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									Incidence of Temporomandibular Joint Changes After Whiplash Trauma: A ProspectiveStudyUsing MR Imaging
HenrikBergman1'2 FredrikAndersson3 AnnikaIsberg1
OBJECTIVE. Thepurpose f thisstudy o wastodescribeheincidence f temporomandib t o
ularjoint (TMJ) changes after a well-defined whiplash trauma.

SUBJECTSAND METHODS. Sixtyconsecutively admitted patients ithsymptoms w in
the neck after rear-end traffic collisions underwent MR imaging of the TMJs within 3—14
days after the collisions. Fifty-three healthy volunteers constituted a control group.

RESULTS.No statisticallyignificant s differences werefound between the60 patients nd a
the 53 volunteers regarding frequency, stage, grade, or direction of TMJ disk displacement or joint effusion.MR imaging revealedthat 45% of the controlgroup and 53% of the patient group had a displaced disk in one or both TMJs (p = .393). Disk displacement was seen in 35% ofTMJs in the control group and 40% ofTMJs in the patient group. Effusion was seen in 8% of TMJs in the control group and 6% of TMJs in the patient group. No signs of bleeding or edemain the softtissues were observed.In 15% of the patients,mild clinical symptomsin the TMJ or masticatory muscles developed in association with the trauma; in one third of these patients the symptoms were transient.

CONCLUSION. Thisprospective study doesnotshowanysignificantly increased ci m
dence of disk displacement, joint effusion, or any other injury to the TMJ after whiplash trauma that could be revealed by MR imaging.

he term “¿whiplash― in medical ter minology is applied to a well-de fined trauma to the cervical spine that includes extension followed by flexion without any direct trauma to the head. Apart from symptoms in the neck and adjacent struc tures after a whiplash trauma, other disorders that can be manifested include deafness, dizzi ness, tinnitus, headache, memory loss, dyspha Received December 2,1997; cceptedafterrevision 2 a gia, and temporomandibularjoint (ThU) pain April27,1998. [lJ. Approximatelytwo thirdsof suchassoci Supported bygrantsrom f theSwedish edical M Research ated disorders occur in women, and one third CouncilProject6877,heJointCommittee t NorthMedical Care Region, theCounty ouncil C ofVIsterbotten, the occur in men [1, 2J. FacultyfOdontology o ofUmelUniversity, theResearch The impact of whiplash trauma on the TMJ andDevelopment Centerof Sundsvall ospital, ndEmil H a is a mailer of debate[3, 41.A calculationof the Andersson's Foundation Sundsvall ospital, weden. of H S mechanical and anatomic prerequisites for the 1Department of Oral and Maxillofacial Radiology, Umel
University, E-90i87Umel, Sweden. S 2Department Radiology, of Sundsvall ospital, E-85i86 H S Sundsvall, weden. ddresscorrespondenceo S A t H.Bergman. 3Department Orthopaedics, of Sundsvall ospital, E-85i H S 86Sundsvall, Sweden. AJR1998;17i:i237—i243 036i—803X/98/i7i5—i237 development of TMJ disk displacement after

T

denceof TMJ pain and clicking, which are signs of reducing disk displacement or tem
poromandibular cal examination dysfunction, was extremely

low [7, 8]. These studies were based on physi
and case history and did not

include imaging of the TMJs. However, other studies based on clinical and radiographic findings suggested a relationship between whiplash trauma and displacement ofthe TMJ disk. In one patient series, arthrography yen fled the diagnosis of disk displacement in
90% of patients who reported that signs and

symptoms orthopedic of TMJ injurybeganaf ter whiplash trauma [9]. Two MR imaging studies performed patients on who hadno his tory of TMJ dysfunction, but in whom TMJ symptoms later developed after whiplash
trauma, revealed the presence of disk dis

© American Roentgen Society Ray

placement in 56% [ 10] and 87% [ I 1] of the ported by the results ofa low-velocity (8-km/hr) joints. Joint fluid or soft-tissue edema was collision testperformed volunteershatmdi on t seenin 65% of the joints [ 10]. Becausethe cated the force magnitudes generated at the prevalence of joint abnormalities was higher TMJ would be insufficientto injure thejoint [6]. in patients than in asymptomatic subjects, a Clinical studiesof patientswith whiplash clear relationship between whiplash trauma injury concluded that the posttraumatic mci and TMJ injuries was concluded [10, 11].

whiplash trauma suggested that such displace ment was not likely [5]. This view was sup

AJR:171, November 998 1

1237

Bergman et al.
However, none of these studies examined the prevalence of such findings in a control popu lation that reflected the population at risk of
exposure to whiplash trauma.

Studies of TMJ whiplash injuries have of ten not specifiedthe type of traumawith ref
erence to the direction ofthe collision, which

ticipate because of claustrophobia, one patient de dined to participate, and one patient could not undergo MR imaging during the acute phase. The remaining 60 patients (37 women, 23 men; aver age age, 34 years; median age, 35 years; age range, 16—55ears) constituted the patients for y this study. MR imaging of the patients was per
formed between 3 and 14 days after trauma, an op timal time for MR depiction of bleeding and

The positionofthe disk was evaluatedboth in the closed- and in the open-mouthpositionsand judged
to be normal superior or displaced according to the classification illustrated in Figure 1. The superior position was determined to be normal

whenthe posteriorbandofthe disk was locatedin the
12-o'clock position relative to the condyle or when

the anterior prominence of the condyle articulated
against the central thin zone of the disk and when the

results in either extension of the cervical spinefollowed by flexionor vice versa[3, 71. Rarely has the occurrence of contact trauma been accounted for, and the symptoms have never, to our knowledge, been graded. Dif
ferent studies seem to have included non in the

edema in the soft tissues. Control Group
Fifty-three volunteers with no history of trauma

disk in the coronal view was located symmetrically on top of the condyle(Fig. 2). Disk displacementin
the sagittal and coronal planes was defined according to previously stated criteria [15, 16]. Anterior dis placement of the disk with and without reduction was

were selected from the same geographicarea as the
patients to form a control group. The volunteers

comparable patient material, a circumstance
that may explain the lack of agreement

were selected to match the patients in sex and age

notedas illustratedin Figures3 and4. The degree of disk displacementwas considered

conclusions. n the studyof Heise et al. [7], I for example, 41% of the patients had a cervi cal skeletal injury, whereas in other studies
[12, 13] and in our own experience, skeletal injury after whiplash trauma was rare. Stud

slight (grade I ) when the posterior band of the disk and included 3 1 women and 22 men (average age, 36 years; median age, 35 years; age range, 15—63 was between the bony joint components but the in termediate thin zone of the disk had lost contact with years). To reflect a population that might presum

ably be exposed to rear-end traffic collisions, we
did not attempt to either attract or reject individuals with TMJ symptoms. Participation of the control

the anterior rounded prominenceof the condyle or when less than two thirds of the disk was displaced
sideways. The degree of disk displacement was con sidered great (grade 2) when the entire disk was an terior to the condyle or when more than two thirds of

ies ofTMJ whiplash injuries have been retro
spective and have focused on patients with

subjects wasapproved theethicscommitteeof by
UmeA University.

persistent symptoms from the TMJ region or the neck. The incidence of TMJ injury after whiplash trauma is not known. Awareness of
possible TMJ injury and related symptoms

Both populationscompleted a self-administered
questionnaire about a history of TMJ signs and symptoms, including joint sounds, functional distur

the disk was displacedsideways(Fig. 5). The shape of the disk was classifiedas either normalbiconcave or deformed. lightdeformation S wascharacterized
by a thickening of the posterior band of the disk; moderate deformation, by a gross thickening of the

as sequelae to whiplash trauma has increased substantially in recent years and resulted in a medicolegal problem [14] arising from an excess of litigations, particularly in the United States. Our aim was to use MR imaging to reveal the incidence ofTMJ changes such as disk dis placement and joint effusion and also the mci denceof bleedingor edemain the softtissues surrounding thejoint in the acutephaseafter a well-definedwhiplashtraumaandto compare the findings with those in a control population. The hypothesis was that whiplash trauma causes TMJ disk displacement. Subjects and Methods Patients
The patients were individuals who had been in rear-end traffic collisions that caused an exten sion—flexionmotion of the cervical spine with no

bances, and pain. Questions were also asked about other symptomsin the head and neck region, medi
cation, and the general state of health. Subsequently,

the patients and control subjects were interviewed and the TMJs were physicallyexamined. To exclude grade 4 whiplash-associateddisor ders,whichincludefractureor dislocationof the cer vical spine, patients underwent radiographyof the cervical spine using posteroanterior, lateral, right and left 45° blique, and open-mouth posteroante o
rior odontoid projections. MR imaging of the TMJs

posteriorband; and excessivedeformation(Fig. SB), by a biconvexconfigurationof the disk. Images were regardedas showing no joint effu
sion when no area of high signal intensity or only a

thin line of high signal intensityalong the articular
surface was seen on 12-weighted images. Joint effu

was performedin both groups.
MR imaging was performed on a 1.0-1 Magne

sion was registered if a thin line was seen in both joint compartmentsthroughoutthe joint or if more than a thin line was seen in more than one image (Fig. 6). Retrodiskaltissue and the soft tissues sun
rounding the joint were evaluated on the closed- and

tom Impactmachine(Siemens,Erlangen,Germany) using designated circular-polarizing a TMJ coilfor
bilateral imaging. We performed spin-echo MR im

open-mouthprojectionsfor alterationsin signal in
tensity suggesting bleeding or edema. Bony compo

aging byprescribing, onthebasis anaxiallocal of izer, MR images (TR/TE, 200/15; one signal
averaged: 300-mm field of view; 256 x 256 matrix; 5-inns slice thickness) graphically perpendicular

nents were classified as normal or abnormal. A normal osseous condition was noted when the joint
components were rounded or slightly remodeled and

had an intactcortex. The images were interpretedby two of us, one
having extensive experience with TMJ imaging and

(sagittalimages)and parallel(coronalimages)to the
horizontal long axis of the condyle. Oblique sagittal Il-weighted images and proton density—and 12-

the other having severalyears' experiencewith MR
imaging in general. Before the study began, the two interpreters practiced evaluating TMJ MR imaging

weightedimageswere obtainedin the closed-mouth
position using 480/15, three signals averaged. a 125-

concomitant direct trauma to the head or neck. In the emergency department of one hospital. the or
thopedic staff classified each patient according to clinical symptoms as either having no complaints

mm field of view,a 256 x 192matrix, and a 3-mm slice thickness with no gap between slices; and 2199/17, 85 (TRlfirst-echoTE, second-echo TE);
three signals averaged; a 125-mm field of view; a 256 x 190 matrix; and a 3-mm slice thickness with

for 1 year.This trainingperiod was neededto estab lishcleardefinitionsofeach radiographiccharacteris tic.The MR imageswere firstevaluatedindividually, withone of the interpretersunawareof clinicalor ra
diographic data, and then both interpreters evaluated

about the neck and no physical signs or having
complaints about the neck. clinical signs. or both.

Only patients with signs or symptoms correspond
ing to grades 1—3 f the Quebec classification of o whiplash-associated disorders were selected I I 1. Patients with cervical spine fractures. that is. grade

no gap between slices. The proton density—nd a T2-weighted images were also obtained in the
open-mouth position. Oblique coronal proton den

the MR imagestogether.If the interpretersdisagreed about any of the variables,consensus was reached throughdiscussion. Statistics For evaluation of statistical significance, chi square tests were performed using the Exact Tests package, version 7.0 (SPSS, Chicago, IL) for Win dows (Microsoft, Redmond. WA). AJR:171, November 1998

sity— and12-weighted imageswereobtainedin the
closed-mouth position using 2000/17, 85; three sig nals averaged; a 100-mm field of view; a 256 x 190

4 whiplash-associated disorders, were excluded.
During 18 months from 1994 to 1996, 64 consecu tive patients met these criteria and were selected

for the study. Two of these patients could not par 1238

matrix,and a 3-mm slice thicknesswith no gap be tween slices.

POST

MED

POST

MED

Pos I. Superior disk position.

Pos 2. Complete anterior

Pos 3. Partial anterior disk

disk displacement.
-“ PO@

displacement in the lateral part of the joint.
POST MED

MED

LAT

@@NT

@)@.L@ANT]

Pos 4. Partial anterior disk

hi

Pos 6. Anteromedial

disk

displacement in the medial part of th@j@@t.

displacement.

Pos 7. Sidewavs lateral disk displacement.

Pos 8. Sideways medial disk
displacement.

Pos 9. Posterior disk
displacement.

Fig.1.—Drawings ninecategories of oftemporomandibularjoint diskposition showaxialviewsfromabove.Various diskpositions (ingray)inrelation condyle seen. to are (Reprintedwith permissionfrom 1161)

Fig.2.—Normal superior diskposition. A, Sagittalprotondensity—weighted image(TRITE, 199/17) f 37-year-old MR 2 o femalepatientwith notemporomandibular joint(TMJ) symptoms showsposterior bandof

disk(arrow)located 12-o'clock osition in p above condyle (C).
B, Coronalproton density—weighted image(2000/17( f 38-year-oldhealthy malevolunteer shows disk (arrows) located on top of condyle (C). MR o C.Sagittal protondensity—weighted MRimage(2199/17) f 16-year-oldfemale patientwith TMJ clicking after accident shows posterior bandof disk (arrow) slightly anterior o to condyle (C).Note that anterior prominenceof condyle articulates against disk. AJR:171,November 1998

1239

@

@,

Bergman et al.

L

L

Fig. 3.—Reducingisk displacementin 23-year-oldfe d malepatientwith notemporomandibularjoint ymptoms. s

A. Sagittal roton p density—weighted MRimage (TRITE,
2199/17) showsdisplacement f disk(arrows)anteriorto o condyle(C)in closed-mouthposition.

B.Sagittal proton density—weighted (2199/17) MRimage in open-mouth position. thatdisk Note (arrows( isreduced to
itsnormal uperior s positionelative condyleC). r to (

1@

I,

A

B

Fig.4.—Nonreducing diskdisplacementn40-year-old i fe malepatientwith notemporomandibularjoint symptoms.

A. Sagittal roton p density—weighted MRimage (TRITE,
2199/17) showsdisplacement f disk(arrows) anteriorto o condyle(C)in closed-mouthposition.

B,Sagittal proton density—weighted MRimage (2199/17) inopen-mouth position. thatdisk(arrows) oes Note d not
reduce to its normal superior position but becomes foldedanteriorto condyle(C).

I
@.

Fig.5.—Gradediskdisplacement 2 andseverediskde formation.

A. Sagittal roton p density—weighted MRimage (TRITE,
2199/17) f 42-year-oldmale patientwith previoustem o poromandibularjoint (TMJ) clicking and postaccident tinnitusshowscompletelydisplaceddisk(arrows)ante riorto condyle(C).

B,Coronal 12-weighted MRimage (2000/85) 19-year of
old healthyfemalevolunteerwith previousTMJ clicking shows grossly deformed and laterally displaced disk (arrow).C= condyle.

A
1240

B
AJR:171, November 998 1

Fig. 6.—Jointeffusion.

A.Sagittal 12-weighted MRimage (TRiTE, 2199/85) of55year-old female patient with previous clicking in right temporomandibularoint (TMJ)andpostaccidentpainin j left ear showssmalleffusionin upperjoint compartment of right TMJ (arrow) and diskdisplacementin that joint No abnormality was detectedin left TMJ. B, Coronal12-weightedimage(2000/85) f 23-year-old o female patient with no IMJ symptomsshows more substantial effusion (arrow) in upper joint compart ment,visualizedbest in coronalview.

p

A
Results @
ComparisonBetweenControlsand PatientsBefore Accident

B
frequency was not statistically significant (p .22). No statistically significant difference was
found between the controls and the patients in

TMJ symptoms were not significantly dif ferent between the control group and the pa tient group before the accident. Eleven (21%) of the control subjects had previous or present TMJ clicking. and one control subject also had earlier locking symptoms. When specifically
asked after selection. none of the control sub

nonreducing displacement of a biconcave disk in one or bothjoints. One of thesefive patients had clicking in the right TMJ. and although MR imaging did not show any abnormality in the joint. nonreducing disk displacement was
revealed in the left joint. Limitation of mouth

opening is typical of acute nonreducing disk
displacen@ent but can also be caused by a mus cle reaction associated with a neck injury with

the frequency of disk displacement, either of the first stage (i.e., reducing disk displace ment) or of the second stage (i.e., nonreducing
disk displacement). The displaced disks in the controls were reducing in 23 joints (62%) and nonreducing in 14 joints (38%). In the pa

out TMJ involvement.
No statistically significant difference was

jects had consulted or intended to consult a dentist or a physician because of any symptoms of the TMJ or other parts of the masticatory
system. Only one of the control subjects asked

found between the patients and the controls in frequency of TMJ disk displacement;
stage. grade, or direction of displacement; or joint effusion. Twenty-ftur controls (45%)

tients, 26 (54%) of the joints had a reducing disk and 22 (46%) had a nonreducing disk. Of the displaced disks in the controls. 43% were
classified as grade 1 and 57% as grade 2. In the

about the outcome of the MR imaging. Four teen patients (23%) reported that TMJ signs and symptoms were present before the acci
dent. Another seven patients ( I2%) could not

and 32 patients (53%) had a displaced TMJ
disk in one or both joints (p = .39). TMJ disk displacement was found unilaterally in

patients, the corresponding figures were 50% for grade 1 and 50% for grade 2, with no statis
tically significant difference between the

groups. The inter- and intraindividual distribu
tions of reducing and nonreducing disk dis

specify the duration of their TMJ clicking or joint tenderness. Regardless of whether the symptoms of these seven patients were classi fled as having begun with the trauma. differ
ences in the prevalence of TMJ signs and symptoms between patients before the accident

I I controls and in 16 patients. Bilateral disk
displacement was present in I 3 controls and in 16 patients. The number of joints with disk displacement was thus 37 (35%) of 106

and controls were not statistically significant. The frequency of nonreducing displacement of a deformed disk with or without secondary osseous changes, indicating a long-standing
chronic condition that could not have been

total in the controls and 48 (40%) of 120 to tal in the patients. Of the 42 asymptomatic controls. 14 (33%) had a displaced disk in one or both joints. The corresponding preva
lence of disk displacement in the 30 asymp tomatic patients was 50%. The difference in

placement are shown in Table 1. Because the patients had been exposed to trauma with forces in the anteroposterior di rection only. the direction of disk displace
ment was studied (Table 2), but no statistically significant difference was found between the

two groups when disk positions 3 and 5 were pooled or when disk positions 4 and 6 were pooled.

caused by the accident. was the same in both groups. Six joints in six controls ( 11%) and
seven joints in six patients ( 10%) showed

@Disk Positionsin IntraindividuallyCoupled Temporomandibular Joints DiskPositions intheTwoJointsPatientsControl
2No.%No.%Superior 1Joint lntraindividual Combination of SubjectsJoint

the condition.
ComparisonBetweenControlsand PatientsAfter

Accident In nine patients ( 15%), TMJ signs or symp
toms began with the accident. These were mild

Superior Superior DDR DDR 6Total6053 DDNRSuperior

DDR DDNR DDR DDNR DDNR28

12 4 6 2 847

20 7 10 3 1329

5 6 8 2 355

9 11 15 4

and included clicking, locking, joint tender
ness, pain from the TMJ region. and limited ability to open the mouth. In three of these pa

tients. the symptoms were transient and had disappeared at the time of the MR imaging. Five (56%) ofthe nine patients had reducing or
AJR:171, November 1998

Note—DOR =diskdisplacement withreduction, DDNR =diskdisplacement withoutreduction.

1241

Bergman et al.
Disk Positions in Patients

and Control Subjects
SubjectsNo.of Disk Position. Joints/01.Superior . Joints/0No.of .

PatientsControl .

2.Anterior 3.Anteriorinlateral part of joint 4.Anteriorinmedial part of joint 6. Anteromedial

15 13 —¿

13 11
—¿

8 8

8 8

2 4
—¿

2 4
—¿

5.Anterolateral 6
3

5
3

with the Quebec Task Force document stating that TMJ pain is one of the symptoms that can occur after whiplash trauma [I]. A combination of onset fTMJ symptoms ftertraumaandoh o a served MR imaging of disk displacement was found in 8% of our patients, but a correlation was not verified. However, the fact that the dis placed disks were biconcave, making displace ment at the accident possible, supports a correlation because a deformed disk indicates a chronic condition. Yet these joints had no effu sion, which is an indication of bleeding and would have been expected in cases of acute in juiy. Mother 7% ofthe patients reported an on set of TMJ symptoms after trauma but had no
positive MR findings. Only a follow-up exami

7.Lateral
8. Medial72 9Total120106

6
560

5
469

5
1065

5

nation of the patients could reveal whether the
mild TMJ symptoms, initially caused by the

whiplash accident, indicate future aggravation. Note—Dash (—I position was not seen in any joint. = If whiplash trauma causes TMJ disk dis placement in many patients, the prevalence of No signs of bleeding or edema in the soft displaced TMJ disks would be higher in a pa tissues surrounding the TMJ or in the retrodis tient group after an accident than in a control cusing on patients with symptoms after whip kal tissuewere found,and the groupsdid not group. However, we did not observe any statis lash trauma, revealed disk displacement in differ in joint effusion. Effusion was found in ticallysignificant orrelation;heprevalence f 56% of the patients and an indefinite amount c t o eight (8%) of 106 joints in seven controls and disk displacement was the same in both of joint fluid or soft-tissue edema in 65% of in seven (6%) of l20joints in five patients. Ef groups. An assumption that the direction of the patients. When the prevalence of disk dis fusion was consistently associated with dis disk displacement might differ between the pa placement in these two studies [10, 111 was tientsand the controlsalsoseemsreasonable, compared with that in asymptomatic volun placement of the disk, with a similar ratio between reducing and nonreducing disks, that because the whiplash trauma was well defined teers, the difference was significant. The disad is, 6:2 in the controls and 6:1 in the patients. by the direction of the collision—rear-end. vantage of such a comparison is that it Four ofthe five patients withjoint effusion had However, no such difference was found, nor disregards the fact that members of the general no signs or symptoms in the affected joint. was one found in relation to stage or grade of population, any of whom may be exposed to whiplash injury, include people with TMJ disk displacement. The frequency ofjoint effu sion was low and almost identical in the two symptoms. A selection of only asymptomatic Discussion groups. One limitation of our study is that the volunteers rejects those members of the popu lation who have TMJ symptoms, whether or Our results did not verify the hypothesis that number of patients was restricted, but we have whiplash trauma causes TMJ disk displace analyzedseveral ariables v withoutfindingany not they have been treated at a facial pain clinic. In turn, a patient group most probably statistically significant difference between pa ment. The control subjects reflected a general tients and controls. includes individuals with symptoms that were population that might presumably be exposed present even before the accident, particularly if The results should not be interpreted as cx to rear-end traffic collision. Their sex and age time lapsed between the accident and the cx werematched thepatients selection, nd cluding the possibility that whiplash trauma to by a can cause TMJ injury, but they show that if amination. This problem was illustrated in our the clinical signs and symptoms ofTMJ agreed study. Although each patient was asked about TMJ injury such as disk displacement or joint in prevalence with those the patients reported previous symptoms within 2 weeks after the effusion does occur as a result of whiplash as being present before the accident. MR imag trauma, the incidence of TMJ injury is low. accident, 12% could not specify whether their ing revealed the same frequency of chronic The findingssupportthe conclusion Heise TMJ symptoms, such as clicking, locking, and by disk displacement in both groups. In our con et al [7]. The low incidence seems relevant joint tenderness,preceded the accident. If trol group, 33% of the asymptomatic individu asked up to 1 year or more after an accident, as als were found to have disk displacement in at both for severe trauma causing grade 4 whip least one joint. This rate agrees with the 30— lash-associated disorders [7] and for grades 1-. happened in other studies, patients were likely 3 whiplash-associated disorders as found in to be even more uncertainaboutthis matter. 33% prevalence ofdisk displacement in asymp The question of whether whiplash trauma can tomatic volunteers reported in several other our study. Therefore, MR imaging ofthe TMJs act as a triggering factor in aggravating a con studies [16—18]. he agreement supports the as a routine procedure after whiplash trauma T dition present before the accident can be an does not seem justified. premise that our control group was represents A recent MR imaging study by Garcia and sweredonly by a follow-up studyof patients fiveof a general opulation, p with nobiased pre Arrington [1 1], in contrast to ours, showed a whose joint conditions are already known sentationof disk displacement. closerelationship betweencervical whiplash when accidents occur. Fifteenpercentof the whiplashpatients re In conclusion, our study did not show a sig andTMJ injuries.Unlike ourstudy,whichwas ported that TMJ signs and symptoms began nificantly increased incidence of disk displace prospective and involved consecutive patients with the accident. This finding is consistent 1242

exposed to whiplash trauma, that study in volved patientswho were selectedbecause they experienced symptoms in the TMJ, the masticatory muscles, and the ear after under going whiplash trauma. TMJ imaging, per formed within 1 year in most of those patients, showed disk displacement in 87% of the joints and effusion, inflammation, or edema in the retrodiskal tissue in 80% of the joints. This prevalence of disk displacement in patients with TMJ-related symptoms agrees well with the MR imaging findings of 77% and 82% disk displacement in two studies [16, 17] of patients referred for MR imaging of their TMJs but with no specific history of whiplash trauma. The results ofthe study by Garcia and Arrington cannot therefore be interpreted as showing a re lationship between whiplash trauma and the de velopmentof disk displacement ut, rather, b confirma highprevalence f diskdisplacement o in patients with TMJ symptoms. Another MR imaging study [10], also fo

AJR:171, November 1998

MR Imaging of
ment, joint effusion, or any other injury of the TMJ that could be revealed with MR imaging
during the acute phase after a well-defined

Joint Changes After Whiplash
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jury. J Craniomandib Disord 1991;5:25l—257 4. Evans RW. Some observations on whiplash inju

whiplash trauma. To evaluate whether whip lash trauma can with time aggravate disk dis placement present before trauma or whether mild symptoms caused by trauma are likely to progress,a follow-up study of patients with a known TMJ status at the time of trauma is necessary.

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Acknowledgment We would like to express our sincere grat itude to Gunnar Nordahl for his skillful sta tistical help.

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16. Tasaki MM, Westesson P-L, Isberg AM, Ren YF, Tallent.sRH. Classification and prevalence of tem miJ Oral axillofac 1994;23:338—34l poromandibular joint disc displacement in patients M Surg 9. Weinberg5, LaPointeH. Cervicalextension-flex and asymptomatic volunteers. Am J Orthod Dento ion injury (whiplash) and internal derangement of facial Orthop 1996:109:249—262 References the temporomandibularoint. J Oral Maxillofac 17. Katzberg RW, Westesson P-L. Tallents RH, Drake j I. Spitzer WO, Skovron ML. Salmi LR, et al. Scien Surg 1987:45:653—656 CM.Anatomicdisordersof the temporomandibu tific monograph of the Quebec Task Force on whip 10. Pressman BD, Shellock FG, Schames J, Schames lar joint disc in asymptomaticsubjects.J Oral lash-associated disorders: redefining “¿whiplash― M. MR imaging oftemporomandibularjoint abnor Maxillofacurg 1996;54:l47—l53 S anditsmanagement. Spine1995:2Olsuppl 81:1—73 malities associated with cervical hyperextensionl 18. Kircos LT, Ortendahl DA, Mark AS, Arakawa M. 2. Bocchi L, Orso CA. Whiplash injuries of the cervi hyperfiexion (whiplash) injuries. JMagn Reson In: Magneticresonanceimagingof the TMJ disc in

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