ORIGINAL ARTICLE

Muscular and condylar response to rapid

maxillary expansion. Part 3: Magnetic resonance
assessment of condyle-disc relationship
F. Emel Arat,a Z. Mirzen Arat,b Bryan Tompson,c and Sumru Tanjud
Toronto, Ontario, Canada, and Ankara, Turkey

Introduction: The aim of this prospective study was to assess temporomandibular joint (TMJ) condyle-disc
positions at the sagittal and coronal planes of magnetic resonance images (MRIs) before and after rapid
maxillary expansion (RME). Methods: The study included 18 subjects (11 girls, 7 boys) with a mean age of
12.54 years with unilateral or bilateral posterior crossbite that included at least 3 posterior teeth. The clinical
and radiographic assessments of the TMJ were done before (T1) and 18 weeks after (T2) RME. A Haas-type
expansion appliance was used for an average treatment time of 3.5 weeks. Results: A visual MRI analysis
of pretreatment condyle-disc positions showed that 8 TMJs had medial disc displacement, 3 had
anteromedial disc displacement, and 2 had lateral disc displacement. The disc positions remained
unchanged at T2 except in 1 subject, who developed unilateral anterior disc displacement. Unilateral joint
sounds developed in 3 subjects without changes in the disc positions. Conclusions: Posterior crossbite can
be considered a minor risk factor for temporomandibular disorder (TMD). RME is neither a risk factor nor a
prevention for TMD. Coronal MRIs contribute complementary information for optimal diagnosis of TMD. (Am
J Orthod Dentofacial Orthop 2008;133:830-6)

T
he relationship of temporomandibular disorder
(TMD) to occlusion and orthodontic treatment
has been extensively discussed since the 1980s.
Recent studies indicated only a minor relationship
between TMD and malocclusion1-6 and orthodontic
treatment.7-14
Seligman and Pullinger3,4 estimated that the total
contribution of occlusal factors to the multifactorial
characterization of TMD patients is about 10% to 20%.
Most variations in TMD patients were not explained by
occlusal parameters. Pullinger et al15 investigated 11
common occlusal features in the prediction of TMD.
They stated that patients with unilateral posterior cross-
bite had a higher risk of TMD. In addition, a functional
occlusal factor that contributes to TMD might be a
reverse sequence (RS) chewing pattern that is observed
a
Postdoctoral fellow, Department of Orthodontics, Faculty of Dentistry, Uni-
versity of Toronto, Toronto, Ontario, Canada.
b
Professor, Department of Orthodontics, School of Dentistry, Ankara Univer-
sity, Ankara, Turkey.
c
Professor and head, Department of Orthodontics, Faculty of Dentistry,
University of Toronto, Toronto, Ontario, Canada.
d
Research assistant, Department of Radiology, School of Medicine, Ankara
University, Ankara, Turkey.
Reprint requests to: F. Emel Arat, Department of Orthodontics, University of
Toronto, Faculty of Dentistry, Toronto, Ontario, Canada; e-mail, femelarat@
yahoo.com.
Submitted, September 2006; revised and accepted, March 2007.
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.03.026
830
in those with unilateral crossbites. This RS pattern of
jaw movement occurs in the coronal plane during
unilateral chewing.16-18 Although these studies mainly
focused on unilateral crossbite, patients with bilateral
crossbite might also have the RS pattern during chew-
ing in the coronal plane caused by undesirable tooth
inclinations.19
Routine clinical examination of the temporoman-
dibular joint (TMJ) occasionally fails to diagnose
derangements of the condyle-disc complex, since some
patients have no signs or symptoms of joint dysfunc-
tions at some stages of disc displacements.20 It was
reported by Tasaki et al21 and Larheim et al22 that a
third of asymptomatic patients showed disc displace-
ment as diagnosed by magnetic resonance imaging
(MRI).
MRI offers an opportunity to evaluate both the hard
and soft tissues of the TMJ. Although the standard
plane for the MRI of the TMJ has been the sagittal
plane, complementary coronal plane images have been
suggested for optimum TMJ evaluation of rotational
disc displacements.23-27
Changes in condyle-disc position after functional or
orthopedic treatment of Class II25,26,28-32 and Class III
malocclusions33 have been studied with the MRI
method. However, the effects of RME on disc positions
in patients with maxillary transverse deficiency are still
unknown.
American Journal of Orthodontics and Dentofacial Orthopedics Arat et al 831
Volume 133, Number 6

Fig 1. Image plane orientation for sagittal and coronal MRIs.

In this prospective study, we investigated the con-

dyle-disc positions before and after RME using sagittal
and coronal MRI.

MATERIAL AND METHODS

The sample included 18 subjects with unilateral and
bilateral posterior crossbites. There were 11 girls and 7
boys, between 9.75 and 14.8 years of age with a mean
age of 12.54 years. Their skeletal maturity varied
between MP3⫽ and MP3cap as assessed from hand-wrist
radiographs.34 Eleven subjects had bilateral and 7 had
unilateral posterior crossbites. The clinical assesment
consisted of a standardized examination for signs and
symptoms of TMD, including mandibular range of Fig 2. Sagittal MRI with normal condyle-disc position.
motion, joint sounds, muscle and joint pain on palpa-
tion, and pain or deviation during mandibular function.
Those without TMD symptoms were included in this
study. The other selection criteria were unilateral or
bilateral posterior crossbite including at least 3 poste-
rior teeth, no congenitally missing teeth, no congenital
craniofacial deformity, and no systemic illness. The
subjects were treated with the Haas expansion appli-
ance, which was activated twice a day (0.5 mm) until
overcorrection of the posterior crossbite was obtained
and then stabilized with cold-cure acrylic. The average
treatment period was 3.5 weeks. The subjects and their
parents were informed about the study procedure.
Informed consent and ethical approval were received.
MRIs of the TMJ were obtained by using a 1.5-T Fig 3. Coronal MRI with normal condyle-disc position
echo speed MRI device (GE Medical Systems, Milwau- (LP, lateral pole; MP, medial pole).
kee, Wis) equipped with TMJ coils for simultaneous
imaging of the right and left joints. The MRI protocol
included closed-mouth parasagittal images at T1 matrix size 256 ⫻ 224, field of view 140 ⫻ 140 mm)
(TR/TE 500/9.8 msec, matrix size 320 ⫻ 224, field of sequences taken parallel to the long axis of the condyle
view 140 ⫻ 140 mm), T2* GRE/25 (TR/TE 340/18 (Fig 1). Slice thickness was 3 mm with no interslice
msec, matrix size 256 ⫻ 224, field of view 140 ⫻ 140 gap. The appliance was removed before each MRI
mm), and coronal T2* GRE/30 (TR/TE 340/13.9 msec, session and replaced after the session to prevent dis-
832 Arat et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2008

Table. Visual assessment of condyle-disc positions at pretreatment and posttreatment

Right TMJ Left TMJ

Subject characteristics T1 T2 T1 T2

Subject Sex Posterior crossbite Maturation stage Sagittal Coronal Sagittal Coronal Sagittal Coronal Sagittal Coronal

1 F U (left) MP3cap (late) NDP NDP NDP NDP NDP NDP NDP NDP
2 M U (left) MP3⫽ ADD MDD ADD MDD NDP MDD NDP MDD
3 F U (left) MP3cap (late) NDP NDP NDP NDP NDP NDP NDP NDP
4 M U (right) MP3⫽ NDP NDP NDP NDP NDP LDD NDP LDD
5 M U (right) MP3cap NDP NDP ADD NDP NDP NDP NDP NDP
6 F U (right) MP3cap (initial) NDP NDP NDP NDP NDP NDP NDP NDP
7 F U (right) MP3cap (initial) ADD MDD ADD MDD ADD MDD ADD MDD
8 F B MP3⫽ NDP LDD NDP LDD NDP NDP NDP NDP
9 F B MP3⫽ NDP NDP NDP NDP NDP MDD NDP MDD
10 M B MP3⫽ NDP NDP NDP NDP NDP NDP NDP NDP
11 M B MP3⫽ NDP MDD NDP MDD NDP MDD NDP MDD
12 F B MP3cap NDP NDP NDP NDP NDP MDD NDP MDD
13 F B MP3cap (late) NDP NDP NDP NDP NDP NDP NDP NDP
14 M B MP3⫽ NDP NDP NDP NDP NDP NDP NDP NDP
15 F B MP3cap (late) NDP NDP NDP NDP NDP NDP NDP NDP
16 F B MP3cap (initial) NDP NDP NDP NDP NDP NDP NDP NDP
17 M B MP3⫽ NDP MDD NDP MDD NDP MDD NDP MDD
18 F B MP3⫽ NDP NDP NDP NDP NDP MDD NDP MDD

F, Female; M, male; U, unilateral; B, bilateral; T1, before expansion; T2, 18 weeks after expansion; NDP, normal disc position; ADD, anterior
disc displacement; MDD, medial disc displacement; LDD, lateral disc displacement.

comfort from the heat of the metal bars of the appliance
during the session and to prevent artifacts on the MRIs.
The MRIs were taken before expansion (T1) and 18
weeks after expansion (T2) in both the sagittal and
coronal planes.
The condyle-disc positions of 36 TMJs at T1 and
T2 were independently assessed visually by a radiolo-
gist (S.T.) and an orthodontist (F.E.A.) who had been
trained to evaluate MRIs of the TMJ for 4 months
before this assessment. The researchers were blinded as
to the clinical information during the assessments of the
joints. In case of disagreement, a final assessment was
made by consensus with the help of another radiologist
(Dr E. Lam).
The image evaluations were based on the criteria of
Katzberg and Westesson35 by using the complete im-
aging series. In the sagittal plane, the TMJ disc position
was considered normal if its posterior band was located
at the 12-o’clock position or between 11 and 12 o’clock
relative to the condyle (Fig 2). This was done to allow
for normal physiologic variations.26 Anterior disc dis-
placement was diagnosed in patients whose posterior
band of the disc was in an anterior position relative to
the superior part of the condyle. In the coronal plane, an
arc-shaped configuration with the medial margin of the
disc attaching just inferior to the medial pole and the
lateral margin attached just under the lateral pole was
considered normal35 (Fig 3). Deviation from the normal
disc position was diagnosed as lateral or medial disc
displacement. In the sagittal and coronal MRIs, disc
positions were classified as (1) physiologic (normal)
disc position (NDP), (2) anterior disc displacement
(ADD), (3) anteromedial disc displacement (AMDD),
(4) anterolateral disc displacement (ALDD), (5) medial
disc displacement (MDD), and (6) lateral disc displace-
ment (LDD).
RESULTS
The Table gives the visual analysis of pretreatment
and posttreatment articular disc positions of each sub-
ject. Of the18 subjects, 9 (50%) had an abnormal disc
position at least in 1 plane. The distribution of disc
displacements in the TMJs at T1 was as follows: NDP
was diagnosed in 23 TMJs (63.9%), AMDD was
diagnosed in 3 TMJs (8.3%), LDD was diagnosed in 2
TMJs (5.6%), and MDD was diagnosed in 8 TMJs
(22.2%) (Fig 4).
The visual analysis of condyle-disc positions at T2
was unchanged relative to T1 except for 1 subject
(number 5, Table, Fig 5), who developed a unilateral
anterior disc displacement but had no signs and symp-
toms of TMD clinically at T2 (Table, Fig 6).
The clinical evaluation of TMJs at T2 showed that
3 patients (numbers 4, 10, and 11) had unilateral (right)
TMJ sounds without a change in the disc position
(Table, Fig 7).
American Journal of Orthodontics and Dentofacial Orthopedics Arat et al 833
Volume 133, Number 6

Fig 4. Distribution of articular disc positions at T1.

Fig 5. Distribution of articular disc positions at T2.

DISCUSSION bite and TMD was analyzed on their pretreatment

We investigated condyle-disc positions on sagittal records, and the relationship between RME and TMD
and coronal closed-mouth MRIs in unilateral and bilat- was analyzed on posttreatment records. The use of
eral posterior crossbite patients before and 18 weeks coronal images with the sagittal MRIs provided com-
after RME. The relationship between posterior cross- plementary information for accurate diagnosis of disc
834 Arat et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2008

Fig 6. Sagittal MRI slices of subject 5, who developed unilateral ADD at T2 without signs or
symptoms of TMD.

Fig 7. Sagittal and coronal MRI slices of subject 11, who developed unilateral (right) TMJ sound
without a change in the ipsilateral condyle-disc position.

positions. Thus, ADD was diagnosed only in 3 sagittal
images, whereas sideways disc displacements were
diagnosed in 13 coronal images (Table). This finding
has 2 important aspects. (1) It is not sufficient to
examine condyle-disc positions only at the sagittal
plane; complementary coronal plane images are re-
quired also. (2) Condyle-disc displacements were
mostly observed in the medial direction in posterior
crossbites.
It was reported that there is a minor relationship
between malocclusion and TMD.3,4 Functional occlusal
features (ie, slide in centric occlusion, occlusal inter-
ferences) are more important than morphologic occlu-
sal features (ie, overjet, open bite).1-3 In patients with
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6
posterior crossbite, RS often appears during jaw move-
ment in the coronal plane during chewing.16-18 There-
fore, it might not be a coincidence to observe disc
displacements mostly in the coronal plane. Of the 18
subjects, 9 (50%) had an abnormal disc position at least
in 1 plane. This rate should not be underestimated. NDP
were observed in 23 of 36 TMJs (63.9%). Of the
remaining 13 TMJs (36.1%), 3 (8.3%) were diagnosed
as AMDD, 2 (5.6%) were diagnosed as LDD, and 8
(22.2%) were diagnosed as MDD. Observation of
sideways disc displacements in 13 coronal plane slices
emphasized the importance of coronal images to com-
plement the sagittal images for optimal TMJ diagnosis.
The disc displacements we diagnosed indicated that the
development of posterior crossbite might have been
beyond the subjects’ physiologic tolerance and become
a cause of internal derangement of the TMJ in 50% of
the study sample.
In the orthodontic literature, there is agreement that
orthodontic treatment is not responsible for the devel-
opment of TMD, and it is not specific to prevent it.7-14
Visual analysis at posttreatment indicated that condyle-
disc positions remained unchanged except in 1 subject,
who developed unilateral ADD with no signs and
symptoms of TMD clinically. Clinical examinations at
posttreatment showed that 3 patients had unilateral
TMJ sounds. It was reported that signs and symptoms
of TMD can occur in healthy subjects and increase with
age, particularly during adolescence.8,9,14 Thus, TMD
that appears during orthodontic interventions might not
be related to the treatment but be a naturally occurring
phenomenon. Accordingly, it can be concluded that
RME does not increase or decrease the risk of TMD.
However, it is accepted that a harmonious functional
environment with normal skeletal relationships is ad-
vantageous.
Pretreatment clinical evaluation of this study sam-
ple indicated that no subject had any signs and symp-
toms of TMD. This emphasizes the importance of MRI
findings because clinical signs and symptoms alone are
not sufficient for differential diagnosis of TMD. Al-
though an optimal diagnosis can be made with MRI
findings, the question must be asked whether these
patients need to undergo MRI examination if they have
no clinical signs and symptoms of TMD. MRI investi-
gation should not be performed unless the patient has
TMD signs and symptoms. However, it would be
beneficial to have MRIs of the TMJs of patients with
TMD signs and symptoms to support the clinical
diagnosis with imaging methods and determine the disc
displacement type. In addition, MRIs of the TMJ are
obtained to observe the effectiveness of TMD treat-
ment. It might be important as a better prediction of
Arat et al 835
prognosis in managing TMD with longitudinal fol-
low-up of these patients. However, the use of MRIs just
to observe TMJ health as a checkup is not suggested.
MRI is a costly procedure and unpleasant for patients.
It is difficult to predict the future clinical condition
of a patient who previously had no clinically signs or
symptoms of TMD but has disc displacement as shown
on the MRI. The defense mechanism of the body plays
a significant role along with the causative factors in the
process of TMD. The defense mechanism of the body is
particular to each person and has a progression as to
tolerance, compensation, and adaptation. Therefore, it
is not predictable when and how a patient develops
TMD clinically. We must question the treatment re-
quirements of clinically TMD-free patients with disc
displacement observed on MRI. If we assume that
adaptation has occurred in these patients, intervention
might be unecessary for TMD. Environmental circum-
stances can be improved by maxillary expansion and
orthodontic treatment that gives an advantage to a
healthy TMJ. However, the patient should be informed
about his or her TMJ situation at pretreatment.
CONCLUSIONS
1. Of the 18 subjects, 9 (50%) had an abnormal
condyle-disc position at least in 1 plane.
2. Posterior crossbite appears as a trigger mechanism
for TMD. As a functional disorder, however, RS is
believed to play a major role in this mechanism.
3. MDD was the most common observation in poste-
rior crossbite patients.
4. Coronal MRIs provide important complementary
information for differential diagnosis of TMD es-
pecially in posterior crossbite subjects. However, it
is unreasonable to use MRI as a checkup in subjects
with no clinical sign and symptoms.
5. RME does not generally increase or decrease the
risk of TMD.
6. The functional pattern is established at an early age.
Thus, early treatment of crossbite subjects is rec-
ommended for a healthy TMJ and stable results.
We thank Dr Ernest W.N. Lam, Department of
Radiology, University of Toronto, for his contributions
in assessing the MRIs; Dr Donald G. Woodside, De-
partment of Orthodontics, University of Toronto, for
his critical reading of this manuscript; and Nazim
Topcu for his assistance in obtaining the MRIs.
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