated the occurrence of bilateral TMJ ID with frequencies ranging from 51.0 to 71.0 percent,3,30–34 more data may be needed if TMJ ID or TMJ ID type are to become generally accepted as a diagnostic guide in the management of patients with TMD who have TMJ-related pain.

Our finding of a significant relationship between structural TMJ OA changes and TMJ-related pain may contrast with the results of researchers who reported high prevalences of radiographic signs of OA in asymptomatic TMJs (range, 50.0–90.0 percent).35–37 The prevalence of TMJ OA, however, is reported with great variation in the literature, and multiple-factor studies using specific clinical and imaging criteria for diagnosing TMJ OA still are lacking. These facts indicate the need for further investigations to test the hypothesis that patients with TMD who have TMJ-related pain and dysfunction with specific clinical symptoms do not differ from control subjects with regard to the presence of specific imaging signs of TMJ OA.38

There was a predominance of TMJ OA in TMJ DDNR (55.7 percent), but OA also was found in 24.6 percent of TMJs with NID and in 19.7 percent of TMJs with DDR. This contradicts the traditional theory of a disease process associated with TMJ DDR, since evidence of OA was present more often in TMJ NID. However, with this clear link between TMJ ID type and TMJ OA, the study emphasizes the need for longitudinal imaging studies to clarify the relationship between TMJ ID and TMJ OA. Further, to identify which parameters may define patients with TMJ pain and those without TMJ pain, multiple-factor studies, including additional morphological variables, are needed, while from a methodological point of view, only a well-controlled incidence study rather than a case-control study may clarify the etiologic contribution of TMJ ID and OA to TMJ pain.39

Our study revealed an unacceptable level of agreement between the clinician’s finding of TMJ pain and the radiologist’s corresponding MRI diagnoses of ID, OA, and ID and OA combined. Several authors investigated the reliability of clinical items for TMJ ID and OA using arthrography and MRI as a "gold standard."26,27,29,40–45 The reported percentage agreement ranged from 59.0 to 90.0 percent for TMJ ID, depending on the diagnostic criteria used in the respective studies. Some researchers investigated a single mandibular range of motion, TMJ sound, dental occlusion, TMJ pain or masticatory muscle pain when predicting TMJ ID values.40–45 Other authors who used strict inclusion criteria for one diagnosis, however, failed to describe essential characteristics that distinguished one diagnosis from another.26,27,29 In two of the studies, OA was validated by arthrography and MRI in 35 percent and 64 percent of the clinical predictions, respectively.27,29 When tomographic films were used before arthrography, validation of OA was described in 95 percent and 100 percent of the predictions.26

This would seem to support the concept that besides clinical joint crepitus, grating or both, the diagnosis of OA is primarily a radiographic diagnosis.46

With regard to the diagnostic approach of TMJ-related pain applied in our study, the overall intra- and interobserver reliability has not been tested yet. The use of strict inclusion and exclusion criteria, however, may have defined a homogeneous TMJ pain group. Further studies including a large sample of patients with and without TMD are warranted to describe TMJ pain–specific data on TMD subject-related and TMJ side-related prevalences of ID and OA.

In terms of clinical decision making, our findings raise the question of whether the use of clinical TMJ-related TMD diagnoses may need to be supplemented by MRI to distinguish among subtypes of TMD. From a methodological point of view, etiology, prognostic statements and treatment implications are considered to be the main indicators for the utility of diagnostic classifications.47 Further research may be needed to assess the diagnostic validity of MRI-related variables of TMJ ID and OA by determining how well these diagnoses show decisive differences in pathogenesis, treatment and prognosis.


   CONCLUSIONS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The study’s findings suggest that while clinical pain is related to TMJ-related MRI findings, the presence of clinical pain in and of itself is not a reliable predictor of TMJ ID, OA or both. Therefore, using MRI to supplement the clinical findings appears warranted and necessary.


   FOOTNOTES
 

Dr. Bertram is a consultant, Department of Oral and Maxillo-Facial Surgery, University of Innsbruck, Austria.


Dr. Rudisch is a resident, Department of Magnetic Resonance Imaging and Department of Radiology, University of Innsbruck, Austria.


Dr. Innerhofer is a research fellow, Department of Oral and Maxillo-Facial Surgery, University of Innsbruck, Austria.


Dr. Pümpel is a resident, Department of Orthodontics, University of Innsbruck, Austria.


Dr. Grubwieser is a resident, Department of Oral and Maxillo-Facial Surgery, University of Innsbruck, Austria.


Dr. Emshoff is an associate professor, Department of Oral and Maxillo-Facial Surgery, University of Innsbruck, Maximilianstr. 10, A-6020, Innsbruck, Austria, e-mail "Ruediger_Emshoff{at}hotmail.com". Address reprint requests to Dr. Emshoff.


   REFERENCES
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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