J Oral Maxillofac Surg

67:314-317, 2009

MRI Findings of Patients With

Temporomandibular Joint Internal
Derangement: Before and After
Performance of Arthrocentesis and
Stabilization Splint
Sang-Hwa Lee, DDS, PhD,* and Hyun-Joong Yoon, DDS, PhD†

Purposes: The purpose of this study was to evaluate the clinical outcome and magnetic resonance
imaging (MRI) changes of patients with temporomandibular joint (TMJ) internal derangement before and
after performance of arthrocentesis and stabilization splint therapy.
Patients and Methods: Thirty-three patients with unilateral TMJ internal derangement that was
successfully treated were included in this study. The clinical outcome and changes in the disc position,
disc mobility, disc morphology, joint effusion, bone marrow edema pattern in the mandibular condyle,
and the degenerative change before and after arthrocentesis and stabilization splint therapy were
compared using MRI.
Results: The average maximum mouth opening (MMO) was increased and the average pain during
MMO was decreased significantly after treatment. The disc position, disc mobility, and joint effusion were
significantly improved after treatment.
Conclusion: The results in this study indicate that arthrocentesis and stabilization splint therapy
provide significant improvement in the clinical outcome, disc position, disc mobility and joint effusion.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:314-317, 2009

Temporomandibular joint (TMJ) disc displacement
without reduction (DDw/oR) is commonly managed
by nonsurgical approaches such as physical therapy,
home exercises, intraoral appliances, and pharmaco-
logic therapy.1,2 Many studies have reported that the
success rate of nonsurgical treatment is approxi-
mately 60%,3 whereas other studies have reported
approximately 40% to 70% self-improvement without
any treatments.4,5 However, a certain group of
DDw/oR patients receiving nonsurgical treatment
may remain unresponsive, thereby prolonging their
Received from the Department of Oral and Maxillofacial Surgery, St
Mary’s Hospital, Catholic University of Korea, Seoul, Republic of
Korea.
*Assistant Professor.
†Associate Professor and Director.
Address corrrespondence and reprint requests to Dr Yoon: De-
partment of Oral and Maxillofacial Surgery, St Mary’s Hospital,
Catholic University of Korea, #62 Youido-dong, Yeongdeungpo-gu,
Seoul, 150-713, Republic of Korea; e-mail: omfsyhj@catholic.ac.kr
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6702-0011$36.00/0
doi:10.1016/j.joms.2008.07.009
suffering and treatment dissatisfaction. Kurita et al6
reported that unsuccessful DDw/oR joints after non-
surgical treatment had a significantly higher preva-
lence of deformed disc and joint effusion, quantita-
tively higher pain scores on the visual analog scale
(VAS), and severe disc displacement.
Currently, the minimally invasive treatments such
as arthrocentesis, as well as arthroscopic lysis and
lavage, are often used as a first-line surgical treatment
or in conjunction with nonsurgical modalities, as they
have been shown to be reversible procedures with
low morbidity and high efficacy.
The purpose of this study was to evaluate the mag-
netic resonance imaging (MRI) changes of patients with
TMJ internal derangement before and after performance
of arthrocentesis and stabilization splint therapy.
Patients and Methods
The study group consisted of 33 consecutive pa-
tients with unilateral TMJ internal derangement, and
they presented at the Department of Oral and Maxil-
lofacial Surgery, St Mary’s Hospital, the Catholic Uni-
versity of Korea, Republic of Korea, from May 2003 to

314
LEE AND YOON
December 2006. All the patients exhibited severe
pain with limited mouth opening and joint effusion or
disc displacement without reduction. The patients
assigned a temporomandibular joint disorder diagno-
sis of myalgia or collagen vascular disease and the
patients with a history of trauma were not included in
this study. The subjects of the study were 30 females
and 3 males, with a mean age of 28 years and an age
range from 13 to 64 years. The subjects were in-
formed about the study procedure, and informed
written consent was received from all the subjects.
This study was approved by the institutional review
board of our hospital.
The arthrocentesis was performed only 1 time for
each subject, and the stabilization splint was worn
immediately after the arthrocentesis. The subjects un-
derwent clinical and MRI investigation preoperatively
and after the treatment was successfully done (time
range when the post-treatment investigation was
done: 7-14.5 months after surgery, mean: 9.4 months
after surgery). The clinical outcomes, including the
maximum mouth opening (MMO) and the pain during
MMO before and after treatment, were compared by
a single clinician. The preoperative and follow-up
evaluations of the TMJ pain during MMO were accom-
plished by patient self-assessment using a visual ana-
log scale (0-100). The arthrocentesis procedures were
performed by a single surgeon, and they were done
under conscious sedation according to the technique
described by Nitzan et al7 in 1991.
MRI
MRI was performed with a GE Signa Exite twin
speed (GE Medical Systems, Madison, WI). The data
were collected with a section thickness of 3 mm and
a 320 ⫻ 224 matrix with a field of view of 120 ⫻ 120
mm. The MR images were corrected to the horizontal
angulation of the long axis of the condyle. Sequential
bilateral oblique sagital images were acquired with
FIGURE 1. The amount of maximum mouth opening (P ⫽ .0074).
Lee and Yoon. MRI Findings of Patients With TMJ Internal Derange-
ment. J Oral Maxillofac Surg 2009.
315
the subject’s mouth closed and also at the maximum
open mouth position.
The MRI studies were assessed in detail in a blinded
fashion for determining the symptoms by 1 of the
investigators using the established criteria. A normal
disc position was defined as the posterior band of the
disc being located at the superior or 12 o’clock posi-
tion relative to the condyle. The primary categories of
the joint status that were assessed and tabulated were
1) a normal disc position, 2) anterior disc displace-
ment with reduction (ADDwR), and 3) anterior disc
displacement without reduction (ADDw/oR). The
categories of the deformity of disc morphology were
biconcave, enlargement of the posterior band/con-
vex, and even thickness.8 Disc mobility was catego-
rized as mobile or immobile (fixed in position in the
both closed and opened projections or “stuck”), as
described by Rao et al.9 Osteoarthrosis (OA) was
defined by the presence of condylar deformities asso-
ciated with flattening, subchondral sclerosis, surface
irregularities, erosion, and an osteophyte.10 The crite-
ria for the definition of joint effusion (JE) have been
previously reported.11 On the T2-weighted images, JE
was identified as an area of high signal intensity in the
region of the joint space. No high signal or a line of
signal along the articular surface was defined as neg-
ative; when more than 1 line of high signal was
present such as a spot of intensity, then this was
regarded as JE. Bone marrow edema (BME) was de-
fined by the presence of a hypointense signal on the
T1-weighted images and a hyperintense signal on the
T2-weighted images.12
For statistical analysis, paired t tests (clinical out-
come) and McNamar’s tests (MRI changes) were used
(P ⬍ .05).
Results
The amount of MMO was increased significantly
(Fig 1) and the average pain during MMO was de-
creased significantly after treatment (Fig 2). Twenty-
four discs showed ADDw/oR before treatment. Ten of
24 joints became ADDwR after treatment, and the
other joints remained ADDw/oR despite treatment.
Five of 6 stuck discs advanced after treatment, and
only 31% of the joints had advanced disc deformity
after treatment. Twenty-two of the 25 JEs advanced
after treatment. BME disappeared in only 2 of 8 joints,
and the OA did not advance after treatment (Table 1).
Discussion
Nonsurgical treatments for TMJ ADDw/oR are often
successful, but the length of time required to reach a
pain-free normal range of motion is not satisfactory. It
has been shown that the ADDw/oR patients who do
316 MRI FINDINGS OF PATIENTS WITH TMJ INTERNAL DERANGEMENT

not respond to nonsurgical treatment can benefit Table 1. THE CHANGES OF MRI FINDINGS
from arthrocentesis or arthrocentesis in conjunction
with nonsurgical modalities because success occurs Before After
more quickly and these approaches are considered to Treatment Treatment P Value
be simple and minimally invasive. Disc position
Although some studies have reported on the impor- ADDwR 9 19 .018
tance of disc position, disc mobility, disc morphology, ADDw/oR 24 14
OA, JE, and BME as the underlying mechanisms in the Disc mobility
Normal 27 32 .025
etiology of TMJ disorders, the modalities selected for
Stuck disc 6 1
the treatment of TMJ ADDw/oR continue to be based Disc morphology
solely on the clinician’s best judgment and experi- Normal 20 24 .2
ence. Especially, there are few reports to evaluate the Deformity 13 9
relationship between the changes of these factors and Joint effusion
Absent 8 30 ⬍.0001
the effectiveness after TMJ treatment. In the present
Present 25 3
study, we evaluated the changes of these factors in Bone marrow edema
patients with TMJ internal derangement before and Absent 25 27 .15
after performance of arthrocentesis and stabilization Present 8 6
splint therapy. Osteoarthrosis
Absent 18 18
Several studies have reported on the changes of
Present 15 15
disc position, disc mobility, disc morphology, OA, JE,
or BME after arthrocentesis. Some of these studies Abbreviations: ADDwR, anterior displacement with reduc-
showed a significant reduction in TMJ pain during tion; ADDw/oR, anterior displacement without reduction.
function and a significant increase in the mandibular Lee and Yoon. MRI Findings of Patients With TMJ Internal De-
rangement. J Oral Maxillofac Surg 2009.
range of motion after arthrocentesis was done.13-17
Some other articles reported that the disc position
changed after arthrocentesis. Ohnuki et al18 reported their article based on a sample of 29 TMJs, were
that even though the clinical signs and symptoms unable to correlate the MRI changes of effusion and
were alleviated by treatment, most discs remained the clinical conditions of the patient before and after
ADDw/oR on MRI despite arthrocentesis. Moses et the performance of arthroscopic lysis and lavage.
al15 reported that only 8% of the TMJs showed a Emshoff et al20 investigated whether arthrocentesis
reduced disc position postoperatively, and Emshoff et is associated with changes in the diagnoses of internal
al15,16 failed to detect any change in the preoperative derangement, OA, effusion, and/or BME, and they
MRI diagnoses of the disc position after treatment. reported the MRI measured variables of internal de-
Ohnuki et al18 evaluated the changes in disc mobility rangement, JE, and BME were related to TMJ internal
and morphology in patients with temporomandibular derangement type III and capsulitis/synovitis; how-
joint disorders in response to 4 different treatments, ever, arthrocentesis was only associated with a signif-
and they reported that all TMJs had mobile discs. icant change in the diagnoses of TMJ BME. Chiba et
Further, the disc deformity had advanced after arthro- al21 reevaluated all the TMJs clinically and they used
centesis, on the post-treatment MRI. Sato et al,19 in the MR images obtained after the relief of joint pain
after arthrocentesis combined with nonsurgical treat-
ment. The reduction in TMJ pain did not correlate
with the resolution of the bone marrow edema pat-
tern in most joints.
Emshoff and Rudisch17 failed to find any change in
the preoperative MRI diagnoses of OA after arthrocen-
tesis.
The results in our study suggest that arthrocentesis
and stabilization splint therapy provide a significant
improvement in the clinical outcome, disc position,
disc mobility, and joint effusion.

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