a comparison of mri, radiographic and clinical findings of the position of the tmj articular disc...

8/13/2019 A Comparison of MRI, Radiographic and Clinical Findings of the Position of the TMJ Articular Disc Following Open Tr

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British Journal of Oral and Maxillofacial Surgery 45 (2007) 534537

A comparison of MRI, radiographic and clinical findings ofthe position of the TMJ articular disc following open

treatment of condylar neck fractures

Alexander Schneider a, Diana Zahnert a, Steffen Klengel b, Richard Loukota c,, Uwe Eckelt a

a Department of Oral and Maxillofacial Surgery, University of Technology Dresden, Fetscherstrae 74, D-01307 Dresden, Germanyb Department of Radiology, University of Technology Dresden, Fetscherstrae 74, D-01307 Dresden, Germanyc Department of Oral and Maxillofacial Surgery, Leeds Teaching Hospitals NHS Trust, Leeds LS2 9LU, United Kingdom

Accepted 23 November 2006

Available online 12 January 2007

Abstract

We examined the position and function of the articular disc after open treatment of condylar fractures by comparing magnetic resonance

images (MRI) and radiographs with clinical data.

MRI and radiographs were taken after treatment of 28 patients with 33 fractures of the mandibular condyles. In all cases, the disc was

located in the fossa after open reduction and internal fixation (ORIF). The MRI, radiographic and clinical findings did not correlate, and

damage to the temporomandibular joint (TMJ) could be seen more clearly on MRI than on clinical or radiographic examination. Damage to

soft tissues seen on MRI after treatment was more pronounced in dislocated than in displaced fractures.

2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: MRI; Condylar fractures; Disc

Introduction

In fractures of the condylar neck, particularly those with

major displacement or dislocation of the condylar head,1 the

joint capsule is injured. During open reduction, the joint cap-

sule should not be opened, if possible, to protect the joint.2

There are few publications about the condition of the soft tis-

sues of thejoint, in particular,regarding thearticular disc after

injury and treatment. Previous data have been obtained only

from clinical follow-up and radiographs, which give merelyan indirect assessment of the soft tissues.

Magnetic resonance imaging (MRI) is the technique that

most accurately displays the soft tissues. It has become the

preferred method for displaying the disc and the ligaments of

Corresponding author at: Leeds Dental Institute, Clarendon Way, Leeds

LS29LU, UnitedKingdom. Tel.: +44 113343 6219; fax: +44 113 3436264.

E-mail address:[email protected](R. Loukota).

the temporomandibular joint (TMJ) particularly in degener-

ative disorders (Fig. 1).35

MRI was therefore used to examine the position and func-

tion of the articular disc after open treatment of fractures of

the condylar process. The results were correlatedwith clinical

data and radiographic findings.

Patients and methods

We studied 28 patients (mean age 33 years, range 1565

years) with 33 fractures of the condylar neck that required

open reduction and internal fixation. Their injuries occurred

over a 5-year period.

The fractures were classified as dislocated or displaced

(Table 1)6 and were treated by ostheosynthesis. The criteria

for open treatment were fracture types IIV, with an angula-

tion of the proximal fragment of more than 30 or a reduction

in the height of the ramus of more than 5 mm or both.

0266-4356/$ see front matter 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2006.11.019
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A. Schneider et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 534 537 535

Fig. 1. Magnetic resonance image of fractured condylar process.

During the follow-up, the following variables were

assessed and recorded on a proforma. All patients were

assessed in a standard seated position: mouth opening (inter-

incisal gap); protrusion (labial surface of upper incisors to

labial surface lower incisors); and lateral excursion left and

right (relative positions of upper and lower centre lines).Patients were also asked to fill in a standard Mandibular

Functional Impairment Questionnaire.7,8

The radiological investigations comprised reverse

Townes view (30 posteroanterior view of the neck of the

mandibular condyle) and panoramic radiographs, together

with MRI.

The latter were taken using an 0.5 tesla device (Phillips

Gyroscan T5 XPA; Phillips Eindhoven, The Netherlands) and

a TJ-surface irrigator with oblique sagittal proton density

and T2 weighted SE sequences, indicating the first and sec-

ond echo of the T2 weighted SE sequences (TR = 1800 ms,

TE = 25/90 ms). MR imageswere individually planned by the

Table 1

Number of the condylar fractures examined in 28 patients classified accord-

ing to the distribution described by Spiessl and Schroll6

Type

Condylar fractures 33

I Fracture without displacement 0

II Low fracture with displacement 6

III High fracture with displacement 3

IV Low fracture with dislocation 18

V High fracture with dislocation 6

VI Intracapsular fracture (diacapitular) 0

position of the articular process in the sagittal axis and verti-

cal to the diagonal axis of the condyle. In MR examinations,

with the mouth open and closed, the position of the articular

disc was viewed bilaterally relative to the joint surfaces of

the condylar process and of the temporal bone. The position

of the articular process relative to the joint cavity and to the

articular prominencewas alsoassessed. Pathological changesin the ligament and capsule, such as widening of the capsule

or an increase in synovial fluid, were also noted.

Conventional radiographs were used to assess the posi-

tion of thefragment (displaced or non-displaced) and arthritic

changes (exostoses, deformation, or development of cysts).

Fishers exact test was used to assess the significance of dif-

ferences among the MRI results between the displaced and

dislocated fractures.

Results

The clinical examination showed mouth opening of at least

30 mm in all the patients.

In four patients, there was a limitation of protrusion to less

than 5 mm, and in three, there was a limitation to less than

5 mm of the lateral excursion.

Subjective responses at the time of follow-up indi-

cated that 27 of the 28 patients were completely satisfied.

The remaining patient complained of restricted mandibular

mobility.

After MR scanning, the function of the disc was shown

to be normal in eight patients. The ventral excursion of the

condyle was increased in four patients (Fig. 2). In all patients,

the disc was in the anterocentral section of the condylar fossaand was only slightly displaced medially in one.

The damage visible on the MRI increased from displaced

to dislocated fractures (Table 2). There was an increase in

Fig. 2. Sagittal magnetic resonance image with increased ventral excursion

of the condylar process.


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536 A. Schneider et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 534537

Table 2

Findings on magnetic resonance images after 33 condylar fractures

Fracture

Dislocated (n = 24) Displaced (n = 9)

Disc function

Normal 12 7

Anterior dislocationWith reduction 2 1

Without reduction 4 1

Disruption of joint 6 0

Ventral excursion of condylar process

Normal 9 8

Increased 6 0

Restricted 7 1

No assessment 1 0

Data are number of fractures.

Fig. 3. Sagittal magnetic resonance image with anterior dislocation of the

disc without reduction.

anterior dislocation with decreased reduction of the disc

(Fig. 3) and restricted mobility of the condyle (Table 3).

Increased excursion of the condylar process and joint dis-

ruption was seen only after dislocated fractures (Table 2).

The differences among the MRI findings between dislocated

and displaced fractures were not significant (p = 0.3 for disc

function and 0.09 for excursion of the ventral condyle). The

radiographicfindings showedthat 3 of the 33 fracturestreatedopenly had healed in slightly displaced positions (Table 3),

each one being a Type IV fracture (Table 1). Six months after

Table 3

Radiological results after condylar fracture

Type of fracture Normal

position

Displaced

condylar head

Arthrosis of the

condylar head

II 6 0 0

III 3 0 0

IV 18 3 1

V 6 0 0

the operation, one condylar head was significantly smaller

than the rest.

Other than those three cases, there were no apparent con-

nections between the type of fracture and the radiographic

findings.

Discussion

Many clinical studies have assessed the operative results

of various osteosynthesis procedures on severely displaced

condylar fractures, most of which have compared the find-

ings after open or closed treatment using clinical, functional,

and radiological examinations.915

However, there have been few publications about the con-

dition of capsular and discal soft tissues after treatment.

Previous descriptions of MR examinations of damage to the

TMJ were published in 1995 by Ozmen et al.16 (n =6) and

by Eckelt and Klengel1 (n =16).

Only in Type IV fractures, arthritic changes were seen onradiographs. There was no correlation between the type of

fracture and the radiographic findings.

All discs were found in the joint cavity after treatment, so

it would seem that, even when the disc is dislocated during

the fracture, a reduction of the condyle is sufficient to reduce

the disc.

The position of the disc immediately after the fracture is

anteromedial, as described by Watabe et al.17 and Takaku et

al.2 For correct repositioning and function of the disc, Takaku

et al.2 advised early repositioning of fragments to avoid mal-

position or malfunction of the disc from a contracture of the

damaged capsule and retrodiscal tissue.The effects on the soft tissues caused by displacement

and even more by dislocation of the fractures are apparent

in the findings of the postoperative MRI (Table 2). These

show anterior dislocation without reduction of the disc in the

fossa, as well as disruption of the joint and the restricted or

increased ventral excursion of the condylar process.

There is a similar amount of restricted movement and

increased ventral displacement of the condyle in dislocated

fractures (Table 3),which may result from the mechanism of

the fracture, swelling of soft tissues, or other factors such as

haemorrhage, oedema, and fibrosis.

Restrictions of the ventral excursion of the condyle were

usually from anterior displacement of the disc in the fossa.

The discrepancies described by Ozmen et al.16 between

the clinical, functional, and MRI findings were confirmed in

the present study. An accurate long-term prognosis of the

condition of the TMJ cannot be made, based on good clini-

cal or functional outcomes in patients with abnormal MRIs,

as described by Muller-Leisse et al.18,19 Marguelles-Bonnet

et al.20 found a good correlation between the clinical diag-

nosis of disc displacement and the results of MRI. However,

they also showed that the clinical examination on its own was

not sufficient to identify structural defects fully. Radiological

examination did not correlate with the MRI results, and sel-


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A. Schneider et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 534 537 537

dom gave any indication of the internal disruption. The lack

of correlation illustrates the complexity of the morphology

and function of the TMJ.

The MRI showed damage to the soft tissue of the TMJ

in a more sensitive way than the clinical examination. This

non-invasive method of recording pathological changes in

patients with clinical problems is useful in diagnosis and inthe planning of treatment.

In future studies, the comparison of the immediate MRI

findings after injury and the long-term results of postopera-

tive treatment will be investigated. This should elucidate the

healing process of the soft tissues.

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