|Year : 2021 | Volume
| Issue : 1 | Page : 33-38
Internal derangement of the temporomandibular joint: Can clinical and magnetic resonance imaging features predict the prognosis?
Omair Ashraf Shah, Tahleel Altaf Shera, Mudasir Bhat, Naseer Ahmad Choh, Tariq Ahmad Gojwari
Department of Radiology, SKIMS Soura, Srinagar, Jammu and Kashmir, India
|Date of Submission||24-Apr-2021|
|Date of Acceptance||16-Jun-2021|
|Date of Web Publication||03-Sep-2021|
Dr. Omair Ashraf Shah
Senior Resident, Department of Radiology, SKIMS Soura, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Purpose: To evaluate the role of magnetic resonance imaging (MRI) in the diagnosis of internal derangement and to assess the complimentary role of MRI and clinical assessment in prognostication. To assess the role of MRI in demonstrating disc displacement and reduction. Methods: A total of 34 patients (28 cases and 6 controls) with clinical features of temporomandibular joint (TMJ) internal derangement underwent a dedicated MRI at our institution. MRI was assessed for disc displacement, morphology, and reduction on open-mouth imaging. For analysis, the patients were divided into those with disc displacement with reduction (WR) and those without reduction (WOR). Clinical and MRI grading of internal derangement were done in all patients and correlated with each other. Prognostication was attempted using the clinical and MRI features, and patients were followed up over a mean period of 6 months. Results: Most of the patients were females (n = 20 71%) in the child-bearing age group (third decade). MRI demonstrated disc displacement in all but two patients in whom disc was not visible. Fourteen (54%) patients were placed in WR group, whereas 10 (38%) were in WOR group. In two (8%) patients, stuck disc was diagnosed. Patients in WR group responded to conservative treatment alone while those in WOR group needed conservative management in some (n = 8 57%) and surgical intervention in others (n = 6 43%). Both patients with stuck disc failed conservative management. Conclusion: MRI is an essential component of TMJ evaluation and helps in diagnosing and staging internal derangement together with disc assessment. Patients with disc displacement WOR and those with higher grades of derangement on MRI including stuck disc require surgical intervention if conservative management fails.
Keywords: Magnetic resonance imaging, temporomandibular joint, with reduction disc displacement with reduction, without reduction disc displacement without reduction
|How to cite this article:|
Shah OA, Shera TA, Bhat M, Choh NA, Gojwari TA. Internal derangement of the temporomandibular joint: Can clinical and magnetic resonance imaging features predict the prognosis?. Muller J Med Sci Res 2021;12:33-8
|How to cite this URL:|
Shah OA, Shera TA, Bhat M, Choh NA, Gojwari TA. Internal derangement of the temporomandibular joint: Can clinical and magnetic resonance imaging features predict the prognosis?. Muller J Med Sci Res [serial online] 2021 [cited 2021 Dec 7];12:33-8. Available from: https://www.mjmsr.net/text.asp?2021/12/1/33/325476
| Introduction|| |
The temporomandibular joint (TMJ) is a synovial joint with a wide range of mobility and is formed between mandibular condyle inferiorly and glenoid fossa and articular eminence of the temporal bone superiorly. A fibrocartilage covers its articular surfaces and allows the wide range of motion including gliding and anteroposterior motion. The frequent use of this joint predisposes it to various functional disorders and derangements which are usually categorized into degenerative disorders, muscular disorders, and internal derangement of the TMJ. The symptoms caused by TMJ disorders and quite wide ranging and therefore clinical assessment alone can rarely point out the abnormality. The common symptoms include headache, clicking joint noise, pain at the joint site, and joint locking (trismus).
The most common internal abnormality of TMJ is internal derangement which is morphologically characterized by abnormal position and dynamic relation between the disc, condyle, and the articular surfaces of the temporal bone. Displacement of the articular disc is the most common cause of internal derangement; however, it is not an absolute finding and disc displacement can be found even in some asymptomatic patients. Adhesions and loose bodies within the joint are the other causes of disc displacement. Imaging of the TMJ has been a challenge for long owing to the small joint size and profound overlap by the skull base structures. Various imaging modalities have been used to image TMJ including plain film radiographs, panoramic radiographs, high-resolution ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI). The disadvantages of radiographs and CT include the lack of soft-tissue resolution and articular disc assessment besides radiation exposure. USG although inexpensive and easily available is difficult to master and lacks bone assessment. MRI in the recent past including dynamic MRI in open- and closed-mouth positions has emerged as an investigation of choice for the evaluation of internal derangement of TMJ., MRI is an excellent modality for disc assessment including its position and morphology. Dynamic assessment can also be done which helps in classifying internal derangement besides lack of radiation exposure is an important advantage. MRI can also help identify bony and muscular abnormalities around the TMJ. With wide use of MRI in the evaluation of TMJ, new findings and variants are being put forth. Although the availability of MRI in resource-constrained regions is limited, it is now being routinely used.
Our study aims at exploring internal derangement of TMJ through the prism of MRI and assess the ability of dynamic MRI provide a morphological correlate of TMJ disorders with a specific attention to the articular disc.
| Methods|| |
We conducted a prospective, observational study over a period of 5 years (2016–2020) in our department of radiodiagnosis and imaging at Sheri Kashmir Institute of Medical Sciences. We included a total of 34 patients (28 symptomatic and 6 asymptomatic) referred to us as cases of clinically diagnosed internal derangement. Volunteers were selected from patients undergoing brain MRI at our center with no present or previous history of TMJ disorder. Patients who were claustrophobic, with MRI noncompatible devices, <18 years or >60 years, and those with a known arthritides (rheumatoid or psoriatic) were excluded.
After an initial demographic and clinical assessment which in most cases was done outside our institute, patients were subjected to an MRI study on a 1.5 Tesla MR system using head coil (Magneton Avanto Siemens medical system, Erlangen Germany). Bilateral TMJ imaging was done in all patients in both open- and closed-mouth position using the following sequences:
- Axial and coronal localizers
- Axial T1W imaging, slice thickness 3 mm, TR-500, TE-10, FOV 150 mm, matrix 256 × 256 in closed-mouth position
- Oblique coronal T1W imaging, slice thickness 3 mm, TR-500, TE-10, FOV 120 mm, matrix 256 × 256 in closed-mouth position
- Bilateral oblique sagittal T2W imaging, slice thickness 3 mm, TR 2000, TE-80, FOV 110 mm, matrix 256 × 256 in closed-mouth position
- Bilateral oblique sagittal PD turbo spin-echo imaging, slice thickness 3 mm, TR 2000, TE-26, FOV 110 mm, matrix 256 × 256 in open- and closed-mouth position.
The clinical evaluation was done in accordance to the Wilkes classification which categorizes patients into five stages:
- No pain or restriction on of movement; clicking during opening or late closing
- Episodes of pain, tenderness and headaches; increased clicking; occasional locking or catching
- Multiple episodes of pain, headaches and joint tenderness; major mechanical symptoms
- Undulating course, reduced motion, and chronic symptoms
- Reduced function, decreased motion, and crepitation on examination.
MRI data were collected and transferred to a dedicated work station for the evaluation by a radiologist with 8–10 years of experience. The imaging evaluation was done in a systematic sequence to help evaluate TMJ completely. The evaluation sequence included:
- Assessing the imaging planes has been correctly obtained
- Assessing the size of both the condyles and the intercondylar angle
- Assessing the disc (position, signal intensity, and any perforation) on both oblique sagittal and oblique coronal closed mouth sequences for anteroposterior and mediolateral displacements, respectively. Normally, the disc is biconcave, and its posterior band is within the arc from 11 to 12 'O clock position in relation to condylar tip
- Open mouth oblique sagittal image assessment to look for recapture of the disc or the presence of stuck disc
- The attachment of the lateral condyle is assessed to look for any abnormal signal or hypertrophy
- Finally bony evaluation of the condyle and glenoid fossa is done to look for any osteophytes, joint space narrowing or dysplasia.
After evaluating the joints, imaging stage was assigned to internal derangement based on the classification given by Schellhas which has five stages:
- Normal disc morphology; anteriorly displaced; reduction on open-mouth imaging
- Disc displacement and deformity; reduces on open-mouth imaging; with or without joint effusion or signal changes in the disc
- Disc displacement and deformity; does not reduce on open-mouth imaging; may have associated effusion
- Severe disc deformity and displacement does not reduce on open mouth imaging, associated joint effusion, and osseous changes
- Severe disc deformity and displacement does not reduce on open mouth imaging, disc perforation and progressive osseous deformity in the form of avascular necrosis, sclerosis, and destruction.
Finally, we tried to correlate the clinical findings with MRI grading of TMJ internal derangement by dividing the patients into two groups: Group A including patients with disc displacement with reduction (WR) on open-mouth imaging and Group B including patients with disc displacement and no reduction on open-mouth imaging. We also assessed the role of imaging in the diagnosis as well as the management of internal derangement. We followed the patients over a period of 6 months with conservative medical and physiotherapeutic management. Those who failed this conservative management were subjected to the surgery.
The data were collected and evaluated using the SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Descriptive data were analyzed by frequencies and categorical data by percentages and continuous variables by means and standard deviations. Continuous variables were compared using the Student's t-test. For all comparisons, P < 0.05 was considered statistically significant.
| Results|| |
We had a total of 34 patients including 28 cases and 6 asymptomatic patients. The cases had a male-to-female ratio of 8:20 and a mean age of 39 ± 7 years. The male-to-female ratio in asymptomatic patients was 2:4, and the mean age was 33 ± 6 years. Among the females, majority (n = 18 90%) were in the child-bearing age group.
The most common presenting feature in our patients was pain (n = 19 68%), clicking (n = 17 61%), deviation of the jaw (n = 10 36%), and decreased jaw movement including locked jaw (n = 6 21%).
Based on Wilkes classification, our patients were grouped into clinical stages [Table 1].
|Table 1: Clinical grading of internal derangement of temporomandibular joint|
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Magnetic resonance imaging findings
The most common MRI finding in symptomatic patients was anterior disc displacement seen in 26 (93%) of the patients. In the remaining two patients, disc was not identified and both these patients had severe symptoms and belonged to clinical stage (Wilkes) 4 and 5. Disc reduction with open-mouth imaging was seen in 14 (54%) patients belonging to clinical Stage 1 and 2. Lack of disc reduction was seen in ten patients (38%) and these patients belonged to clinical Stage 3 and 4. In two patients (8%), a stuck disc was identified, and they had a clinical Stage 3 derangement.
Internal derangement was classified into stages based on MRI findings:
The disc position in all six asymptomatic patients was within the limits of 11–12 O' clock in relation to the mandibular condyle and the disc maintained its position between the condyle and the articular eminence in the open-mouth position. The disc and the articular surface morphology were also normal in all these patients.
Correlation of clinical and magnetic resonance imaging findings
We compared the patients in Group A (anterior disc displacement WR) and Group B (anterior disc displacement without reduction [WOR]) based on clinical and MRI findings and found MRI and clinical findings to be compatible in most cases. MRI and clinical findings were same in 12 cases (86%) of mild internal derangement (Wilkes Stage 1 and 2) with MRI placing these patients in Group A. The patients in Group B (Wilkes Stage 3, 4, and 5) were correctly identified by MRI imaging in 72% of the patients, while in the remaining two patients, (14%) the disc was not identified on MRI. In these two patients, however MRI showed bony changes in the form of condyle flattening and osteophytes. An additional finding of stuck disc was identified in two patients (14%) belonging to Group B.
Most of our patients (n = 22 79%) responded to conservative management and these patients belonged MRI Stages 1 (n = 4), 2 (n = 8), and Stage 3 (n = 10). The remaining six patients (21%) exhibited persistence of symptoms and were referred to a maxillo-facial unit for surgical management. All these six patients were MRI stage 3 or worse.
| Discussion|| |
We conducted a study with a total of 28 patients with clinical diagnosis of internal derangement and 6 asymptomatic controls with a mean age in the thirties. Majority of our patients were females (71%) with over 90% in the child-bearing group. This female dominance has been previously documented in many studies including those by Iqbal et al., Schellhas, and List et al. The female predominance is probably due to the hormonal effects of progesterone on ligaments and muscles causing their laxity with secondary internal derangement. This fact is further supported by the predominance of child-bearing age females presenting with internal derangement in our study. However, other factors including mechanical factors such as joint overloading, malocclusion, and systemic arthiritides may also be responsible. We therefore suggest a clinical screening assessment in all patients, especially females in their third decade to assess for any TMJ dysfunction so that appropriate corrective measures are taken before arthritic changes set in.
The most common presenting feature in our study was pain (68%) and clicking (61%). Other presenting features including restriction in movement were seen in patients with advanced disease. Most of our patients belonged to clinical Wilkes classification Group 2 (43%) and 3 (39%) [Table 1]. These findings are concordant with those of Schellhas, Rudisch et al., and Esmaeelinejad and Sohrabi who in their studies found similar presentation of patients with internal derangement. With regard to Wilkes classification, we found that it is a useful tool for initial evaluation of patients with TMJ internal derangement. We observed in our study that patients belonging to Groups 1 and 2 respond to conservative management and none of these patients required intervention. On the other hand in Groups 4 and 5 patients, conservative treatment was rarely successful and the need of surgical intervention was necessary. Group 3 patients remained a challenge with some showing response to conservative management (n = 8 72%) while others requiring surgical intervention (n = 3 28%). Clinical features being subjective and difficult to assess sometimes justify the use of some form of imaging modality to document the changes associated with internal derangement. Among the various modalities, MRI has been the investigation of choice over the years.
We performed MRI in open- and closed-mouth position in all our patients and documented the changes noted. We first tried to set the standard normal findings using imaging characteristics of six asymptomatic young patients admitted for other causes and undergoing MRI at our center. We found that in all these six patients, the disc was uniformly hypointense and biconcave in shape with its posterior band at 11–12 O' clock position relative to mandibular condyle on closed-mouth imaging [Figure 1]. On open-mouth images, the disc was seen to maintain its position between the condyle and the articulate eminence of the temporal bone, thereby facilitating condylar mobility. These findings are in perfect concordance with studies done by Wang EY et al. and Katzberg. There is however some studies which have shown an anterior disc displacement in normal individuals; however, the disc morphology remains normal in these individuals. Therefore, we suggest caution in diagnosing internal derangement on the basis of closed mouth imaging alone without taking into consideration the clinical features and open mouth MRI imaging.
|Figure 1: T1-weighted oblique sagittal closed (a) and open mouth (b) images in an asymptomatic individual showing normal position of the posterior band of the articular disc (arrow) between 11–12 O'clock in closed mouth and normal position between the condyle (C) and the articular eminence (A) in open-mouth position. Pt- lateral pterygoid muscle|
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We assessed the open and closed mouth MRI images of all our patients and found anterior disc displacement beyond 11 O' clock position in almost all patients (93%). Among these 14 patients belonging to clinical Stage 1 and 2 demonstrated disc reduction on open mouth imaging. The remaining ten patients showed persistently displaced disc with no reduction on open mouth imaging. Two patients in clinical Stage 3 had a stuck disc. Based on MRI findings, most of the patients belonged to Stage 2 (29%) and 3 (43%) of Schellas MRI classification [Table 2]. When comparing MRI findings of patients in Group A and Group B, MRI was highly accurate (sensitivity = 86%) in identifying anterior disc displacement and its reduction on open mouth imaging in Group A patients [Figure 2]. In Group B patients, MRI was able to objectively demonstrate non reducing anteriorly displaced disc in 72% of the patients [Figure 3] and showed additional findings of stuck disc in two patients. The disc could not be identified in two other patients. We therefore believe that MRI is an essential part of diagnosis of internal derangement of TMJ and gives an objective evidence of disc displacement which is sine quo non for TMJ internal derangement diagnosis. Our findings are complemented by those of Iqbal et al., El-Essawy et al., Choi et al., and Costa et al.
|Figure 2: T1 turbo inversion recovery magnitude oblique sagittal closed (a) and open (b) mouth images showing anteriorly displaced articular disc in closed-mouth position (arrow in a) which reduces on open-mouth imaging (arrow in b) being located between the condyle (C) and the articular eminence (D). Oblique coronal T2-weighted image (c) showing no medio-lateral displacement of the disc (D). Pt – lateral pterygoid muscle|
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|Table 2: Magnetic resonance imaging grading of temporomandibular joint internal derangement|
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|Figure 3: T2 weighted oblique sagittal closed (a) and open (b) mouth images showing anteriorly displaced deformed articular disc (arrow in a) which does not reduce on closed mouth imaging (yellow arrow in b). The red arrow in b indicates the “double-disc sign” secondary to changes in lateral pterygoid attachment. A: Articular eminence, C: Condyle, Pt: Pterygoid muscle|
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We also found MRI and clinical findings to be complementary in prognostication of patients with internal derangement. We found that all patients belonging to Group A with disc displacement which reduces on open-mouth imaging on MRI responded to conservative management, and no surgical intervention was required. In comparison, 6 (21%) patients who failed conservative treatment had a MRI Stage 3 or worse disease and were referred for surgical intervention. This was especially true for two patients with stuck disc [Figure 4] and two other with bony changes and nonvisualization of the disc indicating severe disc deformity. We therefore believe that patients with stuck disc and those with bony deformity should undergo surgical management as opposed to those in whom disc morphology is only mildly deformed and the disc reduces with open mouth imaging. In patients with disc displacement WOR, a trial of conservative management is recommended which may relieve the symptoms as seen in 80% of the patients in our study. However, if the conservative management fails, surgical intervention would be imperative.
|Figure 4: T1 Turbo inversion recovery magnitude oblique sagittal closed (a) and open (b) mouth images showing deformed mandibular condyle (C) and anteriorly displaced deformed disc (arrow in a and b). The patient was unable to open his mouth fully and presented with lock jaw. T1 oblique coronal (c) image revealed medial displacement (arrow) of the disc. A- Articular eminence|
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The limitations of our study included the small study group as well as the control group. This number is however comparable to other studies in our part of the world. Second, we did not have surgical confirmation of our findings which would have further consolidated our findings. The lack of TMJ arthroscopy is quite a limitation. Third, direct contrast MR arthrography was not done in our patients which is considered the gold standard for diagnosing perforated disc.
| Conclusion|| |
Internal derangement of the TMJ is more common in females of child-bearing age and a screening TMJ examination should be done in this group to detect the early stages of the disease. Clinical and MRI findings are complimentary and correlate in most of the cases. Patients with clinical or MRI diagnosis of anterior disc displacement WOR should be given a trial of conservative management and surgery should be reserved in cases lacking response. Patients with stuck disc and advanced bony changes are better off with surgery than conservative management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]