Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955

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Review

Prevalence of degenerative disease in temporomandibular disorder

patients with disc displacement: A systematic review and meta-
analysis
Maria Alves Garcia Silva a, *, Letícia Lopes Quirino Pantoja b,
Kamile Leonardi Dutra-Horstmann c, Jose
Valladares-Neto d, Felipe Lucyk Wolff e,

Luís Porporatti , Eliete Neves Silva Guerra g, Graziela De Luca Canto h
Andre f

a
Department of Stomatological Sciences, Faculty of Dentistry, Federal University of Goia
s, Goia^nia, Goia

s, Brazil
b
Laboratory of Oral Histopathology, Health Sciences Faculty, University of Brasília, Brasília, DF, Brazil
c
Brazilian Centre for Evidence-Based Research, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
d
s, Goia
Department of Orthodontics, Faculty of Dentistry, Federal University of Goia ^nia, Goia
s, Brazil
e
polis, Santa Catarina, Brazil
Private Practice, Floriano
f
Brazilian Centre for Evidence-Based Research, Department of Dentistry, Federal University of Santa Catarina, Floriano
polis, Santa Catarina, Brazil
g
Laboratory of Oral Histopathology, Health Sciences Faculty, University of Brasília, Brasília, Brazil
h
Department of Dentistry, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: To assess the available literature on the prevalence of degenerative joint disease (DJD) in patients with
Paper received 4 March 2020 anterior disc displacement (ADD) of the temporomandibular joint (TMJ), using a systematic review with
Accepted 16 August 2020 meta-analysis.
Available online 25 August 2020
Search strategies were performed in the following databases: PubMed/MEDLINE, EMBASE, LILACS,
Web of Science, Scopus, and LIVIVO. A search was also carried out in the gray literature. Two independent
Keywords:
reviewers selected the included articles using a two-phase process based on the eligibility criteria. Three
Temporomandibular joint
reviewers independently collected the required information from the included articles. The methodo-
Disc displacement
Degenerative joint disease
logical quality of the selected studies was assessed individually.
Systematic review In accordance with the inclusion and exclusion criteria, 1349 studies were found and 18 articles were
Evidence-based dentistry included. The total sample size was 3158 TMJs. The sex distribution was predominant for females (1161
females and 345 males). The average age was 46 (range 10e82) years. Among the 1762 TMJs quantita-
tively assessed, the prevalence of DJD involving disc displacement with reduction (DDWR) was 35%,
while for disc displacement without reduction (DDWoR) the prevalence was 66%. The prevalences of
different features of DJD were as follows: sclerosis 24.3%, erosion 23.5%, osteophyte 17.9%, and subcortical
cyst 7.6%.
The prevalence of DJD in temporomandibular disorder patients with disc displacement is around 50%
and is higher in DDWoR (66%) than in DDWR (35%). Sclerosis and erosion would be the most expected
radiological signs in a developing DJD. Clinicians should adequately address the frequent DJD features
associated with disc displacement in terms of diagnostics and therapeutic management.
© 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction

Degenerative joint disease (DJD) of the temporomandibular

joint (TMJ) is characterized by ‘deteriorations of articular tissue
* Corresponding author. Department of Oral Sciences and Oral Radiology, School with concomitant osseous changes in the condyle and/or articular

s, Av. Universita
of Dentistry, Federal University of Goia
ria Esquina com 1a Avenida s/ eminence’ (Schiffman et al., 2014). The terms osteoarthritis and
n, Setor Universita
rio, CEP 74605-220, Goi^ ania, Goi

as, Brazil. Fax: þ55 62 3209 osteoarthrosis are subclasses of DJD, implying the presence and
6067. absence of pain, respectively. Although crepitus detected with
E-mail addresses: mariaagsilva@gmail.com, mags@ufg.br (M.A.G. Silva).

https://doi.org/10.1016/j.jcms.2020.08.004
1010-5182/© 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955
palpation is suggestive of DJD, the diagnosis should be confirmed
by imaging (Schiffman et al., 2014). Cone beam computed tomog-
raphy (CBCT) is becoming the reference standard for the evaluation
of osseous components of the TMJ (Larheim et al., 2015;
Hilgenberg-Sydney et al., 2018). Osseous changes in the DJD are
identified by at least one of the following changes: erosion, sub-
chondral cyst, generalized sclerosis, or osteophyte (Ahmad et al.,
2009). The bony changes are most commonly seen in the
condyle; however, they may also involve the mandibular fossa or
articular eminence. Flattening and cortical sclerosis have been
considered an adaptive change rather than a DJD (Schiffman et al.,
2014). In contrast, magnetic resonance imaging (MRI) is considered
the reference standard for the evaluation of disc displacement and
other soft tissues related to the TMJ (Pupo et al., 2016).
The association between DJD and anterior disc displacement
(ADD) has been investigated in several studies (Emshoff et al., 2002a,

s
2002b; Alexiou et al., 2009; Dias et al., 2012; Melo et al., 2015; Corte
et al., 2016). ADD is a common internal derangement of the TMJ,
which is usually reported in young to middle-aged female adults
(20e50 years of age), with a tendency for more advanced stages of
ADD with increasing age (Alexiou et al., 2009; Melo et al., 2015). ADD
is classified as disc displacement with reduction (DDWR) or disc
displacement without reduction (DDWoR).
Studies have also investigated the prevalence of, and association
between, DDWR or DDWoR and pain, jaw locking, and limited mouth
opening (Emshoff et al., 2002a; Dias et al., 2012; Hasan and
Abdelrahman, 2014; Moncada et al., 2014; Corte
s et al., 2016).
Changes in dentofacial morphology have also been evaluated, with
perhaps more serious consequences expected in a younger population
with DDWoR and DJD, including limited mandibular growth or hori-
zontal mandibular and vertical ramus deficiency (Bertram et al., 2011;
Roh et al., 2012), as well as an important determinant factor of back-
ward mandibular positioning and/or clockwise rotation (Emshoff
et al., 2011). Osseous changes related to DJD are important signs that
need to be considered in diagnosing temporomandibular disorder
(TMD) (Hilgenberg-Sydney et al., 2018), a disease that affects 5e12% of
the population (National Institute of Dental and Craniofacial
Research). The hypothesis that DJD is a progression of previous disc
displacement has often been proposed (Emshoff et al., 2001; Larheim
et al., 2001), particularly in cases of DDWoR. On the other hand, some
authors have not found an association between ADD and DJD (Emshoff
et al., 2002a,
2002b,bib_Emshoff_et_al_2002a,bib_Emshoff_et_al_2002b; Kurita
et al., 2006).
A recent systematic review (Pantoja et al., 2018) reported a high
prevalence of DJD either in patients with a systemic rheumatic
disease (ranging from 40.42% to 93.33%) or in patients with TMD
without systemic involvement (ranging from 18.01% to 84.74%). For
this reason, clinicians should not neglect the relationship between
ADD and DJD; however, this relationship is not completely
understood.
To the best of our knowledge, there has not been a systematic
review that has addressed the prevalence of DJD in patients with
disc displacement. Therefore, the aim of this systematic review and
meta-analysis was to determine the prevalence of the degenerative
joint disease in TMD patients with anterior disc displacement, and
also the prevalence of each type of osseous change, such as erosion,
osteophyte, sclerosis, and subcortical cyst.
2. Materials and methods
2.1. Protocol and registration
A systematic review protocol based on the 2015 Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
943
Protocols (PRISMA-P) statement was prepared (Shamseer et al.,
2015). This protocol was registered with the International Pro-
spective Register of Systematic Reviews (PROSPERO) under number
CRD42018105979. This systematic review was also reported ac-
cording to PRISMA (Moher et al., 2009).
2.2. Focus question
This systematic review was performed to address the following
questions: (1) What is the prevalence of degenerative joint disease
in patients with anterior disc displacement? (2) What is the prev-
alence of each osseous change d for instance, erosion, osteophyte,
sclerosis, and subcortical cyst?
We selected studies using the following PICOS acronym as a
guide. (1) Population: children, adolescents or adults. (2) Inter-
vention/exposition: a degenerative disease in TMJ with disc DDWR
or DDWoR. (3) Comparison or control: not applicable. (4) Outcome:
primary outcome d prevalence of the DJD; secondary outcome d
prevalence of each osseous change (erosion, osteophyte, sclerosis,
and subcortical cyst). (5) Studies included: observational studies.
2.3. Eligibility criteria
2.3.1. Inclusion criteria
Observational studies that assessed the prevalence of DJD with
ADD were included. Only studies that diagnosed ADD by MRI were
assessed. No restrictions on the publication period or language
were applied.
2.3.2. Exclusion criteria
The studies were excluded in two phases.
In phase 1 (titles and abstracts), the following exclusion criteria
were applied: (1) studies conducted in animals or in vitro; (2)
studies that did not investigate the prevalence of, or association
between, DJD and TMJ disc displacement; (3) studies with different
image modalities, such as panoramic radiographs, or without any
images; (4) studies related to the treatment of TMJ disorders; (5)
studies involving patients with systemic articular disease; (6) re-
views, letters, conference abstracts, editorials, case reports, case-
series studies, and guidelines.
In phase 2 (full-text), the following additional exclusion criteria
were applied: (1) studies published twice; (2) studies in which only
CT/CBCT were performed.
2.4. Information sources
Detailed search strategies for each of the following biblio-
graphic databases were developed: PubMed/MEDLINE, EMBASE,
LILACS, Web of Science, Scopus, and LIVIVO. The database search
strategies can be found in Appendix 1. Partial gray literature
searches through Google Scholar, OpenGrey, and ProQuest were
also performed. The Google Scholar search was limited to the first
100 most relevant articles published in the last 10 years. Refer-
ences were managed using EndNoteR X7 (Thomson Reuters,
Philadelphia, PA), and duplicates were removed using Rayyan
(Qatar Computing Research Institute, Doha, Qatar) (Ouzzani et al.,
2016). Furthermore, hand searches were performed on the refer-
ence lists of included articles.
Both the gray literature searches and electronic database
searches were conducted from their coverage starting date to May
11, 2020. Three experts were chosen from the authors who pub-
lished the most relevant papers, and an email was sent asking for
additional references.
944 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955

Fig. 1. Flow diagram of literature search and selection criteria.

2.5. Study selection
In phase 1, two reviewers (MAGS and FLW) independently
reviewed the titles and abstracts of all the identified electronic
database citations. Articles that did not match the inclusion criteria
were discarded. In phase 2, the same two reviewers (MAGS and
FLW) applied the inclusion criteria to the full texts of the articles.
This blind process was ensured and registered through using
Rayyan (Ouzzani et al., 2016). The reference lists of the selected
studies were then critically assessed. Any disagreement in the first
or second phase was resolved by discussion until a mutual agree-
ment between the two authors was attained. When they did not
reach a consensus, a third author (KLDH) became involved to make
a final decision. The final selection was always based on the full text
of each publication.
2.6. Data items and collection process
Three reviewers (MAGS, JV-N, and KLDH) independently
collected the required information from the included articles using
a predetermined extraction form. The following data were collected
from each article: study characteristics (authors, year of publica-
tion, country, and study design); population characteristics (sample
size, age of participants, and sex); intervention (type of imaging
assessment, criteria for ADD and DJD); and outcome characteristics
(main results and conclusions). Again, any disagreement in either
Table 1
Summary of descriptive characteristics of included articles.

Author, year, Study design Sample (N, Settings Age in years, mean Imaging Data collection Criteria for ADD Criteria for DJD Main results Conclusions
country female/male (range) analysis (CT, (calibration/ diagnosis diagnosis
(nTMJ) CBCT, or MRI) reproducibility)

Alkhader et al., Observational 55 University hospital 41 (13e69) MRI (1.5 T) Two calibrated DDWR and Erosion, deformity, DJD ¼ 14.28% (in ADDWoR or disc
2010, Japan descriptive 31/24 (106 TMD patients CBCT observers DDWoR sclerosis, ankyloses, DDWR) deformity on MRI
TMJ) Disagreements by flattening, DJD ¼ 81.63% (in are at risk of having
consensus osteophyte DDWoR) osseous
Inter-examiner Erosion ¼ 42% abnormalities in
concordance: good Sclerosis ¼ 40% the TMJ, and
(0.60e0.74) Osteophytes ¼ 13%further
examination with
CBCT is
recommended
Badel et al., 2012, Cross-sectional 30 with OA Department of 52.6 (19e82) MRI NI DDWR and Flattening, DJD ¼ 43.33% (in DJD is associated

M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955

Croatia 25/5 (60 TMJ) prosthodontics Control: CT DDWoR deformity, ADD) with DDWoR,
TMD patients and 23.5 (21e27) sclerosis, although DJD may
control osteophyte, develop in joints
subcortical cyst with physiological
disc position
Bolzan, 2002, Brazil Observational 51 Clinical files and 40 (18e62) MRI NI DDWR and Sclerosis, cyst, DJD ¼ 43% (in ADD) There is a strong
descriptive 46/5 (102 TMJ) MRI DDWoR osteophyte, erosion correlation
TMD patients between DJD and
disc displacement
Butzke et al., 2007, Observational 37 with TMD MRI files from NI MRI One calibrated DDWR and Deformity, DJD ¼ 27.1% (in DJD is significantly
Brazil descriptive (65 TMJ) occlusion discipline examiner DDWoR flattening, sclerosis, DDWR) more frequent in
TMD patients Two times (15 days osteophyte, erosion DJD ¼ 70.6% (in cases with
interval) DDWoR) ADDWoR
Intra-examiner
concordance:
accepted (0.7)

s et al., 2016,
Corte Observational 180 MRI/CT files 33.4 (16e65) MRI Intra-examiner DDWR and Flattening, erosion,DJD ¼ 20.27% (in There is a
Chile descriptive 179/39 (360 TMD patients Groups: CT concordance: 0.86 DDWoR deformity, DDWO) significant
TMJ) 16e25 osteophyte, cyst DJD ¼ 31.11% (in association
26e35 DDWoR) between DDWoR
36e45 Erosion ¼ 25% and DJD in
46e55 Osteophyte ¼ 3% symptomatic
56e65 Subchondral patients with TMD
cyst ¼ 8% (p < 0.001)
Dias et al., 2012, Observational 112 MRI files from (18e70) MRI One trained and DDWR and Condylar bone Disc displacement/ Disc displacement
Brazil descriptive 91/21 (224 radiology TMD calibrated DDWoR changes: flattening, DJD OR ¼ 3422 (in is correlated with
TMJ) patients examiner osteophyte, general); DJD, particularly in
Intra-examiner erosion, sclerosis, OR ¼ 2.737 (DDWR) cases of DDWoR
concordance:  combined OR ¼ 8.250
0.60 degenerative (DDWoR)
changes
Emshoff et al., 2001 Observational 48 Oral surgery and 35.3 (12e79) MRI NI DDWR and Flattening, DJD ¼ 7.4% (in DDWoR is related
Austria descriptive 40/8 (96 TMJ) oral radiology DDWoR sclerosis, surface DDWR) to DJD, however,
departments irregularities, DJD ¼ 72.2% (in while emphasizing
TMD patients erosion, osteophyte DDWoR) that disc
displacement and
DJD may not be
regarded as the
unique and
dominant factor
(continued on next page)

945
Table 1 (continued )

946
Author, year, Study design Sample (N, Settings Age in years, mean Imaging Data collection Criteria for ADD Criteria for DJD Main results Conclusions
country female/male (range) analysis (CT, (calibration/ diagnosis diagnosis
(nTMJ) CBCT, or MRI) reproducibility)

Gil et al., 2012, Observational 74 TMD patients Female: 40.4 (13 MRI Two experienced DDWR and TMJ and temporal DJD ¼ 5.3% (in DJD in the articular
Brazil descriptive 51/23 (148 e69) radiologists (one DDWoR components: DDWR) eminence and the
TMJ) Male: 35.9 (17e58) doctor, one dentist) osteophyte, DJD ¼ 35.2% (in combination of
sclerosis or erosion DDWoR) erosion and
osteophytes in the
condyle are related
to DDWR
Grossmann et al., Observational 100 Diagnostic clinic 49.48 (18e82) MRI One experienced DDWR and Osteophyte, DJD ¼ 9.4% (in Possible
2016, Brazil descriptive 81/19 (200 TMD patients radiologist DDWoR flattening of the DDWR) relationship of
TMJ) condyle, erosion, DJD ¼ 55.7% (in cause and effect
and bone marrow DDWoR) between
edema osteophytes and

M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955

DDWoR
Hasan and Observational 53, Diagnostic 25.9 (19e43) MRI (1.5 T) NI DDWR and More than one of DJD ¼ 43.2% (in There is a direct
Abdelrahman, descriptive 36/17 (106 radiology DDWoR the following DDWR) relationship
2014, Egypt TMJ) department changes were DJD ¼ 60% (in between the degree
TMD patients noted: flattening, DDWoR) of ADD and other
subcortical Risk of TMJ and soft tissue
sclerosis or cyst, degenerative and bone
erosion, changes increased abnormalities
osteophytes, and significantly in
generalized joints with ADD
sclerosis Compared with
normal:
OR ¼ 1.8 (partial
DDWR)
OR ¼ 3.6 (partial
DDWoR)
OR ¼ 4.8 (complete
DDWR)
OR ¼ 6.2 (complete
DDWoR)
Kurita et al., 2000, Observational 130 TMD clinic 30.7 (16e80) MRI One trained DDWR and Erosion, flattening, DJD ¼ 42.35% (in The prevalence of
Japan descriptive 107/23 (170 Probably TMD radiologist and one DDWoR osteophyte, ADD) DJD is significantly
TMJ) patients author eburnation higher in joints
Any disagreements with advanced
were resolved by internal
forced consensus derangement
(p < 0.05)
Melo et al., 2015, Observational 102 Radiology clinic 17 (10e20) MRI (1.5 T) Two experienced According to Adapted from DJD ¼ 45.1% (in Bilateral DJD is
Brazil descriptive 80/22 (204 TMD patients radiologists Ahmad et al. Ahmad et al. ADD) strongly correlated
TMJ) (2009) e as (2009): with ADD
‘normal’ or osteophytes,
‘displaced’ flattening, erosion,
Subclassified sclerosis, edema
into DDwR or
DDwoR
Moncada et al., Observational 88 Orthodontic and 14.7 (10e18) MRI (1.5 T) Blinded and DwD, DDWR, Erosion, concavity, DJD ¼ 39.8% (in Significant
2014, Chile descriptive 65/23 (176 radiology clinic duplicated analysis and DDWoR flattening, ADD) association
TMJ) TMD patients by one of the osteophyte, DJD ¼ 32% (in between DDWoR
authors sclerosis, DDWR) and DJD in children
(Kappa ¼ 0.86) subchondral cyst, DJD ¼ 71% (in and adolescents
and/or deformity DDWoR) with TMD
 Erosion ¼ 26%
Osteophytes ¼ 2%
Subchondral
cyst ¼ 6%
ütcen-Toller
Og Observational 63 TMD patients 28.13 (16e55) MRI (0.5 T) One investigator Degree of ADD: Spurring, flat- DJD ¼ 32% (in DJD is more severe
et al., 2002, descriptive 48/15 (126 Normal tening, and erosion DDWR) with an increased
Turkey TMJ) Slight along the condylar DJD ¼ 62.85% (in degree of ADD
Mild surface, glenoid DDWoR)
Moderate fossa, or articular
Severe eminence
Rao et al., 1990, Observational 138 TMD patients (15e75) MRI (1.5 T) NI Any forward Flattening, DJD ¼ 45% (in There is a
USA descriptive 127/11 (276 deviation of subchondral cyst DDWR) correlation
TMJ) posterior band, Regressive DJD ¼ 64% (in between the
relative to the remodeling: DDWoR) severity of internal
condylar apex, hypoplastic, small, derangement and
constituted or pointed condyles regressive bony
anterior disc condylar

M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955

displacement remodeling
Roh et al., 2012, Observational 254 MRI files Mean Female 26.2 MRI (1.5 T) Two examiners DDWR and Erosion, sclerosis, DJD ¼ 31.7% (in The risk of
Korea descriptive 162/92 (508 TMD patients Male 32.9 Two examiners Inter-examiner DDWoR flattening, DDWR) degenerative
TMJ) (two times) concordance: 0.80 osteophyte DJD ¼ 47.2% (in changes increase
Groups: for disc DDWoR) with ADD
Normal 18 displacement and (although not all
DDR 134 0.66 for disc displacements
DDWR 102 degenerative progress to
disease degenerative
disease, the
possibility of risk of
progression is
increased)
Şener and Akgünlü, Observational 88 (NI) TMD patients NI MRI (1.5 T) Two observers (one DDWR ¼ 130 Erosion, flattening, DJD ¼ 84.6% (in Degenerative
2004, Turkey descriptive (175 TMJ) One clinician clinician, one DDWoR ¼ 45 osteophyte DDWR) changes do not
DDWR ¼ 130 One radiologist radiologist) DJD ¼ 84.4% (in appear to be
DDWoR ¼ 45 DDWoR) markers of either
DDWR or DDWoR
Zhuo and Cai, 2016, Cohort 28 Department of oral 33.1 (20e57) MRI (1.5 T) One examiner DDWoR Erosion, sclerosis, DJD ¼ 51.8% (in Significant increase
China retrospective 22/6 (56 TMJ) surgery 1st MRI e Intra-examiner flattening, ADD e initial) in bone changes in
Patients with disc baseline concordance: 0.75 osteophyte DJD ¼ 75% (in ADD adults with
displacement 2nd MRI e 24 Kappa ¼ 0.75 e follow-up) bilateral DDWoR
e54 months Inconsistency e all (in cases of long
after no authors follow-up of
treatment (Two DDWoR, all discs
times e 1 week remained displaced
interval) and there was a
significant increase
in bone changes,
although some
remained stable)

CBCT e cone beam computed tomography; CT e computed tomography; DD e disc displacement; DDR e disk displacement with reduction; DDWR e disc displacement without reduction; NI e not informed; MRI e magnetic
resonance imaging; NI e not informed; OA e osseous abnormalities; TMJ e temporomandibular joint; TMD e temporomandibular disorder.

947
948 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955

phase was resolved by discussion and agreement between the
three reviewers. A third author (LQP) was involved, when required,
to enable the formulation of the final decision. In cases where the
required data were not available, three attempts were made to
contact each author by email in order to retrieve any pertinent
unpublished information.
2.7. Risk of bias for individual studies
The risk of bias for the selected studies was assessed using the
Joanna Briggs Institute Critical Appraisal Checklist for Studies
Reporting Prevalence Data (2014) (Munn et al., 2014). This
checklist addresses the critical issues of internal and external
validity that must be considered when assessing observational
studies. Two reviewers (MAGS and LQP) independently scored the
risk of bias as ‘low risk’, ‘moderate risk’, or ‘high risk’. Disagree-
ments were resolved by a consensus involving a third author
(ENSG). The risk of bias was categorized by the authors as high
when up to 49% of the items scored ‘yes’, moderate when 50e69%
of the studies scored ‘yes’, and low when more than 70% of the
studies scored ‘yes’.
2.8. Synthesis of the summary measures
Review Manager 5.3 (Rev-Man 5.3, The Nordic Cochrane Centre,
Copenhagen, Denmark) and MedCalc Statistical Software version
14.8.1 (Ostend, Belgium) were used to analyze the data. Heteroge-
neity was calculated using the inconsistency index (I2), with values
higher than 50% being considered indicative of substantial het-
erogeneity between the studies, implying a random effect. The
prevalence of DJD among cases of ADD of the TMJ was assessed
with 95% confidence intervals (CI). The studies were clustered ac-
cording to the type of disc displacement (DDWR or DDWoR) and
the feature of DJD (erosion, osteophyte, sclerosis, and subcortical
cyst).
2.9. Analysis of the subgroups
Subgroup analysis for prevalence was performed by grouping
studies according to the type of disc displacement (DDWR or
DDWoR) and according to the type of degenerative change of the
TMJ (erosion, osteophyte, sclerosis, or subcortical cyst), following
the classification of DC/TMD (Schiffman et al., 2014). Although
cortical sclerosis has been considered an adaptive rather than direct
DJD, ‘sclerosis’ was included in this study since it was not possible
to differentiate cortical from generalized sclerosis within the
studies.
3. Results
3.1. Study selection
The search strategy resulted in 738 articles after removing the
duplicates. A comprehensive evaluation of the titles and abstracts
was performed, and 695 articles were excluded, resulting in 43
potentially useful articles. There were 102 additional studies from
the gray literature search, but only two were included. Conse-
quently, 45 full-text articles from databases were screened ac-
cording to the inclusion and exclusion criteria. The reference lists of
these studies were screened, but no additional studies were
included. No experts suggested the addition of any articles. Finally,
after full-text reading, 27 studies were excluded (Appendix 2) and
18 studies were finally included in this review. A flowchart of the
process of identification, inclusion, and exclusion of studies is
shown in Fig. 1.

Table 2
Results from Joanna Briggs Institute Critical Appraisal Checklist for studies reporting prevalence data (Munn et al. Int J Health Policy Manag 3(3), 123e128, 2014).

Author, year Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Total Risk of bias

Alkhader et al., 2010 Y U Y Y U Y Y Y Y 70.7% Low

Badel et al., 2012 Y U Y Y U Y Y Y Y 70.7% Low
Bolzan, 2002 Y U Y Y U Y U Y Y 60.6% Mod
Butzke et al., 2007 Y N Y Y U Y N Y Y 60.6% Mod
Corte
s et al., 2016 Y U Y Y Y Y Y Y Y 80.8% Low
Dias et al., 2016 Y N Y Y U Y Y Y Y 70.7% Low
Emshoff et al., 2001 Y N Y Y U Y U Y Y 60.6% Mod
Gil et al., 2012 Y N Y Y U Y Y Y Y 70.7% Low
Grossmann et al., 2016 Y U Y Y U Y N Y U 50.5% Mod
Hasan and Abdelrahman, 2014 Y U Y Y U Y Y Y Y 70.7% Low
Kurita et al., 2000 Y U Y Y Y Y Y Y Y 80.8% Low
Melo et al., 2015 Y U Y Y U Y Y Y Y 70.7% Low
Moncada et al., 2014 Y N Y Y U Y Y Y Y 70.7% Low
Ogütcen-Toller et al., 2002 Y N Y Y U Y N Y Y 60.6% Mod
Rao et al., 1990 U U Y Y U Y U U Y 40.4% High
Roh et al., 2012 Y U Y Y U Y Y Y Y 70.7% Low
Şener and Akgünlü, 2004 Y U Y Y Y Y U Y Y 70.7% Low
Zhuo and Cai, 2015 Y U Y Y U Y Y Y Y 70.7% Low

Y yes, N no, U unclear, NA not applicable.

Q1 e Was the sample representative of the target population?
Q2 e Were study participants recruited in an appropriate way?
Q3 e Was the sample size adequate?
Q4 e Were the study subjects and the setting described in detail?
Q5 e Was the data analysis conducted with sufficient coverage of the identified sample?
Q6 e Were objective, standard criteria used for the measurement of the condition?
Q7 e Was the condition measured reliably?
Q8 e Was there appropriate statistical analysis?
Q9 e Are all important confounding factors/subgroups/differences identified and accounted for?
Total ¼ SY/applicable items (the not applicable (NA) items were excluded from the sum).
Risk of bias was categorized as high when the study reached a score of up to 49% ‘yes’, moderate when the study reached a score of 50e69% ‘yes’, and low when the study
reached a score of more than 70% ‘yes’.
 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955 949

Fig. 2. Risk of bias and applicability concerns graph: review of authors' judgments about each risk of bias item for each included study: (A) risk of bias graph; (B) risk of bias
summary.

Fig. 3. Forest plot of prevalence of DJD among ADD (DDWR þ DDWoR).

950 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955

Fig. 4. Forest plot of prevalence of DJD among DDWR.

Fig. 5. Forest plot of prevalence of DJD among DDWoR.

Fig. 6. (A) Forest plot of prevalence of DJD among ADD cases (DDWR þ DDWoR) e young patients only. (B) Funnel plot of the overall effect of DJD among ADD cases for young
population only.
 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955
3.2. Study characteristics
The total sample size was 3158 TMJs in 1631 patients (1161
females and 345 males d a ratio of 3.37:1), with sex not reported
in 125 cases from two studies (Şener and Akgünlü, 2004; Butzke
et al., 2007). The average age was 46 (range 10e82) years. The
18 selected studies were all published between 1990 and 2016
from the following 10 countries: Austria (Emshoff et al., 2001),
Brazil (Bolzan, 2002; Butzke et al., 2007; Gil et al., 2012; Melo
et al., 2015; Dias et al., 2016; Grossmann et al., 2016), Chile
(Moncada et al., 2014; Corte
s et al., 2016), China (Zhuo and Cai,
2016), Croatia (Badel et al., 2012), Egypt (Hasan and
Abdelrahman, 2014), Japan (Kurita et al., 2000; Alkhader et al.,
2010), Korea (Roh et al., 2012), Turkey (Og ütcen-Toller et al.,
2002; Şener and Akgünlü, 2004), and the USA (Rao et al., 1990).
The sample sizes in these studies ranged from 56 to 508 TMJs. Two
studies (Butzke et al., 2007; Şener and Akgünlü, 2004) did not
elucidate the sex ratio in the total sample. From the sample of 16
studies (n ¼ 2818), 84.5% were female. The patients recruited were
mostly from TMD clinics.
From the total sample, it was possible to include data for 1762
TMJs in the quantitative analysis for the prevalence of DJD in both
ADD groups. It was possible to analyze the prevalence of DJD in 800
TMJs with DDWR, and of DJD in 654 TMJs with DDWoR. For each
Fig. 7. Forest plot of prevalence of each DJD among DD cases (DDWR and DDWoR): (A) erosion (23.5%); (B) osteophyte (17.9%); (C) sclerosis (24.3); (D) subcortical cyst (7.636).
951
osseous change in DJD, 737 TMJs were analyzed for erosion, 921 for
osteophyte, 250 for sclerosis, and 487 for subcortical cyst.
All included studies used MRI for the evaluation of DJD and
ADD; however, four studies also used CT or CBCT imaging (Rao
et al., 1990; Alkhader et al., 2010; Badel et al., 2012; Corte
s et al.,
2016). Therefore, in order to reduce the heterogeneity between
the included data, only MRI data were used. Evaluation of ADD was
carried out in most of the studies (Emshoff et al., 2001; Bolzan,
2002; Og ütcen-Toller et al., 2002; Roh et al., 2012; Dias et al.,
2012; Alkhader et al., 2010; Melo et al., 2015) following the usu-
ally accepted criteria for disc displacement: DDWR when the pos-
terior band of the disc was displaced from its normal position
(11:30e12:30 clock position relative to the top of the condyle in the
closed-mouth position), but assumed a normal position upon jaw
opening; DDWoR when the disc was displaced anteriorly in all
mouth positions (Ahmad et al., 2009).
Variability was observed for the DJD criteria. Some authors
included condylar, articular eminence, and fossa bone changes
(Ogütcen-Toller et al., 2002; Gil et al., 2012), while others considered
only condylar changes for the diagnosis of DJD (Dias et al., 2016;
Grossmann et al., 2016). Most of the studies considered flattening as
DJD. Only two out of the 18 included articles did not consider flat-
tening (Bolzan, 2002; Gil et al., 2012). A summary of the descriptive
characteristics of the included articles is provided in Table 1.
952 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955
3.3. Risk of bias within the studies
The complete analysis of the quality assessment items list is pre-
sented in Table 2. All studies were methodologically acceptable;
however, none of them fulfilled all the risk of bias criteria according to
the Joanna Briggs Institute Critical Appraisal Checklist (Ouzzani et al.,
2016). The main methodological limitations of the studies were
related to poor recruitment (Question 2), since the samples were
mostly recruited by convenience, and to Question 5 (Was the data
analysis conducted with sufficient coverage of the identified sam-
ple?). Of the 18 studies, 12 presented a low risk of bias (Kurita et al.,
2000; Şener and Akgünlü, 2004; Alkhader et al., 2010; Dias et al.,
2012; Roh et al., 2012; Gil et al., 2012; Badel et al., 2012; Hasan and
Abdelrahman, 2014; Moncada et al., 2014; Melo et al., 2015; Zhuo
and Cai, 2016; Corte
s et al., 2016). A moderate risk was observed in
five studies (Emshoff et al., 2001; Og ütcen-Toller et al., 2002; Bolzan,
2002; Butzke et al., 2007; Grossmann et al., 2016), and a high risk of
bias was observed in one study (Rao et al., 1990) (Fig. 2).
3.4. Data synthesis and meta-analysis results
Among all 18 studies, Badel et al. (2012) were the only authors to
present data comparing both TMD and control groups. They found
no DJD in the control group. However, there was a statistically
significant difference for degenerative changes between symp-
tomatic and asymptomatic TMD patients (p ¼ 0.009).
The test for heterogeneity showed mostly high heterogeneity;
therefore, the meta-analyses were applied using a random-effects
model.
The meta-analysis for the prevalence of DJD was performed in
order to evaluate DJD in DDWR and DDWoR, combining 13 studies
Fig. 7. (continued).
(Rao et al., 1990; Kurita et al., 2000; Emshoff et al., 2001; Bolzan,
2002; Og ütcen-Toller et al., 2002; Şener and Akgünlü, 2004;
Butzke et al., 2007; Gil et al., 2012; Roh et al., 2012; Hasan and
Abdelrahman, 2014; Moncada et al., 2014; Melo et al., 2015;
Grossmann et al., 2016). As shown in Fig. 3, which represents the
sum of DDWR and DDWoR, we found a prevalence of DJD of around
50% (95% CI 29 189e84 571; n ¼ 1762; p < 0.0001; and high het-
erogeneity, I2 ¼ 92.59%).
ütcen-Toller
Ten studies (Rao et al., 1990; Emshoff et al., 2001; Og
et al., 2002; Şener and Akgünlü, 2004; Butzke et al., 2007; Gil et al.,
2012; Roh et al., 2012; Hasan and Abdelrahman, 2014; Moncada
et al., 2014; Grossmann et al., 2016) had enough data to calculate
the prevalence of DJD in DDWR. We found a prevalence of DJD in
DDWR of around 35% (95% CI 5263e84 615; n ¼ 800; p < 0.0001;
and high heterogeneity, I2 ¼ 95.64%), as presented in Fig. 4.
Eleven studies (Rao et al., 1990; Emshoff et al., 2001; Og ütcen-
Toller et al., 2002; Şener and Akgünlü, 2004; Butzke et al., 2007;
Gil et al., 2012; Roh et al., 2012; Hasan and Abdelrahman, 2014;
Moncada et al., 2014; Grossmann et al., 2016; Zhuo and Cai, 2016)
included enough data to calculate the prevalence of DJD in DDWoR.
We found a prevalence of DJD in DDWoR of 66% (95% CI
47 826e84 444; n ¼ 654; p ¼ 0.0228 and medium heterogeneity,
I2 ¼ 51.84%), as shown in Fig. 5.
It was not possible to separate older and younger ages in order
to show if the DDWR or DDWoR was more related to a specific age
group, since the original studies did not separate them. However,
when excluding the studies that mixed younger and older pop-
ulations, leaving six studies with only adult populations (Bolzan,
2002; Şener and Akgünlü, 2004; Butzke et al., 2007; Roh et al.,
2012; Hasan and Abdelrahman, 2014; Grossmann et al., 2016), the
meta-analysis showed a slightly higher prevalence of 53% (95% CI
 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955
29 189e57 738; n ¼ 889) of DJD in DDWR and DDWoR combined
(p < 0.0001; high heterogeneity, I2 ¼ 96.40%), as shown in Fig. 6
(supplementary file). On the other hand, a separate meta-analysis
grouping the only two studies (Moncada et al., 2014; Melo et al.,
2015) with a young population (10e20 years of age) showed a
prevalence of 49% (95% CI 47 794e48 649; n ¼ 284) of DJD in DDWR
and DDWoR combined (p ¼ 0.8861; low heterogeneity, I2 ¼ 0.00%),
as shown in Fig. 6A. The funnel plot in Fig. 6B shows that the dis-
tribution was symmetric, confirming that there was no publication
bias.
The prevalence of DJD was also investigated for each osseous
change in DJD, considering both DDWR and DDWoR, as illustrated
in Fig. 7: (A) Erosion 23.5%; 95% CI 2206e28 909; n ¼ 737 (Alkhader
et al., 2010; Moncada et al., 2014; Melo et al., 2015; Corte
s et al.,
2016; Zhuo and Cai, 2016). (B) Osteophyte 17.9%; 95% CI
1351e36 923; n ¼ 921 (Alkhader et al., 2010; Badel et al., 2012;
Moncada et al., 2014; Melo et al., 2015; Corte
s et al., 2016;
Grossmann et al., 2016; Zhuo and Cai, 2016). (C) Sclerosis 24.3%;
95% CI 4412e53 061; n ¼ 250 (Alkhader et al., 2010; Melo et al.,
2015; Zhuo and Cai, 2016). (D) Subcortical cyst 7.6%; 95% CI
4730e10 029; n ¼ 487 (Moncada et al., 2014; Corte
s et al., 2016).
A reverse way was also analyzed (the prevalence of ADD among
cases of DJD), grouping two studies (Alkhader et al., 2010; Badel
et al., 2012). Fig. 9 (supplementary file) shows a prevalence of
49% for ADD (DDWR and DDWoR) in patients with DJD (95% CI 34
286e61 538; n ¼ 100; p ¼ 0.0092; high heterogeneity, I2 ¼ 85.28%).
4. Discussion
This systematic review with meta-analyses was the first to
evaluate the prevalence of DJD in patients with ADD. The findings
showed a relatively high prevalence of DJD among DDWoR.
We considered the following to be osseous changes related to
TMJ degenerative disease, as recommended by the Consortium
Network and Orofacial Pain Special Interest Group (Schiffman et al.,
2014): subchondral cyst, erosion, generalized sclerosis, or osteo-
phyte. Sclerosis was considered ‘general sclerosis’ since it was not
possible to identify which kind of sclerosis had been described in
most of the studies. Additional research is needed to separate
flattening and specify general sclerosis in the findings, in order to
correlate the main features of DJD. It is important to highlight that
flattening was considered a sign of DJD of the TMJ in almost all the
studies. Only two studies (Bolzan, 2002; Gil et al., 2012) did not
include flattening in the imaging criteria for DJD. Since 2014, flat-
tening and/or cortical sclerosis have been considered indeter-
minant findings for DJD (Schiffman et al., 2014); however, most of
the studies reported so far have not been designed without flat-
tening. In order to exclude the influence of flattening from the re-
sults, we carried out meta-analyses considering each osseous
change in DJD when it was possible to collect these data in the
included papers.
The prevalence of DJD was higher in DDWoR than in DDWR. The
presence of DJD related to ADD, especially DDWoR, is a common
finding in the literature (Rao et al., 1990; Emshoff et al., 2001;
Bolzan, 2002; Og ütcen-Toller et al., 2002; Butzke et al., 2007;
Alkhader et al., 2010; Dias et al., 2012, 2016; Roh et al., 2012; Badel
et al., 2012; Hasan and Abdelrahman, 2014; Moncada et al., 2014;

s et al., 2016; Grossmann et al., 2016; Zhuo
Melo et al., 2015; Corte
and Cai, 2016), and seems to be a natural progressive change in TMJ
bones. Only one study (Şener and Akgünlü, 2004) included in this
systematic review found no significant difference between DDWR
and DDWoR associated with DJD; however, degenerative changes
were found to be more severe in DDWoR. In a longitudinal study,
Leeuw et al. (1996) found that degenerative changes were not seen
in joints with DDWR in a 30-year follow-up, while DDWoR resulted
953
in degenerative changes in most of the cases. Although the
degenerative changes were evaluated by conventional images, this
paper documented a probable correlation between DDWoR and
degenerative changes. Other longitudinal studies may endorse this
etiological relationship, and may also ascertain which disorder is
the starting point. Our study could not confirm the association
between DDWoR and degenerative changes because all samples
from primary studies were related to TMD clinics. However, the
higher prevalence of osseous changes in DDWoR points in this di-
rection. We also demonstrated a similar prevalence (49%) of ADD
among patients with DJD. This may contribute to discussions on the
association of the conditions in two ways: the case of DDWR
changing to DDWoR and resulting in bone changes, as well as the
bone changes resulting in disc displacement.
Some studies have postulated that subclinical DJD may lead to
pathological tissue responses in the form of internal derangement;
therefore, disc displacement would represent the outbreak of DJD
and not the other way round (Alkhader et al., 2010). However,
clinical and radiological diagnoses of advanced TMJ internal
derangement correlate with histological findings of degeneration
and inflammation of the articular disc and articular surface
degeneration of the condyle, suggesting that subclinical DJD may
not be the cause of pathological tissue responses such as disc
displacement (Dimitroulis, 2005).
It is important to note that the prevalence of DJD may vary ac-
cording to the criteria used for diagnosis. The pathological process
of DJD can be divided into three slowly progressing stages ac-
cording to the natural course of the disease in the TMJ. The initial
phase is the slowest, and although microscopic tissue damage is
already present, it is often undetectable on images (Kalladka et al.,
2014). In the intermediate and late phases, significant osseous
changes occur and the symptoms worsen.
The use of imaging to confirm the clinical diagnosis is a
requirement of the current reference criteria (Schiffman et al.,
2014). However, this implies that the diagnosis is always made in
a late phase of the degenerative disease, in which the probability of
functional loss is higher (Cevidanes et al., 2014). Although the
prevalence of any disease usually increases with imaging and the
observer's ability to detect disease-associated abnormalities (Black
and Welch, 1990), in the case of DJD this prevalence would be
higher if the diagnostic criteria allowed the diagnosis at an early
stage when structural changes are not yet detectable by imaging
(Michelotti et al., 2016).
The similar prevalence among children and adolescents (49%)
observed in the studies by Melo et al. (2015) and Moncada et al.
(2014) does not corroborate the hypothesis of progressive disease,
and leads us to believe that DJD may not be a time-related disorder.
An association between the onset of DDWoR and degenerative TMJ
changes, as well as the severity of clinical manifestations, has been
demonstrated in adolescents and young adults as early as 1 month
after the onset of DDWoR (Lei et al., 2017; Hasan and Abdelrahman,
2014), reinforcing the recommendation for early diagnosis and
intervention of DDWoR, especially in a young population. This
suggests that aging may not be a crucial factor in the pathogenesis
of DJD (Zhao et al., 2011). It is assumed that in DDWoR, degenerative
changes may progress even after the symptoms and signs of TMJ
disorders are resolved or reduced (Kurita et al., 2006).
One study (Lei et al., 2017) only used CBCT to evaluate DJD.
Therefore, to not compromise the homogeneity of the data, we
decided to exclude the report, since it was intended to also corre-
late ADD, which is better evaluated by MRI.
The criteria for disc displacement were heterogeneous among
the studies, but most authors followed the DC/TMD classification
(Schiffman et al., 2014). A displaced articular disc has been
considered as having an important role in the pathology of internal
954 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955
derangement of the TMJ; however, this is also a common finding in
the asymptomatic population. Ribeiro et al. (1997) observed 25% of
joints as having disc displacement in asymptomatic volunteers;
however, the same paper showed an odds ratio of 12.2, suggesting a
strong association between disc displacement and TMD.
To the best of our knowledge, this is the first systematic review
to show this correlation, while representing the compilation of
primary studies. Even after considering some heterogeneity among
the studies, this finding may corroborate the need for longitudinal
studies in order to determine if prevention or early treatment is
necessary as soon as a DDWoR is diagnosed, and to prevent
anomalies in the facial form or symmetry. Although ADD does not
always evolve into painful situations or DJD due to adaptive ca-
pacity, the possibility of an increased risk of DJD should be evalu-
ated individually with regards to the presence of contributing
factors, including genetics.
The limitations of this study include potential heterogeneity
among observational descriptive studies, including two with a
young population (Moncada et al., 2014; Melo et al., 2015). Het-
erogeneity was especially noted in the recruitment of participants
in the studies reviewed, mostly from the TMD population, and the
lack of sufficient coverage of the identified sample, both of which
are inherent in observational studies. The presence of a young
population, although representing heterogeneity, also serves as a
warning of the importance of prevention and early treatment in
order to prevent changes in dentofacial morphology or limited
mandibular growth, leading to facial deformity (Bertram et al.,
2011; Roh et al., 2012). Another limitation is related to the
methods of imaging. Although CT/CBCT is the reference standard
for investigating DJD (Hilgenberg-Sydney et al., 2018), we could not
analyze ADD using CT/CBCT. On the other hand, although not the
preferred approach, it is possible to visualize DJD by MRI, as we
could find in many studies. The use of MRI to detect osseous
changes probably influenced the prevalence presented in our re-
sults, while underestimating initial erosions, which are better
visualized by CT/CBCT. However, the study by Peck et al. on a
consensus-based classification system and associated diagnostic
criteria recommended TMJ CT/CBCT or MRI to evaluate osseous
changes (Peck et al., 2014). The perfect study should use both
methods; however, this is not always possible for ethical reasons
related to ionizing radiation. This systematic review could not
assess the difference in DJD between the general population and
TMD patients, since all studies were conducted with TMD patients.
Future research should include control groups to better understand
the biological behavior of the TMJ and its correlation with DJD and
TMD.
5. Conclusions
The prevalence of DJD in TMD patients with disc displacement
was around 50%, and was higher in DDWoR (66%) than in DDWR
(35%). The most frequent osseous changes of DJD were sclerosis and
erosion, followed by osteophyte and subcortical cyst. Thus, sclerosis
and erosion would be the first radiological signs to be identified
when DJD is suspected.
This meta-analysis revealed the prevalence of very high rates of
DJD in symptomatic patients with DDWoR, thus challenging the
traditional dogma of a time-related progressive DJD. The results
also suggested that the traditional taxonomic concept considering
disc displacement to be a separate clinical entity from DJD may be
misleading. Instead, TMJ disc displacements d at least in symp-
tomatic patients d should be considered as possibly linked to DJD,
and this may go both ways. Therefore, clinicians should adequately
address the frequent DJD aspects in DD in terms of diagnostics and
therapeutic management.
Ethical approval
Not required.
Patient consent
Not required.
Funding
None.
CRediT author statement
MAG Silva: conceptualization, investigation, writing d original
draft preparation. LLQ Pantoja: investigation. KL Dutra-Horst-
mann: investigation. J Valladares-Neto: conceptualization, inves-
tigation, supervision. FL Wolff: investigation. AL Porporatti:
formal analysis. ENS Guerra: investigation, writing d reviewing
and editing. G De Luca Canto: methodology, writing d reviewing
and editing.
Declaration of competing interest
The authors declare that they have no conflicts of interest to
declare.
Acknowledgments
The authors would like to thank Ms Maria Gorete Monteguti
Savi, a health sciences librarian, for assistance in the bibliographic
search.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jcms.2020.08.004.
References
Ahmad M, Hollender L, Anderson Q, Kartha K, Ohrbach R, Truelove EL, John MT,
Schiffman EL: Research diagnostic criteria for temporomandibular disorders
(RDC/TMD): development of image analysis criteria and examiner reliability for
image analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107:
844e860, 2009
Alexiou KE, Stamatakis HC, Tsiklakis K: Evaluation of the severity of temporo-
mandibular joint osteoarthritic changes related to age using cone beam
computed tomography. Dentomaxillofac Radiol 38: 141e147, 2009
Alkhader M, Kuribayashi A, Ohbayashi N, Nakamura S, Kurabayashi T: Usefulness of
cone beam computed tomography in temporomandibular joints with soft tissue
pathology. Dentomaxillofac Radiol 39: 343e348, 2010
Badel T, Pavi
cin IS, Zadravec D, Krapac L, Kern J: Osteoarthritic temporomandibular
joint changes confirmed by magnetic resonance imaging. Reumatizam 59:
15e21, 2012
Bertram S, Moriggls A, Rudish A, Emshoff R: Structural characteristics of bilateral
temporomandibular joint disc displacement without reduction and osteo-
arthrosis are important determinants of horizontal mandibular and vertical
ramus deficiency: a magnetic resonance imaging study. J Oral Maxillofac Surg
69: 1898e1904, 2011
Black WC, Welch HG: Advances in diagnostic imaging and overestimations of dis-
ease prevalence and the benefits of therapy. N Engl J Med 328: 1237e1243,
1990
Bolzan MC: Estudo da correlaça ~o entre sinais clínicos e achados imagenolo
gicos na
ressona^ncia magne
tica da articulaça
~o te
^mporomandibular. SP, Brazil: University
of S~
ao Paulo, 2002 (Unpublished doctoral thesis)
Butzke KW, Chaves KD, Silveira HD: Evaluation of the presence of bone marrow
edema, effusion and osteoarthrosis in TMJs with displacement disc by nuclear
magnetic resonance. RFO 12: 57e62, 2007
Cevidanes LH, Walker D, Schilling J, Sugai J, Giannobile W, Paniagua B, et al: 3D
osteoarthritic changes in TMJ condylar morphology correlates with specific
systemic and local biomarkers of disease. Osteoarthritis Cartilage 22:
1657e1667, 2014
 M.A.G. Silva et al. / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 942e955
Corte
s D, Exss E, Marholz C, Millas R, Moncada G: Association between disk position
and degenerative bone changes of the temporomandibular joints: an imaging
study in subjects with TMD. Cranio 29: 117e126, 2016
Dias IM, Coelho PR, Assis NMP, Leite FPP, Devito KL: Evaluation of the correlation
between disc displacements and degenerative bone changes of the temporo-
mandibular joint by means of magnetic resonance images. Int J Oral Maxillofac
Surg 41(1051e57), 2012
Dias IM, Cordeiro PC, Devito KL, Tavares ML, Leite IC, Tesch Rde S: Evaluation of
temporomandibular joint disc displacement as a risk factor for osteoarthrosis.
Int J Oral Maxillofac Surg 45: 313e317, 2016
Dimitroulis G: The prevalence of osteoarthrosis in cases of advanced internal
derangement of the temporomandibular joint: a clinical, surgical and histo-
logical study. Int J Oral Maxillofac Surg 34: 345e349, 2005
Emshoff R, Rudisch A, Innerhofer K, Bo € sch R, Bertram S: Temporomandibular joint
internal derangement type III: relationship to magnetic resonance imaging
findings of internal derangement and osteoarthrosis. Int J Oral Maxillofac Surg
30: 390e396, 2001
Emshoff R, Innerhofer K, Rudisch A, Bertram S: Clinical versus magnetic resonance
imaging findings with internal derangement of the temporomandibular joint:
an evaluation of anterior disc displacement without reduction. J Oral Maxillofac
Surg 60: 36e41, 2002a
Emshoff R, Innerhofer K, Rudisch A, Bertram S: The biological concept of ‘internal
derangement and osteoarthrosis’: diagnostic approach in patients with
temporomandibular joint pain? Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 93: 39e44, 2002b
Emshoff R, Moriggl A, Rudisch A, Laimer K, Neunteufel N, Crismani A: Are tempo-
romandibular joint disk displacements without reduction and osteoarthrosis
important determinants of mandibular backward positioning and clockwise
rotation? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 111: 435e441, 2011
Gil C, Santos KC, Dutra ME, Kodaira SK, Oliveira JX: MRI analysis of the relationship
between bone changes in the temporomandibular joint and articular disc po-
sition in symptomatic patients. Dentomaxillofac Radiol 41: 367e372, 2012
Grossmann E, Remedi MP, Ferreira LA, Carvalho AC: Magnetic resonance image
evaluation of temporomandibular joint osteophytes: influence of clinical factors
and artrogenics changes. J Craniofac Surg 27: 334e338, 2016
Hasan NMA, Abdelrahman TEF: MRI evaluation of TMJ internal derangement: de-
gree of anterior disc displacement correlated with other TMJ soft tissue and
osseous abnormalities. Egypt J Radiol Nucl Med 45: 735e744, 2014
Hilgenberg-Sydney PB, Bonotto DV, Stechman-Neto J, Zwir LF, Pache ^co-Pereira C,
Canto GL, Porporatti AL: Diagnostic validity of CT to assess degenerative
temporomandibular joint disease: a systematic review. Dentomaxillofac Radiol
47, 2018 20170389
Kalladka M, Quek S, Heir G, Eliav E, Mupparapu M, Viswanath A: Temporoman-
dibular joint osteoarthritis: diagnosis and long-term conservative manage-
ment: a topic review. J Indian Prosthodont Soc 14(6e15), 2014
Kurita H, Ohtsuka A, Kobayashi H, Kurashina K: Flattening of the articular eminence
correlates with progressive internal derangement of the temporomandibular
joint. Dentomaxillofac Radiol 29: 277e279, 2000
Kurita H, Uehara S, Yokochi M, Nakatsuka A, Kobayashi H, Kurashina K: A long-term
follow-up study of radiographically evident degenerative changes in the
temporomandibular joint with different conditions of disk displacement. Int J
Oral Maxillofac Surg 35: 49e54, 2006
Larheim TA, Katzberg RW, Westesson PL, Tallents RH, Moss ME: MR evidence of
temporomandibular joint fluid and condyle marrow alterations: occurrence in
asymptomatic volunteers and symptomatic patients. Int J Oral Maxillofac Surg
30: 113e117, 2001
Larheim TA, Abrahamsson AK, Kristensen M, Arvidsson LZ: Temporomandibular
joint diagnostics using cone beam computed tomography. Dentomaxillofac
Radiol 44, 2015 20140235
Leeuw R, Boering G, van der Kuijl B, Stegenga B: Hard and soft tissue imaging of the
temporomandibular joint 30 years after diagnosis of osteoarthrosis and internal
derangement. J Oral Maxillofac Surg 54: 1270e1280, 1996
Lei J, Han J, Liu M, Zhang Y, Yap AU, Fu KY: Degenerative temporomandibular joint
changes associated with recent-onset disc displacement without reduction in
adolescents and young adults. J Craniomaxillofac Surg 45: 408e413, 2017
Melo DP, Melo SLS, Oliveira LSAF, Ramos-Perez FMM, Campos PSF: Evaluation of
temporomandibular joint disk displacement and its correlation with pain and
955
osseous abnormalities in symptomatic young patients with magnetic resonance
imaging. Oral Surg Oral Med Oral Pathol Oral Radiol 119: 107e112, 2015
Michelotti A, Alstergren P, Goulet JP, Lobbezoo F, Ohrbach R, Peck C, et al: Next steps
in development of the diagnostic criteria for temporomandibular disorders (DC/
TMD): recommendations from the International RDC/TMD Consortium
Network workshop. J Oral Rehabil 43: 453e467, 2016
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group: Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med
21: e1000097, 2009
Moncada G, Corte
s D, Millas R, Marholz C: Relationship between disk position and
degenerative bone changes in temporomandibular joints of young subjects
with TMD. An MRI Study. J Clin Pediatr Dent 38: 269e276, 2014
Munn Z, Moola S, Riitano D, Lisy K: The development of a critical appraisal tool for
use in systematic reviews addressing questions of prevalence. Int J Health Policy
Manag 3: 123e128, 2014
National Institute of Dental and Craniofacial Research. Facial Pain. https://www.
nidcr.nih.gov/research/data-statistics/facial-pain.
Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A: Rayyan d a web and mobile
app for systematic reviews. Syst Rev 5(2e10), 2016
Ogütcen-Toller M, Taşkaya-Yilmaz N, Yilmaz F: The evaluation of temporoman-
dibular joint disc position in TMJ disorders using MR. Int J Oral Maxillofac Surg
31(603e07), 2002
Pantoja LLQ, de Toledo IP, Pupo YM, Porporatti AL, De Luca Canto G, Zwir LF,
Guerra ENS: Prevalence of degenerative joint disease of the temporomandib-
ular joint: a systematic review. Clin Oral Investig 11. https://doi.org/10.1007/
s00784-018-2664-y, 2018
Peck CC, Goulet JP, Lobbezoo F, Schiffman EL, Alstergren P, Anderson GC, de
Leeuw R, Jensen R, Michelotti A, Ohrbach R, Petersson A, List T: Expanding the
taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral
Rehabil 41(2e23), 2014
Pupo YM, Pantoja LL, Veiga FF, Stechman-Neto J, Zwir LF, Farago PV, De Luca
Canto G, Porporatti AL: Diagnostic validity of clinical protocols to assess
temporomandibular disk displacement disorders: a meta-analysis. Oral Surg
Oral Med Oral Pathol Oral Radiol 122: 572e586, 2016
Rao VM, Babaria A, Manoharan A, Mandel S, Gottehrer N, Wank H, Grosse S: Altered
condylar morphology associated with disc displacement in TMJ dysfunction:
observations by MRI. Magn Reson Imaging 8: 231e235, 1990
Ribeiro RF, Tallents RH, Katzberg RW, Murphy WC, Moss ME, Magalhaes AC,
Tavano O: The prevalence of disc displacement in symptomatic and asymp-
tomatic volunteers aged 6 to 25 years. J Orofac Pain 11: 37e47, 1997
Roh HS, Kim W, Kim YK, Lee JY: Relationships between disk displacement, joint
effusion, and degenerative changes of the TMJ in TMD patients based on MRI
findings. J Craniomaxillofac Surg 40: 283e286, 2012
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, List T, Svensson P,
Gonzalez Y, Lobbezoo F, Michelotti A, Brooks SL, Ceusters W, Drangsholt M,
Ettlin D, Gaul C, Goldberg LJ, Haythornthwaite JA, Hollender L, Jensen R,
John MT, De Laat A, de Leeuw R, Maixner W, van der Meulen M, Murray GM,
Nixdorf DR, Palla S, Petersson A, Pionchon P, Smith B, Visscher CM,
Zakrzewska J, Dworkin SF, International Rdc/Tmd Consortium Network IafDR,
Orofacial Pain Special Interest Group IAftSoP: Diagnostic criteria for temporo-
mandibular disorders (DC/TMD) for clinical and research applications: recom-
mendations of the International RDC/TMD Consortium Network and Orofacial
Pain Special Interest Group. J Oral Facial Pain Headache 28(6e27), 2014
Şener S, Akgünlü F: MRI characteristics of anterior disc displacement with and
without reduction. Dentomaxillofac Radiol 33: 245e252, 2004
Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P,
Stewart LA, PRISMA-P Group: Preferred reporting items for systematic review
and meta-analysis protocols (PRISMAP) 2015: elaboration and explanation. BMJ
349: g7647. https://doi.org/10.1136/bmj.g7647, 2015
Zhao Y, Zhang Z, Wu Y, Zhang W, Ma X: Investigation of the clinical and radio-
graphic features of osteoarthrosis of the temporomandibular joints in adoles-
cents and young adults. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 111:
e27ee34, 2011
Zhuo Z, Cai XY: Radiological follow-up results of untreated anterior disc
displacement without reduction in adults. Int J Oral Maxillofac Surg 45:
308e312, 2016