ORIGINAL ARTICLE

Directional characteristics of incipient

temporomandibular joint disc displacements: A
magnetic resonance imaging study
Renie Ikedaa and Kazumi Ikedab
San Francisco, Calif, and Tokyo, Japan

Introduction: Disc displacement (DD) is common in adolescents, but not much is understood about its cause.
Assessment of the directionality of incipient DDs may provide clues about the etiology. Methods: The sample
consisted of magnetic resonance images of 143 temporomandibular joints with incipient DD from 89 preortho-
dontic patients (mean age, 10.8 years). The severity of DD was evaluated by grading the degree of displacement
depicted in the images in the sagittal and coronal planes, and each incipient DD was categorized based on the
directionality. Results: Of the 143 incipient DDs, rotational anterolateral DD (43.36%) and partial anterior DD in
the lateral portion (27.27%) were the most common; rotational anteromedial DD (9.09%) and partial anterior DD
in the medial portion (1.40%) accounted for only 10.49%. Anterior DD was seen in 12.59%. Pure sideways shift
was rare; lateral DD was seen in 2.80%, and medial DD in 3.50%. Thus, the lateral part of the joint was involved in
a majority of the incipient DDs and the medial part far less. No sex difference was noted in this trend, but the
difference between the right and left sides was statistically significant. Conclusions: These results indicate a
predilection for the lateral part of the joint in incipient DDs and may have etiologic implications. (Am J Orthod
Dentofacial Orthop 2016;149:39-45)

T
he articular disc of the temporomandibular joint
(TMJ) plays a vital role in the development and
function of the TMJ. When the disc is not inter-
posed between the condyle and the articular eminence
in what has been considered a more normal anatomic
relationship,1 the condition can have deleterious effects,
particularly in growth and development.2-10 Studies
have evaluated the different imaging modalities
available to visualize the TMJ and have advocated
magnetic resonance imaging (MRI) as the prime
diagnostic method because of its ability to accurately
depict the disc position in sagittal and coronal
images.11-16 In 1 MRI study, none of the 60 TMJs of
infants and young children up to age 5 years examined
had disc displacement (DD).17 Thus, the study suggested
that DD is not a congenital phenomenon but, rather, an
acquired condition. In addition, research has
a
Private practice, San Francisco, Calif.
b
Private practice, Tokyo, Japan.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Kazumi Ikeda, Daikanyama Plaza 3F, 24-7 Saruga-
kucho, Shibuya-ku, Tokyo 150-0033, Japan; e-mail, ikedakzm@tkd.att.ne.jp.
Submitted, April 2015; revised and accepted, June 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.06.021
consistently shown that DD is not rare in asymptomatic
populations, with a prevalence of approximately
30%,18-20 and that the young adolescent population is
not an exception to this phenomenon.21,22 The peak
incidence of symptomatic DD has been shown to be
during puberty in both boys and girls, making the
adolescent population at risk for developing TMJ
dysfunction symptoms.23,24
An important question is why and how DD occurs.
Several possible etiologic factors have been proposed,
but no definitive answer is available at this time. It is
apparent, however, that the etiology of advanced DD is
usually multifactorial, making establishment of cause-
and-effect relationships difficult. Previous reports of
the relatively higher frequency of anteromedial DD ex-
plained it by the pulling forces of the lateral pterygoid
muscle.12,25 However, several recent studies have
shown that anterolateral displacement is more
frequent.20,25-27 Although MRI evaluation of early DD
can be valuable in showing how DD starts—which in
turn may provide important clues about its etiology—
early DD has not been studied.
The purpose of this study was to determine any
tendency in the direction of early DD. The data were
retrospectively analyzed using available MRIs of a young
preorthodontic population with incipient DD.
39
40
Fig 1. Method used to determine the 12 o'clock position with identifiable anatomic landmarks.
MATERIAL AND METHODS
The study sample was derived from a population of
153 consecutive preorthodontic patients who had
MRIs of their TMJs taken for evaluation of disc status.
In a previous study, all MRIs were evaluated by 2 cali-
brated investigators, and each TMJ disc was categorized
as normal or as 1 of the 4 stages of DD based on the
severity of displacement.28 The study sample consisted
of 143 TMJs from 89 preorthodontic patients (35
boys, 54 girls) who were determined to have incipient
DD in the previous study. The patients ranged in age
from 7 to 15 years, with a mean age of 10.8 years.
Because the MRIs were taken before this retrospective
study for diagnostic purposes, the patient data were
anonymous to the researchers, and our summarized
findings in this study are incidental, the ethical board
did not require approval for this study.
All scans were done at 1 clinic by the same technician
using the 1.5-T MRI system (Gyroscan ACS-NT Intera;
Philips, Amsterdam, The Netherlands) with surface coils.
The images were taken in the oblique sagittal plane and
the oblique coronal plane with the subject in closed-
mouth and open-mouth positions. Open-mouth sagittal
images were obtained using mouth pieces set at 10 mm
below maximal voluntary incisal opening. Proton
density-weighted images were taken with a 2.5-mm-
section thickness, a 12-cm field of view, a repetition
time of 2500 ms, an echo time of 20 ms, and a
256 3 256 measurement phase scanning matrix.
MRIs of the 143 TMJs were previously evaluated by 2
investigators for anterior or posterior displacements in
the sagittal planes and medial or lateral displacements
in the coronal planes using a standardized grading
system, which enabled categorization of the TMJs into
normal and 4 stages of DD based on the severity of the
displacement.28
January 2016  Vol 149  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Ikeda and Ikeda
In the sagittal plane, a method described by Ikeda29
was used to establish the 12 o'clock mark as a reference
point from which to evaluate the severity of DD (Fig 1). A
reference line was drawn connecting the most inferior
point of the articular eminence and the center of the
auditory canal. The reference line was then rotated 2.2
to establish the true horizontal line on the MRIs. The
12 o'clock position is the point at which the true horizon-
tal line is tangential at the deepest point on the glenoid
fossa. The 9 o'clock position is where the true horizontal
line intersects with the eminence when lowered to the
most prominent point on the anterior surface of the
condyle. The center of the clock is the intersection of
the true horizontal line through the 9 o'clock position
with a line perpendicular to the true horizontal line
through the 12 o'clock position. The 10 and 11 o'clock
positions are determined by dividing the angle between
the 9 and 12 o'clock positions into 30 segments.
The position of the posterior margin of the posterior
band was evaluated relative to the established 12 o'clock
position. Disc position were defined as normal, level 1,
level 2, or level 3 when the posterior band was at 12
o'clock, 11 o'clock, 10 o'clock, or 9 o'clock or below,
respectively (Fig 2). The position of the disc in each joint
was evaluated in 3 sagittal MRI slices (medial, central,
and lateral aspects of the joint).
Sideways (mediolateral) DD was evaluated in the
coronal plane parallel to the long axis of the condyle
and assigned the rating of normal when the disc was
centered between the medial and lateral poles. Level
1 was when the disc was markedly thickened on the
side to which it was displaced or when the disc was dis-
placed up to a sixth of the mediolateral width of the
condyle; level 2 was when the disc was displaced up
to a third of the mediolateral width with a drooping
look on the displacement side; and level 3 was when
Ikeda and Ikeda
Sagittal
Auditory
Normal meatus
Anterior Posterior
Level 1
Level 2
Level 3
Fig 2. Illustrations and corresponding MRIs demonstrating the various levels of DD in the sagittal and
coronal planes.
the disc was displaced at least half of its mediolateral
width (Fig 2).
Based on the disc position assessed by the 4 MRI
slices (3 sagittal and 1 coronal), each joint was catego-
rized as normal or as 1 of the 4 stages of DD (Table I),
ranging in severity from incipient DD to total DD
without reduction. We focused on the 143 TMJs that
were in the incipient stage of DD (stage 1) when all 3
sagittal slices and the coronal slice show a displacement
of level 1 or less.
Statistical analysis
Each incipient DD was categorized based on the
direction of displacement using the classification estab-
lished in the study by Tasaki et al26 (Table II), and the
prevalence percentage of DD by directionality was
determined. The data were further analyzed using chi-
square tests to detect any statistically significant
disparity in the prevalence of the various DDs because
of sex or right-to-left differences. Since 2 investigators
(R.I. and K.I.) independently evaluated the MRI data,
American Journal of Orthodontics and Dentofacial Orthopedics
41
Coronal
Medial Lateral
Table I. Definitions used to categorize the DDs into 4
stages based on the severity of displacement
Early DD
Stage 1 (incipient stage)
All 3 sagittal slices and the coronal slice in level 1 or less
Stage 2 (partial DD)
Stage 2A: 2 of 3 sagittal slices in level 1, and coronal slice in level 1
or less
Stage 2B: only 1 of 3 sagittal slices in level 1, and coronal slice in
level 2 or less
Stage 2C: all 3 sagittal slices in level 2 or more, and coronal slice in
level 2 or less
Advanced DD
Stage 3 (total DD with reduction)
All 3 sagittal slices in level 3, and coronal slice in levels 1 to 3 with
disc reduction on opening
Stage 4 (total DD without reduction)
All 3 sagittal slices in level 3, and coronal slice in levels 1 to 3
without disc reduction on opening
interobserver reliability was determined by calculating
the kappa coefficient for their classifications of the entire
sample of 143 TMJs with incipient DDs.
January 2016  Vol 149  Issue 1
42 Ikeda and Ikeda

Table II. Classification of DD based on direction of displacement and resulting disc position
Disc displacement types
Anterior
Partial anterior in lateral
Partial anterior in medial
Rotational anterolateral
Rotational anteromedial
Lateral
Medial
Posterior
Sagittal MRIs Coronal MRIs
Posterior band of disc anterior to 12 o'clock position in Disc centered between medial and lateral poles
multiple sections in all sections
Posterior band of disc anterior to 12 o'clock Disc centered between medial and lateral poles
position in lateral section only in all sections
Posterior band of disc anterior to 12 o'clock position Disc centered between medial and lateral poles
in medial section only in all sections
Posterior band of disc anterior to 12 o'clock position Disc slightly shifted laterally
in one or more sections
Posterior band of disc anterior to 12 o'clock position Disc slightly shifted medially
in one or more sections
Posterior band of disc at 12 o'clock position in all sections Disc slightly shifted laterally
Posterior band of disc at 12 o'clock position in all sections Disc slightly shifted medially
Posterior band of disc posterior to 12 o'clock position in Disc centered or shifted medially/laterally
one or more sections

A DistribuƟon of Incipient DD Types B DistribuƟon of Incipient DD C DistribuƟon of Incipient DD

(Male) (Female)
A
A A
PAL
PAL PAL
RAL
RAL RAL
L
L L
M
M M
RAM
RAM RAM
PAM
PAM PAM
P
P P

D DistribuƟon of Incipient DD E DistribuƟon of Incipient DD

(Right) (LeŌ)

A A
PAL PAL
RAL RAL
L L
M M
RAM RAM
PAM PAM
P P

Fig 3. Distribution of incipient DDs by directionality types: A, collective data for the entire sample; B,
data for boys only; C, data for girls only; D, data for right TMJs only; E, data for left TMJs only. See
Table III for the definitions of the abbreviations.

RESULTS Anterior DD was the third most frequent overall

In this sample of 143 incipient-stage DDs, no joint
had a posterior displacement, but displacements in other
directions (anterior, lateral, and medial) were observed.
As shown in Figure 3, A, and Table III, rotational antero-
lateral DD was the most frequent (62 DDs) and repre-
sented 43.36% of the incipient DDs (see Table II for
classifications). Partial anterior DD in the lateral portion
was the next most common DD (39 DDs, 27.27%).
(18 DDs, 12.59%). As previously stated, no posterior
displacement was observed in this incipient DD sample,
and the prevalence of other displacements (partial ante-
rior in medial, rotational anteromedial, lateral, and
medial) was low.
When the data were considered separately by sex
(Table III; Fig 3, B and C), the same general trend, with
rotational anterolateral DD being the most frequent

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Ikeda and Ikeda 43

Table III. Prevalence of incipient DDs by directionality types

Disc displacement types Total Male Female Right Left
Anterior (A) 18 (12.59%) 5 (8.77%) 13 (15.12%) 15 (20.00%) 3 (4.41%)
Partial anterior in lateral (PAL) 39 (27.27%) 16 (28.07%) 23 (26.74%) 21 (28.00%) 18 (26.47%)
Rotational anterolateral (RAL) 62 (43.36%) 27 (47.37%) 35 (40.70%) 24 (32.00%) 38 (55.88%)
Lateral (L) 4 (2.80%) 1 (1.75%) 3 (3.49%) 1 (1.33%) 3 (4.41%)
Medial (M) 5 (3.50%) 3 (5.26%) 2 (2.33%) 3 (4.00%) 2 (2.94%)
Rotational anteromedial (RAM) 13 (9.09%) 4 (7.02%) 9 (10.47%) 10 (13.33%) 3 (4.41%)
Partial anterior in medial (PAM) 2 (1.40%) 1 (1.75%) 1 (1.16%) 1 (1.33%) 1 (1.47%)
Posterior (P) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Total 143 57 86 75 68

Table IV. Combined categories for the chi-square test

Disc displacement types Total Male Female Right Left
Anterior (A 1 PAL 1 PAM) 59 (41.26%) 22 (38.60%) 37 (43.02%) 37 (49.33%) 22 (32.35 %)
Lateral (L 1 RAL) 66 (46.15%) 28 (49.12%) 38 (44.19 %) 25 (33.33%) 41 (60.29%)
Medial (M 1 RAM) 18 (12.59%) 7 (12.28%) 11 (12.79%) 13 (17.33%) 5 (7.35%)
Total 143 57 86 75 68
See Table III for the definitions of the abbreviations.

type (47.37% in boys, 40.70% in girls), followed in fre-
quency by partial anterior DD in the lateral direction
(28.07% in boys, 26.74% in girls), was observed. Howev-
er, for the less common displacements (medial, lateral,
and rotational anteromedial DDs in particular), the fre-
quency varied between the sexes.
The disparity of the distribution of the incipient DD
types was more evident between the right and left
TMJs (Table III; Fig 3, D and E). Consistent with the gen-
eral trend, rotational anterolateral DD was the most
frequent type (32.00% on the right, 55.88% on the
left), followed by partial anterior DD in the lateral direc-
tion (28.00% on the right, 26.47% on the left). Anterior
DD was much more frequent on the right than on the left
joints (right, 20.00%; left, 4.41%), and the right joints
also showed a higher frequency of rotational anterome-
dial DDs than did the left joints (right, 13.33%; left,
4.41%).
To statistically evaluate the sex and right-left differ-
ences with the chi-square test, contingency tables must
have 5 or more in each cell; this was not satisfied by the 8
initial categories because of the rarity of some types of
DD in this sample. Thus, categories were combined to
anterior (including anterior, partial anterior in lateral,
and partial anterior in medial DD), lateral (including
lateral and rotational anterolateral DDs), and medial
(including medial and rotational anteromedial DDs) for
the chi-square tests (Table IV; Fig 4). The chi-square
tests showed no statistical difference between the distri-
butions of incipient DD types in male vs female subjects
(chi-square 5 0.35; P .0.05) and a statistically
significant difference between the right and left sides
(chi-square 5 10.93; P 5 0.005).
When the kappa coefficient was computed for the
entire sample to evaluate the interobserver reliability be-
tween the 2 investigators on categorization of each DD,
the agreement was excellent (0.82).
DISCUSSION
Although previous studies have shown that antero-
medial DD is the most common type of DD,24,30 more
recent studies with MRI have reported that DD in the
anterolateral direction is more frequent than previously
described.20,21,26,27 This discrepancy in findings could
be due to the investigating methods used previously
(cryosections, plain radiography, arthrography,
computed tomography scans, and so on) compared
with MRI, which has been shown to deliver
significantly more accurate depictions of the TMJ. The
result from our study supports the latter finding, with
rotational anterolateral DD the most frequent
displacement (43.36%), followed by partial anterior DD
in the lateral part of the joint (27.27%). This general
trend was not sex-specific and was consistent between
the right and left sides. Tasaki et al26 and others have
also reported that rotational anterolateral DD was the
most frequent type of DD observed in patients or asymp-
tomatic volunteers.20,21
In this study, pure anterior displacement was less
frequent (12.59%) compared with reports from other
studies.21,26,30 In addition, although the occurrence of

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44 Ikeda and Ikeda

A DistribuƟon of Incipient DD Types B DistribuƟon of Incipient DD C DistribuƟon of Incipient DD

(Male) (Female)

Anterior
Anterior Anterior
Lateral
Lateral Lateral
Medial
Medial Medial

D DistribuƟon of Incipient DD E DistribuƟon of Incipient DD

(Right) (LeŌ)

Anterior Anterior
Lateral Lateral
Medial Medial

Fig 4. Distribution of incipient DDs by combined directionality types for the chi-square test: A, collective
data for the entire sample; B, data for boys only; C, data for girls only; D, data for right TMJs only; E, data
for left TMJs only.

posterior DD has been documented, no posterior
displacement was observed in our study. Although most
studies have included DDs of various severities in the
sample, we did not include advanced DDs, since our aim
was to focus only on the DDs in their incipient phase.
Similarly, in a study of the occurrence of posterior DDs,
no asymptomatic volunteer had posterior DD, although
all other forms of DD were observed.31
Anterior displacements that involved the lateral part
of the joint (rotational anterolateral DD and partial ante-
rior DD in the lateral portion) constituted about 70% of
the incipient DDs overall. On the other hand, DDs
involving the medial aspect of the joint (rotational ante-
romedial DD and partial anterior DD in the medial
portion) totaled only 10%. Therefore, based on these
findings, DD involving the medial portion of the joint
seems less likely at its early stage. Foucart et al27 also
demonstrated a similar trend, where most of the partial
anterior DDs (97%) occurred on the lateral side, and
with progression of DD from complete displacement
with reduction to DD without reduction, the association
with medial displacement became increasingly stronger.
Westesson et al31 reported that in posterior DDs, there
was a strong association with a medial component to
the displacement. As suggested by Foucart et al, partial
anterior DD associated with the lateral part of the condyle
may be the first phase of DD pathology.26 At the onset of
DD, there may be some factor that causes initial insta-
bility of the disc at the lateral part, whereas medial
displacement becomes more prevalent in advanced DDs.
Another interesting finding in this study was the
disparity of certain DDs in the right vs the left joints;
the left side showed a significantly higher frequency of
DDs with a lateral component (rotational anterolateral
and lateral DDs), but sex differences were not statistically
significant. This might indicate that the direction of
incipient DDs can be influenced by local factors rather
than systemic factors. The difference may be attributed
to a right or left side preference in functional or para-
functional activities and the resulting differential joint
loading, but future studies are needed to investigate
this possibility.
CONCLUSIONS
In this study, we sought to investigate the radio-
graphic manifestations of incipient DDs to identify any
tendency in directionality of early DDs. The interobserver
reliability was excellent for the categorization of incip-
ient DDs by evaluating the MRIs. Among the 143 TMJs
with incipient DD, different types of DD were observed

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Ikeda and Ikeda
except for posterior displacements. There was a high
prevalence of displacements in the anterolateral direc-
tion, followed by partial anterior displacement in the
lateral portion. These 2 types involving the lateral part
of the joint encompassed approximately 70% of the
incipient DDs evaluated and were the most frequently
found types in both sexes, as well as the right and left
joints. Lateral and medial displacements and anterior
displacements involving the medial part of the joint
were much less frequently observed. There was a statis-
tically significant disparity between the distributions of
DD types in right vs left joints, with left joints showing
a higher frequency of DDs with a lateral component.
This could be due to differences in joint loading on
the right and left sides. Our results indicate a predilection
for the lateral part of the joint at the onset of DD and
may have further implications in the etiologic aspects
of temporomandibular disorders.
ACKNOWLEDGMENTS
We thank Akira Kawamura and Art Miller for their
assistance with the statistical analyses.
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