Original Article Bisi et al.

Relationship between sounds and disc

displacement of the temporomandibular joint
using magnetic resonance imaging
Relao entre rudo e deslocamento de disco da articulao
temporomandibular utilizando imagem de ressonncia magntica

Abstract Maurcio Andr Bisia,b

Karen Dantur Batista Chavesa
Purpose: Magnetic resonance imaging (MRI) is useful for interpreting temporomandibular joint Edela Puricellia
(TMJ) disorders including disc displacement. This study aimed to evaluate the relationship Deise Ponzonia
Eleutrio Arajo Martinsb
between TMJ sounds and disc displacement with and without reduction by clinical examination
and MRI.
Methods: A sample of 58 patients was clinically examined when after being referred to MRI
due to signs and symptoms of unilateral or bilateral TMJ disc displacement. The diagnosis a Federal University of Rio Grande do Sul, Porto
obtained using MRI was compared with the clinical findings for the presence or absence of Alegre, RS, Brazil
b ABO-RS, Porto Alegre, RS, Brazil
articular sounds.
Results: Most patients (n=39; 67%) had joint sounds manifested as clicking; the other 19
patients (33%) did not present sounds. Among the 39 patients with sounds, bilateral clicking
was observed in 29 (74%), and unilateral clicking in 10 (26%) patients. Unilateral clicking was
equally observed on the right and left sides, each occurring in 5 five patients (13%).
Conclusion: The results suggest that articular sounds do not occur exclusively in TMJ with disc
displacement with reduction. The presence or absence of joint sounds will not suffice as the
only aspect criterion to be considered in the differential diagnosis of disc displacement with
and without reduction.
Key words: Temporomandibular joint; disc displacement; joint sounds; magnetic resonance
imaging

Resumo
Objetivo: A ressonncia magntica nuclear (RMN) de grande utilidade para o diagnstico
das desordens temporomandibulares, inclusive o deslocamento de disco muito comum. O
objetivo deste estudo foi avaliar a relao entre rudo articular e deslocamento de disco com
e sem reduo por meio de avaliao clinica e ressonncia magntica nuclear.
Metodologia: O estudo examinou 58 pacientes clinicamente, que foram submetidos RMN
quando apresentavam de sinais e sintomas de deslocamento de disco uni ou bilateral. O
diagnstico obtido pela RMN foi comparado com os achados clnicos relativos presena
ou no de rudo articular.
Resultados: Dos 58 indivduos estudados, 39 (67%) apresentaram rudo articular do tipo click,
os restantes 19 (33%) no apresentaram rudos. Dos 39 com rudo, a ocorrncia bilateral
foi de 29 (74%) e unilateral em 10 (26%) casos, sendo 5 (13%) do lado direito e 5 (13%) do
lado esquerdo.
Concluso: Os resultados demonstraram que os rudos articulares no esto restritos a
articulaes com deslocamento de disco com reduo. A presena ou ausncia de rudo
articular no devem ser os nicos aspectos considerados para o diagnstico diferencial entre
deslocamento de disco com e sem reduo.
Palavras-chave: Articulao temporomandibular; deslocamento de disco; rudo articular;
imagem por ressonncia magntica Correspondence:
Mauricio Andr Bisi
R. Conde DEu, 1405 B
Caxias do Sul, RS Brasil
95076-090
E-mail: [email protected]

Received: February 20, 2009

Accepted: November 6, 2009

Rev. odonto cinc. 2010;25(1):37-41 37

Relationship between sounds and TMJ disc displacement

Introduction and function of the joint, such as the impact between joint
structures, the deformation of these structures, and the
The normal temporomandibular joint (TMJ) is described changes in the quality of the synovial fluid. The impacts
as silent. However, sounds may be heard in individuals between the condyle and the mandibular fossa are associated
who may or may not present the typical symptoms of with subluxation (Fig. 1), disc displacement (Fig. 2) and
temporomandibular disorders (TMD) (1). Different osteoarthritic changes (Fig. 3). These events lead to an
mechanisms are involved in the occurrence of TMJ sounds, increase in the friction between joint elements and thus
which probably reflect some abnormality in the structure generate sounds (1).

Fig. 1. Subluxation: (A) mouth closed; (B) mouth opened.

Fig. 2. Disc displacement: (A) mouth closed; (B) mouth opened.

Fig. 3. Condyle with

ostheorarthritic change.

38 Rev. odonto cinc. 2010;25(1):37-41

 Bisi et al.

Although the presence of TMJ abnormalities does not Dentistry, Federal University of Rio Grande do Sul, Porto
necessarily imply the progression of symptoms, a detailed Alegre, Brazil. The patients underwent clinical examination
investigation is required every time any of the typical by two calibrated examiners and then by bilateral MRI. The
TMD symptoms is diagnosed. The efficient evaluation of images were obtained on the parasagittal plane and on the
temporomandibular sounds may play an important role in coronal plane in the closed-mouth position. Images were
TMD diagnosis and treatment (2). also obtained in the parasagittal plane, open-mouth position.
One of the criteria adopted to differentiate disc displacements Patients underwent MRI when signs and symptoms of unilateral
with reduction and those without reduction is the presence or bilateral disc displacement were observed. The final
of articular sound. In previous papers, disc displacement diagnosis of the disc position was based on the MRI findings,
without reduction was associated with articular sounds (3,4). according to criteria described by Westesson et al. (12).
Nevertheless, Miller et al. (5) reported that approximately The diagnosis obtained by MRI was compared to the clinical
15% of TMJs with preliminary diagnoses of disc displacement findings related to the presence or absence of articular sound
with reduction, based on the presence of a reciprocal click, using the test.
exhibited disc displacement without reduction in magnetic
resonance imaging (MRI). Conversely, Mueller-Leisse et Results
al. (6) concluded that articular sounds are not helpful as
indicators of the degree of internal TMJ dysfunction. These From the total of 58 subjects examined, 39 presented articular
authors reported that audible sounds during mouth opening sounds defined as clicking. The remaining 19 subjects did
or closing or lateral jaw movements were observed in 52% of not present any articular sounds (Table 1).
TMJs diagnosed with disc displacement without reduction, When these variables are analyzed conjointly, 24 patients
in 67.5% of TMJs with reduction, and in 68.7% of joints who presented disc displacement with reduction also
whose disc was properly positioned. In another study (7), exhibited intra-articular sound (click). Whenever disc
clicking was observed in 36% of the joints presenting normal displacement with reduction was observed, the disorder
disc positions, in 82% of joints with disc displacement with occurred bilaterally. Nevertheless, 15 patients who had
reduction, and in 55% of TMJs exhibiting disc displacement disc displacement without reduction presented unilateral
without reduction. These studies used MRI as a diagnosis or bilateral sound, while the other 10 patients with disc
tool. displacement without reduction did not produce any articular
Other studies have demonstrated the usefulness of MRI sound. Nine patients had no changes in disc position and
in the diagnosis of TMD (8-10). MRI affords excellent noise.
descriptions of the TMJ anatomy of and the likely disorders
that affect the structure due to the high gain using contrasts Discussion
and to the high definition. Serial images of opened and closed
mouths permit the morphological and functional evaluation Different methods have been used to obtain TMJ images
of the TMJs. These images also allow the assessment (13). The physical proximity of the TMJ to the cranial base
of the degree of abnormality when such condition is makes it more difficult to obtain clear radiographs, without
present (11). superimposition of structures. Technological advancements
This study evaluated the relationship between articular sound allowed section images of hard tissues and accurate
and disc displacement with and without reduction using descriptions of soft tissues to be obtained, which in the past
clinical examination and magnetic resonance imaging. were feasible only by conducting invasive procedures (14).
MRI of the TMJ provides essential information on the
Methods position, signal intensity, morphology and structure of
the articular disc. The technique also offers insights into
This study was approved by the Ethics Committee of the the cortical and medullar bone tissue and the retrodisc
School of Dentistry, Federal University of Rio Grande do tissue (15). MRI is a non-invasive method useful in the
Sul, Brazil. detection of TMJ disc displacements and in the landmarking
A retrospective study was conducted with 58 individuals of disc position in patients suspected of internal disorders.
referred for an evaluation of temporomandibular conditions Clinical and experimental studies have demonstrated the
to the Service of the Course of Occlusion Studies, School of high accuracy afforded by this imaging technique (10).

Table 1. Clinical findings related Present

to disc displacement and the presence Displacement/ Sounds Absent N
Right Left Bilateral
or absence of temporomandibular With reduction 24 (41.4%) 24 (41.4%)
joint sounds.
Without reduction 5 (8.6%) 5 (8.6%) 5 (8.6%) 10 (17.2%) 25 (43.0%)
Normal 9 (15.6%) 9 (15.5%)
Total 39 (67.2%)* 19 (32.8%)* 58 (100%)

* 2=38.544, P<0.001.

Rev. odonto cinc. 2010;25(1):37-41 39

Relationship between sounds and TMJ disc displacement

Disc displacements are defined as abnormal positions of that tissue changes in the retrodisc portion, which is subject
the articular disc against the condyle and the TMJ articular to articular efforts, explain this clinical sign. Miller et al.
eminence. The disorder has been linked to pain, articular (5) described the mechanism involved in sounds observed
sounds and limited mouth opening (16). Articular sounds in TMJs presenting disc displacement without reduction as
of the clicking type as during mouth opening and closing a friction impact between the condyle and the posterior band
are characteristic clinical signs of disc displacement with of the displaced disc. This kind of impact would cause a
reduction (17). Nevertheless, the present results demonstrate single sound at the maximum amplitude of movement.
that articular sounds are not restricted to the TMJs that have The extension of disc displacement also influences the
that disorder. The findings of the present study indicate a occurrence of sounds in TMJs with disc displacement without
positive correlation between clicking and disc displacement reduction. Kurita et al. (20) concluded that permanently
with reduction. However, this sound also occurred in disc displaced articular discs are more anteriorly positioned
displacement without reduction. This corroborates with other compared to those presenting reduction. The position of
studies, casting doubt over the use of clinical examination as the articular disc during the mouth opening movement may
the only diagnostic approach to be adopted for the detection determine the type of disc displacement and the occurrence
of internal TMJ disorders (5). of sounds. Articular sounds occur more often in cases of
Other clinical examination procedures may be used to disc displacement with reduction, though sound may also
diagnose disc displacement, such as mouth opening be observed in disc displacement without reduction. This
movements in mandibular protrusion and the use of tongue suggests that the more anteriorly located the disc inside the
depressors between the palatal arches. In this case, the TMJ, the lower the chances that it should produce sounds.
elimination of articular sound may indicate disc displacement The present study demonstrated a variety of TMD signs and
without reduction (18). In the present study, the TMJs with symptoms. Therefore, it is necessary to conduct accurate
disc displacement without reduction also presented sounds, clinical diagnosis of the anatomic and functional changes
similarly to the findings by Miller et al. (5). However, the that are manifested in the TMJ. In this scenario, high
sounds occurred on both the affected and unaffected sides, quality images may be used concurrently to reach a correct
which demonstrates the functional relationship between the diagnosis, which in turn helps to define the best treatment
right and the left TMJ sides. approach for specific cases.
The reporting of different sounds concurrently may influence
results because sounds can vary with the change in disc Conclusions
position due to the treatments conducted and even in the
absence of any intervention. This situation has been described The presence or absence of articular sound should not be
by Lundh et al. (19) with 23 disc displacement patients the only factor considered in the differential diagnosis of
who presented reciprocal clicking and had no treatment for disc displacement with and without reduction. Complemen-
52 weeks. The authors observed that the reciprocal sound tary exams, such as MRI, are highly valuable in the
disappeared in two patients after six weeks, and in only characterization of intra-articular disorders and thus improve
one patient, mandible locking developed after two weeks. accuracy in diagnosis and adequacy in treatment. A more
However, the reciprocal sound remained unaltered in the detailed analysis on the occurrence of disc displacement
other patients. may add to a better comprehension of these differences and
Some cases of disc displacement without reduction were thus establish more precise clinical criteria for the diagnosis
observed with the occurrence of articular sound. It is believed of TMJ disorders.

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