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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 47-56

Temporomandibular joint space


Department of Oral Medicine and Radiology, S P Dental College and Hospital, DMIMS Deemed University, Wardha, Maharashtra, India

Date of Web Publication25-Jan-2018

Correspondence Address:
Dr. Aarati S Panchbhai
Department of Oral Medicine and Radiology, S P Dental College and Hospital, DMIMS Deemed University, Sawangi-M, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_37_17

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  Abstract 


There is a presence of interarticular space between the bony components of the temporomandibular joint (TMJ), i.e., between articular eminence and glenoid fossa of the temporal bone at the base of the skull and the condylar process of the mandible. The intervening articular disc, together with its attachments, divide the joint into two separate compartments, i.e., upper (superior) and lower (inferior) compartments located above and below the disc, respectively, which are referred as joint spaces. The clinical significance of joint space is of great value; the presence of normal joint space is needed for free movement of condyle along with articular disc. The widening or obliteration of joint space may indicate the involvement of TMJ or its pathology. The joint space configuration is greatly influenced by the glenoid fossa, condyle, and condylar positions within the fossa in TMJ on the right and left sides. The present review work is undertaken primarily including 37 studies from PubMed and Medline databases to reveal the information relating to the joint space, its measurement in normal subjects and TMJ disorder (TMD) patients, its correlation to other factors, and its role in TMDs. The review work would be of help to gain insight to predict the TMDs with respect to joint space morphometrics.

Keywords: Coronal, joint space, sagittal, temporomandibular joint


How to cite this article:
Panchbhai AS. Temporomandibular joint space. Indian J Oral Health Res 2017;3:47-56

How to cite this URL:
Panchbhai AS. Temporomandibular joint space. Indian J Oral Health Res [serial online] 2017 [cited 2018 Oct 16];3:47-56. Available from: http://www.ijohr.org/text.asp?2017/3/2/47/223930




  Introduction Top


The morphological changes in the temporomandibular joint (TMJ) including the joint space are closely associated with the etiology of TMJ disorders (TMD); the knowledge of the morphological characteristics of the TMJ is of utmost importance to an oral physician.[1],[2],[3],[4],[5] The clinical significance of joint space is of great value; the presence of normal joint space is needed for free movement of condyle along with articular disc. The widening or obliteration of joint space may indicate the involvement of TMJ joint or its pathology.[2],[6],[7],[8],[9],[10]

There is a presence of interarticular space between the bony components of the TMJ. The TMJ is located between articular eminence and glenoid fossa of the temporal bone at the base of the skull and the condylar process of the mandible. This interarticular space is divided into superior discotemporal joint space and inferior dicomandibular joint space by the articular disc.[2],[11],[12] The interarticular disk (meniscus) has a biconcave shape with a thick anterior band, a thicker posterior band, and a thin middle part. The morphology of the glenoid fossa and the condyle governs the shape of the articular disc. The disc, together with its attachments divide the joint into two separate compartments, i.e., upper (superior) and lower (inferior) compartments located above and below the disc, respectively, which are referred as joint spaces. The roof of the upper compartment is formed by the mandibular fossa, whereas the floor by the discal surface. For the lower compartment, the roof is formed by the inferior surface of disc and the floor by the surface of condyle of the mandible. The volume of joint cavity is estimated to be 1.2 ml for the upper compartment and 0.9 ml for lower compartment when the joint is in a passive state.[2],[11]


  Review of Literature Top


Joint space and condylar position in the glenoid fossa

The dimensions of glenoid fossa and condyle and the condylar positions within the fossa determine the configuration of the joint spaces of TMJ on both right and left sides.[8],[11]

There is no quantitative standard for the optimal position of mandibular condyle in the glenoid fossa in the population. However, it appears that the mandibular condyle is usually in central position in the glenoid fossa when teeth are in occlusion; it means that a condyle is positioned concentrically when the anterior and posterior aspects of the radiolucent joint space are uniform in width.[12],[13] The condyle is retruded when the posterior joint space (Pjs) width is less than the anterior and protruded when the anterior joint space (Ajs) is narrower. The radiographic outline of condyle and glenoid fossa does not correspond to each other which contributes to its eccentricity in medio-lateral aspect to mild extent.[12],[14] The posteroanterior variation of condyle positions in asymptomatic TMJs is greater than commonly thought; further, it varies as per the type of malocclusion.[7],[11],[13],[14] The condyle was positioned more anteriorly in the glenoid fossa in Class II division 1 cases as compared to Class II division 2. The Class III cases had wider and shallower fossa; the condyles were elongated and closer to the roof of the fossa.[15] In pseudo Class III malocclusions, the mandibular condyles are out of the glenoid fossa due to functionally too forward position of the mandible.[16] Paknahad and Shahidi observed that the patients with severe TMDs have posteriorly seated condyle whereas with mild-to-moderate TMDs have concentric and anteriorly seated condyle.[4]

The markedly eccentric condylar positioning leading to alterations in joint spaces may represent an abnormality and may be a matter of concern. The pronounced anterior condylar positioning may suggest the involvement by juvenile rheumatoid arthritis, and the posterior positioning of condyle may propose for the presence of disk displacement. The superior condyle positioning or obliterated joint space may suggest displacement, perforation, or loss of intervening soft tissue components in the joint, while widened joint space or inferior condylar positioning may suggest the presence of blood or fluid within the joint.[1],[5],[6],[17],[18] The disc displacement, deformation, perforation, or osteoarthritis may induce the joint space narrowing.[6] The joint space is said to be altered with condylar rotation with change in vertical dimension, condylar displacement, articular surfaces remodeling or adaptive remodeling in TMJ, and neuromuscular and/or skeletal adaptive changes with orthodontic treatment or with extraction or nonextraction orthodontics. The patient develops dysfunction if it exceeds the adaptive threshold.[1],[19]

Radiographic examination of joint space

The term radiographic joint space or radiographic interarticular space refers to the radiolucent area between the glenoid fossa and the condyle and should not be confused with the superior joint space (Sjs) and inferior joint space above and below the articular disk, respectively. Thus, the radiographic joint space contains the disc, soft tissue components of the joint, and synovial fluid.

The radiographic examination of TMJ allows the joint spaces to be viewed in sagittal or lateral images and axial and coronal images of TMJ radiographically. The sagittal view of TMJ provides the visibility of Ajs, Sjs, and Pjs, while the coronal aspect provides the view of medial joint space (Mjs), central joint space, and lateral joint space (Ljs) of the TMJ. One factor that has always jeopardized the visualization of the TMJs on conventional radiographic examination is the superimposition of neighboring structures. Computed tomography (CT) allows clear visualization and the analysis of TMJ without superimposition; besides, digital volumetric tomography (DVT) or cone-beam CT (CBCT) are considered the most suitable and economic imaging modalities for radiographic TMJ evaluation to facilitate the appropriate treatment planning. The magnetic resonance imaging allows for the visualization of disc and disc position.[3],[11],[20],[21],[22],[23]

The most of the studies conducted in 1981–2000 performed the radiographic evaluation of joint space using CT, while the studies conducted later used DVT or CBCT for the purpose may be considering that it would be more useful and economic mean for radiographic evaluation.[5],[22],[23],[24],[25],[26],[27]

Joint space measurement

The Ajs, Sjs, and Pjs can be measured on sagittal images of TMJ [7],[17],[22],[28],[29],[30] and the Mjs, Sjs, and (Ljs) can be measured on frontal or coronal view.[6],[7],[25],[31] In addition, joint spaces can be measured in axial view of the condyle.[31],[32] In most of the previous studies, the joint space measurement was done in sagittal view using the method described by Pullinger and Hollender.[33]

To measure the joint spaces in the sagittal view [Figure 1], initially, a horizontal line is drawn on deepest or uppermost area of glenoid fossa, the intersection of this line with glenoid fossa is selected as superior reference point (S); then, a line is drawn from S point to the most prominent points on anterior (A) and posterior (P) aspects of the mandibular condyle. Finally, the perpendicular lines from A and P tangent points to the glenoid fossa are drawn and the perpendicular distances are measured as Ajs and Pjs. The distance between S point and superior prominent point of condylar head is considered as Sjs.[7],[17],[22],[28],[29],[30]
Figure 1: Joint space measurement in sagittal view of temporomandibular joint. S: Deepest point in glenoid fossa, A: prominent anterior point on condyle, P: Prominent posterior point on condyle

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For measuring the Mjs and Ljs on the coronal view [Figure 2], the deepest point of glenoid fossa is marked, and then, two tangent lines on medial and lateral slopes of glenoid fossa are drawn. Finally, the perpendicular line from the most prominent points on medial (M) and lateral (L) poles of each condylar head is connected to these tangent lines on slopes of the glenoid fossa.[6],[7],[25],[31] Similarly, for measuring the joint spaces in axial view, the narrowest distance between anterior, medial, and posterior aspect of condyle and glenoid fossa is measured.[31],[32]
Figure 2: Joint space measurement in coronal view of temporomandibular joint. S: Deepest point in glenoid fossa, M: Medial pole on condyle, L: Lateral pole on condyle

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The following joint space measurements can be assessed on the radiographic view of TMJ.[26],[28],[34],[35],[36]

  1. Ajs: Expressed by the narrowest/shortest distance between the most anterior point of the condyle and the posterior wall of the articular eminence
  2. Sjs: Measured as the narrowest/shortest distance between the most superior point of the condyle and the most superior point of the mandibular fossa
  3. Pjs: Expressed by the narrowest/shortest distance between the most posterior point of the condyle and the posterior wall of the mandibular fossa
  4. Mjs: Expressed by the narrowest/shortest distance between the most medial point of the condyle and the medial wall of the mandibular fossa
  5. Ljs: Expressed by the narrowest/shortest distance between the most lateral point of the condyle and the lateral wall of the mandibular fossa.


Kamelchuk et al.[37] attempted to establish a quantifiable method of TMJ space analysis using multidirectional axially corrected tomography. For each joint, the medial, lateral, and central image slices were obtained, traced three times each, and then triplicated for drafting. After randomization and blinding, all the tracings and draftings were measured manually with digital calipers and subjected to analysis. The process was repeated for simulated head rotations of ±10°. There were no significant differences in joint space analysis between −10°, 0°, and +10° of head rotation. It was concluded that the joint space analysis is unaffected by head rotation and this method of joint space analysis has a high reliability as determined for each joint space position and simulated rotation.

Henriques et al.[38] have described the different measurement technique for joint spaces than that was used in most of the previous studies. Initially, the reference line was drawn tangentially to the lowest anterior and posterior extremities of the glenoid fossa. Then, vertical line was drawn from a mid-reference point to the first line; the anterior and posterior condyle to glenoid fossa distances were measured along the line at 45° to the base reference line drawn initially. The distance between the uppermost point of the condyle and the closest internal point of the mandibular fossa was measured as superior distance. For measurements in frontal view, initially, the most medial and lateral points of the condylar head were connected to produce an alpha line. Later, a beta line was drawn overlapping the alpha line up to exactly half of its length; the end point of the beta line was termed as the middle point of reference. The mid-reference point and the uppermost point of glenoid fossa were connected, and the superior distance was measured between fossa and superior point of condylar head along with this line. The two lines were drawn at 45° to the alpha line on medial and lateral aspect; the closest medial and lateral distances were measured along these lines between condyle head and glenoid fossa.[38]

Joint space assessment

For the present review work on joint space measurements, a literature search was undertaken primarily through PubMed and Medline databases with the search expression “joint space, joint space measurements, condyle-fossa relationship.” The search included articles from 1950 to 2016; the 37 studies were relevant to the present review work. For all the included studies, the data relating to the joint space, its measurement in normal controls and TMD patients, and its correlation to other factors were obtained [Table 1], [Table 2], [Table 3], [Table 4]a and [Table 4]b.
Table 1: Characteristics of studies included for joint space assessment (for 1987-2010)

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Table 2: Characteristics of studies included for joint space assessment (for 2011-2016)

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Table 3: Joint space measurements in normal asymptomatic population (for 1987-2016)

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Table 4a: Joint space measurements in patients with temporomandibular joint disorders or malocclusion (for 1994-2010)

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Table 4b: Joint space measurements in patients with temporomandibular joint disorders or malocclusion (for 2011–2016)

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Joint space assessment in normal population

Earlier, various authors attempted to determine the joint space measurements in normal asymptomatic population without TMD [Table 1], [Table 2], [Table 3].[5],[6],[7],[8],[9],[17],[18],[23],[26],[31],[32],[38],[39],[40],[41],[42] It was observed that the condyles are usually in centered position in the joint and there was mild correlation found between right and left joint relationships; hence, it was suggested that the assessment of joint spaces in the right and left sides should be done independently.[7],[13] A study by Pullinger and Hollender showed the concordance between anterior and posterior interarticular spaces with low interobserver variations.[43]

Christiansen et al., 1987 measured the joint spaces in two normal sample populations. The central-Sjs was found to be 2.2 and 2.3 mm; the antero-Sjs was 1.7 and 1.9 mm; and the Mjs-horizontal joint space 3.7 and 3.9 mm, respectively, for prospective and retrospective samples,[39] while Kim estimated central joint space, Mjs, and Ljs in the coronal views in 30 joints to get the normal joint space width which could be used as a standard for comparing with the symptomatic joints. The mean joint space estimated was 2.77 ± 0.51 mm at medial, 3.57 ± 0.63 mm at center, and 2.41 ± 0.41 mm at lateral side of the mandibular condyle. The mean of joint space of male was wider than that of female but only in central measurement.[6] The Ajs and Pjs were also estimated in 14 TMJs in dry skulls, and on the sectioned plaster casts of the impressions of actual joint space, here the individualized horizontal and vertical correction of the condylar axis was done to render joint more visible and joint space more measurable.[8]

The joint space was evaluated in various disc positions as normal, anterolateral, anterior, anteromedial, and medial. The interarticular joint spaces evaluated were anterosuperior, superior, posterosuperior, and posterior. In normal disk position, the antero-Sjs was found to be smaller as compared other joint spaces. When the disc was ahead of condyle, the antero-Sjs was widened; when it was medial, the Sjs was significantly wider than normal. While in anteromedial disc position, the joint space was obliterated.[40] Kinniburgh et al. estimated the joint spaces in normal and in full anterior disc displacement positions. It was observed that there was an increased Ajs and reduced Pjs and Sjs in the anterior disc position as compared to that in normal. The Pjs was significantly reduced in females as compared to males.[23] Dalili et al. found significant differences in Ajs, Sjs, Pjs, Mjs, and Ljs values between two sides.[7] This was unlike to the findings observed in study by Pereira and Gavião [5] and Agrawal and Jain.[32] When compared according to gender, the measured joint spaces except Sjs were not different. This was similar to that seen in the study by Ikeda and Kawamura.[26] Pereira and Gavião [5] established the condylar position and joint space in normal subjects and compared them with TMD patients. No significant differences were found in relation to groups, gender, and sides of the TM joint; however, in TMD group, a higher number of posteriorly positioned condyles were observed as compared to the normal group. The previous studies revealed the similar observations.[4],[9],[26],[41]

The measurement technique used by Henriques et al.[38] was different than that used in most of the other studies. They have evaluated and compared the joint spaces or condyle to fossa distance in normal occlusion subjects in maximum intercuspation and centric relation position of occlusion and found no significant differences between them. Fraga et al. compared asymptomatic subjects with normal occlusion and malocclusions for joint spaces in turn for the condylar positions in the glenoid fossa. The least condylar decentralization was observed in the normal occlusion group, although, there was bilateral asymmetry in anteroposterior condylar positioning.[44] In addition, Imanimoghaddam et al. investigated the relationship of joint spaces with the inclination of articular eminence. The significant correlation was observed between the Sjs and Pjs with an inclination of articular eminence in the normal group.[18]

Overall, the joint space measurements in previous studies in asymptomatic normal occlusion group [Table 3] lie approximately in the similar range except in few studies,[26],[32],[33] where the values differed grossly than that could be estimated in other majority of the studies. Seren et al.[32] observed very wide range of values for Ajs and Pjs, while Ikeda and Kawamura observed them too smaller and Agrawal and Jain estimated them to be in higher range as compared to other studies. Notably, most of the studies performed the joint space measurements in the sagittal view of TMJ followed by the coronal view, whereas Agrawal and Jain performed most of the measurements in the axial view.[31]

In general, the mean values for Sjs were larger than Pjs and Ajs, and among Pjs and Ajs, the mean values for Pjs were larger than Ajs in most of the studies. Comparing Mjs and Ljs, the mean values for Mjs were found to be larger than Ljs although these observations were not significant in all the previous studies. The mean values for joint spaces in normal occlusion group showed a higher trend than the values in malocclusion or TMD group patients.[18],[32],[38],[41]

Joint space measurement in temporomandibular joint disorder or malocclusion cases

The various authors evaluated the joint space in symptomatic patients or patients with TMD or malocclusion [Table 1], [Table 2], 4a and b].[1],[3],[10],[17],[18],[22],[23],[24],[25],[26],[27],[28],[29],[30],[32],[34],[35],[36],[38],[41],[42],[44],[45],[46],[47],[48],[49],[50] Overall, the mean values including standard deviation showed the similar ranges of joint space measurements, except in few studies [17],[45],[49] where the values were comparatively smaller. The gender-wise comparisons for the joint spaces revealed no differences for some of the studies.[5],[22],[23],[26] However, Kinniburgh et al. found significantly greater Pjs in males as compared to females,[23] also Cohlmia et al.[22] found greater Sjs in males than females. Comparing the joint spaces between right and left sides, most of the previous studies revealed no significant differences; however, the studies [24],[25],[27],[34] were contradictory to this to find the significant differences for Ajs [24],[27] and Pjs.[34]

Studies evaluated joint space against various disc positions,[23],[26],[45],[50] the disc position was determined using magnetic resonance imaging, the joint spaces were measured using tomography, and the most of the sample was in the age range of 7–20 years. Ikeda and Kawamura and Manjula et al. estimated the joint space in normal disc position and found no significant differences either in gender-wise or side-wise comparisons.[26],[50] While Kinniburgh et al. found a significant increase in Ajs and reduction in Sjs in patients with anterior disc position than in normal.[23]

The studies compared the joint space morphometrics in patients with TMD and in normal asymptomatic individuals.[5],[10],[17],[18],[45] Major et al. attempted to establish the associations between osseous characteristics of TMJ and internal derangement and observed the relationship between disc displacement and reduced Sjs, increased Ajs and Pjs. It could be inferred that internal derangement in TMJ may be associated with functional osseous adaptation within the joint.[45] While Pereira and Gavião found the weak positive correlation between the Ajs and the dysfunction index with no significant differences in relation to gender and side of the TMJ,[5] Tsuruta et al. investigated condylar morphological changes while condylar movement from the intercuspal position to the reference position dividing subjects into two groups as with or without condylar bone changes. No significant differences in the width of the Ajs and Pjs were observed in two groups.[10] Imanimoghaddam et al. found that the mean values of the Ajs were significantly greater in the TMD group than normal. The significant correlation was observed between Pjs and Sjs in normal and TMD groups.[18] Alves et al. evaluated [17] patients with TMD in elderly age group (23–71 years) than in other studies and found diminished joint spaces, especially Pjs in TMD patients.[17]

The symptomatic patients were also evaluated as per the skeletal morphology and type of growth pattern, the negative correlation was observed between the Sjs and vertical skeletal pattern,[30] the Sjs was found to be decreased in vertical growth pattern patients and increased in horizontal growth pattern patients,[51] Park et al. categorized the patients based on the mandibular plane angle as hypo-, normo-, and hyper-divergent groups. The significant differences were observed for Sjs in the hypo- and hyper-divergent groups.[42] Kikuchi et al., in their study, found a significant negative correlation between the gonial angle and the Ajs and of ramus plane angle with Pjs, Mjs, and Ljs. It was suggested that the craniofacial growth pattern may affect the joint spaces and condylar position.[25] Cohlmia et al. performed the morphological assessment of TMJ with respect to overjet and ANB angle. The adults had significantly smaller joint space as compared to children, the left Ajs and right Pjs were smaller, with significant differences in measurements in Class III and Class II malocclusion cases. The insufficient overjet cases had significantly larger Pjs, while no differences seen as per the varied ANB angles.[22]

Comparing joint space as per the type of malocclusion, there were many observations as mentioned. Irrespective of type of malocclusion, the Ajs was found to be smaller as compared to Sjs and Pjs in general except in few studies;[23],[24],[29] furthermore, in most of the observations, the Pjs was smaller than Sjs with few exceptions.[17],[25],[28],[30],[34],[35],[48] The significant anterior positioning was observed in Class I and Class II malocclusion cases with reduced Ajs.[3],[28],[41],[48] The greater anterior positioning was seen in Class I malocclusion cases than Class II and III cases.[41],[48] Krisjane et al. found significantly greater joint space measurements in Class II than Class III cases.[30] Henriques et al. have evaluated the joint spaces in two contact positions of teeth, that is, centric relation and maximum intercuspation position in normal occlusion and Class I, II, and III malocclusion cases, and found no significant differences between them. However, the measurement technique here was different than that was used in most of the other studies.[38] Fraga et al. investigated and compared the condylar positions and joint spaces in asymptomatic subjects with Class I, II, and III malocclusion. Overall, condylar decentralization and bilateral symmetry were the features observed in all the study groups; however, the greatest condylar decentralization was found in Class II malocclusion group.[44]

Few of the previous studies performed the joint spaces analysis before and after the orthodontic treatment.[1],[47],[49] Major et al.[1] found a significant increase in Ajs dimension in treated nonextraction cases and no joint space change in extraction cases. No other significant observations could be determined in either group for length of Class II elastic wear or means of extraction space closure. Although statistically significant, a mean increase in joint space of approximately 0.39–0.49 mm was not clinically significant. The increase in Ajs in nonextraction cases was irrespective of change in Pjs; hence, it may be suggested that it may be as a result of a change in condylar rotation in vertical dimension of occlusion or remodeling of articular surface of the condyle and articular eminence.[1] Leonardi et al. examined the condyle-fossa relationships and joint spaces in treated functional posterior cross-bite patients; the patients were investigated before and after the treatment for palatal expansion and were also compared with noncross-bite side and with normal control. The joint spaces were greater in posttreatment measurements as compared to that in pretreatment measurements that were statistically significant for the Sjs, however, of small magnitude to influence clinically.[47] Coskuner and Ciger evaluated the TMJ in the Class II malocclusion cases before and after the orthodontic treatment and the differences were nonsignificant.[49]


  Conclusion Top


On the whole, the greater variations were observed in the study findings with respect to joint space analysis, its comparisons and associations with other parameters; the study findings were highly individualized and incomparable. The literature review suggests that although many studies were conducted on joint space analysis, the generalized or common inference could not be drawn as there was lot of heterogeneity with regards to sample size, age groups, type of sample included methodology, and the malocclusion type and the joint space measured.

The joint space analysis and condyle-fossa relationship may be of interest to understand the existing or ensuing TMD; however, currently, a few data are available to have its implications in TMD or to have its clinical application in orthodontic diagnosis and treatment. Although the altered condylar or disc position may manifest in altered joint space, the definitive data are awaited to reach to the concrete conclusions. The present review work would be of help to gain insight to predict the TMD with respect to joint space morphometrics and also has provided baseline data against which future research work may be planned.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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