Classification and prevalence of temporomandibular

joint disk displacement in patients and

symptom-free volunteers
Mark M. Tasaki, DDS, MS, PhD, a Per-Lennart Westesson, DDS, PhD, b'°
Annika M. Isberg, DDS, PhD, a Yan-Fang Ren, DDS, MD," and Ross H. Tallents, DDS °
Umett, Sweden, and Rochester, N.Y.

The purposes of this study were to develop a classification system for disk displacement in the
temporomandibular joint (TMJ) and to study the prevalence of the various types of TMJ disk
displacement in patients and symptom-free volunteers. The study was based on bilateral MRIs of
243 patients and 57 symptom-free volunteers. Eight different types of disk displacements were
identified in addition to the superior disk position and a tenth indeterminate category. Superior disk
position was observed bilaterally in 18% of the patients and bilaterally in 70% of the symptom-free
volunteers. (AM J ORTHODDENTOFACORTHOP1996;109:249-62.)

D i f f e r e n t types of disk displacement are
the most frequent findings when imaging the tem-
poromandibular joint (TMJ) of patients having
signs and symptoms of T M J disorders. ~ The most
frequent type of disk displacement described in the
publications has b e e n anterior displacement. 2-5
More recent studies with arthrography 6 and mag-
netic resonance imaging ( M R I ) 7 have shown that
lateral and medial displacements also occur. A few
cases of posterior displacement have been de-
scribed as w e l l s
W e have observed large variations of disk dis-
placements in clinical work with MRI. Several of
the observed directions of disk displacement did
not fit into the categories of displacement de-
scribed in the earlier publications, sometimes mak-
ing it difficult to communicate the results of imag-
ing studies to referring clinicians. A significant
variation in how radiologists have interpreted mag-
netic resonance (MR) images of the T M J has
sometimes given referring clinicians the impression
that M R I of the T M J is inaccurate despite the
Supported by the Torsten and Ragnar S6derberg Foundation, Ulla and
Gustaf af Uggla's Foundation, and the Swedish Medical Research Coun-
cil, grant no, 6877, Stockholm, Sweden, and by USPHS Research Grant
DE-8059 from the National Institute of Dental Research, National
Institutes of Health, Bethesda, Md.
This article was prepared while Drs. Tasaki, Isberg, and Ren were visiting
researchers in the Department of Radiology, University of Rochester
School of Medicine and Dentistry.
aDepartment of Oral and Maxillofacial Radiology, University of Ume~,
Ume,~, Sweden.
bDepartment of Radiology, University of Rochester School of Medicine
and Dentistry, Rochester, N.Y.
CDepartment of Orthodontics, Eastman Dental Center, Rochester, N.Y.
Copyright © 1996 by the American Association of Orthodontists.
0889-5406/96/$5.00 + 0 8/1/65599
correlative studies showing accuracy rates of 90%
or higher. 9 The observer variation can be traced
back to a lack of strict criteria for how disk dis-
placement of the T M J should be classified. Mag-
netic resonance imaging is currently the most ac-
curate imaging modality for identification of disk
position in the T M J 9 and was selected as the gold
standard for disk position identification purposes.
The purposes of this study were to develop a
classification system for disk displacement of the
T M J and to document the prevalence of different
types of disk displacement in patients and symp-
tom-free volunteers.
MATERIALS AND METHODS
The study was based on bilateral temporomandibular
joint MR images of 300 persons, including 243 patients
with clinical signs and symptoms of TMJ disorders and 57
symptom-free volunteers. The patients consisted of 197
females and 46 males with a median age of 30 years, a
mean age of 32 years, and a range from 10 to 81 years. The
symptom-flee volunteers consisted of 31 females and 26
males with a median age of 26 years, a mean age of 27
years, and a range from 19 to 46 years. The patients repre-
sent a consecutive series referred for MRI of the TMJs,
based on physical examination findings. Patients did not
represent a consecutive series of persons with temporo-
mandibular disorders (TMD). Symptom-free volunteers
were selected on the basis of having no previous or present
clinical signs and symptoms of TMJ disorders including
pain, no previous or present treatment for TMJ disorders,
no joint sound on auscultation with a stethoscope or pal-
pable noises, having normal range of vertical ( _>40 mm)
and horizontal ( ->5 mm) movement, and a willingness to
participate in our study.
Cryosections of the TMJs were obtained from several
249
250 T a s a k i et al. American Journal of Orthodontics and Dentofacial Orthopedics
March 1996

Table I. C r i t e r i a for classification o f disk p o s i t i o n s

Superior disk position
Anterior disk displacement
Partial anterior disk displacement
in lateral part of joint
Partial anterior disk displacement
in medial part of joint
Rotational anterolateral disk
displacement
Rotational anteromedial disk
displacement
Lateral disk displacement
Medial disk displacement
Posterior disk displacement
Indeterminate
Posterior band of disk superior to condyle or central thin zone (intermediate zone) of disk
located between anterior prominence of condyle and posterior aspect of articular emi-
nence (Fig. 2).
Posterior band of disk anterior to anterior prominence of condyle throughout mediolateral
dimension of joint (Fig. 3).
Disk anteriorly displaced in lateral part of joint and disk in superior position in medial part
of joint with no sideways component to displacement (Fig. 4).
Disk anteriorly displaced in medial part of joint and in superior position in lateral part of
joint with no sideways component to displacement (Fig. 5).
Disk anteriorly and laterally displaced (Fig. 6).
Disk anteriorly and medially displaced (Fig. 7).
Disk displaced lateral to lateral pole of condyle (Fig. 8).
Disk displaced medial to medial pole of condyle (Fig. 9).
Disk displaced posterior to 12 o'clock position on top of condyle (Fig. 10).
This category was used when a large perforation, prior surgical therapy or no clear image of
the disk prevented classification into any of the above categories.

prior studies 9'1° for illustration purposes. The age of the
subjects from whom the specimens were removed ranged
between 55 and 96 years with a mean age of 80 years.
The TMJ specimens were removed within 48 hours of
death and obtained from cadavers with a distinct closed
mouth position relative to either dentures or natural
dentition. A closed mouth position was maintained dur-
ing removal of the specimens through repeated applica-
tions of liquid nitrogen. With the aid of videofluoroscopy,
cryosections perpendicular and parallel through the sag-
ittal and the coronal planes of the joint were then
obtained. These sections were used for multiple purposes
in previous studies, 9'1° but in the present study they were
used only for illustration.
The MRI was performed on a 1.5 Tesla Signa MR
imager (General Electric, Milwaukee, Wis.) with bilateral
6 × 8 cm surface coils. On the basis of an axial localizer
(TR/TE = 400/12 msec, NEX = 1, F O V = 18 cm, ma-
trix = 256 × 128, and slice thickness = 3 ram, with a gap
between slices = 0.5 ram), MR images were prescribed
graphically perpendicular (sagittal images) and parallel
(coronal images) to the horizontal long axis of the condyle.
Images were obtained in the closed and open mouth posi-
tion with TR/TE = 2000/19, 80, NEX = 0.5, FOV = 10
cm~ matrix = 256 × 192, slice thickness = 3 ram, with a
gap = 0.5 mm between slices. Disk position was analyzed
and grouped into 1 of 10 categories described in Table I.
Disk function was analyzed in the sagittal plane only and
categorized as normal, displaced with reduction or with-
out reduction, or indeterminate. Normal function was
noted when a disk in the superior position in the closed
mouth position maintained a position interposed between
the condyle and the articular eminence in the open mouth
position. Reduction was noted when a displaced disk in
the closed mouth position assumed a position interposed
between the condyle and the articular eminence in the
open mouth position. No reduction was noted when a
displaced disk in the closed mouth position did not achieve
a position between the condyle and the articular eminence
in the open mouth position. Indeterminate disk function
was noted when the disk could not be identified because of
surgical removal, metallic artifacts, or postsurgical scar-
ring. Osseous components were classified as normal or
abnormal. Normal osseous condition was noted when the
joint components were rounded or slightly remodeled with
an intact cortex. Abnormal osseous condition was noted
when there were osteophytes or severe flattening.
Two of the investigators individually interpreted the
MR images without knowledge of the interpretation of
the other investigator. In cases where a difference in
diagnosis existed, a consensus diagnosis was reached.
Interobserver variation in interpretation of MR images
of the TMJs has been reported separately."
The Chi-square test was used to compare the preva-
lence of disk displacement in patients and symptom-free
volunteers. A two-tailed statistical analysis was used
where a probability less than 0.05 was considered statis-
tically significant.
RESULTS
A n a l y s i s o f the M R i m a g e s of the 600 j o i n t s
s t u d i e d r e s u l t e d in t h e f o r m u l a t i o n o f c r i t e r i a t h a t
e n a b l e d t h e classification o f disk d i s p l a c e m e n t into
eight c a t e g o r i e s in a d d i t i o n to t h e s u p e r i o r p o s i t i o n
a n d a t e n t h i n d e t e r m i n a t e category. T h e criteria
for classification o f a j o i n t into e a c h o f t h e s e g r o u p s
a r e d e s c r i b e d in T a b l e I. T h e t e n t h i n d e t e r m i n a t e
c a t e g o r y was u s e d w h e n a large p e r f o r a t i o n , p r i o r
surgical t r e a t m e n t , o r no clear d e l i n e a t i o n o f t h e
disk p r e v e n t e d classification o f disk p o s i t i o n into
any of t h e o t h e r nine categories. T h e n i n e c a t e g o -
ries o f disk p o s i t i o n a r e i l l u s t r a t e d in Figs. 1 to 10.
M a g n e t i c r e s o n a n c e i m a g e s w e r e o b t a i n e d from
American Journal of Orthodontics and Dentofacial Orthopedics T a s a k i et al. 251
Volume 109, No. 3

.~~!!~;:::: ~.~ ~°,**~4;;'~~

Fig. 1. 1 to 9 schematically illustrate nine categories of disk position described in Table I. Insets are
axial views from above. 1, Superior disk position; 2, anterior disk displacement; 3, partial anterior disk
displacement in lateral part of joint; 4, partial anterior disk displacement in medial part of joint; 5,
rotational anterolateral disk displacement; 6, rotational anteromedial disk displacement; 7, lateral disk
displacement; 8, medial disk displacement; 9, posterior disk displacement.
252 Tasaki et al. American Journal of Orthodontics and Dentofacial Orthopedics"
March t996

Fig. 2. Superior disk position. A, Sagittal MR image shows central thin zone of disk interposed
between anterior prominence of condyle and posterior prominence of articular eminence. Posterior
band (arrow) is superior to condyle. B, Coronal MR image (same joint as A) shows disk (arrows)
superior to condyle. C, Sagittal cryosection (different joint than A-B) shows posterior band of disk
(arrow) superior to condyle. D, Coronal cryosection (different joint than A-B and C) shows disk
(arrows) superior to condyle.

Table II. Distribution of unilateral and bilateral disk displacements in patients and
symptom-free volunteers
Disk position

Superior disk position Unilateral disk displacement Bilateral disk displacement

Volunteers (n = 57) 40 (70.2%) 10 (17.5%) 7 (12.3%)

Patients (n = 243) 44 (18.1%) 58 (23.9%) 141 (58.0%)

patients and volunteers. Cryosections were ob-
tained from cadavers and are for illustration pur-
poses only.
The distribution of unilateral and bilateral disk
displacements in patients and symptom-free volun-
teers is shown in Table II. Unilateral and bilateral
disk displacement was significantly more prevalent
in the patients than in the symptom-free volunteers
(p < 0.001).
The distribution of the different types of disk
positions in patients' and symptom-free volunteers'
joints are listed in Table III. Anterolateral and
anterior disk displacements were the most frequent
types of disk displacement observed in the patients.
The other types of disk displacement were evenly
distributed, with the exception of posterior disk
displacement with only three observed cases. In the
symptom-free volunteers, anterolateral displace-
ment was the most frequent displacement observed
as well, followed by partial anterior disk displace-
ment in the medial part of the joint.
The distribution of the different types of disk
positions in female and male patients' joints are
listed in Table IV. The distribution of the different
American Journal of Orthodontics and Dentofacial Orthopedics T a s a k i et aL 253
Volume 109, No. 3

Fig. 3. Anterior disk displacement. A, Sagittal MR image shows posterior band of disk (arrow)
anterior to condyle. B, Coronal MR image (same joint as A) shows no medial or lateral displacement
of disk (arrows). C, Sagittal cryosection (different joint than A-B) shows disk (arrow) anterior to
condyle.

types of disk positions in the symptom-free female
and symptom-free male volunteers' joints are listed
in Table V. No significant relation was found be-
tween sex and the prevalence of any specific disk
position.
Normal function with normal osseous condition
was noted in all the joints that had disks in the
superior disk position for both patients and symp-
tom-free volunteers. In the patient group, 36.0%
(175 of 486) of the joints reduced on opening and
had normal osseous condition, whereas 4.1% (20 of
486) of the joints reduced on opening and had
osseous changes. Of the joints in the patient group,
15.4% (75 of 486) had displaced disks without
reduction and normal osseous condition, whereas
13.0% (63 of 486) of the joints had displaced disks
without reduction and abnormal osseous changes.
Indeterminate status was detected in 1.4% (7 of
486) of the patient sample.
In the symptom-free volunteer group, 21.1% (24
of 114) of the joints had one form of disk displace-
ment or another. However, all joints with displaced
disks reduced and had normal osseous condition.
None of the joints in the symptom-free volunteer
group presented without reduction, with abnormal
osseous condition, or indeterminate status.
DISCUSSION
On the basis of the MR images of the 600 TMJs
in patients and symptom-free volunteers, prior
clinical experience and work with cryosectional and
histologic studies, a classification system for differ-
ent types of disk displacement was developed. Ten
different categories of disk position into which
254 Tasaki et aL American Journal of Orthodontics and Dentofacial Orthopedics
March 1996

Fig. 4. Partial anterior disk displacement in lateral part of joint. A, Sagittal MR image of lateral part of
joint shows disk (arrow) anterior to condyle (C). B, Sagittal MR image of medial part of joint (same
joint as A) shows disk (arrow) superior to condyle. C, Coronal MR image (same joint as A-B) shows
no medial or lateral displacement of disk. D, Sagittal cryosection of lateral part of joint (different joint
than A-C) shows anterior displacement of disk (arrow). Disk deformation is more prominent in clinical
picture in A than in cadaver section from different joint in D. E, Sagittal cryosection of medial part of
joint (same joint as D; different joint than A-C) shows disk (arrow) superior to condyle.

Table III. Prevalence of disk positions in patients (n = 243) and symptom-flee volunteers (n = 57)
Numbers of Number of
Disk position joints in patients Percentage joints in volunteers Percentage

Superior disk position 146 30.0 90 79.0

Anterior disk displacement 110 22.6 1 0.9
Partial anterior disk displacement in lateral part of joint 40 8.2 2 1.8
Partial anterior disk displacement in medial part of joint 4 0.8 7 6.1
Rotational anterolateral disk displacement 113 23.3 10 8.8
Rotational anteromedial disk displacement 21 4.3 1 0.9
Lateral disk displacement 22 4.5 2 1.8
Medial disk displacement 20 4.1 1 0.9
Posterior disk displacement 3 0.6 0 0
Indeterminate 7 1.4 0 0
Total 486 99.8* 114 100.2"

*Percentages vary from 100% due to rounding.

normal and abnormal TMJs could be classified
were identified. This classification system should
function as a communication tool among clinicians
and between clinicians and researchers in scientific
studies. With this system, it is possible to classify
the position of the disk into definitive categories,
and it should be possible to keep observer variation
to a minimum. A study on observer variation that
used this classification system has shown a low level
of intraobserver and interobserver variability. 11
This is consistent with the observation that the use
of reference radiographs will improve observer per-
f o r m a n c e . 12
An analysis of the prevalence of different disk
positions in both patients and volunteers in this
study showed a strong association between the
American Journal of Orthodontics and Dentofacial Orthopedics Tasaki et aI. 255
Volume 109, No. 3

Fig. 5. Partial anterior disk displacement in medial part of joint. A, Sagittal MR image of lateral part
of joint shows disk (arrow) superior to condyle. B, Sagittal MR image of medial part of joint (same joint
as A) shows disk (arrow) anterior to condyle (C). C, Coronal MR image (same joint as A-B) shows no
medial or lateral displacement of disk. D, Sagittal cryosection of central part of joint (different joint
than A-C) shows disk (arrow) superior to condyle. E, Sagittal cryosection of medial part of joint
(different joint than A-C; same joint as D) shows disk (arrow) anterior to condyle (C).

Table IV. Prevalence of disk positions in female patients (n = 197) and male patients (n = 46)
Numbers of Number of
joints in joints in
Disk position female patients Percentage male patients Percentage

Superior disk position 107 27.2 39 42.4

Anterior disk displacement 90 22.8 20 21.7
Partial anterior disk displacement in lateral part of joint 31 7.9 9 9.8
Partial anterior disk displacement in medial part of joint 4 1.0 0 0
Rotational anterolateral disk displacement 99 25.1 14 15.2
Rotational anteromedial disk displacement 20 5.1 1 1.1
Lateral disk displacement 19 4.8 3 3.3
Medial disk displacement 17 4.3 3 3.3
Posterior disk displacement 1 0.3 2 2.2
Indeterminate 6 1.5 1 1.1
Total 394 100.0 92 100.1"
*Percentage varies from 100% due to rounding.

patients and disk displacement, and between symp-
tom-free volunteers and superior disk position. In
the superior position, the posterior band of the disk
was located superior to the condyle. There was
some variation in the position of the posterior band
for the superior disk position category. Variations
in position occurred most frequently anterior to the
12 o'clock position. In cases where this happened,
the positional relationship of the central thin zone
of the disk to the anterior prominence of the
condyle overrode the relative position of the pos-
terior band of the disk in reference to the condyle
in determining whether the disk was in a superior
position. If the anterior prominence of the condyle
and the inferior concavity of the central thin zone
of the disk were in contact and if the anterior
prominence of the condyle was within the bicon-
cave portions of the disk, the criteria of a normal
256 Tasaki et al. American Journal of Orthodontics and Dentofacial Orthopedics
March 1996

Fig. 6. Rotational anterolateral disk displacement. A, Sagittal MR image shows disk (arrow) anterior
to condyle. B, Coronal MR image (same joint as A) shows disk (arrow) lateral to condyle. C, Sagittal
cryosection (different joint than A-B) shows disk (arrow) anterior to condyle. D, Coronal cryosection
(different joint than A-B and C) shows disk (arrow) lateral to condyle (C).

Table V. Prevalence of disk positions in female symptom-free volunteers (n = 31) and male
asymptom-free volunteers (n = 26)
Numbers of Number of
joints in joints in
Disk position female volunteers Percentage male volunteers Percentage

Superior disk position 44 71.0 46 88.5

Anterior disk displacement 0 0
Partial anterior disk displacement in lateral part of joint 2 3.2
Partial anterior disk displacement in medial part of joint 4 6.5
Rotational anterolateral disk displacement 9 14.5
Rotational anteromedial disk displacement 1 1.6
Lateral disk displacement 2 3.2
Medial disk displacement 0 0
Posterior disk displacement 0 0
Indeterminate 0 0
Total 62 100.0
1 1.9
0 0
3 5.8
1 1.9
0 0
0 0
1 1.9
0 0
0 0
52 100.0

position of the disk was fulfilled. If these two
surfaces were separated by at least 2 mm, the disk
was considered displaced.
Disk displacement was observed in one or both
joints of nearly one third of the symptom-free
volunteers in this study. These subjects had no past
or present signs and symptoms of TMD. This
observation is consistent with prior studies of symp-
tom-free volunteers 1~'14 but contradicts the obser-
vations by Kaplan et al. 15 who found no disk dis-
placement in symptom-free volunteers as observed
with arthrography. Possible explanations for the
difference between Kaplan's study and the other
studies are that different selection criteria for par-
ticipation and diagnostic criteria were used in the
interpretation of the images. We used M R I instead
American Journal of Orthodontics and Dentofacial Orthopedics T a s a k i et aL 257
Volume 109, No. 3

Fig. 7. Rotational anteromedial disk displacement. A, Sagittal MR image shows disk (arrow) anterior
to condyle. B, Coronal MR image (same joint as A) shows disk (arrow) medial to condyle. C, Coronal
cryoseotion (different joint than A-B) shows disk (arrow) medial to condyle.

of arthrography, which could be responsible for the
higher report of disk displacements in our study,
since a correlative study has shown that single
contrast lower space arthrography is relatively in-
sensitive for identifying sideways disk displace-
ments. 16The MR! with coronal projection has been
shown to be sensitive for detecting sideways disk
displacements. Iv The observation of 30% disk dis-
placement in symptom-free volunteers suggests
that disk displacement is not always associated with
pain or dysfunction. On the other hand, the obser-
vation of 82% disk displacement in the patient
group suggests that disk displacement is signifi-
cantly more prevalent in patients than in persons
without symptoms and that disk displacement is
associated with clinical symptoms. The female-to-
male ratio in our volunteer group was almost equal
compared with a higher prevalence of females to
males in our patient group. This inequity does not
necessarily result in an underrepresentation of disk
displacement in the symptom-free volunteer group.
The female dominance in the patient group may
indicate that chronic inflammation and pain asso-
ciated with disk displacement develops more fre-
quently in females than in males. The exact relation-
ship between disk displacement and pain must await
further studies. Disk displacement may be part of a
prerequisite physiologic condition or a sequela or
may be coincidental to pain. Longitudinal studies
with both physiologic and emotional conditions con-
trolled are necessary to determine the effect that
disk displacement has on pain in the various articu-
lations of the body including the TMJs.
The observation of abnormalities within articu-
lating tissues in the symptom-free volunteers is not
unique to the TMJ. A magnetic resonance study of
258 Tasaki et aL American Journal of Orthodontics and Dentofacial Orthopedics
March 1996

Fig. 8. Lateral disk displacement. A, Sagittal MR image shows disk (arrow) superior to condyle. B,
Coronal MR image (same joint as A) shows disk (arrow) lateral to condyle. C, Sagittal cryosection
(different joint than A-B) shows disk (arrow) superior to condyle. D, Coronal cryosection (different joint
than A-B; same joint as C) shows disk (arrow) lateral to condyle.

asymPtomatic knees has shown a 16% prevalence
of meniscal abnormalities consistent with a tear. 18
This abnormality was more frequently seen in those
older than 45 years than in younger person. Also
concerning the cervical spine 19 and lumbosacral
spine, 2°'21 magnetic resonance studies of symptom-
free subjects have shown abnormalities in 13% to
54% of the subjects investigated. A recent study
with MRI of the lumbosacral spine showed a high
prevalence of abnormalities in symptom-free per-
sons, raising the question of the correlation be-
tween abnormalities and symptoms.= These obser-
vations suggest that musculoskeletal abnormalities
such as internal derangement of the TMJ caused by
disk displacement may or may not be associated
with clinical symptoms. This has been observed in
t h e T M J a3"14 and in several other parts of the
musculoskeletal system,ls22 Thus the disorder is
not always associated with clinical signs and symp-
toms. For self-limiting conditions, operative proce-
dures are not always required that may be contrary
to conditions that are life threatening, debilitating,
or disfiguring. This emphasizes the danger of bas-
ing operative decisions on diagnostic tests, without
matching clinical signs and symptoms. Patient
symptoms should govern treatment decisions, while
imaging observations of the abnormality help to
determine what kind of treatment should be per-
formed or in which way treatment should be car-
ried out. However, treatment decisions should be
based solely on observation of morphologic abnor-
malities such as disk displacement if disturbances
of facial growth are shown to be at risk.
The cause of pain symptoms in patients with
disk displacement is not fully understood. Disk
displacement probably plays a significant role in the
pain process, but disk displacement alone is not
always associated with pain, since several studies
have shown that disk displacement may occur in
symptom-free joints, a3'14'23 An alteration in disk
position alone is therefore not the only factor in the
development of pain. Disk displacement, combined
with disk dysfunction or an inflammatory reaction
as shown in extirpated disk and posterior disk
attachment tissue from temporomandibular joints
with chronic pain, z4"25are key issues for pain symp-
American Journal of Orthodontics and Dent@~cial Orthopedics
Volume 109, No. 3
Fig. 9. Medial disk displacement. A, Sagittal MR image shows disk (arrow) superior to condyle. B,
Coronal MR image (same joint as A) shows disk (arrow) medial to condyle. C, Sagittal cryosection
(different joint than A-B) shows disk (arrow) superior to condyle. D, Coronal cryosection (different joint
than A-B and C) shows disk (arrow) medial to condyle.
toms. A recent study has indicated that the preva-
lence of magnetic resonance evidence of joint ef-
fusion is more strongly associated with pain than
disk displacement alone. 26 It appears as if disk
displacement can cause some reaction in the joint
that can initiate pain. This reaction could be syno-
vitis, capsulitis, impingement on the capsule from
the inside, and impingement or compression of the
posterior disk attachment.
This study documents a high prevalence of
anterolateral disk displacement, which was seen
both in patients and in symptom-free volunteers.
The high prevalence of a lateral component to the
disk displacement was more evident than in earlier
studies, 6'7'27 which showed a higher prevalence of
medial displacements than lateral displacements. A
plausible explanation for the difference in findings
was that an underdiagnosis of lateral disk displace-
ments occurred in the earlier studies because of
different imaging techniques. In the study by
Khoury and Dolans, 6 lower joint space sagittal
projection arthrography was used. Studies, which
have tested the diagnostic accuracy of this tech-
nique by using cryosections as the morphologic
standard, have shown that one of the deficiencies of
Tasaki et aL 259
this technique rests in its inability to consistently
identify sideways displacements of the disk. 28 Du-
voisin et al.27 showed a higher prevalence of disk
displacements with a medial component when they
used dual joint space, sagittal and anteroposterior
arthrography with surgery as the morphologic stan-
dard. Surgical confirmation of imaging findings may
not be as precise as cryosectional observations
because surgery does not provide a cross-sectional
view of the joint. This may be an explanation for
the higher report of medial disk displacements by
Duvoisin et al. Another explanation for Duvoisin's
higher finding of medial displacements may be
different patient selection criteria for imaging than
in our study. In our study, symptom-free subjects
also had a higher prevalence of lateral disk dis-
placement, which lends support to our findings of a
greater prevalence of lateral disk position com-
pared with medial disk position in both patients
and symptom-free subjects.
In the previous magnetic resonance study by
Katzberg et al., 7 the coronal images were obtained
in the true coronal plane without correction for the
angulation of the condyle in the horizontal plane.
That means that the laterally displaced disk was
260 Tasaki et aL American Journal of Orthodontics and Dentofacial Orthopedics
March 1996

Fig. 10. Posterior disk displacement. A, Sagittal MR image shows disk (arrows) posterior to condyle.
B, Coronal MR image (same joint as A) shows no medial or lateral displacement of disk. C, Sagittal
cryosection (different joint than A-B) shows disk (arrows) posterior to condyle.

not depicted in the same image as the condyle that
could have lead to an underdiagnosis of lateral disk
displacements. The uncorrected coronal images
also have a tendency to show the medial part of the
disk in the same image as the condyle, possibly
leading to a false impression of medial displace-
ment. Thus a combination of underdiagnosis of
lateral disk displacement and an overdiagnosis of
medial disk displacements could explain the differ-
ence in imaging findings between our studies. An-
other possibility would be that in our study, the
higher signal to noise in the vicinity of the coil
laterally showed lateral disk displacements in
greater detail than medial disk displacements. This
theory of inaccuracy is contradicted by the findings
in a prior study on diagnostic accuracy of MRI
where an accuracy of more than 90% was docu-
mented. ~ It is therefore our strong belief that the
lateral component is a significant part of TMJ disk
displacement. Also note that the patients were
selected for MRI on the basis of physical examina-
tion findings. They do not represent a consecutive
series of patients with TMJ or a general group of
patients with TMDs.
There is extensive debate concerning treatment
and prognosis for patients with temporomandibular
joint disorders. Multiple treatment modalities are
often applied empirically to patients with these
symptoms. The classification of disk positions devel-
oped should serve as a precise guide to define pa-
tients! morphologic abnormalities, which should
serve as the basis for more precise treatment studies.
On the basis of the morphologic findings, 29 side-
ways disk displacement has been offered as the
probable explanation for peripheral neurologic
symptoms reported in the area of distribution of the
auriculotemporal nerve in patients who have symp-
toms of temporomandibular disk displacement. 3°
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 109, No. 3
Thus the classification system for TMJ disk displace-
ment should be used in clinical settings where disk
position is compared with patient symptoms.
The classification system should be valuable for
treatment studies as well. Past treatment studies
have indicated that medial disk displacement is
more difficult to treat with protrusive onlays than
pure anterior disk displacement? ~ Perhaps one
direction of disk displacement is highly amenable
to protrusive splint therapy, another may require
surgical intervention, whereas others may not re-
quire any treatment.
This study has developed a classification system
for disk displacements of the TMJ. A significantly
higher prevalence of disk displacement was seen in
patients as compared with symptom-free volunteers
and conversely a significantly higher prevalence of
superior disk position was observed in the symp-
tom-free volunteers as compared with the patients.
Anterior and lateral and pure anterior disk dis-
placements were observed more frequently than
any other displacement. This classification system
should be valuable for communication among cli-
nicians and between clinicians and researchers.
CONCLUSION
Different types of disk displacement was ob-
served unilaterally or bilaterally in 82% of the
patients and in 30% of the symptom-free volun-
teers. The significantly higher prevalence of disk
displacement in patients than in volunteers sug-
gests that disk displacement is associated with tem-
p o r o m a n d i b u l a r j o i n t p a i n a n d d y s f u n c t i o n b u t also
suggests that disk displacement can be asymptom-
atic. Disk displacement presents as a spectrum of
displacements in all directions with anterolateral
and anterior displacement being the most common.
This classification system developed covered the
different types of disk displacement seen in this
material and should form a reference base for
accurate and consistent communication among cli-
nicians and researchers.
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Reprint requests to:
Dr. Annika Isberg
Department of Oral and Maxillofacial Radiology
Ume~ University
S-901 87 Umeg
Sweden