Wireless detector-based magnetic resonance imaging for grading assessment of the peridiscal attachments in temporomandibular joint internal derangement

Introduction

Temporomandibular disorders (TMD), a prevalent group of conditions in the general population, are characterized by dysfunction of the masticatory muscles and/or the temporomandibular joint (TMJ) (1,2). Among the various etiologies, disc displacement is the most prevalent, while TMJ internal derangement (ID) is the most common subtype of TMD (3,4).

The disc-condyle complex consists of the articular disc, condyle, and surrounding peridiscal attachments. These peridiscal attachments serve as direct connective structures between the disc and condyles, forming the critical anatomical foundation that collectively maintains stable movement of the TMJ. In TMJ ID, a dynamic functional triangle forms among the articular disc, condylar head, and peridiscal attachments, establishing reciprocal mechanical couplings. Previous studies have characterized disc-condyle interactions during pathological progression; however, research on the biomechanical roles of the peridiscal attachments remains limited (5,6), and their precise role in the pathogenesis of disc derangement has not yet been systematically investigated.

Magnetic resonance imaging (MRI) is the imaging modality of choice for the diagnosis of disc displacement. Its superior soft-tissue contrast enables precise visualization of the location, configuration, and integrity of the articular disc, along with other joint components. Multiple studies have confirmed the exceptional diagnostic precision of MRI in assessing disc displacement, with sensitivity and specificity values reaching up to 96% and 100% (7-9), respectively. Compared with the articular disc, the peridiscal attachments are smaller in size, and conventional MRI is generally limited in its ability to accurately and clearly visualize the peridiscal attachments.

Recent preclinical studies have demonstrated that wireless detector (WD) technology substantially enhances the resolution and visualization of microscopic tissue structures in biological systems. By leveraging nonlinear capacitive principles, this technique effectively amplifies weak magnetic resonance signals through external field pumping. This approach yields a marked improvement in imaging quality, specifically evidenced by increased signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) (10,11). In initial applications, this technology was successfully implemented as an implantable renal surface detector, demonstrating its clinical potential (12). The redesigned WD for human use has significantly improved MRI image quality for the evaluation of the TMJ condylar bone and articular disc (13,14).

This study aimed to investigate the relationship between the imaging features of the peridiscal attachments and TMJ ID using wireless detector-based magnetic resonance imaging (WD-MRI). We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2026-0677/rc).

Methods

Patients

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Guizhou Provincial People’s Hospital (No. LYSZ [2022] 256), which waived the requirement of informed consent due to the retrospective nature of the study.

In total, 61 outpatients with TMD undergoing treatment at the Department of Oral and Maxillofacial Surgery, Guizhou Provincial People’s Hospital, from October 2021 to May 2022, were included in this study. Of the patients, 49 were female and 12 were male. The patients were aged between 18 and 72 years old, with a mean age of 32.54±13.05 years. The inclusion criteria are as follows: (I) presence of one or more of the following symptoms within the preceding 3 months: orofacial pain, joint sounds (clicking or crepitation), masticatory difficulty, or restricted mouth opening; (II) diagnosis of TMD established by oral and maxillofacial surgeons in accordance with the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) (15); and (III) age ≥18 years. The exclusion criteria were as follows: (I) a history of maxillofacial neoplasms, severe infections, chronic suppurative otitis media, or other relevant orofacial pathologies; (II) contraindications to MRI (e.g., claustrophobia or fixed metallic dental restorations); and/or (III) non-diagnostic MRI image quality precluding assessment of the peridiscal attachment structures.

WD

As illustrated in Figure 1, the WD features a diameter of 70 mm and conforms closely to the surface anatomy of the TMJ. Previous studies have reported that this technique significantly improves the ability of MRI to visualize TMJ anatomical structures, validating the application of WD-MRI in high-resolution TMJ imaging (13,14). Accordingly, the present study did not further explore the feasibility of WD in enhancing MRI image quality. By employing wireless coupling technology, WD enhances signal transmission, thereby improving signal integrity and ultimately yielding higher-quality MRI images (Figure 2).

Figure 1 Position of the WD coil, which was tightly attached to the surface of the TMJ during MRI scanning. This image is published with the participant’s consent. MRI, magnetic resonance imaging; TMJ, temporomandibular joint; WD, wireless detector.

Figure 2 Images acquired using conventional MRI and WD-MRI, respectively, from the same participant. Visual comparison demonstrates a significant enhancement in image clarity with WD-MRI compared to conventional MRI. (A,C) In the conventional MRI images, the boundaries of the articular disc (white arrow) appear blurred, with poorly defined internal structure. (B,D) In contrast, WD-MRI provides a much sharper visualization of the articular disc and its surrounding fine anatomical features (red arrow), resulting in substantially improved image quality. SNR, signal-to-noise ratio; WD, wireless detector; WD-MRI, wireless detector–based magnetic resonance imaging.

MRI examinations

All participants underwent MRI using a 3.0T magnetic resonance scanner (MAGNETOM Vida, Siemens Healthineers, Erlangen, Germany) with a 32-channel phased-array coil. Oblique sagittal fat-suppressed proton density-weighted imaging (PDWI) sequences were acquired in both closed- and open-mouth positions using the WD (16). The imaging parameters were configured as follows: repetition time/echo time =2,000/30 ms, flip angle =90°, field of view 150×150 mm, matrix size 256×256, slice thickness =3 mm, number of excitations =2, and total scan duration =140 seconds. The closed-mouth position was defined as lip seal with maximal intercuspation of the posterior teeth (centric occlusion). For oblique sagittal alignment, the imaging plane was oriented orthogonally to the long axis of the condylar head, verified using multiplanar localizers.

MRI image analysis

Two board-certified, senior radiologists (each with 10 years of experience) independently evaluated all MRI images under blinded conditions to assess disc positional status and grade peridiscal attachments in each TMJ. Disc position was classified as follows (17): (I) normal: in the closed-mouth position, the disc-condyle relationship is considered normal when the disc boundary angle is within 10° (anterior or posterior to the vertical line). In the open-mouth position, the disc remains centered over the condylar head; (II) disc displacement with reduction (DDWR): in the closed-mouth position, the disc is displaced anteriorly with a disc boundary angle exceeding 10° anterior to the vertical line. In the open-mouth position, the displaced disc returns to a normal anatomical relationship with the condyle; (III) disc displacement without reduction (DDWOR): the disc is displaced anteriorly in the closed-mouth position and remains anterior to the condyle during the entire open-mouth phase, failing to return to its normal anatomical relationship with the condylar head. Disagreements between the two observers were resolved by consultation with a third senior radiologist to reach a consensus.

The peridiscal attachment includes the anterior attachment superior (AAS), anterior attachment inferior (AAI), posterior attachment superior (PAS), and posterior attachment inferior (PAI) (Figure 3). In this study, the peridiscal attachments were classified into three types based on their MRI features, which were treated as an ordinal scale (1–3 points) reflecting a progressive loss of anatomical clarity.

Figure 3 Images obtained by WD-MRI clearly demonstrate the periarticular ligamentous structures of the TMJ. (A) In the TMJ closed-mouth position, the anterior attachment is clearly visualized, with the red arrow indicating AAS and the white arrow indicating AAI. (B) In the TMJ open-mouth position, the posterior attachment is clearly visualized, with the yellow arrow indicating PAS and the green arrow indicating PAI. AAI, anterior attachment inferior; AAS, anterior attachment superior; PAI, posterior attachment inferior; PAS, posterior attachment superior; TMJ, temporomandibular joint; WD-MRI, wireless detector-based magnetic resonance imaging.

MRI manifestations of the peridiscal attachments were evaluated on oblique sagittal PDWI sequences in both closed- and open-mouth position. The scoring criteria were as follows: clearly visualized (1 point); indistinctly visualized (2 points); and non-visualized (3 points) (Figure 4). This scoring system was treated as an ordinal scale, as the scores represent a progressive decline in the clarity and integrity of the anatomical structures on MRI. In case of scoring discrepancies between the two physicians, a senior attending radiologist was consulted to determine the final score.

Figure 4 WD-MRI manifestations of the peridiscal attachments. (A-C) Closed-mouth position WD-MRI images of the temporomandibular joint. (D-F) Open-mouth position WD-MRI images of the temporomandibular joint. (A) The AAS of the articular disc (red arrow) shows a uniform signal, continuous course, and clear visualization, and was thus assigned as score of 1. (B) The AAI of the articular disc (white arrow) exhibits an irregular morphology, with uneven signal intensity on the PDWI sequence, and was thus assigned as score of 2. (C) The anterior attachment of the articular disc (red frame) is not visualized, and was thus assigned as score of 3. (D) The PAS of the articular disc (green arrow) shows a continuous course and uniform signal, and was thus assigned as score of 1. (E) The PAI of the articular disc (orange arrow) shows a continuous course and uniform signal, and was thus assigned as score of 2. (F) The posterior attachment of the articular disc (orange frame) is not visualized, and was thus assigned as score of 3. AAI, anterior attachment inferior; AAS, anterior attachment superior; PAI, posterior attachment inferior; PAS, posterior attachment superior; PDWI, proton density-weighted imaging; TMJ, temporomandibular joint; WD-MRI, wireless detector–based magnetic resonance imaging.

Statistical analysis

SPSS 26.0 (IBM Corp) was used for all analyses. Inter-observer reliability between the two radiologists was evaluated using the weighted kappa coefficient. Kappa values were interpreted as follows: 0–0.40, poor agreement 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; and 0.81–1, almost perfect agreement. The student’s t-test was used for normally distributed data (mean ± standard deviation), while the Mann-Whitney U test was used for non-normally distributed data. For intergroup comparisons of peridiscal attachment scores across the three TMJ disc position groups, the Kruskal-Wallis H test was used as the primary non-parametric test. Post-hoc pairwise comparisons were performed using the Mann-Whitney U test with Bonferroni correction. The Chi-squared test and Spearman correlation analysis were used to assess correlations between TMJ peridiscal attachment scores and disc position (Spearman correlation coefficients of 0.4–0.6 indicate a moderate correlation, while values >0.6 indicate a strong correlation). Statistical significance was set at P<0.05.

Results

Clinical characteristics

This study included 61 patients (12 males, 49 females; mean age 32.54±13.05 years), corresponding to 122 TMJs. Among the evaluated TMJs, 12 (9.836%) were classified as normal, 37 (30.328%) exhibited DDWR, and 73 (59.836%) exhibited DDWOR. The distribution of TMJ pathologies is summarized in Table 1.

Inter-observer variability in peridiscal attachment scoring

Inter-observer reliability for AAS, AAI, PAS, and PAI demonstrated almost perfect agreement, with kappa values of 0.838 [95% confidence interval (CI): 0.746–0.930], 0.896 (95% CI: 0.825–0.967), 0.852 (95% CI: 0.774–0.930), and 0.799 (95% CI: 0.705–0.893), respectively.

Comparison of peridiscal attachment scoring in disc position

The scoring of all four peridiscal attachments (AAS, AAI, PAS, and PAI) differed significantly among the three groups (normal, DDWR, and DDWOR; all P<0.001). The frequency distribution of peridiscal attachment grades across the study groups is shown in Table 2. Spearman correlation analysis revealed that all peridiscal attachment scores were positively correlated with the severity of disc displacement (P<0.001). The posterior attachment scores (PAS and PAI) exhibited strong positive correlations with disc position, with correlation coefficients of 0.745 and 0.682, respectively. In contrast, the anterior attachment scores (AAS and AAI) showed moderate positive correlations (r=0.460 and r=0.440, respectively).

As indicated in Tables 3-5, pairwise comparisons of peridiscal attachment scores among the three groups (normal disc position vs. DDWR, DDWR vs. DDWOR, and normal disc position vs. DDWOR) were conducted using the Mann-Whitney U test. In the comparison between the normal disc position and DDWR groups, only the PAI score was significantly higher in the DDWR group (Z=2.653, P<0.05). No significant differences or correlations were found for the AAS, AAI, or PAS scores (all P>0.05). When comparing the normal disc position and DDWOR groups, all four peridiscal attachment scores (AAS, AAI, PAS, and PAI) were significantly higher in the DDWOR group (Z=2.571–5.624, all P<0.05). Similarly, in the comparison between the DDWR and DDWOR groups, all four peridiscal attachment scores were significantly higher in the DDWOR group (Z=3.715–7.516, all P<0.05). The grading of the peridiscal attachments showed significant positive correlations with disc reducibility. These correlations were moderate for AAS (r=0.467) and AAI (r=0.356), and strong for PAS (r=0.720) and PAI (r=0.630) (Table 5).

Discussion

This study used WD-MRI and an ordinal grading system to systematically evaluate structural alterations in the peridiscal attachments. The results revealed that all four peridiscal attachment scores were significantly higher in the DDWOR group than in the normal disc position group (P<0.001). This upward trend suggests that disc displacement severity is closely associated with progressively higher peridiscal attachment scores. The study findings indicate that structural alterations in the peridiscal attachments, particularly the posterior attachment, are significantly correlated with the severity of TMJ ID as visualized on WD-MRI.

A primary finding of this study is the significant difference in correlation strength between the posterior and anterior attachments. Statistical analysis revealed that the posterior attachment scores (PAS and PAI) exhibited strong positive correlations with disc displacement severity (r=0.745 and r=0.682, respectively). In contrast, the anterior attachment scores (AAS and AAI) showed only moderate positive correlations (r=0.460 and r=0.440, respectively). These findings indicate that the structural integrity of the posterior attachment is a more sensitive indicator of disc positional changes.

Further, pairwise comparisons provide important clinical insights into the progression of TMJ ID. In the early stage of displacement (DDWR) (18,19), the PAI score was the only parameter to show a significant increase compared to the normal group (P=0.008), while AAS, AAI, and PAS showed no statistically significant differences (P>0.05). However, as the DDWR progressed to DDWOR, all four scores increased significantly (P<0.05), with the posterior attachment scores showing strong positive correlations (PAS: r=0.720; PAI: r=0.630). These findings suggest that increased posterior attachment scores, as visualized on WD-MRI, may serve as a critical radiological marker of TMJ ID severity.

To date, the specific relationship between the peridiscal attachments and TMJ ID has not been addressed in clinical studies. However, compared with the articular disc, the peridiscal attachments are much smaller in size, and conventional MRI generally has limited capability to clearly and accurately visualize the peridiscal attachments. Therefore, this study used a high-definition MRI technique to achieve clear and accurate evaluation of the peridiscal attachments. The WD has previously been applied to evaluate condylar bone changes in the TMJ, with the results showing no statistically significant difference compared with cone beam computed tomography, highlighting its high-resolution and detailed imaging capabilities (13). Compared with conventional MRI, WD-MRI significantly improves the SNR and CNR of TMJ images (14). Consequently, we did not perform a redundant validation of the capability of WD-MRI to enhance TMJ image quality, as this has been previously established.

The posterior attachment functions as the primary “tethering” mechanism of the articular disc (20). It anchors the articular disc to the posterior condylar neck, providing the tensile strength and passive elastic recoil—driven by its high collagen and elastin content—necessary to prevent excessive anterior displacement and facilitate disc reduction (21,22). The posterior attachment is predominantly composed of collagen fibers arranged to confer high tensile stiffness and passive elastic recoil, both necessary for effective disc reduction (21). Our imaging findings, which showed a shift from localized signal changes in DDWR to extensive structural deterioration in DDWOR, likely reflect the progressive loss of this mechanical integrity. Pathological remodeling of the posterior attachment, characterized by disorganized fiber patterns and decreased elastin content, may eventually reach a critical threshold (20,21,23). At this stage, its capacity to counteract the anterior forces exerted by the lateral pterygoid muscle may become compromised, potentially leading to a shift in the mechanical equilibrium. Collectively, the study results suggest that MRI-based grading of the posterior attachment may serve as a potential imaging indicator for TMJ ID severity.

In addition, the role of the anterior attachment should not be overlooked. Clinical evidence from TMJ anchoring surgeries suggests that the anterior attachment, including its connection to the superior head of the lateral pterygoid muscle, plays a biomechanical role in preventing posterior displacement (24-26). When anterior displacement occurs, this mechanical equilibrium is disrupted. While the anterior attachment provides a stabilizing constraint, its relatively lower collagen content compared to the posterior attachment may result in different compensatory capacities (25,27). Therefore, during the DDWOR stage, the tethering effect of these attachments may fail to counteract the traction exerted by the lateral pterygoid muscle on the disc (28), marking a point at which the joint’s internal supports fail to keep the disc in its proper place. By identifying these specific structural alterations on WD-MRI, our study establishes a reliable radiological foundation for grading peridiscal attachment changes in patients with TMJ ID.

This study had several limitations. First, the original data of this study were non-parametric, and the MRI-based evaluation of characteristics of the disc–condyle complex and the ordinal grading assessment of the peridiscal attachments demonstrated inherent subjective variability. Second, the clinical implications of the findings require further validation through multicenter studies. Third, the left and right TMJs from the same patient were treated as independent units. Although this approach is commonly used in TMD research due to bilateral asymmetry, it may influence the statistical power and should thus be interpreted with caution. Fourth, the relatively small sample size, particularly in the normal disc position group, may limit the statistical power and generalizability of our findings. While this may increase the risk of type II errors, the highly significant differences observed suggest sufficient statistical power to detect key pathological alterations. Future studies with larger healthy cohorts are needed to validate these results. Finally, although WD-MRI was used in this study, the current analysis was limited to morphological imaging. Future research should incorporate advanced techniques such as diffusion imaging, T2 mapping, ultra-short echo time, and zero echo time to enable functional and quantitative assessments. This multimodal approach may facilitate a more comprehensive exploration of ultrastructural changes in peridiscal attachment tissues, thereby enhancing our understanding of physiological adaptations and early pathological alterations in TMJ ID.

Conclusions

This study, based on WD-MRI and an ordinal grading system, systematically evaluated the relationship between peridiscal attachment scores and TMJ ID in patients with TMD. The study findings demonstrate that structural alterations in the peridiscal attachments, particularly the posterior attachment, are significantly correlated with TMJ ID severity on WD-MRI, suggesting their potential value in the assessment of TMD.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2026-0677/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2026-0677/dss

Funding: This study was supported by National Natural Science Foundation of China (No. 82460344), the Key Research and Development Project of Ningbo (Nos. 2024Z220 and 2022S133) and Natural Science Foundation of Zhejiang Province (No. LKLY25H200010).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2026-0677/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Guizhou Provincial People’s Hospital (No. LYSZ [2022] 256). Because this research was designed as a retrospective analysis of archived medical records, the institutional ethics committee granted a waiver for informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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