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CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

MR Abnormalities of the Lateral Pterygoid Muscle


in Patients with Nonreducing Disk Displacement of
the TMJ

Xiaojiang Yang D.D.S., Hannu Pernu D.D.S., M.D., Juhani Pyhtinen M.D., Ph.D.,
Petri A. Tiilikainen D.D.S., Kyösti S. Oikarinen D.D.S., Ph.D. & Aune M. Raustia
D.D.S., Ph.D.

To cite this article: Xiaojiang Yang D.D.S., Hannu Pernu D.D.S., M.D., Juhani Pyhtinen M.D.,
Ph.D., Petri A. Tiilikainen D.D.S., Kyösti S. Oikarinen D.D.S., Ph.D. & Aune M. Raustia D.D.S., Ph.D.
(2002) MR Abnormalities of the Lateral Pterygoid Muscle in Patients with Nonreducing Disk
Displacement of the TMJ, CRANIO®, 20:3, 209-221, DOI: 10.1080/08869634.2002.11746213

To link to this article: http://dx.doi.org/10.1080/08869634.2002.11746213

Published online: 13 Jul 2016.

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Download by: [Cornell University Library] Date: 22 September 2016, At: 19:59
• RADIOLOGY

MR Abnormalities of the Lateral Pterygoid Muscle


in Patients with Nonreducing Disk Displacement of
theTMJ
Xiaojiang Yang, D.D.S.; Hannu Pernu, D.D.S., M.D.; Juhani Pyhtinen, M.D., Ph.D.;
Petri A. Tiilikainen, D.D.S.; Kyôsti S. Oikarinen, D.D.S., Ph.D.; Aune M.
Raustia, D.D.S., Ph.D.

ABSTRACT: The aim of this study was to investigate the pathological changes of the lateral pterygoid
muscle (LPM) using magnetic resonance imaging (MAl) in patients with anterior disk displacement with
0886-9634/2003-
209$05.00/0, THE nonreduction (ADDnr) of the temporomandibular joint (TMJ) and to compare the abnormal findings of
JOURNAL OF the LPM with the clinical symptoms and other pathological MAl alterations of the TMJ. Bilateral or uni-
CRANIOMANDIBULAR
PRACTICE, lateral ADDnr was demonstrated in 142 patients by MAl (176 TMJs; 106 females; 36 males; range 19 to
Copyright © 2002 72 years; mean 43.9 years). ln 123 TMJs, the LPMs were clear1y observed in MAls and analyzed in this
by CHROMA, lnc.
study. Pathological changes of the LPM were found in 92 TMJs (74.8%) in MAl. Hypertrophy, atrophy
and/or contracture were detected in the superior belly of the LPM (SBLPM) (35.8%, 44/123) or in the
Manuscript received
June 22, 2001; revised inferior belly of the LPM (IBLPM) (9.8%, 12/123) or in both bellies (29.3%, 36/123). The pathological
manuscript received changes of the LPM in MAl presented a significant association with the main clinical symptoms of TMJs
October 9, 2001; accepted
January 8, 2002 with ADDnr, i.e. pain on jaw movement (P<0.01 ), pain in the LPM (P<0.01 ), pain in TMJ (P<0.05) and
Address for reprint requests: restricted jaw opening (P<0.05). The proportion of the abnormalities in LPM was significantly lower in
Dr. Xiaojiang Yang TMJs with condylar limitation (63.6%) than in TMJs with condylar hypermobility (83.3%) and normal
Dept. of Prosthodontic Dentistry
and Stomatognathic Physiology motion (88.9%)(P=0.008). Osteoarthritis was found to be correlated with condylar limitation (P<0.01).
lnstitute of Dentistry The results of this study indicate that the pathological changes of the LPM in TMJs with ADDnr cou Id be
University of Oulu
Box 5281 detected by MAl and have a significant association with the main clinical symptoms of the patients.
90014 University of Oulu When condylar limitation happened, on the contrary, the pathological changes of the LPM in MAl were
Fin land
e-mail: Xiaojiang.yang@oulu.fi reduced. The alteration of the clinical symptoms in the patients with ADDnr might be associated with the
pathological situations and symptoms of the LPM.

nterior disk displacement with nonreduction

A (ADDnr) is a severe internai derangement of the


temporomandibular joint (TMJ). 1 Clinical stud-
ies have reported that ADDnr could be related to jaw lim-
itation, TMJ locking, disk deformities, osteoarthritic
Dr. Xiaojiang Yang received his D.D.S. changes in the TMJ, and the painful symptoms of the
degree from the West China University of patients. 2· 5
Medical Science in 1985 and his Master's
degree as a specialist in maxil/ofacial Many treatment methods are suggested for manage-
surgery from the Chine se General ment of ADDnr, such as occlusal appliances, 6 muscle
Military Postgraduate lmtitute in 1990. ln exercising,7 injection of sodium hyaluronate, 8 arthrocen-
1991 he was a visiting scholar at the
Departmellt of Maxillofacial Surgery tesis, 9 and surgery . 10 Sorne reports fi nd that considerable
Leuven University Hospital, Belgium. improvement of the clinical symptoms of patients with
Currelltly, Dr. Yang is a researcher at the ADDnr can be achieved after conservative or surgical
Jnstitute of Delltistry. Oulu University,
Fin/and. treatment, even though disk displacement and combined
disk deformities as weil as osteoarthritis persist. 8•10 Other
authors suggest that clinical symptoms, especially pain-
fui ones, of the patients with ADDnr can be eased even
without treatment. 11 • 12 The explanations for this are
unclear. 12

209
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Abnormal fonction of the lateral pterygoid muscle superior belly of the LPM (SBLPM) runs posteriorly
(LPM) has been found using electromyography (EMG) in from its origin in an inferior and lateral direction to the
patients with temporomandibular joint disorders (TMD) 13 crest of the eminence where its fibers become more
and bas also been observed to be associated with pain horizontal and insert into the condyle or disk. The inferior
symptoms in TMJ. 14 A few studies report that the normal bell y of the LPM (IBLPM) runs posteriori y and laterally
morphology and pathological changes of the masticatory to the insertion into the pterygoid fovea. The normal
muscles, 15 -16 including the LPM, 17 - 19 can be detected by structure of the LPM in oblique sagittal MRI is consid-
magnetic resonance image (MRI). lt is suggested that ered a fan-like muscle from the origins of the two bellies
pathological findings and the structural changes of the to the neck of the mandibular condyle or the disk. On
LPM in MRI might be associated with TMD symp- either Tl-weighted or PD images, a high signal layer of
toms;17-19 however, there are no reports on the pathologi- fat tissue could separate the SBLPM from the IBLPM.
cal changes of the LPM in MRI in patients with ADDnr The signal of normal muscle tissue was isointense on ali
or a correlation between abnormal LPM findings in MRI MRI sequences. 17-18 In closed mouth position, the upper
and the clinical symptoms of ADDnr. and lower edges of the two bellies of the LPM are
The aim of this study was to investigate the pathologi- weil identified.
cal changes of the LPM using MRI in patients with Enlargement and increased size of muscles on ali MRI
ADDnr and to analyze abnormal MRI findings of the sequences were considered a sign of hypertrophy of the
LPM by comparing them with clinical symptoms and skeletal muscles.I7. 21 -22 Hypertrophy of the LPM mani-
other MRI alterations of the TMJ. fested as an obvious enlargement in the middle part ofthe
belly, because the two ends of the belly connected with
Materials and Methods bony tissues. The hypertrophie bell y of the LPM showed
that the upper and lower edges of the bell y changed into
For this retrospective study, bilateral or unilateral convex curves. Contracture of the LPM presented as the
ADDnr was diagnosed in 142 patients using MRI (176 size of the muscles increased, and at the same time, fibro-
TMJ s; 106 females; 36 males; range 19 to 72 years; mean sis was found as low signais in the muscles on PD and
43.9 years). The cases were selected from a total of 325 T2-weighted images. 17 -23 Atrophy of the LPM was char-
patients examined by MRI because of TMJ problems acterized by fatty replacement with high signais appear-
(1991-2001). The patients had been originally referred to ing in large areas in the muscles on short and long
the Oral and Maxillofacial Surgery Department of Oulu TRIshort TE images with nonincreased or reduced size of
University Central Hospital for diagnostic examination the LPM. 17 Diagnosis was made when the same patholog-
and treatment of TMJ dysfonction. Clinical symptoms ical finding was shown clearly on at least two slices of
included occasional TMJ clicking, TMJ locking, restricted the image.
movement of the jaw, progressing or constant pain in the Out of the 176 TMJs in this study, the LPM was not
TMJ, jaw movement pain, palpation and/or provocation clearly distinguishable and only one belly could be
pain in the lateral pterygoid muscle (LPM) and other observed on the MR images in 53 TMJs. These images
masticatory muscles. The history ofTMD and the clinical could not be used for evaluation of pathological changes
symptoms of the patient were recorded. of the LPM (Figure 1, A and B). The condition of the
Prior to 1996 the studies were performed with a 1.0-T LPM in 123 TMJs was analyzed in this study.
magnet (Magnetom, Siemens), and after 1996, with a 1.5- Disk position, disk morphology, condyle osteoarthritic
T magnet (Signa, GE.) Tl-weighted (200-400112-2011,2) changes, condyle mobility, and effusion of the TMJ were
(TR range/TE range/excitations), T2-weighted (2000- also evaluated in MRI.
3000/80-200/1) and Proton Density (PD) (2000-3000114- Disk position was diagnosed according to Katzberg, et
30/1), with nine 3-mm-thick imaging slices, a IOXIO al. 1 Normal disk position was defined as the posterior
field of view (FOY) and a 256Xl92-256 or l28Xl28 (in band of the disk being located at the superior or twelve
1.0-T) matrix were used for the images. o'clock position relative to the condyle. If the displaced
Ali the patients underwent bilateral MRI examinations disk remained in an anterior position of the condyle in the
of the TMJ with TMJ surface-coil. Oblique sagittal, maximal mouth open position, it was demonstrated as
direct sagittal, and coronal projections were used in anterior disk displacement with nonreduction (ADDnr) .
closed mouth position. In maximally open mouth posi- The morphology of the disk was assessed using the
tion, only proton density (PD) oblique sagittal or T 1- biconcave shape as the normal point of reference. Disk
weighted direct sagittal images were taken. deformity was defined when folded, thickening changes
According to the anatomie study of Wilkinson, 2o the in ali parts of the disk, convex, or posterior band en large-

210 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERVGOID MUSCLE

Figure lA and B
These images could not be used for evaluation of pathological changes of the LPM: A (above left). Folded disk with posterior band enlargement (D)
and erosion of the condyle (C) show clearly in the oblique sagittal closed mouth TMJ image, but both bellies of the lateral pterygoid muscle (LPM)
are not observed; B (above right). Only the superior belly of the LPM (SB) can is observed. (D=disk; C=condyle).

ment of the disk were found in the images.2.4.8 Benito, et al. 5 and the standards of Boering, applied by
According to Westesson,3 the diagnosis of osteoarthri- Dijkstra, et al. 24
tis was made when one or more of the following signs According to Schellhas,25 effusion of the TMJ defined
were present on the condyle: flattening, osteophytes, ero- as a high fluid signal was found in T2-weighted MR
sions and sclerosis. images. Effusion might be detected either in compart-
Condylar mobility was classified as hypomobility ments of TMJ or in the bilaminar zone of the disk, or
(limitation), normal mobility and hypermobility by MRI both.
findings. For this procedure, a horizontal tangential Iine Statistical analysis of the data was performed using
of the top of the articular fossa and a verticalline through SPSS 10.0 (SPSS, Inc., Chicago, IL) including Pearson
the top of articular eminence were made on sagittal or Chi-square test and Fisher's exact test.
oblique sagittal image of TMJ. Two !ines met in point
"0". From the point "0", the articular eminence was Results
divided by angles into three parts: oo -90°, 90°-120°, and
120°-180°. The top of the articular fossa was at oo and the In MRI of 123 TMJs with ADDnr, pathological changes
top of the articular eminence was at 90° (Figure 2). The of the LPM were found in 92 TMJs (74.8%). Pathological
diagnosis of condylar mobility was made by measuring changes found in the su peri or bell y of the LPM (SBLPM)
the location of the top of the condyle in maximal mouth- (35.8%, 44/123) and in both bellies (29.3%, 36/123) were
open images. Hypomobility or limitation of the condyle more frequently observed in this study. Abnormalities
was diagnosed if the top of the condyle was located in 0°- only conceming the inferior bell y of the LPM (IBLPM)
900 (<90°). In this region, the condyle did not translate or were relatively rare (9.8%, 12/123). Atrophy (Figure 3)
translated only slightly (<30°), or translated but did not hypertrophy (Figures 4-7), and contracture (Figures 8
reach the top of the eminence (<90°) (Figure 2A). If the and 9) of the LPM were observed. Among these findings,
top of the condyle was located in 90°-120° of the hypertrophy and atrophy of the muscle were seen more
eminence, the mobility of the condyle was considered to often (Table 1). In 31 TMJs with ADDnr, the LPM
be normal (Figure 2B). When the condyle translated showed as normal in MRls (Figures 10-12).
excessive! y, beyond and su peri or to the leve! of the artic- Pain in the TMJ (56.9%, 70/123), pain in the LPM
ular eminence (>120°) (moved more than 30° from the (60.1 %, 74/123), TMJ locking (52.8%, 62/123), and
top of the eminence), hypermobility of the condyle could restricted mouth opening (54.5%, 67/123) were found as
be defined (Figure 2C). This measurement was per- the main clinical symptoms of the TMJs with ADDnr in
formed according to the princip les of the standards of this study. Nearly half of the joints had pain on jaw

JULY 2002, VOL 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 211
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Figure3
Atrophy of the su peri or bell y of the LPM is seen in a 25-year-old
female who received orthodontie treatment during the past two years.
Before orthodontie treatment she complained of slight occasional
clicking in the left TMJ. Pain on jaw movement, opening difficulties,
and facial pain on the left appeared after the orthodontie treatment was
completed. The symptoms did not improve after two months of splint
use. Pain fui loc king and severe pain on palpation of the LPM were
detected on the left side. There were no symptoms on the right side. In
a closed mouth, oblique sagittal image of the left TMJ (3000/14, 1.5-T
magnet), atrophy of the superior bell y of the LPM with a large area of
high signal fatty replacement (open arrow) is seen. The inferior belly
is normal (ffi). There is anterior disk displacement (D) and osteophyte
of the condyle (C). The displaced disk cannot reduce in the open
mouth image (not shown here).

movement (48.0%, 59/123) and pain concerning other


masticatory muscles (48.0%, 59/123). Occasional click-
ing was complained of and detected in 41 patients (33.3%,
41/123) (Table 2). The results in Table 2 indicate that the
pathological changes of the LPM found in MRI bad a sig-
nificant association with pain in the LPM (P<O.Ol), pain
on jaw movements (P<0.01), pain in TMJ (P<0.05) and
restricted jaw opening (P<0.05).
The pathological findings on MRI of the 123 TMJs are
presented in Table 3. Condylar osteoarthritic changes
- (55.3%, 68/123), limitation of condylar mobility (53.7%,
c 66/123), and TMJ effusion (57.7%, 71/123) were found
Figure 2, A, B, and C
Classifications of condylar mobility: a horizontal tangentialline on
as main MR imaging abnormalities in the joints with
top of the articular fossa and a vertical li ne through the top of the ADDnr. Disk deformities were observed in 39 TMJs
articular eminence are made on a sagittal or oblique sagittal image (31. 7% ). The pathological changes of the LPM in MRI
of the TMJ. The two li nes meet at point "0". From point "0", angles
were drawn todi vide the articular eminence into three parts: 0°-90°,
showed a high significant association with condyle
90°-120°, and> 120°. The top of the articular fossa (TF) is at oo mobility (P=0.008). The proportion of the pathological
and the top of the articular eminence (TE) on 90°. A (above top): findings ofthe LPM was significantly lower in the TMJs
Hypomobility (limitation) of the condyle: in maximal open mouth
images, the top of the condyle (TC) is located in the 0°-90° (<90°).
with ADDnr in the condylar limitation group (63.6%)
B. Normal mobility of the condyle: the top of the condyle located than in the condylar hypermobility group (83.3%) and the
at 90°-120° of the eminence in maximal mouth opening. C. Hyper- condylar normal motion group (88.9% ). The pathological
mobility of the condyle: the condyle translates excessively, beyond
and su peri or to the lev el of the articular eminence (> 120°) in the
changes of the LPM in MRI showed no significant asso-
images of mouth maximal opening. ciation with other MRI findings (P>0.05)

212 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERYGOID MUSCLE

Figure 4 (A and B)
Hypertrophy of the superior bell y of the LMP shows in images of a 40-year-old male who has experienced chronic facial pain, jaw movement pain,
and TMJ pain on the left side for nine years and whose symptoms were relieved after splint treatment. Pain and restricted mandibular movement
recurred after three months. Pain of the left LPM and loc king were observed. Palpation pain of the temporal muscles was found on both sides.
Anterior disk displacement without reduction was found in the left TMJ using MRI. The disk position and movement were normal on the right side.
A. Closed mouth image (oblique sagittal, 3000/14, 1.5T, 3 mm thick) of the Ieft TMJ, hypertrophy of the superior belly of the LPM is suggested
based on the enlarged size of the bell y (open arrow) (compare to image B above right). Osteoarthritic changes to the condyle (C) were observed
(ffi= inferior bell y of the LPM). B. The LPM image is normal in the closed mouth image of the right TMJ (oblique sagittal, 3000/14, 1.5T, 3 mm
thick). The superior bell y (open arrow) and the inferior bell y (lB) of the LPM appear normal (C=condyle)

As an etiological analysis for condylar limitation, the Discussion


relationships among condyle mobility and other MRI
findings are summarized in Table 4. The osteoarthritic Excessive work and overloading of the skeletal
changes of the condyle were found to be significantly muscles have been reported to be important factors caus-
associated with the limitation of the condyle in TMJs ing hypertrophy of the muscles. Atrophy and contracture
with ADDnr (P=0.004). of the muscles are considered secondary changes of

Figure 5 (A and B)
Hypertrophy of the superior belly of the LMP of the Ieft TMJ shows in the closed mouth image (oblique sagittal, 3000/15, 3 mm thick, 1.5T) of a 20-
year-old male who complained of facial pain, TMJ pain, and jaw movement pain on the left side with mouth opening difficulty for six months. The
pain symptoms improved after two months of splint treatment. Palpation pain of the LPM and the masseter muscle was detected on the left si de. The
mandible deviated to the Ieft during mouth opening. Restricted movement without pain was found in the right TMJ. Anterior disk displacement
without reduction was demonstrated in both left and right TMJs on MRI. A. Closed mouth image of the left TMJ shows thal hypertrophy of the
inferior belly of the LPM increased in the middle part of the bell y (lB) (compare to image B). The superior bell y appears normal. The disk is anteri-
orly displaced (D). (C=condyle). B. The closed mouth image of the right TMJ reveals a normal LPM. Note the thickening disk is anteriorly displaced
(D). (IB=inferior belly of the LPM)

JULY 2002, VOL. 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 213
MAl STUDV OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Figure 6 (A and B)
Hypertrophy of the two bellies of the LPM was found in a 41-year-old female with long-term chronic pain of both TMJs, and who had suffered
subluxation three months earlier and then continuous pain of the left TMJ. Movement pain, pain on palpation of the left TMJ and masticatory mus-
cles (temporal muscle and LPM) were found on the left side. The mandible deviated to the left during mouth opening. Anterior disk displacement
without reduction was noted in both TMJs on MRI. A. The closed mouth image of the left TMJ (oblique sagittal, 3000/20) shows hypertrophy of the
superior bell y and inferior bell y of the LPM by the increased size of the bellies (compare with the bellies of the LPM on the right side in image B).
The edges of the bellies become convex curves (open arrows). The disk shows changes in thickness (D) and is anteriorly dislocated. (C=medial pole
of the condyle). B. Image of the closed mouth righi TMJ (above righi) (oblique sagittal, 3000/20). The superior belly and inferior bell y of the LPM is
normal (C=condyle).

long-tenn muscle stretching and work overload.22 and control the angular relationship between the disk and
Pathological changes of the LPM may occur if abnor- the condyle. The IBLPM pulls the condyle forward in
mal overloading exists in its functional procedures. The mouth opening. 13 •26 In a TMJ with ADDnr, the perma-
function of the LPM is not totally clear; however, EMG nently dislocated disk might cause disturbances in jaw
studies of the LPM have shown that the SBLPM behaves functional movements. Disk rotating, 4 disk flexure2 and
like a jaw-closing muscle and shows characteristic activ- disk compressing 27 might occur. Restricted jaw move-
ity in relation to the bi ting force. The function of SBLPM ment might also appear. 4 Under these conditions, the rela-
might be to stabilize the condyle against the biting force tionship between the disk and the condyle is unstable and

Figure 7 (A and B)
Atrophy of the su peri or belly and hypertrophy of the inferior bell y of the LMP observed in the righi TMJ of a 40-year-old female with recurring
pain in the TJM, movement pain on the righi side for five years, head and neck pain, and painfullocking. A. Closed mouth (oblique sagittal, PD
image, 3000/20, 3 mm thick) of the righi TMJ shows atrophy, fatty replacement in the superior bell y of the LMP (curved arrow), and hypertrophy
of the inferior bell y (ffi). The disk is anteriorly displaced (D). B. T2-weighted image (3000/127, 3 mm thick) of the same TMJ as in image A, the
high signal of fatty replacement atrophy of the superior bell y (curved arrow) shows strong contraction with the isointense hypertrophie inferior
belly (lB).

214 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERYGOID MUSCLE

Figure 8 (A, 8, C and D)


Contracture of the superior bell y of the LPM is suspected in a 35-year-old female with occasional clicking and chronic pain of the right TMJ for four
years and pain upon jaw movement on the right side for nine months. Symptoms did not improve after splint use and muscle exercise treatment.
Severe pain on palpation of the lateral pterygoid muscle (LPM) was found on the right side and clicking with no pain on the left side. On MRis
anterior disk displacements were found on both sides. A displaced disk with reduction was observed on the left TMJ and a nonreducing on the right
side. A. The normal LPM shown in closed mouth, oblique sagittal, proton dense (PD) image of the left TMJ (3000/14, 1.5-T magnet). A high signal
layer of fatty tissue (open arrow) separates the superior bell y (SB) from the inferior bell y of the LPM (18). The upper and lower edges of the two
bellies of the LPM are quite plain. The disk is anteriorly displaced (small arrow). (C=condyle). B. ln a T2-weighted (3000/125, 1.5-T magnet)
closed mouth oblique sagittal image of the left TMJ, the normal LPM shows isotense signais in either PD or T2-weighted images (compare with
image A). The high signal fatty tissue layer between the two bellies of the LPM is more clearly observed (curved arrow). (C=condyle; IB=inferior
belly of the LPM). C. Contracture of the su peri or bell y of the LPM is seen in the closed mouth, oblique sagittal, proton dense image of the right
TMJ (3000/14, 1.5-T magnet). Fatty replacement and fibrosis are found in the superior bell y (arrow). The size of the superior bell y on the right side
is larger than the left superior belly (compared with image A). Anterior disk displacement can be seen (D). D.ln a T2-weighted (30001125, 1.5-T
magnet) image of mouth closed oblique sagittal image of the right TMJ, fatty replacement and fibrosis in the superior belly of the LPM are evident
(arrow). (C=condyle; IB=inferior belly of the LPM).

might lead to overloading on the SBLPM. The SBLPM by the increased obstruction of the non-reducing disk in
has to work excessively to keep the disk stable. In this the condylar forward movement. On the other hand,
study, the restricted movement of the jaw showed a close according to an EMG study by Lafreniere, et al. 13 the
association with the imaging abnormalities of LPM abnormal function and alterations of the IBLPM might be
(P=O.O 14 )(Table 2). Grunert, et al. 28 observed evident considered as a secondary change of the SBLPM. In their
hypertrophy of the SBLPM in an autopsy study. In his report, excessive work of the IBLPM was found when the
report, chronic overloading was also discussed as a possi- SBLPM seemed to have !ost its function. 13 Under this
ble cause of the hypertrophy of the SBLPM. 28 The condition, pathological changes should have occurred in
pathological changes of the IBLPM might be also caused two bellies of the LPM. Pathological changes conceming

JULY 2002, VOL. 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 215
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Figure 9 (A and 8)
Contracture and atrophy of the LMP in a 46-year-old female with a long history of chronic facial pain, pain upon movement on both sides, and
occasionallocking of the left TMJ. Anteri or disk displacement without reduction was found in the left TMJ on MRI. A. In a closed mouth, oblique
sagittal image of the left TMJ (3000/14, 3 mm thick), atrophy of the superior belly of the LPM shows as a high signal fatty replacement (curved
arrow). The contracture of the inferior belly shows fibrosis with lower signais (open arrow). The thickened disk is anteriorly displaced
(D).(C=condyle) B. In a T2-weighted image (3000/125, 3 mm thick) of the TMJ shown in image A, the fatty replacement of the superior belly of the
LPM (curved arrow) and the contracture of the inferior belly with lower signal fibrosis (open arrow) are more clearly shown. Effusion of the bilami-
nar zone (arrow head) is suspected. (C=mandibular condyle).

the two bellies of the LPM were found in 29.3% (36/123)


of the TMJs with ADDnr in this study (Table 1) (Figures
6, 7, and 9). The relationships between the pathological
changes in the SBLPM and in the IBLPM, and the rela-
Table 1 tionships among the hypertrophy, atrophy, and contrac-
Lateral Pterygoid Muscle (LPM) Findings on ture of the LPM are expected to be discussed in further
MRI in 123 TMJs of Patients with Anterior Disk studies by combining the different stages of TMD and
Displacement Without Reduction more clinical information.
LPM findings on MRI N=23 (100%)
The results of this study indicate that the pathological
SB abnormal 44 {35.8%)
changes of the LPM in MRI are significantly associated
Atrophy 19
Hypertrophy 18 with pain symptoms in the LPM, pain in TMJ, pain on
Contracture 7 jaw movement, and jaw restriction in the patients with
ADDnr (Table 2). This indicates that the patients with
IBabnormal 12 {9.7"/o) ADDnr might complain of these symptoms when patho-
Hypertrophy 7
logical changes in the LPM happen.
Contracture 5
In an anatomical study, Schmidt, et al. 29 observed that
Abnormalities ln both bellies 36 {29.3%) the single trunk of the auriculotemporal nerve was evi-
Hypertrophy (both) 13 dent along the medial aspect of the condylar neck and
SB atrophy w/IB hypertrophy 11 was in direct contact with the condylar neck at the poste-
SB atrophy w/IB contracture 8
SB contracture w/IB hypertrophy 4
rior border of the LPM. The anteriorly dislocated disk
and displaced capsular tissue were considered to produce
LPM normal 31 {25.2%) nerve irritation and to cause painful symptoms. In addi-
LPM: lateral pterygoid muscle tion, the au thors proposed that hypertrophy of the LPM
TMJ: temporomandibular joint might also lead to entrapment or compression of the
SB: superior belly of the LPM nerve. However, hypertrophy of the LPM was only
lB: inferior belly of the LPM
expected but not proven in their study. 29 In this study,
hypertrophy of the LPM was observed in TMJ with
ADDnr in MRI (Figures 4-7). As mentioned by sorne

216 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERVGOID MUSCLE

Figure 10 (A and B)
Normal LPM image found in a 35-year-old male with painfullocking, crepitation and movement pain in the right TMJ, palpation pain of the LPM,
and head/neck pain on both sides for three years. Painful symptoms showed clearly discernable improvement after splint use and physical therapy;
however, the limitation of mouth opening became worse in five months. He had no pain on palpation of the LPM or pain upon movement in either
TMJ. There was slight pain upon palpation of the right TMJ. Mouth opening was only 20 mm. No symptoms were found on the left side and the left
TMJ is normal on MRI. A. A closed mouth oblique sagittal PD image (3000/20, 3 mm thick) of the right TMJ shows severe erosion of the condyle
(C). The disk has thinned (white arrow). The LPM is normal. B. Maximized mouth open sagittal image (400/12, 3 mm thick) of the right TMJ with
condyle hypomobility and osteoarthritic changes (C). Nonreduced disk is compressed (D).

authors, side-to-side comparison of morphology charac- and contracture of the LPM were also detected in patients
teristics within each individual should be given special with ADDnr in this study (Figures 3, 6, 8, and 9). The
attention during the diagnosis ofhypertrophy 15· 17 (Figures abnormalities of the LPM were found to be associated
4-6, 8). Other studies have reported that not only hyper- with the pain symptoms of the patients (Table 2).
trophy but also atrophy and contracture of the muscle Normal images of the LPM were found in 31 TMJs
might lead to painful symptoms in muscles, abnormal with ADDnr in this study; 24 of them were found in the
joint movements and pain on movement. 17 •22 •23 Atrophy condylar limitation group (Table 3). In sorne cases,

Figure 11 (A and B)
Normal LMP in a 72-year-old female who experienced severe jaw movement pain, masticatory muscle pain (masseter, LPM, and temporal), and
painfullocking of the left TMJ for two years. The painful muscle symptoms were reduced after two months of splint therapy; however the pain in the
left TMJ and the limitation of jaw opening became severe in three months. A. Anterior disk (arrow) displacement in closed mouth oblique sagittal
image of the left TMJ (300/14, 3 mm thick). The LPM appears normal (open arrow=superior belly; IB=inferior bell y; C=condyle. B. The disk is
nonreduced in open mouth (400112, sagittal). Note that the disk is static and thickened (arrow), almost without movement during mouth opening
(compare the disk positions in images A and B). Condyle (C) limitation is defined in a maximal mouth open image. Diskectomy of the left TMJ was
performed after this MRI. Adhesions among the disk, fossa, and condyle were found during the operation.

JULY 2002, VOL. 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 217
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Figure 12 (A and B)
The LPM appears normal in a 61-year-old male who has had chronic recurring pain, jaw movement pain, and occasionallocking in the left TMJ for
two years. The symptoms improved without any treatment. The limitation of the jaw movement and locking progressed for six months. Difficulties in
speaking and eating, pain on palpation of the left TMJ, pain and limitation of jaw movement in the TMJ improved after two months of splint therapy;
however, limited mouth opening stiJl existed. A. Normal LPM in a closed mouth image of the left TMJ (oblique sagittal, 3000/14) with isointensity
of the superior (SB) and inferior bell y (lB). Severe osteoarthritic change of the condyle (C) is found. Note the effusion of the bilaminar zone (arrow·
head). Disk anteriorly displaced (arrow). B. Open mouth image of the left TMJ (sagittal, 400/12) showing an anteriorly displaced disk without
reduction (arrow). Erosion and limitation of the condyle (C) are observed.

Table2
Relationship Between Pathological Changes of the LPM on MRI and
Clinical Symptoms of 123 TMJs in Patients with ADDnr
LPMan LPMn Total p
(n=92) (n=31) (n=123) 2-side
TMJ clicking 35 6 41 0.056
Nonclicking 57 25 82
TMJ locking 44 18 62 0.324
Nonlocking 48 13 61
Jaw restricted movement 56 11 67 0.014*
Nonrestricted movement 36 20 56
Pain in TMJ 58 12 70 0.018*
No pain in TMJ 34 19 53
Pain in LPM 62 12 74 0.005**
No pain in LPM 30 19 49
Pain in jaw moving 52 7 59 0.001**
No pain in jaw moving 40 24 64
Pain in other MM 42 17 59 0.376
No pain in other MM 50 14 64
[PM: literai pterygoid muscle; TMJ: temporomandibular joint
ADDNr: anterior disk displacement without reduction
LPMn: LPM appears normal on MRI; LPMan:
LPM appears abnormal on MRI
Pearson chi-square test:
*Significant level at P<0.05; **Very significant level at P<0.01

218 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERYGOID MUSCLE

Table3
Relationship Between Pathological Changes to the LPM and
Other MRI Findings in 123 TMJs of Patients with ADDnr
LPMan LPMn Total p
(n=92) (74.8%) (n=31) (n=123) (100%) (2-side)
Osteoarthritis 52 (76.5%) 16 68 0.634
No osteoarthritis 40 (72.7%) 15 55
Condyle mobility 0.008*•
Limited 42 (63.6%) 24 66
Hypermobility 10 (83.3%) 2 12
Normal 40 (88.9%) 5 45
Disk deformity 31 (79.5%) 8 39 0.414
No disk deformity 61 (72.6%) 23 84
Effusion 0.711•
TMJ compartment 12 (70.6%) 5 17
Bilaminar zone 25 (73.5%) 9 34
TMJ & bilaminar zone 17 (85.0%) 3 20
No effusion 38 (73.0%) 14 52
LPM: lateral pterygoid muscle; TMJ: temporomandibular joint
ADDNr: anterior disk displacement without reduction
LPMn: LPM appears normal on MRI; LPMan:
LPM appears abnormal on MRI
% (indicates proportion of LPM abnormality in each image finding)=LPMan/Total
Significant level based on Pearson Chi-square test or Fisher's Exact test• at P<0.05
*Very significant level at P<0.01

Table 4
Relationship Between Condyle Mobility and Other MRI Findings
in 123 TMJs in Patients with ADDnr
Condyle mobility
Limited Normal Hypermobility Total p
(n=66) (n=45) (n=12) (n=123) (2-sided)
Osteoarthritis 45 20 3 68 0.004*
No osteoarthritis 21 25 9 55
Disk deformity 20 14 5 39 0.734
No disk deformity 46 31 7 84
Effusion 0.667•
TMJ compartment 8 6 3 17
Bilaminar zone 21 9 4 34
TMJ & bilaminar zone 10 9 1 20
No effusion 27 21 4 52
TMJ: temporomandibular joint
ADDnr: anterior disk displacement without reduction
Significant level based on Pearson Chi-square test or Fisher's Exact test• at P<0.05
*Very significant level at P<0.01

JULY 2002, VOL 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 219
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

although evident osteoarthritic changes and limitation of ail. This method may not be a suitable way to make an
the condyle were observed, the LPMs were normal accurate diagnosis of the dysfunction of the LPM;32,33
(Figures 10-12). Limitation of the jaw movement was however, the results of this study show that the pain
regarded as a progressive symptom of TMD 2·5·30 ; on the symptoms found by the intraoral palpation of the IBLPM
contrary, statistical analysis of this study indicates that had a close association with the abnormalities found of
the proportion of the LPM abnormality was significantly the LPM on imaging (Table 2).
lower in the condylar hypomobility group (Table 3). In conclusion, pathological changes of the LPM in the
Osteoarthritic changes were found to be associated with TMJ with ADDnr could be detected by MRI. These
jaw limitation (Table 4). Benito, et al. have reported that pathological changes are found in association with most
a disk might show hypomobility in TMJ with osteoarthri- of the clinicat symptoms of ADDnr. The lower propor-
tis, and limitation of jaw opening was significantly asso- tion of the imaging abnormality in the LPM is found in
ciated with a static disk. Adhesion of the disk was the condylar limitation group of the patients with ADDnr.
suspected. 5 When the possibility of the condyle move- The clinicat symptom alterations of ADDnr might be
ment becomes poor due to a fixed disk5 or because adhe- associated with the pathological situations and symptoms
sion has occurred between osteoarthritic bony tissues and oftheLPM.
the disk,25. 27 the relationship between the disk and the
condyle might become relatively stable. The overloading Reference
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