Movements of the Temporomandibular Joint Disk

Luigi M. Gallo
The etiology of temporomandibular joint (TMJ) disorders, including osteoarthritis, is largely unexplained. TMJ disk integrity is crucial, as its failure appears to precede degeneration of the joint. During mandibular function, the TMJ disk undergoes displacements and deformations, generating strains and stresses. Dynamic stereometry, a combination of imaging and jaw tracking, yields a noninvasive, 3-dimensional, and dynamic representation of the relationship between the articular surfaces of the human TMJ. The aim of this study was to rene this method to depict also movement and deformation of the TMJ disk during jaw opening/closing. Data collected in 4 asymptomatic subjects (2 male and 2 female subjects, aged between 24 and 32 years) indicated large disk displacements and deformations that can load TMJ soft tissues during opening and closing of the jaw. Such displacements and deformations can trigger disk damage during dysfunctional loading and/or compromised state of TMJ tissues. These displacements and deformations can also be used for numerical joint modeling. (Semin Orthod 2012;18:92-98.) 2012 Elsevier Inc. All rights reserved.

he temporomandibular joint (TMJ) is one of the least understood joints in the human body, despite the fact that a large population is aficted with its disorders and signicant morbidity related to a number of TMJ disorders, which has an impact on the quality of life of such patients. Epidemiology reveals that approximately 30% of the population shows temporomandibular disorders (TMD) signs and symptoms,1, whereas only 3-4% of the population seeks treatment.2 The most common TMD conditions are masticatory pain, internal derangement (ie, an abnormal relationship between articular disk and condyle, which most commonly is disk displace-

Laboratory for Physiology and Biomechanics of the Masticatory System. Clinic of Masticatory Disorders, Removable Prosthodontics, Geriatric and Special Care Dentistry. Center of Dental Medicine. This work was supported by the standard nancial plan of the University of Zurich. The author thanks S. Erni, D. Gssi, and D. Dembski for data collection and analysis. Address correspondence to Luigi M. Gallo, PhD, Plattenstr 11, CH-8032 Zurich, Switzerland. E-mail: Luigi.Gallo@zzmk.uzh.ch 2012 Elsevier Inc. All rights reserved. 1073-8746/12/1801-0$30.00/0 doi:10.1053/j.sodo.2011.10.005

ment), and osteoarthritis (ie, cartilage destruction that eventually involves subchondral bone).3-6 TMD etiology is largely unexplained. Several extrinsic environmental as well as intrinsic biological factors have been implicated in precipitating and/or perpetuating TMD. The numerous risk factors described in the literature include age, gender, parafunctions (ie, repetitive nonfunctional oral behaviors), trauma, genetics, psychological factors, etc.7 In the investigations for the etiology of TMJ osteoarthritis, special attention has been paid to TMJ disk integrity since several animal studies have shown that damage, displacement, or removal of the disk can result in osteoarthritis.8-11 Indeed, the TMJ disk appears to redistribute stresses and provide lubrication in the joint.12,13 To explain TMJ disk failure, numerous studies on joint loading in animals and humans have been carried out. Mechanical wear and biological catabolic response due to abnormal loads are both thought to be responsible for TMJ disk breakdown. Experimentation on animals using implanted transducers has allowed researchers to observe the strains of TMJ soft tissue during mandibular

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function.14,15 Differences have been found between passive and active movements. Indeed, it was found that in spontaneous porcine mastication, the TMJ disk was elongated dorsoventrally in the balancing joint during compressive loading in the power stroke phase, possibly because of a Poisson effect. Furthermore, a stretching of the capsule was observed simultaneously to disk elongation, thus suggesting a maximal loading of disk and capsule, especially on the balancing side, during the power stroke phase. This information needs to be evaluated in context of the human TMJ function with its peculiar anatomy and kinematics, although several ndings, including the location of the instantaneous mandibular axis of rotation for spontaneous movements, appear to be similar.15,16 In vivo studies on humans have largely analyzed the dynamic 3D relationship between the articular surfaces during function by means of dynamic stereometry.16,17 Finite element (FEM) analyses of disk strains and stresses also have been performed for small mandibular movements.17-23 On the basis of such data, indirect information on TMJ disk compression and plowing has been derived for different various mandibular activities, including mastication. Plowing effects are initiated by the movement of the condyle as it is pressed and simultaneously displaced tangentially to the poroviscoelastic disk cartilage. This generates a sort of moving wave in the disk tissue and a resulting shear stress. Figure 1 shows an example of the path of a stress-eld centroid during jaw opening/closing and an example of the magnitude of the velocity vector of the stress-eld centroid.25,26 Other numerical studies also have predicted strains in the soft tissues of models of human TMJ anatomy.27-29 Findings of this study agree with the plowing effects demonstrated previously in vivo and indicate a large inter- and intraindividual variability of tensile stresses during various stages of mandibular movement. The articular disk of the TMJ appears to be locally as well as globally deformed and loaded during function. Overloading might alter the disks mechanical properties, by modifying stress distribution and lubrication, thus increasing the likelihood of tissue failure.30,31 Indeed, recent investigations have shown that energy density in the disk appears to be locally increased in subjects with internal derangement.32 To date, how-

ever, it is not yet known how the overloading timing pattern must look to initiate or precipitate disk failure. Deformation and movement of the human TMJ disk have been observed by static and dynamic magnetic resonance imaging (MRI) technique.33,34 Dynamic MRI has permitted the capture of quasi-spontaneous disk movements, but this has been possible only in a single sagittal plane, at a low geometrical resolution and low frame rate. Furthermore, during jaw opening/ closing, the section of disk tissue imaged is shifted mediolaterally because of the angle between the condylar main axis and the sagittal direction.35 To date, MR scanners still do not allow accurate direct measurements of the whole joint anatomy in real time. At present, one feasible method to obtain more precise measurement of TMJ disk movement and deformation is to lock it at different positions of a given movement and take static scans for each step. The scans are then reconstructed 3-dimensionally and visualized sequentially. In this study, we therefore present and discuss a method to visualize TMJ disk deformation during jaw opening/ closing by sequencing 3D-reconstructed MR scans statically recorded at different positions.

Methods
For the acquisition of the spontaneous motion of the TMJ, we used an optoelectronic tracker.36 This system measures jaw motion relative to the head and calculates the 3D trajectory of any mandibular point of interest. During a jaw opening/closing cycle, we visualized the trajectory of the origin of the mandibular coordinate system and chose 12 positions on this trajectory at which we xed the jaw. For this purpose, 2 female and 2 male subjects (aged 24-32 years), free of signs and symptoms of TMD according to research diagnostic criteria for TMD (RDC/ TMD), bit on customized keys made of acrylic tooth impressions glued to plastic blocks of different thickness. The subjects gave informed consent for this study. The anatomy of the TMJ bony and disk structures in the different jaw positions was obtained by recording a series of 14 magnetic resonance parasagittal slices through the TMJ using a 1.5-T scanner and 12-cm surface coils. The scan protocol was a proton density-weighted turbo

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lateral

dorsal

path of minimum intraarticular distance

medial

ventral
(A)
80 70 60 50 velocity [mm/s] 40 30 20 10 0 0 -10 -20 2 4 6 8 10

velocity [mm/s]

open/close cycles
tim e [s]

(B)

Figure 1. (A) Path of stress-eld centroid (top view) during jaw opening/closing (trace in red, condyle-fossa distance mapped in pseudocolors on the condylar surface).16,22,23,24 A mediolateral translation occurs through the disk tissue. (B) Example of velocity prole of the stress-eld centroid of one joint during 5 open/close cycles at 0.5-Hz pace. The magnitude of the velocity vector of the center of the stress eld is shown in blue. The open/close cycle is indicated in purple: a value of 0 mm indicates the closed position, and a minimal negative value (about 13 mm) indicates maximum opening. (Color version of gure is available online.)

spin-echo sequence with a TR of 2300 ms and TE of 15 ms. A eld of view of 130 mm and a scan resolution of 256 pixels yielded an image resolution of 0.5 mm. The slice thickness was 2 mm. Scan time for both joints (left and right sides) was around 4 minutes. Before recording each series of TMJ sections, a new key had to be

placed between the subjects teeth so that every time the subjects head was slightly displaced. Therefore, the cranial structures were never perfectly coincident at each recording. For the 3D reconstruction of the MR images, we used a self-developed interactive contour editor and rendering program implemented on a

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graphic workstation.37,38 To precisely superimpose the fossa surfaces, we used a special numerical method called trimmed iterative closest point algorithm, which searched the closest distance between each point of one object and the other object.39 The resulting distances were sorted by size, and the smallest 70-90% was used for further calculation, depending on the possible overlap of the objects. The optimal relative displacement of the objects was then computed by using the unit quaternion method.40 For check purposes, this animation was overlaid and compared with a standard animation (without disk) obtained by moving only the condyle with the data obtained from jaw tracking. The reconstructed models of the same TMJ in the different jaw opening stages were positioned so that all fossae were best superimposed to the fossa of the reconstructed TMJ in central occlusion. The sequential visualization of the differ-

ent TMJ models resulted in an animation of condyle and disk.

Results
The single models of condyle and fossa in the 12 recorded positions were registered relative to a standard opening/closing recording sequence. The mean translations of the 12 single models from the positions of a standard opening/closing animation was 0.5 mm, and the mean rotations were 3. Head repositioning caused a mean translation of 1 mm and a mean rotation of 1. The reconstructed joints, including the movement and the deformation of the disk, are visible in Figure 2. The condylar movement in the sequence coincides with the positions of the condyle obtained by animating it with jaw tracking information. The small images show the corre-

Figure 2. Movement and deformation of the TMJ disk for 9 selected positions during a jaw opening phase. Oblique lateral view. (Color version of gure is available online.)

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sponding MR scans on the medial slice. During the jaw opening sequence, the disk slid along the dorsal slope of the eminence until it was situated caudally to the tuberculum. At the beginning of the sequence, the condyle was located underneath the dorsal part of the disk, whereas during the progression of the opening, it slid more ventrally relative to the diskal tissue. In the MR scans on the medial slice, a better disk denition along the progression of jaw opening could be observed. An example of movement and deformation of the disk is shown in Figure 3. On the left side of Figure 3, the single disk positions are displayed all together at their natural location. The translation and rotation along the fossa are clearly visible from this top view. The right side of Figure 3 shows the disk at the same time points after individual rotations around its main axis, so that the reconstructed disks are all in the same plane. The deformationthe disk changes from a convex shape to a atter shapein the mediolateral direction is clearly visible. The deformation the disk changes more pronouncedly to a biconcave shapein the dorsoventral direction is visible in Figure 2.

Discussion
The method presented in this study gives a good visual impression of TMJ disk movement in 3D.

From the motion sequences, it is evident that during function asymptomatic TMJ disks undergo dorsoventrally large displacements and deformations that need to be considered in FEM analyses, when investigating TMJ disk loading. Deformations in the mediolateral direction as well as changes in convexity/concavity were visible during jaw opening/closing. Furthermore, a moderate mediolateral shift of the disk appeared to occur that suggested capsular loading, and this has been demonstrated by another study as well.14 The viscoelastic properties of the disk are excluded during static image acquisition of the TMJ in different positions for opening and closing movement reconstruction. Because of the very small size of the TMJ, the segmentation had to be performed manually by B-spline curves to achieve a better resolution than 1 pixel. Thus, in the future, we need to consider subpixel interpolations in developing more rened manual and automated segmentation criteria and algorithms. Also, the use of a reference system attached to the upper jaw and scanned simultaneously to the TMJ could improve the accuracy in joint repositioning. A limitation, typical of imaging methods, is the amount of subjectivity in anatomical segmentation, especially in the delineation of the ventral and dorsal borders of the disk. This is an issue even with sophisticated image processing software. Plausibility criteria, such as iterative

Figure 3. Movement and deformation of the TMJ disk. Four selected positions during a jaw opening phase (in the sequence green, blue, red, and yellow) at the disks natural sequential locations (left) and aligned to show its deformation (right). Top view. (Color version of gure is available online.)

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checking of disk volume, could improve the accuracy of the method. Furthermore, the method presented here is primarily suited for symmetric movements, such as jaw opening/closing and protrusion, whereas masticatory movements still appear to be too complex to be replicated by a set of clutches. Indirect assessment of disk deformation by estimation of joint space is the most reliable method, if quantitative measurements are required. This is true for both static and dynamic loading, for example, in masticatory cycles, where disk compression can be estimated with high accuracy.17 As a matter of fact, this approach provides a realistic estimate of how the disk is deformed mediolaterally, since TMJ disks appear to be less mobile in this direction, provided their ligaments are intact (Fig. 3 left). Therefore, comparisons of disk compression between the medial and lateral areas of the disk17 as well as the determination of the mediolateral component of plowing effects (Fig. 1) appear to yield reliable results.22,23,24 These changes of disk shape and variation of disk compression in the mediolateral direction have been demonstrated not only for stress-eld translation but also when studying the biomechanical effect of occlusal splints, as well as investigating disk loading patterns depending on TMJ morphology in asymptomatic TMJs and joint with internal derangements.35,41 In conclusion, dynamic visualization of TMJ soft tissue motion and deformation in vivo in humans is still a challenging topic requiring sophisticated technology and technical skills. FEM analysis for the study of TMJ disk loading needs further development, especially with regard to large deformations and modeling of viscoelastic effects.

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