Dentomaxillofacial Radiology (2002) 31, 373 ± 378

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RESEARCH
Alteration of the horizontal mandibular condyle size associated
with temporomandibular joint internal derangement in adult
females
H Kurita*,1, A Ohtsuka1, H Kobayashi1 and K Kurashina1
1
Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, Matsumoto, Japan

Objectives: The purpose of this retrospective study was to analyse the relationship between
horizontal size of the mandibular condyle and internal derangement (ID) of the
temporomandibular joint (TMJ).
Methods: One hundred and thirty-nine joints in 88 women aged over 18 years were included in
this study. The horizontal condylar size was measured in the antero-posterior and medio-lateral
(ML) dimensions using axial magnetic resonance (MR) images. Radiological ®ndings of ID
were also assessed from MR imaging.
Results: The condyles in the joints with permanent disk displacement were smaller than those
in joints without displacement in both dimensions (Fisher's protected least signi®cant
di€erence, P50.05). There were statistically signi®cant correlations between horizontal
condylar size in the ML dimension and both disk morphology and radiological stage of ID
(Spearman's correlation coecient by rank, P50.05).
Conclusions: The results of this study suggest a possible relationship between horizontal
condylar size and disk displacement. It is also suggested that the condyle becomes smaller in the
ML dimension with advancement of ID.
Dentomaxillofacial Radiology (2002) 31, 373 ± 378. doi:10.1038/sj.dmfr.4600727

Keywords: temporomandibular joint; condylar size; internal derangement

Introduction

A variety of condylar OA (osteoarthritis/osteoarthro- between disk displacement and changes in TMJ

sis) changes are observed in patients with internal
derangement (ID) of the temporomandibular joint
(TMJ).1 These morphological changes may lead to
alteration of the size of the TMJ condyle. De Bont et
al.2 have described a reduction in TMJ size in joints
with disk displacement and perforation. However, a
few other investigators have focused on the changes of
the TMJ condylar size associated with ID.3,4
Experimentally-induced displacement of the TMJ
disk induced shortening of the mandibular ramus on
the ipsilateral side.5 It has also been reported that ID
may be associated with disturbed facial skeleton
growth such as retrognathia and mandibular asymme-
try.6,7 These results suggest a possible relationship
*Correspondence to: H Kurita, Department of Dentistry and Oral Surgery,
Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, 390-8621,
Japan; E-mail: hkurita@hsp.md.shinshu-u.ac.jp
Received 29 January 2002; revised 18 June 2002; accepted 12 August 2002
condylar size.
The aim of this study was to analyse the relationship
between disk displacement and the size in the antero-
posterior (AP) and medio-lateral (ML) dimensions of the
TMJ condyle. We also tested the hypothesis that the size
of the TMJ condyle is altered with advancing ID,
anticipating controversy over whether the change of the
TMJ condylar size is a cause or a result of the TMJ ID.
Materials and methods
This study was based on examining selected subjects
from among a consecutive series of 145 patients who
underwent magnetic resonance (MR) imaging between
1994 and 2000. Patients under the age of 18 years were
excluded from this study because their characteristic
TMJ condyle pro®le has yet to be developed,8,9 and
only women were included because of the speculation
 Condylar size and TMJ ID
H Kurita et al
374
that there might be di€erences in the size of the TMJ
condyle between sexes. Consequently, 139 joints in 88
women were included in this study. The mean age was
33.5 years (s.d. 14.3), with a range of 18 ± 80 years.
An MR imaging study was performed with a 1.5-
tesla system (General Electric Medical System,
Milwaukee, WI, USA) with a TMJ surface coil
(6.0 mm in diameter). An initial axial localizer (TR
300 ms, TE 16 ms, FOV 24 cm, 5-mm slice thickness,
2566192 scanning matrix) that was nearly parallel to
the Frankfort horizontal plane and could maximally
visualize the lateral and medial poles of both condyles
was obtained in the closed-mouth position. Five 3-mm
slice thickness, oblique sagittal images of the TMJ (TR
500 ms, TE 15 ms, FOV 16 cm, 2566192 scanning
matrix) were then obtained with the jaw in each of the
closed- and open-mouth positions. Oblique sagittal
MR images were assessed for disk displacement, degree
of disk displacement, and disk morphology at a
representative center depth of the TMJ (on a sagittal
image that crossed the middle third of the condyle and
where the disk was imaged the clearest). Disk
displacement was de®ned as previously reported.10,11
The degree of disk displacement was classi®ed
according to the criteria reported by Takase et al.12
Namely, in the sagittal images, disk displacement was
classi®ed as slight if the posterior band of the
anteriorly displaced disk touched the condyle in the
closed-mouth projection, moderate if the posterior
band was located within the posterior slope of the
articular eminence, and severe if the posterior band
was located under the articular eminence or more
anterior. Disk morphology was classi®ed in the closed-
mouth projection in the sagittal plane and categorized
as either biconcave, biplanar, biconvex, folded, or
amorphous.13,14 Each MR image was separately
evaluated by a trained radiologist and one of the
authors (H Kurita). Any disagreements were discussed
until consensus was reached.
All joints were subsequently classi®ed into one of the
®ve radiological stages of ID described by Wilkes15 and
Schellhas,16 as shown in Table 1. Because we had no
data on the presence of perforation of the disk and/or
the attachment, we could not di€erentiate stage 4 from
stage 5.
A method for describing the horizontal condyle size
is illustrated in Figure 1. In the printed image of the
Table 1 Radiological stages of internal derangement described by
Wilkes15 and Schellhas16
Stage 1 Simple disk displacement without changes in the morphol-
ogy of the disk or OA
Stage 2 Reducible disk placement with mild-moderate deformity of
the disk (usually associated with biplanar or biconvex disk)
and/or OA
Stage 3 Permanent disk displacement with mild-moderate deformity
of the disk (usually associated with biplanar or biconvex
disk) and/or OA
Stages 4 Severe permanent displacement and deformity of the disk
and 5 (usually associated with folded or amorphous disk) with
OA
Dentomaxillofacial Radiology
initial axial localizer (magni®cation: 0.4*1.1, mean 0.6
(s.d. 0.2)), a line was drawn through the medial (m)
and lateral poles (l) of the condyle. A perpendicular
line was drawn to bisect the line m ± l, and this
intersected the anterior edge and the posterior edge
of the condyle at points a and p, respectively. The
distances of l ± m and a ± p were measured in half
millimeters with a ruler. The horizontal sizes of the
condyle in the AP and ML dimensions were obtained
by computing the individual magni®cation in each
patient as follows: (medio-lateral dimension)=(the
distance of m ± l)/(magni®cation) and (antero-posterior
dimension)=(the distance of a ± p)/(magni®cation). The
measurements were taken two separate times by one of
the authors (H Kurita) blinded to the results of the
MRI study. The di€erence between the ®rst and second
measurements was little (average, 70.06; standard
deviation, 1.63; skewness, 71.01; kurtosis, 4.48;
median, 0.00). The horizontal sizes were then obtained
by calculating the mean value for each patient.
Thereafter, the horizontal sizes of the condyles were
compared among the joints with no disk displacement
(NDD), with disk displacement with reduction
(DDWR), and with disk displacement without reduc-
tion (DDWOR). Di€erences were tested using the post-
hoc test. Relationships between the horizontal size of
the condyle and either degree of disk displacement,
disk morphology, or the radiological stage of ID were
analysed and tested by Spearman's correlation coeffi-
cient by rank. P50.05 was considered to indicate
signi®cance.
Results
The results for the assessment of disk displacement,
degree of disk displacement, and disk morphology are
shown in Table 2. There was little disagreement in the
assessments. Consequently, 30 joints had changes
Figure 1 Measurement of the horizontal size of the TMJ condyle. A
line was drawn through the medial (m) and lateral (l) poles of the
condyle. A perpendicular line was drawn to bisect the line m ± l, and
this intersected the anterior edge and the posterior edge of the
condyle at points a and p, respectively. The distances m ± l and a ± p
were measured in half millimeters
 Condylar size and TMJ ID
H Kurita et al
375
compatible with radiological stage 1, 31 stage 2, 20 stage was a statistically signi®cant correlation between the
3, and 29 stages 4 or 5. Twenty nine joints were normal. condyle size in the ML dimension and disk morphol-
The mean horizontal condylar size in the di€erent ogy (Spearman's correlation coecient by rank,
diagnoses of disk displacement is shown in Table 3. P50.05). The condyle became smaller in the ML
There were statistically signi®cant di€erences in the dimension with morphological alteration of the disk.
sizes of both the ML and AP dimension between the On the other hand, there was no signi®cant correlation
joints with NDD and those with DDWOR (Fisher's between the condyle size in the AP dimension and disk
protected least signi®cant di€erence, P50.05). The morphology (Spearman's correlation coecient by
condyle in the joints with DDWOR is smaller than that rank, P40.67).
in the joints with NDD. There also was a signi®cant The correlation between the horizontal size of the
di€erence in the size of the AP dimension between the condyle and the radiological stage of ID is shown in
joints with NDD and those with DDWR (Fisher's Figure 4. The condyle became smaller in the ML
protected least signi®cant di€erence, P50.05). The dimension with advancement of ID, and the correla-
condyle in the joints with DDWR is smaller than that tion between them was signi®cant (Spearman's
in the joints with NDD in the AP dimension (Fisher's correlation coecient by rank, P50.05). On the other
protected least signi®cant di€erence, P50.05). hand, there was no signi®cant correlation between the
The correlation between horizontal condylar size and condyle size in the AP dimension and radiological
degree of disk displacement is shown in Figure 2. In the stage of ID (Spearman's correlation coecient by rank,
ML dimension, the condyle tended to become smaller P40.36). The condyle was biggest in the joints with
with advancement of disk displacement. On the other the most advanced stages of ID in the AP dimension.
hand, in the AP dimension, the condyle was smallest in
the joints with slight disk displacement and tended to
become bigger with the advancement of disk displace- Discussion
ment. However, there was no statistically signi®cant
correlation between the degree of disk displacement This study was carried out to clarify the relationship
and the horizontal condylar size (Spearman's correla- between the horizontal TMJ condyle size and ID. For
tion coecient by rank; P40.17 in the ML dimension this purpose, MR images of an initial axial localizer
and P40.55 in the AP dimension). were retrospectively used to measure the horizontal
The relationship between the horizontal condylar condyle size. There might be a concern that the axial
size and disk morphology is shown in Figure 3. There image would not be representative of the entire
condylar head. In this study, the axial image that was
nearly parallel to the Frankfort horizontal plane and
Table 2 Results of MR assessment of 139 joints in 88 patients with that could maximally visualize the lateral and medial
internal derangement of the TMJ
poles of both condyles was obtained. We know that the
Disk displacement lateral and medial poles of both condyles are not
None 29 usually seen on an axial plane. However, we believe the
With reduction 58 use of this axial image is practical. In the measure-
Without reduction 52
Degree of disk displacement ments of the condyle size, we used printed ®lms with
None 29 the mean magni®cation of 0.6. The single observer
Slight 44 recorded little di€erence between the ®rst and second
Moderate 47 measurements. However, further studies that employ a
Severe 19
Morphological changes in the displaced disk
more valid measurement method are needed.
Biconcave 56 The results of this study showed that the TMJ
Biplanar 19 condyle is smaller in joints where the TMJ disk is
Biconvex 35 anteriorly displaced than in joints without a displaced
Folded 7 disk in both the ML and AP dimension. Previously,
Amorphous 22
Ohgushi et al.4 evaluated the relationship between
anterior displacement and the size of the condyle using
Table 3 Mean horizontal condyle size in joints with different MR images. They reported that the size of the condyles
diagnoses of disk placement with anterior disk displacement was signi®cantly
Horizontal condyle size smaller than that of condyles without anterior
Disk displacement medio-lateral antero-posterior displacement. Kobayashi et al.3 measured the horizon-
(No. of joints) dimension dimension tal size of the TMJ condyle using axial images of X-ray

] ]
No displacement (29) 19.0+3.0 8.7+1.7 computed tomography and found that the horizontal
Anterior displacement 18.1+2.9 7.9+1.2 ] size of the condyle in joints with a displaced disk was
with reduction (58) a a
Anterior displacement 17.6+2.7 7.9+1.3
smaller both in the long and short axis than in those
without reduction (52) without a displaced disk.3 Our results were compatible
a
There was a statistically signi®cant di€erence between the groups
with theirs. These data suggest that there might be a
(Fisher's protected least signi®cant di€erent; P50.05). (Mean+ relationship between the size of the TMJ condyle and
standard deviation, mm) disk displacement.

Dentomaxillofacial Radiology
 Condylar size and TMJ ID
H Kurita et al
376

Figure 2 Horizontal condyle size in relation to degree of TMJ disk displacement

Biconcave Biplanar Biconvex Folded Amorphous Biconcave Biplanar Biconvex Folded Amorphous

Figure 3 Horizontal condyle size in relation to TMJ disk morphology. The correlation between the condyle size in the medio-lateral dimension
and disk morphology is statistically signi®cant (Spearman's correlation coecient by rank, P50.05)

There may be some controversy as to whether joints result in a small condyle because of concurrent
with a small condyle might have a greater tendency for degenerative bony changes. In this study, the condyle
disk displacement or whether disk displacement might size in the ML dimension decreased with advancing
Dentomaxillofacial Radiology

Figure 4 Horizontal condylar size in relation to radiological stage of TMJ internal derangement. The correlation between the condyle size in
the medio-lateral dimension and ID stage is statistically signi®cant (Spearman's correlation coecient by rank, P50.05)
stage of ID. This result appears to support the latter
possibility. It was experimentally shown that TMJ disk
displacement could induce reduction of mandibular
height and length,5 which implies that disk displace-
ment may have an adverse e€ect on condyle growth.
On the other hand, there was no correlation between
the condyle size in the AP dimension and the
radiological stage of ID. The mechanism of disk
displacement is still unclear, and there remains a
possibility that a small condyle in the AP dimension
is one of the predictors for disk displacement.
A possible relationship between the decreased
condyle size in the ML dimension and disk morphol-
ogy was suggested in this study. The condyle became
smaller in the ML dimension as the disk was deformed.
In addition, there was a tendency for the condylar ML
dimension to decrease as the disk became more
anteriorly displaced. Previously, de Leeuw et al.17
reported shortening of the condyle in the mediolateral
direction (reduction of the oval projection) in patients
with internal derangement and osteoarthrosis. This
®nding is compatible with our ®ndings. Previously, we
reported that resorption of the lateral pole of the
condyle occurred with advancing stage of ID.18 The
TMJ disk is ®rmly ®xed at the medial and lateral poles
to the corner region of the posterior aspect of the
condyle.19,20 Anterior disk displacement would cause
some pathological changes to the lateral disk-condyle
attachment or to the area of the lateral part of the
condyle. We think that regressive condylar remodeling
Condylar size and TMJ ID
H Kurita et al
377
at the postero-lateral corner of the condyle may cause
resorption, resulting in a decreased condyle size in the
ML dimension. We think it is fair to speculate that
more pronounced regressive changes occur in the joints
where the disk is displaced far to the anterior and the
disk is severely deformed.
The results of this study showed that the TMJ
condyle became bigger in the AP dimension in the
joints with the most advanced stages of ID. In these
joints, the TMJ disk is severely and permanently
displaced and deformed and is sometimes associated
with disk perforation.15,16 Rao et al.22 studied MR
images of 276 TMJ and reported that the altered bony
morphology (condylar remodeling, erosion, spurring,
etc.) correlated with the severity of ID, that is, bony
changes in the joints with an anterior closed lock were
noted in 64% compared to 45% with reducible disk.22
It has also been reported that disk perforation could
lead to osteoarthritis.21 We speculated that proliferative
condylar degenerative changes including ¯attening,
spurring, and eburnation might be responsible for
lengthening of the condyle in the antero-posterior
direction. Legrell et al.5 experimentally induced non-
reducing disk displacement in rabbits and demon-
strated a substantial regressive remodeling resulting in
a change of condyle shape with forward/downward
rotation of the enlarged articulating surface. This result
is consistent with our speculation.
In conclusion, our results suggested (1) a possible
relationship between disk displacement and decreased
Dentomaxillofacial Radiology
 Condylar size and TMJ ID
H Kurita et al
378
size of the TMJ condyle, and (2) that the condyle
became smaller in the ML dimension with advance-
ment of ID. Further study that could clarify a
relationship between condylar bony changes and
condyle size is needed.
References
1. Larheim TA. Current trends in temporomandibular joint
imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1995; 80: 555 ± 576.
2. de Bont LG, Boering G, Liem RSB, Eulderink F, Westesson P-
L. Osteoarthritis and internal derangement of the temporoman-
dibular joint: a light microscopic study. J Oral Maxillofac Surg
1986; 44: 634 ± 643.
3. Kobayashi F, Matsushita T, Hayashi T, Ito J. A morphological
study on the temporomandibular joint using x-ray computed
tomography: relation to anterior disk displacement. Dental
Radiology 1996; 36: 73 ± 80. (Article in Japanese)
4. Ohgushi M, Kubota H, Yamaguchi K, Shibata K. Relation
between anterior displacement of the temporomandibular joint
disc and size of the condyle. Nippon Igaku Hoshasen Gakkai
Zasshi 1996; 56: 377 ± 384. (Article in Japanese)
5. Legrell PE, Reibel J, Nylander K, Horstedt P, Isberg K.
Temporomandibular joint condyle changes after surgically
induced non-reducing disk displacement in rabbits: a macro-
scopic study. Acta Odontol Scand 1999; 57: 290 ± 300.
6. Schellhas KP, Pollel SR, Wilkes CH. Pediatric internal
derangements of the temporomandibular joint: e€ect of facial
development. Am J Orthod Dentofacial Orthop 1993; 104: 51 ±
59.
7. Trpkova B, Major P, Nebbe B, Prasad N. Craniofacial
symmetry and temporomandibular joint internal derangement
in female adolescents: a posteroanterior cephalometric study.
Angle Orthod 2000; 70: 81 ± 88.
8. Oberg T, Carlsson GE, Fajers CM. The temporomandibular
joint: a morphological study on a human autopsy material. Acta
Odontol Scand 1971; 29: 349 ± 383.
9. Vallee-Cussac V. The craniofacial architecture of class III
malocclusion using the Coben analysis. Orthod Fr 1991; 62:
995 ± 1018. (Article in French)
10. Rao VM, Liem MD, Faroke A, Razek AAKA. Elusive stuck
disk in the temporomandibular joint: diagnosis with MR
imaging. Radiology 1993; 189: 823 ± 827.
11. Kurita H, Ohtsuka A, Kobayashi H, Kurashina K. Is the
morphology of the temporal component of the temporoman-
dibular joint a predisposing factor for disk displacement?
Dentomaxillofac Radiol 2000; 29: 159 ± 162.
Dentomaxillofacial Radiology
Acknowledgements
We wish to thank the doctors in the Department of
Radiology of Shinshu University School of Medicine for
their assistance in the imaging study of TMJ.
12. Takase H, Ogawa T, Kobayashi K, Miyamoto S, Itoh K, Akira
J, et al. A clinical study on indication of pumping manipulation
and subsequent occlusal management. J Jpn Soc TMJ 1996; 8:
50 ± 61. (Article in Japanese)
13. Katzberg RW, Westesson P-L. (ed). Temporomandibular joint
imaging. In: Som PM, Bergeron RT, (eds). Head and Neck
Imaging, 2nd edn. St. Louis, MO: Mosby, 1991, pp. 349 ± 378.
14. Hasson AN, Alder ME, Knepel KA. (eds). Magnetic resonance
imaging. In: Christiansen EL, Thompson JR, (ed). Tempor-
omandibular Joint Imaging. St. Louis, MO: Mosby, 1990,
pp. 147 ± 161.
15. Wilkes CH. Internal derangement of the temporomandibular
joint: pathological variations. Arch Otolaryngol Head Neck Surg
1989; 115: 469 ± 477.
16. Schellhas KP. Internal derangement of the temporomandibular
joint: radiologic staging with clinical, surgical, and pathologic
correlation. Magn Reson Imaging 1989; 7: 495 ± 515.
17. de Leeuw R, Boering G, van der Kuijl B, Stegenga B. Hard and
soft tissue imaging of the temporomandibular joint 30 years after
diagnosis of osteoarthrosis and internal derangement. J Oral
Maxillofac Surg 1996; 54: 1270 ± 1280.
18. Kurita H, Ohtsuka A, Kobayashi H, Kurashina K. Resorption
of the lateral pole of the temporomandibular condyle in
temporomandibular disc displacement. Dentomaxillofac Radiol
2001; 30: 88 ± 91.
19. Choukas NC, Sicher H. The structure of the temporomandib-
ular joint. Oral Surg 1960; 13: 190 ± 195.
20. Kino K, Ohmura Y, Kurokawa E, Shioda S. Reconstruction of
the bilarminar zone in the retrodiscal connective tissue of the
TMJ: I. Relation between discal ®ber and the condyle and
components around the disk. J Jpn Soc TMJ 1989; 1: 321 ± 332.
(Article in Japanese)
21. Helmy E, Bays R, Sharawy M. Osteoarthrosis of the
temporomandibular joint following experimental disc perfora-
tion in Macaca fascicularis. J Oral Maxillofac Surg 1988; 46:
979 ± 990.
22. Rao VM, Babaria A, Manoharan A, Mandel S, Gottehrer N,
Wank H, et al. Altered condylar morphology associated with
disc displacement in TMJ dysfunction: observations by MRI.
Magn Reson Imaging 1990; 8: 231 ± 235.