Oral Radiology

https://doi.org/10.1007/s11282-020-00483-6

ORIGINAL ARTICLE

MRI characteristics of the asymptomatic temporomandibular joint

in patients with unilateral temporomandibular joint disorder
C. Jerele1,2   · J. Avsenik1,2 · K. Šurlan Popović1,2

Received: 23 April 2020 / Accepted: 29 August 2020

© Japanese Society for Oral and Maxillofacial Radiology and Springer Nature Singapore Pte Ltd. 2020

Abstract
Objective  To determine the association between unilateral temporomandibular joint disorder (TMD) and the presence of
imaging abnormalities in the contralateral, asymptomatic joint.
Methods  MRI studies of 219 subjects with symptoms of unilateral TMD were examined for signs of disc displacement,
osteoarthritis, disc deformation, and effusion in both temporomandibular joints (TMJ). The Chi-Square test and stepwise
logistic regression analysis were performed.
Results  Disc displacement, osteoarthritis, disc deformation, and effusion were more common on the symptomatic side.
However, in the category of disc displacement with a reduction in open mouth position (DDWR), the difference was not
significant between the symptomatic and the asymptomatic TMJs. Stepwise logistic regression showed that the presence of
any imaging abnormality other than DDWR was related to osteoarthritis and disc deformity on the symptomatic side. On
the other hand, the presence of any MRI abnormality (including DDWR) on the asymptomatic side was related only to the
presence of osteoarthritis on the symptomatic side.
Conclusions  Unilateral symptomatic TMD is related to the presence of imaging abnormalities on the contralateral, asympto-
matic side, suggesting that the development and progression of joint changes in symptomatic and contralateral asymptomatic
TMJs are interrelated.

Keywords  Temporomandibular joint disorders · Temporomandibular joint · Magnetic resonance imaging · Osteoarthritis

Introduction clicking, and restricted mandibular movement, which have

The temporomandibular joint (TMJ) is a diarthrodial joint
connected by the mandible. The two sides cannot, therefore,
function independently. The two TMJs must work together to
produce the movements necessary for speech, mastication,
deglutition, and facial expression [1]. Mandibular mechanics
during the opening, closing, and mastication are abnormal in
the presence of symptomatic internal derangement (ID) [2].
Temporomandibular joint disorder (TMD) is a relatively
common clinical condition, affecting up to 28% of the world
population [3], with a prevalence of symptoms between 17%
and 68.8% [4, 5]. Patients usually complain of pain, joint
* C. Jerele
cene.jerele@gmail.com
1
Clinical Institute of Radiology, University Medical Centre
Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia
2
Faculty of Medicine, University of Ljubljana, Vrazov trg 2,
1104 Ljubljana, Slovenia
a significant effect on their quality of life [1].
Magnetic resonance imaging (MRI) has a central role in
the evaluation of TMD. It is reported to have 95% accuracy
for disc position and disc form and about 93% for osseous
change [6]. However, some authors have reported a lack of
correlation between abnormalities observable on MRI and
the extent of pain and dysfunction in patients with ID [7, 8].
Disc displacement was, in fact, found in a substantial num-
ber of asymptomatic volunteers [8–10] and several studies
have found that osteoarthritis was not a significant factor in
TMJ pain [11–13]. In contrast, several other studies have
found a correlation between osteoarthritis and TMJ pain
[14–16].
Despite the inconsistencies of the results, many studies
have proven that it is important to detect early MRI signs of
TMJ dysfunction [17–19]. Although there are several treat-
ment options, the outcomes are considerably worse when
the disease is treated in its irreversible stage [20]. It has also
been proposed that TMD might be progressive in nature,

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advancing to the contralateral joint due to the unified action • PD turbo spin-echo (TSE) sequence in the coronal plane,
of the two joints [9]. all in the closed-mouth position (twenty slices at 2.8 mm
To the best of our knowledge, there have been no studies thickness, TR 1500 ms, TE 30 ms),
investigating the relationship between TMD and contralat- • PD TSE sequence in the sagittal plane in the open-mouth
eral asymptomatic joint abnormalities. In this study, there- position (twenty slices at 2.5 mm thickness, TR 1500 ms,
fore, we tried to determine whether radiological abnormali- TE 30 ms).
ties on the symptomatic side are associated with abnormal
imaging findings in contralateral, asymptomatic TMJ. This The data were acquired on a 256 × 256–352 × 352 matrix.
would further clarify the value of early-stage TMD diagnosis Images were assessed by two experienced head and neck
and treatment and its potential in limiting the progression of radiologists (Clinical Institute of Radiology, University
the dysfunction. Medical Centre Ljubljana). Sagittal and coronal MR images
in the closed-mouth position were obtained to establish the
presence of joint derangement. Both sides were evaluated for
disc displacement (Fig. 1). Joints with internal derangement
Materials and methods
consisting of anterior displacement were divided into groups
according to the location of the posterior band of the disc in
Subjects
relation to the condyle. Normal disc position was defined as
the posterior band of the disc is at the superior position (i.e.,
The study group consisted of 219 subjects (175 females and
12 o’clock or max. 10° off) relative to the condyle. In the
44 males; mean age 44.8 years; range 12–83 years), who
case of anterior disc displacement, the degree of displace-
were assigned a clinical diagnosis of unilateral TMJ dys-
ment was determined (grade 0 – no displacement, grade
function according to the Research diagnostic criteria for
1–30°–60°; grade 2–60°–90°; grade 3–90°  – 120°). The
temporomandibular disorders (RDC-TMD).
presence of disc reduction was assessed on sagittal images
[21]. Inclusion criteria consisted of clinical signs of TMJ
in the open-mouth position. The open-mouth position was
dysfunction (joint pain during rest, function or on palpa-
acquired with a spacer, which is a part of GE Healthcare
tion, noises/clicking, limited opening, etc.) on one side. The
imaging system equipment (Medrad TMJ-200 Bi-Direc-
patients were referred to our department by maxillofacial
tional Device).
surgeons from the Maxillofacial Surgery Department in
We also evaluated TMJs for the presence of disc deform-
Ljubljana who performed questionnaires and clinical exam-
ity. Discs were considered normal when they had a bicon-
inations of both joints as well as provided the diagnosis.
cave shape. On the other hand, disc deformity was character-
Patients with a history of bilateral TMD in the last 30 days or
ized by a folded, lengthened, round or biconvex disc, as well
with presently bilaterally symptomatic TMD were excluded
as a disc with a thick posterior band, according to Murakami
from the study. All subjects underwent an MRI investigation
et al. [22].
of both TMJs between January 2012 and April 2018. The
radiologists were not blinded to the clinical diagnosis.
Written informed consent was obtained from each sub-
ject. This study was approved by the National medical ethics
committee of Slovenia.

MRI

The MRI examinations were performed on a 1.5-T imaging

system (Philips Achieva Nova, Netherlands) with the use of
dual-surface coils:

• T1 spin-echo (SE) sequence in the sagittal plane (twenty

slices at 3 mm thickness, repetition time (TR) 450 ms,
echo time (TE) 15 ms),
• Proton density spin-echo (PDE SE) sequence in the sagit-
tal plane (twenty slices at 2.5 mm thickness, TR 1500 ms,
TE 30 ms),
• T2 3-dimensional fast field echo (FFE) sequence in the
sagittal plane (20 slices, TR 40 ms, TE 18 ms),
Fig. 1  Sagittal proton density (PD) MRI images of both temporoman-
dibular joints in a patient with unilateral left-sided temporomandibu-
lar dysfunction show grade 3 anterior displacement of the left disc (a)
without a reduction in open mouth position (not shown). Left con-
dyle shows osteoarthritic changes grade 2. The articular disc on the
asymptomatic side (b) shows grade 3 anterior displacement with no
signs of osteoarthritis

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Oral Radiology
Joint effusion was determined by the intra-articular area
of the high signal on T2 weighted images (i.e., inside ante-
rior or posterior recess, superior or inferior joint space).
Chronic osteoarthritic (OA) changes were evaluated using
T1- and T2-weighted MR images.
We graded the severity of changes in three stages:
Grade 0 – no osteoarthritic changes.
Grade 1 – presence of osteophyte formation and/
or deformities of the articular surfaces associated with
flattening and/or subchondral sclerosis and/or surface
irregularities.
Grade 2 – presence of bone erosions.
Statistical analysis
Statistical analysis was performed using SPSS Statistics v.20
(IBM Corp., Armonk, New York, USA). Frequencies of
MRI abnormalities between symptomatic and asymptomatic
joints were compared using the Chi-Square test. The associa-
tion between abnormal imaging findings on the symptomatic
side as well as age and gender and the presence of imaging
abnormalities on the asymptomatic side was analyzed using
stepwise logistic regression models. The significance level
was set to p < 0.05.
Results
Of 219 symptomatic TMJs, 73 (33.3%) showed disc dis-
placement with reduction (DDWR), and 139 (63.5%)
showed disc displacement without reduction (DDWOR) in
open mouth position. OA was present in 173 symptomatic
joints (79.0%), effusion was present in 26 cases (11.9%) and
the disc was deformed in 162 cases (74.0%). One sympto-
matic TMJ (0.5%) was normal on MRI.
On the asymptomatic side, 17 TMJs (7.8%) were nor-
mal on MRI, 132 (60.3%) showed DDWR, and 37 (16.9%)
showed DDWOR. In 94 cases (42.9%), there were signs of
OA, in 14 cases (6.4%) effusion was present and 72 discs
(32.9%) were deformed.
The difference in the occurrence of DDWR between
symptomatic and asymptomatic joints was not significant
(p = 0.379). On the other hand, the difference in the occur-
rence of DDWOR between symptomatic and asymptomatic
joints was significant (p = 0.001), as were differences in the
occurrence of OA, effusion, and disc deformity (p = 0.000)
(Fig. 2).
The association between imaging findings on the sympto-
matic side and the presence of any MRI abnormality on the
asymptomatic side as a dichotomous dependent variable was
studied using stepwise logistic regression models [23]. The
same procedure was applied for the presence of any patho-
logic finding other than DDWR on the asymptomatic side.
Age, gender, presence of disc displacement with and
without reduction, presence of disc deformity, effusion, and
MRI signs of osteoarthritis on the symptomatic side were
included as independent variables.
The presence of any imaging abnormality other than
DDWR on the asymptomatic side was related to the pres-
ence of OA and the presence of disc deformity on the symp-
tomatic side. MRI abnormalities other than DDWR on the
asymptomatic side were not found to be related to age
(p = 0.609), gender (p = 0.373), or any other MRI finding
on the symptomatic side.
On the other hand, the presence of any MR abnormality
on the asymptomatic side, including DDWR, was related
only to the presence of OA on the symptomatic side. The
detailed results of logistic regression analysis are provided
in Table 1.
Discussion
Several studies have shown a consistent correlation between
clinical symptoms of TMD and joint abnormalities observ-
able on MRI [15, 24, 25]. The results of our study are con-
sistent with these observations. In the symptomatic group,
217 of 218 joints showed changes on MRI. The prevalent
disorder was DDWOR (63.8%), while DDWR was the sec-
ond most common (33.5%).
The difference in the prevalence of DDWOR between
symptomatic and asymptomatic joints was statistically sig-
nificant (p = 0.001). This is in line with the study by Maizlin
et al. [20].
However, we did not find a significant difference in
DDWR between symptomatic and asymptomatic TMJs (Chi-
Square test, p = 0.379). In our study, DDWR was present
in a significant proportion (60.6%) of asymptomatic joints.
Current literature reports a prevalence of DDWR between 20
and 34% in asymptomatic volunteers [9, 17, 26, 27].
We also encountered 37 cases (17%) of DDWOR in the
asymptomatic joint group. This is incongruent with current
literature data. The majority of studies report no DDWOR in
asymptomatic joints [20, 28, 29] and a single study found a
2.6% prevalence (2 cases) of DDWOR in the asymptomatic
group [9]. Our results suggest that there is a strong connec-
tion between the pathologies on the two sides. This notion is
further supported by the observation that TMJ pathologies
tend to progress over time [9].
The higher number in our population may be due to sev-
eral reasons. The first one is the possibility of the previous
history of symptoms in the presently asymptomatic joint.
The patients are referred to our department based on the
unilateral diagnosis of TMD by maxillofacial surgeons. The
clinical evaluation based on RDC-TMD considers the joint
asymptomatic if there were no symptoms in the joint in the
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Fig. 2  MRI abnormalities in symptomatic and asymptomatic joints. Star (*) marks abnormalities with significant differences in frequencies
between symptomatic and asymptomatic side. (p < 0.05)

Table 1  The table shows the results of stepwise logistic regression volunteers. This hypothesis is supported by Katzberg
analysis used to assess the association between imaging findings et al. [9], which suggests that disc displacement in one
on the symptomatic side and the presence of MRI abnormalities on
TMJ increases the probability of disc displacement on the
asymptomatic
contralateral side.
OR CI low CI high P value We confirmed a significant relationship between the pres-
Any imaging abnormality other than DDWR ence of any imaging abnormality other than DDWR with the
Osteoarthritis 3.258 1.981 8.039 0.001 presence of OA and disc deformity on the symptomatic side.
Disc deformation 2.039 1.055 3.937 0.034 Our findings suggest that disc deformity on the sympto-
Any MRI abnormality including DDWR matic side may be related to contralateral joint abnormali-
Osteoarthritis 5.729 2.114 15.529 0.001 ties. This is to some extent supported by the natural course
of disc position and configuration in DDWOR. It shows the
OR odds ratio, CI confidence interval (set to 95%); P value was set to persistent existence of disc displacement, continued disc
p < 0.05
deformity, and accelerated bone change in the affected joint
[30–32]. These factors lead to significant differences in
last 30 days. Consequently, there is lacking data about the TMJ loads and energy densities among TMD patients com-
possible previous symptoms in the currently asymptomatic pared to the asymptomatic population [33, 34]. Consequent
joints. There is a high probability that the currently asymp- increases in mechanical strains imposed on the articulat-
tomatic joints were symptomatic at some point in the past. ing tissues during jaw function could lead to tissue fatigue
On the other hand, the higher prevalence of joint in these groups [35]. Together with the unified action of
changes in asymptomatic joints could be due to co-existing TMJs, this could contribute to the induction and progression
TMD in the contralateral, symptomatic joint, while most of contralateral ID. However, further studies are needed to
of the above studies were performed on asymptomatic assess this relationship.

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Oral Radiology
On the other hand, the presence of any MR abnormality
(including DDWR) was only related to the presence of OA
on the symptomatic side.
There is a lack of studies examining the relationship
between OA and contralateral joint changes in humans.
There has been a single study performed on mice with uni-
lateral OA-like TMJ changes induced by unilateral partial
discectomy [36]. It found that OA-like changes in one TMJ
could initiate early-onset articular cartilage degeneration in
the contralateral TMJ. Comprehensive human studies are
needed to confirm the validity of this theory in humans.
We did not find any association of MRI abnormalities in
asymptomatic joints with age, gender, or any MRI abnormal-
ity in the symptomatic joint. In terms of gender prevalence,
it is important to note that out of 219 subjects, 175 (79.9%)
were females and 44 (20.1%) were males. This is partially
in line with the current literature, in which a 2018 meta-
analysis reported a 2:1 female/male ratio in TMD prevalence
[37]. Our findings might suggest that, once TMD is in the
symptomatic phase, there is no difference in the progression
of dysfunction between genders.
One possible explanation for the higher prevalence of
joint pathology in the asymptomatic joint might be the
changes in the chewing pattern due to unilateral TMD. Sev-
eral studies have found significant differences in chewing
patterns between patients with TMD and asymptomatic
volunteers [38–43]. Patients with moderate to severe TMD
were found to have increased masticatory muscle electro-
myographic (EMG) activity. Those studies also found lower
precision in muscle coordination and increased function
during lateral jaw movements, both working and balancing
sides [39, 41]. Uncoordinated and hyperactive masticatory
muscles were found to be the primary source of repetitive,
tensive, and compressive forces against the TMJ, the teeth,
and other masticatory system structures [44]. Furthermore,
this leads to increased relative activity in the balancing side
during chewing, resulting in a loss of the protective mecha-
nism of balancing TMJ [43, 45]. Reorganization and redis-
tribution of activity occurring within and between muscles
may help to preserve functional demands but has potential
long-term consequences [46–49]. Despite several studies
confirming the connection, some studies have found no cor-
relation between TMD and chewing dysfunctions [50–52].
Moreover, because of the variation in methodology between
the studies involving TMD and chewing dysfunction, the
strength of an association between the two is difficult to
conclude [53].
In summary, our study found a significant association
between unilateral OA and/or disc deformity and MRI
observable changes in the contralateral asymptomatic joint.
The results of our study suggest that the development and
progression of joint changes in symptomatic and contralat-
eral asymptomatic TMJs are interrelated. The natural course
of TMD might be progressive, which is in accordance with
several other studies [54–58]. However, at the time of clini-
cal evaluation, many of the joint changes can be asympto-
matic. Therefore, we propose that careful radiological imag-
ing evaluation of both symptomatic and asymptomatic joints
is necessary to determine the extent of joint changes and to
establish the best possible plan of treatment. Early TMD
diagnosis and treatment could be central to limiting further
TMJ dysfunction. This may improve patient outcomes and
increase the quality of life. It is important to note, however,
that MRI findings should not alone dictate treatment strate-
gies. Patients’ clinical presentation, signs, and symptoms
together with TMJ imaging must be combined when devel-
oping a treatment plan [59].
Our study had several limitations. First, we included
patients with a wide range of symptoms. These symptoms
are part of the wide spectrum of TMJ myofascial pain syn-
dromes, which may explain why some symptomatic joints
had no disc displacement, effusion, or osteoarthritis.
Second, due to the cross-sectional design of this study,
we cannot demonstrate whether contralateral, MRI-proven
joint changes are the result of unilateral symptomatic TMD.
Third, the diagnosis of TMD was made according to
RDC-TMD. Considering RDC-TMD only takes into account
the signs and symptoms that occurred in the last 30 days,
there is lacking history about the asymptomatic joint. There-
fore, even though the joints were asymptomatic at the time
of diagnosis, past clinical signs and symptoms of TMD
could not be ruled out.
We did not examine the time course of TMJ pathology, so
longitudinal studies are needed to confirm the causal nature
of the associations found in our study.
Conclusions
Our results show that unilateral symptomatic TMD is associ-
ated with imaging abnormalities in contralateral, asympto-
matic TMJ. Specifically, the presence of osteoarthritis and/
or disc displacement on the symptomatic side seems to be
associated with pathologic MRI findings on the asympto-
matic side. The results of our study suggest that early treat-
ment of unilateral TMD may be beneficial in terms of limit-
ing the progression of pathology in both symptomatic and
contralateral TMJ. However, additional longitudinal studies
are needed to confirm the time course of these observations.
Compliance with ethical standards 
Conflict of interest  Jerele C, Avsenik J and Šurlan Popović K declare
that they have no conflict of interest.
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Human rights statement  All procedures followed were in accordance
with the ethical standards of the responsible committee on human
experimentation (institutional and national) and with the Helsinki
Declaration of 1964 and later versions.
Informed consent  Informed consent was obtained from all patients for
being included in the study. This article does not contain any studies
with human or animal subjects performed by any of the authors.
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