CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

MR Abnormalities of the Lateral Pterygoid Muscle

in Patients with Nonreducing Disk Displacement of
the TMJ

Xiaojiang Yang D.D.S., Hannu Pernu D.D.S., M.D., Juhani Pyhtinen M.D., Ph.D.,
Petri A. Tiilikainen D.D.S., Kyösti S. Oikarinen D.D.S., Ph.D. & Aune M. Raustia
D.D.S., Ph.D.

To cite this article: Xiaojiang Yang D.D.S., Hannu Pernu D.D.S., M.D., Juhani Pyhtinen M.D.,
Ph.D., Petri A. Tiilikainen D.D.S., Kyösti S. Oikarinen D.D.S., Ph.D. & Aune M. Raustia D.D.S., Ph.D.
(2002) MR Abnormalities of the Lateral Pterygoid Muscle in Patients with Nonreducing Disk
Displacement of the TMJ, CRANIO®, 20:3, 209-221, DOI: 10.1080/08869634.2002.11746213

To link to this article: http://dx.doi.org/10.1080/08869634.2002.11746213

Published online: 13 Jul 2016.

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 • RADIOLOGY

MR Abnormalities of the Lateral Pterygoid Muscle

in Patients with Nonreducing Disk Displacement of
theTMJ
Xiaojiang Yang, D.D.S.; Hannu Pernu, D.D.S., M.D.; Juhani Pyhtinen, M.D., Ph.D.;
Petri A. Tiilikainen, D.D.S.; Kyôsti S. Oikarinen, D.D.S., Ph.D.; Aune M.
Raustia, D.D.S., Ph.D.

0886-9634/2003-
209$05.00/0, THE
JOURNAL OF
CRANIOMANDIBULAR
PRACTICE,
Copyright © 2002
by CHROMA, lnc.
Manuscript received
June 22, 2001; revised
manuscript received
October 9, 2001; accepted
January 8, 2002
Address for reprint requests:
Dr. Xiaojiang Yang
Dept. of Prosthodontic Dentistry
and Stomatognathic Physiology motion (88.9%)(P=0.008). Osteoarthritis was found to be correlated with condylar limitation (P<0.01).
lnstitute of Dentistry
University of Oulu
Box 5281
90014 University of Oulu
Fin land
e-mail: Xiaojiang.yang@oulu.fi
ABSTRACT: The aim of this study was to investigate the pathological changes of the lateral pterygoid
muscle (LPM) using magnetic resonance imaging (MAl) in patients with anterior disk displacement with
nonreduction (ADDnr) of the temporomandibular joint (TMJ) and to compare the abnormal findings of
the LPM with the clinical symptoms and other pathological MAl alterations of the TMJ. Bilateral or uni-
lateral ADDnr was demonstrated in 142 patients by MAl (176 TMJs; 106 females; 36 males; range 19 to
72 years; mean 43.9 years). ln 123 TMJs, the LPMs were clear1y observed in MAls and analyzed in this
study. Pathological changes of the LPM were found in 92 TMJs (74.8%) in MAl. Hypertrophy, atrophy
and/or contracture were detected in the superior belly of the LPM (SBLPM) (35.8%, 44/123) or in the
inferior belly of the LPM (IBLPM) (9.8%, 12/123) or in both bellies (29.3%, 36/123). The pathological
changes of the LPM in MAl presented a significant association with the main clinical symptoms of TMJs
with ADDnr, i.e. pain on jaw movement (P<0.01 ), pain in the LPM (P<0.01 ), pain in TMJ (P<0.05) and
restricted jaw opening (P<0.05). The proportion of the abnormalities in LPM was significantly lower in
TMJs with condylar limitation (63.6%) than in TMJs with condylar hypermobility (83.3%) and normal
The results of this study indicate that the pathological changes of the LPM in TMJs with ADDnr cou Id be
detected by MAl and have a significant association with the main clinical symptoms of the patients.
When condylar limitation happened, on the contrary, the pathological changes of the LPM in MAl were
reduced. The alteration of the clinical symptoms in the patients with ADDnr might be associated with the
pathological situations and symptoms of the LPM.

nterior disk displacement with nonreduction

A (ADDnr) is a severe internai derangement of the

Dr. Xiaojiang Yang received his D.D.S.
degree from the West China University of
Medical Science in 1985 and his Master's
degree as a specialist in maxil/ofacial
surgery from the Chine se General
Military Postgraduate lmtitute in 1990. ln
1991 he was a visiting scholar at the
Departmellt of Maxillofacial Surgery
Leuven University Hospital, Belgium.
Currelltly, Dr. Yang is a researcher at the
Jnstitute of Delltistry. Oulu University,
Fin/and.
temporomandibular joint (TMJ). 1 Clinical stud-
ies have reported that ADDnr could be related to jaw lim-
itation, TMJ locking, disk deformities, osteoarthritic
changes in the TMJ, and the painful symptoms of the
patients. 2· 5
Many treatment methods are suggested for manage-
ment of ADDnr, such as occlusal appliances, 6 muscle
exercising,7 injection of sodium hyaluronate, 8 arthrocen-
tesis, 9 and surgery . 10 Sorne reports fi nd that considerable
improvement of the clinical symptoms of patients with
ADDnr can be achieved after conservative or surgical
treatment, even though disk displacement and combined
disk deformities as weil as osteoarthritis persist. 8•10 Other
authors suggest that clinical symptoms, especially pain-
fui ones, of the patients with ADDnr can be eased even
without treatment. 11 • 12 The explanations for this are
unclear. 12

209
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE
Abnormal fonction of the lateral pterygoid muscle
(LPM) has been found using electromyography (EMG) in
patients with temporomandibular joint disorders (TMD) 13
and bas also been observed to be associated with pain
symptoms in TMJ. 14 A few studies report that the normal
morphology and pathological changes of the masticatory
muscles, 15 -16 including the LPM, 17 - 19 can be detected by
magnetic resonance image (MRI). lt is suggested that
pathological findings and the structural changes of the
LPM in MRI might be associated with TMD symp-
toms;17-19 however, there are no reports on the pathologi-
cal changes of the LPM in MRI in patients with ADDnr
or a correlation between abnormal LPM findings in MRI
and the clinical symptoms of ADDnr.
The aim of this study was to investigate the pathologi-
cal changes of the LPM using MRI in patients with
ADDnr and to analyze abnormal MRI findings of the
LPM by comparing them with clinical symptoms and
other MRI alterations of the TMJ.
Materials and Methods
For this retrospective study, bilateral or unilateral
ADDnr was diagnosed in 142 patients using MRI (176
TMJ s; 106 females; 36 males; range 19 to 72 years; mean
43.9 years). The cases were selected from a total of 325
patients examined by MRI because of TMJ problems
(1991-2001). The patients had been originally referred to
the Oral and Maxillofacial Surgery Department of Oulu
University Central Hospital for diagnostic examination
and treatment of TMJ dysfonction. Clinical symptoms
included occasional TMJ clicking, TMJ locking, restricted
movement of the jaw, progressing or constant pain in the
TMJ, jaw movement pain, palpation and/or provocation
pain in the lateral pterygoid muscle (LPM) and other
masticatory muscles. The history ofTMD and the clinical
symptoms of the patient were recorded.
Prior to 1996 the studies were performed with a 1.0-T
magnet (Magnetom, Siemens), and after 1996, with a 1.5-
T magnet (Signa, GE.) Tl-weighted (200-400112-2011,2)
(TR range/TE range/excitations), T2-weighted (2000-
3000/80-200/1) and Proton Density (PD) (2000-3000114-
30/1), with nine 3-mm-thick imaging slices, a IOXIO
field of view (FOY) and a 256Xl92-256 or l28Xl28 (in
1.0-T) matrix were used for the images.
Ali the patients underwent bilateral MRI examinations
of the TMJ with TMJ surface-coil. Oblique sagittal,
direct sagittal, and coronal projections were used in
closed mouth position. In maximally open mouth posi-
tion, only proton density (PD) oblique sagittal or T 1-
weighted direct sagittal images were taken.
According to the anatomie study of Wilkinson, 2o the
210 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
YANG ET AL.
superior belly of the LPM (SBLPM) runs posteriorly
from its origin in an inferior and lateral direction to the
crest of the eminence where its fibers become more
horizontal and insert into the condyle or disk. The inferior
bell y of the LPM (IBLPM) runs posteriori y and laterally
to the insertion into the pterygoid fovea. The normal
structure of the LPM in oblique sagittal MRI is consid-
ered a fan-like muscle from the origins of the two bellies
to the neck of the mandibular condyle or the disk. On
either Tl-weighted or PD images, a high signal layer of
fat tissue could separate the SBLPM from the IBLPM.
The signal of normal muscle tissue was isointense on ali
MRI sequences. 17-18 In closed mouth position, the upper
and lower edges of the two bellies of the LPM are
weil identified.
Enlargement and increased size of muscles on ali MRI
sequences were considered a sign of hypertrophy of the
skeletal muscles.I7. 21 -22 Hypertrophy of the LPM mani-
fested as an obvious enlargement in the middle part ofthe
belly, because the two ends of the belly connected with
bony tissues. The hypertrophie bell y of the LPM showed
that the upper and lower edges of the bell y changed into
convex curves. Contracture of the LPM presented as the
size of the muscles increased, and at the same time, fibro-
sis was found as low signais in the muscles on PD and
T2-weighted images. 17 -23 Atrophy of the LPM was char-
acterized by fatty replacement with high signais appear-
ing in large areas in the muscles on short and long
TRIshort TE images with nonincreased or reduced size of
the LPM. 17 Diagnosis was made when the same patholog-
ical finding was shown clearly on at least two slices of
the image.
Out of the 176 TMJs in this study, the LPM was not
clearly distinguishable and only one belly could be
observed on the MR images in 53 TMJs. These images
could not be used for evaluation of pathological changes
of the LPM (Figure 1, A and B). The condition of the
LPM in 123 TMJs was analyzed in this study.
Disk position, disk morphology, condyle osteoarthritic
changes, condyle mobility, and effusion of the TMJ were
also evaluated in MRI.
Disk position was diagnosed according to Katzberg, et
al. 1 Normal disk position was defined as the posterior
band of the disk being located at the superior or twelve
o'clock position relative to the condyle. If the displaced
disk remained in an anterior position of the condyle in the
maximal mouth open position, it was demonstrated as
anterior disk displacement with nonreduction (ADDnr) .
The morphology of the disk was assessed using the
biconcave shape as the normal point of reference. Disk
deformity was defined when folded, thickening changes
in ali parts of the disk, convex, or posterior band en large-
JULY 2002, VOL. 20, NO. 3
YANG ET AL.
Figure lA and B
These images could not be used for evaluation of pathological changes of the LPM: A (above left). Folded disk with posterior band enlargement (D)
and erosion of the condyle (C) show clearly in the oblique sagittal closed mouth TMJ image, but both bellies of the lateral pterygoid muscle (LPM)
are not observed; B (above right). Only the superior belly of the LPM (SB) can is observed. (D=disk; C=condyle).
ment of the disk were found in the images.2.4.8
According to Westesson,3 the diagnosis of osteoarthri-
tis was made when one or more of the following signs
were present on the condyle: flattening, osteophytes, ero-
sions and sclerosis.
Condylar mobility was classified as hypomobility
(limitation), normal mobility and hypermobility by MRI
findings. For this procedure, a horizontal tangential Iine
of the top of the articular fossa and a verticalline through
the top of articular eminence were made on sagittal or
oblique sagittal image of TMJ. Two !ines met in point
"0". From the point "0", the articular eminence was
divided by angles into three parts: oo -90°, 90°-120°, and
120°-180°. The top of the articular fossa was at oo and the
top of the articular eminence was at 90° (Figure 2). The
diagnosis of condylar mobility was made by measuring
the location of the top of the condyle in maximal mouth-
open images. Hypomobility or limitation of the condyle
was diagnosed if the top of the condyle was located in 0°-
900 (<90°). In this region, the condyle did not translate or
translated only slightly (<30°), or translated but did not
reach the top of the eminence (<90°) (Figure 2A). If the
top of the condyle was located in 90°-120° of the
eminence, the mobility of the condyle was considered to
be normal (Figure 2B). When the condyle translated
excessive! y, beyond and su peri or to the leve! of the artic-
ular eminence (>120°) (moved more than 30° from the
top of the eminence), hypermobility of the condyle could
be defined (Figure 2C). This measurement was per-
formed according to the princip les of the standards of
JULY 2002, VOL 20, NO. 3
MRI STUDY OF THE LATERAL PTERVGOID MUSCLE
Benito, et al. 5 and the standards of Boering, applied by
Dijkstra, et al. 24
According to Schellhas,25 effusion of the TMJ defined
as a high fluid signal was found in T2-weighted MR
images. Effusion might be detected either in compart-
ments of TMJ or in the bilaminar zone of the disk, or
both.
Statistical analysis of the data was performed using
SPSS 10.0 (SPSS, Inc., Chicago, IL) including Pearson
Chi-square test and Fisher's exact test.
Results
In MRI of 123 TMJs with ADDnr, pathological changes
of the LPM were found in 92 TMJs (74.8%). Pathological
changes found in the su peri or bell y of the LPM (SBLPM)
(35.8%, 44/123) and in both bellies (29.3%, 36/123) were
more frequently observed in this study. Abnormalities
only conceming the inferior bell y of the LPM (IBLPM)
were relatively rare (9.8%, 12/123). Atrophy (Figure 3)
hypertrophy (Figures 4-7), and contracture (Figures 8
and 9) of the LPM were observed. Among these findings,
hypertrophy and atrophy of the muscle were seen more
often (Table 1). In 31 TMJs with ADDnr, the LPM
showed as normal in MRls (Figures 10-12).
Pain in the TMJ (56.9%, 70/123), pain in the LPM
(60.1 %, 74/123), TMJ locking (52.8%, 62/123), and
restricted mouth opening (54.5%, 67/123) were found as
the main clinical symptoms of the TMJs with ADDnr in
this study. Nearly half of the joints had pain on jaw
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 211
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE
- (55.3%, 68/123), limitation of condylar mobility (53.7%,
c 66/123), and TMJ effusion (57.7%, 71/123) were found
Figure 2, A, B, and C
Classifications of condylar mobility: a horizontal tangentialline on
top of the articular fossa and a vertical li ne through the top of the
articular eminence are made on a sagittal or oblique sagittal image
of the TMJ. The two li nes meet at point "0". From point "0", angles
were drawn todi vide the articular eminence into three parts: 0°-90°,
90°-120°, and> 120°. The top of the articular fossa (TF) is at oo
and the top of the articular eminence (TE) on 90°. A (above top):
Hypomobility (limitation) of the condyle: in maximal open mouth
images, the top of the condyle (TC) is located in the 0°-90° (<90°).
B. Normal mobility of the condyle: the top of the condyle located
at 90°-120° of the eminence in maximal mouth opening. C. Hyper-
mobility of the condyle: the condyle translates excessively, beyond
and su peri or to the lev el of the articular eminence (> 120°) in the
images of mouth maximal opening.
212 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
YANG ET AL.
Figure3
Atrophy of the su peri or bell y of the LPM is seen in a 25-year-old
female who received orthodontie treatment during the past two years.
Before orthodontie treatment she complained of slight occasional
clicking in the left TMJ. Pain on jaw movement, opening difficulties,
and facial pain on the left appeared after the orthodontie treatment was
completed. The symptoms did not improve after two months of splint
use. Pain fui loc king and severe pain on palpation of the LPM were
detected on the left side. There were no symptoms on the right side. In
a closed mouth, oblique sagittal image of the left TMJ (3000/14, 1.5-T
magnet), atrophy of the superior bell y of the LPM with a large area of
high signal fatty replacement (open arrow) is seen. The inferior belly
is normal (ffi). There is anterior disk displacement (D) and osteophyte
of the condyle (C). The displaced disk cannot reduce in the open
mouth image (not shown here).
movement (48.0%, 59/123) and pain concerning other
masticatory muscles (48.0%, 59/123). Occasional click-
ing was complained of and detected in 41 patients (33.3%,
41/123) (Table 2). The results in Table 2 indicate that the
pathological changes of the LPM found in MRI bad a sig-
nificant association with pain in the LPM (P<O.Ol), pain
on jaw movements (P<0.01), pain in TMJ (P<0.05) and
restricted jaw opening (P<0.05).
The pathological findings on MRI of the 123 TMJs are
presented in Table 3. Condylar osteoarthritic changes
as main MR imaging abnormalities in the joints with
ADDnr. Disk deformities were observed in 39 TMJs
(31. 7% ). The pathological changes of the LPM in MRI
showed a high significant association with condyle
mobility (P=0.008). The proportion of the pathological
findings ofthe LPM was significantly lower in the TMJs
with ADDnr in the condylar limitation group (63.6%)
than in the condylar hypermobility group (83.3%) and the
condylar normal motion group (88.9% ). The pathological
changes of the LPM in MRI showed no significant asso-
ciation with other MRI findings (P>0.05)
JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERYGOID MUSCLE

Figure 4 (A and B)
Hypertrophy of the superior bell y of the LMP shows in images of a 40-year-old male who has experienced chronic facial pain, jaw movement pain,
and TMJ pain on the left side for nine years and whose symptoms were relieved after splint treatment. Pain and restricted mandibular movement
recurred after three months. Pain of the left LPM and loc king were observed. Palpation pain of the temporal muscles was found on both sides.
Anterior disk displacement without reduction was found in the left TMJ using MRI. The disk position and movement were normal on the right side.
A. Closed mouth image (oblique sagittal, 3000/14, 1.5T, 3 mm thick) of the Ieft TMJ, hypertrophy of the superior belly of the LPM is suggested
based on the enlarged size of the bell y (open arrow) (compare to image B above right). Osteoarthritic changes to the condyle (C) were observed
(ffi= inferior bell y of the LPM). B. The LPM image is normal in the closed mouth image of the right TMJ (oblique sagittal, 3000/14, 1.5T, 3 mm
thick). The superior bell y (open arrow) and the inferior bell y (lB) of the LPM appear normal (C=condyle)

As an etiological analysis for condylar limitation, the Discussion

relationships among condyle mobility and other MRI
findings are summarized in Table 4. The osteoarthritic
changes of the condyle were found to be significantly
associated with the limitation of the condyle in TMJs
with ADDnr (P=0.004).
Excessive work and overloading of the skeletal
muscles have been reported to be important factors caus-
ing hypertrophy of the muscles. Atrophy and contracture
of the muscles are considered secondary changes of

Figure 5 (A and B)
Hypertrophy of the superior belly of the LMP of the Ieft TMJ shows in the closed mouth image (oblique sagittal, 3000/15, 3 mm thick, 1.5T) of a 20-
year-old male who complained of facial pain, TMJ pain, and jaw movement pain on the left side with mouth opening difficulty for six months. The
pain symptoms improved after two months of splint treatment. Palpation pain of the LPM and the masseter muscle was detected on the left si de. The
mandible deviated to the Ieft during mouth opening. Restricted movement without pain was found in the right TMJ. Anterior disk displacement
without reduction was demonstrated in both left and right TMJs on MRI. A. Closed mouth image of the left TMJ shows thal hypertrophy of the
inferior belly of the LPM increased in the middle part of the bell y (lB) (compare to image B). The superior bell y appears normal. The disk is anteri-
orly displaced (D). (C=condyle). B. The closed mouth image of the right TMJ reveals a normal LPM. Note the thickening disk is anteriorly displaced
(D). (IB=inferior belly of the LPM)

JULY 2002, VOL. 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 213
MAl STUDV OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Figure 6 (A and B)
Hypertrophy of the two bellies of the LPM was found in a 41-year-old female with long-term chronic pain of both TMJs, and who had suffered
subluxation three months earlier and then continuous pain of the left TMJ. Movement pain, pain on palpation of the left TMJ and masticatory mus-
cles (temporal muscle and LPM) were found on the left side. The mandible deviated to the left during mouth opening. Anterior disk displacement
without reduction was noted in both TMJs on MRI. A. The closed mouth image of the left TMJ (oblique sagittal, 3000/20) shows hypertrophy of the
superior bell y and inferior bell y of the LPM by the increased size of the bellies (compare with the bellies of the LPM on the right side in image B).
The edges of the bellies become convex curves (open arrows). The disk shows changes in thickness (D) and is anteriorly dislocated. (C=medial pole
of the condyle). B. Image of the closed mouth righi TMJ (above righi) (oblique sagittal, 3000/20). The superior belly and inferior bell y of the LPM is
normal (C=condyle).

long-tenn muscle stretching and work overload.22
Pathological changes of the LPM may occur if abnor-
mal overloading exists in its functional procedures. The
function of the LPM is not totally clear; however, EMG
studies of the LPM have shown that the SBLPM behaves
like a jaw-closing muscle and shows characteristic activ-
ity in relation to the bi ting force. The function of SBLPM
might be to stabilize the condyle against the biting force
and control the angular relationship between the disk and
the condyle. The IBLPM pulls the condyle forward in
mouth opening. 13 •26 In a TMJ with ADDnr, the perma-
nently dislocated disk might cause disturbances in jaw
functional movements. Disk rotating, 4 disk flexure2 and
disk compressing 27 might occur. Restricted jaw move-
ment might also appear. 4 Under these conditions, the rela-
tionship between the disk and the condyle is unstable and

Figure 7 (A and B)
Atrophy of the su peri or belly and hypertrophy of the inferior bell y of the LMP observed in the righi TMJ of a 40-year-old female with recurring
pain in the TJM, movement pain on the righi side for five years, head and neck pain, and painfullocking. A. Closed mouth (oblique sagittal, PD
image, 3000/20, 3 mm thick) of the righi TMJ shows atrophy, fatty replacement in the superior bell y of the LMP (curved arrow), and hypertrophy
of the inferior bell y (ffi). The disk is anteriorly displaced (D). B. T2-weighted image (3000/127, 3 mm thick) of the same TMJ as in image A, the
high signal of fatty replacement atrophy of the superior bell y (curved arrow) shows strong contraction with the isointense hypertrophie inferior
belly (lB).

214 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERYGOID MUSCLE

Figure 8 (A, 8, C and D)

Contracture of the superior bell y of the LPM is suspected in a 35-year-old female with occasional clicking and chronic pain of the right TMJ for four
years and pain upon jaw movement on the right side for nine months. Symptoms did not improve after splint use and muscle exercise treatment.
Severe pain on palpation of the lateral pterygoid muscle (LPM) was found on the right side and clicking with no pain on the left side. On MRis
anterior disk displacements were found on both sides. A displaced disk with reduction was observed on the left TMJ and a nonreducing on the right
side. A. The normal LPM shown in closed mouth, oblique sagittal, proton dense (PD) image of the left TMJ (3000/14, 1.5-T magnet). A high signal
layer of fatty tissue (open arrow) separates the superior bell y (SB) from the inferior bell y of the LPM (18). The upper and lower edges of the two
bellies of the LPM are quite plain. The disk is anteriorly displaced (small arrow). (C=condyle). B. ln a T2-weighted (3000/125, 1.5-T magnet)
closed mouth oblique sagittal image of the left TMJ, the normal LPM shows isotense signais in either PD or T2-weighted images (compare with
image A). The high signal fatty tissue layer between the two bellies of the LPM is more clearly observed (curved arrow). (C=condyle; IB=inferior
belly of the LPM). C. Contracture of the su peri or bell y of the LPM is seen in the closed mouth, oblique sagittal, proton dense image of the right
TMJ (3000/14, 1.5-T magnet). Fatty replacement and fibrosis are found in the superior bell y (arrow). The size of the superior bell y on the right side
is larger than the left superior belly (compared with image A). Anterior disk displacement can be seen (D). D.ln a T2-weighted (30001125, 1.5-T
magnet) image of mouth closed oblique sagittal image of the right TMJ, fatty replacement and fibrosis in the superior belly of the LPM are evident
(arrow). (C=condyle; IB=inferior belly of the LPM).

might lead to overloading on the SBLPM. The SBLPM
has to work excessively to keep the disk stable. In this
study, the restricted movement of the jaw showed a close
association with the imaging abnormalities of LPM
(P=O.O 14 )(Table 2). Grunert, et al. 28 observed evident
hypertrophy of the SBLPM in an autopsy study. In his
report, chronic overloading was also discussed as a possi-
ble cause of the hypertrophy of the SBLPM. 28 The
pathological changes of the IBLPM might be also caused
by the increased obstruction of the non-reducing disk in
the condylar forward movement. On the other hand,
according to an EMG study by Lafreniere, et al. 13 the
abnormal function and alterations of the IBLPM might be
considered as a secondary change of the SBLPM. In their
report, excessive work of the IBLPM was found when the
SBLPM seemed to have !ost its function. 13 Under this
condition, pathological changes should have occurred in
two bellies of the LPM. Pathological changes conceming

JULY 2002, VOL. 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 215
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Figure 9 (A and 8)
Contracture and atrophy of the LMP in a 46-year-old female with a long history of chronic facial pain, pain upon movement on both sides, and
occasionallocking of the left TMJ. Anteri or disk displacement without reduction was found in the left TMJ on MRI. A. In a closed mouth, oblique
sagittal image of the left TMJ (3000/14, 3 mm thick), atrophy of the superior belly of the LPM shows as a high signal fatty replacement (curved
arrow). The contracture of the inferior belly shows fibrosis with lower signais (open arrow). The thickened disk is anteriorly displaced
(D).(C=condyle) B. In a T2-weighted image (3000/125, 3 mm thick) of the TMJ shown in image A, the fatty replacement of the superior belly of the
LPM (curved arrow) and the contracture of the inferior belly with lower signal fibrosis (open arrow) are more clearly shown. Effusion of the bilami-
nar zone (arrow head) is suspected. (C=mandibular condyle).

the two bellies of the LPM were found in 29.3% (36/123)

of the TMJs with ADDnr in this study (Table 1) (Figures
6, 7, and 9). The relationships between the pathological
changes in the SBLPM and in the IBLPM, and the rela-
Table 1 tionships among the hypertrophy, atrophy, and contrac-
Lateral Pterygoid Muscle (LPM) Findings on ture of the LPM are expected to be discussed in further
MRI in 123 TMJs of Patients with Anterior Disk studies by combining the different stages of TMD and
Displacement Without Reduction more clinical information.
LPM findings on MRI N=23 (100%)
The results of this study indicate that the pathological
SB abnormal 44 {35.8%)
changes of the LPM in MRI are significantly associated
Atrophy 19
Hypertrophy 18 with pain symptoms in the LPM, pain in TMJ, pain on
Contracture 7 jaw movement, and jaw restriction in the patients with
ADDnr (Table 2). This indicates that the patients with
IBabnormal 12 {9.7"/o) ADDnr might complain of these symptoms when patho-
Hypertrophy 7
logical changes in the LPM happen.
Contracture 5
In an anatomical study, Schmidt, et al. 29 observed that
Abnormalities ln both bellies 36 {29.3%) the single trunk of the auriculotemporal nerve was evi-
Hypertrophy (both) 13 dent along the medial aspect of the condylar neck and
SB atrophy w/IB hypertrophy 11 was in direct contact with the condylar neck at the poste-
SB atrophy w/IB contracture 8
SB contracture w/IB hypertrophy 4
rior border of the LPM. The anteriorly dislocated disk
and displaced capsular tissue were considered to produce
LPM normal 31 {25.2%) nerve irritation and to cause painful symptoms. In addi-
LPM: lateral pterygoid muscle tion, the au thors proposed that hypertrophy of the LPM
TMJ: temporomandibular joint might also lead to entrapment or compression of the
SB: superior belly of the LPM nerve. However, hypertrophy of the LPM was only
lB: inferior belly of the LPM
expected but not proven in their study. 29 In this study,
hypertrophy of the LPM was observed in TMJ with
ADDnr in MRI (Figures 4-7). As mentioned by sorne

216 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERVGOID MUSCLE

Figure 10 (A and B)
Normal LPM image found in a 35-year-old male with painfullocking, crepitation and movement pain in the right TMJ, palpation pain of the LPM,
and head/neck pain on both sides for three years. Painful symptoms showed clearly discernable improvement after splint use and physical therapy;
however, the limitation of mouth opening became worse in five months. He had no pain on palpation of the LPM or pain upon movement in either
TMJ. There was slight pain upon palpation of the right TMJ. Mouth opening was only 20 mm. No symptoms were found on the left side and the left
TMJ is normal on MRI. A. A closed mouth oblique sagittal PD image (3000/20, 3 mm thick) of the right TMJ shows severe erosion of the condyle
(C). The disk has thinned (white arrow). The LPM is normal. B. Maximized mouth open sagittal image (400/12, 3 mm thick) of the right TMJ with
condyle hypomobility and osteoarthritic changes (C). Nonreduced disk is compressed (D).

authors, side-to-side comparison of morphology charac-
teristics within each individual should be given special
attention during the diagnosis ofhypertrophy 15· 17 (Figures
4-6, 8). Other studies have reported that not only hyper-
trophy but also atrophy and contracture of the muscle
might lead to painful symptoms in muscles, abnormal
joint movements and pain on movement. 17 •22 •23 Atrophy
and contracture of the LPM were also detected in patients
with ADDnr in this study (Figures 3, 6, 8, and 9). The
abnormalities of the LPM were found to be associated
with the pain symptoms of the patients (Table 2).
Normal images of the LPM were found in 31 TMJs
with ADDnr in this study; 24 of them were found in the
condylar limitation group (Table 3). In sorne cases,

Figure 11 (A and B)
Normal LMP in a 72-year-old female who experienced severe jaw movement pain, masticatory muscle pain (masseter, LPM, and temporal), and
painfullocking of the left TMJ for two years. The painful muscle symptoms were reduced after two months of splint therapy; however the pain in the
left TMJ and the limitation of jaw opening became severe in three months. A. Anterior disk (arrow) displacement in closed mouth oblique sagittal
image of the left TMJ (300/14, 3 mm thick). The LPM appears normal (open arrow=superior belly; IB=inferior bell y; C=condyle. B. The disk is
nonreduced in open mouth (400112, sagittal). Note that the disk is static and thickened (arrow), almost without movement during mouth opening
(compare the disk positions in images A and B). Condyle (C) limitation is defined in a maximal mouth open image. Diskectomy of the left TMJ was
performed after this MRI. Adhesions among the disk, fossa, and condyle were found during the operation.

JULY 2002, VOL. 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 217
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE YANG ET AL.

Figure 12 (A and B)
The LPM appears normal in a 61-year-old male who has had chronic recurring pain, jaw movement pain, and occasionallocking in the left TMJ for
two years. The symptoms improved without any treatment. The limitation of the jaw movement and locking progressed for six months. Difficulties in
speaking and eating, pain on palpation of the left TMJ, pain and limitation of jaw movement in the TMJ improved after two months of splint therapy;
however, limited mouth opening stiJl existed. A. Normal LPM in a closed mouth image of the left TMJ (oblique sagittal, 3000/14) with isointensity
of the superior (SB) and inferior bell y (lB). Severe osteoarthritic change of the condyle (C) is found. Note the effusion of the bilaminar zone (arrow·
head). Disk anteriorly displaced (arrow). B. Open mouth image of the left TMJ (sagittal, 400/12) showing an anteriorly displaced disk without
reduction (arrow). Erosion and limitation of the condyle (C) are observed.

Table2
Relationship Between Pathological Changes of the LPM on MRI and
Clinical Symptoms of 123 TMJs in Patients with ADDnr
LPMan LPMn Total p
(n=92) (n=31) (n=123) 2-side
TMJ clicking 35 6 41 0.056
Nonclicking 57 25 82
TMJ locking 44 18 62 0.324
Nonlocking 48 13 61
Jaw restricted movement 56 11 67 0.014*
Nonrestricted movement 36 20 56
Pain in TMJ 58 12 70 0.018*
No pain in TMJ 34 19 53
Pain in LPM 62 12 74 0.005**
No pain in LPM 30 19 49
Pain in jaw moving 52 7 59 0.001**
No pain in jaw moving 40 24 64
Pain in other MM 42 17 59 0.376
No pain in other MM 50 14 64
[PM: literai pterygoid muscle; TMJ: temporomandibular joint
ADDNr: anterior disk displacement without reduction
LPMn: LPM appears normal on MRI; LPMan:
LPM appears abnormal on MRI
Pearson chi-square test:
*Significant level at P<0.05; **Very significant level at P<0.01

218 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2002, VOL. 20, NO. 3
YANG ET AL. MRI STUDY OF THE LATERAL PTERYGOID MUSCLE

Table3
Relationship Between Pathological Changes to the LPM and
Other MRI Findings in 123 TMJs of Patients with ADDnr
LPMan LPMn Total p
(n=92) (74.8%) (n=31) (n=123) (100%) (2-side)
Osteoarthritis 52 (76.5%) 16 68 0.634
No osteoarthritis 40 (72.7%) 15 55
Condyle mobility 0.008*•
Limited 42 (63.6%) 24 66
Hypermobility 10 (83.3%) 2 12
Normal 40 (88.9%) 5 45
Disk deformity 31 (79.5%) 8 39 0.414
No disk deformity 61 (72.6%) 23 84
Effusion 0.711•
TMJ compartment 12 (70.6%) 5 17
Bilaminar zone 25 (73.5%) 9 34
TMJ & bilaminar zone 17 (85.0%) 3 20
No effusion 38 (73.0%) 14 52
LPM: lateral pterygoid muscle; TMJ: temporomandibular joint
ADDNr: anterior disk displacement without reduction
LPMn: LPM appears normal on MRI; LPMan:
LPM appears abnormal on MRI
% (indicates proportion of LPM abnormality in each image finding)=LPMan/Total
Significant level based on Pearson Chi-square test or Fisher's Exact test• at P<0.05
*Very significant level at P<0.01

Table 4
Relationship Between Condyle Mobility and Other MRI Findings
in 123 TMJs in Patients with ADDnr
Condyle mobility
Limited Normal Hypermobility Total p
(n=66) (n=45) (n=12) (n=123) (2-sided)
Osteoarthritis 45 20 3 68 0.004*
No osteoarthritis 21 25 9 55
Disk deformity 20 14 5 39 0.734
No disk deformity 46 31 7 84
Effusion 0.667•
TMJ compartment 8 6 3 17
Bilaminar zone 21 9 4 34
TMJ & bilaminar zone 10 9 1 20
No effusion 27 21 4 52
TMJ: temporomandibular joint
ADDnr: anterior disk displacement without reduction
Significant level based on Pearson Chi-square test or Fisher's Exact test• at P<0.05
*Very significant level at P<0.01

JULY 2002, VOL 20, NO. 3 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 219
MRI STUDY OF THE LATERAL PTERYGOID MUSCLE
although evident osteoarthritic changes and limitation of
the condyle were observed, the LPMs were normal
(Figures 10-12). Limitation of the jaw movement was
regarded as a progressive symptom of TMD 2·5·30 ; on the
contrary, statistical analysis of this study indicates that
the proportion of the LPM abnormality was significantly
lower in the condylar hypomobility group (Table 3).
Osteoarthritic changes were found to be associated with
jaw limitation (Table 4). Benito, et al. have reported that
a disk might show hypomobility in TMJ with osteoarthri-
tis, and limitation of jaw opening was significantly asso-
ciated with a static disk. Adhesion of the disk was
suspected. 5 When the possibility of the condyle move-
ment becomes poor due to a fixed disk5 or because adhe-
sion has occurred between osteoarthritic bony tissues and
the disk,25. 27 the relationship between the disk and the
condyle might become relatively stable. The overloading
of the LPM might be reduced because of condylar
limitation. The pathological changes of the LPM might
also reduce in TMJs with ADDnr as observed in this
study (Table 3). lt is quite understandable that the symp-
toms associated with the LPM could be relieved with the
lower proportion of the abnormalities in the LPM. If
condylar limitation was considered as a pathway for
ADDnr,3ü,3t the symptoms, especially the symptoms con-
cemed with the LPM, probably improved in sorne cases
even without treatment.
Osteoarthritis, joint effusion, and disk deformities
were found to have no association with the abnormal
findings of the LPM in MRI in this study (Table 3). This
indicates that the pathological changes of the LPM and
the related symptoms might be reduced when condylar
limitation has happened, but the changing of the LPM
seems independent from osteoarthritic changes on the
condyle, joint effusion, and disk deformities (Table 3).
Osteoarthritis, joint effusion and disk deformities would
not be improved when the pathological changes and the
symptoms of the LPM had been improved. This finding
might explain the result of the study by Sato, et al. 11 in
which they suggested that the clinical symptoms of the
patients with ADDnr could be relieved significantly with-
out treatment, but the condylar limitation, disk deformity,
and osteoarthritis still remained.
Sorne clinical studies have shown that intraoral palpa-
tion of the IBLPM might give an unreliable evaluation by
false palpation on other masticatory muscles, 32·33 although
this palpation method used to be a standard exarnination
method in clinicat practice in detecting the pain of the
LPM 34 as well as the materials of this study traced back to
1991. In an anatomie study, Stratmann, et al.3 3 pointed
out that it was nearly impossible to palpate the IBLPM
anatomically and this method cannot reach the SBLPM at
220 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
YANG ET AL.
ail. This method may not be a suitable way to make an
accurate diagnosis of the dysfunction of the LPM;32,33
however, the results of this study show that the pain
symptoms found by the intraoral palpation of the IBLPM
had a close association with the abnormalities found of
the LPM on imaging (Table 2).
In conclusion, pathological changes of the LPM in the
TMJ with ADDnr could be detected by MRI. These
pathological changes are found in association with most
of the clinicat symptoms of ADDnr. The lower propor-
tion of the imaging abnormality in the LPM is found in
the condylar limitation group of the patients with ADDnr.
The clinicat symptom alterations of ADDnr might be
associated with the pathological situations and symptoms
oftheLPM.
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Dr. Hannu Pernu received his D.D.S. degree from the lnstitute of
Dentistry, University of Turku, Fin/and in 1972 and his M.D. degree at
the same university in 1979. He became a specialist in oral surgery in
1983 and in maxillofacial surgery in 1995 at the University of Oulu,
Fin/and. He works as senior lecturer and maxillofacial surgeon at the
Department of Maxillofacial Surgery, Oulu University Central Hospital.
Dr. Jubani Pyhtinen received his M.D. degree in 1971 from the
University of Oulu, Fin/and where he also received a Ph.D. degree in
1977. He became a specialist in radio/ogy in 1978 and a subspecialist in
neuroradiology in 1981. He is currently a professorat the Department of
Neuroradiology, Oulu University Central Hospital.
Dr. Petri A. Tiilikainen received his D.D.S. degree in 1999 from the
1nstitute of Dentistry, University of Oulu, Fin/and. He is a research
assistant in the Department of Prosthetic Dentistry and Stomatognathic
Physiology at the lnstitute of Dentistry, University of Oulu, Fin/and.
Dr. Kytisti S. Oikarinen received his D.D.S. degree from the 1nstitute of
Dentistry, University of Turku, Fin/and in 1978 and his Ph.D. degree in
1987 at the University of Oulu, Fin/and. He received a D.M.D. degree in
1988 at Hamburg University, Germany. He is a professor and head of
the Department of Oral and Maxillofacial Surgery, 1nstitute of Dentistry,
University of Oulu, and chief dentist in the Oral and Maxi/lofacial
Department of Oulu University Hospital. Current/y, he is a professorat
the Department of Oral and Maxillofacial Surgery in the Faculty of
Dentistry, Kuwait University.
Dr. Aune M. Raustia received her D.D.S. degree in 1974 at the 1nstitute
ofDentistry, University of Helsinki, Fin/and. She obtained her Ph.D.
degree in 1986 at the University of Oulu, Fin/and. Dr. Raustia is a
professorat the Department of Prosthetic Dentistry and Stomatognathic
Physiology at the lnstitute of Dentistry, and Dean of the lnstitute of
Dentistry, University of Oulu, Fin/and.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 221