Normal Anatomy

The area where carniomandibular articulation occurs is called the

temporomandibular joint (TMJ). The TMJ is certainly one of the most

complex joints in the body. It provides for hinging movement in one

plane and therefore can be considered a ginglymoid joint. However, at

the same time it also provides for gliding movements, which classifies

it as an arthrodial joint. Thus it has been technically considered a

ginglymoarthrodial joint.

The TMJ is formed by the mandibular condyle fitting into the

mandibular fossa of the temporal bone. Separating these two bones

from direct articulation is the articular disc. The TMJ is classified as a

compound joint. By definition, a compound joint requires the

presence of at least three bones, yet the TMJ is made up of only two

bones. Functionally, the articular disc serves as a nonossified bone

that permits the complex movements of the joint. Since the articular

disc functions as a third bone, the craniomandibualr articulation is

considered a compound joint. The articular disc is composed of dense

fibrous connective tissue, for the most part devoid of any blood vessels

or nerve fibers. The extreme periphery of the disc however is slightly

innervated. In the sagittal plane it can be divided into three regions

according to thickness. The central area is the thinnest and is called

the intermediate zone. The disc becomes consider thicker both anterior

and posterior to the intermediate zone. The posterior border in the

1
normal joint the articular surface of the condyle is located on the

intermediate zone the disc, bordered by the thicker anterior and

posterior regions.

From an anterior view the disc is generally thicker medially than

laterally, which corresponds to the mandibular fossa, toward the

medial portion of the joint. The precise shape of the disc is determined

by the morphology of the condyle and mandibular fossa. During

movement the disc is somewhat flexible and can adapt to the

functional demands of the articular surfaces. Flexibly and adaptability

do not imply that the morphology of the disc is reversibly altered

during function, however the disc maintains its morphology unless

destructive forces or structural charges occur in the joint. If these

changes occur, the morphology of the disc can be irreversibly altered,

producing biomechanical changes during function. These changes are

discussed in later chapters.

The articular disc is attached posteriorly to a region of loose connective

tissue that is highly vascular zed and innervated. This is known as the

restrodiscal tissue or posterior attachment. Superiorly, it is bordered

by a lamina of connective tissue that contains many elastic fibers, the

superior restrodiscal lamina. The superior retrodiscal lamina attaches

the articular disc posterirly to the tympanic plate. At the lower border

of the retrodiscal tissues is the inferior retrodiscal lamina, which

attaches the inferior border of the posterior edge of the disc to the

2
posterior margin of the articular surface of the condyle. The inferior

retrodiscal lamina is composed chiefly of caliginous fibers, not elastic

fibers like the superior resrtodiscal lamina. The remaining body of the

retrodiscal tissue is attached posteriorly to a large venous plexus,

which fills with blood as the condyle moves forward. The superior and

inferior attachments of the anterior region of the disc are to the

capsular ligament, which surrounds most of the joint. The superior

attachment is to the anterior margin of the articular surface of the

temporal bone. The inferior attachment is to the anterior margin of the

articular surface of the condyle. Both these anterior attachments are

composed of caliginous fibers. Anteriory, between the attachments of

the capsular ligament the disc is also attached by tensinous fibers to

the superior lateral pterygoid muscle.

The articular disc is attached to the capsular ligament not only

anterory and posteriorly but also medially and laterally. This divides

the joint into two distinct cavities. The upper or superior cavity is

bordered by the mandibular fossa and the superior surface of the disc.

The lower or inferior cavity is bordered by the mandibular condyle and

the inferior surface of the disc. The internal surfaces of the cavities are

surrounded by specialized endothelial cells that form a syndovial

fringe located at the anterior border of the restrodiscal tissues,

produces synovial fluid, which fills both joint cavities. Thus the TMJ is

referred to as a synovial joint. This synovial fluid acts as a medium for

3
providing metabolic requirements to these tissues. Free and rapid

exchange exists between the vessels of the capsule, the synovial fluid

and the articular tissues. The synovial fluid also serves as a lubricant

between articular surfaces during functions. The articular surfaces of

the disc, condyle and fossa are very smooth so friction during

movement is minimized. The synovial fluid helps to minimize this

friction further.

Synovial fluid lubricants the articular surfaces by way of two

mechanisms. The first is called boundary lubrication, which occurs

when the joint is moved and the synovial fluid is forced from one area

of the cavity into another. The synovial fluid located in the border or

recess areas is forced on the articular surface, thus providing

lubrication. Boundary lubrication prevents friction in the moving joint

and is the primary mechanism of joint lubrication.

A second lubricating mechanism is called weeping lubrication.

This refers to the ability of the articular surfaces to absorb a small

amount of synovial fluid. During function of a joint, forces are created

between the articular surfaces. These forces drive a small amount of

synovial fluid in and out of the articular tissues. This is the

mechanism by which metabolic exchange occurs. Under compressive

forces therefore a small amount of synivial fluid is released. This

synivial fluid acts as a lubricant between articular tissues to prevent

sticking, weeping lubrication helps eliminate friction In the

4
compressed but not moving joint. Only a small amount of friction is

eliminated as a result of weeping lubrication, there fore prolonged

compressive forces to the articular surfaces will exhaust this supply.

The consequence of prolonged static loading of the joint structures is

discussed in later chapters.

Histology of the articular surfaces

The articular surfaces of the condyle and mandibular fossa are

composed of four distinct layers or zones. The most superficial layer is

called the articular zone. It is found adjacent to the joint cavity and

forms the outermost functional surface. Unlike most other synovial

joints, this articular layer is made of dense fibrous connective tissue

rather than hyaline cartilage. Most of the collagen fibers are arranged

in bundles and oriented nearly parallel to the articular surface. The

fibers are tightly packed and are able to withstand the forces of

movement. It is thought that this fibrous connective tissue affords the

joint several advantages over hyaline cartilage. It is generally less

susceptible than hyaline cartilage to the effects of aging and therefore

is less likely to break down over time. It also has a much better ability

to repair than does hyaline cartilage. The importance of these two

factors is significant in TMJ function and dysfunction and is discussed

more completely in later chapters.

The second zone is called the proliferate zone and is mainly

cellular. It is in this area that undifferentiated mesenchymal tissue is

5
found. This tissue is responsible for the proliferation of articular

cartilage in response to the functional demands placed on the articular

surfaces during loading.

The third zone is the fibro cartilaginous zone. In this zone the

collagen fibrils are arranged in bundles in a crossing pattern, although

some of the collagen is seen in a radial orientation. The fibro cartilage

appears in a random

Orientation, providing a three-dimensional network that offers

resistance against compressive and lateral forces.

The fourth and deepest zone is the calcified zone. This zone is

made up of chondrocytes and chondroblasts distributed throughout

the articular cartilage. In this zone the chondrocytes become

hypertrophic die, and have their cytoplasm evacuated, forming bone

cells from within the modularly cavity. The surface of the extracelluar

matrix scaffolding provides an active site for remodeling activity as

ensosteal bone growth proceeds as it does elsewhere in the body.

The articular cartilage is composed of chondrocytes and

intercellular matrix. The chondrocytes produce the collagen,

proteoglycans, glycoproteins, and enzymes that form the matrix.

Proteoglycans are complex molecules composed of a protein core and

glycoproteins chains. The Proteoglycans are connected to a hyaluronic

acid chain, forming Proteoglycans aggregates that make up a great

protein of the matrix. These aggregates are very hydrophilic and are

6
intertwined throughout the collagen network. Since these aggregates

tend to bind water, the matrix expands and the tension in the collagen

fibrils counteracts the swelling pressure of the Proteoglycans

aggregates. In this way the interstitial fluid contributes to support

joint loading. The external pressure resulting from joint loading is in

equilibrium with the internal pressure of the articular cartilage. As

joint loading increases tissue fluid flows outward until a new

equilibrium is achieved. As loading is decreased, fluid is reabsorbed

and the tissue regains its original volume. Joint cartilage is nourished

predominantly by diffusion of synovial fluid, which depends on this

pumping action during normal activity. The pumping action is the

basis for the weeping lubrication that has previously been discussed

and this action is thought to be very important in maintaining healthy

aricular cartilage.

Innervation

As with all joints, the TMJ is innervated by the same nerve that

provides motor and sensory innervation to the muscles that control it

(the trigeminal nerve). Branches of the mandibular nerve provide the

afferent innervation. Most innervation is provided by the

auriculaotemporal nerve as it leaves the mandibular nerve behiand

the joint and ascends laterally and superiorly to wrap around the

posterior region of the joint. Additional nnervation is porivided by the

deep temporal and masseteric nerves.

7
Vascularization-

The TMJ is richly supplied by a variety of vessels that surround it.

The predominant vessels are the superficial temporal artery from the

anterior; and the internal maxillary artery from the inferior. Other

important arteries are the deep auricular, anterior tympanic, and

ascending pharyngeal arteries. The condyle receives its vascular

supply through its marrow spaces by way of the inferior alveolar artery

and also receives vascular supply through its marrow spaces by way of

the inferior alveolar artery and also receives vscular supply by way of

“feeder vessels” that enter directly into the condylar head (both

anteriorly and posteriorly) from the larger vessels.

LIGAMENTS-

As with any joint system, ligaments play and important role in

protecting the structures. The ligaments of the joint are made up of

collagenous connective tissues, which do not stretch. They do not

enter actively into joint function but instead act as passive restraining

devices to limit and restrict border movements. Three functional

ligaments support the TMJ: 1) the collateral ligaments 2) the capsular

ligaments, 3) the TM ligament. There are also two accessory ligaments:

4) the sphenomandibular and 5) the stylomandibular.

Collateral (discal) ligaments

The collateral ligaments attach the medial and lateral borders of the

discal ligaments attaches the medical edge of the disc to the medical

8
pole of the condyle. These ligaments are responsible for dividing the

joint mediolaterally into the superior and inferior joint cavities. The

discal ligaments are true ligaments, composed of collagenous

connective tissue fibers, therefore they do not stretch. They function to

restrict movement of the disc away from the condyle. In other words,

they allow the disc to move passively with the condyle as it glides

anterirly and posteriory. The attachments of the discal ligaments

permit the disc to be rotated anteriory and posterirly on the articular

surface of the condyle. Thus these ligaments are responsible for the

hinging movement of the TMJ, which occurs between the condyle and

the articular disc.

The discal ligaments have a vascular supply and are innervated. Their

innervation provides information regarding joint position and

movement. Strain on these ligaments produces pain.

Capsular ligament

As previously mentioned the entire TMJ is surrounded and

encompassed by the capsular ligament. The fibers of the capsular

ligament are attached superiorly to the temporal bone along the

borders of the articular surfaces of the mandibular fossa and articular

eminence, inferiorly the fibers of the capsular ligament attach to the

neck of the condyle. The capsular ligament acts to resist any medial,

lateral or inferior forces that tend to separate or dislocate the articular

surfaces. A significant function of the capsular ligament is to

9
encompass the joint, thus retaining the synovial and provides

proprioceptive feedback regarding position and movement of the joint.

Temporomandibular ligament

The lateral aspect of the capsular ligament is reinforced by strong,

tight fibers that make up the lateral ligament or the TM ligament. The

TM ligament is composed of two parts, an outer oblique portion and an

inner horizontal portion.

The outer portion extends from the outer surface of the articular

tubercle and zygomatic process posteroinferiorly to the outer surface of

the condylar neck. The inner horizontal portion extends from the outer

surface of the articular tubercle and zygomatic process posteriorly and

horizontally to the lateral pole of the condyle and the posterior part of

the articular disc.

The oblique portion of the TM ligament resists excessive dropping of

the condlye, therefore limiting the extent of mouth opening. This

portion of the ligament also influences the normal opening movement

of the mandible. During the initial phase of opening, the condyle can

rotate around a fixed point of insertion on the neck of the condyle is

rotated posteriorly. When the ligament is taut, the neck of the condyle

cannot rotate further. If the mouth were to be opened wider, the

condyle would need to move downward and forward across the

articular eminence. This effect can be demonstrated clinically by

closing the mouth and applying mild posterior force to the chin. With

10
this force applied, begin to open the mouth. The jaw easily rotates

open the mouth. The jaw easily rotates open until the teeth are 20 to

25 mm apart. At this point, resistance is is felt when the jaw is

opened wider. If the jaw is opened still wider, a distinct change in the

opening movement occurs, which represents the change from rotation,

of the condyle about a fixed point to movement forward and down the

articular eminence. This change in opening movement is brought

about by the tightening of the TM ligament.

This unique feature of the TMligament, which limits rotational

opening, is found only in humans. In the erect postural position and

with a vertically placed vertebral column, continued rotational opening

movement causes the mandible to impinge on the vital submandibular

and retromandibular structures of the neck. The outer oblique portion

of the TM ligament functions to resist this impingement.

The inner horizonatal portion of the TM ligament limits posterior

movement of the condyle and disc. When force applied to the

mandible displaces the condyle posteriorly, this portion of the

ligamnent becomes tight and prevents the condyle from moving into

the posterior region of the mandibular fossa. The TM ligament

therefore protects the retrodiscal tissures from trauma created by the

posterior displacement of the condlyle. The inner horizontal portion

also protects the lateral pterygoid muscle from overlengthening or

overextension. The effectiveness of the TM ligament is demonstrated

11
during cases of extreme trauma to the mandible. In such cases the

neck of the condyle is seen to fracture before the rhetorical tissues are

served or the condyle enters the middle cranial fossa.

Sphenomandibular ligament

The Sphenomandibular ligament is one of two TMJ accessory

ligaments. It arises from the spine of the sphenoid bone and extends

downward to a small bony prominence on the medial surface of the

ramus of the mandible called the lingual. It does not have any

significant limiting effects on mandibular movement.

Stylomandibular ligament

The second accessory ligament is the stylomandibular ligament. It

arises from the styloid process and extends down ward and forward to

the angle and posterior border of the ramus of the mandible. It be

comes taut when the mandible is protruded but is most relaxed when

the mandible is opened. The stylomandibular ligament therefore limits

excessive protrusive movements of the mandible.

BIOMECHANICS-

The TMJ is an extremely complex joint system. The fact that two TMJs

are connected to the same bone (mandible) further complicates the

function of the entire masticatory system. Each of the joints can

simultaneously act separately and yet not completely withoutinflunce

from the other. A sound understanding of the biomechnaics of the

12
 TMJ is essential and basic to the study of function and dysfunction in

the masticatory system.

The TMJ is a compound joint. Its structure and function can be

divided into two distinct systems;

1. One joint system is the tissues that surround the inferior synovial

cavity (i,e., the condyle and the artuicular disc). Since the disc is

tightly bound to the condyle by the lateral and medical discal

ligaments, the only physiologic movement that can occur between

these surfaces is rotation of the disc on the articular surface of the

condyle. The disc and its attachment to the condyle are called the

condyle –disc complex and is the joint system responsible for

rotational movement in the TMJ.

2. The second system is made up of the condyle-disc complex

functioning against the surface of the mandibular fossa, free sliding

movement is possible between these surfaces in the superior cavity.

This movement occurs when the mandible is moved forward (referred

to as translation). Translation occurs in this superior joint cavity

between the superior surface of the articular disc and the mandibular

fossa. Thus the articular disc acts as a no ossified bone contributing to

both joint systems, and hence the function of the disc justifies

classifying the TMJ as a true compound joint.

The articular disc has been referred to as a meniscus. However, it is

not a meniscus at all. By definition, a meniscus is a wedge – shaped

13
crescent of fibro cartilage attached on one side to the articular capsule

and unattached on the other side, extending freely into the joint

spaces. A meniscus does not divide a joint cavity, isolating the synovial

fluid, nor does it serve as a determinant of joint movement. Instead, it

functions passively to facilitate movement between the bony parts.

Typical menisci are found in the knee joint. In the TMJ the disc

functions as a true articular surface in both joint systems and is

therefore more accurately termed articular disc.

Now that the two individual joint systems have been described, we can

consider once again the entire TMJ. The articular surfaces of the joint

have no structural attachment or union, yet contact must be

maintained constantly for joint stability. Stability of the joint is

maintained by constant activity of the muscles that pull across the

joint, primarily the elevators. Even in the resting state, these muscles

are in a mild state of contraction called tonus. As muscle activity

increases, the condyle is increasingly forced against the disc and the

disc against the mandibular fossa, resulting in an increasing in the

interarticular pressure of these joint structures. In the absence of

intrearticular pressure, the articular surfaces separate and the joint

technically dislocates.

The width of the articular disc space varies with interarticular

pressure. When the pressure is low, as in the closed rest position, the

disc space widens. When the pressure is high, as during clenching of

14
the teeth, the disc space narrows. The contour and movement of the

disc permit constant contact of the articular surfaces of the joint,

which is necessary for joint stability. As the interarticular pressure

increases, the condyle seats itself on the thinner intermediate zone of

the disc. When the pressure is decreased and the disc space is

widened, a decreased and the disc is rotated to fill the space. Since the

anterior and posterior bands of the disc are wider than the

intermediate zone, technically the disc could be rotated either

anteriory or posteriorly to accomplish this task. The direction of the

disc rotation is determined not by chance, but by the structures

attached to the anterior and posterior borders of the disc.

Attached to the posterior border of the articular disc are the

retrodiscal tissues, some times referred to as the posterior attachment.

As previously mentioned, the superior retrodiscal lamina is composed

of varying amounts of elastic connective tissue. Since this tissue has

elastic properties and because in the closed mouth position it is

somewhat folded over itself, the condyle can easily move out of the

fossa without creating any damage to the superior retrodiscal lamina.

When the mouth is closed (the closed joint position), the elastic

traction on the disc is minimal to none. However during mandibular

opening, when the condyle is pulled forward down the articular

eminence, the superior retrodiscal lamina becomes increasingly

stretched, creating increased forces to retract the disc. In the full

15
forward position, the posterior retroactive force on the disc created by

the tension of the stretched superior retrodiscal pressure and the

morphology of the disc prevent the disc from being overrectracted

posteriorily. In other words as the mandible moves into a full forward

position and during its return, the retraction force of the superior

retrodiscal lamina holds the disc rotated as far posteriorly on the

condyle as the width of the articular disc space permits. This is an

important principle in understanding joint function. Likewise, it is

important to remember that the superior retrodiscal lamina is the only

structure capable of retracting the disc posterirly on the condyle.

Attached to the anterior border of the articular disc is the superior

lateral petrygoid muscle. When this muscle is active, the fibers that

are attached to the disc pull anteriory and medially. Therefore the

superior lateral petrygoid muscle is technically protractor of the disc.

Remember, however that this muscle is also attached to the neck of

the condyle. This dual attachment does not allow the muscle to pull

the disc through the discal space. Protraction of the disc however does

not occur during jaw opening. When the inferior lateral petrygoid

muscle is protracting the condyle forward, the superior lateral

petrygoid muscle is inactive and therefore does not bring the disc

forward with the condyle. The superior lateral petrygoid muscle is

activated only in conjunction with activity of the elevator muscles

during mandibular closure or a power stroke.

16
It is important to understand the features that cause the disc to move

forward with the condyle in the absence of superior lateral petrygoid

muscle activity. The anterior capsular ligament attaches the disc to

the anterior margin of the articular surface of the condyle. Also the

inferior retrodiscal lamina attaches the posterior edge of the disc to the

posterior margin of the articular surface of the condyle. Both these

ligaments are composed of caliginous fibers and do not stretch.

Therefore a logical assumption is that they force the disc to translate

forward with the condyle. Although logical such an assumption is

incorrect: these structures are not primarily responsible for movement

of the disc with the condyle. Remember that ligaments do not activity

participate in normal joint function but only passively restrict extreme

border movements. The mechanism by which the disc is maintained

with the translating condyle is dependant on the morphology of the

disc and the interarticular pressure. In the presence of a normally

shaped articular disc, the articulating surface or the condyle rests on

the intermediate zone, between the two thicker portions. As the

interarticular pressure is increased the discal space narrows, which

more positively seats the condyle on the intermediate zone.

During translation the combination of disc morphology and

interaarticular pressure maintains the condyle on the intermediate

zone, and the disc is forced to translate forward with the condyle. The

morphology of the disc therefore is extremely important in maintaining

17
proper position during function. Proper morphology plus interarticular

pressure results in an important self-positioning feature of the disc.

Only when the morphology of the disc has been greatly altered does

the ligament us attachments of the disc affect joint function. When

this occurs the biomechanics signs begin. These conditions are

discussed in detail in later chapters.

As with most muscles the superior lateral petrygoid muscle is

constantly maintained in a mild state of contraction or tonus, which

exerts a slight anterior and medical force on the disc. In the resting

closed joint position this anterior and medical force normally exceeds

the posterior elastic retraction force provided by the nonstrechted

superior retrodiscal lamina. Therefore in the resting closed joint

position when the intrarticular pressure is jaw and the disc space

widened, the disc occupies the most anterior rotary position on the

condyle permitted by the width of the space. In other words, at rest

with the mouth closed, the condyle is positioned in contact with the

intermediate and posterior zones of the disc.

This disc relationship is maintained during minor passive rotational

and translatory mandibular movements. As soon as the condyle is

moved forward enough to cause the retractile force of the superior

retrodiscal lamina to be greater than the muscle tonus force of the

superior lateral petrygoid muscle, the disc is rotated posteriorly to the

extent permitted by the width of the articular disc space. When the

18
condyle is returned to the resting closed joint position, once again the

tonus of the superior lateral petrygoid muscle becomes the

predominant force and the disc is repositioned forward ad far as the

disc space permits.

The importance of the function of the superior lateral petrygoid muscle

during the power stroke becomes apparent when the mechanics of

chewing are observed. When resistance is met during mandibular

closure, such as when biting on hard food, the interarticular pressure

on the biting side is decreased. This occurs because the force of

closure is not applied to the joint but is instead applied to the food.

The jaw works as a fulcrum around the hard food, causing an increase

in interarticular pressure in the contra lateral joint and a sudden

decrease in interarticular pressure in the ipisilateral joint. This can

lead to separation of the articular surfaces, resulting in dislocation. To

avoid this the superior lateral petrygoid muscle becomes active during

the power stroke, rotating the disc forward on the condyle so the

thicker posterior border of the disc maintains articular contact.

Therefore joint stability is maintained during the power stroke of

chewing. As the teeth pass through the food and approach

interception, the interarticualer pressure is increased. As the pressure

is increased the disc space is decreased and the disc is mechanically

rotated posteriorly so that the thinner intermediate zone fills the

19
 space. When the force of closure is discontinued the resting closed

joint position is once again assumed.

Understanding these basic concepts in TMJ function is essential to the

understanding of joint dysfunction. Normal biomechanical function of

the TMJ must follow the orthopedic principles just presented.

Remember the following.

TMJ IMAGING

 Plane film radiography

 Transcranial view

 Transorbital view

 Transpharyngeal view

 Reverse towns projection

 Cephalometry

 Xeroradiography

 CONVENTIONAL TOMOGRAPHY

 OPG

 TMJ ARTHROGRAPHY

 NUCLEAR MEDICINE

 CT

 MRI

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 TRANSCRANIAL PROJECTION:(Lindblom technique)

Lateral aspect of TMJ well visualized.

Central / medial patient of TMJ not clearly seen- since x-ray beam is

not tangent to these articular surfaces.

This disadvantage partly compensated because of most of early

osseous changes occurs laterally in joint.

MAIN INDICATIONS:

TMJ pain dysfunction syndrome and internal derangement of joint

producing pain, clicking, limitation in opening.

1. To investigate size and position of disc this can only be inferred

indirectly from relative position of bony elements of joints.

2. To investigate range of movement in joint.

TECHNIQUE AND POSITIONING:

Patient is placed in craniostome with head rotated through 90º, so

that TMJ under investigation is touching the film and sagittal plane of

head is parallel to film. Initially patient mouth closed.

X-Ray tube head positioned on contra lateral side with central ray

aimed downwards at 25º and anteriorly to 20º horizontal across

cranium, centering through TMJ of interest.

The central beam is projected across the cranium passes just above

petrous ridge of temporal bone on film side and finally through TMJ in

line with long axis of obliquely oriented condyle.

21
 Procedure repeated with patient mouth open a bite block used for

stability. Procedure repeated for other TMJ, both closed, open mouth

using bite block of same size. Because of positive beam angulation’s

central and medial aspect of joints are projected inferiorly. Only lateral

contour are visible in this projection. Ipsilateral petrous ridge

superimposed often condylar or temporal component, joint space is

distorted.

DIAGNOSTIC INFORMATION:

Information provided by closed view includes:

- This provides indirect information about position and shape of disc.

(Joint space radiologically refers to radiolucent zone between condylar

head and glenoid fossa, which includes disc and upper /lower

anatomical joint spaces.)

- Position of head of condyle within fossa-

- Shape and condition of glenoid fossa a articular eminence (on lateral

aspect only).

- Shape of head of condyle and condition of articular surface. (On

lateral aspect only)

- A comparison of both sides.

INFORMATION PROVIDED BY OPEN VIEW INCLUDES:

1. Range and type of movement of condyle.

2. Comparison of degree of movement on both sides.

22
 TRANS PHARYNGEAL:

(Infra cranial TMJ projection, Parma, Mc Queen projection)

MAIN INDICATIONS:

1. TMJ pain dysfunction syndrome.

2. To investigate presence of joint disease particularly Osteoarthritis &

Rheumatoid arthritis.

3. To investigate pathological conditions affecting condylar head,

including cysts or tumors.

4. Number of neck and head of condyle.

5. Sup surface of condyle visualized.

TECHNIQUE AND POSITIONING:

- Can be taken with dental x-ray set and extra oral cassette.

- Patient holds cassette against side of face over TMJ of interest.

- The film and sagittal plane of head are parallel.

- Patient mouth is open and bite block inserted for stability

- X-Ray tube head positioned in front of opposite condyle and beneath

zygomatic arch. It is aimed through sigmoid notch, slightly

posteriorly, across the pharynx at condyle under investigation. Usually

view taken of both condyle to allow comparison.

- Because of negative beam angulation, this views medial aspect of

condyles and Temporal component is not imaged well.

23
- Effective in visualizing erosive changes of condyle and shape of head

of condyle and condition of articular surface from lateral aspect.

TRANS ORBITAL PROJECTION: (ZIMMER)

Conventional frontal TMJ projection is most routinely successful in

delineating joint with minimal super imposition is transorbital

(ZIMMER) projection, also called Transmaxillary Projection.

Advantage- Lack of major superimposition over most of condylar

process. Productions of relatively true “enface” frontal projection of

condyle (directing central ray perpendicular to long axis of condyle)

and simplicity with which it is made.

Patient positioning-

- Seat patient in upright position and trip of head downward about

10º, so that canthomeatal line is horizontal.

- Place the tube head in front of patient and direct central ray through

ipsilateral orbit and through TMJ of interest, exiting through skull

behind mastoid process.

- Position X Ray cassette behind patient head, so that central ray

projected to its centre and perpendicular to it.

- Then ask patient to open mouth as wide as possible to move condyle

of interest out of articular fossa and on to crest of articular surface.

24
- This maneuver also provides profile visualization of ideally entire

lateromedial range of articulating surfaces of both condyle and

articular eminence.

- If patient cannot open wide, condylar neck may be well soon on

resultant view, but areas of joint articulating surface will be obscured,

because of mutual superimposition.

- T.P with open mouth wide – condyle and major portion condylar neck

visualized.

- Main contribution of transorbital view in demonstration of convex

articulating surface of condyle and slightly concave or flat broad ridge

of articulating eminence.

- Ideally TMJ should be imaged in both lateral and frontal (coronal)

planes for adequate evaluation of condylar heads and articular

eminence.

- Imaging in frontal plane is important because degenerative changes

often start in lateral portion of joint and early changes may be missed

or sub optimally demonstrated on lateral projections.

- Often lateral projection may overestimate or underestimate extent of

osseous pathology.

- Optimal plane film visualization of condylar head and articular

eminence in frontal plane can be obtained using transorbital

projection.

25
Therefore conventional frontal projection of choice to complement

transcranial projection, when presences of extent of arthritic change

are to be defined.

SUBMENTOVERTEX PROJECTION: -

This view helps ruling out TMJ erosion from nasopaharygeal

carcinoma extending to base of skull. Also be used to define

angulations of condyle in transverse plane of skull.

REVERSE TOWNE’S:

MAIN INDICATIONS:

- To investigate articular surface of condyle and disease within joint.

- Fracture of condylar head and neck (especially medially displaced

fracture of condyle)

- Condylar hypo/hyperplasia.

TECHNIQUE:

- Patient positioning facing film with head tipped forward in forehead

position.

- Mouth is open and x-ray tubehead is aimed upwards at 30º from

behind

26
PATIENT POSITIONING-

- X Ray tube aimed upwards at 30º from behind. And the central ray

directed perpendicular to film in sagittal plane through occipital bone.

Collimating beam to area of interest.

- Head centered in front of cassette with cantomeatal line oriented

downward 25-30º

USES-

- To know the Shape of condylar heads and condition of articular

surface from posterior aspect.

- A direct comparison of both condyles.

XERORADIOGRAPHY

Xeroradiography is a photoelectric process by which X-ray intensity

transmitted by an object is recorded as a charge density pattern on the

surface of a semi-conducting selenium plate. Thus the process differs

from the photo-chemical process of conventional radiography which

uses film as the recording medium.

The selenium layer is a good insulator in the dark and will retain a

uniform superficial charge for some hours (Boag et al, 1972). The

plates become electrically conducting when exposed to light or X-

radiation, thus allowing the surface charge to leak away in the

exposed areas and leave on the surface of the plate a ‘charge image’ of

the incident radiation pattern. This charge image is then developed

27
and transferred on to a plastic-coated paper and is viewed by reflected

light.

The xeroradiographic image is of medium to low contrast but it

displays very fine detail because of the so-called ‘edge effect’. Any

structure with a well-defined interface (e.g. blood vessels, bone,

cyst, soft tissue, calcification) is clearly outlined because the field

strength is greatest near any sharp discontinuity in the charge pattern

and an electro-static build-up of powder occurs on one side of the

interface with a corresponding depletion on the other.In

xeroradiography, there is considerable latitude for exposure factors,

particularly at high kilovoltage. In the examination of the breast, the

kilovoltage used is 45-50 and a tube with a tungsten target can be

used, one with a molybdenum anode being unnecessary. In the

examination of denser structures such as the chest or for

anteroposterior views of the soft tissues of neck, the use of higher

kilovoltage with increased filtration reduces the incident skin dose and

improves the image (Davis, 1977).

Xerograms have wide image latitude and allow simultaneous

demonstration of bone and soft tissue structures, with a high degree of

detail (Ottoe et al, 1976). To demonstrate these by convectional

radiography, several radiographs must be taken using different

kilovoltage. Greater detail can be obtained by xerography because of

its high resolution compared with conventional radiography, i.e. 15-50

28
lines per cm as against 8-16 lines per cm.The part of the body being

examined must not be covered, nor should a foam pad or mattress be

used under it. A ‘tunnel’ is used to protect the plate from damage and

pressure, which would cause it to lose its charge. The part to be

examined is placed directly on this tunnel.

Accurate marking of xerograms is essential because a mirror image is

produced. Thus, the marker must be placed as for a posteroanterior

radiograph and particular care take to use the correct marker

‘Richardson, 1977). Apparatus: The sequence of charging, processing,

Cleaning and relaxing the plates is now performed automatically ‘Rank

Xerox System 125’ and the apparatus consists of two units: (a) the

conditioner and (b) processor. Conditioner. Charging, Cleaning and

Relaxing of the plates takes place in this unit, Six plates, which are

made of aluminium and coated on one side with selenium, are stored

for use. When an empty cassette is inserted into the conditioner, a

plate is taken from the storage magazine in the unit and the surface of

the plate is charged uniformly to a positive potential of about 1600

volts. The plate is then inserted into the cassette and is ready for use.

During exposure to radiation, a latent electro-static image is formed,

corresponding to the various densities of the object being examined.

After the exposure, the cassette is inserted into the processor. The

latent image is developed by means of electrically charged, finely

divided particles (blue in color), which adhere to the discharge pattern

29
 of the latent image, thus rendering it visible. The image is then

transferred on to a plastic-coated paper by bringing the plate and

paper into contact with each other. This reverses the electro-static

field and causes the powder to leave the plate and adhere to the paper.

The paper is then heated to make the (blue) image permanent. The

processing cycle takes 90 seconds. The plates can be processed in

either the positive or the negative mode. Positive xerograms provide

better soft tissue demonstration but negative xerograms are of value

when both bone and soft tissue detail need to be demonstrated. The

negative mode image requires additional powder fixative. After

processing, the plate is put back into the conditioner, where any

residual powder is cleaned off and it is the ‘relaxed’ by heating it to

remove any residual or the memory of a previous exposure. It is then

stored ready for charging when next required.

DENTAL PANAROMIC TOMOGRAPHY:

MAIN INDICATIONS:

1. TMJ pain dysfunction syndrome.

2. To investigate disease within joint.

3. To investigate pathological condition affecting condylar head.

4. Fracture of condylar head or neck.

5. Condylar hypo/hyperplasia.

30
DIAGNOSTIC INFORMATION:

- It gives information of shape of condylar heads and condition of

articular surfaces from lateral aspect.

- Direct comparison of both condylar heads.

- Some panaromic machines can give closed and open view of condyle

is not of information.

- Two views of condyle at maximum opening will reflect maximum

translation from initial closed position, it will maximize information

and minimize patient absorbed x-ray dose.

TOMOGRAPHY:

MAIN INDICATIONS:

- Estimation of joint space, examination of condylar surface from

medical to lateral pole for arthritic changes, visualization of condylar

translation, visualization of articular eminence changes.

- It helps in assessment of whole of joint to determine presence and

site of any bone disease or abnormality.

- To investigate condyle and articular fossa, when patient unable to

open mouth.

- Assessment of fracture in the articular fossa and intra capsular

space.

31
 Tomography in Coronal Plane provides information about medial and

lateral poles of condyle, which is not adequately depicted on sagittal

tomograms.

Disadvantage of Tomography is large irradition dose delivered to lens

of eye.

Types-

1. Linear tomogram

2. Multidirectional Hypocycolloidal tomogram

3. Multi-Computer Controlled Spiral tomogram

LINEAR TOMOGRAPHY:

Provides crude investigations because linear blurring of unwanted

structures result in poor image quality and resolution , because the

augmentation of joints to coronal plane necessitates a minimal, but

somewhat arbitrary, rotation of patient head to side of interest, from

true cross-sectional imaging.

MULTI DIRECTIONAL HYPOCYCLOIDAL TOMOGRAPHY:

It results in improved image quality and resolution but patient

positioning for true cross sectional imaging remains subjective.

MULTI DIRECTIONAL SPIRAL TOMOGRAPHY:

Development of scanora multifunctional spiral tomography unit has

improved conventional tomographic images of bony elements of TMJ in

both near sagittal and coronal planes. This is because patient

positioning is objective and tomography movement is spiral.

32
 PROCEDURE:

An initial computer controlled sagittal orientation programme is

selected, which enables correct angulation for ideal cross sectional

imaging to be assessed, by taking relatively thick (16mm) tomographic

views of TMJ at four different angles.

Optimal angulations are chosen and fed into unit and narrow (2-

4mm), detailed, computer controlled spiral tomographic cross

sectional slices of joint produced.

Parallel coronal orientation and detailed tomographic programme can

be selected to produce narrow (6mm) coronal tomographic slices.

DIAGNOSTIC INFORMATION: to know

 Size of joint space.

 Position of head of condyle within fossa.

 Shape of head of condition of articular surface including medial and

lateral aspects.

 Shape and condition of articular fossa and eminence.

 Information on all aspects of joint.

 Position and orientation of fracture fragment.

33
 - Body section tomography provides most definitive radiologic

information about TMJ.

- Complex motion tomography (hypocycloidal) /spiral motion) is

superior to transcranial radiography for demonstrating changes on

articulating surface and position of condyle within mandibular fossa.

- An initial SMV projection required to measure angles of each condyle

within information patient head may be oriented correctly for

performing Tomography examination.

- Tomographic section of TMJ made in 2 orientations with respect to

joint

1. With head positioned so that section is at right angle to long axis of

condyle (the lateral tomographic section.)

2. Often with section parallel to long axis of condyle (frontal tomographic

section)

3. A proper tomographic examination is comprised of from 4-7section at

2-3 mm intervals.

CORRECTED LATERAL TOMOGRAPHY

 For this tomographic section, superior visualization of joint can be

accomplished, when head positioned to align central ray with long axis

of condyle.

34
 Exact degree of head rotation is established individually for each TMJ

to ensure most precise alignment of joint long axis  this technique

(called individualized as opposed to standardized correct TMJ

tomography) require that as SMV radiography obtained as preliminary

films with plotting of individual condylar angles against intermeatal

(coronal) axis.

Condylar angles then determined, used to precise head rotation angles

as tomograms are made from left to right TMJ.

 It requires rotatable head stabilizing device (cephlosted) to precisely

control and maintain head position.

 A standardized rotation of 20º towards side of interest often adequate

to effect a nearly profile view adequate to effect a nearly profile view of

joint long axis.

 TMJ radiography best made with patient in a natural, upright posture

not lying on table, therefore TMJ tomogram should be obtained with

patient sitting upright in chair or standing at foot of an upright

radiographic table (because bony relationship of joint should be

evaluated in natural postural setting.

 Patients ask to bite on post teeth.

 If open mouth view needed  open wide till not strain muscles or

usually use bite block because exposure time long (up to 6 sec) to

maintain open position. This lateral tomographic section often best

35
 lateral view of cortical margins of TMJ and position of condyle within

mandibular fossa and its range translating motion.

 Axial (sub mental) tomography also useful for evaluating position of

condyle.

CORRECTED FRONTAL TOMOGRAPHY:

 Made with patient upright position.

 Head rotation again made before exposure, so that long axis of condyle

and fossa are seen enface (perpendicular to course of central ray)

 X Ray beam collimated to expose only joint stresses of interest

unilaterally with no attempt to obtain both joints on same

radiographic exposure.

 Best to ask patient to protrude lower jaw, but keep teeth in light

contact. This affect of bringing condyle forward below articular

eminence, so that condyle visualized.

 Superior aspect of condyle seen from lateral to medial pole.

COMPUTED TOMOGRAPHY

In 1972, Godfrey Hounsfield announced the invention of a

revolutionary imaging technique, which he referred to as computerized

axial transverse scanning. With this technique he was able to produce

an axial cross-sectional image of the head using a narrowly collimated,

moving beam of x rays. A scintillation crystal detected the remnant

radiation of this beam, and the resulting analog signal was fed into a

36
computer, digitized, and analyzed by a mathematical algorithm and

the data reconstructed as an axial tomographic image. The image

produced by this technique was like no other x-ray image. Claimed to

be 100 times more sensitive than conventional x-ray systems, it

demonstrated differences between various soft tissues never before

seen with x-ray, imaging techniques. Since 1972 computed

tomography has had many names, each of which referred to at least

one aspect of the technique: “computerized axial tomography,”

computerized reconstruction tomography, “ computed tomographic

scanning”, “axial tomography” and “computerized transaxial

tomography.” Currently the preferred name is computed tomography”

abbreviated as CT.

In its simplest form a CT scanner consists of a radiographic the that

emits a finely collimated, fan-shaped x-ray beam directed to a series of

scintillation detectors or ionization chambers. Depending on the

scanner’s mechanical geometry, both the radiographic tube and

detector may rotate synchronously about the patient, and he x ray

tube may move in a circle within the detector ring. CT scanners that

employ this type of movement for image acquisition are called because

the final image set consists of a series Of Contiguous or overlapping

axial images. More recently CT scanners have been developed that

acquire image data in a spiral or helical fashion. With these scanners,

while the gantry containing the x-ray tube and detectors revolves

37
around the patient, the table on which the patient is lying

continuously advances through the gantry. This results in the

acquisition of a continuous spiral of data as the x-ray beam moves

down the patient. It is reported that, compared with incremental CT

scanners, spiral scanners provide improved multiplanar image

reconstructions, reduced examination time (12 seconds versus 5

minutes), and a reduced radiation dose (up to 75%). Regardless of the

mechanical geometry, the transmission signal recorded by the

detectors represents a composite of the absorption characteristics of

all elements of the patient in the pith of the x-ray beam.The CT image

is a digital image, reconstructed by computer, which mathematically

manipulates the transmission data obtained from multiple projections

(Fig. 13-12). For example, if one projection is made every one third of

a degree, 1080 projections result during the course of a single 360-

degree rotation of the scanner about the patient. Data derived from

these 1080 projections (1080 projections constitute one scan) contain

all the information necessary to construct a single image. The CT

image is recorded and displayed as a matrix of individual blocks called

voxel.5 (volume elements). Each square of the image matrix is a pixel.

Whereas the size of the pixel (about 0.1 mm) is determined partly by

the computer program used to construct the image, the length of the

voxel (about 1 to 20 mm) is determined by the width of the x-ray beam,

which in turn is controlled by the prepatient and post patient

38
collimators. Volex length is analogous to the tomographic layer in film

tomography. For image display, each pixel is assigned a CT number

representing density. This number is proportional to the degree to

which the material within the volex has attenuated the x-ray beam. It

represents the absorption characteristics, or linear attenuation

coefficient, of that particular volume of tissue in the patient. CT

numbers, also known as housefield units (named in honor of the

inventor Godfrey Hounsfield), may range from –1000 to +1000, each

constituting a different level of optical density. This scale of relative

densities is based on air (-1000), water (0), and dense bone (+1000).

CT has several advantages over conventional film radiography and film

tomography, first, CT completely eliminates the superimposition of

images of structures outside the area of interest. Second, because of

the inherent high-contrast resolution of CT. differences between

tissues that differ in physical density by less than 1% can be

distinguished conventional radiography requires a 10% difference in

physical density to distinguished between tissues. Third, data from a

single CT imaging procedure consisting of either multiple contiguous

or one helical scan be viewed as images in the axial, coronal, or

sagittal planes, depending on the diagnostic task. This is referred to as

multiplanar reformatted imaging.Primarily because of its high-contrast

resolution and ability to demonstrate small differences in soft tissue

density. CT has become useful for the diagnosis of disease in the

39
maxillofical complex (fig. 13-13), including the salivary glands and

TMJ. However, with the advent of magnetic resonance imaging, which

has proved superior to CT scanning for assessment of internal

derangements of the TMJ has decreased significantly. Additionally, CT

has been shown to be useful for evaluation of patients before

placement of endosseous oral implants. Despite the fact that similar

information about maxillary and mandibular anatomy can be obtained

with film tomography, CT allows maxilla or mandible or both from a

single imaging procedure. Multiplanar CT imaging has made a

significant contribution to diagnosis. However, these images are two

dimensional and require a certain degree of mental integration by the

viewer for interpretation, this limitation has led to the development of

computer programs that reformat data acquired from axial CT scans

into three- dimensional images (3d CT). Three- dimensional

reformatting requires that each original voxel, shaped as a rectangular

parallel piped or rectangular solid, be dimensionally altered into

multiple cuboidal volexs. This process, called interpolation, creates

sets of evenly spaced cubiodal voxels (cuberilles) that occupy the same

volume as the original voxel . the CT numbers of the cuberilles

represent the average of the original voxel CT numbers surrounding

each of the mew voxels. Creation of these new cuboidal voxels allows

the imageto be reconstructed in any plane without loss or resolution

by locating their position in space relative to one another. In

40
construction of the 3D CT image, only cuberilles representing the

surface of the object scanned are projected onto the viewing monitor.

The surface formed by these cuberilles may then appear as if

illuminated by a light source located behind the viewer. In this manner

the visible surface of each pixel is assigned a gray-level value,

depending on its distance from and orientation to the light source.

Thus pixels that face the light source and/or are closer to it appear

brighter than those that are turned away from the source and/or are

farther away. The effects of this shading and the resulting image

perceived by the viewer have been described as similar to an artist’s

three-dimensional medium. Once constructed, 3D CT images may be

further manipulated by rotation about any axis to display the

structure imaged from many angles. Also, external surfaces of the

image can be removed electronically to reveal concealed deeper

anatomy.One of the first applications of 3D CT was the study of

patients with suspected intervertebral disk herniation and spinal

stenosis. Since that time 3D CT has been applied to craniofacial

reconstructive surgery and has been used both for treatment of

congenital and acquired deformities and for evaluation of intracranial

tumors, benign and malignant lesions of the maxillofacial format also

has also allowed the construction of life-sized models that can be used

for trial surgeries and the construction of surgical stents for guiding

dental implant placement, as well as the creation of accurate

41
implanted prostheses.CT technology is being is being continually

advanced. Imatron (San Francisco) has developed a CT Scanner

capable of acquiring data up to 10 times faster than conventional CT.

Its Ultrafast CT, which has scan times on the order of 50 msec, is able

to freeze cardiac and pulmonary motion, enhancing the quality

without motion artifacts.

MAGNETIC RESONANCE IMAGING

In contrast to the techniques described above, which use x rays for

acquisition of information pertaining to an object studied, magnetic

resonance imaging (MRI) uses nonionizing radiation from the

radiofrequency (RF) band of the electromagnetic spectrum. To produce

an MR image, the patient is placed inside a large magnet, which

induces a relatively strong external magnetic filed. This causes the

nuclei of many atoms in the body, including hydrogen, to align

themselves with the magnetic field. This causes the nuclei of many

atoms in the body including hydrogen, to align them with the magnetic

field. After application of an RF signal, energy is released from the

body is deducted, and used to construct the MR image by computer.

The high contrast sensitivity of MRI to tissue differences and the

absence of radiation exposure are the reasons MRI for the most part

have replaced CT for imaging soft tissue. CT remains an important

technique for imaging body tissues. The theory of MRI is based on the

42
magnetic properties of an atom. Atomic nuclei spin about their axes

much as the earth spins about its axis. In addition, individual protons

and neutrons (nucleons), which make up the nuclei of atoms, each

possess a spin, or angular momentum. In nuclei in which the

protons and neutrons are evenly paired. The spin of each nucleon

cancels that of another, producing a net spin of zero. In nuclei that

contain an unpaired proton or neutron, a net spin is created. Because

spin is associated with an electrical charge, a magnetic field is

generated in nuclei with unpaired nucleons, causing this nuclei to act

as magnets with North and South poles (magnetic dipoles). The

nucleus of the element hydrogen contains a single unpaired proton

and therefore acts as a magnetic dipole. A sample containing many

hydrogen atoms would find this magnetic dipoles to be randomly

oriented. This results in a total magnetization for the sample of zero,

In this natural state, if an external magnetic field is applied to the

sample, all the hydrogen nuclear axes line up in the direction of the

magnetic field, producing a quantity of net magnetization. However,

not all north poles point in the same direction. Rather 2 states are

possible: spin-up, which parallels the external magnetic fields, and

spin-down, which is anti-parallel with the field. Because more energy

is required to align anti-parallel with the magnetic field, those

hydrogen nuclei are considered to be at a higher energy state than

those align parallel with the field. Nuclei prefer to be in a lower energy

43
state, and usually more are aligned parallel with the magnetic filed.

Nuclei can be made to undergo transition from one energy state to

another by absorbing or releasing a certain quantity of energy. Energy

required for transition from the lower to the higher or from the higher

to the lower energy level can be supplied or recovered in the form of

electromagnetic energy in the RF portion of the electromagnetic

spectrum. The transition from one energy level to another is called

Resonance. When an external magnetic field is applied to a sample of

nuclei, their north and south poles do not align exactly with the

direction of the magnetic field. The axes of spinning protons actually

oscillate or wobble with a slight tilt from a position absolutely parallel

with the flux of the external magnet. This titling or wobbling, called

precession, is similar to that of spinning toy top, which does not spin

in a perfectly upright position as it slows down, because of the effect of

the earth’s gravitational field. The axis of the spinning top wobbles

about the direction of the local gravitational field, and the axis of the

spinning protons wobbles (or processes) about the applied magnetic

field. Because of the spin-up and spin-down states, the spinning

protons process together in the direction of their spin states, which

can be visualized as two cones placed end to end. The rate or

frequency of precession is called the resonant or Larmor frequency: it

depends on the species of nucleus and is proportional to the strength

of the external magnetic filed. The Larmor frequency of hydrogen is

44
42.58 MHz in a magnetic field of 1 Tesla (T). One Tesla is 10,000 times

the earth’s magnetic field. The magnetic range from 0.1 to 4.0 T .In

summary, when nuclei are subjected to the flux of an external

magnetic filed, two energy states result: spin-up which is in the

direction of the field, and spin-down, which is in the opposite direction

of the field. The combined effect of these two energy states is a weak

net magnetic moment, or magnetization vector (Mv), parallel with the

applied magnetic field. Spin-up, which is in the direction of the field,

and spin-down, which is in the opposite direction of the field. The

combined effect of these two energy states is a weak net magnetic

moment, or magnetization vector (Mv), parallel with the applied

magnetic filed.

When energy in the form of an electromagnetic wave in the radio

frequency range from an RF antenna coil is directed to tissue with

protons (hydrogen nuclei) that are aligned in the Z axis by an external

static magnetic filed (by the imaging magnet), the protons in the tissue

that have a Larmor frequency matching that of the electromagnetic

wave absorb energy and shift or rotate away from the direction

induced by the imaging magnet. The longer the RF pulse is applied,

the greater the angle of rotation. If the pulse is sufficient intensity

(duration), it will rotate the net tissue magnetization vector into the

transverse plane (XY plane), which is perpendicular to longitudinal

alignment (Z axis), and cause all the protons to precess in phase. This

45
is referred to as a 90-degree RF pulse or a flip angle of 90 degrees.

During an MR imaging sequence, many RF pulses with intensities can

be used, along with different times between repetitions of the

pulse.The net magnetization of the tissue in the transverse plane and

the amount of transverse magnetization that exists at the termination

of the RF pulse are equal to the amount of longitudinal magnetization

that existed just before the pulse. Both are directly proportional to the

strength of the static magnetic field and the number of hydrogen

nuclei (protons) present in the tissue. At this precise moment, a

maximal RF signal is induced in a receiver coil. The magnitude of this

signal represents information about the overall concentration of

hydrogen nuclei (proton density) in a sample of tissue, or about the

number of hydrogen nuclei in a sample of different types of tissue.

This signal depends not only on the presence or absence of hydrogen

but also on the degree to which hydrogen is bound within a molecule.

Tightly bound hydrogen atoms, such as those present in soft tissues

and liquids tilt and align to produce a detectable signal. The measure

of the concentration of loosely bound hydrogen nuclei available to

create the signal is referred to as the proton density or spin density of

the tissue in question. The higher the concentration of these nuclei of

loosely bound hydrogen atoms, the stronger the net magnetization at

equilibrium and at all degrees of excitement, the more intense the

recovered signal, and the lighter the MR image.As soon as the radio

46
 waves (the resonant, RF pulse) are turned off, two events occur

simultaneously – the radiation of energy and the return of the nuclei

to their original spin state at a lower energy. This process is called

relaxation and the energy loss is detected as a signal, which is called

free induction decay (FID):

 First, the nuclei in transverse alignment begin to realign themselves

with the main magnetic field (i.e., to relax), and net magnetization

regrows to the original longitudinal orientation. Relaxation is accom-

plished by a transfer of energy from individual hydrogen nuclei (spin)

to the surrounding molecules (lattice). The time constant that

describes the rate at which net magnetization returns to equilibrium

by this transfer of energy is called T1 relaxation time T1 varies with

different tissues and the ability of nuclei founder to transfer their

excess environment, A TI-weighted image is produced by a short

repetition time between RF pulses and a short signal recovery time.

Because Fl is an exponential growth time constant, a tissue with a

short TI produces an intense MR signal, displayed as bright white in a

TI-weighted image. A tissue with a long TI produces a low-intensity

signal and appears dark in the MR image.

 Second, the magnetic moments of adjacent hydrogen nuclei begin to

interfere with one another; this causes the nuclei to dephase, with a

resultant loss of transverse magnetization. The time constant their

describes the rate of loss of transverse magnetization is called the T2

47
relaxation time or transverse relaxation time. The transverse

magnetization rapidly decays (exponentially) to zero, as do the

amplitude and duration of the detected radio signals. A T2-weighted

image is acquired using a long reperition time between RF pulses and

a long signal recovery time. A tissue with a long T2 produces a high-

intensity signal and is dark in the image.

The FID relates signal intensity, to time. A mathematical technique

called the Fourier transform converts the relationship of signal

intensity versus time to signal intensity versus resonant frequency,

oscillating FID signal to a pulse of energy (current), the MR signal.

When FIDs are received from a mixture of tissues, as is the case when

a section of the body is examined, each volume of tissue generates a

different radio signal at different frequencies. The antenna does not

separate the individual signals; rather, they are summed to form a

complex FID signal. The Fourier transform also separates the complex

FID signal from the different tissues into its various frequency

components. This procedure is coupled with reconstruction

techniques similar to those used in CT to produce diagnostic images.

Image contrast among the various tissues in the body is manipulated

in MRI by varying the rate at which the RF pulses are transmitted. A

short repetition time (TR) of 500 msec between pulses and a short

echo or signal recovery time (TE) of 20msec produce a TI-weighted

image; a long TR (2000 msec) and a long TE (80 msec) produce a T2-

48
weighted image. For every diagnostic task, the operator must decide

which imaging sequence will bring out optimal image contrast. T1 –

weighted images are called fat images because fat has the shortest TI

relaxation time and the highest signal relative to other tissues and

thus appears bright in the image. High anatomic detail is possible in

this type of image because of good image contrast. T1-weighted

images are thus useful for depicting small anatomic regions (e.g., the

TMJ) where high spatial resolution is T2-weiglited images are called

water images because water has the longest T2 relaxation time and

thus appears bright in the image. In general, the T2 time of abnormal

tissues is longer than that of normal tissues. Images with T2

weighting are most commonly used when the practitioner is looking for

inflammatory or other pathological changes. T1 – weighted image are

more commonly used to demonstrate anatomy. In practice, images

often must be acquired with both TI and T2 to separate tissues the

several tissues by contrast resolution. Localization of the MR image to

a specific part of the body (selecting a slice) and the ability to create a

three-dimensional image depend on the fact that the Larmor frequency

of a nuclei is governed in part by the strength of the external magnetic

field. When this strength is changed in a gradient across a body of

tissue (selectively exciting the image slice), the Larmor frequency of

individual nuclei or groups of nuclei (voxels) in the gradient also

changes.

49
Three electromagnetic coils within the bore of the imaging magnet

produce this magnetic gradient. The coils surround the patient and

produce magnetic fields that oppose and redirect the magnetic flux in

three orthogonal or right angle directions to delineate individual

volumes of tissue (voxels), which are subjected to magnetic fields of

unique strength. Partitioning the local magnetic fields tunes all the

hydrogen protons in a particular voxel to the same resonant

frequency. This is called selective excitation. When an R-F pulse with

a range of frequencies is applied, a voxel of tissue tuned to one of the

frequencies is excited; when the RF radiation is terminated, the excited

voxel radiates that distinctive frequency, identifying and localizing it.

The bandwidth or spectrum of the RF pulse and the magnitude of the

slice-selecting gradient determine the slice thickness. Slice thickness

can be reduced by increasing gradient strength or decreasing the RF

bandwidth (frequency range).

MRI has several advantages over other diagnostic imaging procedures.

First, it offers the best resolution of tissues of low inherent contrast.

Although the x-ray attenuation coefficient may vary by no more than

1% between soft tissues, the spin density and T1 and T2 relaxation

times may vary by up to 40%. Second, no ionizing radiation is

involved with MRI. Third, because the region of the body imaged in

MRI is controlled electrically v, direct multiplanar imaging is possible

without reorienting the patient. Disadvantages of MRI include

50
relatively long imaging times and the potential hazard imposed by the

presence of ferromagnetic metals in the vicinity of’ the imaging

magnet. This latter excludes from MRJ any patient with implanted

metallic foreign objects or medical devices that consist of or contain

ferromagnetic metals (e.g; cardiac pacemakers, some cerebral

aneurysm clips). Finally, some patients suffer from claustrophobia

when positioned in a MRI machine.

Because of its excellent soft tissue contrast resolution, MRI has proved

useful in a variety of circumstances: diagnosing a suspected internal

derangement of the TMJ and evaluating the treatment of that

derangement after surgery; identifying and localizing orofacial soft

tissue lesions; and providing images of salivary gland parenchyma.

RADIONUCLIDE IMAGING:

This imaging provides the only means of assessing physiologic change

that is direct result of biochemical alteration. It is based on radiotracer

method, which assumes that radioactive atoms or molecules in an

organism behave in a manner identical to that their stable

counterparts because they are chemically indistinguishable.

Radiopharmeceutical used in scintigraphy is technetium labeled

phospate complexes. Adminstered intravenously in doses of 15-25

mCi.Data processing, including uniformity

correction,smoothing,reconstruction by filtered back projection is used

51
to produce images representing slices of two or more millimeters in

thickness.

Image interprtation: in normal individual, the perfusion is

symmetrical.

TMJ being perfused same rate as rest of facial structure

Immediate images no evidence of increased activity in the areas of the

TMJ.

Delayed images same activity in the region of the TMJ as in the areas

of the base of the skulls

Localizes in areas of osteoblastic activity by chemi –absorption with

immature apatite crystal.

The amount of absorption is dependent upon

- Degree of blood flow

- Bone remodeling

- Physiologic and hormonal factors influencing bone metabolism

INSTRUMENTATION-

- Intrinsic resolution of Gamma camera is less than 4mm

- Sensitivity of scintigraphy, compensates poor resolution

- Improved spatial resolution through (SPECT)- This technique

employs a gamma camera coupled to a computer

- The information may be reconstructed in different planes usually

sagittal, coronal, and transaxial

52
- Obtaining serial images at 3 seconds intervals following in injection

of the complex as a bolus.

- Perfusion increased in case of inflammation or extensive

osteoblastic activity.

TMJ ARTHROGRAPHY: -

Temporuniandibular arthrography utilizes the injection of radiopaque

material into on or both of the joint compartments to enhance the

contrast between the disc and spaces. The shape and position of the

disc are then inferred from the shapes of opacities above and below it.

The normal position of the TMJ disc is illustrated in Figure 16-1. The

thick posterior band of the disc lies superior to the condyle in the

closed mouth position. During opening, the condyles rotate, tightening

the collateral, ligaments and rotating the disc forward. The condyle

translates, coming into contact wi the anterior band and pushing the

disc forward as opening continues. The biconcave contour of the disc

helps hold it in position. During closing, the condyle returns to the

bma, pushing against the posterior band and returning the disc to the

fossa. The thinner intermediate zone remains between the two

articular surfaces throughout the range of motion, with the anterior

band remaining ahead of the condyll and the posterior band remainin

behind it.

53
The arthrograms reveal the normal position of the TMJ disc in Figures

16-1B – D. Contrast medium has been injected into the upper and

lower joint compartments. The radiolucent band between these

opacities represents the disc and the posterior attachment. The thicker

posterior band lies superior to the condyle in the closed mouth

position. During opening, as the condyle translates, the contrast

material is extruded from the anterior recesses of the joint spaces to

pool in the posterior recesses. Usually, in an arthrogram of a normal

TMJ, little contrast medium appears anterior to the condyle in the

closed mouth position and this volume is further reduced in the

opened mouth position. Throughout the range of motion, the posterior

band remains behind the condyle, the anterior band remians ahead,

and the thin intermediate zone remains between the two functional

surfaces.

The other major category of internal derangement is the anterior disc

displacement without reduction during opening. The displaced disc

can be deformed further or its ligamentous attachments stretched to

the extent that the posterior band remains anterior to the condyle

throughout the range of motion. Figure 16-3A reveals a flattened,

eroded, retropositioned condyle. This alteration in form is consistent

with a radiographic diagnosis of temporomandibular degenerative joint

disease (TMDJD). The relationship of TMDJD to disc derangement is

well documented in the literature.

54
The closed mouth arthrotomogram (Fig16-4B) reveals perforation of an

anteriorly displaced articular disc. In figure 16-4B, the disc appears as

a formless, radiolucent mass in the anterior part of the TMJ capsule.

There is no evidence of the posterior attachment dividing the joint into

upper and lower compartments. In the opened mouth view, (Fig 16-

4D), the condyle has translated downward and forward until it

contacts the remnants of the disc and posterior attachment.

Perforations usually occur in the bilaminar zone behind the posterior

band of the disc. Atthrographic evidence of perforation is seen

fluoroscopically during injection of the contrast medium into the lower

joint compartment. The radiopaque material can be seen flowing into

the upper joint space, and injection of this compartment becomes

unnecessary.

It would be a mistake to view these stages as distinct and separate

from each other. A disc displacement may occur intermittently for a

short time before becoming constant. Reduction of the disc can occur

with certain jaw motions, but not in others. Head posture can

influence reduction. In addition, the displaced disc can gradually

become distorted. Perforation is more common in cases with

nonreducing discs, but it can still occur in cases with anterior disc

displacement with reduction.

55
Single-space arthrography is less painful, faster, and involves less

radiation than double-space arthrotomography. These arthrograms are

usually transcranial or Schuler views with contrast medium in the

lower compartment; however, single-space arthrograms can be used.

Westesson and Bronstein demonstrated that disc position and

perforation can be determined by either method with equal accuracy.

However, opacifying both compartments gives more inforamtion

regarding disc contours and medial-lateral position of the disc.

The contrast medium has been injected, shown in Figure 16-6C. In

this normal arthrogram, only the small amount of contrast meduim

appears ahead of the condyle in the closed position (Fig. 16-6E).

Single-space arthrography is by necessity more dependent on

inferences regarding disc position made from observations of the size

and contour of the opacified lower compartment. Traditionally, the

anterior recess of the lower compartment is considered to be quite

small with a rounded triangular or symmetric teardrop shape. In the

opened mouth position (Fig 16-6D), the posterior band of the reduced

disc makes a depression behind the condyle and gives a sigmoid curve

to the superior margin of the opacified posterior recess of the lower

joint compartment.

The posterior band encroaches upon the posterior recess of the lower

compartment, giving it the characteristic, “half-heart” shape. When the

reduciton does not occur (16-8B), the opaque lower compartment has

56
a flat upper margin as the posterior attachment is pulled taut. The

concavity in the upper margin of opacified anterior recess of the lower

compartment can be made by the anterior band as well as by the

posterior band when the condyle is in the closed mouth position.

Double-contrast arthrography has advantages. Contrast medium is

injected first, followed by injection of air. This produces a radiopaque

line at the margins of the joint compartments without opacifying the

entire space. As a result, there is less of the extremely radiopaque

medium superimposing the fine, radiolucent anatomicstructures

within a thin tomographic image layer. The size and location of

perforations can be evaluated. 58** As with any radiographic

procedurethe additional time and effort involved need to be weighted

against the additional diagnoistic yield. Air arthrograms themeselves

can be used in the case of iodine allergy.

TECHNIQUE: -

High-yield Criteria

Arthrograms should be ordered only after a medical and dental history

and a thorugh physical examination of the patient. With a clear

understanding of the nature of the actual or suspected condition and

its response to the treatment in mind, the decision to use

arthrography rests on the professional judgement of the practitioner.

High-yeild criteria serve as patient selection guidelines and are the

basis of professional judgement. They are historical and clinical

57
findings that suggest that radiography will contribute to the proper

diagnosis and treatment of the patient. The purpose of an

arthrographic study is clear; it is for diagnosis and treatment

planning. Histroy and physical examinations are limited in their ability

to evaluate the extent of the pathology and to stage the preogression of

the derangement accurately.

Historical findings of value include pain in the preauricular area. Pain

might radiate to thje temporal and mandibular ramus areas. The

classic progression of the TMJ internal derangement with clicking,

following by momentary locking, and later limited jaw motion, is not

always present. According to Roberts and co-workers, 19 percent of

patients with arthrographic evidence of ante rior disc displacement

without reduction give no prior history of locking. Limited range of

motion is often a complaint in acute cases with nonreducing discs, but

patients with more chronic conditions may report apparently normal

opening ability. A change in the occlusion can occur when condylar

position is altered by displacement of the disc. Head and neck trauma

with facial pain and compromised jaw function can indicate the use of

arthrograms. jaw pain following intubation or complaints of jaw fatigue

or weakness at longer dental appointments could be evidence of TMJ

internal derangement.

58
Pertinent examination findings include the presence of TMJ clicking or

crepitus. However, disc reduction can occur without audible or visible

evidence. Incoordinate jaw movements may be an easier, less painful

way of reducing discs during opening or dislocating them during

closing. This can become an unconscious, learned behavior. Limited

opening with a deviation to the affected side and restricted lateral

movement to the opposite side is the classic description of a unilateral,

acute, nonreducing disc, but bilateral and more chronic displacement

is harder to diagnose clinically. Tenderness to palpation of the TMJ

capsule over its lateral pole or through the external auditory canal

suggests inflammation that could be associated with an internal

derangement. Chipped teeth or a facial scar might be the only

evidence of a forgotten injury.

Tomograms and transcranial views of the TMJ are useful, but they

have limitations. Condylar position is so variable that disc position

cannot be reliably inferred from the images. Although condylar

position is of no value in the determination of disc position in the

presence of temporomandiblar degenerative joint disease, internal de-

ngement and TMDJD are highly correated. In patients with highly

advanced rthritis featuring extremely narrowed joint paces,

arthrography is less necessary to emonstrate the severely altered and

dislaced disc that is almost certainly present. Arthrograms can

influence treatment planing. The outline of the disc and posterior

59
ttachment can help the surgeon to decide etween disc repair or disc

removal. The osterior band of cartilage might be made inner and

perforations removed as the posterior attachment is shortened. A

placation may be used if the posterior attachment is extremely thin.

Medial displacement may suggest shortening the lateral collateral lig-

ament. Lateral displacements could suggest meniscectomy.

Restricted disc movement or inability to inject the normal volume of

contrast medium suggests that adhesions are present.

Early stage anterior disc displacements with reduction on occasion

can be managed by repositioning the mandible 1 or 2 mm anterior to

the patient's habitual closure position, holding that position for several

months with an appliance and then re-establishing a good occlusion in

this new craniomandibular relationship. Manzione and colleagues,

reported that 46 percent of mandibular repositioning cases with the

treatment position determined by clinical findings rather than

arthrography failed to “capture” the disc. To reposition the mandible

anteriorly and to subject the patient to several months of treatment

followed possibly by extensive orthodontics or restorative care is hard

to justify if the prognosis is unaltered. There are more conservative

methods for relieving pain in the presence of the unresolved internal

derangement.

Ideally, arthrography should be used only when the diagnosis is

unclear and the arthrograms will affect the choice or course of

60
treatment. If the care provided is unaffected by the additional

information they yield, arthrograms should not be made. However, if

the clinical and radiographic findings were such that a TMJ internal

derangement was present and undiagnosed, failure to make this

diagnosis could lead to incorrect treatment or, at least, to decision

making without the correct information about the risks and benefits of

various treatment alternatives. A patient’s consent to treatment would

not be an informed consent, and the decision to forgo treatment would

not be based on an understanding of the nature of the problem

without treatment. In addition to these indications, some arthrog s, it

seems, are made for legal purposes.

Arthrographic Equipment: -

Arthrograms can be made with equipment as simple as a dental x-ray

unit and syringes of local anesthesic and contrast meduim. Opened

and closed transcranial or Schuler views of the TMJ with the lower

joint compartment opacified provide useful information. However, the

three-dimensional natur of the internal derangement and the contou

of the upper joint compartment as it extends downward laterally to

superimpose the lower compartment suggest that doublespace

arthrotomography can be superior to plain film arthrograms in

revealing more information regarding the pathology present.

The value of arthrography is enhanced by the use of fluoroscopy.

Needle placement must be precise, and the amount of contrast

61
medium injected can influence the diagnostic field as well as the level

of discomfort experienced by the patient. The flow of contrast during

opening adds to the information obtained from static images.

Videotaping these movements of the condyle and disc as they appear

on a television monitor can be very useful in the diagnosis of small

perforations or subtle movements of a biplanar disc as it is reduced or

partially reduced. Spot films of the closed, one-fourth opened, half-

opened, and fully opened positions are often made. The opening

position just prior to the disc reduction could te substituted, and

limited opening,Tay reduce the number of useful ex osures.

Patient Positioning: -

The patient lies on the fluoroscopy table in a semiprone position, with

the head turned to present the injection site to the operator. With the

patient lying partly on the side, the arm is down and behind the back

so that the chest rests on the table. The opposite arm is up and the

opposite knee bent to enable the patient to reduce the amount of

necessary head rotation. The head is tipped toward the table to shift

the image of the TMJ away from the base of the skull. The patient

should be able to maintain this natural and comfortable resting

position.

Asepsis: -

The patient’s hair is kept out of the field with a surgical scrub cap and,

when necessary, taped to cover a sideburns A subtle shave or clipping

62
of a few strands of hair may help. The preauricular area is cleaned

with povidine-iodine (Betadine). The area is isolated with an adhesive

aperture drape, or a cloth surgical drape with a 5 x 5 cm aperture, The

margins are adapted to the skin surface with more Betadine on a

sponge applicator. Arthmgraphy is contraindicated by the presence of

an infection in the TMJ, overlying skin, or adjacent structures. The

use of current asepsis guidelines on employing new needles,

disposable or autoclaved instruments and supplies, and covered work

surfaces needs no more discussion than this reminder.

Anesthesia: -

To anesthetize the TMJ and overlying structures, use a 27-gauge, 36-

mm needle and inject 1.0 ml of 2 percent lidocaine subcutaneously at

a point 5 mm anterior to the tragus. The patient opens the mouth to

the width of one finger, the condyle is palpated, and the needle

advanced in a forward, inward, and slightly upward direction until it

contacts the posterolateral aspect of the condyle. Aspirate, check for

hemorrhage, and then deposit 0.4 ml within the lower compartment.

Any resistance to the injection suggests that the needle is not within

the joint space. Next, inject the upper compartment. The point of

entry is 5 mm superior to the lower compartment site. With the

mouth opened wider, the needle is advanced toward the superior

aspect of the fossa. After contacting bone, withdraw the needle 1 to 2

mm, aspirate, and inject the last 0.4 ml in the cartridge. Anesthesia

63
occurs in 3 to 4 minutes. If pain during the procedure becomes a

problem, an auriculotemporal nerve block could be obtained by

injecting 1 to 1.8 ml of the lidocaine at a point 1 cm anterior to the

earlobe. The nerve becomes superficial as it wraps around the

posterior border of the mandibular ramus, then upward and forward

across the parotid gland toward the zygomatic arch. The needle tip is

positioned below the condylar neck behind the posterior border of the

ascending ramus. However, facial nerve parathesia is more common

with this injection and the patient will need postoperative instructions.

Opacifying the Lower Joint Compartment

When the area has been fully anesthetized, a new 27-gauge, 36-mm

needle or angiocatheter is positioned with its tip approximately 1 cm

anterior to the tragus of the ear. The lateral pole of the condyle is

palpated as the patient opens the mouth to the width of one finger.

The needle is placed on the skin surface overlying the condyle to

evaluate the relationship of needle tip to the superior aspect of the

condyle fluoroscopically. The needle tip should be aligned with the

superior aspect of the condyle because excessive upward angulation

during insertion may result in perforation into the upper compart-

ment. Advancing the needle with a 45-degree forward angulation and

15 degrees upward, the tip will contact the posterolateral aspect of the

condyle. The bevel is placed toward the condyle as the needle tip is

stepped medially to the posterosuperior aspect of the condyle. Tubing

64
with a closed stopcock is attachpd to the needle. The stop-cock is

opened, and during fluoroscopic observation 0.5 to 1.0 ml of contrast

medium is slowly injected. The patient can open and close the mouth

slowly to move the contrast medium in the anterior recess of the lower

compartment. During this injection, a perforation of the posterior

attachment or disc can be seen because the contrast would fill the

upper compartment as well. If resistance is immediately encountered

during the injection and the contrast remains near the needle tip

rather than spreading out to fill the entire compartment, the needle is

imbedded in the posterior attachment, disc, or articular cartilage of

condyle, or blood plugs the tip. When the contrast has filled the lower

compartment, the syringe is removed and the fluid level in the tube is

allowed to change and equalize pressure within the TMJ with the

surround structures. The stopcock is then closed.

Opacifying the Upper Joint Compartment-

Another needle is positioned fluoroscopically by aligning its tip with

the superior aspect of the glenoid fossa. The point of entry is 5 mm

superior to the lower compartment needle. The patient opens the

mouth more than halfway, and the needle is advanced inward in a

forward and upward direction. If the needle immediately encounters

bone, it is the lateral aspect of the fossa curving downward. The

needle should be removed and reinserted from a farther inferior

location with more upward angulation to reach the superior aspect of

65
the ‘fossa After contacting bone, the needle is then withdrawn 1 to 2

mm. Generally, more contrast can be injected into the upper com-

partment. The tubing is attached to the needle, the stopcock is

opened, and 1 to 1.5 ml of contrast is injected while the filling is

observed on the fluoroscope. Pressures are allowed to equalize as the

syringe is removed before the stopcock is closed. Both needles and

tubes are taped down securely to avoid displacement during head

positioning and jaw movement for the arthrotomograms.

Exposure

The beam is collimated as much as possible to increase contrast and

decrease the field of exposure. The head position determined with the

scout tomograms is re-established. The arthrotomograms seen in this

chapter were made on a Siemens Sieragraph Remote Control

Tomographic and Fluorographic Unit, with exposure factors of 65 to

75 kVp for a 400 speed film-screen combination, a 40-degree

tomographic angle to produce image layers 3 mm thick, and 60 mA at

a source-film distance of 42 inches. Closed, partially opened, and fully

opened views are made at several depths to appreciate the position of

the disc in all three dimensions.

Postoperative Instructions: -

Contrast can be aspirated and the joint compartment gently irrigated

with saline. The needles are then removed, and direct pressure is

applied to the preauricular area for a few minutes. The patient is

66
asked to sit up, postoperative instructions are given. At this time, the

patient’s response to the procedure can be further assessed. Patients

may feel a little swollen, and an ice pack can be used for a couple of

hours. At that time, the lidocaine will start to wear off and, as the

sensation returns, patients may have some discomfort. If they expect

it, generally Aspirin or Acetaminophen is adequate. However, operative

technique and patient variablity may modify this. Patients might feel

as if their teeth do not fit together. A softer diet is advised for the next

couple of meals. When patients are educcated properly, if one of the

infrequent adverse reaciton does occur, they will seek care promptly.

This is an important basis of sound professional care. Good

communication, shared goals, and respect are combined in the

educational aspect of the doctor-patient relationship.

67
References-

Oral and maxillofacial imaging Delbaso : 2nd edition

Temporomandibular disorder,diagnosis and treatment: Okeson 3rd edition

Oral radiology principles and interpretation :white and pharaoh 5 th edition

68