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Review Article

Current Status of Temporomandibular Joint Imaging for the

Diagnosis of Internal Derangements
Phoebe A. Kaplan1 and Clyde A. Helms2

Temporomandibular joint (TMJ) pain and dysfunction are nificant soft-tissue structure is the dense fibrous disk (or
common and important clinical problems. With the recent meniscus). The disk is interposed between the condyle and
advances in imaging technology, radiologists have made ma- temporal bone, completely separating the joint into two joint
jor contributions to the understanding of TMJ diseases. The spaces (superior and inferior) that do not communicate. The
purpose of this article is to review the anatomy of the TMJ superior joint space is about three times as large as the
and to put into perspective the relative merits of each imaging inferior space. The inferior space is arbitrarily divided into
technique (conventional radiography and tomography, scintig- anterior and posterior recesses. The ovoid disk is thin centrally
raphy, CT, MR imaging, and arthrography) as it pertains to with a thickened peripheral ridge. The anterior and posterior
diagnosing internal derangement, the most common disorder ridges of the disk are called the anterior and posterior bands;
of the joint. the posterior band is larger than the anterior. The anterior
band of the disk is in continuity with the anterior margin of
the condyle and the articular eminence, as well as with the
Normal Anatomy and Function
joint capsule. The disk is attached to the neck of the condyle
The anatomy of the TMJ can be understood best by medially and laterally and to the superior head of the lateral
considering the osseous, soft-tissue, and functional anatomy pterygoid muscle anteromedially. The posterior band of the
Separately as described by Murphy [1] (Fig. 1). disk is continuous with the highly vascular and well-innervated
The TMJ is a synovial articulation formed by the condyle of elastic connective tissue called the bilaminar zone (or poste-
the mandible and the glenoid (mandibular) fossa and articular nor attachment). The superior portion of the bilaminar zone
eminence of the temporal bone at the base of the skull. The attaches to the posterior wall of the mandibular fossa; the
glenoid fossa and eminence form a smooth sigmoid curve. inferior portion attaches to the posterior condyle.
The condyle is approximately twice as long in the mediolateral Both TMJs function synchronously. Motion of the disk is
dimension as it is in the anteropostenor dimension and is closely coordinated with condylar motion. The synovial re-
oriented perpendicular to the ramus of the mandible. The joint cesses formed in the superior and inferior joint spaces are
surfaces are smooth, and the condyle is located symmetrically redundant, allowing normal motion of the condyle and disk.
in the fossa with a uniform joint space. The articular surfaces The normal position of the disk with the mouth closed is with
of the joint are covered by fibrocartilage rather than hyaline the apex of the condyle immediately subjacent to the posterior
cartilage. band of the disk. The initial phase of mouth opening is a hinge
The condyle is held in place relative to the temporal bone action (rotation about a horizontal axis that passes through
by muscles, ligaments, and the joint capsule. The most sig- the condyles). The hinge action is a function of the inferior

Received October 6, 1988; accepted after revision December 16, 1988.

1 Department of Radiology, University of Nebraska Medical Center, 42nd and Dewey Ave., Omaha, NE 68105. Address reprint requests to P. A. Kaplan.
2Department of Radiology, University of California, San Francisco, San Francisco, CA 94143.

AJR 152:697-705, April 1989 0361 -803X/89/1 524-06970 American Roentgen Ray Society
698 KAPLAN AND HELMS AJA:152, April 1989

Posterior Band of Disk

\ Glenoid

\ Articular Eminence

Bilaminar Superior Joint Space

Zone < Anterior Band of Disk

Inferior Joint Space

(anterior recess)

Fig. 1.-A and B, Cadaveric section (A) and diagram (B) of normal osseous and soft-tissue structures of temporomandibular joint. Inferior joint space
(white arrow); superior joint space (black arrow); posterior band of disk (). eac = external auditory canal; GF = glenold foss.; E = articular eminence; C
= condyle; o = anterior band.

joint space as the condyle rotates forward so that it articulates Internal derangement of the TMJ is three to five times more
with the thin central zone of the disk. The second action of common in women than in men. Symptoms usually occur in
mouth opening occurs from deformation of the superior joint early adulthood, typically in the fourth decade of life [1 1]. No
space and consists of anterior translation of the condyle under predisposing factors are found in most patients; however, a
the eminence. With incremental mouth opening, there is a history of trauma just before the onset of symptoms can be
coordinated relationship among disk, condyle, and eminence elicited in approximately 25% of patients [1 2]. A traumatic
with the posterior band of the disk coming to rest posterior origin is more common in men and children than in women.
to the condyle. These relationships reverse as the mouth About one-third of the trauma-induced derangements are
closes. All interactions are smooth and continuous. iatrogenic, usually from procedures that hyperextend the jaw
such as endoscopy, third molar tooth extraction, and tonsil-
lectomy [1 2]. A loss of elasticity of the bilaminar zone and
other ligaments that control disk position and function is
Internal Derangement
probably the underlying defect regardless of the cause of the
Various disorders of the TMJ occur; however, the most ligamentous laxity.
common is internal derangement [1 -4]. Internal derangement Internal derangement is classically divided into three cate-
is defined as an abnormal relationship (subluxation or dislo- gones progressing from least to most severe (Fig. 2) [1 2, ,

cation) of the disk relative to the condyle, fossa, and articular 1 1]. These categories are (1) anterior displacement with re-
eminence. The disk usually is displaced anteriorly, but it may duction of the disk to normal position with mouth opening, (2)
also sublux medially, laterally, or (rarely) posterior to the anterior displacement without reduction of the disk to normal
condyle [5]. position with mouth opening, and (3) anterior displacement
Internal derangement occurs in up to 28% of the adult with perforation of the disk. Frequently patients have a history
population [3]. Despite the prevalence of this disorder, it has typical of sequential progression from one category to the
been poorly understood and investigated until only recently. next.
Historically, derangements of the TMJ were initially described Anterior displacement of the disk with reduction usually
in the 1 830s and in 1 887 by Cooper (cited in [1]) and Annan- causes joint noise (popping, clicking) with or without associ-
dale [6], respectively. Other scattered reports mainly con- ated pain. The disk is displaced (usually anteriorly but may
cerned surgery of the TMJ, but not until 1 951 did another also be subluxed medially or laterally) with the mouth dosed
investigator publish work concerning possible causes of in- and returns to normal position as the mouth opens and the
ternal derangement [7], and this study passed relatively un- click is heard. The click occurs during both opening and
noticed. In the late 1 960s, Laskin [8] popularized the myofa- closing (reciprocal clicking) but is much louder during opening.
cial pain-dysfunction syndrome (facial pain originating in soft- The click is a result of friction between the posterior band of
tissue structures without a detectable origin or defect). It was the disk and the condyle as they move in opposite directions
believed that secondary anatomic abnormalities of the TMJ and the disk returns to normal position relative to the condyle.
could occur as a result of the syndrome. An organic basis for In general, the later the dick during mouth opening, the more
TMJ pain and dysfunction was supported by the work of severe the derangement (greater loss of elasticity of the
Farrar [9] and Farrar and McCarty [10] in the 1970s and has bilaminar zone). The extent of mouth opening is normal in this
since been confirmed by numerous investigators. category.

detailed osseous anatomy may be seen via other methods

such as CT or conventional tomography. Several different
views are required to show all aspects of the joint. The
location of the TMJ in the base of the skull with numerous
superimposed structures makes imaging difficult and often
not reproducible without meticulous attention to positioning
and technique. The transcranial lateral view (opened and
dosed mouth) is the most valuable (Figs. 3A and 3B). It shows
the joint in profile as well as showing the range of motion of
the joint. It is obtained by angling the tube or the patients
head so the TMJ is projected above the structures in the
base of the skull. A small variation in positioning can signifi-
cantly alter the appearance of the condyle. Special positioning
units have been developed to standardize radiographs and
C D alleviate such problems [17-19].
Fig. 2.-Disk position in internal derangement. eac = external auditory Supplementary views used to depict the osseous anatomy
canal. indude the Towne and submentovertex projections, which
A, Anteriorly displaced disk with both anterior and posterior bands in
front of condyle. show the medial and lateral poles of the condyle as well as
B, Disk reduces to normal position as mouth opens. Friction between different portions of the cortical surface. Panoramic radio-
condyle and posterior band passing In opposite directions is one cause of
graphs, which are used routinely for evaluation of the mandi-
audible click.
C, Disk after reduction to normal position when mouth is completely ble and dentition, can also be used to show the TMJs simul-
open. taneously and in a near-lateral projection. Most physicians
D, Displaced disk with perforated bilaminar zone.
believe that the transcranial lateral radiographs are most
useful and may use the other views mentioned in unusual
Disk displacement without reduction occurs when the loss circumstances to clarify the anatomy. The Towne projection
of elasticity is so great the disk is unable to return to normal is probably the most valuable view to supplement the trans-
position with the condyle and remains displaced anterior to it. cranial lateral view.
The displaced disk forms a physical barrier to the condyle Conventional tomography shows osseous anatomy with
and there is limited anterior translation. The condyle continu- even greater detail than plain films. For many years before
ously impacts on the innervated bilaminar zone and causes sectional imaging and TMJ arthrography, tomography was
pain. Generally, these patients have limited mouth opening used as the main technique for radiographic evaluation of the
(closed lock), with the midline of the mandible deviated to joint[1, 11,20, 21].
the abnormal side. Usually no joint noise is heard because The abnormalities that can be seen on conventional radio-
the posterior band of the disk does not reduce over the graphs and tomograms in patients who have internal derange-
condyle into normal position. ment are infrequent and nonspecific [1 1]. Limitation of anterior
Chronic disk displacement without reduction may lead to a translation of the condyle can be shown, but the cause is not
perforated disk. The perforation usually is in the bilaminar evident. Degenerative joint disease with osteophytosis, flat-
zone or occasionally is in the disk. These patients have pain tening, and sclerosis of the condyle is virtually diagnostic of
and limitation ofmouth opening. Paradoxically, mouth opening a displaced and perforated disk; unfortunately, this is present
may be normal because of chronic stretching of the bilaminar in only a few patients and is a late manifestation of the disease
zone. Chronic disk displacement can lead to a thickened disk process (Fig. 3D). A radiographic feature of degenerative joint
that may not function properly even if it is in the correct disease that may occur first is an erosion of the apex of the
position. Degenerative joint disease generally occurs in those condyle (Fig. 3C). The cause of the erosion is not clear from
with a perforated disk as bone articulates with bone. Joint the plain films, and similar radiographic changes occur with
noise may be present owing to secondary degenerative joint infection or inflammatory arthritides, or as a consequence of
disease. a condylar shaving surgical procedure.
Pain in patients with internal derangement may occur di- TMJ arthrography was pioneered by Norgaard [22] in the
rectly over the TMJ or in the neck, ear, face, or head. Clicking mid 1 940s, but it did not become popular until the late I 970s.

of a TMJ may occur in patients without a displaced disk There are several related methods of performing TMJ arthrog-
reducing to normal position [13]. Similarly, restricted mouth raphy [23-30]. In general, the patient is prepared in a sterile
opening may have numerous causes other than a displaced fashion and injected with a local anesthetic as for any arthro-
disk. Diagnostic imaging is important to confirm a clinically gram. A small-gauge needle is inserted into the posterior
suspected diagnosis, particularly because many disorders recess of the lower joint space via a preauricular approach,
may cause similar symptoms. and about 0.5 ml of contrast media are injected under fluo-
roscopic guidance. Some radiologists also inject the superior
joint space followed by arthrotomography. If tomography is
TMJ Imaging
not used, routine static images are obtained. Videofluoros-
Conventional radiography is well suited to evaluation of the copy to document the dynamic function of the joint is essential
osseous structures of the TMJ [11, 14-16]. However, more in all patients [29, 311. The only true contraindication to
700 KAPLAN AND HELMS AJR:152, April 1989

Fig. 3.-A and B, Plain films show normal tem-

poromandibular joint in closed-mouth (A) and
open-mouth (B) positions. Note central location of
condyle (C) within glenold fossa with mouth closed
(A). Apex of condyle passes to, or slightly beyond,
eminence (E) with mouth fully opened (B). eac =
external auditory canal.
C and D, Plain films show degenerative changes
that occur as a result of internal derangement. C
shows an erosion of condyle (arrowheads) that not
only may occur with derangements but also may
be seen with other entitles, such as Infection and
arthritis. D shows a patient with a displaced and
perforated disk who developed a degenerative
osteophyte (arrowheads) on anterior condyle.



arthrography is a local skin infection that might contaminate When there is internal derangement, the disk is displaced
the joint. anterior to the condyle. The posterior band creates a large
The elements that can be evaluated by arthrography are concave impression on the anterior recess that is diagnostic
the osseous anatomy; disk position, size, or shape; presence of disk displacement [1 1 1 23-28].
, , There is commonly a
of a perforated disk; reduction of the disk to normal position; biconcave appearance of the anterior recess formed by both
dynamic anatomy; and range of motion (Fig. 4). the anterior and posterior bands while the disk is folded on
In the closed position, the posterior recess has a thin itself in the thin central zone. The anterior recess is larger
curvilinear configuration that conforms to the outline of the in patients with disk displacement than in normal patients
condyle. The anterior recess is larger and forms a teardrop (Fig. 5).
configuration directed obliquely downward. The contrast ma- As the mouth opens, the concavity formed by the posterior
terial outlines the undersurface of the disk. The superior band on the anterior recess is accentuated until the posterior
aspect of the anterior recess may be straight and smooth or band and condyle pass over one another in opposite direc-
else concave owing to the impression made by the anterior tions, creating a friction rub manifest as an audible click.
band of the disk, which varies in size in different people [32]. Irregular movements with sudden changes in configuration of
As the mouth opens, the condyle and disk move together in contrast material are seen at fluoroscopy as this occurs. As
a smooth and coordinated manner. The anterior recess de- soon as the disk has reduced to normal position, the arthro-
creases in size until it is a small, crescent-shaped collection graphic appearance is identical to that of a normal joint. If,
of Contrast material collapsed against the anterior condyle. however, the disk does not reduce with mouth opening, there
Simultaneously, the posterior recess enlarges and the supe- is a persistent concave defect on the anterior recess, and this
rior aspect becomes concave because of the impression frequently is associated with limited translation of the condyle.
made by the posterior band of the disk. The condyle articu- The most severe category of derangements occurs when the
lates with the posterior band while the mouth is closed and disk is displaced without reduction and has a perforation. A
with the thin central zone during all stages of mouth opening. perforation is diagnosed by the simultaneous appearance of
All relationships reverse as the mouth closes. contrast material in both the superior and inferior joint spaces

Fig. 4.-Normal temporomandibular joint ar-

A and B, Closed-mouth (A) and open-mouth (B)
arthrograms, with contrast material in inferior joint
space only, show teardrop-shaped anterior recess
that becomes very thin when mouth opens (ar-
rows). conversely, posterior recess is very thin
with mouth closed and Increases In anteroposte-
rior dimension with opening (arrowheads). Top of
posterior recess is concave from posterior band
of disk impinging on ft. E = eminence; eac =
external auditory canal; c = condyle.
C and D, Arthrograms show normal position of
disk relative to condyle with mouth closed (C) and A B
open (D) with contrast material in superior and
inferior joint spaces. condyle is directly subjacent
to posterior band () with mouth closed and artic-
ulates with thin central zone of disk during all
phases of mouth opening. Anterior recess (arrow).
o = anterior band.


when contrast material was injected into the inferior space density anterior to the condyle that is greater than that of
only. normal muscle is consistent with an anteriorly displaced disk
Arthrography has also been reported as being useful in (Fig. 6). Multiple sagittal slices through each condyle are
determining the cause of postoperative symptoms and intra- examined for this increased density, and the medial aspect of
articular adhesions, and in developing splints for treatment of each condyle usually has the majority of positive findings
mild derangements [33-36]. because the lateral pterygoid muscle tends to pull the disk
Despite the high yield of diagnostic information from TMJ anteromedially.
arthrography, the technique has been criticized because it is The direct sagittal technique requires the patients head to
more technically demanding to learn to perform than other be turned sideways in the gantry so that the slices run
kinds of arthrography, and it is an invasive procedure. Despite sagittally through the condyles; thus, reformations are unnec-
these contentions, the morbidity from TMJ arthrography has essary. Approximately 1 0% of patients cannot tolerate this
been reported to be minimal if performed by someone expe- position and are unable to be studied with this technique. The
rienced with the procedure [37, 38]. Investigations have images obtained from the direct sagittal technique are supe-
showed also that postprocedural discomfort could be dimin- nor to those obtained with the axial method with reformations;
ished further by using nonionic contrast agents [37, 39]. however, no increase in diagnostic accuracy has been re-
Scintigraphy with single-photon emission CT (SPECT) re- ported. By imaging with the direct sagittal technique, the lens
portedly detects alterations of the TMJ [40]. Unfortunately, of the eye is often seen, which allows an inordinate amount
the findings are nonspecific, indicating only that a biomechan- of radiation exposure (4-6 rad [40-60 mGyJ) to a radiosen-
ical or inflammatory process exists but not specifying the sitive organ.
nature or precise location of the alteration. Because of these Regardless of which technique is used, the evaluation of
inherent limitations, scintigraphy plays no practical role in the the bony structures is superb with CT. Early degenerative
diagnosis or management of TMJ disorders. It may be valu- disease is seen easily and can be localized as to medial or
able in detecting other causes of facial pain unrelated to the lateral in position on the condylar head. The cost of a CT
TMJ. examination is roughly twice that of unilateral arthrography.
CT has been shown to be an accurate method of diagnos- The accuracy of diagnosing a displaced disk is about the
ing displaced menisci [41 -47]. It requires some technical same as with arthrography, and there is no morbidity. A
expertise, depending on whether the axial or direct sagittal perforation of the disk cannot be diagnosed with CT; however,
technique is used, but both methods are highly accurate and many clinicians do not alter their treatment on the basis of
easily learned. CT scanners are widely available throughout the presence or absence of a perforation. Ukewise, joint
the world; therefore, availability is not an issue. No morbidity dynamics cannot be obtained with CT but are not believed to
is associated with CT scanning of the TMJ, and radiation be essential for many clinicians. Many centers have replaced
dose is thought to be relatively low. arthrography with CT scanning of the TMJ and have subse-
The direct axial technique requires that 15-20 thin-section quently supplanted CT with MR.
slices be obtained of the TMJs with subsequent sagittal MR imaging is highly accurate in diagnosing TMJ meniscus
reformations. The identity or blink mode is then used to help displacement [48-56]. Because of its ability to image hydro-
differentiate the tissue densities anterior to the condyle. A gen protons, information about the state of disk hydration
702 KAPLAN AND HELMS AJR:152, April 1989

Fig. 5.-Abnormal temporomandibular joint ar-

thrography. E = eminence; C = condyle.
A, Displaced disk has caused large concave
defect on superior aspect of anterior recess. Re-
cess (arrow) Is also abnormally elongated.
B, Biconcave defect of anterior recess is formed
by displaced anterior (arrowhead) and posterior
(arrow) bands that are folded at thin central zone.
C, As mouth opens, there Is a clicking noise as
condyle and posterior band (arrow) pass over one
anothergoing In opposite directions. Anterior band
0, Umited anterior translation of condyle with
mouth opening occurs because of displaced disk
that doss not reduce (white arrow). Contrast me-
dium simultaneously fills superior and Inferior joint
spaces, Indicative of perforated disk. Anterior re-
cess (black arrow); bilaminar zone (arrowheads).


can perhaps be ascertained and used to classify the degree weighted sagittal images are acquired, the study can be
of disk abnormality. This is done routinely in imaging the performed rapidly, thus reducing the time and cost of the
lumbar spine and may be useful in imaging the TMJ. The examination. T2-weighted images can be obtained rapidly
histopathology of the disk is similar to that of the lumbar spine with gradient-echo refocusing techniques. These afford eval-
disk; hence, one might expect similar MR appearances [57]. uation ofjoint fluid and the state of hydration of the disk (Fig.
Both structures are made up of proteoglycans, which break 1 0). Although this information does not currently alter treat-
down under stress. The normal lumbar spine disk has high ment, it may eventually be valuable. In most centers, a bilateral
signal on T2 weighting, as does the normal TMJ disk (Fig. 7). study with closed- and open-mouth positions can be per-
As a result of technical innovations available in the past few formed in 30 mm. The cost for this examination is about equal
years, MR of small anatomic areas such as the TMJ has to that of a CT examination, or roughly twice that of unilateral
improved dramatically, allowing higher spatial resolution and arthrography.
a greater signal-to-noise ratio. Not only can the position of There is some debate as to whether full open-mouth images
the disk be accurately ascertained, but the size and shape of are necessary. It is generally accepted that disk reduction
the disk as well as its signal characteristics can be seen (Figs. can be determined clinically in most cases. Also, whether a
8 and 9). Bony changes can be evaluated also, although not disk reduces and at which degree of opening it does reduce
with the clarity afforded by conventional tomography and CT. seems to be quite variable from week to week in many
Use of certain fast-scan techniques in conjunction with an patients; therefore, the information obtained during the MR
automatic mouth-opening device makes a dynamic MR study study may be different 1 week later when the dinician ex-
possible [58]. It remains to be seen if this information is truly amines the patient. Furthermore, these patients experience
useful to the clinicians treating these patients. pain and difficulty in wide mouth opening; therefore, when
MR scanning techniques vary among different examiners placed in a wide-open-mouth position for 10-15 mm, they
and with different types of magnets; however, most agree often have muscle spasm and pain, resulting in motion and
that surface coils are necessary for an acceptable study. Most degradation of the image. For these reasons, many radiolo-
investigators state that only Ti -weighted images are neces- gists study patients in closed-mouth and partial-open-mouth
sary, and most recommend only sagittal images. If only Ti - (before a click) positions. The partial-open-mouth position

Fig. 6.-A, Sagittally reformatted CT scan

through right temporomandibularjoint with identity
or blink mode reveals increased soft-tissue den-
sity anterior to condyle (arrow), which Is consistent
with anteriorly displaced disk.
B, Similar Image in another patient has no in-
creased soft-tissue density anterior to condyle.
This Is consistent with normally positioned disk.


Fig. 7.-A, TI-weighted image In normal tern-

porornandibular joint shows disk In normal position
with some Intermediate signal In posterior band
B, Same joint imaged with gradient refocusing
shows posterior band to have high signal, consis-
tent with normal hydration. A small amount of
Increased signal can also be appreciated in re-
mainder of disk.

Fig. 8.-A, TI-weighted sagittal MR image In

normal individual with mouth closed. Posterior
band is seen as low-signal-intensity structure
above apex of condyle; anterior band (arrow) is
just anterior to condyle. Thin intermedIate zone Is
not clearly seen but is between two most closely
opposed cortical surfaces of temporal bone and
condyle. Anterior is to the right.
B, Same as In A with mouth open. condyle is
translated anteriorly. Posterior band of disk (ar-
row) is just posterior to condyle and has Interme-
diate signal. Thin intermediate zone remains be-
tween two closely opposed cortical surfaces of
temporal bone and condyle.

removes the condyle from the glenoid fossa slightly and allows Conclusions
the disk to be seen with greater clarity than does the closed-
mouth position. The ideal imaging technique for diagnosing internal de-
As MR of the TMJ continues to be investigated, additional rangements should provide (at a reasonable cost) information
imaging parameters undoubtedly will be recommended and about the status of the osseous structures, disk, and dynamic
evaluated. Too many variables exist-both clinically and with function. The severity of the disease process should be
MR-to ever obtain a general consensus on how to best delineated to determine the type of therapy to be used and
image these patients. MR does offer the hope that more than the prognosis. Controversy exists as to which technique is
just disk position can be assessed. In many centers, MR has best suited to this task. The relative advantages and disad-
completely replaced arthrography and CT as the imaging vantages of each are summarized below.
study of choice because of its ability to visualize directly the Conventional radiography is of limited value because only
disk and its lack of associated morbidity and radiation. the osseous anatomy can be evaluated, and most of those
704 KAPLAN AND HELMS AJR:152, April 1989

Fig. 9.-Ti-weighted sagfttal MR Image In pa- Fig. 10.-A, Ti-weighted image in patient with anteriorly displaced disk shows some intermediate
tient with acute onset of pain and locking of tem- signal in posterior band (arrow).
poromandibular joint. Posterior band Is clearly B, Same joint imaged with gradient refocusing shows disk anteriorly displaced and high signal in
seen to be displaced anteriorly (arrow) and has posterior band (arrow). This image was obtained in half the time of A.
some Intermediate sIgnal. Disk is folded down-
ward at intermediate zone.

with derangements will show either no abnormalities or non- requirements, availability of equipment, and skill and predilec-
specific findings. Plain films have a limited role as an inexpen- tion of the radiologist.
sive screening method either to show degenerative changes
or to exclude old traumatic abnormalities or congenital de-
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