Magnetic resonance imaging on TMJ disc

thickness in TMD patients: A pilot study

Meiqing Wang, DDS, MD, PhD,a Hongtao Cao, DDS, MD,
PhD,b Yali Ge,c and Sven E. Widmalm, DDS, Dr Odontd
School of Stomatology, Fourth Military Medical University, Xi’an,
China; School of Dentistry, University of Michigan, Ann Arbor,
Mich
Statement of problem. Studies of temporomandibular joint (TMJ) discs removed from autopsy specimens and in
surgery indicate that they are often thicker in patients with temporomandibular disorders (TMDs). Disc thickness may
also change when the condyle moves in and out of the joint fossa during opening and closing.

Purpose. The purpose of this pilot study was to test the hypothesis that the TMJ disc thickness is greater in TMD pa-
tients than in healthy subjects and is affected by the degree of jaw opening.

Material and methods. Magnetic resonance images (MRI) were made of the TMJs in young volunteers, 9 asymptom-
atic subjects and 9 TMD subjects, at closed and at 10-, 20-, and 30-mm open positions. The thickness of the anterior
and posterior bands of the discs and the intermediate zones was measured and compared between TMD and con-
trol groups, and between closed and opened positions, using the repeated-measures method in general linear model
(α=.05).

Results. The hypothesis that the disc was thicker in the TMD than in the control group was supported with respect to
the anterior band and intermediate zone (P<.046), but not with respect to the posterior band. The hypothesis that the
thickness is affected by the degree of jaw opening was only supported for the posterior band, where it increased dur-
ing opening in both groups (P<.005).

Conclusions. The results indicate that the anterior band and the intermediate zone of the TMJ discs are thicker in
TMD patients than in healthy subjects. The posterior band thickness increases with mouth opening in both asymp-
tomatic and TMD subjects. (J Prosthet Dent 2009;102:89-93)

Clinical Implications
The findings of this pilot study are of diagnostic interest because
they indicate that TMD is associated with increased disc thick-
ness in the anterior band and the intermediate zone, and that
the open positions are associated with a thicker posterior band.

Supported by grant no. 30540130469 from the Nature Science Foundation of China (NSFC).

Presented at the 21st Annual Meeting of the Japanese Society for Temporomandibular Joint, Osaka, Japan, July 2008.

a
Professor and Chair, Department of Oral Anatomy and Physiology and TMD, School of Stomatology, Fourth Military Medical
University.
b
Lecturer, Department of Oral Anatomy and Physiology and TMD, School of Stomatology, Fourth Military Medical University.
c
Senior Technican, Department of Radiology, Xijing Hospital, Fourth Military Medical University.
d
Associate Professor, Department of Biological and Materials Sciences, Division of Prosthodontics, School of Dentistry, University
of Michigan; Visiting Professor, Department of Oral Anatomy and Physiology and TMD, School of Stomatology, Fourth Military
Medical University.
Wang et al
90
The condylar and disc positions
in the temporomandibular joint
(TMJ) have attracted significant at-
tention in clinical TMD research.1-8
Magnetic resonance imaging (MRI)
provides noninvasive images of the
TMJ disc position and shape.9-11 The
role of TMJ disc deformity is of great
interest.12,13 Kondoh et al14 found a
high prevalence of morphologic disc
changes in a study of fresh cadavers.
Taskaya-Yilmaz and Ogütcen-Toll-
er15 concluded that the degenerative
changes in the TMJ disc are influ-
enced by the degree and type of disc
displacement. The more advanced
the internal derangement, the more
deteriorated was the disc configura-
tion. Sener and Akgänlü,16 in an MRI
study, found that the prevalence of
disc deformation was greater in TMJs
with anterior disc displacement with-
out reduction than in those with re-
duction. Milano et al17 found the
most frequent deformation to be that
the discs had flattened surfaces on
both superior and inferior surfaces
that the authors defined as biplanar.
Marchetti et al18 studied the central
portion of the disc in patients with se-
rious alterations in TMJ function. The
authors showed that the anomalous
discs had an increased content of cel-
lular components, such as fibrocytes,
fibroblasts, myofibroblasts, and, also,
but less frequently, smooth muscle
cells and mast cells. The majority of
the altered discs had numerous blood
vessels, such as a capillary network,
as well as larger vessels. In one disc,
several myelinated and unmyelinated
fibers, isolated or in nerve bundles,
were also seen.
One important function of the
disc is to compensate for the differ-
ences in shape between the articular
surfaces of the condyle and the tem-
poral components of the TMJ, the
fossa and the articular eminence.19
Therefore, it is possible for the disc to
adjust its shape to fit the changes in
joint space associated with osseous
remodeling of the TMJ that often oc-
curs in response to changes in occlu-
sion, according to Mongini.20
The Journal of Prosthetic Dentistry
A recent autopsy study suggested
an association between unbalanced
occlusion and increased TMJ disc
thickness.21 The gradually created dis-
ordered occlusion increased the disc
thickness in the intermediate zone
in rats.22 Kurita et al23 reported that
one of the most frequent characteris-
tics of discs surgically removed from
TMD patients was that they were
thicker than normal. A recent MRI
study reported that a thickened pos-
terior band was the most common
change in patients with anterior disc
displacement.24
The purpose of this pilot study
was to compare the disc thickness,
as measured on MRIs, between liv-
ing subjects, with and without clinical
TMD signs and symptoms, in closed
and open jaw positions. The hypothe-
sis was that the disc thickness is great-
er in patients with TMD and increases
when the jaw position changes from
closed to open.
MATERIAL AND METHODS
Eighteen volunteers were diag-
nosed by a single author (MW) and
divided into 2 groups, an experimen-
tal group with 9 subjects with signs
and symptoms of TMD and a con-
trol group with 9 healthy subjects.
The age ranges of the experimental
and control groups were 19-28 and
21-25 years, respectively, with means
and SDs of 23 ±3.7 years and 23 ±1.1
years, respectively. In each of the
groups there were 5 men and 4 wom-
en, all with complete dentitions and at
least 28 permanent teeth. No subject
had clinically observable deviations
during opening or closing. The TMD
patients were recruited from the TMD
clinic in Qindu Oral Hospital, Xi’an,
China, during the summer of 2005.
They were diagnosed as having TMD
using the criteria reported in the Na-
tional Institutes of Health Technology
Assessment Conference Statement of
1996,25 and had a disease history of
3-15 months. Subjects had to be able
to open widely enough, more than 35
mm, to allow placement of a 30-mm-
Volume 102 Issue 2
thick block in the premolar area. The
control subjects were recruited from
university students who had never
been aware of having TMJ sounds,
orofacial pain, or mandibular move-
ment problems. All participants pro-
vided informed consent for the study,
which was approved by the Human
Subjects Ethics Committees of the
Fourth Military Medical University,
Xi’an, China.
MRIs were made with the jaws in
4 different positions: with the teeth
closed in centric occlusion (CO), and
with the mouth opened 10 mm, 20
mm, and 30 mm. Three sets of rectan-
gular polyester blocks (Department
of Mechanics and Techniques, Fourth
Military Medical University, Xi’an,
China) with the same length, 40 mm,
but different thicknesses, 10 mm, 20
mm, and 30 mm, were made. During
the scanning sessions, the subjects
were asked to occlude on the blocks,
but only hard enough to maintain the
block in position.
An MRI system (Gyroscan Intera
Master 1.5 T Magnetic Resonance
Imaging System; Philips Healthcare,
Eindhoven, The Netherlands) was
used with a TMJ coil as the transmit-
ter. The following settings were used:
time repeat (TR) = 2000, time echo
(TE) = 90, echo = 1/1, transient spin
echo (TSE) fact = 12, field of view
(FOV) = 150/1.3, signal-to-noise ratio
(SNR) = 6, thickness (Thk) = 3/0.3.
The matrix was 240 pixels x 256 pix-
els. The scanning was performed in
axial (Fig. 1) and oblique sagittal di-
rections (Fig. 2). Left and right joints
were scanned separately in each posi-
tion. The total scanning time was ap-
proximately 50 minutes per subject.
Disc thickness was measured on
serial sections of each joint in each of
the 4 positions, the CO and 3 open
positions. Three layers, 1 central, 1
lateral, and 1 medial, were selected
for measuring (Fig. 1). Images that
were not clear or did not have com-
plete depictions of the condyle and
fossa were excluded. The maximal
thickness of the anterior and posteri-
or bands and the minimal thickness of
Wang et al
August 2009 91

1 Axial scanning of TMJ (coronal plane). Border of joint 2 Sagittal scanning of middle section in Figure 1. Three
area is outlined. Three parallel lines mark where 3 layers bars illustrate where thickness of anterior band, interme-
were imaged, with lateral, central, and medial section diate zone, and posterior band of disc was measured.
slices (from left to right, respectively).

the intermediate zone were measured
(Fig. 2) using an electronic meter (de-
signed by Cao J, Lin Z, and Duan YZ,
and produced by Xi’an Jiaotong Uni-
versity Press, Xian City, Shaanxi Prov-
ince, China) accurate to the nearest
0.0001 mm.21 Measurements were
performed on the MRI images made
and stored by the Department of Ra-
diology, Xijing Hospital, the Fourth
Military Medical University, as 72-dpi
JPG image files.
All measurements were performed
by one of the authors who was blind-
ed to the group to which the images
belonged. The mean of the disc thick-
ness in the MRI images, from 3 layers
in each TMJ, the lateral, the central,
and the medial parts, was calculated
3.0
Control Group
Means of Disc Thickness
and used for statistical analysis. For
individuals with missing data, aver-
ages were based on the available data
for that site. The total number of
measurements was 1296, performed
on 432 images. Sixty images were se-
lected from among the 432 images
by using 3-digit random number and
simple random sampling; if the 3-dig-
it random number was greater than
432, the difference between the ran-
dom number and 432 was obtained.
Measurements (n=360) were repeat-
ed 2 times for the 60 images by the
same author.
Statistical software (SPSS 15.0;
SPSS, Inc, Chicago, Ill) was used to an-
alyze the differences in disc thickness
between TMD and control groups
TMD Group
and between positions, separately for
the anterior and posterior bands and
the intermediate zone. The repeated-
measures method in general linear
model was used (α=.05). The within-
subjects variables were side, the data
from right and left joint discs, and
positions, the data from closed and
open positions. The between-subject
factor was group, TMD and control.
When significant effects were found,
specific comparison between sub-
groups was made by the Bonferroni
post hoc test (α=.05).
RESULTS
The mean (SD) values are given in
Figure 3. The thickness of the anterior
2.23
2.13 (0.383)

2.03 (0.300)
2.5 (0.262)
in MRI Images (mm)

1.56
2.0 1.46
1.48 (0.282)
1.40 (0.244)
1.36 (0.170)
(0.209)
(0.172)
1.5 2.14
1.96
(0.492)
(0.394)
1.87
0.69 0.61 0.65 (0.538)
1.0 1.28 1.32 1.26 0.64 (0.131) (0.083) (0.151) 1.38
1.18 (0.219) (0.069) (0.275)
(0.214) (0.185)
(0.161)
0.5
0.52 0.52 0.55 0.56
(0.102) (0.106) (0.139) (0.116)
0
CO 10 mm 20 mm 30 mm CO 10 mm 20 mm 30 mm CO 10 mm 20 mm 30 mm
Anterior Band Intermediate Zone Posterior Band
3 Mean (SD) of TMJ disc thickness (mm) of anterior band, intermediate zone, and posterior band in control
and TMD groups. Anterior band (P=.046) and intermediate zone (P=.029) were thicker in TMD than in con-
trol group. Posterior band was thicker in 3 open positions than in closed position, both in TMD and control
subjects (P<.005). It was also thicker in 20-mm open position than in 10-mm open position (P=.003).
Wang et al
92 Volume 102 Issue 2
Table I. Values of F and P obtained by repeated-measures method in general linear model when
comparing disc thickness in anterior, intermediate, and posterior parts between groups (healthy sub-
jects and TMD patients), positions (closed and 10-, 20-, and 30-mm open) and sides (left and right)

F P

Group: Between TMD and controls Anterior band 4.742 .046

Intermediate zone 5.809 .029
Posterior band 1.271 .277

Position: Between closed and open positions Anterior band 1.224 .286
Intermediate zone 0.350 .563
Posterior band 5.067 .040

Sides: Between left and right Anterior band 0.122 .732

Intermediate zone 1.195 .291
Posterior band 0.355 .560

Position x group Anterior band 0.034 .856

Intermediate zone 1.557 .231
Posterior band 0.934 .349

Sides x group Anterior band 0.659 .430

Intermediate zone 1.421 .252
Posterior band 0.595 .452

Position x sides Anterior band 0.520 .482

Intermediate zone 0.844 .373
Posterior band 0.501 .490

Position x sides x group Anterior band 0.096 .761

Intermediate zone 0.096 .761
Posterior band 1.256 .280

band (F=4.742, P=.046) and the in-
termediate zone (F=5.809, P=.029),
but not the posterior band (F=1.271,
P=.277), was larger in the TMD group
than in the control group. Neither of
the within-subject factors, side and
position, were significant for the ante-
rior band and the intermediate zone.
There was no significant difference
between sides for the posterior band.
The thickness of the posterior band
was, however, significantly affected
by the position (F=5.067, P<.040).
The Bonferroni post hoc test showed
that the posterior band was signifi-
cantly thicker in the 3 open positions
than in the closed position (P<.005),
and was significantly thicker in the 20-
mm open position than in the 10-mm
open position (P=.003).
The Journal of Prosthetic Dentistry
There was high agreement between
the repeated measurements, r=0.847,
0.819, 0.908, respectively, for the an-
terior band, the intermediate zone,
and the posterior band. The values of F
and P obtained by the repeated-mea-
sures method in general linear model
when comparing disc thickness in the
anterior, intermediate, and posterior
parts between groups, positions, and
sides are shown in Table I.
DISCUSSION
The results of this pilot study
support acceptance of the research
hypothesis, indicating that the TMJ
discs of TMD patients have a thicker
anterior band and intermediate zone
than the discs of the healthy control
subjects. The findings are in agree-
ment with an earlier autopsy study21
and are of clinical interest because
morphological changes in the disc
are important signs of TMJ pathology
and/or TMJ dysfunction.
The MRI of the disc is influenced
by the hydrogen level of the tissues.
An increase of hydrogen-rich materi-
als, such as joint fluid, will therefore
increase the strength of the signal. The
result that the thickness of the poste-
rior band increased during opening
thus indicates that the posterior band
contains more fluid in the open posi-
tion than in the closed position. That
may be due to decreased compres-
sive load by the condyle in the open
positions. Accordingly, the increased
thickness of the anterior band and the
Wang et al
August 2009
intermediate zone in the TMD group
implied a decreased compressive load
from the condyle which, however,
needs confirmative research with a
larger sample. Recently published
articles indicate that experimentally
created nonbalanced occlusion may
cause increased thickness in the TMJ
disc of rats22 and degradation of the
mandibular condyle.26 Continued
evaluation of subjects with nonbal-
anced occlusion to study the effect
of this occlusion on disc thickness is
indicated. This may allow for deter-
mining if increased disc thickness in
subjects with nonbalanced occlusion
is associated with TMD signs and/or
symptoms.
There are several limitations of
this study. The images provided by the
imaging center were limited in resolu-
tion, and a future study should cor-
rect for this error. Imaging of the right
and left TMJs independently may have
introduced error due to an inability to
standardize occlusal pressures. In ad-
dition, the degree of opening for all
subjects had to be at least 35 mm for
study participation.
CONCLUSIONS
The results of the present study
indicate that the TMJ disc is thicker
in TMD patients than in healthy sub-
jects in the intermediate zone and the
anterior band, and demonstrate that
the posterior band of the disc is sig-
nificantly thicker in the open position
than in the closed position.
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Corresponding author:
Dr Meiqing Wang
Department of Oral Anatomy and Physiology
and TMD
School of Stomatology
Fourth Military Medical University
Changle Western Road #145
Xi’an
CHINA
Fax: 86-29-83223047
E-mail: mqwang@fmmu.edu.cn
Acknowledgements
The authors thank Jielai Xia for statistical as-
sistance and Haitao Zhao for MRI technique
assistance.
Copyright © 2009 by the Editorial Council for
The Journal of Prosthetic Dentistry.