Ultrasound in Med. & Biol., Vol. 32, No. 5, pp.

633– 639, 2006

Copyright © 2006 World Federation for Ultrasound in Medicine & Biology
Printed in the USA. All rights reserved
0301-5629/06/$–see front matter

doi:10.1016/j.ultrasmedbio.2006.02.1401

● Original Contribution

3-D SONOGRAPHY FOR DIAGNOSIS OF DISK DISLOCATION OF THE

TEMPOROMANDIBULAR JOINT COMPARED WITH MRI

CONSTANTIN A. LANDES,* WOJCIECH A. GORAL,* ROBERT SADER,* and MARTIN G. MACK†

*Department of Oral Maxillofacial and Plastic-Facial Surgery; and †Department of Diagnostic and Interventional
Radiology, Frankfurt University Medical Centre, Frankfurt, Germany

(Received 19 September 2005, revised 31 January 2006, in final form 10 February 2006)

Abstract—This study determines the value of three-dimensional (3-D) sonography for the assessment of disk
dislocation of the temporomandibular joint (TMJ). Sixty-eight patients (i.e.,136 TMJ) with clinical dysfunction
were examined by 272 sonographic 3-D scans. An 8- to 12.5-MHz transducer, angulated by step-motor, was used
after picking a volume box on 2-D scan; magnetic resonance imaging followed immediately. Every TMJ was
scrutinized in closed- and open-mouth position for normal or dislocated disk position. Fifty-three patients had
complete data sets, i.e., 106 TMJ, 212 examinations. Sonographic examination took 5 min, with 74% specificity
(62% closed-mouth; 85% open-mouth); sensitivity 53% (62/43%); accuracy 70% (62/77%); positive predictive
value 49% (57/41%); and negative predictive value 77% (67/86%). This study encourages more research on the
diagnostic capacity of 3-D TMJ sonography, with the advantage of multidimensional joint visualization. Al-
though fair in specificity and negative predictive value, sensitivity and accuracy may ameliorate with future
higher-sound frequency, real-time 3-D viewing and automated image analysis. (E-mail: c.landes@lycos.com)
© 2006 World Federation for Ultrasound in Medicine & Biology.

Key Words: 3-D ultrasound, Temporomandibular joint, Temporomandibular dysfunction, MRI, Disk dislocation,
3-D sonography, Four-dimensional sonography.

INTRODUCTION tablished comparing postmortem cryosections to previ-

Temporomandibular joint dysfunction (TMD) is a com-
mon disorder and is clinically classified (Helkimo 1976)
because it presents with an array of symptoms: pain, joint
sounds, headaches, tinnitus and irregular jaw movements
(Eversole and Marchade 1985; Dworkin and LeResche
1992). Magnetic resonance assessment evidenced disk
dislocation, degeneration, perforation and fibrosis (West-
esson et al. 1985; Lundh and Westesson 1989; Truelove
et al. 1992) to be associated with TMD. Disk dislocation
is the most obvious pathology and, therefore, a new
sonographic diagnostic technique should in the first place
become evaluated here with defined parameters against
the standard diagnostics.
Magnetic resonance imaging (MRI) of the temporo-
mandibular joint (TMJ) today is widely used and can
reliably depict anatomic details of the disk-condyle
alignment. A diagnostic accuracy of 95% has been es-
Address correspondence to: Dr. C. Landes, Oral Maxillofacial
and Plastic-Facial Surgery, The Frankfurt University Medical Centre,
Theodor-Stern-Kai 7, 60596 Frankfurt, Germany. E-mail:
c.landes@lycos.com
ous TMJ-MRI (Westesson et al. 1985; Tasaki and West-
esson 1993), whereas arthrography shows merely 83%
accuracy combined with videofluoroscopy (Westesson
and Bronstein 1987) and is associated with radiation
exposure, invasive and may be complicated by allergy,
infection and pain. Rapid MRI sequences permit recon-
structed, yet not real-time, motion cycles (Eberhardt et
al. 2000). MRI as diagnostic aid is limited by the costs
and low availability (variable according to country, in-
vestigator and clinical setting). Therefrom results limited
repeatability; moreover, reduced patient comfort and
considerable duration of the examination occur.
Sonography allows dynamic real-time visualization
of the TMJ (Landes et al. 2000), yet so far only conven-
tional sonography in two dimensions has been reported
(Stefanoff et al. 1992; Emshoff et al. 1997; Hayashi et al.
2001; Uysal et al. 2002; Emshoff et al. 2002). Two-
dimensional (2-D) sonography allows fast reliable as-
sessment of condylar translation, considerable informa-
tion of disk position, yet without three-dimensional (3-D)
viewing (Landes and Sterz 2003a,b; Landes 2004). TMJ
examinations are comfortable for the patient. There is no

633
634 Ultrasound in Medicine and Biology Volume 32, Number 5, 2006

need for intraoral examination at low cost and high

availability. Transducer position lateral to the condyle,
disk and joint capsule gives a frontal (Emshoff et al.
1997) or axial (Landes et al. 2000) section view. How-
ever, 2-D sonography does not show the complete 3-D
lateral joint architecture, which might be helpful for
better differentiation of lateral vs. anterior disk disloca-
tion. The validity of 3-D TMJ sonography for assessment
of disk dislocation is assessed by this study.

PATIENTS AND METHODS

From July 2002 to May 2003, 68 consecutive TMD
patients (44 females, 24 males; mean age 32 y, range 14 Fig. 1. Showing the standard closed-mouth and open-mouth
to 77 y; 136 TMJ examinations) were referred to the positions of the transducer parallel and inferior to the zygo-
TMJ Clinic at our department for static 3-D sonography. matic arch (parallel to the Camper-line).
As their primary complaint, all patients reported pain and
dysfunction of the temporomandibular area. Informed
imaging protocol included sagittal oblique and coronal
consent was obtained and sonography was performed in
oblique T1-weighted spin echo (SE) sequences (450/15
single-blind manner, i.e., sonograms were analyzed with-
[repetition time ms/echo time ms], imaging matrix 256 !
out knowledge of the MRI results. The first author’s
256, field of view 128 mm, pixel size 0.5 ! 0.5 mm, slice
examination results with regard to disk position were
thickness 3 mm) and sagittal oblique T2- and proton
reported to the second examiner for statistical analysis.
density-weighted turbo spin echo (TSE) sequence (2840/
The results were compared with those assessed by the
103 to 15, matrix 512 ! 512, field of view 128 mm, pixel
radiologist who assessed the MRI pictures from the iden-
size 0.3 ! 0.3 mm, slice thickness 3 mm). All sagittal
tical joint. MRI examination was performed directly after
oblique sections were orientated perpendicular to the
the sonographic examination. To maintain comparable
long axis of the condyle in transverse plane. The patient
jaw position, the closed-mouth and maximum opening
was positioned in supine position. Sequential bilateral
positions were used for comparison.
images were obtained in the closed-mouth and maximum
All 3-D sonographic trials were performed with
opening position.
Voluson 530 equipment (General Electric-Kretz, Solin-
The MR images were interpreted without knowl-
gen, Germany). The transducer was an 8- to 12.5-MHz
edge of the findings at sonography.
linear array, moved by a step motor.
The disk position was considered to be normal if the
Initially, a 2-D positioning of the target-volume
posterior band of the disk was located in a 12 o’clock or
over the joint and mandibular condyle was performed,
superior position relative to the condyle. Disk displace-
first tilting the transducer to obtain optimum visualiza-
ment was diagnosed in patients in whom the posterior
tion. The transducer was oriented in the standard planes
band of the disk was situated anterior, anteromedial,
of head and neck sonography, parallel-inferior to the
anterolateral, medial or lateral relative to the condyle.
zygomatic arch (Siegert 1987). Therefore, the transducer
The functional disk-condyle relationship of the TMJ
intersected axially the lateral superior and inferior joint
was diagnosed as normal (grade 0), displacement with
compartment. Sections parallel to the route of condylar
reduction (grade I) or displacement without reduction
translation were obtained by positioning the transducer
(grade II). This classification depended on whether disk
in anterioposterior orientation parallel to the zygomatic
displacement was found in situ in the closed-mouth po-
arch (Fig. 1). The static examination was held in occlu-
sition or the disk was absent between the condyle and
sion and maximal mouth opening.
articular eminence in the open-mouth position.
The disk was seen as a hypoechogenic band over-
The statistical parameters—sensitivity, specificity,
lying the lateral condylar pole (Figs. 2 and 3). The disk
accuracy, positive and negative predictive value of 3-D
position was considered to be normal when overlying the
sonography—were compared with MRI. The results
condyle between the most anterior-superior point and
were moreover compared by !2 testing.
lateral pole. The MRIs were judged independently by an
experienced radiologist. A 1.5-T MRI (Magnetom Vi-
RESULTS
sion, Siemens, Erlangen, Germany) with a dedicated
surface TMJ coil was used to acquire simultaneous bi- The datasets of 53 patients (106 joints) were com-
lateral sagittal oblique and coronal oblique images. The plete. Nine (14% of the total of 68 joints) MRI exami-
 3-D TMJ-sonography for disk dislocation ● C. A. LANDES et al.
Fig. 2. (a) Shows the proper closed 3-D sonography in a
previously defined volume box in frontal (above left), top
(above right) and side view (below left). The scan axially
transects the lateral joint. Scrolling permits choosing of delib-
erate sections within the scanned volume (below right); and (b)
depicts the manual cut placed into the volume box and the 3-D
volume block (below right). The disk was seen as a hypoecho-
genic band overlying the hyperechogenic lateral condyle pole.
The frontal view informs about lateral-medial disk position, the
top view about anterior-dorsal disk displacement and the lateral
view transects the disk and lateral pole.
nations and four (6%) sonographs dropped out as the
images were lost. Two (3%) patients developed claus-
trophobia during MRI and interrupted the procedure.
One patient had communication problems and did not
properly open her mouth on demand. Altogether, 212 of
272 images were analysed (105 in the closed-mouth
position, 107 in the open-mouth position).
For the diagnosis using 3-D sonography, it proved
valuable to cut the data block into several transections
because hypoechogenic structures were displayed as
transparent and echogenic structures displayed as opaque
in proportion to their echogenicity. Initially, an axial cut
just transecting the upper condylar pole and disk was
preferred. This was later changed to a coronal and sag-
ittal cut (Figs. 4 and 5, or online at www.constantinland-
es.net). The latter was the most important for diagnosis
635
of disk position because it allowed the easiest determi-
nation of anteroposterior disk position.
Three-dimensional sonography revealed n " 29
(62%) of 47 MRI-verified internal derangements (e.g.,
disk displacements; see Tables 1-4). Three-dimensional
sonographic accuracy vs. MRI reached 70% (62% in the
closed-mouth, 77% in the open-mouth position).
The sensitivity was 53% overall (62% closed-
mouth/43% open-mouth position); more disk disloca-
tions were correctly discerned in closed position.
The specificity reached 74% (62/85%); the open-
mouth position was more specific for disk dislocation
and permitted correct determination of normal disk po-
sition.
The positive predictive value was 49% (57/41%);
the negative predictive value was 77% (67/86%).There-
fore, the closed-mouth position was more reliable for
disk dislocation assessment and the open-mouth position
for normal disk position.
Disk displacement grade 0 was correctly diagnosed
by 3-D sonography in 36 (62%) of 58 grade-0 TMJ, disk
displacement with reduction in 19 (68%) of 28 grade-I
TMJ, grade II displacement without reduction was cor-
rectly diagnosed in eight (40%) of 20 TMJ.
In 18 of 105 available closed-mouth examinations,
sonography produced false-negative results, i.e., 17%. In
several cases, MRI revealed a medially displaced disk in
the closed-mouth position.
Comparing positive and negative results, sonogra-
phy depicted disk dislocation in the closed-mouth posi-
tion with more precision than in the open-mouth position
(29 of 105 examinations were true positive, 22 exami-
nations were false positive. In the open-mouth position,
nine of 107 examinations were true positive, 13 exami-
nations were false positive). Grade I reduction was iden-
tified more accurately than grade II without reduction
(accuracy 68% vs. 40%). Sonography comparably de-
tected grade I and grade 0 (68% vs. 62%). Chi-square
testing revealed statistically significant deviation from
the expected (MRI) results in the closed-mouth position:
p " 0.04, not in the open-mouth position: p " 0.8;
overall nonsignificant p " 0.26; at a level of significance
of " " 0.05.
DISCUSSION
A close association of symptoms of TMD and
disk displacements has been repeatedly emphasized,
and this study supports this concept. The percentage of
disk dislocation of 45% was below the 77% to 89%
quoted in other studies (Tasaki et al. 1996), whereas in
asymptomatic patient groups, 30% to 33% of dislo-
cated disks were detected (Katzberg et al. 1996). This
may be an indication that many patients had TMD
636 Ultrasound in Medicine and Biology Volume 32, Number 5, 2006

Fig. 3. Shows the volume block on the left in the sagittal and outlined disk overlying the likewise outlined lateral
condylar pole in shape of a beret on the right in (a) closed mouth (on the right is a blueprint of the condyle, disk and
capsule); (b) open mouth with normal disk position; (c) shows a closed mouth; and (d) open-mouth position with
dislocated, nonrepositioning disk position or dislocation.

with a muscular imbalance and merely incipient de-

generative joint disease.
The accuracy of high-resolution 2-D sonograms
compared with MRI, in general, was reported to be
83% to 95% (Landes et al. 2000; Emshoff et al. 2002);
even a “perfect agreement” was found (Uysal et al.
2002). This study examined the benefit of 3-D sonog-
raphy and compared 3-D sonograms with MRI for
assessment of disk dislocation. Three-dimensional
sonographic examination of the TMJ had an accuracy

Fig. 4. Above left and right show the sagittal cut that is Fig. 5. The 3-D view in sagittal (left) and additional frontal
manually placed through the volume block to provide a frontal (right) viewing mode in (a) closed-mouth; and (b) open-mouth
view of the mediolateral disk position. positions.
 3-D TMJ-sonography for disk dislocation ● C. A. LANDES et al. 637

Table 1. Sonographic result distribution compared with MRI in (a) closed- and (b) open-mouth positions
Disk dislocation, mouth closed

# –

3-D # 29 True positives (TP) 22 False positives (FP) All with positive test Positive predictive value "
sonography 51 TP/(TP # FP) 0.57
– 18 False negatives (FN) 36 True negatives (TN) All with negative test Negative predictive value "
54 TN/(FN # TN) 0.67
All with disk dislocation All without disk dislocation Everyone TP # FP # FN # TN
47 68
Sensitivity " Specificity " Pre test probability "
TP/(TP#FN) " 0.62 TN/(FP#TN) " 0.62 (TP#FN)/(TP#FP#FN#TN) " 0.45
(a)

Disk dislocation, mouth open

# –

3D # 9 (TP) 13 (FP) All with positive test Positive predictive value "
sonography 22 TP/(TP # FP) 0.41
– 12 (FN) 73 (TN) All with negative test Negative predictive value "
85 TN/(FN#TN) 0.86
All with disk dislocation All without disk dislocation Everyone TP # FP # FN # TN
21 86
Sensitivity " Specificity " Pre test probability "
TP/(TP # FN) " 0.43 TN/(FP # TN) " 0.85 (TP # FN)/(TP # FP # FN # TN) " 0.20
(b)

of 70% (62% closed-mouth, 77% open-mouth) com-

pared with MRI. This is a value not as significant than
Table 3. MRI and 3-D sonography diagnoses
previous 2-D studies by other authors; however, this
probably indicates investigator and equipment varia-
MRI diagnoses
tion. However, specificity and sensitivity could be 160 144
optimized compared with a previous 2-D study by the 140
total
author (Landes et al. 2000). Diagnostic capacities may 120
closed
100
be improved when 7.5-MHz transducers are replaced 80 68
86
71 73
open
right TMJ
by 12-MHz transducers (Emshoff et al. 2002). The 60 47
58
left TMJ
35 33
transducer in this study used 8- to 12-MHz, depending 40
21
20
on the focus. Using the high “resolution mode” with 0
enhancement of echoes between 12.5 and 4.5 MHz and Dis loc ation No dis loc ation

(a)

3-D Sonography Diagnoses

Table 2. Distribution of true/false positives vs. MRI in open- 160
139
and closed-mouth position. 140 total
120 closed
100 85 open
True/False-Positive and Negative Distribution 80 73 76
right TMJ
63
51 54 left TMJ
60 43
80 73 40 30
22
70 20
60 0
true positive Dislocation No dislocation
50
40 36 false-positive (b)
29 true negative
30 22
18 false-negative
20 13
9 12 In the a) MRI diagnoses, 68 of 212 examinations showed disk
10 dislocations (32%) and b) 3D TMJ sonography showed 73 of 212
0 examinations with disk dislocation (34%). Disk dislocation was more
Closed-mouth Open-mouth frequent in closed mouth position than in open mouth position left and
right joint were evenly distributed.
638 Ultrasound in Medicine and Biology
Table 4. Synopsis of 3D-sonographic accuracy, sensitivity,
specificity, positive predictive value and negative predictive
value in diagnosing disk dislocation grades, fibrosis and
perforation vs. MRI
Results
100% Total average Closed-mouth Open-mouth
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Accurracy Sensitivity Specificity Positive Negative
predictive predictive
value value
near-field focus did improve the diagnostic efficacy,
and this was therefore employed throughout this study.
Selecting a second frontal or axial visualization plane
in cases where the disk position in the standard sagittal
plane was uncertain was the biggest advantage over
2-D sonography. The data block whose acquisition did
not take more time than regular 2-D sonography could
be cut at any plane, making the diagnosis of lateral,
medial disk dislocation feasible; this is not possible
with 2-D sonography. Three-dimensional visualization
may improve when automated image enhancement is
available. The use of “4-D sonography” was explored
on a trial basis (see www.constantinlandes.net).
A disadvantage of the method is that suboptimal
angulation of the transducer may easily cause the cor-
rectly positioned disk to disappear from the sonographic
picture in the 2-D linear B-scan. This was the major
reason for false-negative results in 2-D sonography. If
the beam does not intersect the disk at its lateral portion
in the axial plane, higher echoes resulting in part from
artifactual echoes (multiple reflection echoes) between
the osseous surfaces (Malzer 1992) make the disk appear
scarred, flat or dislocated. False-negative results were
mainly caused by effusion and joint capsule edema that
mimicked a disk in regular position. The medial joint is
not accessible to 2-D sonography and, thus, a medially
dislocated disk cannot be identified (Emshoff et al.
2002). The tissue block obtained by 3-D sonography
made the diagnosis of combined dislocations easier and
a 3-D in-depth view of the hypoechogenic disk was
possible.
Cryosections have shown high correlation of MRI
findings to postmortem histologic examination and,
therefore, it seems justified to correlate to MRI as refer-
ence standard in this study (Tasaki and Westesson 1993).
Volume 32, Number 5, 2006
The observers have been involved with TMJ sonography
and MRI for more than 5 y, and the learning curve has
entered a steady slope; however, despite this, individual
observer variation can influence the result. Retest exam-
inations have shown a 96% concordance.
MRI is a somewhat artificial examination setting,
and an anxious patient in the prone position may exhibit
stronger dislocation as consequence of bruxism. Prob-
lems with interpretation of MRI sections have been an-
notated by Brady et al. (1993) when MRI results only
correlated with 71% sensitivity and 91% specificity com-
pared with clinical assessment.
The principal advantage of using 3-D sonography
was to obtain a complete overview of the condyle and
disk, not a transection. This made the interpretation
much more feasible. The transducer position and, thus,
the insonating angle, were not viewed as keenly as in 2-D
sonography. Yet the upper margin of the selected 3-D
“box” from the 2-D pilot picture has to be adjusted as a
box-cube and cannot follow the slope of the condyle in
real-time mode to reproduce the translation of an iden-
tical point in motion. An adjustable nonlinear border
might enhance the results. The potential of TMJ sonog-
raphy lies in noninvasive, increasingly reliable diagnosis
of TMJ disk dislocation at times where budgetary con-
siderations play an important role in patient manage-
ment.
The high specificity (85%) and negative predictive
value (86%) in open-mouth position should exclude a
pathologic disk position with about 90% certainty. When
the sonographic examination is unobtrusive, it will need
to be prospectively combined with higher sensitivity to
clearly select TMD patients for splint therapy (Okeson
1988), with the remaining cases submitted to MRI only.
Prospectively, real-time 3-D sonography will be com-
pared with rapid MRI sequences.
In this report, 3-D-sonography is applied in the first
assessment for the diagnosis of disk dislocation of the
temporomandibular joint. The proposed measurement
takes $5 min and is adequate for a differentiation of
normal disk position and partial and full dislocation with
repositioning or without. Sonography is fast and com-
fortable for the patient, setting aside the initial outlay for
sonographic equipment; it is an economic and versatile
alternative, although only advanced equipment provides
3-D reconstruction. Alternative methods for TMJ diag-
nosis, such as arthrography or arthroscopy, are invasive;
MRI is limited by cost, expense, duration and availabil-
ity. 3-D sonography should be further enhanced by im-
proved image resolution, automated image enhancement
and higher emission frequency. As satisfactory specific-
ity and negative predictive value for a screening instru-
ment were obtained, sensitivity and accuracy may im-
prove with future higher frequency, real-time viewing
 3-D TMJ-sonography for disk dislocation ● C. A. LANDES et al.
and automated imaging and tissue analysis. This study
justifies further research on the diagnostic capacity of
3-D sonography, with the advantage of multidimensional
joint visualization at suitable angles.
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