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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 3  |  Page : 956-961

Magnetic resonance imaging of temporomandibular joint disorders


1 Department of Radiodiagnosis, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Diagnostic Radiology at Ministry of Health, Shebin Elkom Neurosurgery Hospital, Menoufia, Egypt

Date of Submission27-Oct-2018
Date of Decision21-Nov-2018
Date of Acceptance25-Nov-2018
Date of Web Publication30-Sep-2020

Correspondence Address:
Maged F. A. El Monem
Gamal Shahen Street, Al-Bagour, Menoufia 32821
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_325_18

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  Abstract 


Objective
The aim was to highlight the role of MRI in the evaluation of temporomandibular joint (TMJ) disorders.
Background
MRI has become a mainstay in the evaluation of TMJ disorders given its ability of noninvasively depicting major regional anatomic structures and demonstrating the presence of joint effusion and bone marrow signal-intensity abnormalities. Consequently, MRI has become the gold standard in diagnosing articular disc displacement.
Patients and methods
In this study, we included 30 patients (60 joints) who were referred from dentist's and rheumatologist clinics. They had clinical manifestations of TMJ affection. They were subjected to clinical history and examination. The main tool for diagnostic assessment was the conventional MR study of the TMJ in both opened and closed mouth positions.
Results
This study suggests the use of MRI as a proper diagnostic modality for TMJ disorders owing to the excellent soft tissue contrast and multiplanar capabilities that enable enhanced demonstration of complex anatomy and superior assessment of the pathological conditions of the TMJ, especially internal derangement of the TMJ.
Conclusion
There were 28 normally positioned discs out of the examined 60 joints. There were 13 joints showing partial anterior disc displacement (ADD) with reduction. We found five joints showing partial ADD without reduction. We found 13 joints showing complete ADD without reduction. We found one joint showing osteoarthritis.

Keywords: disc, disorders, magnetic resonance imaging, mouth, temporomandibular joint


How to cite this article:
Al Wakeel AM, Abdullah MS, El Monem MF. Magnetic resonance imaging of temporomandibular joint disorders. Menoufia Med J 2020;33:956-61

How to cite this URL:
Al Wakeel AM, Abdullah MS, El Monem MF. Magnetic resonance imaging of temporomandibular joint disorders. Menoufia Med J [serial online] 2020 [cited 2020 Oct 22];33:956-61. Available from: http://www.mmj.eg.net/text.asp?2020/33/3/956/296662




  Introduction Top


Temporomandibular joint (TMJ) dysfunction is a common condition that, according to some studies, affects up to 28% of population [1].

MRI has become a mainstay in the evaluation of TMJ disorders given its ability of noninvasively depicting major regional anatomic structures and demonstrating the presence of joint effusion and bone marrow signal-intensity abnormalities. Consequently, MRI has become the gold standard in diagnosing articular disc displacement [2].

MRI is accepted as the most advanced imaging modality for diagnosis of TMJ abnormalities. It is noninvasive and has the potential to yield high-quality tomographic imaging in any plane with bone as well as soft tissue spatial resolution. Additionally, the patient is not exposed to ionizing radiation or any biological hazards. Other advantages of MRI are its sensitivity, specificity, and diagnostic accuracy [3].

The most frequent cause of TMJ disorder, or TMJ dysfunction, is internal derangement, which is defined as an abnormal relationship of the disc to the condyle. Precise localization of the disc is very important in the diagnosis of TMJ internal derangement and can easily be achieved with MRI. Furthermore, MR imaging helps in the assessment of signs of TMJ dysfunction (e.g. joint effusion, thickening of lateral pterygoid muscle attachment, and rupture of retrodiscal layers). MRI also demonstrates degenerative changes (e.g., osteoarthritis) [1].

MRI represents the best method for studying clinically affected joints, for the evaluation of morphological status of TMJ, and analysis of dynamic process during mouth opening [4]. These are not true dynamic images, but pseudodynamic MRI obtained from the serial multiple static images [5].

MRI has been shown to accurately delineate the structures of TMJ and is the best technique to correlate and compare TMJ components such as bone, disc, fluid, capsule, and ligaments with autopsy specimens [6].

MRI may depict joint abnormalities not seen with any other imaging method and thus is the best method to make a diagnostic assessment of TMJ status [7].

This study aims to highlight the role of MRI in evaluation of TMJ disorders.


  Patients and Methods Top


In this prospective study, we included 30 patients (60 joints) who were referred from dentist's and rheumatologist clinics. Of these 30 patients, there were 22 female and eight male patients. This study was performed in the period from January 2017 to May 2018.

Patients were referred from both dentistry and rheumatology clinics. They had clinical manifestations of TMJ affection. The clinical inclusion criteria for the study group were assessed on following five clinical characteristics: limited mouth opening, deflection of mandible to the affected side at the maximal mouth opening, TMJ pain at the preauricular region during mandibular movement, limitation of condylar translation at the maximal mouth opening, crepitation during mouth opening, and/or closing movement.

The exclusion criteria for the study group were as follows: patient with cerebral aneurysm clip, patient with cardiac pace maker, patient with obvious skeletal jaw deformity, patient undergoing/with history of orthodontic treatment, patient with history of traumatic extraction, patients who were claustrophobic and uncooperative, and those with metallic prosthesis like heart valves and ferromagnetic foreign bodies in critical location like eye. This study was conducted according to the guidelines of the ethics committee of our university and was approved by our institutional review board. All patients gave written informed consent to be imaged in our study.

The patients were subjected to full clinical history and examination including palpation of the TMJ and muscles of mastication for pain, palpation of joint sounds, and mouth opening for any limited movement. The main tool for diagnostic assessment was the conventional MR study of the TMJ in both opened and closed mouth positions.

All of the 30 cases underwent routine bilateral TMJ MR examination on 1.5 Tesla machine (Toshiba, Tokyo, Japan), HS (high speed) 1.5 T system, in MRI Unit of Radiodiagnosis Department at Menoufia University Hospital. Patients were laid supine with both arms adducted where the special TMJ dual coil was applied for examination. Imaging started by axial localizer including the whole skull base. Pulse sequence spin echoes were obtained from all patients in closed and maximal open mouth positions on corrected (oblique) sagittal T1-weighted, proton density (PD), and T2-weighted images, with corrected (oblique) coronal views done in T1 and PD weighted images. Matrix: 256_128, field of view: 10–12 cm. Number of slices: 18, Slice thickness/space: 3 mm, imaging time: 3.14 min TMJ Localizer: plane: Axial, Pulse sequence: Spin-echo, number of slices: 10, slice thickness/space: 5/2 mm, TR/TE: 300 ms/12 ms. Imaging time: 28 s. Sagittal and coronal oblique T1 weighted image – repetition time: 400–500 ms, echo time: 10–20 s. Sagittal and coronal oblique PD weighted image – repetition time: 2000 ms, echo time: 10–14 ms. Sagittal oblique T2 weighted image: – repetition time: 2600 ms, echo time: 120 ms. Mouth opening devices such as Burnett opening devices may be used or anything like empty syringe put in mouth to keep it opened.

Image interpretation was done by two consultant radiologists with experience of fifteen years and six years correspondingly. Both TMJs were examined for disk position, disk configuration, presence or absence of joint effusion in TMJ space, and morphology of mandibular condyle.


  Results Top


In this study, 30 patients and 60 joints were included, having clinical manifestations of TMJ affection. Age and sex distribution of the examined patients is shown in [Table 1].
Table 1: Age and sex distribution of the examined patients

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Clinical manifestations of the examined patients are shown in [Table 2].
Table 2: Clinical manifestations of examined joints

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Of the examined 60 joints, 32 joints showed abnormal MRI findings, of which 31 joints showed anterior disc displacement (ADD) and one joint showed osteoarthritis, which shows that there was a statistically significant difference between the different etiologies of the TMJ disorders. Regarding the presence of clicking (P < 0.05), clicking was present in 100% of patients with partial ADD with reduction, whereas there was no statistical significant difference regarding the presence of pain and limited mouth opening (P > 0.05) [Table 3].
Table 3: Laterality of affection of the temporomandibular joint

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Bilateral TMJ affection was frequently seen, representing 43.3% of cases.

The final results of the TMJs of the patients examined by conventional MRI as shown in [Table 4] were categorized according to following MR criteria into the following: (a) normal state, no disc displacement: there were 28 normally positioned joints out of the examined 60 (46.7%) joints. Normal disc position is shown in [Figure 1] (the thin intermediate zone interposed between the condyle and the adjacent temporal bone, wherever the two bones are most closely opposed to one another regardless of whether or not the mouth was open or closed) [3]. (b) Partial anterior disc displacement with reduction (PADDWR): disc displaced anteriorly in closed mouth up to the posterior band interposed between the two most closely apposed cortical bone surfaces of the condyle and eminence with disc reduction to normal location in open mouth position as shown in [Figure 2] [3]. There were 13 joints showing PADDWR. Of these 13 joints, only three joints showed degenerated discs with altered signal intensity. Of these 13 joints, nine joints showed adequate condylar forward translation, two joints showed limited condylar forward translation, and two joints showed excessive condylar translation. (c) Partial anterior disc displacement without reduction (PADDWOR): disc displaced anteriorly in closed mouth as described in category B, that maintained displaced with mouth opening, as shown in [Figure 3] [3]. They represented five joints. All joints showed deformed disc either buckled or flattened or degenerated. Of these, two joints showed limited condylar forward translation and three joints showed adequate condylar forward translation. (d) Complete anterior disc displacement with reduction (CADDWR): disc displaced anteriorly in closed mouth up to no disc substance interposed between the two most closely apposed cortical bone surfaces of the condyle and eminence with disc reduction to normal location in open mouth position [3]. No joints showed CADDWR in our study. (e) Complete anterior disc displacement without reduction (CADDWOR): disc displaced anteriorly in closed mouth as described in category D, which maintained displacement with mouth opening, as shown in [Figure 4] [3]. There were 13 joints showing CADDWOR. Of these 13 joints, all of them showed deformed disc either buckled or flattened or degenerated with altered signal intensity. Moreover, five joints showed secondary osteoarthritic changes in the form of irregularity of bony surfaces and osteophytes with erosion of both bony surfaces, and only three joints showed joint effusion, as shown in [Figure 5]. Of these 13 joints, seven joints showed adequate condylar forward translation and six joints showed limited condylar forward translation.
Table 4: Final results of examined patients with temporomandibular joint disorders

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Figure 1: Left temporomandibular joint sagittal oblique closed- mouth and open-mouth PD-weighted imaging shows normal disc position with normal condyle-disc complex forward translation on mouth opening.

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Figure 2: Right temporomandibular joint sagittal oblique closed-mouth and open-mouth PD-weighted imaging shows partial anterior disc displacement with reduction with excessive condylar forward translation.

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Figure 3: Right temporomandibular joint sagittal oblique closed-mouth and open-mouth PD-weighted imaging shows partial anterior disc displacement with no recapture on mouth opening with deformed buckled disc with double disc sign (arrow) (lateral pterygoid insertion thickening).

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Figure 4: Left temporomandibular joint sagittal oblique closed-mouth and open-mouth PD-weighted imaging shows complete anterior disc displacement with no condylar-disc complex forward translation on mouth opening and crumbled deformed disc.

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Figure 5: Right temporomandibular joint sagittal oblique (a) closed-mouth and (b) open-mouth T2-weighted imaging shows complete anterior disc displacement without reduction with deformed disc and joint effusion. Left temporomandibular joint sagittal oblique (c) closed-mouth and (d) open-mouth T2-weighted imaging shows complete anterior disc displacement without reduction with deformed disc, joint effusion, and secondary osteoarthritic changes (irregularity and spiking of the articular surfaces, erosive changes of the mandibular condyle, and irregularity of the temporal bone).

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  Discussion Top


TMJ pain and dysfunction are commonly seen important clinical problems [2]. Temporomandibular joint dysfunction (TMD) is a common disorder affecting more than 5% of the general population. With the rapid progress made in TMJ imaging techniques, many studies have focused on the importance of internal derangement, osteoarthrosis, effusion, and bone marrow edema as the underlying mechanisms in the etiology of TMJ disorders [8]. The current work included 30 patients and 60 joints with symptoms and signs of TMJ dysfunction as follows: joint pain and tenderness, joint noise and clicking sensation, limited jaw opening, and muscle tenderness. In the present work, sex showed statistically significant differences between the studied group. The ratio of female to male in this group of patients with TMDs was 2.7: 1. The results of this study show that the prevalence of TMD was higher in women than in men. This is in agreement with those of Amin et al. [9] who found increased ratio of female to male patients with TMDs (2.5: 1). Several related studies by Okeson [10] and Wiens and Priebe [11] have reported comparable results. In another study done by Dalkiz et al.[12], pain and dysfunction TMJ disorders seem to affect women more than men, with clinical reports have emphasized the high ratio (8: 1) of female to male patients for TMJ disorders. The factors responsible for this predominance are not known [13]. These findings may represent a sex-limited expression of joint laxity that is related to altered collagen synthesis, which is affected by either the level of circulating estrogen or the concentration of estrogen receptors within joints. It is suggested that individuals with joint laxity as a result of altered collagen synthesis are at greater risk of developing bilateral TMD when subjected to etiological factors such as trauma, joint overextension, or joint overuse [14]. In this study, the most common clinical sign group was pain/tenderness in preauricular region (32 out of 60 joints 53.3%). Pain is a symptom that arises frequently in cases of TMJ pathologies. The main findings that are responsible for the etiology are disc malposition, effusion, and osteoarthrosis [2]. This is in agreement with those of Okeson [10] who reported that disc displacement of TMJ is the important cause of facial and TMJ pain. On the contrary, Schiffman et al. [15] in their study stated that the cause of pain/tenderness could be associated with retrodiscal tissue alteration, capsulitis, and synovitis. This is in agreement with a study done by Farina et al. [16] showing that the MR signal changes in the retrodiscal tissueare highly correlated with TMJ pain. In a study carried out by Kobs et al.[17], it was concluded that although clicking is a predictor of anterior disc displacement with reduction, it was not present in their entire study population. In the present study, joint clicking was found in 17 of 60 joints (28.3%), thus indicating that TMJ clicking might occur as a consequence of frictional incompatibility between disc and the eminence, when the posterior band of the disc moves anteriorly or posteriorly beyond the apex of the articular eminence. Other causes may be deviation in condylar form (remodeling), adhesion, or muscular incardination. In our study, bilateral affection of the TMJs was noted in 13 patients representing 43.3% of the examined patients. Bilateral internal derangement has been demonstrated in 79% of patients in a study comprising 96 joints done by Limchaichana et al. [18] and Whyte et al. [19] obtained similar results by using MRI to examine bothTMJs in every patient with signs and symptoms of TMJ internal derangement whether unilateral or bilateral. In the study done by Roh et al.[20], bilateral TMJs affection was noted in 63% of cases examined with MRI. The reason for the high incidence of bilateral involvement of the TMJs is unknown. In the present study, the incidence of disc displacement was 51.7% compared with 54% in the study done by Maizlin et al.[21]. In a study done by Amin et al. [9] on 28 joints examined by MRI, 8 joints showed disc displacement with reduction (28.7%), whereas 16 joints showed disc displacement without reduction (57.1%). In a study done by Yilmaz et al. [22] evaluating 133 TMJs by MRI, they found that the articular disc is deformed in 52.3% of the joints with reduced anteriorly displaced disc, whereas 85.7% of the nonreducible discs were deformed. In the present study, the deformed discs represent 38.5% of the anteriorly displaced nonreducible discs. In the anteriorly displaced reducible discs, disc deformities represented 6.5%. The close association between permanent disc displacement (without reduction) and bone changes is well documented [23]. In our study, bony changes as osteoarthritic changes were diagnosed in six joints out of 60 joints showing anteriorly displaced disc without reduction, representing 10%. This is in agreement with those of Milano et al.[23], who found bony changes in 15 joints of the 43 joints with nonreducible ADD. In our study, we have diagnosed 29 (48.3%) TMJs showing normally positioned articular disc out of the examined 60 joints. The remaining 31 joints showed ADD, representing 51.7% of all examined joints. In our study, joint effusion was diagnosed only in three joints of the anteriorly displaced discs without reduction with secondary bony changes representing 9.4% of the joints (32 joints). Moreover, we diagnosed one joint in osteoarthritic changes of TMJ with normally positioned disc with reduction showing effusion. Thus, we diagnosed 4 joints with effusion out of the 32 joints showing internal derangement (12.5%). This is in agreement with a study done by Emshoff et al. [24] who reported joint effusion in eight of 16 TMJs with ADD. These results also agreed with those of Orlando et al.[25]. They found that there is a significant correlation between discdisplacement and joint effusion and that a nonreducible disc represents a risk factor for the occurrence of joint edema more than a reducible one. Moreover, Ahmad et al. [26] stated that joint effusion was recognized in 40–50% of patients with disc displacement and 27% of patients with TMJ arthritis and identified a strong association between joint pain and joint effusion. The present study had some limitations because comparison of our results with other studies was somewhat problematic owing to differences in number of patients and examination techniques, so it is recommended to conduct studies on a larger scale of patients complaining of TMJ disorders and apply dynamic (kinematic) MRI assessment of the TMJ to assess the biomechanics of the joint and in patients with normal static MRI in spite of clinical signs and symptoms. Despite these limitations, the present study revealed that high tesla MRI is a powerful diagnostic tool in TMJ disorders in a fast, easy, and noninvasive way. Moreover, the current study showed that TMJ internal derangement is the commonest disorder seen in young females among those who complain of TMJ disorders, and MRI is the most sensitive and specific diagnostic tool. This fact has gained a wide agreement among a large number of international studies.


  Conclusion Top


This study suggest the use of MRI as a proper diagnostic modality for TMJ disorders owing to the excellent soft tissue contrast and multiplanar capabilities that enable well demonstration of complex anatomy and well assessment of the pathological conditions of the TMJ, especially internal derangement of the TMJ.

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]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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