Int. J. Oral Maxillofac. Surg.

2013; 42: 1108–1115

http://dx.doi.org/10.1016/j.ijom.2013.03.012, available online at http://www.sciencedirect.com

Clinical Paper
TMJ Disorders

Magnetic resonance imaging- W.-S. Jung1, H. Kim2, D.-M. Jeon1,

S.-J. Mah1, S.-J. Ahn1
1
Dental Research Institute and Department of

verified temporomandibular joint Orthodontics, School of Dentistry, Seoul

National University, Seoul, Republic of Korea;
2
Graduate School of Public Health, Seoul
National University, Seoul, Republic of Korea

disk displacement in relation to

sagittal and vertical jaw
deformities
W.-S. Jung, H. Kim, D.-M. Jeon, S.-J. Mah, S.-J. Ahn: Magnetic resonance imaging-
verified temporomandibular joint disk displacement in relation to sagittal and vertical
jaw deformities. Int. J. Oral Maxillofac. Surg. 2013; 42: 1108–1115. # 2013
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. This retrospective study was designed to analyze the relationships between
temporomandibular joint (TMJ) disk displacement and skeletal deformities in
orthodontic patients. Subjects consisted of 460 adult patients. Before treatment,
lateral cephalograms and TMJ magnetic resonance imaging (MRI) were recorded.
Subjects were divided into six groups based on TMJ MRI according to increasing
severity of TMJ disk displacement, in the following order: bilateral normal TMJs,
unilateral disk displacement with reduction (DDR) and contralateral normal,
bilateral DDR, unilateral disk displacement without reduction (DDNR) and
contralateral normal, unilateral DDR and contralateral DDNR, and bilateral DDNR.
Subjects were subdivided sagittally into skeletal Class I, II, and III deformities
based on the ANB (point A, nasion, point B) angle and subdivided vertically into
hypodivergent, normodivergent, and hyperdivergent deformities based on the facial
height ratio. Linear trends between severity of TMJ disk displacement and sagittal
or vertical deformities were analyzed by Cochran–Mantel–Haenszel test. The
severity of TMJ disk displacement increased as the sagittal skeletal classification
changed from skeletal Class III to skeletal Class II and the vertical skeletal
classification changed from hypodivergent to hyperdivergent. There were no
Key words: TMJ; disk; displacement; jaw;
significant differences in the linear trend of TMJ disk displacement severity deformities.
between the sexes according to the skeletal deformities. This study suggests that
subjects with skeletal Class II and/or hyperdivergent deformities have a high Accepted for publication 18 March 2013
possibility of severe TMJ disk displacement, regardless of sex. Available online 23 April 2013

0901-5027/0901108 + 08 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 TMJ disk displacement and jaw deformities 1109

Disk displacement is defined as an altered
position of the disk from its normal loca-
tion on the top of the mandibular condyle
in the temporomandibular joint (TMJ). It
may lead to TMJ clicking, pain, and jaw
movement limitations.1 TMJ disk displa-
cement is the principal clinical sign of
internal derangement of the TMJ, which
progresses from reduction to nonreduc-
tion.2
There are currently several methods and
devices used to diagnose TMJ disk dis-
placement. Magnetic resonance imaging
(MRI) has been used to evaluate the TMJ
disk with direct visualization of the articu-
lar disk position. In addition, MRI has
many advantages, such as non-invasive-
ness, no soft tissue distortion, no exposure
to ionizing radiation, and multiplanar ima-
ging.3,4
Previous studies have reported relation-
ships between TMJ disk displacement and
facial morphology using MRI. In general,
a decreased posterior facial height and
backward position and rotation of the
mandible are principal characteristics
associated with TMJ disk displace-
ment.5–10 This means that patients with
TMJ disk displacement may have a lower
possibility of having skeletal Class III and
hypodivergent deformities. However,
there have been few studies addressing
the association of TMJ disk displacement
with sagittal or vertical skeletal deformi-
ties, specifically skeletal Class III or hypo-
divergent deformities. In addition, most
studies have only included female parti-
cipants and it is still unclear if TMJ disk
displacement is associated with dentofa-
cial morphology in males.
The purpose of the present study was to
analyze the relationships between TMJ
disk displacement and sagittal or vertical
skeletal deformities in adult male
and female patients with various
malocclusions using TMJ MRI. The null
hypothesis of our study is that there are no
linear correlations between TMJ disk
displacement and sagittal or vertical ske-
letal deformities.
Materials and methods
Subjects seeking orthodontic or surgical
orthodontic treatments who visited a
department of orthodontics from 2002 to
2012 were recruited. A total of 460 adult
patients (117 males and 343 females) were
selected and analyzed in this study (Table
1). The age range of male patients was
18.1–37.8 years (mean age 22.7  5.8
years), while that of female patients was
17.0–47.3 years (mean age 24.1  4.9
years). There was no significant difference
in age distribution among the six study
groups (defined below) or between the
sexes. To be included in the study sample,
men had to be over the age of 18 years and
women over the age of 17 years, in order
to avoid growth-related size differences;
growth in Korean males and females is
almost complete after the age of 17 and 16
years, respectively.11 Exclusion criteria
were (1) any systemic disease, (2) history
of orthodontic treatment, (3) history of
facial cosmetic surgery or orthognathic
surgery, (4) history of trauma involving
the TMJs, (5) juvenile rheumatoid arthri-
tis, and (6) history of TMJ treatment.
Routine lateral cephalograms were taken
for all the subjects using an Asahi CX-
90SP II instrument (Asahi Roentgen,
Kyoto, Japan).
Patients with a history of TMJ symp-
toms, such as TMJ sounds, TMJ pain on
palpation, limitation of mandibular move-
ment, and locking, and patients in whom
specific skeletal characteristics associated
with TMJ disk displacement were present,
such as an anterior open bite, a retro-
gnathic mandible, severe facial asymme-
try, and decreased posterior facial height,
were examined using MRI.5–10 The MRIs
were obtained using a Signa Horizon
instrument (GE, Waukesha, WI, USA)
operating at 1.5 T, with a unilateral 3 inch
surface receiver coil (GE). Initially, the
axial scout images were obtained at the
level of the TMJs in order to identify the
long axes of the condyles. Non-orthogonal
sagittal sections were obtained perpendi-
cular to the condyles and non-orthogonal
coronal oblique sections were also
obtained. Closed mouth images were
obtained at maximum dental intercuspa-
tion, and open mouth images were taken at
maximum unassisted vertical mandibular
opening, using a Burnett bidirectional
TMJ device (Medrad, Pittsburgh, PA,
USA). T1-weighted 600/12 (repetition
time (TR) ms/echo time (TE) ms) and
proton-density 4000/14 (TR ms/TE ms)
pulse sequences were performed in the
sagittal plane using a 3-mm slice thick-
ness, a 10-cm field of view, a number of
excitations of 2, and an image matrix of
254  192 pixels. A T1-weighted 500/12
(TR ms/TE ms) pulse sequence was per-
formed in the coronal plane under the
same conditions.
Two radiologists with TMJ MRI experi-
ence interpreted the images without clin-
ical information on the patient. TMJ disk
position was divided into three categories
according to the following criteria. (1)
Normal disk position: in the closed mouth
position, the intermediate zone of the disk
is interposed between the condyle and the
posterior slope of the articular eminence,
with anterior and posterior bands equally
spaced on either side of the condylar load
point. (2) Disk displacement with reduc-
tion (DDR): the disk is anteriorly dis-
placed relative to the posterior slope of
the articular eminence and the head of the
condyle; however, the disk is reduced on
mouth opening. (3) Disk displacement
without reduction (DDNR): the disk is
anteriorly displaced relative to the poster-
ior slope of the articular eminence and the
head of the condyle, but without reduction
of the disk on mouth opening.
TMJ disk status was carefully evaluated
according to the classification criteria for

Table 1. Age (years) distribution of patients with various TMJ disk displacements.
Group 1a Group 2b Group 3c Group 4d Group 5e Group 6f
(mean  SD) (mean  SD) (mean  SD) (mean  SD) (mean  SD) (mean  SD)
Male 22.3  3.2 22.5  3.9 25.7  9.9 22.2  3.5 21.8  3.0 21.8  2.5
Female 23.4  6.1 25.1  7.1 24.9  5.8 25.3  6.4 22.4  4.4 24.1  5.2
Total 23.0  5.3 24.4  6.5 25.1  6.7 24.3  5.8 22.3  4.2 23.7  4.9
SD, standard deviation; TMJ, temporomandibular joint.
a
Bilateral normal TMJs.
b
Unilateral disk displacement with reduction and normal contralateral TMJ.
c
Bilateral disk displacement with reduction.
d
Unilateral disk displacement without reduction and normal contralateral TMJ.
e
Unilateral disk displacement with reduction and disk displacement without reduction in the contralateral TMJ.
f
Bilateral disk displacement without reduction.
1110 Jung et al.

disk position. Ambiguous cases such as

partial disk displacement or partial disk
reduction were excluded in this study.
Subjects were divided into six groups
based on the results of TMJ MRI accord-
ing to increased TMJ disk displacement
severity, in the following order: bilateral
normal TMJs (BN, group 1), unilateral
DDR and normal contralateral TMJ
(group 2), bilateral DDR (group 3), uni-
lateral DDNR and normal contralateral
TMJ (group 4), unilateral DDR and
DDNR in the contralateral TMJ (group
5), and bilateral DDNR (group 6).
All cephalograms were traced by a sin-
gle investigator and recorded using a digi-
tizer with a desktop computer. The
positions of all landmarks and the mea-
surements used in this study are shown in
Figs. 1 and 2. In order to analyze relation-
ships between the severity of TMJ disk
displacement and sagittal or vertical ske-
letal deformities, we selected the ANB
(point A, nasion, point B) angle and facial
height ratio (FHR) as references of sagittal
and vertical skeletal classifications, Fig. 1. Landmarks used in this study: 1, sella; 2, nasion; 3, point A; 4, point B; 5, menton; 6,
gonion.
respectively. Subjects with an ANB angle
or FHR within 1 standard deviation
(SD) of normal Korean adults,12 were
designated as skeletal Class I (ANB angle
1.4–4.48 in males and 0.8–4.48 in females)
or normodivergent pattern (FHR 66.0–
72.0 in males and 63.0–68.0 in females),
respectively. Subjects with an ANB angle
of greater than 1 SD were designated as
having a skeletal Class II deformity (ANB
angle of >4.48 in both males and females)
and those with an ANB angle of less than 1
SD were designated as having a skeletal
Class III deformity (ANB angle <1.48 in
males and <0.88 in females). Those with a
FHR greater than 1 SD from average FHR
measurements were assigned a hypodiver-
gent deformity (FHR >72.0 in males and
>68.0 in females) and those with a FHR
less than 1 SD from the average were
assigned a hyperdivergent deformity
(FHR <66.0 in males and <63.0 in
females).
Before data were analyzed, duplicate
determinations were performed on 30
cephalometric radiographs, from which
Fig. 2. Skeletal parameters used in this study. The ANB (a) is the angle in point A–nasion–point
measurement errors were calculated with
B. The facial height ratio (FHR) is the ratio of the posterior facial height (c, sella–gonion) to the
an intraclass correlation coefficient. The anterior facial height (b, nasion–menton).
tracing reliability, landmark identification,
and analytical measurements had intra-
class correlation coefficients of >0.98. skeletal deformities in both sexes was specific skeletal deformities were ana-
Two-way analysis of variance confirmed by a general correlation coeffi- lyzed by x2 test. Values were considered
(ANOVA) with Scheffe’s multiple cient method through the Cochran–Man- statistically significant when P < 0.05.
comparisons was used to determine any tel–Haenszel test. In order to evaluate
significant differences in age according to relationships between TMJ disk displace-
ment and specific skeletal deformities, Results
sex and TMJ disk displacement status. The
linear trend in TMJ disk displacement homogeneity or differences in severity Table 2 shows the distribution of patients
severity according to sagittal or vertical of TMJ disk displacement in patients with with various TMJ disk displacements.
 TMJ disk displacement and jaw deformities 1111

Table 2. The distribution (number (%)) of patients with various TMJ disk displacements.
Group 1a Group 2b Group 3c Group 4d Group 5e Group 6f Total
Male 42 (35.9) 19 (16.2) 17 (14.5) 9 (7.7) 11 (9.4) 19 (16.2) 117 (100)
Female 69 (20.1) 52 (15.2) 73 (21.3) 18 (5.2) 48 (14.0) 83 (24.2) 343 (100)
Total 111 (24.1) 71 (15.4) 90 (19.6) 27 (5.9) 59 (12.8) 102 (22.2) 460 (100)
TMJ, temporomandibular joint.
a
Bilateral normal TMJs.
b
Unilateral disk displacement with reduction and normal contralateral TMJ.
c
Bilateral disk displacement with reduction.
d
Unilateral disk displacement without reduction and normal contralateral TMJ.
e
Unilateral disk displacement with reduction and disk displacement without reduction in the contralateral TMJ.
f
Bilateral disk displacement without reduction.

Seventy-five (64.1%) of 117 male patients
and 274 (79.9%) of 343 female patients
had TMJ disk displacement. Twenty-five
(33.3%) of 75 male patients who had TMJ
disk displacement did not show any
detectable TMJ signs or symptoms, while
28 (35.8%) of the symptomatic male
patients had bilateral normal TMJs.
Among female patients, 108 (39.4%) out
of 274 female patients who had TMJ disk
displacement did not show any detectable
TMJ signs or symptoms, while 26.0% of
symptomatic patients had bilateral normal
TMJs (data not shown).
Fig. 3 and Table 3 show the relation-
ships between the severity of TMJ disk
displacement and sagittal skeletal defor-
mities in male and female patients. Since
the linear trend in the severity of TMJ disk
displacement was not significantly differ-
ent between the sexes, the results of both
sexes were combined. Results indicated
that TMJ disk displacement severity from
BN to bilateral DDNR (from groups 1 to
6) increased as the sagittal skeletal classi-
fication changed from skeletal Class III to
Class II (P < 0.0001). In contrast, TMJ
disk displacement severity from groups 1
to 6 decreased as the sagittal skeletal
classification changed from skeletal Class
Fig. 3. Distribution chart of TMJ disk displacement according to sagittal skeletal classification.
Group 1, bilateral normal TMJs; group 2, unilateral disk displacement with reduction (DDR) and
contralateral normal; group 3, bilateral DDR; group 4, unilateral disk displacement without
reduction (DDNR) and contralateral normal; group 5, unilateral DDR and contralateral DDNR;
and group 6, bilateral DDNR.
II to Class III (P < 0.0001). As a result,
bilateral DDNR was most prevalent in
patients with skeletal Class II, whereas
BN was most prevalent in patients with
skeletal Class III. In addition, 88.1% of
patients with skeletal Class II had TMJ
disk displacement on at least one side of
the TMJ. This indicates that the severity of
TMJ disk displacement is associated with
sagittal skeletal deformities.
Fig. 4 and Table 4 show the relation-
ships between the severity of TMJ disk
displacement and vertical skeletal defor-
mities. Given that there was no significant
difference between the sexes in the linear
trend of TMJ disk displacement severity
according to the FHR, the results of both
sexes were combined. Although linear
trends in the severity of TMJ disk displa-
cement according to vertical skeletal
deformities were less evident than those
of sagittal skeletal deformities, trends in
the severity of TMJ disk displacement
from BN to bilateral DDNR (from groups
1 to 6) increased as vertical skeletal
classes changed from hypodivergent to
hyperdivergent deformities (P < 0.01).
This indicates that the severity of TMJ
disk displacement is associated with dif-
ferent vertical skeletal deformities and
that TMJ disk displacement is more pre-
valent in patients with a hyperdivergent
deformity than those with a hypodivergent
deformity or the normodivergent. As a
result, bilateral DDNR was found to have
the highest prevalence in patients with a
hyperdivergent deformity, while BN had
the highest prevalence in patients with a
hypodivergent deformity.
Fig. 5 shows that the prevalence of
patients with both skeletal Class III and
hypodivergent deformities tended to
decrease as TMJ disk displacement pro-
gressed from BN to bilateral DDNR (from
groups 1 to 6), while those with both
skeletal Class II and hyperdivergent defor-
mities tended to increase as TMJ disk
displacement progressed from BN to bilat-
eral DDNR. This inverse trend between
the patients with both skeletal Class III
and hypodivergent deformities and the
patients with both skeletal Class II and
hyperdivergent deformities was statisti-
cally significant (P < 0.0001).
Discussion
A successful surgical orthodontic treat-
ment is based on the assumption that the
condyle and the TMJ respond normally to
the various treatment modalities. In the
case of TMJ disk displacement, an unfa-
vorable response may be expected by the
orthodontic force or surgical procedures,
because the functional environment of the
TMJ and adaptive capacity are altered.13–
15
In addition, individuals without any
distinct clinical signs and symptoms
may become symptomatic during and/or
after the treatment. In particular, adult
patients can present TMJ signs and symp-
toms unexpectedly because the adaptive
and healing capacity decreases gradually
with ageing. Therefore, it may be useful
for orthodontists and surgeons to screen
adult patients with potential TMJ disk
displacement before commencing treat-
ment. MRI is the first choice for imaging
most disorders of the TMJ, because MRI is
a proven method in the assessment of soft
1112 Jung et al.

Table 3. The prevalence (number (%)) of subjects with various TMJ disk displacements according to sagittal skeletal deformities.
Group 1a Group 2b Group 3c Group 4d Group 5e Group 6f Total
Male
Skeletal Class III 28 (23.9) 15 (12.8) 4 (3.4) 2 (1.7) 2 (1.7) 0 (0.0) 51 (43.6)
Skeletal Class I 9 (7.7) 3 (2.6) 5 (4.3) 3 (2.6) 3 (2.6) 2 (1.7) 25 (21.4)
Skeletal Class II 5 (4.3) 1 (0.9) 8 (6.8) 4 (3.4) 6 (5.1) 17 (14.5) 41 (35.0)
Total 42 (35.9) 19 (16.2) 17 (14.5) 9 (7.7) 11 (9.4) 19 (16.2) 117 (100)

Female
Skeletal Class III 29 (8.5) 10 (2.9) 2 (0.6) 6 (1.7) 2 (0.6) 1 (0.3) 50 (14.6)
Skeletal Class I 16 (4.7) 23 (6.7) 25 (7.3) 7 (2.0) 14 (4.1) 6 (1.7) 91 (26.5)
Skeletal Class II 24 (7.0) 19 (5.5) 46 (13.4) 5 (1.5) 32 (9.3) 76 (22.2) 202 (58.9)
Total 69 (20.1) 52 (15.2) 73 (21.3) 18 (5.2) 48 (14.0) 83 (24.2) 343 (100)

Both sexes
Skeletal Class III 57 (12.4) 25 (5.4) 6 (1.3) 8 (1.7) 4 (0.9) 1 (0.2) 101 (22.0)
Skeletal Class I 25 (5.4) 26 (5.7) 30 (6.5) 10 (2.2) 17 (3.7) 8 (1.7) 116 (25.2)
Skeletal Class II 29 (6.3) 20 (4.3) 54 (11.7) 9 (2.0) 38 (8.3) 93 (20.2) 243 (52.8)
Total 111 (24.1) 71 (15.4) 90 (19.6) 27 (5.9) 59 (12.8) 102 (22.2) 460 (100)
TMJ, temporomandibular joint. The linear trend of TMJ disk displacement according to ANB (A point, nasion, B point) angle in both sexes was
confirmed by the general correlation coefficient method of the Cochran–Mantel–Haenszel test (P < 0.0001).
a
Bilateral normal TMJs.
b
Unilateral disk displacement with reduction and normal contralateral TMJ.
c
Bilateral disk displacement with reduction.
d
Unilateral disk displacement without reduction and normal contralateral TMJ.
e
Unilateral disk displacement with reduction and disk displacement without reduction in the contralateral TMJ.
f
Bilateral disk displacement without reduction.

tissue and osseous structures.3,4,16 In addi- TMJ symptoms, and in patients with man- with TMJ disk displacement are not sig-
tion, MRI has an accuracy of 95% in the dibular hypoplasia there is a high possi- nificantly different between the sexes.
assessment of disk position and form.17 bility of TMJ disorder.18 This is partly Therefore, all data collected from males
Nevertheless, the routine use of MRI for explained by the fact that patients in whom and females were combined and analyzed
the evaluation of the TMJ in patients is specific skeletal characteristics associated together.
limited by its high cost. The use of MRI to with TMJ disk displacement were present, TMJ disk displacement severity
evaluate the relationships between TMJ such as an anterior open bite and a retro- increased from BN to bilateral DDNR as
disk displacement and skeletal deformities gnathic mandible, were included in this the sagittal skeletal classification changed
would facilitate the diagnosis and treat- study.5–10 from skeletal Class III to skeletal Class II
ment planning of patients with potential This study showed that there were no deformities, and as the vertical skeletal
TMJ disk displacement. significant differences in the linear trend of classification changed from hypodiver-
In this study, more than 50% of subjects TMJ disk displacement severity between gent to hyperdivergent deformities,
had a skeletal Class II or hyperdivergent the sexes according to sagittal or vertical regardless of sex (Tables 3 and 4). Rela-
deformity. This is mainly because MRIs skeletal deformities. This means that dif- tionships between TMJ disk displacement
were taken in patients with a history of ferences in facial morphology associated and sagittal or vertical skeletal deformities
can be explained by differences in skeletal
morphology associated with TMJ disk
displacement. Previous studies have
reported that patients with TMJ disk dis-
placement have a higher percentage of
altered skeletal morphology, such as a
decreased ramus and posterior facial
height, and clockwise rotation of the
ramus and mandible,5,6,10 indicating that
TMJ disk displacement is associated with
skeletal Class II and/or hyperdivergent
deformities. In addition, these skeletal
differences are more likely to progress
to more severe forms as TMJ disk displa-
cement progresses from mild to severe.5,6
Fig. 4. Distribution chart of TMJ disk displacement according to vertical skeletal classification. This may explain differences in TMJ disk
Group 1, bilateral normal TMJs; group 2, unilateral disk displacement with reduction (DDR) and displacement severity according to sagittal
contralateral normal; group 3, bilateral DDR; group 4, unilateral disk displacement without or vertical skeletal changes.
reduction (DDNR) and contralateral normal; group 5, unilateral DDR and contralateral DDNR; However, the relationships between the
and group 6, bilateral DDNR. severity of TMJ disk displacement and
 TMJ disk displacement and jaw deformities 1113

Table 4. The prevalence (number (%)) of subjects with various TMJ disk displacements according to vertical skeletal deformities.
Group 1a Group 2b Group 3c Group 4d Group 5e Group 6f Total
Male
Hypodivergent 8 (6.8) 2 (1.7) 4 (3.4) 0 (0.0) 0 (0.0) 0 (0.0) 14 (12.0)
Normodivergent 11 (9.4) 10 (8.5) 5 (4.3) 1 (0.9) 6 (5.1) 3 (2.6) 36 (30.8)
Hyperdivergent 23 (19.7) 7 (6.0) 8 (6.8) 8 (6.8) 5 (4.3) 16 (13.7) 67 (57.3)
Total 42 (35.9) 19 (16.2) 17 (14.5) 9 (7.7) 11 (9.4) 19 (16.2) 117 (100)

Female
Hypodivergent 12 (3.5) 7 (2.0) 6 (1.7) 1 (0.3) 2 (0.6) 2 (0.6) 30 (8.7)
Normodivergent 26 (7.6) 21 (6.1) 26 (7.6) 8 (2.3) 12 (3.5) 16 (4.7) 109 (31.8)
Hyperdivergent 31 (9.0) 24 (7.0) 41 (12.0) 9 (2.6) 34 (9.9) 65 (19.0) 204 (59.5)
Total 69 (20.1) 52 (15.2) 73 (21.3) 18 (5.2) 48 (14.0) 83 (24.2) 343 (100)

Both sexes
Hypodivergent 20 (4.3) 9 (2.0) 10 (2.2) 1 (0.2) 2 (0.4) 2 (0.4) 44 (9.6)
Normodivergent 37 (8.0) 31 (6.7) 31 (6.7) 9 (2.0) 18 (3.9) 19 (4.1) 145 (31.5)
Hyperdivergent 54 (11.7) 31 (6.7) 49 (10.7) 17 (3.7) 39 (8.5) 81 (17.6) 271 (58.9)
Total 111 (24.1) 71 (15.4) 90 (19.6) 27 (5.9) 59 (12.8) 102 (22.2) 460 (100)
TMJ, temporomandibular joint. The linear trend of TMJ disk displacement according to facial height ratio in both sexes was confirmed by the
general correlation coefficient method of the Cochran–Mantel–Haenszel test (P < 0.01).
a
Bilateral normal TMJs.
b
Unilateral disk displacement with reduction and normal contralateral TMJ.
c
Bilateral disk displacement with reduction.
d
Unilateral disk displacement without reduction and normal contralateral TMJ.
e
Unilateral disk displacement with reduction and disk displacement without reduction in the contralateral TMJ.
f
Bilateral disk displacement without reduction.

vertical skeletal deformities are less evi- the ramus and mandible,5,6,10,19 patients and vertical skeletal deformities, combin-
dent than those between TMJ disk displa- with hyperdivergent deformities should ing sagittal and vertical skeletal deformities
cement severity and sagittal skeletal have a higher prevalence of severe TMJ will allow for the better identification of
deformities. In particular, the relationships disk displacement. This may be due to the patients with potential TMJ disk displace-
between the severity of TMJ disk displa- fact that the vertical skeletal morphology ment, rather than considering each skeletal
cement and vertical skeletal deformities is less associated with TMJ disk displace- deformity separately (Fig. 5). The results
are not evident in the BN or the early stage ment compared to sagittal or mandibular clearly demonstrate that increased TMJ
of TMJ disk displacement (Table 4). Con- skeletal morphologies, particularly in the disk displacement severity is more closely
sidering that TMJ disk displacement is early stages of TMJ disk displacement.5,6 associated with both skeletal Class II and
associated with a decreased posterior Due to the fact that TMJ disk displace- hyperdivergent deformities than either ske-
facial height and clockwise rotation of ment was highly associated with sagittal letal Class II or hyperdivergent deformities
alone. In the case of patients with both
skeletal Class II and hyperdivergent defor-
mities, most (80.5%) had bilateral TMJ
disk displacement and only a small portion
(8.6%) had BN. In addition, most patients
with both skeletal Class III and hypodiver-
gent deformities showed BN or mild TMJ
disk displacement severity (mostly groups
1–3; 94.1%). Patients with both skeletal
Class II and hyperdivergent deformities
may have a higher probability of having
a severe TMJ disk displacement status,
while patients with both skeletal Class III
and hypodivergent deformities may have a
greater chance of a normal TMJ or a mild
TMJ disk displacement status, regardless of
Fig. 5. Distribution chart of patients with skeletal Class III with hypodivergent deformities and sex. The differences in skeletal profilo-
skeletal Class II with hyperdivergent deformities, according to TMJ disk displacement. Group 1, grams between hypodivergent and hyper-
bilateral normal TMJs; group 2, unilateral disk displacement with reduction (DDR) and divergent deformities are illustrated in
contralateral normal; group 3, bilateral DDR; group 4, unilateral disk displacement without
Fig. 6. The profilograms show the groups
reduction (DDNR) and contralateral normal; group 5, unilateral DDR and contralateral DDNR;
and group 6, bilateral DDNR. Homogeneity of groups between skeletal Class III with that have a high or low possibility of TMJ
hypodivergent deformities and skeletal Class II with hyperdivergent deformities was rejected disk displacement according to various
by the Cochran–Mantel–Haenszel x2 test (P < 0.0001). skeletal deformities.
1114 Jung et al.
Fig. 6. The comparison of skeletal profilograms between hypodivergent (A) and hyperdivergent
(B) skeletal deformities.
When we did the same analyses using
other skeletal parameters, such as Wits
appraisal, facial convexity, SN to mandib-
ular plane angle, and FH to mandibular
plane angle, instead of ANB and FHR, we
observed the same trend between skeletal
deformities and TMJ disk displacement
severity (data not shown). This indicates
that patients with specific skeletal defor-
mities, such as skeletal Class II with a
hyperdivergent deformity, are more likely
to have severe TMJ disk displacement.
Because TMJ disk displacement can pro-
vide a poor base upon which to build any
skeletal functional reconstruction, these
results partly explain why mandibular
hypoplasia and high mandibular plane
angle are risk factors for condylar resorp-
tion and late relapse in orthognathic sur-
gery.20–23
Although this study showed an associa-
tion between TMJ disk displacement
severity and skeletal deformities, it is still
uncertain whether TMJ disk displacement
affects facial morphology or whether
altered facial morphology affects TMJ
disk displacement. Skeletal Class II and/
or a hyperdivergent deformity may cause
TMJ disk displacement, while TMJ disk
displacement may cause skeletal Class II
and/or a hyperdivergent deformity. Con-
sidering that experimentally induced TMJ
disk displacement leads to significant
impairment of vertical and horizontal
mandibular growth, and the amount of
vertical and/or horizontal skeletal change
gradually increases as TMJ disk displace-
ment increases in severity,24,25 the specific
skeletal deformities may be the result of
progress in TMJ disk displacement. These
results suggest that clinicians should care-
fully monitor the TMJ status in adult
patients with both skeletal Class II and
hyperdivergent deformities, because these
patients might have potential TMJ disk
displacement even in the absence of
TMJ symptoms.
The relationships between the severity
of TMJ disk displacement and various
skeletal deformities in this study are diffi-
cult to apply directly to the general popu-
lation, as the subjects in this study were
orthodontic patients with various skeletal
deformities. However, this study may pro-
vide orthodontists and surgeons with valu-
able information on the relationships
between the severity of TMJ disk displa-
cement and various skeletal deformities in
adult orthodontic patients. Additionally,
this study is particularly useful because
it is the first to include large numbers of
MRI samples with various TMJ disk dis-
placement conditions, including unilateral
disk displacement. Further longitudinal
research including the general population
is required to evaluate an association
between TMJ disk displacement and var-
ious skeletal malocclusions.
In conclusion, TMJ disk displacement
may be present in patients with various
skeletal deformities, regardless of TMJ
symptoms. In addition, the severity of
TMJ disk displacement increases as the
sagittal skeletal classification changes
from skeletal Class III to Class II defor-
mities, and vertical skeletal classification
changes from hypodivergent to hyperdi-
vergent deformities, irrespective of sex.
This study suggests that clinicians should
carefully evaluate the status of the TMJ in
patients with both skeletal Class II and
hyperdivergent deformities during the
whole treatment period.
Funding
None to declare.
Competing interests
None to declare.
Ethical approval
The research protocol was reviewed and
approved by the institutional review board
of the University Hospital (CRI11040).
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Address:
Sug-Joon Ahn
Dental Research Institute and Department of
Orthodontics
School of Dentistry
Seoul National University
101 Daehak-ro
Jongro-gu
Seoul 110-768
Republic of Korea
Tel: +82 2 2072 2672;
Fax: +82 2 2072 3817
E-mails: titoo@snu.ac.kr,
orthopia@gmail.com