Indian Journal of Dental Research

: 2006  |  Volume : 17  |  Issue : 1  |  Page : 22--26

Correlation of clinical and MRI findings of tempero mandibular joint internal derangement

UV Chowdary, P Rajesh, RS Neelakandan, CM Nandagopal 
 Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Maduravoyal, Chennai, India

Correspondence Address:
U V Chowdary
Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Maduravoyal, Chennai


The most common clinical features of tempero-mandibular joint internal derangement are correlated with the MRI findings of shape of the disc in an attempt to find the etiology of tempero-mandibular joint internal derangement. In this study, the clinical parameters of pain, muscle tenderness, clicking with in the joint (like early, middle and late) are correlated with the MRI findings of disc shapes. (like biconcave, thick, lengthened, folded, adhesion). The study reveals any trauma that leads to muscle tenderness results in internal derangement of tempero-mandibular joint.

How to cite this article:
Chowdary U V, Rajesh P, Neelakandan R S, Nandagopal C M. Correlation of clinical and MRI findings of tempero mandibular joint internal derangement.Indian J Dent Res 2006;17:22-26

How to cite this URL:
Chowdary U V, Rajesh P, Neelakandan R S, Nandagopal C M. Correlation of clinical and MRI findings of tempero mandibular joint internal derangement. Indian J Dent Res [serial online] 2006 [cited 2021 Jun 13 ];17:22-26
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The most common symptoms of internal derangements of tempero mandibular joint are pain, muscle tenderness a 'clicking' or 'popping' sensation with in the joint, headache, earache and limited ability to open the mouth [1],[2],[3]. Aural symptoms include subjective hearing loss, pain and sensation of blockage, vertigo and timiitus [4],[5],[6],[7],[8],[9],[10],[11]. A grading system for internal derangements has been proposed that grades the severity of internal derangements according to the morphology of the disc [12],[13]. An anteriorly displaced disc that maintains its normal bi­concave configuration is grade I (anterior disc displacement with reduction). An anteriorly displaced disc that does not have normal morphology is grade It (anterior disc displacement with out reduction).


We investigated 60 tempero mandibular joints in 30 patients (11 women, 19 men) with internal derangements by MRI in addition to clinical examination of musclet enderness and clicking.

Images were obtained by a 1.5 T MRI system (Gyro scan Intera Philips) using a transmit and receive head coil and 2mm thick section with a 150 ram field of view and 256 x 256 matrix. T2 PD/TSE images were obtained at coronal, axial, sagittal planes and kinematics using a transmit and receive head coil. Sequential bilateral images were taken with the subjects mouth closed and at the respective maximum open mouth positions.

The radiologist assessed the MRIs using established criteria for normal disc position versus disc displacement. The normal disc position in the posterior band of the disc located superior (12 0' Clock) to the condyle, where as disc displacement is the posterior, band of the disc being in anterior, antero-lateral, medial (or) lateral position, relative to the superior part of the condyle.

The parameters evaluated clinically were collaborated with MRI findings. Based on this disc condyle relationships were categorized as normal, disc displacement with reduction and disc displacement without reduction. The configuration of the disc in the sagittal plane was classified as biconcave-normal, thick posterior band, lengthened, biconvex, folded and rounded.


Correlation of clinical findings of muscle tenderness, click with MR1 findings of disc deformity.

Out of twenty six cases of biconcave disc, twenty had no symptoms (muscle tenderness and click); six had muscle tenderness without click,Out of thirteen cases of thickened disc, twelve had muscle tenderness and click; one had muscle tenderness without clickOut of seventeen cases of lengthened disc, sixteen had muscle tenderness and click, but one had muscle tenderness without clickOut of three cases of folded disc, two had muscle tenderness but no click; one had no symptoms (muscle tenderness and click).One had adhesion with muscle tenderness, but no click.


Helms et al [2] found that 17% of joints that had anteriorly displaced discs with reduction also had degenerative joint disease whereas 95% of joints with displaced discs without reduction had degenerative changes. Most of these joints had discs that were not repairable whereas virtually all of the joints in which disc repair was attempted had reduced discs. The AM can grade the severity of the hydration; in the posterior band, this is best seen as an intermediate signal on TI-weighed images and a high signal on T2 images [13]. Miller et al [16] reported that the discs were thickened and deformed in all cases of anterior disc displacement without reduction. Disc displacement without reduction was usually associated with an absence of joint sounds, the presence of TMJ pain and muscle spasms and a limitation of jaw opening with deviation to the affected side. On the other hand, Sutton et al [17] reported that the condyle-disc relation was more likely to be in the normal position (with the middle of the posterior band of the disc in the 12 O'clock position relative to the center of the head of the condyle) in the clinically silent group than in the group with clinically discernible sounds.

In an electromyographic study, Isberg et al [18] found that electromyo graphic activity of the temporalis and masseter muscles occurred when the condyle slid over the posterior band of the disc and could be interpreted as an arthrokinetic reflex caused by distraction. Continuous muscle activity could be provoked by displacement of the TMJ disc and ceased when the disc was returned to a normal position on opening mouth only to recur every time the disc became displaced on closure of mouth. Anterior disc displacement without reduction (closed lock) could cause spastic activity in the temporalis muscle on the affected side. Spastic activity of the masseter and temporalis muscles on the same side as a joint with anterior disc displacement hinders the condylar movement necessary to achieve reduction [18]. Sigaroudi and Knap [19] reported soreness of lateral pterygoid muscles and temporal muscles in 62% of the patients with internal derangements of the TMJ. It has been suggested that the click occurs because of in-coordination of the lateral pterygoid and temporal muscles, anterior displacement of the disc, posterior displacement of the condyle, folding or wrinkling of the disc, roughness of the joint surface and prolonged opening during dental procedures. However, our results were slightly different as the incidence of tenderness of medial pterygoid, masseter and temporalis muscles, was less than that of the lateral pterygoid muscle.

In arthrographic study combined with sound recordings, Eriksson et al [21] reported that joints with reciprocal clicking showed disc displacement with reduction and silent and crepitating joints showed disc displacement without reduction. All joint with clicking (and most silent joints) had nonarthritic articular surfaces, whereas crepitatinn was recorded in both arthritic and nonartheric joints, implying that crepitations are an unreliable sign of arthritis. They concluded that clicking can be considered to be an accurate sign of reduction of anteriorly displaced discs [17], [22],[23],[24]. However, Roberts et al [25] argued that all joint 'clicking' is not necessarily a sign of a reducing disc. Yatani et al [26] suggested that anterior disc displacement with reduction could be diagnosed with considerable accuracy by clinical examination alone, as the overall accuracy of the clicking test combined with the other tests was about 90%. However, they reported that the ability to predict the position of disc from the patient's history and clinical findings and to differentiate anterior disc displacement without reduction from other diagnoses was not high and that the overall accuracy of the clinical findings ranged from 71 to 81% [27] Wilkes [24] reported that the degree of clinical expression in any given case is proportional to the degree of the pathological condition present.


Muscle tenderness is a common finding in all the cases even in discs with biconcave shape. But click was not associated with all the cases of muscle tenderness. Tenderness of the muscles of mastication is the initial symptom, if persists it causes lack of coordination between the disc and head of the condyle resulting in click, thus leading to in-coordination between both the joints.


Systemic correlation of clinical signs and symptoms with results of MR1 reveals, muscle tenderness leads to internal derangement. Prevention of muscle tenderness can prevent internal derangement. Finding the cause of muscle tenderness can be the study for future.


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