Seminar: Part 2

1. Diagnostic imaging of the
temporomandibular joint
BY : ASHISH RANGHANI
PG STUDENT PART 1
DEPARTMENT OF ORAL MEDICINE & RADIOLOGY
05/11/2015

2. TRANSCRANIAL VIEW
STRUCTURE
SHOWN
AREA OF JOINT
SEEN
Arthritic changes on the
articular surface
Lateral aspect of:
Glenoid fossa
Articular eminence
Joint space
Condylar head
It helps to evaluate the
joint’s bony relationship
Changes on the central
and medial surface are
not seen

3. • Film position: flat against patients ear centered
over TM joint of interest against facial skin
parallel to sagittal plane
• Position of patient: head adjusted so sagittal
plane is vertical & ala tragus line parallel to
floor
• View :3 positions
• open, close, rest mouth

4. Central ray
• A) Postauricular/ Lindblom Technique
-1/2 inch behind and 2 inch above auditory meatus
-central ray should be directed posteriorly so
it passes along long axis of condyle.
• B) Grewcock approach
-central ray passes through a point 2 inches above ext.
auditory meatus.
• C) Gill’s approach
- ½ inch anterior and 2 inch above EAM

5. • Central ray aimed downwards at 25 degree to the
horizontal, across the cranium, centering through
TMJ of interest
• Closed view- size of joint space, position of head of
condyle, shape & condition of glenoid fossa & articular
eminence
• Open view- range & type of movement
• Comparison of both sides
Disadvantages :
• Superimposition of ipsilateral petrous ridge over the
condylar neck

6. Exposure Parameters
Intra Oral X-ray Machine
kVp – 70
mA – 07
Seconds – 1.5

7. Transcranial projections of the left
TMJ.closed view (A) and the open view
1
1. articular eminence
2
2 glinoid fossa
3
3 head of condyle
4
4 external auditory meatus
5
1
2
3
4
5
5 joint space

8. TRANSPHARYNGEAL
VIEW/Infracranial/McQueen Dell
INDICATION AREA OF JOINT
SEEN
Tmj pain dysfunction
syndrome
Medial surface of the
Condylar head & neck
Articular surface
Osteoarthritis &
rheumatoid arthritis
Pathology-condylar
head-cyst & tumor
Fracture of neck &
condyle

9. • Film placement-
patient holds the cassette flat against
patients ear centered over TM joint of interest
against facial skin parallel to sagittal plane
½ inch anterior to EAM
 Position of patient- occlusal plane parallel to transverse
axis of film-soft parts are in a line with nasopharynx and
joint
• Patient instructed to inhale slowly through nose, filling of
nasopharynx with air
• Open mouth-condyles move away from base of skull and
mandibular notch is enlarged on opp side.

10. • Central ray- directed from opp side cranially at angle(-
5 to -10 degrees)
• Beneath the zygomatic arch, through sigmoid notch
posteriorly across pharynx at the condyle
• Comparison of both condylar heads

11. Exposure Parameters
Intra Oral X-ray Machine
kVp – 65-70
mA – 7-10
Seconds – 0.8
Using Extra Oral X-ray Machine
kVp – 40
mA – 40
Seconds – 1

12. TRANSPHARYNGEL VIEW
Medial profile of the condyle
1 condylar head
2 articular eminence
3 sigmoid notch
4 pterygoid plate
1
2
3
45
5 zygoma

13. TRANSORBITAL (ZIMMER
PROJECTION)
INDICATION AREA OF JOINT
SEEN
Trauma
Fracture cases
Ant view of TMJ
Medial displacement of
fractured condyle
Fracture of neck of
condyle

14. • Film position-behind patients head at an angle of 45
degree to sagittal pane
• Position of patient-
-Sagittal pane vertical
-Canthomeatal line should be 10 degree to the
horizontal with head tipped downwards
-The mouth should be wide open
• Central ray-
-tube head-front of patients face
-directed to joint of interest at an angle of +20 degrees
to strike cassette at right angles

15. Point of entry-
- Pupil of the same eye-asking patient to look straight
ahead
- Medial canthus of the same eye
- Medial canthus of the opposite eye
- Disadvantage :if the patient cannot open wide, areas of
the joint articulating surfaces will be obscured because
of mutual superimposition

16. Transorbital projection showing a frontal
view of the
condyle. The lateral pole is indicated with
an arrow.
Exposure Parameters
Intra Oral X-ray
Machine
kVp – 65-70
mA – 7-10
Seconds – 0.8
Extra Oral X-ray
Machine
kVp – 40
mA – 40
Seconds – 1

17. Reverse towne’s
INDICATION AREAS OF JOINT
SEEN
Articular surface of
condyles and disease
within joint
Posterior view of both
condylar head and
neck
Fracture of condylar
head & neck,
Intracapsular fracture
Condylar
hypo/hyperplasia

18. • Film position-cassette placed perpendicular to the
floor
Long axis of cassette placed vertically
• Position of patient-
-sagittal plane vertical & perpendicular to film
-lips are centered on the film
-only forehead should touch the film
-mouth wide open
-radiographic base line is at angle of negative 30 degrees
to film
• Central ray-directed midsagittal plane at the level of
mandible and perpendicular to film

19. Forehead –nose
position
Exposure Parameters Using Extra Oral
Machine
kVp – 70-80
mA – 60-50
Seconds – 1.6 (Bucky Grid)

20. Towne’s view/anteroposterior view
• Observe occipital area of skull
• Neck of condylar process
• Film position-cassette perpendicular to floor, long
axis-vertically
• Position of patient- A-P view with the back of patients
head touching film. canthomeatal line perpendicular
to film
• Central ray-30 degree to canthomeatal line & passes it
at a point b/n external auditory canals
Exposure Parameters Using Extra Oral Machine
kVp – 70-80
mA – 60-50
Seconds – 1.6 (Bucky Grid)

21. Observe occipital area of skull
Neck of condylar process
Towne’s view/anteroposterior view

22. Structures Shown
A full axial view of the base of the cranium showing
a symmetrical projection of the petrosa, the mastoid
process, foramen ovale, spinosum canals, carotid
canals, sphenoidal sinuses, mandible, maxillary
sinus,
nasal septum, odontoid process of the atlas and the
entire atlas, axial inclination of the
mandibular
condyles.
Helps to study destructive/expansile lesions
affecting the palate, pterygoid region or base of the
skull, sphenoidal sinus.
Submentovertex projection
the radiographic base line is
parallel to the film,
and the X-ray is perpendicular to
the film
Film Placement
The cassette is placed perpendicular to the floor in a
cassette holding device. The long-axis of the cassette
is placed vertically.
Submentovertex Projection

23. Position of Patient
The head is centered on the cassette, with the
patient’s head and neck tipped back as far as possible,
the vertex (top) of the skull touches the cassette. Both
the midsagittal plane should be perpendicular to the
plane of the film and the radiographic base line should
be parallel to the film.
Central Ray
Is directed perpendicular to the film and through
the midsagittal plane, between the angles of the
mandible, perpendicular to an imaginary line joining
the mandibular 1st molars (approximately 1 inch from
the chin).
In order to view the petrous portion, the central
ray is directed at right angles (or 5° to the horizontal)
to the film midway between the external auditory
Exposure Parameters
kVp – 50 mA – 20-30 Seconds – 0.4

24. Zygomatic arch
Lateral wall of the
orbit
Anterior arch of
the atlas
Shenoidal air
sinus
condyle
Upper & lower
teeth
suprrimposed
Occipital condyle
Foramen megnum
Mastoid air sinus
Shadow of the
spine

25. Panoramic Projection
it provides an overall view of the teeth and jaws, provides a
means of comparing left and right sides of the mandible
Gross osseous changes in the condyles may be identifi ed,
such as asymmetries, extensive erosions, large osteophytes,
tumors or fractures
No information about condylar position or function
is provided because the mandible is partly opened and
protruded
when this radiograph is exposed.
Exposure Parameters
kVp – 76
mA–15
Seconds – 15

26. Panoramic images that
revealed right
condylar hyperplasia (A)
and destruction of the
condyle by a malignant
tumor (B) (arrows).

27. Computed Tomography (CT)
• Three-dimensional shape and internal structure of the
osseous components
• Surrounding soft tissue
• Both axial & coronal images
• Reformat images in sagittal plane
• Not diagnostic for disk
Indications
• Extent of ankylosis
• neoplasms-bone involvement
• Complex fractures
• Heterotopic bone growth

28. Regional Cone-Beam Imaging. A, Corrected coronal and, B, sagittal images
of a right
TMJ with erosive defects on the superior surface of the condyle associated with active
mild degenerative
joint disease.

29. MAGNETIC RESONSNCE IMAGING (MRI)
• Magnetic field and radiofrequency pulses
• Tissue with greater water content emit a higher
signal
• Bilateral dual surface coils- 0.5 to 2 tesla-
Improve image resolution
Oblique sagittal/oblique coronal scans with t1, t2
Closed mouth, partially open and fully open
positions

30. • images in the sagittal and coronal planes without
repositioning the patient
• T1-weighted images best –osseous & diskal
tissues
• T2-weighted images-inflammation and joint
effusion.
• Motion MRI studies-during opening and closing
the patient open in a series of stepped distances
and using rapid image acquisition. ("fast scan ")

31. MRI of a normal TMJ.
A, Closed view showing the condyle and temporal component. The
biconcave disk is located with its posterior band (arrow) over the
condyle.
B. Coronal image showing the osseous components and disk
(arrows) superior to the condyle.

32. • Advantages of CT • Advantages of MRI
• Direct delineation of bony
structures-surgical anatomy
• Reconstruction in all planes
• Some soft tissues-lateral
pterygoid muscle
• 3-D images from any angle
• Disadvantages-
-high radiation exposure
-soft tissues cant be
appreciated
• Soft tissues-esp disk
and its association
• Information in short
acquisition time
• Disadvatages-
-expensive
-claustophobia
MRI is contraindicated in pregnant patient or who
have pacemakers,
intracranial vascular clips, or metal particles in vital structures.
Claustrophobic patient or an inability to remain
motionless.

33. WHAT ARE THE SIGNS AND SYMPTOMS OF
TMD?
Pain, discomfort and tenderness of the jaw joint and surrounding muscles
Radiating pain in the face, jaw, or neck,
jaw muscle stiffness,
Reduced mouth opening
painful clicking, popping or grating in the jaw joint when opening or
closing the mouth,
A change in the way the upper and lower teeth fit together.
Locking of the jaw on opening
Neck ache, headeche, dizziness, Sleep disturbance

34. I - Muscular Diagnoses
a - myofascial pain
b - myofascial pain with limited opening
II - Disk Displacement
a - disk displacement with reduction
b - disk displacement without reduction and with limited opening
c - disk displacement without reduction and without limited opening
III - Arthralgia, osteoarthritis and osteoarthrosis
a - arthralgia
b - temporomandibular joint (TMJ) osteoarthritis
c - temporomandibular joint (TMJ) osteoarthrosis
Categories of clinical TMD conditions according to the
RDC/TMD.

35. Disorders of the
Temporomandibular Joint
1- Developmental Abnormalities
2- Soft Tissue Abnormalities

36. Developmental Abnormalities:
1- Condylar Hyperplasia
2- Condylar Hypoplasia
3- Juvenile Arthrosis
4- Coronoid Hyperplasia
5- Bifid Condyle

37. 1- Condylar Hyperplasia:
- Enlargement and deformity of the
condylar head
- Secondary effect on the mandibular
fossa as it remodels to accommodate
the abnormal condyle
Etiology: Trauma, infection,
hereditary
• More common in males
• Self limiting
• Progresses slowly or rapidly
• Mandibular asymmetry
• Chin deviated to the unaffected side
or it may remain unchanged but
with an increase in vertical
dimention of ramus, mandibular
body,alveolar process of the affected
side
Asymmetry of mandible in PA
skull view

38. • Radiographic Features:
• May appear normal but
symmetrically enlarged
• Maybe more radiopaque due
to additional bone present
• Condylar neck may be
elongated
• Glenoid fossa may also be
enlarged
• Ramus and mandibular body
on the affected side also may
be enlarged, resulting in a
characteristic depression of
the inferior mandibular
border
• The affected ramus may have
increased vertical depth and
may be thicker in the
anteroposterior dimension
Panaromic image: hyperplasia of right
condyle

39. • Failure of the condyle to attain normal size because of
congenital and developmental abnormalities or acquired
diseases that affect condylar growth.
• The condyle is small, but condylar morphology is normal
• Underdeveloped ramus and occasionally mandibular body
• Unilateral or bilateral
2- Condylar Hypoplasia
Hypoplasia of
left condyle

40. • Radiographic Features:
• The condylar neck and coronoid process usually
are very slender and are shortened or elongated
in some cases

41. 3- Juvenile Arthrosis:
• Manifests as hypoplasia and characteristic
morphologic abnormalities
• May be a form of condylar hypoplasia
• It affects children and adolescents during the of
mandibular growth
• More common in females
• Incidental finding in a panoramic projection

42. • Radiographic appearance:
• Condylar head develops a characteristic
“toadstool” appearance
• Condylar neck is shortened or even absent in
some cases

43. 4- Coronoid Hyperplasia:
• - acquired or developmental
• - elongation of the coronoid process
• - developmental -> bilateral
• acquired -> uni or bilateral
• - inability to open mouth
• - painless

44. • Radiographic features:
• Best seen in panoramic,
Waters, and lateral
tomographic views and on
CT scans
• TMJs usually appear
normal

45. 5- Bifid Condyle:
• Vertical depression,
notch, or deep cleft
in the center of the condylar head
• Rare, often unilateral
• Incidental finding
• Some patients may have sings of TMDs (noises +
pain)
• Radiographic Features:
• Depression on the superior condylar surface giving a
heart shape

46. Condylar agenesis
• The absence of all or portions
of condylar process, coronoid
process, ramus or mandible
• other first and second arch
anomalies seen
• early treatment maximizes
condylar growth
• A costocondral graft may help
with facial development
Panoramic view and CT Scan
show absence of left condylar
head.

47. Soft Tissue Abnormalities
Internal Derangements – TMJ in which there displacement
of the disc from its normal functional relationship with the
mandibular condyle and the articular portion of the temporal
bone. abnormality in the articular disc and may interfere
with normal function
• - Cause is unknown
• - Internal derangements can be diagnosed by MRI
• Clinical Features:
• - found in both symptomatic and healthy pts
• - symptomatic pts may have a decreased range of
mandibular motion
• -displacements may be unilateral or bilateral

49. • Radiographic Features:
• - MRI is the technique of choice
• Disc Displacement:
• - Anterior displacement is most common
• - The articular disc is located anterior to the condylar
head
• Disk reduction and nonreduction:
• - reduction is when an anteriorly displaced disk may
reduce to a normal relationship with the condylar head
during any part of the mouth opening movement
• - nonreduction is when the disk remains anteriorly
displaced and will undergo permanent deformation.

50. A 3D graphic lateral view
of the TMJ with the
capsule partially removed
depicts the normal
position of the articular
disc between the articular
eminence (AE)
the mandibular condyle
(C)
a thicker anterior band
(AB)
posterior band (PB)
separated by a thinner
intermediate zone (IZ).
The bilaminar zone (BZ)
and the superior (SLP)
and inferior (ILP) bellies
of the lateral pterygoid
muscle are also indicated.

51. STAGE CLINICAL RADIOGRAPHIC
1 EARLY Painless clicking; no limitation
of opening
Mild disk displacement with
early reduction; normal disk
morphology
2
EARLY/INTERMEDI
ATE
Occasional painful clicking,
intermittent locking
Mild to moderate disk
displacement with late
reduction, mild disk
deformity
INTERMEDIATE Joint tenderness ,limited mouth
opening, frequent pain
Displaced, non reducing disk
INTERMEDIATE/LA
TE
Chronic pain,limited opening Severe displacement without
reduction, degenerative
osseous change
LATE Variable joint pain, joint
crepitus
Non reduction of disk with
perforation of disk
attachment or disk
degenerative osseous changes.
Wilkes classification of internal derangement of TMJ

56. • perforations between the superior and inferior joint spaces
most commonly occur in the retrodiskal tissue, just behind
the posterior band of the disk
• Not detected with MRI
Perforation and Deformities:
Fibrous Adhesions and Effusion:
- Fibrous adhesions are masses of fibrous or scarred tissue
that form in the joint space, particularly after TMJ surgery
- Joint Effusion means fluid in the joint and is considered to
be and early change that may precede degenerative joint
disease
- Both can be detected by MRI

57. Remodeling and Arthritic condition
• Remodeling:
• - Adaptive response of cartilage and osseous tissue
to forces applied to the joint that maybe excessive,
resulting in alteration of the shape of the condyle
and articular eminence
• - no destruction or degeneration of articular soft
tissue occurs
• - occurs throughout adult life
• - considered abnormal only if it is accompanied by
clinical signs and symptoms of pain or dysfunction

58. • - Radiographic Features:
• - flattening
• - cortical thickening of articulating surfaces
• - subchondral sclerosis
A- The right temporal component shows subchondral sclerosis and flattening (arrow)
B- The right condyle shows mild flattening of the lateral aspect and subchondral
sclerosis of the medial aspect (arrow)
C- Cadaver specimen. Note the flattening of the temporal component (black arrows) and
large perforation posterior to a residual deformed disk (white arrow)

59. • 2- Degenerative joint disease
(osteoarthritis):
• - non inflammatory disorder of the joints
characterized by joint deterioration and
proliferation
• - can occur at any age (increases with age)
• - female predominance
• - asymptomatic or pts may complain of signs +
symptoms of TMJ dysfunction
• - Radiographic features:
• - more accurately seen in CT but gross osseous
changes maybe evident in MRI studies
• At the maximum intercuspation joint space
may be narrow or absent
• Loss of cortex or erosions of the articulating
surfaces of the condyle or temporal component
are characteristics of this disease
Deterioration: characterized by loss of articular cartilage and bone erosion
Proliferation: proliferative component is characterized by new bone formation at the
articular surface and in the subchondral region
ELY cyst: small round radiolucent
area with irregular margins
surrounded by broad zone 0f
sclerosis

60. Bilateral destruction of condyles
anterior open bite
Chin appears receded
• 3- Rheumatoid Arthritis:
• - Synovial membrane inflammation
• Female with increase age
• - Patients with TMJ involvement complain
of swelling, pain, tenderness, stiffness on
opening, limited range or motion, and
crepitus
• - Radiographic Features:
• - Osteopenia (decreased density) of the
condyle and temporal component
• The pannus may destroy the disk, resulting
in diminished width of the joint space.
• Bone erosions by the pannus most often
involve the articular eminence and the
anterior aspect of the condylar head, which
permits anterosuperior positioning of the
condyle when the teeth are in maximal
intercuspation and results in an anterior
open bite.
• Erosion of the anterior and posterior
condylar surfaces at the attachment of the
synovial lining may result in a “ sharpened
pencil ” appearance of the condyle. Erosive
changes may be so severe that the entire
condylar head is destroyed.
Result of synovitis which lead to
formation of synovial
granulomatous tissu(pannus) that
grows into fibrocartilage & bone
reliasing enzymes that destroy
articular surface & underlying bone

61. 4- Juvenile Arthritis:
• - Inflammatory disease that is characterized by
chronic, intermittent synovial inflammation
results in: synovial hypertrophy, joint effusion, and
swollen, painful joints
• Before the age of 16 years (mean age 5 years)
• -pain and tenderness of affected joint or joints
• - can be asymptomatic
• - unilateral is common
• - facial appearance known as “bird face”
• - possible mandibular asymmetry if one side is more
severely affected with chin deviated toward affected
side

62. • Radiographic features:
• - Osteopenia (decreased density) maybe only an
initial radiographic finding
• - Impaired mandibular growth
• - Severe cases: only pencil shaped small condyle
remains
• - Abnormal disk shape is often observed in
patients with TMJ involvement

63. Trauma
1- Effusion:
- Influx of fluid into the joint as a result of trauma
(hemorrhage or inflammation)
- Swelling over affected joint
• Pain in TMJ, preauricular region, and limited
range of motion
• Radiographic Features:
- Commonly seen in conjunction with internal
derangements
- Joint space is widened

64. 2- Dislocation:
- Abnormal positioning of the condyle out of the
mandibular fossa but within the joint capsule
- Unable to close mandible to maximal
intercuspation
* Radiographic Features:
- In bilateral cases, both condyles are located
anterior and superior to summits of articular
eminentia

65. 3- Fracture:
- Usually occur at condylar neck and often are
accompanied by dislocation of the condylar head
- Unilateral fractures more common
- May be accompanied by parasymphyseal or
mandibular body fracture on contralateral side
- Swelling over TMJ
- Limited range of motion

66. • Radiographic features:
- Radiolucent line limited
to the outline of the neck
is visible
- If bone fragments
overlap, an area of
increase in radiopacity
may be seen
- Town’s view panorama is
taken to view fractures

67. 4- Neonatal Fracture:
- Use of forceps during delivery of neonates may
result in fracture and displacement of the
rudimentary condyle
- Severe mandibular hypoplasia
comminuted displaced left subcondylar
neck fracture

68. 5- Ankylosis:
- Condition in which condylar movement
is limited by a mechanical problem in
the joint or by a cause not related to
joint components
- Restricted jaw opening or limited jaw
opening
* Radiographic Features:
- In fibrous ankylosis articulating
surfaces are usually irregular because of
erosions
- In bony ankylosis joint space may be
partly or completely obliterated by the
osseous bridge
- Coronal CT images are the best
to evaluate ankylosis
Bony ankylosis (CT coronal
image slice) right condyle and
ramus are markedly enlarged.
Articular surface irregular and
central and lateral aspect fused
to the roof of glenoid fossa,
lack of joint space

69. 1- Benign Tumors:
- Osteoma, osteochondroma, Langerhans histocytosis
and osteoblastomas
- Chondroblastomas, fibromyxomas, benign giant cell
lesions and anneurysmal bone cysts also occur
- Benign tumors and cysts of the mandible
(ameloblastoma, OKC) may involve the entire ramus
and condyle
- Grow slowly
- TMJ swelling
- Pain and decrease in range of motion
- Tumors of coronoid process are painless but may
complain of progressive limitation of motion

70. Radiographic Features:
- Condylar tumors  condylar
enlargement with irregular
outline
- Osteoma and osteochondroma
appear as abnormal,
pedunculated mass attached to
the condyle
Axial bone algorithm. CT image of an
osteochondroma extending from the
anterior surface of the left condylar head
(arrow)

71. 2- Malignant Tumors:
A- Primary (rare): - Intrinsic
- Extrinsic
Intrinsic: Chondrosarcoma
Osteogenic sarcoma
Synovial sarcoma
Fibrosarcoma
Extrinsic: Direct extension of adjacent parotid
salivary gland malignancies
rhabdomyosarcoma

72. 1- chondrosarcoma (CT axial section bone algorithm) radiolucent destructive lesion
present in the left condylar head and faint radiopacities (soft tissue calcifications) are
visible anterior to the condylar head (arrows)
2- Axial soft tissue algorithm CT image of a metastatic lesion from a carcinoma of the
thyroid gland that has destroyed all of the left mandibular condyle.

73. TMJ ARTHROGRAPHY
Indications:
Position and function of disk -pain and
dysfunction-long standing
History of locking-persistent
Perforations of the disk and retrodiskal
tissue.
Joint dynamics
Disc displacement-ant/anteromedial

74. Contraindications:
Infections in the preauricular region.
Patients allergic to contrast media.
Patients with bleeding disorders and on anticoagulant therapy
Therapeutic :
Diagnostic aspiration of joint fluid.
Intraarticular injections of steroids

75. Techniques
Single contrast – lower compartment arthrography
is most commonly done
Double contrast – contrast medium into the lower
compartment and injection of air into the upper
compartment.

76. STEPS
• Contrast media – non ionic agents such as iopamidol-
370,iodohexol-350
• Fluoroscopy aids in accurate positioning of needle
• Primary record-video-allows imaging of joint compartments as
they move
• Only lateral parts seen
• Medial aspect of joint-thin section multidirectional hypocycloidal
tomography
• 5-6 slides ,2-3 mm apart, patient mouth open and closed
• If further info-contrast –upper joint space-repeat investigation

77. ARTHROSCOPY
Contraindications
Absolute
Bony ankylosis.
Advanced resorption of the glenoid fossa.
Infection around the joint area.
Malignant tumors.
Relative
Patients at increased risk of hemorrhage.
Patients at increased risk for infection.

78. References
• White & Pharoah(6th Edition)
• Eric Whaites( 3rd Edition)
• Karjodkar (2nd Edition)
• Grey`s Anatomy (38th Edition)
• Anatomy Of Head & Neck By B.D Chaursia
• Textook Of Oral & Maxillofacial Surgery By Neelima
Malik.

79. THANK YOU