MRI TMJ TUTORIAL

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Abstract

Anatomy

Physiology

Disk or Meniscus. Morphology

Disk Displacement. Closed-mouth positi

on
Disk Displacement. Open-mouth positio
n

Joint Effusion

Retrodiscal Tissue

Insertion of the Lateral Pterygoid Muscle

Osteoarthritic Changes

References

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MRI TMJ TUTORIAL

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Abstract

LEARNING OBJECTIVES
1. To describe the basic concepts of temporo-mandibular joint MR imaging.
2. To review the role of MR imaging in the assessment of temporo-mandibular joint
dysfunction. Special emphasis is placed on new indirect signs of dysfunction.
3. To correlate MR imaging features with clinical symptoms.
ABSTRACT
Dysfunction of the TMJ is a frequent disease which, in some studies, may affect up to
28 % of the population. In recent years, MRI has been confirmed as the imaging
technique of choice in the study of TMJ meniscal displacement in patients. Despite of,
a high frequency of disk displacement appears in asymptomatic volunteers. Further
studies using the latest techniques allow a better understanding of the sources of joint
pain and the discrepancy between imaging findings and patient symptoms. We have
systematically analyzed clinical symptoms and MRI signs of TMJ dysfunction which
have been previously developed in other studies, such as disk morphology, articular
effusion or osseous degenerative changes, as well as other variables not reported,
such as the thickness of the insertion zone of external pterygoid muscle and the
rupture of retrodiscal ligaments, which may have an important role in the evolution of
TMJ dysfunction before osteoarthritic changes lead to a more advanced stage of the
dysfunctional spectrum.

MRI TMJ TUTORIAL

Anatomy
1. Condyle
2. Temporal Bone. Articular eminence
3. Temporal bone. Mandibular fossa
4. Disk. Anterior band (AB)
5. Disk. Intermediate zone (IZ)
6. Disk. Posterior band (PB)
7. Bilaminar zone. Superior retrodiscal layer
8. Bilaminar zone. Inferior retrodiscal layer
9. Bilaminar zone. Vasculo-nervous structures
10. Capsular superior attachment
11. Capsular inferior attachment
12. Superior joint space
13. Inferior joint space
14. Lateral superior pterygoid muscle (SLP)
15. Lateral inferior pterygoid muscle (ILP)
16. Interpterygoid space
17. External auditory canal

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MRI TMJ TUTORIAL

Physiology
Initial closed-mouth position (2A)
Beginning of the open-mouth position
(2B). Digastric muscle forces condylar
drop. The condyle rotates in the lower
joint
space.
Afterthat,
condylar
displacement begins when jaw is opened
beyond to 20-25 mm. Retrodiscal
ligaments stabilize the disk.
Condylar protraction. Maximum openmouth position (2C). ILP muscle is basic
in this step, and SLP can displace the
disk,
probably
to
maintain
joint
congruence. Superior retrodiscal layer
avoids complete abnormal displacement.
Progression to the maximum clenching
position (2D). ILP muscle is normally very
active in this phase too.

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MRI TMJ TUTORIAL

Disk or Meniscus. Morphology.
Biconcave. Normal disk in a sagittal
section in closed-mouth position
(upper image) . The margins of disk
(bands), are thick, and the center
(arrow; intermediate zone) is thin.
PB and retrodiscal tissue are best
depicted in open-mouth position [1]
(arrow; lower image). Normal signal
intensity use to be hypointense in BA
and ZI, and slightly hyperintense in
PB; hypointense signal intensity in
PB is more frequent in patients with
disk pathology [2].
Bulge AB. Some authors have
described this morphology as a
normal variant of disk [3-5].

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Disk or Meniscus. Morphology.
Irregular The disk (arrow; left
upper figure) has lost its typical
biconcave morphology, getting
crumpled.
Rounded (arrow; right upper
figure). Irregular and rounded
morphologies
are
universally
considered pathologic conditions
[6-8]
Flat (arrow; left bottom figure).
In the study of the first author,
this morphology appeared as a
pathologic finding [9]
Central perforation (arrow; right
bottom
figure).
Abnormal
condition.

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Disk Displacement. Closed-mouth position.

12-oclock position of the condyle in
sagittal-oblique
plane.
Pathologic
condition has been considered if the
angle between PB and 12-oclock line is
over +/- 10 [10-12] (upper figure).
Other studies have shown that, in this
way,
a
large
number
(33%)
of
asymptomatic volunteers presented disk
displacement [13-14] .
Discal Intermediate Zone as point of
reference. Helms and Kaplan emphasize
the interposition of IZ between condyle
and temporal bone; 12-oclock position is
not considered [15].
An important disk displacement in closedmouth position is showed here, in a
patient with TMJ dysfunction (lower
figure). IZ (arrow) is clearly beyond of
condyle. The angle between PB and 12-o
clock line is close to 50.

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Disk Displacement. Closed-mouth position.

1-to-2 oclock position.
Rammelsberg have recommended this
modification to better correlate disc
displacement with clinical symptoms to
TMJ dysfunction. With this modification,
disk displacement up to 30 could be
considered normal [16] (upper figure).
Sagittal and coronal planes.
Consideration of both views have been
suggested to exclude medial and lateral
displacements.
Other
authors
have
described mid-lateral disk displacement
only in sagittal views [17]. A medial
displacement is clearly showed in sagittal
view; disk is floating alone (arrow;
lower figure); condyle is out of image.

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Disk Displacement. Closed-mouth position.

Posterior disk displacement.
This rare pathologic entity has an overall
incidence between 0.01 to 0.001 of TMJ
disorders [18,19]. The main clinical sign
is sudden molar open bite. MRI shows a
posterior band located anywhere less
than at one oclock position. Figures
depict a PB posteriorly displaced in
closed (upper left figure) and openmouth position (arrow; upper left
figure).
Jaw is nearly locked in this
case. In other patient PB remains close
to the mandibular fossa in close (arrow;
lower left figure) and open-mouth
position (arrow; lower right figure); open
jaw was seriously limited.

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Disk Displacement. Open-mouth position.

Normal disk displacement. The
disk preserves its normal
position, between the condyle
and temporal bone, centered in
the intermediate zone, in
closed (arrow; upper figure)
and
open-mouth
position
(arrow; bottom figure), during
condylar
movement.
This
interposition avoids abnormal
contact between osseous joint
surfaces.

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Disk Displacement. Open-mouth position.

Internal
derangement
with
reduction. The disk returns to the
normal
position,
between
the
condyle and temporal bone, during
jaw
movement
(arrow;
upper
figures), generally producing a noise
(clicking or popping) [20].
Internal
derangement
without
reduction.
The
disk
remains
displaced from its normal location in
closed-mouth (arrow; lower left
figure) and open-mouth position
(arrow;
lower
right
figure).
Furthermore,
disk
shows
an
abnormal morphology.

MRI TMJ TUTORIAL

Joint Effusion
Clinical Impact. Presence of large
amounts of joint effusion have been
associated with TMJ pain and disk
displacement. It is an early change,
which can precedes to osteoarthritis
changes [21]. Is an unusual sign in
asymptomatic individuals [10], and
only small amounts of fluid is seen in
this case [22,9].
MRI. The joint effusion is best
depicted on T2-WE images. If a large
accumulation exists, a so-called
arthrographic effect can be seen;
the fluid clearly remarks the shape of
the disk in the upper and lower joint
spaces (arrow; figure).

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Retrodiscal Tissue
Retrodiscal layers. Collagen fibers form the
inferior retrodiscal layer and elastic fibers
the superior retrodiscal layer (arrow; upper
figures). These structures play an important
role in normal disk displacement. SRL fibers
rupture can produce an important disk
instability. This sign can be shown in two
different patients with severe non-reducted
disk displacement (arrow; lower figures). In
our knowledge, this sign has not been
previously described.
Vasculo-nervous structures. A higher T2weighted signal intensity, due to a higher
degree of vascular supply, have seen found
in the retrodiscal tissue of painful joints
compared with the non-painful joints
[23,24]. By the other side, a decreased
signal may be associated with fibrous
changes [25].

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Insertion of the Lateral Pterygoid Muscle

Function of LPM. This muscle has two
bellies: superior (SPL) and inferior (IPL).
Some authors [26,27] believe that those
bellies are really two differenciated muscles.
The ILP muscle may become hyperactive in
specific positions to help in stabilizing and
positioning the condyle and the disk in cases
with TMJ internal derangement. Temporalis
and the masseter muscles are not
hyperactive in TMJ internal derangement
[28-30].
LPM Normal MR Imaging. Thin insertional
area of ILP (arrow; upper left figure), just
below of the disk. Thin insertional area of
SLP (arrow; upper right figure), just in front
of the disk. During open-mouth position,
because of contraction of the muscle,
insertional area of ILP grows (arrow; bottom
left figure), respect to closed-mouth position
(arrow; bottom right figure).

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Insertion of the Lateral Pterygoid Muscle

LPM Pathologic MR Imaging. A MRI
study of first author, comparing 80
patients suffering TMJ dysfunction
and 12 normal volunteers, found that
the mean diameter of the insertion of
SPL and IPL was higher in patients
than
in
the
control
group.
Furthermore, the diameter of IPL
showed a parallel increase in respect
to disk displacement degree (diagram
shows
significative
relationship
between diameter of IPL in mm. and
disk
displacement
in
degrees.
Statistic Altman Test was done) [9].
In our knowledge, these findings
have been previously described only
in isolated patients [31], but not
systematically analyzed.

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Insertion of the Lateral Pterygoid Muscle

LPM Pathologic MR Imaging. Figures.
Symptomatic TMJ of a patient.
Complete
disk
displacement.
Insertional area of SLP (arrowhead)
and ILP (arrow; upper left figure) are
really thicker that in opposite
asymptomatic TMJ in the same
patient,
where
a
subtle
disk
displacement, with minimum thick
insertional area of SLP (arrowhead)
and ILP (arrow; upper right figure)
are shown. Symptomatic TMJ in other
two
patients.
Complete
disk
displacement. Thick insertional area
of ILP (arrow; lower figures), that
runs parallel to disk (arrowhead),
conforming a new double-disk sign.

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Osteoarthritic Changes
Clinical
Impact.
Osteoarthritic
changes use to be the last expression
of TMJ dysfunction. These pathologic
changes
develops
when
disk
displacement is well stablished [1].
These changes can be seen in young
patients.
MR Imaging. There are four imaging
signs: condylar flattening (arrow;
upper
left
figure),
osteophytes
(arrow; upper right figure), sclerosis
and erosions (lower figures). The
author found that flattening and
osteophytes
were
significantly
correlated with TMJ dysfunction [9].
The other two signs could be more
difficult to detect, due to MRI
techniques applied.

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References
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Tomas X Estudio por resonancia magntica, mediante secuencias GE T2 (flash 2D) y SE T1, de
la deteccin de patologa disfuncional a nivel de la articulacin temporomandibular. Doctoral
Thesis. University of Barcelona, 1999. Code 3790 (2000).

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and

the

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