TEMPOROMANDIBULAR JOINT IMAGING PPT

1. Imaging Of
Temporomandibular Joint
MODERATOR
DR.AMIT VERMA
ASSISTANT PROFESSOR
PRESENTER
DR.NABA KUMAR
JR 2

2. Introduction to TMJ
Imaging Modalities of TMJ
1. Imaging of osseous structures
2. Imaging of soft tissues
Abnormal Findings in TMJ
Contents

3. TMJ is a ginglymo-diarthroidal joint
that is freely mobile with superior and
inferior joint spaces separated by
articular disc.
“Ginglymus” meaning a hinge joint,
allowing motion only backward and
forward in one plane, and
“Arthrodia” meaning a joint of which
permits a gliding motion of the
surfaces
INTRODUCTION

4. Components of TMJ
Drawing illustrates the anatomy of the TMJ

5. Ligaments :
1-collateral(discal)
2-capsular
3-temporomandibular
4-sphenomandibular
5-stylomandibular

6. Diagnostic Imaging Of TMJ
The type of imaging technique depends upon the clinical problems
associated, so either imaging of hard tissue (OSSEOUS) or soft
tissue is desired.
TMJ Imaging
Osseous Structure Soft tissue structure
Plain film radiography Arthrography
Panoramic Radiograph MRI
USG
CT
CBCT

7. 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
Central Ray
1. The central ray is direct at an angle of 25degree (+ve
angulation)from the opposite side, through the cranium and
above the petrous ridge of the temporal bone.
2. The horizontal angulation can be individually corrected for
the condylar long axis, or an average 20 degree anterior angle
may be used.

8. 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 ipsi-lateral petrous
ridge over the condylar neck
Transcranial projections of the left TMJ.
Degree of translatory movement
between the closed view (A) and the open
view(B)

9. Computed Tomography (CT)
Indicated to assess:
• 3D-shape
• internal structure of the bones and joint
• surrounding soft tissue
Axial and coronal planes,
Coronal images are more useful.
Three dimensional reformatted images
CT cannot produce accurate images of the articular disk.

10. Indications:
• Extent of ankylosis
• Neoplasms-bone involvement
• Complex fractures
• Complications -polytetrafluoroethylene or
silicon sheet implants
Erosions into the middle cranial fossa
• Heterotopic bone growth

11. Soft tissue imaging indication
TMJ pain and dysfunction
clinical findings suggest disk displacement
unresponsive to conservative therapy
Imaging should be prescribed only when the anticipated results are expected to
influence the treatment plan.
The imaging modalities for soft tissues are:
1. Arthrography
2. Magnetic Resonance Imaging (MRI)
3.USG

12. Arthrography
Indirect image of the disk is obtained by injecting a radiopaque contrast agent into the joint
spaces under fluoroscopic guidance.
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

13. MRI has replaced Arthrography in todays context and is
now the imaging technique of choice for soft tissues
Contraindications:
Infections in the preauricular region.
Patients allergic to contrast media.
Patients with bleeding disorders
Anticoagulant therapy

14. ULTRASONOGRAPHY
Ultrasonography was described to be an alternative method in the imaging of the
TMJ by Stefanoff et al. (1992).
High resolution ultrasonography was used to show satisfying results in further
studies by Emshoff et al. (2002) and Jank et al. (2002)
Noninvasive and inexpensive
Disc displacement and joint effusion
Scarce accessibility of the medial part of the
TMJ structures
Need for trained and calibrated operators
Advantages
Disadvant
ages

16. MRI Technique
• Small surface coil and small FOV
• Axial scout images of 4-5 mm thickness
• T1W sagittal imaging – basic anatomy and disc position well seen; however, disc is
not well evaluated as it is of low signal intensity, especially in closed mouth position
• T2W sagittal imaging – disc morphology and movement well seen, joint effusion
detected
• T2W oblique imaging – preferred over sagittal imaging
• Gradient echo imaging – also shows disc morphology well
• Coronal imaging – very important, anterior displacement often associated with lateral
or medial displacement

17. Newer techniques
• Dynamic MR imaging – gradient echo sequences, device
which opens mouth incrementally; however, altered
biomechanics as movement is not voluntary
• Cine-looped MR imaging – especially to diagnose ‘stuck
disc’
• 3D volume acquisition – faster patient throughput
• Contrast enhanced MRI
• MR arthrography

18. Protocol used in magnetic resonance imaging of the
temporomandibular joint

19. Sagittal oblique gradient-echo T2-
weighted MR image (closed-mouth position)
Sagittal oblique gradient-echo T2-
weighted MR image (open-mouth position)

20. DISEASE OF TEMPOROMANDIBULAR
JOINT

21. What do we need to tell the clinicians?
1. Shape of the disc
2. Position of disc in open and closed mouth views
3. Reduction, if the disc is dislocated
4. Joint effusion
5. Shape and signal of mandibular condylar head
6. Cortical structure of mandibular fossa
7. Any other pathology

22. What options would the clinician consider?
1. Medical treatment – anti-inflammatory
drugs, behavior modification, bite plates
2. OPD procedures – Cortisone injection, TMJ
wash
3. Surgery – disc replacement and
repositioning

23. Internal Derangement
General orthopedic term implying a mechanical fault that interferes with
the smooth action of a joint
Clinical Features:
Clicking sounds from joint(s)
Restricted or normal mouth opening capacity
Deviation on opening
Pain
Causes:
Most common is myofascial pain dysfunction syndrome
Others – trauma, bruxism, malocclusion, etc.

24. Imaging Features
Anterior disc displacement: posterior band of the disc located anterior to the
superior portion of the condyle at closed mouth on oblique sagittal images
 Disc may have normal (biconcave) or deformed morphology (biplanar, hemiconvex,
biconvex or folded)
 In opened mouth position disc may be in a normal position (“with reduction”) or
continue to be displaced (“without reduction”)
Stuck disc is when the disc remains fixed in normal on displaced position
Disc perforation is very difficult to diagnose on conventional MRI

27. Anterior disk displacement with reduction

28. Anterior disk displacement without reduction

29. Stuck disk.

30. Posterior disk displacement.

31. Stage MR features
I Anterior displacement, normal disk morphology, reduces
with opening
II Disk displacement and deformity, reduces with opening ±
signal changes in disk ± effusions
III Disk displacement and deformity, no reduction with opening
± effusion
IV Severe disk deformity and displacement, no reduction with
opening, effusion, osseus changes
V Severe deformity and no reduction, perforation at
attachment, progressive osseus deformity (AVN,
osteochondritis, sclerosis)
Schellas’ Classsification

32. Degenerative Joint Disease
Term used for the secondary bony changes as a result of long term or severe internal
derangement of TMJ
Flattened condyle
Osteoporosis of the condylar bone
Thickening of the fibrous covering of the condyle
Thinning of the cartilagenous zone of condyle
Thinning of the disc
Fibrotic synovial folds
Decrease the number of nerve endings

34. Anteriorly displaced and deformed, degenerated disc
and irregular cortical outline with osteophytosis and
sclerosis of condyle

35. Advanced osteoarthritis and anterior disc displacement, with
joint effusion

36. Rhematoid Arthritis
• May affect the TMJ, especially in children (JRA).
• Inflammation of synovial membrane characterized by edema, cellular accumulation, and
synovial proliferation (villous formation).
Clinical Features
• Swelling of joint area, not frequently seen in TMJ
• Pain (in active disease) from joints
• Restricted mouth opening capacity
• Morning stiffness, in particular stiff neck
• Dental occlusion problems; “my bite doesn’t fit”

37. Completely destroyed disc, replaced by fibrous or vascular pannus and
cortical punched-out erosion (arrow) with sclerosis in condyle

38. Calcium pyrophosphate dehydrate deposition disease
CT- calcium deposition in the disk or
periarticular tissue.
MRI- hypointense both on T1 and
T2 weighted sequences.
Erosions near both the condyle and fossa with
adjacent CPPD deposits.
Involvement of other joints with
chondrocalcinosis is a clue to the diagnosis.
D/D- synovial chondromatosis,
synovial osteochondroma
osteosarcoma

39. Psoriatic arthropathy
Oblique coronal and oblique sagittal CT images show
punched-out erosion in lateral part of condyle (arrow).

40. Anomalies of Condylar Head
overgrowth, undergrowth or bifid appearance

41. NormalTMJ
Condylar Hypoplasia
Condylar hypoplasia and
facial asymmetry

42. Bifid condyle

43. 1. Cartilage tumors Osteochondroma
chondroma
Chondroblastoma
Synovial chondromatosis
2. Osteogenic tumors Osteoma
Osteoid osteoma
Ostaoblastoma
3. Giant cell tumors Giant cell tumor
4. Vascular tumors Hemangioma
5. Lipogenic tumors Lipoma
6. Bone-related odontogenic tumors Ossifying fibroma
Soft tissue tumor
1. Fibrohistiocytic tumors Pigmented villonodular synovitis
2. Tumors of uncertain differentiation Juxta-articular myxoma
Benign Tumor of TMJ

44. Synovial Chondromatosis
• Benign tumor characterized by cartilaginous metaplasia of
synovial membrane producing small nodules of cartilage,
which essentially separate from membrane to become
loose bodies that may ossify.

45. Osteochondroma
Slow-growing tumor that cartilage-capped bony projection
Arising from the outside surface of bone containing a marrow cavity that is continuous with
that of the underlying bone appears close to the growth plate
Medial surface of mandibular condyle .
The average age of occurrence is 16.5 yr
M:F-3:1 .

46. Osteoma

47. Malignant Tumors
Osteosarcoma mandible; 18-yearold female

48. Malignant tumor, mandible; 70- year-old male
with metastasis from lung cancer

49. MCQ

50. Disc displacement is Abnormal when angle of displacement is :
A. >10 degree
B. >15 degree
C. >20 degree
D. >30 degree
ANS: A (Journal of Oral and Maxillofacial Radiology2013/Vol1/Issue 3)

51. Most common disc displacement is
A. Anterior
B. Posterior
C. Medial
D. Lateral
ANS: A(Journal of Oral and Maxillofacial Radiology2013/Vol1/Issue 3)

52. • Double disk sign is seen due to
A. ADD( anterior disc displacement) + thickning of retrodiskal tissue
B. ADD + atrophy of retrodiskal tissue.
C. ADD + Thickened inferior LPM
D. ADD + atrophy of inferior LPM.
ANS: C(Journal of Oral and Maxillofacial Radiology2013/Vol1/Issue 3)

53. Bilaminar zone includes:
A. Retrodiskal Layers.
B. Vasculonervous Structures.
C. Both
D. None Of These.
ANS: C(Journal of Oral and Maxillofacial Radiology2013/Vol1/Issue 3)

54. Sagittal reformatted computed
tomography
image through the
temporomandibular joint
demonstrates a focal defect
(arrow)
in the tympanic plate.
Diagnosis?
A.EPITYMPANUM
B.TEGMAN TYMPANI
C.FORAMEN OF HUSCHKE
D.STYLOMASTOID FORAMEN
World J Radiol 2014 August 28; 6(8): 567-582
ISSN 1949-8470 (online)
© 2014 Baishideng Publishing Group Inc. All rights reserved

55. A 45 year-old female presents with a history of chronic ear pain and headaches. She
recently experienced an episode of locking of her jaw. Oblique sagittal proton
density-weighted images were obtained through the right temporomandibular joint
in both the closed (1a) and open (1b) mouth positions. What are the findings? What
is your diagnosis
Oblique sagittal proton density-weighted images were obtained through the right
temporomandibular joint in both the closed (1a) and open (1b) mouth positions.
A) .ANT DISC
DISPLACEMENT
B).POST DISC
DISPLACEMENT
C).ANT DISC
DISPLACEMENT WITH
REDUCTION
D).ANTERIOR
DISPLACEMENT OF THE
ARTICULAR DISC
WITHOUT REDUCTION

56. Diagnosis is
Internal derangement of the right temporomandibular joint with
anterior displacement of the articular disc without reduction.
MRI Web Clinic — December 2012
Internal Derangement of the Temporomandibular Joint
William N. Snearly, M.D.
Reference

57. Sagittal reformation of the axial dataset
demonstrates extensive cloud-like calcification
(arrows) filling and expanding
the joint space anterior to the mandibular
condyle . Calcification is
also present posterior to the mandibular
condyle.Diagnosis?
A.chondrocalcinosis,
B.osteoarthritis,
C.chondrosarcoma.
D.Synovial chondromatosis
World J Radiol 2014 August 28; 6(8): 567-582
ISSN 1949-8470 (online)
© 2014 Baishideng Publishing Group Inc. All rights reserved

58. A 57 yr female with chronic jaw pain, popping, and clicking.
Oblique sagittal fat suppressed proton density-weighted
image in the open mouth position of the right TMJ is shown
The condylar head is slightly deformed with
small anterior osteophytes (arrowhead). High
signal of the intermediate zone of the articular
disc is seen (arrow).Diagnosis?
A STUCK DISC
B.DEGENERATIVE DISC
C.OSTEOCHONDRITIS DESSICANS
D.DISC PERFORATION

59. Right mandibular parasymphyseal/ body minimally displaced fracture
and bilateral moderately displaced comminuted fractures of mandibular
condyles.
A 40 yr old male hit face
On ground ,his ct coronal image
Is shown .Diagnosis?

60. A guardsman fracture, also referred to as parade ground fracture, is
one of the common forms of mandibular fracture which is caused by a fall
on the midpoint of the chin resulting in fracture of the symphysis as well
as both condyles.
It is usually seen in epileptics, elderly patients and occasionally in soldiers
(fall forwards due to syncope) and is known as guardsman fracture.
(Journal of Oral and Maxillofacial Radiology2013/Vol1/Issue 3)Ref:

61. Thank you