Journal of Oral and Maxillofacial Radiology / May-August 2014 / Vol 2 | Issue 2 41

Magnetic resonance imaging observation

of bone marrow edema of the mandibular
condyle in patients with temporomandibular
joint osteoarthritis
Galal Omami
1,2
1
Department of Oral Diagnosis and Polyclinics, Clinical Assistant Professor,
2
Faculty of Dentistry, The University of Hong Kong,
Hong Kong, China
INTRODUCTION
Many magnetic resonance imaging (MRI) studies
have shown bone marrow abnormalities may occur in
the mandibular condyle.
[1-3]
Furthermore, histology-
correlated MRI data have suggested bone marrow
edema or necrosis may precede the development
of osteoarthritis.
[4]
It has been hypothesized that
necrosis and/or edema of bone marrow can lead to
collapse of the articular surface and eventually result
in osteoarthritis. The pathogenesis of bone marrow
edema is thought to be related to the blockage of the
osseous microcirculation, with associated venous stasis,
which may lead to increased intramedullary pressure that
eventually results in bone necrosis.
[5,6]
The main advantages of MRI over all other imaging
modalities are the lack of ionizing radiation and the
high soft-tissue resolution.
[7]
T1-weighted images
are preferred for outlining morphology because of
the greater latitude and better visualization of disk
tissue relative to the osseous anatomy of the condyle.
T2-weighted images are obtained routinely to document
the presence of joint effusion and inammatory changes
in the joint capsule.
The purpose of this study was to investigate the relationship
between bone marrow edema and osteoarthritis of the
mandibular condyle in a group of symptomatic patients
using MRI. Accordingly, the null hypothesis (H
0
) was: There
is no signicant association between bone marrow edema
of the mandibular condyle and temporomandibular joint
(TMJ) osteoarthritis.
A B S T R A C T
Purpose: The purpose of the study was to demonstrate the relationship between bone marrow edema of the mandibular condyle and
osteoarthritic changes of the temporomandibular joint (TMJ) in a group of symptomatic patients using magnetic resonance imaging
(MRI). Materials and Methods: MRI data of 96 TMJ dysfunction patients were investigated for association between bone marrow
edema of the mandibular condyle and TMJ osteoarthritis. Chi-square test was used for statistical analysis and P values less than
0.05 were accepted as statistically signicant. Results: There was statistically signicant association between osteoarthritis and bone
marrow edema of mandibular condyle. Conclusion: Bone marrow edema of the mandibular condyle appears to be a predictor of TMJ
osteoarthritis. Further histology-based MRI data are needed to improve our understanding of the pathophysiology of TMJ osteoarthritis.
Key words: Bone marrow edema, osteoarthritis, magnetic resonance imaging, temporomandibular joint
Address for correspondence: Dr. Galal Omami, The University of Hong Kong, Faculty of Dentistry, Hong Kong, China.
E-mail: jellodent@yahoo.com
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DOI:
10.4103/2321-3841.138631
Original Article
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Omami: Bone marrow edema in TMJ osteoarthritis
Journal of Oral and Maxillofacial Radiology / May-August 2014 / Vol 2 | Issue 2 42
MATERIALS AND METHODS
This study comprised consecutive temporomandibular
dysfunction patients referred to the Department of Oral and
Maxillofacial Radiology, University of Connecticut School
of Dental Medicine, from January 2005 to December 2011.
All patients presented with at least one of the following
TMJ clinical features: Pain, clicking, locking, or restricted
jaw movement. This study was approved by the Institutional
Review Board (IRB) of the University of Connecticut
Health Center (IRB number 11-158-1). For MRI techniques,
all patients were examined with a 1.5-T system (8-truly
in-dependent-channel radiofrequency head coil; Siemens,
Magnetom Avanto 1.5 T, Erlangen, Germany). Sagittal
oblique imaging of the TMJ was acquired with the use
of turbo spin-echo (TSE; half-Fourier acquisition TSE)
T1-weighted (in open- and closed-mouth positions) and
T2-weighted (in closed-mouth position) sequences. Coronal
imaging was acquired with TSE T1-weighted sequences in
closed-mouth position. All MRI studies were static and
used a stepped plastic bite-block placed between the upper
and lower incisors to control the mouth-opening position.
The gradient pulse sequences and parameters were as
follow: For T1-weighted images: Field of view (FOV)-
14 cm, slice thickness-3.00 mm, slice gap-3.30 mm, TR
-770 ms, TE-12 ms, ip angle (FA)-150, matrix 320
256, acquisition mode two-dimensional; for T2-weighted
images: FOV-14 cm, slice thickness-3.00 mm, slice gap-3.30
mm, TR-3,000 ms, TE-65 ms, FA-150, matrix 256 204,
acquisition mode two-dimensional.
The imaging data were analyzed on workstation of Philips
IntelliSpace PACS Enterprise (Philips Healthcare, Amsterdam,
The Netherlands). Bone marrow edema was dened by the
presence of a hypointense signal on T1-weighted images and
a hyperintense signal on T2-weighted images in the mandibular
condyle in at least one sagittal section. On T1-weighted images,
diagnosis of osteoarthritis was dened by visualization of
attening, surface irregularities, erosion, and/or osteophytosis
in the condylar or temporal component of the joint.
The association of osteoarthritis with bone marrow edema
was evaluated by Chi-square test, and P < 0.05 were
accepted as statistically signicant.
RESULTS
Among the total number of 108 TMJ-MRI exams, 12
patients were excluded for poor image quality or prior
TMJ surgery. The nal study population comprised 96
patients (192 joints), of whom 80 women and 28 men.
Their ages ranged from 18 to 73 years (mean, 42 years).
Osteoarthritic changes were seen in 142 (73%) joints.
Bone marrow edema was encountered in 116 (60%) joints
[Table 1]. The remaining 76 joints were used as a control
group. Hence, the control group was simply selected on
virtue of absence of osteoarthritis. Concurrent presence
of bone marrow edema and osteoarthritis was encountered
in 100 joints [Figure 1]. Chi-square test showed signicant
association between bone marrow edema and osteoarthritis
(P < 0.0001); thus, the null hypothesis was rejected.
DISCUSSION
Several MRI studies have reported bone marrow
abnormalities, in terms of edema and avascular necrosis,
of the femoral head.
[5,6]
Therefore, it has been postulated
that similar conditions could occur in the TMJ.
[1-3]

Larheim et al. used core biopsy to document that edema
and osteonecrosis may occur in the marrow of the
mandibular condyle.
[4]
They suggested that osteoarthritis
may develop secondary to bone marrow edema and/or
necrosis in the mandibular condyle. The prevalence of
TMJ osteoarthritis reported in the literature is highly
variable. This study has shown fairly high prevalence
rate of osteoarthritis (73%); however, it was based on
Table 1: Relationship between osteoarthritis and bone
marrow edema (n = 192 joints in 96 patients)
Finding No bone
marrow edema
Bone marrow
edema
Total
No
osteoarthritis
34 16 50
Osteoarthritis 42 100 142
Total 76 116 192
Figure 1: Osteoarthritis associated with bone marrow edema. (a) Sagittal
T1-weighted magnetic resonance imaging (MRI) shows surface irregularities of
the anterior slope of the condylar head suggestive of osteoarthritis (arrow).
Articular disc is anteriorly displaced (arrowhead). (b) Sagittal T2-weighted
MRI of the same joint shows high signal intensity of the condylar head
suggestive of bone marrow edema (arrow). Note uid effusion in the upper
joint compartment (arrowhead)
a b
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Omami: Bone marrow edema in TMJ osteoarthritis
Journal of Oral and Maxillofacial Radiology / May-August 2014 / Vol 2 | Issue 2 43
symptomatic subjects. Osteoarthritis has been described
as a painful TMJ condition. However, it is diagnosed in a
sizable proportion of asymptomatic older individuals.
[8]

The discrepancy between imaging ndings and patient
symptoms indicates the need for a comprehensive clinical
examination to determine which imaging ndings are
clinically signicant.
This study shows that abnormal bone marrow signal is more
frequently seen in osteoarthritic joints. Such an observation
has been reported in other studies. Authors have described
the frequency of osteoarthritis in TMJ with bone marrow
edema as ranging from 58.8% to 59.5%.
[2,9]
These ndings
were fairly consistent with my result (52%). Emshoff et al.
suggested that the MR imaging ndings for TMJ bone
marrow edema are related to those of osteoarthritis.
[3]

However, their results are inconsistent with ndings in
previous studies that showed incidence of bone marrow
edema in patients with TMJ dysfunction ranging from 2.5%
to 6.5%.
[10,11]
The inconsistent results may be explained
on the basis of the studies were conducted without use
of meticulous selection and interpretation criteria. The
development of osteoarthritis secondary to bone marrow
abnormalities is not clearly understood. Bone marrow
edema has been suggested as a diagnostic predictor of
TMJ osteoarthritis.
[4]
The small size of the TMJ, in addition
to the structure and thinness of the articular soft tissue
covering may facilitate early development of secondary
osteoarthritis subsequent to bone marrow edema in the
mandibular condyle. However, the same nding appears
to hold true for the other synovial joints.
[12]
Multifactorial
casecontrol studies using specic imaging criteria are
recommended to further investigate the relationship of
TMJ osteoarthritis with bone marrow abnormalities of
the mandibular condyle.
CONCLUSION
This analysis has shown that bone marrow edema of
the mandibular condyle is suggestive, or probably a
forerunner, of osteoarthritis. The study provides a piece
of evidence about the usefulness of MRI in the evaluation
of osteoarthritic changes involving TMJ. In order to
improve our understanding of the pathophysiology of
TMJ disorder, more histology- and imaging-based studies
are suggested to clarify whether bone marrow edema is a
precursor to osteoarthritis or rather occurs as a separate
entity that does not essentially develop into osteoarthritis.
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Cite this article as: Omami G. Magnetic resonance imaging observation
of bone marrow edema of the mandibular condyle in patients with
temporomandibular joint osteoarthritis. J Oral Maxillofac Radiol 2014;2:41-3.
Source of Support: Nil. Conict of Interest: None declared.
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