Dentomaxillofacial Radiology (2013) 42, 84227642

ª 2013 The British Institute of Radiology

http://dmfr.birjournals.org

RESEARCH
Disc displacement and changes in condylar position
K Ikeda*,1 and A Kawamura2,3
1
Hillside View Orthodontic Office, Tokyo, Japan; 2Kawamura Orthodontic Office, Ibaraki, Japan; 3Department of Orthodontics,
Nihon University School of Dentistry at Matsudo, Matsudo, Japan

Objectives: To determine whether disc displacement (DD) can be a factor causing changes in
condylar position in the glenoid fossa, using limited cone beam CT (LCBCT) images taken in
the same time period as MRI that verified DD.
Methods: The study included 60 joints in 57 male and female subjects aged 12–20 years
(mean age 14.8 years). Subjects fulfilling the inclusion criteria were enrolled from a pool of
post-orthodontic patients, and divided into four groups according to their disc status
confirmed by MRI: partial DD (PDD), total DD with reduction (TDDWR), lateral DD
(LDD) and medial DD (MDD). Changes in joint space from previously reported norms were
measured on LCBCT images.
Results: In PDD, the condyles were displaced posteriorly in the fossae with a mean anterior
space of 2.7 6 0.5 mm (normal 1.3 6 0.2 mm) and a posterior space of 1.8 6 0.4 mm (normal
2.1 6 0.3 mm). In TDDWR, the condyles were displaced not only posteriorly as observed in
PDD, but also vertically with a reduced superior space of 1.9 6 0.4 mm (normal 2.5 6 0.5 mm).
In LDD, the lateral space was significantly increased to 2.5 6 0.3 mm (normal 1.8 6 0.4 mm),
while central and medial spaces were significantly decreased to 2.2 6 0.5 mm (normal
2.7 6 0.5 mm) and 1.7 6 0.4 mm (normal 2.4 6 0.5 mm), respectively. In MDD, the medial
space was increased and the lateral and central spaces were significantly decreased.
Conclusions: These results indicate that DD in adolescents and young adults can cause the
condyle to change its position in the fossa with alterations in joint space which depend on the
direction and extent of DD.
Dentomaxillofacial Radiology (2013) 42, 84227642. doi: 10.1259/dmfr/84227642

Cite this article as: Ikeda K, Kawamura A. Disc displacement and changes in condylar position.
Dentomaxillofac Radiol 2013; 42: 84227642.

Keywords: cone beam CT; MRI; disc displacement; condylar position; temporomandibular
joint

Introduction

The intimate association of the disc–condyle assembly
to the eminence in the glenoid fossa1,2 is reflected in the
structure of the disc with the orientation of its fibres
suitable for distribution of the pressure applied to the
temporomandibular joint (TMJ).3 The intermediate
zone of the disc located between the anterior band and
the posterior band dissipates the applied pressure side-
ways with collagen fibre bundles running predom-
inantly perpendicular to the mediolateral axis of the
disc.4 The disc is interposed between the posterior slope
*Correspondence to: Dr Kazumi Ikeda, Hillside View Orthodontic Office,
Daikanyama Plaza 3F, 24-7, Sarugakucho, Shibuya-ku, Tokyo 150-0033,
Japan. E-mail: ikedakzm@tkd.att.ne.jp
Received 15 March 2012; revised 8 June 2012; accepted 13 June 2012
of the eminence and the functional surface of the con-
dyle to act as a buffer between the two bones.
Potential causes of changes in the position of the
condyle in the fossa include disc displacement (DD),
disc hypertrophy,5 discrepancies between centric occlu-
sion (CO) and centric relation (CR) at the joint level,6–8
excessive joint effusion,9 and altered osseous morphol-
ogy of the condyle and eminence due to degenerative
joint disease (DJD),10 not to mention trauma to the jaw.
Although there are articles discussing the correlation
between DD and condylar displacement,11–17 no study
has quantified changes in condylar position associated
with DD in the sagittal and coronal planes, using re-
cords that enable objective assessments of DD.18,19 This
study was conducted to determine how the position of
 DD and space change in TMJ
2 of 8 K Ikeda and A Kawamura
the condyle varied in the fossa depending on the di-
rection and extent of DD, using limited cone beam CT
(LCBCT) images of the same parts of the TMJ acquired
in the same time period as MR images that verified disc
status. Optimal condylar position has been studied in
three planes of space in subjects with the normal disc
position confirmed on MR images taken in maximum
intercuspation (CO).20,21 The norms found in these
studies were used as reference values to investigate the
effect of DD on condylar position in the present study.
Materials and methods
The study included 60 joints with MRI-confirmed DD
in 57 subjects aged 12–20 years (mean age 14.8 years)
from a pool of post-orthodontic patients for retrospec-
tive analysis of their disc positions on LCBCT images.
The MR and LCBCT images used in the study had been
obtained as part of the initial examination upon in-
formed consent, as patient history and chairside exam-
ination22 had indicated the need for objective TMJ
status assessment by diagnostic imaging prior to or-
thodontic treatment. Subjects meeting the following
inclusion criteria were enrolled based on the temporal
order of the initial visit between January 2006 and
September 2009: (1) no history of trauma to the face; (2)
no DJD; (3) no excessive joint effusion;23 (4) no major
CO–CR discrepancy at the joint level; (5) no hypertro-
phy of the disc; and (6) no thinning of the disc. The
absence of DJD was confirmed on open-mouth MR
images according to the severity and non-reducing
Figure 1 MRI (a) and CT (b) images of partial disc displacement
Dentomaxillofac Radiol, 42, 84227642
status of DD, and joints with marked osseous alter-
ations on CBCT images were excluded.24 T2 weighted
MR images were used to detect excessive joint effusion.
CO–CR discrepancies at the joint level were checked
with a condylar position indicator (CPI; Panadent,
Grand Terrace, CA) to exclude vertical and ante-
roposterior discrepancies of 1.8 mm or more and
transverse discrepancies of 0.6 mm or more.25 Overt
hypertrophy or thinning of the disc was identified with
MRI. The subjects who met these criteria were divided
into four DD groups: partial DD (PDD), total DD with
reduction (TDDWR), lateral DD (LDD) and medial
DD (MDD). PDD was defined as a posterior band of
the disc displaced to the middle third of the eminence on
one or two of the three sagittal (medial, central and
lateral) MR slices examined (Figure 1a). TDDWR was
defined as a more advanced stage of DD where one or
two of the three sagittal slices revealed the displacement
of a posterior band down to the inferior one-third of the
eminence, the remaining sagittal slice(s) not showing
a posterior band within the superior one-third of the
eminence (Figure 2a). Figure 3 is a schematic repre-
sentation of normal disc position, PDD and TDDWR
in the sagittal plane. A medial or lateral component of
DD had to be less than one-quarter of the disc width in
the coronal plane for both PDD and TDDWR. LDD
was defined as one-third to one-half of the disc dis-
placed laterally on the coronal MR slice, but the pos-
terior band was retained within the superior half of the
eminence on the lateral sagittal slice (Figures 1 and 4).
Figure 5b illustrates LDD, as defined in this study,
compared with the normal disc position in the coronal
plane (Figure 5a). MDD was defined as one-third to
 DD and space change in TMJ
K Ikeda and A Kawamura 3 of 8

Figure 2 MRI (a) and CT (b) images of total disc displacement with reduction

one-half of the disc displaced medially (Figure 5c) on
the coronal MR slice.
LCBCT slices that most closely matched the MR
slices confirming DD were selected and magnified five
times to trace the outlines of the TMJ osseous struc-
tures. Reference lines and landmarks were placed as
previously reported20,21 (Figures 6 and 7). Joint space
distances were then measured to two decimal places
with a digital calliper (Digimatic, Mitutoyo Corpora-
tion, Kanagawa, Japan) by a single dentist. To assess
the significance of any errors during measurement, 17
joints of 20 subjects were re-evaluated 1 month later.
The mean difference between the first and second
measurements was analysed by the paired t-test. The
error variance was calculated as a percentage of total
variance (error %) using Dahlberg’s double determination
method. The mean differences were less than 0.04 mm
(0.00–0.04 mm) with no significant difference for all mea-
sures. The error % was below 1.11% (0.34–1.11%).
The images used to assess disc position were taken
with an MRI scanner (Gyroscan ACS-NT Intera,
Philips, Best, Netherlands) with surface coils. The
section thickness was 2.5 mm and the slice interval was
0.2 mm. Proton density-weighted images were acquired
with the following parameters: field of view 12 cm,
repetition time (TR) 2500 ms, echo time (TE) 20 ms,
and 256 3 256 matrix. Ten slices each were obtained
perpendicular to the long axis of the condyle in both
sagittal and coronal planes in CO, as well as in the
sagittal plane in the open-mouth position. T2 weighted
imaging was performed for ten sagittal slices perpen-
dicular to the long axis of the condyle under the im-
aging conditions of TR 2500 ms and TE 100 ms with
fat suppression.

s-SF

Auditory
meatus

s-IF

Anterior Posterior

a b c
Figure 3 Classification of disc position by sagittal MRI. The line connecting the sagittal superior fossa (s-SF) and the sagittal inferior fossa (s-IF)
along the eminence was divided into three equal parts. Partial disc displacement was defined as the posterior band (PB) of the disc displaced down
to the middle third of the eminence, and total disc displacement with reduction as the PB displaced down to the inferior third of the eminence. (a)
Sagittal normal disc position; (b) partial disc displacement; (c) total disc displacement with reduction

Dentomaxillofac Radiol, 42, 84227642

 DD and space change in TMJ
4 of 8 K Ikeda and A Kawamura

Figure 4 MRI (a) and CT (b) images of lateral disc displacement

The osseous components of the TMJ were evaluated
using LCBCT images acquired in the same time period
as the confirmatory MR images (within 2 weeks). The
patient was placed in the natural head positon.26 The joints
were scanned with a dental LCBCT machine (PSR9000N,
Asahi Roentgen, Kyoto, Japan) with a radiation field of
413 40 mm, voxel size of 0.1 mm, scan time of 13.3 s,
tube voltage of 80 kV, tube current of 10 mA; slice
thickness and interval were both 0.1 mm. The radiation
dose of bilateral TMJ imaging was 84 mSv.27 LCBCT
images that most closely matched the confirmatory MR
images were acquired perpendicular to and parallel
to the long axis of the condyle in the sagittal and cor-
onal planes, respectively, for joint space measurement.
The joint space distance measurements derived from the
sagittal normal disc position (s-NDP) and coronal
normal disc position (c-NDP) in our previous studies
were used as reference values.20,21 Hence there is a
group consisting of a small number of samples that is
also non-normal distribution; the statistical significance
of differences among those four groups was calculated
using the Steel–Dwass test for multiple comparisons.
Statistical analysis was performed using Excel 2003
(Microsoft, Seattle, WA) with the add-in software Statcel
3.28 Differences were considered significant when the
p-value was less than 0.05.
Since the images were taken prior to this retrospective
study for diagnostic purposes and the findings summa-
rized in this study are incidental findings, ethics board
approval was not required.

Lateral Medial

a b c
Figure 5 Classification of disc position by coronal MRI. Lateral disc displacement was defined as one-third to one-half of the disc displaced
laterally. Medial disc displacement was defined as one-third to one-half of the disc displaced medially. (a) Normal disc position; (b) lateral disc
displacement; (c) medial disc displacement

Dentomaxillofac Radiol, 42, 84227642


True horizontal line
(Standard plane) SS
AS PS
SC
PC Auditory
AC meatus
Anterior Posterior
Figure 6 Landmarks and linear measurements of the space between the
condyle and the glenoid fossa in the sagittal plane. The true horizontal
line (THL) parallel to the floor with the patient in the natural head
position was used as the reference plane. Superior joint space (SS) was
defined as the distance measured along a line perpendicular to the THL
extending from the most superior condyle point (SC) to the glenoid
fossa. Lines tangent to the most prominent anterior and posterior aspects
of the condyle were drawn from the intersection of the perpendicular line
and the glenoid fossa. Distances from the anterior (AC) and posterior
(PC) tangent points to the nearest point on the glenoid fossa were
measured as the anterior joint space (AS) and posterior joint space (PS)
True horizontal line
(Standard plane)
CS
LS
MS
CC
CL CM
Lateral Medial
Figure 7 Landmarks and linear measurements of the space between the
coronal condyle and the glenoid fossa. Landmarks and linear measure-
ments of the space between the condyle and the glenoid fossa in the
coronal plane. The true horizontal line (THL) was used as a standard
plane. The mediolateral width of the condyle on the coronal cross-
sectional image was divided into sextants. The mid-point of the total
width was projected to the surface of the condyle along a line
perpendicular to the THL and designated as the coronal central point
(CC). Similarly, the points on the condylar surface derived from lines
perpendicular to the THL that extend from the junction of the medial first
and second sextants and that of the lateral first and second sextants were
designated as the coronal medial point (CM) and coronal lateral point
(CL). Linear measurements of the joint space from CM, CC, and CL to
the fossa were measured as the shortest distances from the respective
points to the surface of the glenoid fossa and termed as the coronal medial
space (MS), coronal central space (CS) and coronal lateral space (LS)
DD and space change in TMJ
K Ikeda and A Kawamura 5 of 8
Results
Sagittal section
Table 1 shows joint space measurements in the sagittal
section. The mean anterior space (AS) was significantly
larger in PDD and TDDWR than in the previously
reported s-NDP.20 No significant difference in AS was
observed between PDD and TDDWR. The mean su-
perior space (SS) was significantly smaller in TDDWR
than in s-NDP and PDD with no significant difference
between s-NDP and PDD. The mean posterior space
(PS) was significantly smaller in PDD and TDDWR
than in s-NDP, with no significant difference between
PDD and TDDWR.
Table 1 shows the ratios of the mean AS, SS and PS
values in PDD and TDDWR to the respective joint
space values in s-NDP that were set to 1.0. The ratios
were AS 2.1, SS 1.0 and PS 0.9 for PDD, and AS 2.1, SS
0.8 and PS 0.8 for TDDWR.
Coronal section
The mean lateral space (LS) in LDD was significantly
larger than in the previously reported c-NDP, whereas
that in MDD was significantly smaller than in c-NDP,
as shown in Table 2. The LS in LDD was significantly
larger than in MDD. The mean central space (CS) was
significantly smaller in both LDD and MDD than in c-
NDP. No difference in CS was observed between LDD
and MDD. The mean medial space (MS) in LDD was
significantly smaller than in c-NDP. The MS in MDD
was significantly larger than in LDD.
Discussion
The results of this study involving adolescents and
young adults demonstrate that DD can cause the con-
dyle to change its position in the fossa. The mean an-
terior space value was 2.7 mm for both PDD and
TDDWR, significantly (2.1 times) larger than the nor-
mal value of 1.3 mm, as depicted in Table 1. There was
no significant difference in SS between s-NDP (2.5 mm)
and PDD (2.5 mm). The SS in TDDWR was 1.9 mm,
significantly smaller than in s-NDP and PDD, in-
dicating significant narrowing of the superior joint
space. The PS was significantly narrower in PDD and
TDDWR, with mean values of 1.8 mm and 1.6 mm,
respectively, compared with the normal value of 2.1
mm. Anterior space widening and PS narrowing were
seen in both PDD and TDDWR, but SS narrowing was
observed only in TDDWR, suggesting that the position
of the disc, the posterior band in particular, has a great
bearing on condylar position in the fossa (Figure 8).
In the coronal section, the mean LS value in LDD
was 2.5 mm, significantly (1.4 times) larger than the
normal value of 1.8 mm in c-NDP, as shown in Table 2.
The CS, on the other hand, was diminished to a signif-
icantly smaller value of 2.2 mm in LDD than the nor-
mal value of 2.7 mm. The same was true for the mean
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Dentomaxillofac Radiol, 42, 84227642

Table 1 Sagittal section
s-NDP (n 5 24) PDD (n 5 20) TDDWR (n 5 20) Steel–Dwass test
Ratio
Variables Mean SD (standard) Mean SD Ratio Mean SD Ratio s-NDP–PDD s-NDP–TDDWR PDD–TDDWR
Anterior joint space 1.3 0.2 1.0 2.7 0.5 2.1 2.7 0.6 2.1 s-NDP , PDDa s-NDP , TDDWRa n.s.
Superior joint space 2.5 0.5 1.0 2.5 0.5 1.0 1.9 0.4 0.8 n.s. s-NDP . TDDWRa PDD . TDDWRa
Posterior joint space 2.1 0.3 1.0 1.8 0.4 0.9 1.6 0.4 0.8 s-NDP . PDDa s-NDP . TDDWRa n.s.
n.s.: not significant; PDD, partial disc displacement; SD, standard deviation; s-NDP, sagittal normal disc position; TDDWR, total disc displacement with reduction.
a
p , 0.01.
DD and space change in TMJ
K Ikeda and A Kawamura

Table 2 Coronal section

c-NDP (n 5 24) LDD (n 5 20) MDD (n 5 6) Steel–Dwass test
Ratio
Variables Mean SD (standard) Mean SD Ratio Mean SD Ratio c-NDP–LDD c-NDP–MDD LDD–MDD
Lateral joint space 1.8 0.4 1.0 2.5 0.3 1.4 1.3 0.4 0.7 c-NDP , LDDb c-NDP . MDDa LDD . MDDb
Central joint space 2.7 0.5 1.0 2.2 0.5 0.8 2.0 0.5 0.7 c-NDP . LDDb c-NDP . MDDa n.s.
Medial joint space 2.4 0.5 1.0 1.7 0.4 0.7 2.6 0.4 1.1 c-NDP . LDDb n.s. LDD , MDDb
c-NDP, coronal normal disc position; LDD, lateral disc displacement; MDD, medial disc displacement; n.s., not significant; SD, standard deviation.
a
p , 0.05.
b
p , 0.01.
 DD and space change in TMJ
K Ikeda and A Kawamura 7 of 8

True horizontal line

mean (ratio)
(Standard plane) SS 2.5mm (1.0) SS 1.9mm (0.8)
PS 1.8mm (0.9) PS 1.6mm (0.8)
AS 2.7mm (2.1) AS 2.7mm (2.1) SC
SC Auditory
PC AC PC
AC meatus

Anterior Posterior

Partial Disc Displacement (PDD) Total Disc Displacement with reduction (TDDWR)
Figure 8 Schematic representation of mean distances and ratios for partial disc displacement and total disc displacement with reduction in the
sagittal plane. AC, anterior tangent point; AS, anterior space; PC, posterior tangent point; PS, posterior space; SC, superior condyle point; SS,
superior space

MS value of 1.7 mm in LDD, which was significantly
smaller than the normal value of 2.4 mm. In LDD, the
LS was greatly widened while the CS and MS were
constricted, and in MDD, in contrast, an increment in
the MS and a reduction in the CS and LS were ob-
served, indicating that the joint space in the coronal
section is also affected by the direction of DD, as found
in the sagittal section (Figure 9). All these results taken
together suggest that the direction and extent of DD
may be estimated from the joint space distances visu-
alized on LCBCT images.
CBCT is far more easily accessible for clinical use
than MRI. The ability to estimate disc position on
LCBCT images contributes greatly to treatment plan-
ning even if it does not lead to a definitive diagnosis.
This study has demonstrated that it is possible to dif-
ferentiate PDD from TDDWR based on their joint
space changes. In TDDWR with a more advanced stage
of DD, a superior shift of the condyle was observed in
addition to a posterior shift. It has been shown that
more advanced stages of DD are accompanied by
marked morphological alterations of the disc, making it
increasingly difficult for the disc to reduce back onto the
functional surface of the condyle.29 Furthermore, the
posterior border of the condyle is flattened as a result of
remodelling, and fibrosis of the posterior disc attach-
ment becomes more pronounced.30 These morpho-
logical and histological alterations are associated with
severe mandibular dysfunction, and extensive joint ef-
fusion indicated by high signal intensity on T2 weighted
images. Attempts should be made to prevent PDD from
further progressing to TDDWR. In this regard, it is
important to know what stage of DD the patient is at
before starting any definitive occlusal treatment.
Lateral or medial displacement is commonly ob-
served even in adolescents and young adults. Although
LDD is more prevalent, some exhibit MDD. The LDD
group of this study consisted of joints with one-third to

True horizontal line mean (ratio)

(Standard plane) CS 2.2mm (0.8) CS 2.0mm (0.7)
LS 2.5mm (1.4) LS 1.3mm (0.7) MS 2.6mm (1.1)
MS 1.7mm (0.7)
CC CC
CL CM CL CM

Lateral Medial

Lateral Disc Displacement (LDD) Medial Disc Displacement (MDD)

Figure 9 Schematic representation of mean and ratios for lateral and medial disc displacement in the coronal plane. CC, coronal central point; CL,
coronal lateral point; CM, coronal medial point; CS, coronal central space; LS, coronal lateral space; MS, coronal medial space

Dentomaxillofac Radiol, 42, 84227642

 DD and space change in TMJ
8 of 8 K Ikeda and A Kawamura
one-half of the disc displaced laterally, and the lateral
part of posterior band displaced halfway or less down
the eminence in the sagittal plane as confirmed by MRI.
At this stage of LDD, the central and medial portions of
the posterior band are located well within the superior
half of the eminence. When the entire disc from medial
to lateral is displaced to the inferior one-third of the
eminence, the joint space between the condyle and the
fossa in the coronal plane is reduced so much that in-
terpretation of diagnostic images becomes difficult. This
is the reason why LDD was defined as the posterior
band displaced no more than halfway down the emi-
nence as viewed on a sagittal MR slice of the lateral part
of the joint. We were able to demonstrate that MRI-
confirmed LDD with one-third to one-half of the disc
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