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ORIGINAL ARTICLE

Directional characteristics of incipient


temporomandibular joint disc displacements: A
magnetic resonance imaging study
Renie Ikedaa and Kazumi Ikedab
San Francisco, Calif, and Tokyo, Japan

Introduction: Disc displacement (DD) is common in adolescents, but not much is understood about its cause.
Assessment of the directionality of incipient DDs may provide clues about the etiology. Methods: The sample
consisted of magnetic resonance images of 143 temporomandibular joints with incipient DD from 89 preortho-
dontic patients (mean age, 10.8 years). The severity of DD was evaluated by grading the degree of displacement
depicted in the images in the sagittal and coronal planes, and each incipient DD was categorized based on the
directionality. Results: Of the 143 incipient DDs, rotational anterolateral DD (43.36%) and partial anterior DD in
the lateral portion (27.27%) were the most common; rotational anteromedial DD (9.09%) and partial anterior DD
in the medial portion (1.40%) accounted for only 10.49%. Anterior DD was seen in 12.59%. Pure sideways shift
was rare; lateral DD was seen in 2.80%, and medial DD in 3.50%. Thus, the lateral part of the joint was involved in
a majority of the incipient DDs and the medial part far less. No sex difference was noted in this trend, but the
difference between the right and left sides was statistically significant. Conclusions: These results indicate a
predilection for the lateral part of the joint in incipient DDs and may have etiologic implications. (Am J Orthod
Dentofacial Orthop 2016;149:39-45)

T
he articular disc of the temporomandibular joint consistently shown that DD is not rare in asymptomatic
(TMJ) plays a vital role in the development and populations, with a prevalence of approximately
function of the TMJ. When the disc is not inter- 30%,18-20 and that the young adolescent population is
posed between the condyle and the articular eminence not an exception to this phenomenon.21,22 The peak
in what has been considered a more normal anatomic incidence of symptomatic DD has been shown to be
relationship,1 the condition can have deleterious effects, during puberty in both boys and girls, making the
particularly in growth and development.2-10 Studies adolescent population at risk for developing TMJ
have evaluated the different imaging modalities dysfunction symptoms.23,24
available to visualize the TMJ and have advocated An important question is why and how DD occurs.
magnetic resonance imaging (MRI) as the prime Several possible etiologic factors have been proposed,
diagnostic method because of its ability to accurately but no definitive answer is available at this time. It is
depict the disc position in sagittal and coronal apparent, however, that the etiology of advanced DD is
images.11-16 In 1 MRI study, none of the 60 TMJs of usually multifactorial, making establishment of cause-
infants and young children up to age 5 years examined and-effect relationships difficult. Previous reports of
had disc displacement (DD).17 Thus, the study suggested the relatively higher frequency of anteromedial DD ex-
that DD is not a congenital phenomenon but, rather, an plained it by the pulling forces of the lateral pterygoid
acquired condition. In addition, research has muscle.12,25 However, several recent studies have
shown that anterolateral displacement is more
a
Private practice, San Francisco, Calif. frequent.20,25-27 Although MRI evaluation of early DD
b
Private practice, Tokyo, Japan. can be valuable in showing how DD starts—which in
All authors have completed and submitted the ICMJE Form for Disclosure of Po- turn may provide important clues about its etiology—
tential Conflicts of Interest, and none were reported.
Address correspondence to: Kazumi Ikeda, Daikanyama Plaza 3F, 24-7 Saruga- early DD has not been studied.
kucho, Shibuya-ku, Tokyo 150-0033, Japan; e-mail, ikedakzm@tkd.att.ne.jp. The purpose of this study was to determine any
Submitted, April 2015; revised and accepted, June 2015. tendency in the direction of early DD. The data were
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists. retrospectively analyzed using available MRIs of a young
http://dx.doi.org/10.1016/j.ajodo.2015.06.021 preorthodontic population with incipient DD.
39
40 Ikeda and Ikeda

Fig 1. Method used to determine the 12 o'clock position with identifiable anatomic landmarks.

MATERIAL AND METHODS In the sagittal plane, a method described by Ikeda29


The study sample was derived from a population of was used to establish the 12 o'clock mark as a reference
153 consecutive preorthodontic patients who had point from which to evaluate the severity of DD (Fig 1). A
MRIs of their TMJs taken for evaluation of disc status. reference line was drawn connecting the most inferior
In a previous study, all MRIs were evaluated by 2 cali- point of the articular eminence and the center of the
brated investigators, and each TMJ disc was categorized auditory canal. The reference line was then rotated 2.2
as normal or as 1 of the 4 stages of DD based on the to establish the true horizontal line on the MRIs. The
severity of displacement.28 The study sample consisted 12 o'clock position is the point at which the true horizon-
of 143 TMJs from 89 preorthodontic patients (35 tal line is tangential at the deepest point on the glenoid
boys, 54 girls) who were determined to have incipient fossa. The 9 o'clock position is where the true horizontal
DD in the previous study. The patients ranged in age line intersects with the eminence when lowered to the
from 7 to 15 years, with a mean age of 10.8 years. most prominent point on the anterior surface of the
Because the MRIs were taken before this retrospective condyle. The center of the clock is the intersection of
study for diagnostic purposes, the patient data were the true horizontal line through the 9 o'clock position
anonymous to the researchers, and our summarized with a line perpendicular to the true horizontal line
findings in this study are incidental, the ethical board through the 12 o'clock position. The 10 and 11 o'clock
did not require approval for this study. positions are determined by dividing the angle between
All scans were done at 1 clinic by the same technician the 9 and 12 o'clock positions into 30 segments.
using the 1.5-T MRI system (Gyroscan ACS-NT Intera; The position of the posterior margin of the posterior
Philips, Amsterdam, The Netherlands) with surface coils. band was evaluated relative to the established 12 o'clock
The images were taken in the oblique sagittal plane and position. Disc position were defined as normal, level 1,
the oblique coronal plane with the subject in closed- level 2, or level 3 when the posterior band was at 12
mouth and open-mouth positions. Open-mouth sagittal o'clock, 11 o'clock, 10 o'clock, or 9 o'clock or below,
images were obtained using mouth pieces set at 10 mm respectively (Fig 2). The position of the disc in each joint
below maximal voluntary incisal opening. Proton was evaluated in 3 sagittal MRI slices (medial, central,
density-weighted images were taken with a 2.5-mm- and lateral aspects of the joint).
section thickness, a 12-cm field of view, a repetition Sideways (mediolateral) DD was evaluated in the
time of 2500 ms, an echo time of 20 ms, and a coronal plane parallel to the long axis of the condyle
256 3 256 measurement phase scanning matrix. and assigned the rating of normal when the disc was
MRIs of the 143 TMJs were previously evaluated by 2 centered between the medial and lateral poles. Level
investigators for anterior or posterior displacements in 1 was when the disc was markedly thickened on the
the sagittal planes and medial or lateral displacements side to which it was displaced or when the disc was dis-
in the coronal planes using a standardized grading placed up to a sixth of the mediolateral width of the
system, which enabled categorization of the TMJs into condyle; level 2 was when the disc was displaced up
normal and 4 stages of DD based on the severity of the to a third of the mediolateral width with a drooping
displacement.28 look on the displacement side; and level 3 was when

January 2016  Vol 149  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Ikeda and Ikeda 41

Sagittal Coronal
Auditory
Normal meatus

Medial Lateral
Anterior Posterior
Level 1
Level 2
Level 3

Fig 2. Illustrations and corresponding MRIs demonstrating the various levels of DD in the sagittal and
coronal planes.

the disc was displaced at least half of its mediolateral


Table I. Definitions used to categorize the DDs into 4
width (Fig 2).
stages based on the severity of displacement
Based on the disc position assessed by the 4 MRI
slices (3 sagittal and 1 coronal), each joint was catego- Early DD
Stage 1 (incipient stage)
rized as normal or as 1 of the 4 stages of DD (Table I),
All 3 sagittal slices and the coronal slice in level 1 or less
ranging in severity from incipient DD to total DD Stage 2 (partial DD)
without reduction. We focused on the 143 TMJs that Stage 2A: 2 of 3 sagittal slices in level 1, and coronal slice in level 1
were in the incipient stage of DD (stage 1) when all 3 or less
sagittal slices and the coronal slice show a displacement Stage 2B: only 1 of 3 sagittal slices in level 1, and coronal slice in
level 2 or less
of level 1 or less.
Stage 2C: all 3 sagittal slices in level 2 or more, and coronal slice in
level 2 or less
Statistical analysis Advanced DD
Stage 3 (total DD with reduction)
Each incipient DD was categorized based on the
All 3 sagittal slices in level 3, and coronal slice in levels 1 to 3 with
direction of displacement using the classification estab- disc reduction on opening
lished in the study by Tasaki et al26 (Table II), and the Stage 4 (total DD without reduction)
prevalence percentage of DD by directionality was All 3 sagittal slices in level 3, and coronal slice in levels 1 to 3
determined. The data were further analyzed using chi- without disc reduction on opening
square tests to detect any statistically significant
disparity in the prevalence of the various DDs because interobserver reliability was determined by calculating
of sex or right-to-left differences. Since 2 investigators the kappa coefficient for their classifications of the entire
(R.I. and K.I.) independently evaluated the MRI data, sample of 143 TMJs with incipient DDs.

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42 Ikeda and Ikeda

Table II. Classification of DD based on direction of displacement and resulting disc position
Disc displacement types Sagittal MRIs Coronal MRIs
Anterior Posterior band of disc anterior to 12 o'clock position in Disc centered between medial and lateral poles
multiple sections in all sections
Partial anterior in lateral Posterior band of disc anterior to 12 o'clock Disc centered between medial and lateral poles
position in lateral section only in all sections
Partial anterior in medial Posterior band of disc anterior to 12 o'clock position Disc centered between medial and lateral poles
in medial section only in all sections
Rotational anterolateral Posterior band of disc anterior to 12 o'clock position Disc slightly shifted laterally
in one or more sections
Rotational anteromedial Posterior band of disc anterior to 12 o'clock position Disc slightly shifted medially
in one or more sections
Lateral Posterior band of disc at 12 o'clock position in all sections Disc slightly shifted laterally
Medial Posterior band of disc at 12 o'clock position in all sections Disc slightly shifted medially
Posterior Posterior band of disc posterior to 12 o'clock position in Disc centered or shifted medially/laterally
one or more sections

A DistribuƟon of Incipient DD Types B DistribuƟon of Incipient DD C DistribuƟon of Incipient DD


(Male) (Female)
A
A A
PAL
PAL PAL
RAL
RAL RAL
L
L L
M
M M
RAM
RAM RAM
PAM
PAM PAM
P
P P

D DistribuƟon of Incipient DD E DistribuƟon of Incipient DD


(Right) (LeŌ)

A A
PAL PAL
RAL RAL
L L
M M
RAM RAM
PAM PAM
P P

Fig 3. Distribution of incipient DDs by directionality types: A, collective data for the entire sample; B,
data for boys only; C, data for girls only; D, data for right TMJs only; E, data for left TMJs only. See
Table III for the definitions of the abbreviations.

RESULTS Anterior DD was the third most frequent overall


In this sample of 143 incipient-stage DDs, no joint (18 DDs, 12.59%). As previously stated, no posterior
had a posterior displacement, but displacements in other displacement was observed in this incipient DD sample,
directions (anterior, lateral, and medial) were observed. and the prevalence of other displacements (partial ante-
As shown in Figure 3, A, and Table III, rotational antero- rior in medial, rotational anteromedial, lateral, and
lateral DD was the most frequent (62 DDs) and repre- medial) was low.
sented 43.36% of the incipient DDs (see Table II for When the data were considered separately by sex
classifications). Partial anterior DD in the lateral portion (Table III; Fig 3, B and C), the same general trend, with
was the next most common DD (39 DDs, 27.27%). rotational anterolateral DD being the most frequent

January 2016  Vol 149  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Ikeda and Ikeda 43

Table III. Prevalence of incipient DDs by directionality types


Disc displacement types Total Male Female Right Left
Anterior (A) 18 (12.59%) 5 (8.77%) 13 (15.12%) 15 (20.00%) 3 (4.41%)
Partial anterior in lateral (PAL) 39 (27.27%) 16 (28.07%) 23 (26.74%) 21 (28.00%) 18 (26.47%)
Rotational anterolateral (RAL) 62 (43.36%) 27 (47.37%) 35 (40.70%) 24 (32.00%) 38 (55.88%)
Lateral (L) 4 (2.80%) 1 (1.75%) 3 (3.49%) 1 (1.33%) 3 (4.41%)
Medial (M) 5 (3.50%) 3 (5.26%) 2 (2.33%) 3 (4.00%) 2 (2.94%)
Rotational anteromedial (RAM) 13 (9.09%) 4 (7.02%) 9 (10.47%) 10 (13.33%) 3 (4.41%)
Partial anterior in medial (PAM) 2 (1.40%) 1 (1.75%) 1 (1.16%) 1 (1.33%) 1 (1.47%)
Posterior (P) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Total 143 57 86 75 68

Table IV. Combined categories for the chi-square test


Disc displacement types Total Male Female Right Left
Anterior (A 1 PAL 1 PAM) 59 (41.26%) 22 (38.60%) 37 (43.02%) 37 (49.33%) 22 (32.35 %)
Lateral (L 1 RAL) 66 (46.15%) 28 (49.12%) 38 (44.19 %) 25 (33.33%) 41 (60.29%)
Medial (M 1 RAM) 18 (12.59%) 7 (12.28%) 11 (12.79%) 13 (17.33%) 5 (7.35%)
Total 143 57 86 75 68
See Table III for the definitions of the abbreviations.

type (47.37% in boys, 40.70% in girls), followed in fre- significant difference between the right and left sides
quency by partial anterior DD in the lateral direction (chi-square 5 10.93; P 5 0.005).
(28.07% in boys, 26.74% in girls), was observed. Howev- When the kappa coefficient was computed for the
er, for the less common displacements (medial, lateral, entire sample to evaluate the interobserver reliability be-
and rotational anteromedial DDs in particular), the fre- tween the 2 investigators on categorization of each DD,
quency varied between the sexes. the agreement was excellent (0.82).
The disparity of the distribution of the incipient DD
types was more evident between the right and left
DISCUSSION
TMJs (Table III; Fig 3, D and E). Consistent with the gen-
eral trend, rotational anterolateral DD was the most Although previous studies have shown that antero-
frequent type (32.00% on the right, 55.88% on the medial DD is the most common type of DD,24,30 more
left), followed by partial anterior DD in the lateral direc- recent studies with MRI have reported that DD in the
tion (28.00% on the right, 26.47% on the left). Anterior anterolateral direction is more frequent than previously
DD was much more frequent on the right than on the left described.20,21,26,27 This discrepancy in findings could
joints (right, 20.00%; left, 4.41%), and the right joints be due to the investigating methods used previously
also showed a higher frequency of rotational anterome- (cryosections, plain radiography, arthrography,
dial DDs than did the left joints (right, 13.33%; left, computed tomography scans, and so on) compared
4.41%). with MRI, which has been shown to deliver
To statistically evaluate the sex and right-left differ- significantly more accurate depictions of the TMJ. The
ences with the chi-square test, contingency tables must result from our study supports the latter finding, with
have 5 or more in each cell; this was not satisfied by the 8 rotational anterolateral DD the most frequent
initial categories because of the rarity of some types of displacement (43.36%), followed by partial anterior DD
DD in this sample. Thus, categories were combined to in the lateral part of the joint (27.27%). This general
anterior (including anterior, partial anterior in lateral, trend was not sex-specific and was consistent between
and partial anterior in medial DD), lateral (including the right and left sides. Tasaki et al26 and others have
lateral and rotational anterolateral DDs), and medial also reported that rotational anterolateral DD was the
(including medial and rotational anteromedial DDs) for most frequent type of DD observed in patients or asymp-
the chi-square tests (Table IV; Fig 4). The chi-square tomatic volunteers.20,21
tests showed no statistical difference between the distri- In this study, pure anterior displacement was less
butions of incipient DD types in male vs female subjects frequent (12.59%) compared with reports from other
(chi-square 5 0.35; P .0.05) and a statistically studies.21,26,30 In addition, although the occurrence of

American Journal of Orthodontics and Dentofacial Orthopedics January 2016  Vol 149  Issue 1
44 Ikeda and Ikeda

A DistribuƟon of Incipient DD Types B DistribuƟon of Incipient DD C DistribuƟon of Incipient DD


(Male) (Female)

Anterior
Anterior Anterior
Lateral
Lateral Lateral
Medial
Medial Medial

D DistribuƟon of Incipient DD E DistribuƟon of Incipient DD


(Right) (LeŌ)

Anterior Anterior
Lateral Lateral
Medial Medial

Fig 4. Distribution of incipient DDs by combined directionality types for the chi-square test: A, collective
data for the entire sample; B, data for boys only; C, data for girls only; D, data for right TMJs only; E, data
for left TMJs only.

posterior DD has been documented, no posterior anterior DD associated with the lateral part of the condyle
displacement was observed in our study. Although most may be the first phase of DD pathology.26 At the onset of
studies have included DDs of various severities in the DD, there may be some factor that causes initial insta-
sample, we did not include advanced DDs, since our aim bility of the disc at the lateral part, whereas medial
was to focus only on the DDs in their incipient phase. displacement becomes more prevalent in advanced DDs.
Similarly, in a study of the occurrence of posterior DDs, Another interesting finding in this study was the
no asymptomatic volunteer had posterior DD, although disparity of certain DDs in the right vs the left joints;
all other forms of DD were observed.31 the left side showed a significantly higher frequency of
Anterior displacements that involved the lateral part DDs with a lateral component (rotational anterolateral
of the joint (rotational anterolateral DD and partial ante- and lateral DDs), but sex differences were not statistically
rior DD in the lateral portion) constituted about 70% of significant. This might indicate that the direction of
the incipient DDs overall. On the other hand, DDs incipient DDs can be influenced by local factors rather
involving the medial aspect of the joint (rotational ante- than systemic factors. The difference may be attributed
romedial DD and partial anterior DD in the medial to a right or left side preference in functional or para-
portion) totaled only 10%. Therefore, based on these functional activities and the resulting differential joint
findings, DD involving the medial portion of the joint loading, but future studies are needed to investigate
seems less likely at its early stage. Foucart et al27 also this possibility.
demonstrated a similar trend, where most of the partial
anterior DDs (97%) occurred on the lateral side, and CONCLUSIONS
with progression of DD from complete displacement In this study, we sought to investigate the radio-
with reduction to DD without reduction, the association graphic manifestations of incipient DDs to identify any
with medial displacement became increasingly stronger. tendency in directionality of early DDs. The interobserver
Westesson et al31 reported that in posterior DDs, there reliability was excellent for the categorization of incip-
was a strong association with a medial component to ient DDs by evaluating the MRIs. Among the 143 TMJs
the displacement. As suggested by Foucart et al, partial with incipient DD, different types of DD were observed

January 2016  Vol 149  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Ikeda and Ikeda 45

except for posterior displacements. There was a high 12. Katzberg RW, Westesson PL, Tallents RH, Anderson R, Kurita K,
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