JADA Continuing Education
Condylar and Disk Position and Signs and Symptoms of Temporomandibular Disorders in Stress-Free Subjects
José Osmar Vasconcelos Filho, PhD,
Alynne Vieira de Menezes, MSc,
Deborah Queiroz de Freitas, MSc,
Flávio Ricardo Manzi, PhD,
Frab Norberto Bóscolo, PhD and
Solange Maria de Almeida, PhD
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ABSTRACT
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Background. The authors conducted a study in subjects who tested free of psychological stress to determine the position of the condyle and whether that position was related to signs and symptoms of temporomandibular disorders (TMDs).
Methods. Forty subjects underwent psychological evaluation to ensure freedom from psychological stress. The authors evaluated tenderness of the masticatory muscles and temporomandibular joints (TMJs) by means of bimanual digital palpation, and they determined the positions of the condyle and disk by using magnetic resonance imaging.
Results. A total of 23.75 percent of the condyles were displaced away from the centric position either anteriorly (3.75 percent) or posteriorly (20.00 percent). 
2 analysis showed a relationship between the position of the condyle and displacement of the disk, as well as a relationship between the position of the condyle and tenderness of the TMJs.
Conclusion. Although these relationships proved significant, it cannot be assumed that displacement of the condyle away from the centric position is predictive of TMD.
Clinical Implications. Only two subjects were judged to have had TMJ internal derangement. Thus, the absence of psychological stress seems to have played a role in this finding.
Key Words: Temporomandibular joint disorders; temporomandibular joint disk; condylar position; pain; stress; magnetic resonance imagingAbbreviations: ID: Internal derangement • MR: Magnetic resonance • RDC/TMD: Research Diagnostic Criteria for Temporomandibular Disorders • TMD: Temporomandibular disorder • TMJ: Temporomandibular joint
Temporomandibular disorders (TMDs) comprise a number of clinical problems that can be clustered into the categories of muscle disorders, degenerative changes and intracapsular derangements of the temporomandibular joint (TMJ) components.1
The cause of TMDs is considered to be multifactorial, but the relative importance of individual causative factors is controversial. However, psychosocial factors have been reported to play an important role in the etiology of TMD, adaptation to pain and eventual recovery.2
According to Manfredini and colleagues,3 the potential causative factors of TMD include parafunctional habits, psychological events and systemic diseases. McNeill4 also included psychological conditions as predisposing and perpetuating factors in TMD. Therefore, stress deserves emphasis as a significant underlying cause of TMD in patients in whom no obvious anatomical alteration or physical change has occurred.
An association of stress factors and TMJ pain has been noted in several studies,5–8 which showed that 50 to 75 percent of TMD patients experienced stressful life events before the onset of their symptoms. Parker9 also concluded that psychological stressors cause increased muscle activity and that TMD patients respond to stress factors with increased and prolonged masticatory muscle tension.9
The relationship between the position of the condyle in the fossa and internal derangement has been discussed previously.10–13 However, a probable relationship has not been associated widely with psychological stress. Therefore, the study of subjects free of psychological stress and the tenderness of masticatory muscles and TMJs by means of magnetic resonance (MR) imaging evaluation of their TMJs offers a unique opportunity to draw some conclusion about the probable relationship between signs and symptoms of TMD. The aim of our investigation was to evaluate the position of the condyle and the TMJ disk to determine whether there was any association between the condyle’s position and signs and symptoms of TMD in stress-free subjects, by means of MR imaging of the TMJs.
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MATERIALS AND METHODS
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The sample in our study consisted of 80 TMJs in 40 subjects (18 women, 22 men, mean age 31.1 years) from Curimans, Trairi, Ceará, Brazil, and included both people with pain and people without pain. We selected this sample for their stress-free lifestyle, which was the only inclusionary criterion. Initially, we asked 120 subjects whether they considered themselves to be stressed, and when not, we administered to 98 subjects a second screening test consisting of 10 questions to investigate the presence of work, social and other stress factors in their lifestyles. Then a psychologist administered Lipp’s Inventory of Stress Symptoms for Adults,14 a psychological evaluation tool developed and validated for use in Brazil, to 76 subjects. Each subject signed a consent form once the absence of psychological stress was confirmed (n = 40).
Each subject underwent a clinical examination, performed by one of the authors (F.R.M.). The clinician measured the distance between the maxillary and mandibular anterior teeth during jaw opening and after lateral movements, listened for TMJ sounds during jaw movement, and performed bimanual digital palpation of the masticatory muscles and TMJs according to guidelines set forth by the Research Diagnostic Criteria for TMD (RDC/TMD).15
We imaged the TMJs of each subject by means of bilateral high-resolution MR imaging and used time 1 (T1) -weighted imaging to study each joint in the sagittal (both open- and closed-mouth positions) and coronal planes (open-mouth position only). We obtained sequential sections by means of time 2 (T2) -weighted imaging to evaluate the presence of inflammatory process, cysts and tumors. The sagittal sections were perpendicular to the long axis of the condyle of the mandible, and the coronal sections were parallel to it. We performed MR imaging on a 1.5-tesla imager (Signa HDx, General Electric Medical Systems, Milwaukee) with 3-inch receiver surface coils.
A specialist in oral radiology (J.O.V.F.) interpreted the images. He evaluated the position and function of the TMJ disk according to criteria set forth by Tasaki and colleagues.16 He classified the condylar position as anterior, centric, posterior, medial or lateral by using a modification of the classification set forth by Incesu and colleagues.17
The clinician (F.R.M.) performed statistical analysis with the 2 test for comparison of proportions; P < .05 was considered significant. He calculated the sensitivity (the probability that a person with disease is indeed tested as having disease) and specificity (the probability that a person without disease is tested as not having disease).
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RESULTS
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In most subjects, the disk was positioned in the fossa (Table 1
), which is considered the normal position. Anterior and partial anterior displacements occurred in 20 percent of the subjects. The condyle was in the centric position in approximately three-fourths of the subjects (Table 2). The second most common position was posterior.
2 analysis showed that when the disk was displaced away (anterior-posterior) from the centric position, the condyle also was positioned away (anterior-posterior) from the centric position (P = .005) (Table 3, page 1254).
There was no association between the presence or absence of muscle tenderness on palpation and a centered or anterior and posterior condyle position (P = .45, 2 test) (Table 4, page 1254). However, 2 analysis confirmed a relationship between tenderness of the TMJs and a condylar position away (anterior-posterior) from the centric position (P < .001) (Table 4).
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TABLE 4 Associations between condyle position and muscle pain and between condyle position and temporomandibular joint (TMJ) pain.
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We found a marginally acceptable specificity of 0.83 for the centric position of the condyle in subjects without TMJ tenderness on palpation. However, we found a low sensitivity of 0.66 for the position of the condyle away (anterior-posterior) from centric position in subjects with TMJs that were tender to palpation.
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DISCUSSION
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A problem common to internal derangement (ID) is that the disk is positioned either anteriorly or posteriorly in relation to the condyle, fossa and articular eminence in the closed-mouth position. Recently, MR imaging has become a reliable method of diagnosing ID.17 The TMJ disk can be displaced in many directions,16 and MR imaging allows for a more detailed classification of disk position through oblique, multiple sagittal and coronal sections.18
From oblique sagittal and coronal images in the closed-mouth position, we found that 30 percent of our sample had a disk displacement. The most common noncentric position found in our study was the partial anterolateral location in the lateral part of the TMJ, which occurred in 8.75 percent (n = 7) of subjects’ TMJs. These results are in agreement with those of Matsuda and colleagues19 and Tasaki and colleagues16 Although many studies describe an association between disk position and pain,10,19–23 an anterior or a posterior disk position also can be present in subjects free of symptoms.16 An association between a posterior condyle position and anterior disk displacement has been reported.11,12,17,24,25 The results of our study are in partial agreement, although we did not test for posterior condyle displacement alone.
Ren and colleagues12 evaluated the condyle position in joints in asymptomatic volunteers with normal disk position and compared it with different stages of ID. They concluded that the condyle positions of TMJs with normal disk positions are distributed randomly and can include anterior, central and posterior positions, although a posterior condyle position was more prevalent in joints with anterior disk displacement. However, a posterior condyle position cannot be interpreted as a diagnostic sign for ID of the TMJ when anterior or centered condyle positions also often are seen in patients with ID. Nonetheless, a posterior position of the condyle has a higher prevalence in symptomatic patients than in asymptomatic volunteers, according to other investigators.11,12
Two conditions could explain an association between posterior condyle position and disk displacement. One is that the condyle is displaced posteriorly because of the reduced joint space that results when the disk is positioned anterior to the condyle. Another is that the condyle is de facto situated posteriorly, which predisposes the disk to displacement. However, neither this study nor previous studies12,17 were designed to evaluate cause, so we cannot explain the association between condyle position and disk displacement; only longitudinal studies will be able to explain this association.
Those with tenderness of the masticatory muscles appear to be more susceptible to the influence of psychological stress than do those with TMJ pain.26 In one study, stressed subjects also had significantly more marked subjective symptoms and clinical signs of TMJ dysfunction than did subjects in a healthy control group.27 The results of our study showed an association between the condyle position away from the centric position and TMJ tenderness, but not between that condyle position and tenderness of the masticatory muscles. Other studies have evaluated the effect of stress on the TMJ28–31 and have associated stress with signs and symptoms without the use of any imaging. In our study, MR imaging allowed comparisons of the disk and condyle positions. The only inclusionary criterion was the absence of stress, which sets this study apart from most others. Thus, it is difficult to compare the results of our study with those of earlier ones because the sample populations are not exactly equivalent. We found disk displacement or TMJ pain more often with an anterior-posterior condyle position. However, according to the American Academy of Orofacial Pain,32 it is necessary to observe the following signs and symptoms to diagnose TMD: painful TMJ and/or masticatory musculature, limitation of mandibular function and sounds in the TMJ. Thus, in our study, we diagnosed TMD in subjects who exhibited not only the signs and symptoms indicated by the American Academy of Orofacial Pain, but also disk displacement, finding only two of the 40 subjects with TMD. Thus, this study was not a study of people with disease, and extrapolation of the results to patients with TMDs is not entirely valid. This study, however, is one of the first to evaluate TMJ disk and condyle position in stress-free subjects, and further studies that evaluate the influence of stress on the TMJ would be welcome.
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CONCLUSIONS
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We found a significant relationship between the position of the condyle and displacement of the disk with tenderness of the TMJs on palpation. On the basis of the findings of our study, it cannot be assumed that the position of the condyle away from the centric position is predictive of TMD in subjects free of psychological stress.
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FOOTNOTES
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Dr. Vasconcelos Filho is a professor, Department of Oral Radiology, University of Fortaleza, Fortaleza, Ceará, Brazil.
Ms. Menezes is a doctoral student, Department of Oral Radiology, Piracicaba Dental School, State University of Campinas, Piracicaba, São Paulo, Brazil.
Ms. Freitas is a professor-UNIRP, and a doctoral student, Department of Oral Radiology, Piracicaba Dental School, State University of Campinas, Av. Limeira, 901—Areião, 13414-901, Piracicaba, São Paulo, Brazil, e-mail "deborahqf{at}hotmail.com". Address reprint requests to Ms. Freitas.
Dr. Manzi is a professor, Department of Oral Radiology, School of Dentistry, Pontificia Catholic University, Belo Horizonte, Minas Gerais, Brazil.
Dr. Bóscolo is a professor, Department of Oral Radiology, Piracicaba Dental School, State University of Campinas, Piracicaba, São Paulo, Brazil.
Dr. Almeida is an associate professor, Department of Oral Radiology, Piracicaba Dental School, State University of Campinas, Piracicaba, São Paulo, Brazil.
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ABSTRACT
MATERIALS AND METHODS
