TMJ Disroders


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Radiology II
Forth Year

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TMJ Disroders

  1. 1. Tempromandibular joint Disorders (TMJDs) ! By Dr. Hassan M. Abouelkheir BDS, MSC, Phd.
  2. 2. Anatomy & Function: ■ Tempromandibular Joint (TMJ) is a unique joint as it is capable of hing-type and gliding movements with bony components enclosed and connected by fibrous capsule.
  3. 3. ■ TMJ is located between the glenoid fossa, inferior surface of temporal bone and condylar process of the mandible. ■ It is synovial type of joint and characterized by : ■ 1-Fibrocartilage → articulating surfaces are covered by fibrous C.T.with cartilage cells. ■ 2- it is the only joint with rigid end point of closure. ■ 3- It has bilateral articulation with cranium. Anatomy & Function (Cont):
  4. 4. Anatomy (cont.) ■ It consists of : ■ 1- Mandibular condyle with medial & lateral pole. ■ 2- Glenoid fossa & Articular eminence of temporal bone. ■ 3- Interarticular disk (meniscus); it divides joint cavity into superior and inferior part. It is biconcave with thick anterior band,thicker posterior band & thin intermediate band.
  5. 5. Anatomy (cont.) ■ 4- posterior attachment (retrodiskal tissues): it consists of a bilaminar zone of vascularized and innervated loose fibroelastic tissue. ■ Superior lamina inserts in posterior wall of mandibular fossa while inferior lamina attaches to posterior surface of the condyle.
  6. 6. Anatomy (cont.) ■ 5- Synovial membrane which secretes synovial fluid to lubricate the joint. It lines the articular disk, capsule and retrodiskal tissue. ■ Masticatory Muscles attachments: ■ 1- Superior and inferior belly of lateral pterygoid muscle attached to anteromedial aspect of the condyle. ■ 2- masseter muscle inserted into inferior border of mandibular angle from lateral side.
  7. 7. Anatomy (cont.) ■ 3- Medial pterygiod muscle attached to inferior border of mandibular angle from medial side. ■ 4- Temporalis muscle inserted into coronoid process & anterior aspect of the mandibular ramus.
  8. 8. Radiographic anatomy ■ Radiographic joint space: radiolucent area between the condyle and temporal component. ■ The condyle is centeralized when anterior & posterior aspects of radiolucent joint space are uniform in width.
  9. 9. Radiographic Anatomy (cont.) ■ At maximum opening the condyle moves down & forward to the summit of the articular eminence or slightly anterior to it. ■ Hypermobility of the joint if condyle translates more than 5mm anterior to the eminence. ■ This may permit dislocation or locking of condyle.
  10. 10. Radiographic Examination: ■ Hard tissue imaging: ■ 1- Panoramic Projection: ■ It has a limited value as it does not give full information on condylar movement in open and close position. It can be used for a preliminary survey.
  11. 11. 2-Conventional tomography ■ It produces multiple thin image slices at right angle through the joint. ■ It exposed in lateral plane with several image slices in closed and maximium opening positions. ■ Deviating pt’s head 20˚could correct angulation . ■ Frontal view of condyle could be exposed in cases of errosive changes or abnormalities of condyle.
  12. 12. 2-Conventional tomography (cont.)
  13. 13. 3- computerized tomography ■ Computed tomography (CT) can be used to diagnose internal derangement and other disorders of the TMJ. The patient is scanned in either the transverse or direct sagittal plane using thin sections (1-2 mm) and a soft tissue technique. If transverse sections are obtained, sagittal reconstructions are made through the condyle. The meniscus can be visualized on CT since it is slightly higher in density than the surrounding muscle and soft tissue normal  TMJ  CT  showing  normal  disk  posterior   and  superior  to  condyle  (C)
  14. 14. 4-Cone beam CT(CBCT) ■ The imaging offered by current CBCT machines has been shown to provide a complete radiographic evaluation of the bony components of the TMJ. ■ The resulting images are of high diagnostic quality. Given the significantly reduced radiation dose and cost compared with conventional CT. ■ CBCT may soon become the investigational tool of choice for evaluating bony changes of the TMJ
  15. 15. Soft tissue imaging: ■ 1- Arthrography: is a technique in which indirect image of disk is obtained by injecting a radiopque contrast agent into one or both joint spaces under flouroscopic guidance . ■ It is invasive technique and may encounter allergy to contrast media.
  16. 16. 2- Magnetic resonance imaging . Magnetic resonance (MR) can also be used to diagnose internal derangement and other disorders of the TMJ. The patient is scanned in the sagittal plane using a surface coil and a high resolution technique. The low intensity cortex of the condyle surrounds the high signal fat in the marrow. The meniscus is a low intensity structure which is attached posteriorly by the intermediate intensity bilaminar zone
  17. 17. Radiographic abnormalities: ■ I- Developmental Abnormalities: ■ a) Condylar Hyperplasia: ■ Developmental unilateral enlargement & deformity of condylar head. ■ Clinical features: ■ It occurs in males under 20 years. Mandibular asymmetry and chin may be deviated to unaffected side. ■ Posterior open bite on affected side with limited or deviated mandibular opening.
  18. 18. a) Condylar Hyperplasia (cont.): ■ Radiographic features: ■ Enlarged condyle with irrigular outline. ■ Elongated condylar head & neck with bending forward (inverted –L). ■ Normal cortical thickness and trabecular pattern. ■ Enlargement of gleniod fossa on expenses of posterior slob of articular eminence → inferior border midline depression.
  19. 19. Condylar Hyperplasia (cont.): ■ Differential diagnosis: ■ osteochondroma→ more irrigular. ■ Treatment: ■ Orthodontic + orthognatic surgery.
  20. 20. b- condylar hypoplasia: ■ It is failure of the condyle to attain normal size as a result of congenital & developmental abnormalites. ■ The condyle is small with normal morphology. ■ Clinical features: ■ It is unilateral or bilateral. ■ Mandibular asymmetry & TMJ symptoms. ■ The chin is deviated to the affected side during closure & opening.
  21. 21. condylar hypoplasia(cont.): ■ Radiographic features: ■ Condyle normal in shape but small in size. ■ Smaller mandibular ramus and body. ■ Mandibular asymmetry and deeping antegonial notch. ■ Treatment: ■ Orthognatic surgery, bone grafts & orthodontic therapy.
  22. 22. C- Bifid Condyle: ■ A bifid condyle have a vertical depression, notch or deep cleft in the center of condylar head in sagittal plane. ■ Radiographic features: ■ A depression or notch is present on the superior condylar surface (heart – shaped) with remodling of condylar fossa.
  23. 23. II Soft Tissue Abnormalities: ■ 1- Internal Derangement: ■ It is abnormal disk position in function. It may be displaced anteriorly, anteromedially, medially or antero-laterally. ■ The disk may resume a normal position with condyle during mandibular opening (called reduction of disk). ■ When the disk remains displaced during entire movement , it is called nonreduction.
  24. 24. 1- Internal Derangement(cont.):
  25. 25. 1- Internal Derangement(cont.): ■ Clinical Features: ■ I.D. is unilateral or bilateral. ■ Deviation of mandible to defected side in unilateral cases during opening. ■ Clicking of jaw during opening or closing or both in disk reduction. ■ Crepitus in non reducing disk. ■ Pain in pre-auricular area
  26. 26. 1- Internal Derangement(cont.): ■ Radiographic features: ■ Arthrography and or tomography are techniques of choice. ■ Disk Displacement: ■ Anterior disk displacement is most common as indicated by anterior location of the posterior band of the disk from normal position.
  27. 27. 1- Internal Derangement(cont.): ■ Disk perforation and Deformities: ■ Arthrography can reveal a tear in joint capsule or perforation of disk flow of contrast agent from inferior to superior disk space. ■ Disk Adhesion can be identified by resistance to injection of contrast agent .
  28. 28. III Remodeling and Arthritic conditions. ■ 1- Remodeling: ■ It is adaptive response of cartilage and osseous tissue to forces applied to the joint. ■ Clinically , pt may be asymptomatic or muscle tenderness. ■ Radiographic features: ■ Flattening, cortical thickening of articulating surfaces and sub condral sclerosis.
  29. 29. 2- Degenerative joint disease (Osteoarthritis): ■ DJD is non inflammatory disorder of joints characterized by joint deterioration and proliferation. ■ Clinical features: ■ Female predeliction , increase with age. ■ Asymptomatic or pt feels TMJDs . ■ Pain on palpation, crepitus, limited range of motion & muscle spasm. anteriorly displaced and deformed, degenerated disc and irregular cortical outline with osteophytosis and sclerosis of condyle .
  30. 30. DJD (cont.) ■ Radiographic features: ■ Joint space may be narrow or absent → max. intercuspation. ■ It may be related to internal derangement → bone to bone contact. ■ Flattening & subchondral sclerosis. ■ Irrigular radiolucent areas near articulating surfaces (Ely cysts). ■ New bone formation may be formed on the anterosuperior surface of condyle (osteophyte). ■ When they break off & lie free on space (joint mice). ■ Enlarged of glenoid fossa ■ Treatment: ■ Splint therapy, physiotherapy, NSAIDs.
  31. 31. 3-Rheumatoid arthritis: ■ ٌِRA is a heterogenous group of systemic disorders with general synovial membrane inflammation in several joints. ■ Clinical features: ■ More in female , increase with age . ■ It affects small joint of hands, wrists, knees and feet, bilateral symmetric . ■ Pain, swelling,stiffness of jaw opening bilateral involvement.
  32. 32. Radiographic features (RA) ■ Osteopenia (decrease density) of the condyle & temoral component. ■ anterosuperior Erosion of the condyle which may lead to anterior open bite. ■ Anterior & posterior condylar erosion → sharpened pencil appearance. ■ Total joint destruction may occur. ■ Subchondral cyst and osteophyte formation. ■ Treatment: ■ Analgesics & anti-inflammatory drugs NSAIDs, gold salt, coricosteroids). ■ Physiotherapy. ■ Disk replacement.
  33. 33. IV Trauma: ■ 1- Effusion: ■ Influx of fluid into the joint due to trauma (hemorrhage ) or inflammation (exudate). ■ Clinical features: ■ Swelling or pain inpreauricular region with limited range of motion. ■ Radiographic: ■ Widening of joint space. ■ MRI show bright signal (white) indicating fluid adjacent ot disk.
  34. 34. IV Trauma (cont.): ■ 2- Dislocation: ■ Abnormal positioning of the condyle out of mandibular fossa but within the joint capsule. ■ Bilaterally in anterior direction. ■ Etiology: muscular in coordination, sublaxation or external trauma. ■ Clinical picture: ■ Pt cannot close the mandible to maximum intercuspation with pain and muscle spasm. Some able to reduce the mandible by manipulation.
  35. 35. IV Trauma (cont.): ■ Radiographic features: ■ Condyles are located anterior and superior to the summits of the articular eminentia. ■ Treatment: ■ Manual manipulation of the mandible to reduce the dislocation.
  36. 36. IV Trauma (cont.): ■ 3- Fracture: ■ Most common on condylar neck and rarely on condylar head. ■ Clinical features: ■ Unilateral neck fracture with parasymphyseal or mandibular body fracture on contra lateral side. ■ Swelling, limited opening & anterior open bite.
  37. 37. IV Trauma (cont.): ■ Radiographic features: ■ - Condylar neck fracture→ radiolucent line around neck , narrow if it is aligned or wider if there is displacement. ■ If there is overlapping →increase radiopacity with irrigular outer boundaries→ step deformity.
  38. 38. IV Trauma (cont.): ■ Condylar head fracture→vertical. ■ Multiple right angle radiographic projections are required to show the fracture. ■ Degenerative changes may occur e.g. flattening, erosion & osteophytes. ■ Treatment : ■ Surgical reduction.
  39. 39. IV Trauma (cont.): ■ 4- Ankylosis: ■ Mechanical lock of condylar movement. ■ True ankylosis→ osseous or fibrous ankylosis. ■ False ankylosis→ muscle spasm, myositis ossificans or coronoid process hyperplasia.
  40. 40. 4- Ankylosis (cont.) ■ Clinical Features: ■ Unilateral cases → truama or infection. ■ Bilateral cases → rheumatoid arthritis. ■ Limited mouth opening. ■ Radiographic features: ■ Fibrous ankylosis → irrigular articulating surfaces (erosion). ■ Narrow or absence of joint space. ■ 2ry degenerative changes are common. ■ Bony changes as elongationof coronoid process due to muscle . ■ Coronal CT is best diagnostic image. ■ Treatment → surgical correction.
  41. 41. V –Tumors: ■ A- Benign tumors: ■ Most common tumors of TMJ: osteomas, osteochondromas & osteoblastomas. ■ Clinical features: ■ Condylar tumors grow slowly and may show swelling , facial asymmetry, malocclusion and deviation of mandible to unaffected side. ■ Coronoid tumors are painless. Multiple myeloma
  42. 42. A- Benign tumors (cont.): ■ Radiographic features: ■ Osteochondroma is most common benign tumor of condyle. ■ Abnormal pedunculated mass attached to condyle. ■ Altered trabeculation with abnormal new bone formation or radiolucency. ■ Treatment : surgical excision.
  43. 43. B- Malignant tumors: ■ They either primary or metastatic. ■ Primary lesions are rare. ■ Metastatic neoplasms originating from breast, kidney, lung, colon, prostate and thyroid gland. ■ Clinical Features: ■ Most of malignant tumors are asymptomatic or may have symptoms of TMJ dysfunction as pain, limited opening, deviation & swelling. chondrosarcoma
  44. 44. B- Malignant tumors: ■ Radiographic features: ■ all malignant tumors have variable degrees of bone destruction with ill defined margins (radiolucencies) except osteogenc sarcoma which causes bone formation (radiopaque.) ■ Treatment : ■ Wide surgical excision for 1ry tumors. ■ 2ry tumors treated with radiotherapy and chemotherapy.
  45. 45. THE END