Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2013 40; 239--246

Stress analysis in human temporomandibular joint affected by anterior disc displacement during prolonged clenching
S. ABE*, F. KAWANO*, K. KOHGE, T. KAWAOKA, K. UEDA, E. HATTORIH A R A , H . M O R I , S . K U R O D A & E . T A N A K A *Department of Oral Care and Clinical Education, The
Tokushima University Hospital, Tokushima, Department of Comprehensive Dentistry, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Digital Solution Inc., Hiroshima and Department of Orthodontics and Dentofacial Orthopedics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan

SUMMARY Parafunctional habits, such as prolonged clenching and bruxism, have been associated with dysfunctional overloading in the temporomandibular joint (TMJ). In this study, stress distributions in the TMJ were analysed during prolonged clenching, using three-dimensional nite element (FE) models of the TMJ with and without disc displacement. The aim of this study was to investigate stress distribution of the cartilaginous tissues in the TMJ with and without disc displacement. Finite element models were developed on the basis of magnetic resonance images from two subjects with and without anterior disc displacement. Condylar movements recorded during a 5-min clenching were used as the loading condition for stress analysis. In the asymptomatic model, the highest von Mises stresses were located in the lateral area (491 MPa) of the disc surfaces, and after 5-min clenching, the higher stresses were still

located at the lateral area (365 MPa). In all the cartilaginous tissues, 3050% of stress reduction occurred during 5-min clenching. In contrast, the von Mises stress in the cartilaginous tissues of the symptomatic model with disc displacement was markedly lower, compared with the asymptomatic model. However, in the condylar cartilage, stress relaxation during clenching was not recognised. Furthermore, relatively high stresses were observed in the retrodiscal tissues throughout clenching. The present results indicate that disc position could be involved in the stress distribution of the TMJ components during prolonged clenching. KEYWORDS: temporomandibular joint disorders, parafunction, nite element analysis Accepted for publication 10 January 2013

Introduction
Daily muscle activity accompanies joint motion, resulting in joint loads. These loads must be sustained by these biological bearings, the diarthrodial joints, with tribological characteristics such as friction, lubrication and wear (1). The brocartilaginous nature of the temporomandibular joint (TMJ) disc and articular cartilage, along with the lubrication function of the intra-articular synovial uid, allows the cartilaginous structures of the TMJ to conform under function and ensures that loads are absorbed and spread over larger
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contact areas (2, 3). Consequently, the dysfunctional overloading in the TMJ is prevented by the presence of the disc and articular cartilage (3, 4). Internal derangement of TMJ (TMJ-ID) dened as an abnormal positional relationship of the disc relative to the mandibular condyle, and the temporal bone is a major TMJ disorder and accompanied with TMJ pain, clicking and/or crepitus, muscle tenderness and limitation of mouth opening as the symptoms (5). The return to prominence of the concept of TMJ-ID has contributed greatly to treatment of the TMJ disorder. The role of the disc
doi: 10.1111/joor.12036

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in the progression of TMJ-ID is controversial. From a review of aetiological events of TMJ-ID, trauma, functional overloading, parafunctional habit, degenerative joint disease and increased friction between the moving parts were considered to play a major role in the aetiology of disc displacement (6, 7). Therefore, the biomechanical environment in the TMJ is a key feature to understand the inducing and progressive mechanism of TMJ-ID. Parafunctional habits, such as prolonged clenching and bruxism, have been associated with dysfunctional overloading in the TMJ (8, 9). Most of tooth grinding was recognised as sleep bruxism, which caused the morning headache and fatigue in addition to tooth wear, fracture and sensibility (911). A previous study reported that severe sleep bruxism patients were associated with the TMJ disorders in Japanese adolescents (12), while other study indicated the relatively large tooth grinding was not associated with TMJ disorders (13). Thus, the relation between tooth grinding/sleep bruxism and TMJ disorders must be considered unclear. On the other, diurnal tooth clenching has been demonstrated a risk factor of TMJ-ID in adolescents (14), and prolonged clenching might be associated with degenerative changes in the TMJ (6). The aim of this study was to investigate stress distribution of the cartilaginous tissues in the symptomatic joint with disc displacement in comparison with healthy joint without disc displacement during prolong clenching. Two nite element (FE) models of the TMJ were constructed based on magnetic resonance (MR) images from one healthy subject and one symptomatic subject with anterior disc displacement, and the stress distributions in the articular disc and cartilages during prolonged clenching were analysed. images of the TMJ (thickness, 15 mm) were taken by a 30-Tesla MRI system* with a 3-inch dual-surface TMJ coil. The scanning variables with a 3-inch dual-surface coil were 2200/20 ms (repetition time TR/echo time TE). The axial scans parallel to the Frankfort plane were taken to determine the long axis of the condyle. Based on the axial images, the sagittal plane of imaging was designed to be perpendicular to the long axis of the condyle. The coronal plane of imaging was determined to be perpendicular to the median sagittal plane and the Frankfort plane. Contiguous 15 mm thick sagittal and coronal slices were obtained with the dentition in full intercuspal occlusion. The 3-D modelling of the TMJ from the MR slices was performed using the ZedView. The ZedView allows one to perform as a semi-automatic segmentation tool for rapid processing of 3-D data. The validity of this modelling programme and analysis has already been reported elsewhere (15). From contiguous sagittal slices of MRI for each subject, the contours of mandibular condyle, temporal bone (glenoid fossa) and articular disc were semi-automatically traced on a computer display, and piled up to represent the 3-D geometry of each component. The coronal MRI was used for modication of the shapes of the lateral and medial portions. Both the upper and lower surfaces of the TMJ disc confronted a uniform-thickness layer (02 mm) onto the temporal bone and mandibular condyle, which were temporal and mandibular condylar cartilage, respectively. To allow the disc to deform and move along the articulating surfaces without penetration, gap elements were placed at the cartilagedisc interface. Because of the detection limit of the MRI, the tissue surrounding the articular disc was modelled as a homogeneous mass of connective tissue, representing the anterior mandibular attachment, the lateral and medial capsular ligaments and retrodiscal tissue. Finally, the number of nodes for the asymptomatic and symptomatic models was 24 856 and 25 678, respectively, in the bone components, and 17 874 and 18 997, respectively, in the soft tissue including the disc (Fig. 1).

Material and methods

Reconstruction of three-dimensional TMJ models A fully dentate female volunteer (age: 25 years old) with no history of present and past TMJ-ID and a symptomatic female patient (age: 24 years old) with anterior disc displacement without reduction were selected as asymptomatic and symptomatic subjects, respectively. For each subject in maximum intercuspal occlusion, contiguous sagittal and coronal

*Signa, GE Healthcare, Faireld, CT, USA.

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(a) (b)

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written et r 0 se ER se sr se et=sr for t ! 0 2

The dashpot is completely relaxed as time tends to innity. The stressstrain relationship then becomes that of the undamped spring given by
(c)

e1 r0 =ER From the initial condition of equation (1), another elastic constant E0 (the elasticity of the two parallel springs) is dened as e0 r0 =E0 where

Fig. 1. Whole model of the mandible (a) and nite element models of the asymptomatic (b) and symptomatic (c) joints. The green, red, pink and blue parts indicate the glenoid fossa, temporomandibular joint disc, connective tissue and condyle, respectively.

E0 ER sr =se Here, the instantaneous moduli E0 were 309 MPa for the TMJ disc, 122 MPa for the articular cartilages and 15 MPa for connective tissues (3, 17, 18). Finally, by modication of equation (2), the relaxation modulus E(t) is written as Et r0 =et ER se sr se et=sr se ER E0 ER et=sr

Boundary conditions and stress analysis The cortical bone was assumed to be linear elastic (elastic modulus, 13 700 MPa; Poissons ratio, 030) (16). The materials properties of the articular disc, articular cartilages and connective tissue were modelled using a Kelvin model. This linear viscoelastic model is composed of two linear springs with elastic constants l1 and l2, combined with a dashpot with coefcient of viscosity g. The relationship between the stress r and the strain e under compression is formulated as _ _ ER e sr e 1 r se r where e = g/l1 and r = g/l2 (1 + l2/l1) are time constants for strain relaxation and stress relaxation, respectively. The relaxed elastic moduli ER are 158, 74, and 02 MPa for the TMJ disc, articular cartilages and connective tissue, respectively (3, 17, 18). The time constant e, indicating relaxation time was 312 s for the TMJ disc and articular cartilages and 112 s for the connective tissue (3, 17, 18). When a stress r(0) = r0 is applied instantaneously at time t = 0, the initial condition of equation (1) is given by se r0 ER sr e0 If the stress is kept constant at r(t) = r0 for t ! 0, the time-dependent behaviour of the strain e(t) can be
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The model of the temporal bone was restrained for all degrees of freedom. It was constrained at the rearmost point of occlusal contact and at the central point of the anterior teeth on the mandible for mediolateral displacements, leaving three degrees of freedom in the sagittal plane. Contact in the TMJ was modelled using gap elements between the disc and both articular cartilages with a frictional coefcient of l = 00001. Joint loading was simulated with a condylar displacement. The condylar displacement during clenching was recorded using a Gnatho-hexagraph, which records jaw movements related to stomatognathic functions. The relevant 3-D mandibular pathway and its time course were recorded with six degrees of freedom and an accuracy of 150 lm (19). By comparing the data of condylar displacements to those measured by a jaw-tracking devise, we conrmed the validity of the analysed data.

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Stress analysis was executed by the FE analysis program Nastran. The von Mises stresses in the TMJ disc, articular cartilages and connective tissue were evaluated during 5-min clenching. (057 MPa) (Fig. 5). These stress distribution patterns indicated that the mandibular condyle pushed the retrodiscal tissue forward and upward, resulting in forward movement of the disc (Fig. 3b). After 5-min clenching, the highest stress (025 MPa) was located in the retrodiscal tissue, which was 264% of the highest stress value at onset (Fig. 6). The disc surfaces and the temporal cartilage also showed approximately 6080% reduction during clenching. However, the highest stress (041 MPa) was found in the middle and medial areas of the condylar cartilage, which was 1487% of the stress value at the onset of clenching (Figs 4b and 6). These implied that instead of TMJ disc, the retrodiscal tissue in the symptomatic joint played a role in stress absorber during clenching and that the stress relaxation had hardly occurred in the mandibular condylar cartilage.

Results
For the asymptomatic joint, the stress distributions in four TMJ components during prolonged clenching at two different instances of time (0 s and 5 min) are shown in Figs 24. At the onset (t = 0 s) of clenching, the highest von Mises stress was located in the lateral area (491 MPa) of the superior and inferior disc surfaces (Fig. 2). At the surface of the mandibular condylar cartilage, a relatively high stress (250 MPa) was found in the middle and lateral areas, while the surface of the temporal cartilage had a relatively low stress (131 MPa) in the lateral area. A relatively low stress (094 MPa) was found in the retrodiscal tissue adjacent to the posterior band of the disc. The stress concentrations were relieved towards the temporal cartilage through the mandibular condylar cartilage and the disc (Fig. 3a). After 5-min clenching, the highest stress was located in the lateral area of the superior and inferior disc surfaces (365 MPa), which was 742% of the stress value at the onset. The stresses induced in the mandibular condylar cartilage, temporal cartilage and retrodiscal tissue were also reduced to approximately 2050% of those at the onset of clenching. The largest reduction of stress value was found in the retrodiscal tissue. The stress reduction during prolonged clenching indicated stress relaxation in the TMJ components (Figs 3a and 4). For the symptomatic joint, the stress distribution pattern in the TMJ components was considerably different from that for the asymptomatic joint, although the von Mises stresses were smaller (Figs 3b and 56). At the onset of clenching, the largest stress (094 MPa) was located in the lateral area of the retrodiscal tissue adjacent to the disc (Fig. 5). The both superior and inferior surfaces of the disc showed the highest stress in the lateral area (049 and 037 MPa, respectively). On the mandibular condylar cartilage, the highest stress (028 MPa) was found in the middle and medial areas, meanwhile the anterior and lateral areas of the temporal cartilage showed the highest stress

Discussion
Finite element method has been proven to be a suitable tool for approximating the stress distribution in the structures of the TMJ (15, 20, 21). Finite element analysis has been successfully used in this eld because it enables us to estimate stresses in the TMJ without an invasive approach. Obviously, biomechanical models of the human TMJ are not real and perfect, while they are based on a number of assumptions and simplications. With respect to the present analysis the following remarks have to be made. First: As human material was not available, viscoelastic material characteristics for the articular disc, cartilages, and retrodiscal tissue had been derived from animal materials (3, 17, 18). These tissues were represented as viscoelastic structures by means of a standard viscoelastic Kelvin model. Although the soft tissue such as the disc and retrodiscal tissue has been modelled as a biphasic, non-linear, or poroelastic structure (20, 21); recently, the viscoelastic model according to Kelvin has been suggested to be more adequate for stress analysis in the TMJ than biphasic or poroelastic models (22). However, assuming the behaviour of cartilaginous tissues as only viscoelastic may be too simplied for a quantitative stress analysis in the TMJ. Second: As little is available about the viscoelastic properties of the temporal cartilage, its viscoelastic parameters were determined to be similar to those of the condylar cartilage. Prior to this study, we measured the viscoelastic properties of the porcine
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NEi Software Co., Westminster, CA, USA.

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Fig. 2. von Mises stress distribution in the asymptomatic joint at the onset of clenching (time = 0 s).

temporal cartilage in stress relaxation and conrmed the similarity of the viscoelastic parameters between the two porcine cartilages (unpublished data). Finally, the amount of friction in the contacting surfaces, as GAP elements, was considerably low compared to that

(a)

(b)

Fig. 3. von Mises stress distribution in the soft tissues of the asymptomatic (a) and symptomatic joints (b) (sagittal section) during prolonged clenching.
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in the experimental studies (23). In addition, as the frictional coefcient of the TMJ is associated with joint surface roughness and cartilage deterioration (24), the different values of frictional coefcient in the TMJ should be used in the two models with and without disc displacement. The present study demonstrated that the stress distribution on the surface of the mandibular condylar cartilage were remarkably different between the asymptomatic and symptomatic joints. In the asymptomatic joint, all the soft tissues showed a large reduction (3050%) of stress value after prolonged clenching. In contrast, in the symptomatic joint, stress reduction during clenching was not recognised on the surface of the condylar cartilage. This stress reduction is caused by stress relaxation, which indicates that energy-dissipation mechanisms exist in the soft tissues of the asymptomatic joint (2). The viscoelasticity of a material is a principal cause of energy dissipation. Without the dissipation of strain energy, storage of excessive strain energy can lead to breakage of the articular disc and cartilages in the TMJ. Taken together, the present results indicated that cartilaginous tissues in the healthy joints played an important role in stress distribution during prolonged clenching,

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Fig. 4. von Mises stress distribution in the asymptomatic joint after prolonged clenching (time = 5 min).

Fig. 5. von Mises stress distribution in the symptomatic joint at the onset of clenching (time = 0 s).
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Fig. 6. von Mises stress distribution in the symptomatic joint after prolonged clenching (time = 5 min).

while stress distribution in the TMJ components might be affected by the disc malposition. The present results revealed that relatively high stresses were observed in the retrodiscal tissues throughout prolonged clenching. Previously, we measured the compressive elastic modulus of the bovine retrodiscal tissue and demonstrated that the elastic modulus of the retrodiscal tissue in compression was approximately 1/20th smaller than that of the TMJ disc (18). Furthermore, the retrodiscal tissue exhibited 90% reduction in the instantaneous stress during stress relaxation. Therefore, the retrodiscal tissue has a great capacity for energy dissipation during stress relaxation, although it has little or no function to stand continuous compression in the TMJ. Anatomically, the retrodiscal tissue is continuous with the posterior band of the disc, and its organisation is a function of condylar position (25). When the jaws are closed, the retrodiscal tissue is formed into a thick sheet behind the condyle. When the jaws are widely opened, the retrodiscal tissue is expanded in all directions (25). Considering our results, continuous overloading such as prolonged clenching and bruxism, on this specic retrodiscal tissue, may result in the tissue perforation and consequently lead to the degenerative disease as osteoarthritis.
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Conclusions
Cartilaginous tissues in the healthy joints play an important role in stress distribution during prolonged clenching, while stress distribution in the TMJ components might be affected by disc malposition.

Acknowledgments
This study was approved by the Institutional Ethical Committee of Tokushima University Hospital.

Funding
This work was supported partially by a Grant (No. 23659966) for Science Research from the Ministry of Education, Science and Culture, Japan.

Competing interests
The authors have declared that no competing interests exist.

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Correspondence: Eiji Tanaka, Department of Orthodontics and Dentofacial Orthopedics, Institute of Health Biosciences, The University of Tokushima Graduate School, 3-18-15 Kuramoto-cho, Tokushima 770-8504, Japan. E-mail: etanaka@tokushima-u.ac.jp

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