Radiographic imaging of TMJ


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Radiographic imaging of TMJ. Dia

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  • But is thought to differ in that the affected condyle at one time was normal, becoming abnormal during growth.
  • Heart shape: anteroposterior silhouette
  • Disc is most often displaced in an anterior direction, but maybe be displaced anetromedially, medially, or anterolaterally. (lateral and posterior RARE)
  • A- position and movement of the disk during jaw opening B- mildly displaced anteriorly with reductionC- Severely displaced anteriorly without reduction
  • Reduction: appear normal in MRINonreduction: false interpretation because of the fibrotic changes on the bilaminar zone
  • Fibrous adhesions: Low signal intensityAdhesion: High signal intensity
  • 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)
  • 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* Signs and sympts: pain on palpation + movement, joint noises (crepitus), limited range of motion and muscle spasm
  • Bilateral destruction of condyles I \\/anterior open biteChin appears receded
  • 2- TMJ involvement occurs in approximately 40% of pts. Unilateral or bilateral 6- Contralateral involvement may occur as the disease progresses 7- Because pts have micrognathic + posteroinferior chin rotation
  • During quiescent periods the cortex of joint surface may appear, and the surfaces will be flattened
  • Coronal reformat CT image of a case of septic arthritis involving the right joint. Note the erosions, sclerosis and periosteal reaction that extends along the back of the condyle and lateral neck of the condyle
  • Cropped panoramic image of a right joint involved with osteochondramatosis
  • CT axial image bone algorithm. Note the calcifications anterior to the right condyle and large erosions involving the medial pole of the condyle.
  • Right condyle and ramus are markedly enlarged
  • Most common benign tumor osteochondroma
  • Axial bone algorithm. CT image of an osteochondroma extending from the anterior surface of the left condylar head (arrow)
  • 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.
  • Unfortunately some patients are treated occasionally for temporomandibular joint dysfunction without recognition that the underlying condition is a malignancy
  • Radiographic imaging of TMJ

    1. 1. Diagnostic Imaging of theTemporomandibular Joint Fares H. Hanafieh & Fahad F. Salehi
    2. 2.  What is the Temporomandibular joint? Unique in that it constitutes of two separate joints anatomically and they function together as a single unit Consists of: Condyles Articular Disc Mandibular Fossa Has a fibrous capsule that surrounds and encloses the joint
    3. 3.  CONDYLE:- Shape of condyle varies considerably- Superior aspect maybe flattened, rounded or markedly convex- Mediolateral contour is usually slightly convex- Variations in shape may cause difficulty with radiographic interpretation- Extreme aspects of the condyle are the medial pole and lateral pole
    4. 4.  MANDIBULAR FOSSA: Composed of the glenoid fossa and atricular eminence. INTERARTICULAR DISK: - Between condylar head and mandibular fossa - Biconcave shape
    5. 5. Disorders of the temporomandibular joint areabnormalities that interfere with the normal form or function of the joint
    6. 6. Disorders of the Temporomandibular Joint1- Developmental Abnormalities2- Soft Tissue Abnormalities
    7. 7.  Developmental Abnormalities:1- Condylar Hyperplasia2- Condylar Hypoplasia3- Juvenile Arthrosis4- Coronoid Hyperplasia5- Bifid Condyle
    8. 8. 1- Condylar Hyperplasia: - Enlargement and deformity of the condylar head - Secondary effect on the mandibular fossa as it remodels toaccommodate the abnormal condyle Etiology: Trauma, infection, hereditary More common in males Self limiting Progresses slowly or rapidly Mandibular asymmetry Chin deviated to the affected side
    9. 9.  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 D/D: - Osteochondroma - Condylar osteoma or osteophyte that occurs in chronic degenerative joint disease
    10. 10.  Treatment: Orthodontics combined with orthognathic surgery
    11. 11.  2- Condylar Hypoplasia 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
    12. 12.  Radiographic Features: The condylar neck and coronoid process usually are very slender and are shortened or elongated in some cases The ramus and mandibular body on the affected side may also be small, resulting in a mandibular asymmetry and occasional dental crowding, depending on the severity of mandibular underdevelopment D/D: Juvenile rheumatoid arthritis and arthritic conditions Treatment: orthognathic surgery bone grafts orthodontic therapy maybe required
    13. 13.  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
    14. 14.  Radiographic appearance: Condylar head develops a characteristic “toadstool” appearance Condylar neck is shortened or even absent in some cases D/D: developmental hypoplasia rheumatoid arthritis* Treatment: orthrognathic surgery orthodontic therapy
    15. 15.  4- Coronoid Hyperplasia: - acquired or developmental - elongation of the coronoid process - developmental -> bilateral acquired -> uni or bilateral - inability to open mouth - painless
    16. 16.  - Radiographic features: Best seen in panoramic, Waters, and lateral tomographic views and on CT scans TMJs usually appear normal -D/D: Unilateral cases should be differentiated from a tumor of the coronoid process (osteochondroma or osteoma) Unlike coronoid hyperplasia, tumors have an irregular shape -Treatment: surgical removal or the coronoid process and postoperative physiotherapy
    17. 17.  5- Bifid Condyle: Vertical depression, notch, or deep cleftin 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
    18. 18.  D/D: Vertical fracture through the condylar head Treatment: Not indicated unless pain or functional impairment is present
    19. 19. Soft Tissue Abnormalities Internal Derangements - 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
    20. 20.  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.
    21. 21.  Perforation and Deformities: - perforations between the superior and inferior joint spaces most commonly occur in the retrodiskal tissue, just behind the posterior band of the disk - Not reliably detected with MRI 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
    22. 22. Remodeling and Arthritic conditions 1- 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
    23. 23.  - Radiographic Features: - flattening - cortical thickening of articulating surfaces - subchondral sclerosis -D/D: flattening and subchondral sclerosis maybe difficult to differentiate from early degenerative joint disease - Treatment: - Only indicated when signs and symptoms are present. (ex. Splint therapy)
    24. 24.  2- Degenerative joint disease (osteoarthritis): - non inflammatory disorder of the joints characterized by joint deterioration and proliferation - can occur at any age (incidence 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
    25. 25.  D/D: - Erosive appearance  inflammatory arthritides (rheumatoid arthritis) - Proliferative appearance with extensive osteophyte formation  benign tumor  osteoma or osteochondroma Treatment: - Relieving joint stress (e.g. Splint therapy) - relieving secondary inflammation with anti-inflammatory drugs - Increasing joint mobility and function  physiotherapy
    26. 26.  3- Rheumatoid Arthritis: - Synovial membrane inflammation - 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 - erosion of anterior and posterior condylar surfaces if erosion is severe  condylar head is destroyed
    27. 27.  D/D: severe DJD and psoriatic arthritis and osteopenia Treatment: - pain relief (analgesics) - anti inflammatory drugs - physiotherapy - surgery (joint replacement)
    28. 28.  4- Juvenile Arthritis: - Inflammatory disease that is characterized by chronic, intermittent synovial inflammation - results in: synovial hypertrophy, joint effusion, and swollen, painful joints -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
    29. 29.  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
    30. 30. Psoriatic Arthritis and Akylosing SpondylitisSeptic Arthritis: Infection and inflammation of a joint that can result in jointdestruction- Affects any age- No sex predilection- Occurs unilaterally- Redness and swelling over joint- Trismus- Severe pain on opening- Inability to occlude the teeth- Large, tender cervical lymph nodes- Fever and malaise
    31. 31.  Radiographic Features:- No radiographic signs may be present in early stages of the disease- Osteopenic (radiolucent) changes of the joint components and mandibular ramus may be evident (7-10 days after onset of clinical symptoms)- Osseous ankylosis may occur after infection subsides
    32. 32.  D/D: radiographic changes caused by septic arthritis may mimic those of severe DJD or RA Treatment:- Antimicrobial therapy- Drainage of effusion and joint rest- Physiotherapy
    33. 33. Articular Loose Bodies- Radiopacities of varying origin located in the joint synoviom, within the capsule in the joint spaces, or outside in soft tissue1- Synovial Chondromatosis:- Uncommon disorder characterized by metaplastic formation of multiple cartilaginous and osteocartilaginous nodules within connective tissue of the synovial membrane of joint- Asymptomatic- May complain of preauricular swelling, pain, and decreased range of motion- Some patients have crepitus or other joint noises
    34. 34.  Radiographic Features:- Osseous components may appear normal or may exhibit osseous changes similar to those in DJD- Sclerosis of glenoid fossa and condyle may be seen (chronic bone reaction to an active lesion)- MRI may be useful in defining the tissue planes between the synovial chondromatosis and surrounding soft tissue* D/D: DJD with joint mice or chondrosarcoma or osteosarcoma* Treatment: Arthroscopic or open joint surgery  remove loosebodies and resection of abnormal synovial tissue
    35. 35. 2- Chondrocalcinosis:- Characterized by acute or chronic synovitis and precipitation of calcium pyrophosphate dihydrate crystals in the joint space- Most commonly affected joints are knee, wrist, shoulder, and elbow- TMJ involvement uncommon- Unilaterally and more common in males- Asymptomatic or complaints of pain and joint swellings
    36. 36.  Radiographic Features:- May simulate synovial chondromatosis- Bone erosions and severe increase in condylar bone density- Erosions of the glenoid fossa may be present (detected with CT)- Soft tissue swelling and edema of the surrounding muscles may be seen with MRI* D/D: DJD with joint mince or chondrosarcoma or osteosarcoma* Treatment:- Surgical removal of crystalline deposits- Steroids, aspirin, and non steroidal anti inflammatory agents may provide relief
    37. 37. Trauma1- 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
    38. 38.  Radiographic Features:- Commonly seen in conjunction with internal derangements- Joint space is widened* D/D: septic arthritis* Treatment:- Anti-inflammatory drugs- Surgical drainage
    39. 39. 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* Treatment:- Manual manipulation to reduce the dislocation- Surgery in the case of fracture dislocation
    40. 40. 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
    41. 41.  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* D/D: Town’s view panorama is taken to view fractures* Treatment: Reduced surgically
    42. 42. 4- Neonatal Fracture:- Use of forceps during delivery of neonates may result in fracture and displacement of the rudimentary condyle- Severe mandibular hypoplasia* D/D: Developmental hypoplasia* Treatment: Combination of orthodontic andorthognathic surgery
    43. 43. 5- Akylosis:- 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* D/D: Condylar Tumor* Treatment:- Surgical removal of osseous bridge- Creation of pseudoarthrosis
    44. 44. Tumors- Intrinsic or extrinsic- Intrinsic develop in condyle, temporal bone or coronoid process- Extrinsic tumor may affect the morphology, structure and function of the joint without invading the joint itself
    45. 45. 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 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
    46. 46. * Radiographic Features:- Condylar tumors  condylar enlargement with irregular outline- Osteoma and osteochondroma appear as abnormal, pedunculated mass attached to the condyle* D/D: Condylar neoplasms may simulate condylarhyperplasia because of condylar enlargement although itmight be irregular in appearance* Treatment: Surgical excision of tumor and occasionallyexcision of condylar head or coronoid process
    47. 47. 2- Malignant Tumors:A- Primary (rare): - Intrinsic - ExtrinsicIntrinsic: Chondrosarcoma Osteogenic sarcoma Senovial sarcoma FibrosarcomaExtrinsic: Direct extension of adjacent parotid salivary glandmalignancies
    48. 48. B- Metastatic (more common)- May be asymptomatic or patients may have symptoms of TMJ dysfunction (pain, limited mandibular opening, mandibular deviation and swelling)* Radiographic Features:- Variant degree of bone destruction with ill defined, irregular margins- CT modality of choice- MRI useful for displaying extent of involvement into surrounding tissues* D/D: Osseous destruction of bone seen in severe DJD* Treatment:- Wide surgical removal of tumor- May include radiotherapy and chemotherapy
    49. 49. Thank you