Int. J. Oral Maxillofac. Surg.

2001; 30: 104–112

doi:10.1054/ijom.2000.0017, available online at http://www.idealibrary.com on

Leading clinical paper:

Orthognathic surgery/trauma/TMJ disorders
Tore A. Larheim1,2
MR grading of Per-Lennart Westesson3,
Tsukasa Sano4
1

temporomandibular joint fluid: Department of Maxillofacial Radiology,

Faculty of Dentistry, University of Oslo,
Norway; 2Eastman Department of Dentistry,
University of Rochester School of Medicine

association with disk and Dentistry, NY, USA; 3Department of

Radiology, Division of Neuroradiology,
University of Rochester School of Medicine

displacement categories, and Dentistry, Rochester NY, USA;

4
Department of Oral Radiology, Showa
University School of Dentistry, Tokyo, Japan

condyle marrow abnormalities

and pain
T. A. Larheim, P.-L. Westesson, T. Sano: MR grading of temporomandibular joint
fluid: association with disk displacement categories, condyle marrow abnormalities
and pain. Int. J. Oral Maxillofac. Surg. 2001; 30: 104–112.  2001 International
Association of Oral and Maxillofacial Surgeons

Abstract. The purpose of this study was to investigate temporomandibular joint

(TMJ) effusion on magnetic resonance (MR) images, and its association with specific
categories of disk displacement, bone marrow abnormalities and pain. From a series
of 523 consecutive TMJ MR imaging studies of patients referred to imaging because
of pain and dysfunction, those with TMJ effusion, defined as an amount of fluid that
exceeded the maximum amount seen in a control group of asymptomatic volunteers,
were analysed. The selected patients were reassessed and the amount of TMJ fluid
was graded bilaterally according to a set of reference films. Other parameters
recorded included disk displacement categories and condyle marrow abnormalities.
Pain self-records were obtained from the patients immediately before MR imaging.
The association between the recorded parameters and TMJ pain was analysed with
t-tests and regression analysis. Of the 523 patients, 70 (13%) had TMJ effusion,
which was unilateral in 61%. Only 9% of the 70 patients had effusion bilaterally,
whereas bilateral disk displacement was found in 80%. In the 76 joints with effusion,
83% showed two specific categories of disk displacement at closed mouth. Condyle
marrow abnormalities were found in 31% of the 70 patients, mostly on one side, and
in 24% of the 76 joints. An in-patient regression analysis of the side difference in Key words: temporomandibular joint; internal
TMJ pain showed that effusion and condyle marrow abnormalities were significant derangement; joint effusion; bone marrow
pain-increasing factors. In conclusion, patients with TMJ effusion represent a edema; bone marrow necrosis; osteonecrosis.
subgroup with pain and dysfunction with more severe intra-articular pathology than
those with disk displacement but no other joint abnormalities. Accepted for publication 24 September 2000

Numerous studies have demonstrated a (TMJ) pain and dysfunction, but studies edge of why disk displacement is sometimes
high prevalence of disk displacement in have also shown that displacement may painful and is sometimes not, other intra-
patients with temporomandibular joint present without any pain6. To gain knowl- articular abnormalities should be studied.
0901-5027/01/020104+09 $35.00/0  2001 International Association of Oral and Maxillofacial Surgeons

Previous magnetic resonance (MR)
imaging studies have focused on signal
alterations in the joint compartments
indicating fluid. In one of these studies
an association with pain was found23,
whereas in another, this association was
questioned14. Magnetic resonance signal
alterations in the condyle marrow have
also been reported, suggesting the occur-
rence of marrow edema and osteonecro-
sis18,20 while others have considered
such alterations to be caused by osteo-
arthritis11. Recently, histological evi-
dence for the existence of marrow edema
and osteonecrosis was documented9.
In a series of 62 asymptomatic
volunteers examined bilaterally by MR
imaging, we could demonstrate that
small amounts of fluid were present in
more than half of the subjects, whereas
none had signal alterations in the con-
dyle marrow7. The observations were
compared to those in a group of 58
patients with TMJ pain and dysfunction,
and about 10% proved to have an
amount of fluid that exceeded the
maximum amount seen in the volun-
teers. A similar percentage showed
signal intensity alterations in the man-
dibular condyle7, supporting recent
studies11,17. In another study comparing
different categories of disk position in
the same subjects, we could show that
two specific categories of disk displace-
ment were the only ones that were sig-
nificantly more prevalent in the patients
than in the volunteers10.
Fig. 1. MRI of the TMJ in a 28 year-old man. (A) Sagittal oblique proton density image and (B) Corresponding T2-weighted image show
displaced disk (arrow) in lateral part of the joint (condyle not seen) and fluid in upper compartment of the anterior recess (arrow head). This was
used as reference film for the definition of moderate fluid, which was at least this amount.
TMJ effusion and marrow abnormalities 105
Table 1. Grading system for categorizing the amount of TMJ fluid on MR images
Category Definition Illustration
No or minimal fluid No bright T2 signal from joint compartments or dots or
lines of bright T2 signal along articular surfaces
Moderate fluid Equal to this amount of bright T2 signal or more, but Fig. 1
less than the amount defined as marked fluid
Marked fluid Equal to this amount of bright T2 signals or more, but Fig. 2
less than the amount defined as extensive fluid fluid
Extensive fluid Equal to this amount of bright T2 signal or more Fig. 3
The aim of the present study was preted by one of the authors (P-L W).
to study TMJ effusion in a larger The cases with a report of ‘joint fluid’
consecutive series of patients with were reassessed by another author
pain and dysfunction referred for MR (TAL). In the reassessment, only
imaging, and its association with specific patients with an amount of TMJ fluid
categories of disk displacement, condyle that was larger than the maximum
marrow abnormalities and pain. amount found in the control subjects,
were selected for further analyses. This
series consisted of 70 patients with a
Material and methods mean age of 35.6 years (SD=14.2) and a
To recruit patients with TMJ pain and range from 11 to 81 years.
dysfunction and with amounts of fluid All MR imaging studies were obtained
exceeding those seen in a control group with a 1.5 T Signa Imager (General
of asymptomatic volunteers7, we Electric, Milwaukee, WI) and consisted
reviewed the reports of bilateral TMJ of oblique sagittal and oblique coronal
MR imaging studies of 523 consecutive proton density and T2 weighted images
patients examined from January 1995 to at closed mouth and, additionally,
May 1996. Those with previous TMJ oblique sagittal proton density and T2
surgery, systemic inflammatory joint weighted images at open mouth15.
disease, facial growth disturbances, Both TMJs in each of the selected
direct trauma to or fractures of patients were graded for joint fluid
facial bones, condylar hypoplasias/ according to a set of reference films as
hyperplasias/tumours and inferior image described in Table 1 and Figures 1–3.
quality had been excluded (83 from the Condyle marrow abnormalities were
total consecutive series of 606 patients). recorded as present or absent and classi-
All of these studies were initially inter- fied as proposed by L et al.9, and
106 Larheim et al.

Fig. 2. MRI of the TMJ in a 30 year-old woman. (A) Sagittal oblique proton density image of lateral part of the joint (c=condyle) and (B)
Corresponding T2-weighted image show anteriorly displaced and deformed disk (arrow) and fluid in upper compartment of the anterior recess
(arrow head). This was used as reference film for the definition of marked fluid,which was at least this amount.

Fig. 3. MRI of the TMJ in an 18 year-old woman. (A) Sagittal oblique proton density image of lateral part of the joint (c=condyle) and (B)
Corresponding T2-weighted image show anteriorly displaced and deformed disk (arrow) and fluid in upper compartment of the anterior recess
(arrow head). This was used as reference film for the definition of extensive fluid, which was at least this amount.

shown in Table 2. Cortical bone abnor-
malities (erosions, osteophytes, sclerosis)
indicating osteoarthritis or inflamma-
tory arthritis, were recorded as present
or absent. A detailed classification of
disk position at closed mouth was made,
modified after T et al.22, as recently
described10. Additionally, disk position
at open mouth was determined.
Pain record was obtained from the
questionnaire, which the patient filled in
before MR imaging and was based on
TMJ pain on chewing. In particular, the
patients were asked to specify the side
and side difference if they had bilateral
pain. The degree of pain was reported as
none, mild, moderate, severe or extreme.
Of the 70 patients, five did not have pain
records available.
In the statistical analyses all variables
recorded were first dichomotized: TMJ
fluid (all joints with moderate fluid or
more were included), condyle marrow
abnormalities, abnormal disk position
at closed mouth (all joints with com-
plete anterior or anterolateral disk dis-
placements were included) and anterior
disk displacement at open mouth. The
variables of the pain-free joints in
the patient group and the joints in the
control group of asymptomatic volun-
teers were compared using Fisher’s
exact test. A regression analysis of the
in-patient side difference of TMJ pain
was then made with the following vari-
ables: age, sex and differences between
the right and left joint concerning fluid,
disk displacement at closed mouth,
disk displacement at open mouth, bone
 TMJ effusion and marrow abnormalities 107

Table 2. Alterations in the mandibular condyle marrow on MR images categorized according Discussion
to L et al.9
Category Definition The present investigation focused on
Normal marrow Homogeneous bright signal on proton density and homogeneous TMJ effusion and condyle marrow
intermediate signal on T2 weighted images abnormalitites in addition to disk dis-
Marrow edema Decreased signal on proton density and increased signal on T2 weighted placement, and showed that pain-free
images; edema pattern joints in the patient group had signifi-
Osteonecrosis A. Decreased signal on proton density and on T2 weighted image;s; cantly more disk displacement, fluid and
sclerosis pattern
B. Combination of edema pattern and sclerosis pattern; ‘combined’
cortical bone abnormalities, but not
pattern bone marrow abnormalities, than joints
in the asymptomatic volunteer group.
Thus, the patients seemed to have cer-
Table 3. Number of joints (n=76) with marked or extensive joint fluid (see Table 1) related to tain joint abnormalities when compared
disk position at closed mouth10 (modified after T et al.22), disk displacement at open to healthy controls. As a result of
mouth, bone marrow abnormalities (see Table 2) and cortical bone abnormalities bilateral disk displacement being so
Disk position categories at closed mouth* common in the patient group, we made a
regression analysis of the in-patient side
NL PA (lat) A PAL AL AM L Total
difference of the recorded variables that
All joints 3 4 35 4 28 1 1 76 showed a significant and positive associ-
Disk displacement at open mouth 27 22 1 1 51
ation between TMJ pain, effusion and
Bone marrow abnormalities 1 10 6 1 18
Cortical bone abnormalities 2 16 1 10 1 1 31 bone marrow abnormalities.
Since MR evidence of TMJ fluid was
*NL=disk is normally positioned in all oblique sagittal and coronal images. first recognized in 19852, several studies
PA(lat)=disk is anteriorly displaced in lateral portion of joint and otherwise normally have demonstrated the typical bright sig-
positioned. nal on T2-weighted images from the
A=disk is anteriorly displaced in entire joint without a lateral or medial displacement.
PAL=disk is anteriorly displaced in lateral portion of joint with a lateral displacement in
joint space in patients with TMJ pain
addition and otherwise normally positioned. and dysfunction14,16,19,23. However,
AL=disk is anteriorly displaced in entire joint with a lateral displacement in addition. observations in healthy volunteers have
AM=disk is anteriorly displaced in entire joint with a medial displacement in addition. been limited to only a few cases until we
L=disk is laterally displaced and otherwise normally positioned. could demonstrate in a larger series of
volunteers that dots or lines of bright
T2-signal are commonly seen and evenly
marrow abnormalities and cortical condyle, of which 20 (90.9%) had uni- distributed between upper, lower and
bone abnormalities. lateral findings. Of the 24 joints, eight both TMJ compartments7. More than
showed edema pattern (Fig. 6), eight this amount was categorized as moder-
showed sclerosis pattern (Fig. 7) and ate fluid and found in about one fifth of
Results
eight showed ‘combined’ pattern (Fig. the volunteers. When compared to find-
Seventy of the 523 patients (13.4%) had 8). Of the total of 76 joints, 18 (23.7%) ings in a patient group with pain and
TMJ effusion, i.e., either marked (Fig. 2) had condyle marrow abnormalities dysfunction, about 10% proved to have
or extensive TMJ fluid (Fig. 3), which (Table 3). an amount of TMJ fluid that was larger
was unilateral in 43 (61.4%). Of those Concerning pain-free joints, t-tests than that found in any of the volun-
with bilateral fluid, the majority had between patients and volunteers showed teers7. In the study group of 58 patients,
moderate fluid (Fig. 1) in the contra- that the patient group had significantly this constituted six patients.
lateral joint. Only six (8.6%) of the 70 more joint fluid, disk displacement at In the present study we wanted to
patients had effusion bilaterally. Of the closed mouth, disk displacement at record more patients with unquestion-
total of 76 joints (Table 3), 68.4% open mouth and cortical bone abnor- able TMJ effusion. Of the 85 patients
showed effusion exclusively or predomi- malities. No significant differences with a routine report of ‘joint fluid’, 15
nantly in the upper compartment of the could be found concerning the were excluded when the MR films were
anterolateral recess (Figs 2, 3). The condyle marrow abnormalities in these reassessed and compared to the set of
most impressive effusions also occurred comparisons. reference films. The majority of those
in other parts of the joint (Fig. 4). Regression analysis showed that the excluded had an amount of fluid that
Sixty-seven (95.7%) of the 70 patients self-reported in-patient TMJ pain side was similar to the maximum amount of
had disk displacement, which was difference was positively dependent on fluid seen in the healthy volunteers7.
bilateral in 56 patients (80%). Of the TMJ fluid (P=0.000) and condyle mar- Thus, the frequency of 13.4% virtually
total of 76 joints, 63 patients (82.9%) row abnormalities (P=0.001), and nega- represents those with TMJ effusion, i.e.
had either anterior disk displacement in tively dependent on cortical bone an increased amount of TMJ fluid when
all oblique sagittal images without any abnormalities (P=0.005) when they compared to the healthy controls.
sideways component, i.e. complete occurred simultaneously with fluid and Our figure can not be compared with
anterior disk displacement (Fig. 4) or abnormal bone marrow. The following previously reported frequencies of TMJ
complete anterior disk displacement variables did not show significance in the effusion, which have been as high as
with a lateral component, i.e. antero- regression analysis: age (P=0.311), sex 88%19, because most studies have not
lateral displacement (Fig. 5). (P=0.204), disk displacement at closed graded the amount of fluid in patients or
Twenty-two (31.4%) of the 70 patients mouth (P=0.177) and disk displacement in volunteers. A differentiation between
had bone marrow abnormalities in the at open mouth (P=0.610). normal and abnormal joint fluid has
108 Larheim et al.

Fig. 4. MRI of the TMJ in a 54 year-old man. (A) Sagittal oblique proton density image and (B) Corresponding T2-weighted image show
anteriorly displaced and deformed disk (arrow), severe osteoarthritis (c=condyle) and extensive fluid in upper compartment of the anterior recess
and in posterior recess as well (arrow heads). (C) Coronal oblique proton density image and (D) Corresponding T2-weighted image show the disk
(arrows) in anterior position to the condyle (not seen) without any lateral or medial component and extensive fluid in upper compartment of the
lateral and medial recesses (arrow heads).

only been suggested in two studies,
defining no T2-signal or a line of signal
along the articular surfaces as nor-
mal14,23. With this definition, about 30%
of patients7 and about 30% of joints in
patients23 referred for TMJ MR imaging
have shown joint effusion.
Our detailed imaging analysis
showed that the joint effusion was
most commonly seen in the upper space
of the anterolateral recess. This specific
localization is in agreement with pre-
vious reports19,23. From the present
study, however, it was clear that TMJ
effusions may also occur in the lower or
in both spaces. Although most effusions
were seen in the lateral part of the joint,
some effusions were also seen in the
medial part. The oblique coronal images
were helpful to visualize the distribution
of fluid in the mediolateral direction. In
the present study, all the joint effusions
were seen in both the sagittal and coro-
nal images. In joints with a smaller
amount of fluid, it could occasionally be
seen either in sagittal or in coronal
images, substantiating a previous study
using both imaging planes23.
About 83% of the joints with effusion
in the present series showed either
complete anterior disk displacement or
complete anterior disk displacement
with a lateral component, i.e. antero-
lateral displacement. This association
with specific subgroups of disk displace-
ment at closed mouth has not previously
been stated. Our finding is in line, how-
ever, with recent observations indicating
that these two categories of disk dis-
placement are frequently seen in patients
but seldom in asymptomatic volun-
teers10,22. In the present study of joints
with effusion, anterolateral disk dis-
placements constituted almost the same
number as those with pure anterior disk
 TMJ effusion and marrow abnormalities 109

Fig. 5. MRI of the TMJ, same patient as in Fig. 3. (A) Coronal oblique proton density image and (B) corresponding T2-weighted image anterior
to the condyle (not seen) show laterally displaced disk (arrow) and fluid in lateral recess of the upper compartment (arrow head).

Fig. 6. MRI of the TMJ in a 33 year-old woman. (A) Sagittal oblique proton density image and (B) Corresponding T2-weighted image of the
lateral part of the joint (c=condyle) show anteriorly displaced and deformed disk (arrow) and marrow edema in the condyle.

displacement. The high occurrence of a
lateral component to the anterior dis-
placement is in accordance with recent
studies indicating that the medial
component is more uncommon10,22,
although more equal frequencies of
lateral and medial components to the
displacements have been reported5.
More importantly, we found that joints
with effusion had severe, i.e. complete,
disk displacement, which is very seldom
seen in asymptomatic volunteers.
Almost every disk displacement in vol-
unteers is partial and shows a reduction
on mouth opening10,22. In the present
series of joints with effusion, more than
two-thirds showed disk displacement
without reduction.
We categorized the MR signal abnor-
malities in the bone marrow of the man-
dibular condyle either as marrow edema,
marrow sclerosis or a combination of the
two patterns. This is in accordance with
a recent study correlating MR imaging
and histological findings in the condyle
marrow9. These patterns of bone mar-
row abnormalities have also been used in
other TMJ MR imaging studies11,17. In
the present study almost one-third of the
patients had bone marrow abnormalities
and this figure is three to four times as
frequent (8–10%) as found in consecu-
tive series of patients referred for MR
imaging7,11,17. Our finding of an
increased prevalence of bone marrow
abnormalities in patients with joint effu-
sion versus those consecutively exam-
ined, is in agreement with the core
biopsy study of the mandibular condyle
marrow in patients surgically treated for
internal derangement9. Histological evi-
dence of bone marrow edema or
osteonecrosis was displayed in 36% of
the joints and MR imaging evidence of
effusion was found in half of the joints
with osteonecrosis9. In the present MR
imaging study of joints with effusion,
almost a quarter of the joints had bone
110 Larheim et al.

Fig. 7. MRI of the TMJ in a 41 year-old woman. (A) Sagittal oblique proton density image and (B) Corresponding T2-weighted image show
anteriorly displaced and deformed disk (arrow), severe osteoarthritis (c=condyle), extensive fluid in upper compartment of the anterior recess
and around the condyle (arrow heads) and marrow sclerosis in the condyle.

Fig. 8. MRI of the TMJ in a 53 year-old woman. (A) Sagittal oblique proton density image and (B) Corresponding T2-weighted image show
anteriorly displaced disk (arrow), osteoarthritis (c=condyle), and both marrow edema (open arrow head) and marrow sclerosis (open arrow) in
the condyle.

marrow abnormalities. The association
between osteonecrosis and joint effusion
is well known from studies of the hip13.
Joints with bone marrow abnormali-
ties in our series proved to be a subgroup
of severe joint conditions. More than
91% (22 of 24 joints) showed a displaced
disk that did not reduce on mouth open-
ing and more than 95% (23 of 24 joints)
showed cortical bone abnormalities indi-
cating osteoarthritis or inflammatory
arthritis. In the total series of joints these
figures were 67% and 41%, respectively.
The association between bone marrow
abnormalities and osteoarthritis sup-
ports observations in the core biopsy
study9, although joints with marrow
edema or osteonecrosis occasionally
showed normal cortical bone. A recent
MR imaging study has also demon-
strated that bone marrow abnormalities
may occur in the absence of osteo-
arthritis17, substantiating the view that
marrow edema or osteonecrosis of the
mandibular condyle may be separate
entities from osteoarthritis. In other
joints such as the hip, the osteonecrotic
process starts in the marrow and second-
arily, after weakening of the subarticular
bone with collapse and fracture, osteo-
arthritis develops21.
Our observation of large amounts of
TMJ fluid and evident bone marrow

abnormalities in the mandibular condyle
are in agreement with the growing evi-
dence that inflammatory reactions may
take place in patients with TMJ pain and
dysfunction, but with no generalized
inflammatory joint diseases, as demon-
strated at arthroscopy and in surgical
specimens1,3,4,12,24. Histological obser-
vations have even suggested that inflam-
matory changes in patients with known
inflammatory arthritidis and internal
derangement without such arthritidis
can be quite similar1. One patient in the
present series had a follow-up MR imag-
ing study, suggesting an evident altera-
tion in the amount of fluid within a
2-year period. The inflammatory activity
in some TMJs with internal derange-
ment may possibly resemble the fluctu-
ating disease activity that has previously
been demonstrated by a longitudinal
MR imaging study of a patient with
psoriatic TMJ arthritis8. In fact, both
that patient and the patient in the
present study had pain records that
followed the variation in joint effusion.
Almost every patient in the present
series showed disk displacement and the
displacement was frequently bilateral.
This supports the general view that disk
displacement plays a significant role in
patients with TMJ pain and dysfunction.
In contrast to the displacement, the effu-
sions and the bone marrow abnormali-
ties were predominantly unilateral. Since
all the patients had pain and they were
selected with regard to the amount of
joint fluid, we could certainly expect an
association between pain and fluid. In
the in-patient regression analysis of the
side differences in TMJ pain, in which
the patient was his own control, it was
virtually demonstrated that the pain was
significantly dependent on fluid as well
as bone marrow abnormalities. Obvi-
ously, TMJ effusion could also be
asymptomatic as shown in our compari-
sons between the pain-free joints in
the patient group and the joints in
the asymptomatic volunteer group.
Additionally, the patients had signifi-
cantly more disk displacement and
cortical bone abnormalities. Some indi-
viduals are possibly predisposed to the
development of such abnormalities,
which eventually become symptomatic.
The severity of such abnormalities must
be of importance for the patient symp-
tomatology. Interestingly, the majority
of the joints with effusion did not have
cortical bone abnormalities indicating
osteoarthritis or inflammatory arthritis.
This is in line with the study by
W & B23, demonstrating
TMJ effusion and marrow abnormalities
that TMJ effusion occurred less fre-
quently in joints with osteoarthritis than
in joints with disk displacement but
without osteoarthritis. In our regression
analysis, osteoarthritis proved to be a
pain-decreasing factor when occurring
simultaneously with fluid and bone
marrrow abnormalities, which proved to
be pain-increasing factors. This is well in
accordance with our clinical experience
and the general view that patients even
with severe osteoarthritis, may be pain-
free.
In conclusion, the patients with TMJ
effusion, i.e. an amount of fluid that
exceeded the maximum amount seen in a
control group of asymptomatic volun-
teers, seem to represent a subgroup with
pain and dysfunction with more severe
intra-articular pathology than those
with disk displacement but no other
abnormalities.
Acknowledgments. This study has been
supported by The Research Council of
Norway. We thank Dr Marek Rösler
for the statistical analyses and Hakon
Störmer for the photographic work with
the illustrations.
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