Diagnostic Imaging

of the
Temporomandibular
Joint

Anatomy of TMJ
CondyleGlenoid fossArticular eminenceInteraraticulardisk(Fibrous CT ,
divides joint cavity
into two sup. and
inf. )

Anatomy of TMJ

CONDYLAR MOVMENT
Normal full jaw opening is 40-50 millimetres as measured from edge of lower front teeth to
edge of upper front teeth
Condyle undergoes complex movment (sliding downward and forward , rotation)

Diagnostic Imaging of the TMJ

OSSEOUS*
STRUCTURES

Panoramic Projection(1
Plan film(2
Conventional Tomography( 3
Computed Tomography( 4

SOFT TISSUE STRUCTURES*

Arthrography( 1
Magnetic Resonance( 2
Imaging(MRI)

OSSEOUS STRUCTURES

Panoramic Projection(1:

.limited qualityonly grossly osseous changes in .condyle may be identified

.no info. about condyle position malignant tumor
Plan film(2
multiple tichniques (transcranial,transpharyngeal,transorbital and submentovertex)

Conventional Tomography( 3

.multiple image at right angles showing condyler position and osseous .changes
Computed Tomography( 4
.cant produce accurate images of the articular disk.useful for ankylosis ,neoplasms ,complex fracture-

sagittal

frontal

SOFT TISSUE STRUCTURES

Arthrography( 1

indirect image of the disk is obtained by injecting a radiopaque contrast agent into the join spaces under fluoroscopic guidance

Magnetic Resonance Imaging(MRI)( 2

MRI uses a magnetic field and radiofrequency pulses to -

produce multiple digital image slices

contraindicated in patients who are pregnant ,have pacemakers, intracranial vascular clips, or metal particles in vital
structures
disk
disk

Abnormalities of
Radiographic the
Temporomandibular Joint
:DEVELOPMENTAL ABNORMALITIES
Condylar Hyperplasia(1
Condylar Hypoplasia(2
Juvenile Arthrosis(3
Coronoid Hyperplasia(4
Bifid Condyle(5
:SOFT TISSUE ABNORMALITIES
Internal Derangement-

:Remodeling and Arthritic Conditions

Remodeling(1
Degenerative Joint Disease (2
Rheumatoid Arthritis(3
Juvenile Arthritis(4

Psoriatic Arthritis and Ankylosing

:Spondylitis
Septic Arthritis-

:Articular Loose Bodies

Synovial Chondromatosis(1
Chondrocalcinosis(2
:Trauma
Effusion(1
Dislocation(2
Fracture(3
Neonatal Fractures(4
Ankylosis(5
:Tumors
Benign Tumors(1
Malignant Tumors(2

DEVELOPMENTAL
ABNORMALITIES
:Condylar Hyperplasia(1
:Definition
developmental abnormality that results in enlargement and .deformity of the condylar head

:Clinical Features
more common in malesusually is discovered before the age of 20 yearsself-limiting and tends to arrest with termination of skeletal growthmandibular asymmetrychin may be deviated to the unaffected sideincrease in the vertical dimension of the affected sideposterior open bite on the affected sidelimited mandibular opening-

Radiographic Features
Condyle enlarged ,altered in shape and more radiopaque glenoid fossa may be enlarged ramus and mandibular body on the affected side also may be enlarged -

Differential Diagnosis: osteochondroma

Treatment :orthodontics combined with orthognathic surgery

: Condylar Hypoplasia(2
:Definition
failure of the condyle to attain normal size:Clinical Features
mandibular growth deficiencyunilateral or bilateralmay be associated with congenital defects of the ear and zygomatic arch mandibular asymmetrychin commonly is deviated to the affected side: Radiographic Features
Small condyl and fossaramus and mandibular body on the affected side may also be small mandibular asymmetrycondylar neck and coronoid process usually are very slender and areshortened

hypoplasi
a

minimum involvement of the mandibular ramus and

.body

Differential Diagnosis:
-juvenile rheumatoid arthritis

Treatment :
-Orthognathic surgery, bone grafts, and orthodontic therapy

:Juvenile Arthrosis(3
:Definition
condylar growth disturbance, manifests as hypoplasia but is thought todiffer in that the affected condyle at one time was normal, becoming
.abnormal during growth

:Clinical Features
unilateral or bilateralmore common in femalesmay have mandibular asymmetry-

: Radiographic Features
.toadstool appearance-
condylar neck is shortened or even absent in someflattening and apparent elongation of the articulating condylar surface anddorsal (posterior) inclination of the condyle and neck

toadstool
appearance

:Differential Diagnosis
hypoplasia of the condyle-

: Treatment
Orthognathic surgery and orthodontic therapy-

:Coronoid Hyperplasia(4
:Definition
elongation of the coronoid process-

:Two types
Developmental
usually bilateralAcquired
unilateral or bilateral:Clinical Features
Bilateral developmental coronoid hyperplasia is more common in males.inability to open the mouth.painless: Radiographic Features
coronoid processes are elongatedcoronoid processes may impinge on the medial surface of the zygomatic archduring opening

closed
mouth

impingement of hyperplastic coronoid

processes
open mouth

axial CT images

:Differential Diagnosis
.tumor of the coronoid (osteochondroma or osteoma).ankylosis-

: Treatment
surgical removal of the coronoid process andpostoperative physiotherapy

:Bifid Condyle(5
:Definition
vertical depression, notch, or deep cleft in the center of the condylar head :Clinical Features
RareMore often unilateral.Symptoms of temporomandibular dysfunction (joint noises and pain) : Radiographic Features
.depression or notch is present on the superior condylar surface.heart shape:Differential Diagnosis
vertical fracture through the condylar head: Treatment
Treatment is not indicated unless pain orfunctional impairment is present

glenoid fossa has

remodeled

heart shape
Sagitt
al

Corona
l

:SOFT TISSUE ABNORMALITIES

:Internal Derangement:Definition
abnormality in the position and sometimes the morphology of the articular .disk that may interfere with normal function
:Clinical Features
Symptomatic or asymptomatic(1
Symptomatic patients may have a decreased range of mandibular motion(2
unilateral or bilateral(3
: Radiographic Features
MRI is the technique of choice
The normal disk has a low signal intensity

:Disk Displacement
Anterior displacement is the most commonindication of anterior displacement is positioning of the posterior band forward so that it sits between the anterosuperior surface of
the
.condyle and the eminence (hard to identify)

posterior
band

anterior disk

NORMA

:Disk Reduction and Nonreduction

:Perforation and Deformities

Perforations between the superior and inferior joint spacesenlargement of the posterior bandmay be increase the intensity-

:Fibrous Adhesions and Effusion

Fibrous adhesions: fibrous tissue or scar tissue that form inthe joint space, particularly after TMJ surgery
Joint effusion: fluid in the joint-

Perforation

joint
effusion

:Tumors

Benign Tumors(1
The most common
Osteomas(1
Osteochondromas
most common(2
Langerhans histiocytosis(3
osteoblastomas(4

Less common
Chondroblastomas(1
fibromyxomas(2
benign giant cell lesions(3
aneurysmal bone cysts(4

:Clinical Features
grow slowly(1
TMJ swelling(2
accompanied by pain(3
decreased range of motion(3
facial asymmetry(4
Malocclusion(5
: Radiographic Features
Condylar tumors
condylar enlargement, irregular outline, trabecular pattern .altered
Osteoma or osteochondroma
appears as an abnormal, pedunculated mass attached to the .condyle

:Differential Diagnosis
.condylar hyperplasiacoronoid hyperplasia-

: Treatment
.surgical excision of the tumor-

osteochondrom

Malignant Tumors(2
:Primary
,chondrosarcoma
,osteogenic sarcoma
synovial sarcoma
fibrosarcoma of the joint capsule

:Metastatic
originating in the breast, kidney, lung, colon, prostate, and
.thyroid gland

:Clinical Features
asymptomatic or patients may have symptoms of TMJ dysfunction such as pain, limited mandibular opening, mandibular deviation,
.and swelling
: Radiographic Features
Variable degree of bone destruction with ill-defined, irregular .margins
.CT
view bone involvement.MRI
view soft tissues involvement:Differential Diagnosis
. severe Degenerative Joint Disease: Treatment
.primary
Metastatic

Wide surgical removal of the tumorpalliative , radiotherapy and chemotherapy -

radiopacities (soft tissue

calcifications)

radiolucent destructive lesion in condylar

head

Chondrosarcoma

Remodeling and Artritis conditions

Remodeling(1:
:Definition
is an adaptive response of cartilage and osseous tissue to forces applied to the
joint that may be excessive, resulting in alteration of the shape of the condyle

.and articular eminence

Clinical Features:
.may be asymptomatic.or patients may have signs and symptoms of temporomandibular dysfunction .internal derangement of the disk -

Radiographic Features:
.changes may affect the condyle, temporal component,or both :The radiographic appearance may include one or a combination of the following flattening*
cortical thickening of articulating surfaces *
subchondralsclerosis*

Subchondral sclerosis
& flattening
sagittal

.Differential Diagnosis:

coronal
degenerative joint disease

:Treatment
No clinical signs or symptoms are presents >>> no treatment indicated.Stress on the joint>>>treatment indicated ( splint therapy )-

Degenerative joint disease (Osteoargitis)(2

Definition:
is a non-inflammatory disorder of joints characterized by ( DJD )
: joint deterioration-1
loss of the articular cartilage and bone erosion>>>more common in acute
disease
:proliferation-2
new bone formation at the articular surface and in the subchondral region>>>in
.chronic disease
.etiology is unknownfactors may be important, including acute trauma, hypermobility, and loading .of the joint

:Clinical features
.occur at any age.female preponderanceThe disease may be asymptomatic, or patients may complain of signs and symptoms of
.TMJ dysfunction
The onset of symptoms may be sudden or gradual, and symptoms may disappear spontaneously

:Radiographic Features
Loss of cortex or erosions of the articulating surfaces of the condyle or .temporal component (or both)
In some cases small, round, radiolucent areas with irregular marginssurrounded by
a varying area of increased density are visible deep to the articulating
Surfaces >>> called Ely or subchondral bone cysts>>> they are areas
.of degeneration

Ely cyst

Thin joint
space

Later in the course of the disease, bony proliferation occurs at the periphery of the articulating surface, increasing the articulating surface area. This new bone is
.called an osteophyte

flattening
Joint
mouse

erosions

osteophyte

:Differential Diagnosis
rheumatoid arthritisosteomaosteochondroma-

:Treatment
,relieving joint stress (splint therapy), relieving secondary inflammation with anti-inflammatory drugs.And increasing joint mobility and function (physiotherapy)-

3)Rheumatoid Arthritis( RA)

Definition:
is a heterogeneous group of systemic disorders that manifests mainly as synovial ( RA)
.membrane inflammation in several joints
.The TMJ becomes involved in approximately half of affected patients -

:Clinical Features
.common in females and can occur at any age.Usually the small joints of the hands, wrists, knees, and feet.The chin appears receded(anterior open bite).TMJ involvement usually is bilateral and symmetric-

Radiographic Features
.generalized osteopenia>> initial changesBone erosions by the pannus involve the articular eminence and the anterior aspect of the condylar >>>anterior open bite
Subchondral sclerosis and flattening of articulating surfaces,subchondral cyst .and osteophyte formation
.Fibrous ankylosis or osseous ankylosis, may occur-

Sharped pencile
appearance

Open bite

Irregular surface of the condyle

&articular eminence >fibrous ankylosis

Oblique-sagittal CT image shows osteophyte

. formation (arrow)

:Differential Diagnosis
severe DJD.Psoriatic arthritis(may be ruled out by the patients history)

Treatment:
pain relief (analgesics),reduction or suppression of inflammation (non-steroidal anti-inflammatory drugs(gold salts, corticosteroids
.preservation of muscle and joint function (physiotherapy)Joint replacement surgery may be necessary in patients with severe joint.destruction

Juvenile Arthritis(Stills disease)(4

:Definition
is a chronic inflammatory disease that appears before the age of 16 years (the
. mean age is 5 years)
It is characterized by chronic, intermittent synovial inflammation that results in .synovial hypertrophy, joint effusion, and swollen, painful joints
TMJ involvement occurs in approximately 40% of patients and may be unilateral or .bilateral

Clinical Features:
.pain and tenderness in the affected joint or joints.can be asymptomaticUnilateral onset is common, but contra-lateral involvement may occur as the .disease progresses
.Severe TMJ involvement results in inhibition of mandibular growthAffected patients may have micrognathia and posteroinferior chin rotation>> bird ,face
.which may also be accompanied by an anterior open bite

Radiographic Features:
Osteopenia of the affected TMJ components may be the only initial radiographic .finding
findings are similar to those for the adult form except for the addition of impaired.mandibular growth
, Manifestations of inhibited mandibular growth***
such as deepening of the antegonial notch, diminished height of the ramus, and
dorsal bending of the ramus and condylar neck, also may occur unilaterally or
bilaterally>>>obtuse angle
Erosions may extend to the mandibular fossa, and the articular eminence may be .destroyed
As a result of bone destruction, the condylar head typically is positionedanterosuperiorly in the mandibular fossa
Erosin of
eminence

Erosions may extend to the mandibular fossa, and.the articular eminence may be destroyed

Oblique-sagittal image shows wide flat fossa and condyle, with

sclerosis

Psoriatic Arthritis and Ankylosing Spondylitis

Septic Arthritis
:Definition
.Septic arthritis is infection and inflammation of a joint that can result in joint destruction

Clinical Features:
.any age, no sex predilection. It usually occurs unilaterally .The mandible may be deviated to the unaffected side as a result of joint effusion -

Radiographic Features:
.No radiographic signs may be present in early stages of the disease.Osteopenic changes (joint and ramus )More obvious bony changes are seen approximately 7 to 10 days after the onset of.clinical.S
As a result of the osteolytic effects of inflammation, the condylar articular cortex may become slightly radiolucent, erosions of the surface of the condyle and articular
eminence may be seen, sequestra may become apparent, and there may be
.periosteal new bone formation

Differential Diagnosis:
Inflammatory changes may be seen in
CT images, such as involvement of mastoidair cells, osteomyelitis of the mandible,(1
.and inflammation of surrounding soft tissue
MRI, muscle enlargement, joint effusion, or abscess( 2.

Treatment
, antimicrobial therapydrainage of effusion.joint restPhysiotherapy to re-establish joint mobility is initiated after the acute phase of infection has passed
coronal
Erosions, sclerosis &
periosteal reaction extend
along back and lateral
neck of the condyle

sagittal

Axial

Articular Loose Bodies

1) Synovial Chondromatosis
Synovial chondrometaplasia ,Osteochondromatosis
Definition:
uncommon disorder characterized by metaplastic formation of multiple
cartilaginous and osteocartilaginous nodules within connective tissue of the
.synovial membrane of joints

Clinical Features
may be asymptomaticmay complain of preauricular swelling, pain, and decreased range of motion and .joint noises
.usually unilaterally-

:Radiographic Features
The joint space may be widened, and if ossification of the cartilaginous nodules has occurred, a radiopaque mass or several radiopaque loose bodies may be
.seen surrounding the condylar head
.Sclerosis of the glenoid fossa and condyle may be seenerosion through the glenoid fossa into the middle cranial fossa may occur>>CT -

panoramic

:Differential Diagnosis
DJD with joint micechondrosarcoma.osteosarcoma-

Treatment:

removal of the loose bodies and resection of

abnormal synovial tissue in the joint by arthroscopic
.or open joint surgery

Axial CT image
multiple ossified bodies
surrounding the
condyle and within the joint
.capsule

Chondrocalcinosis(2
Pseudogout and calcium pyrophosphate dihydrate deposition
disease
Definition:
Chondrocalcinosis is characterized by acute or chronic synovitis and precipitation of
.calcium pyrophosphate dihydrate crystals in the joint space

:Clinical Features
.TMJ involvement is uncommon.occurs unilaterally ,,more common in males.asymptomatic or may complain of pain and joint swelling-

:Radiographic Features
Often the radiopacities within the joint space are finer and have a more even -
.distribution than in osteochondromatosis
.Bone erosions and a severe increase in condylar bone density.Erosion of the glenoid fossa may be present.Soft tissue swelling and edema of the surrounding muscles-

:Differential Diagnosis
DJD with joint micechondrosarcomaosteosarcoma-

Treatment:

calcifiations anterior to the right condyle and the

large erosion involving the medial pole of the
.condyle

.surgical removal of the crystalline deposits

Steroids, aspirin, and nonsteroidal anti-infl ammatory agents may
provide relief. Colchicine may be used to alleviate acute symptoms and
.for prophylaxis

Trauma

Effusion(1
Definition:

Effusion is an influx of fluid into the joint, usually as a result of trauma (hemorrhage)
or
.inflammation (exudate)

:Clinical Features
.swelling & pain in the TMJ, preauricular region, or ear; and limited range of motion Patients may also complain of the sensation of fluid in the ear, tinnitus, hearing .difficulties

Radiographic Features:
more commonly seen in conjunction with internal derangements, although it has .been described in normal joints
, The joint space is widenedMRI studies may show a bright signal (white), indicating fluid adjacent to the disk or posterior to the condyle
Differential Diagnosis:
.septic arthritis; in the latter case>>signs and symptoms of infection are present Treatment:
anti-inflammatory drugs, although surgical drainage of the effusion occasionally is .necessary

collection of joint effusion (arrowheads) in

the anterior recess of the upper joint space

the joint effusion (arrowheads) in the

anterior and posterior recesses of the
(. upper joint space

Dislocation(2

Definition:

abnormal positioning of the condyle out of the mandibular fossa but within the .joint capsule
.It usually occurs bilaterally and most commonly in an anterior direction-

Clinical Features:
In anterior dislocation, patients are unable to close the mandible to maximal .intercuspation
.In the former case associated pain and muscle spasm often are present-

Radiographic Features:
In bilateral cases both condyles are located anterior and superior to the summits of
.the articular eminentia

:Differential Diagnosis
CT or tomography is essential for diagnosis because routine plain film views maynot show
.the dislocation because of anatomic superimpositions

Treatment:
Surgery occasionally is necessary to reduce the condyle in the case of a fracture ,dislocation
.treatment may not be indicated if mandibular function is adequate-

Fractures(3
Definition:
Fractures of the TMJ usually occur at the condylar neck and often are
.accompanied by dislocation of the condylar head

Clinical Features:
.Unilateral fracturesIf a condylar fracture occurs during the period of mandibular growth, growth may.be inhibited because of damage to the condylar growth center
Injury to the joint may result in hemorrhage or effusion into the joint spaces:Radiographic Features
.TMJ remodeling after a condylar fracture-

The condyle show degenerative changes,(flattening, erosion, osteophyte . formation, ankylosis

associated with damage of the intracapsular soft tissues, with hemarthrosis .and joint effusion

Condylar neck
. fracture

Open Towne s view of a compression

fracture of the right condylar head
(arrow)

Differential Diagnosis:
. developmental abnormalities of the condyle-

Treatment:
;Treatment may not be indicated if mandibular mobility is adequate
.otherwise, the fracture is reduced surgically

Neonatal Fractures(4
The use of forceps during delivery of neonates may result in fracture and
displacement of the rudimentary condyle, which later manifests as severe
mandibular hypoplasia and lack of development of the glenoid fossa and articular
.eminence

Differential Diagnosis:
.developmental hypoplasia of the mandible, which is unrelated to birth injury
Treatment:
The fracture usually is not treated, but the mandibular asymmetry may be corrected
.with a combination of orthodontics and orthognathic surgery

Ankylosis(5

Definition:

Ankylosis is a condition in which condylar movement is limited by amechanical problem in the joint ( true ankylosis) or by a mechanical
.cause not related to joint components ( false ankylosis)
. True ankylosis may be bony or fibrous**
In bony ankylosis the condyle or ramus is attached to the temporal or zygomatic.bone by an osseous bridge
In fibrous ankylosis a soft tissue (fibrous) union of joint components occurs; the.bone components appear normal

Clinical Features
.Most unilateral cases are caused by mandibular trauma or infectioncommon cause of bilateral TMJ ankylosis is rheumatoid arthritis, although in rare.cases bilateral fractures may be the cause
Most if not all cases of TMJ ankylosis in infancy occur as a result of.birth injury
Patients have a history of progressively restricted jaw.opening, or they may have a long-standing history of limited opening

Radiographic Features:
In fibrous ankylosis the articulating surfaces are usually irregular because of .erosions
The joint space is usually very narrow and the two irregular surfaces may appear to .fit one another
.This extensive new bone may fuse the condyle to the cranial baseIf ankylosis occurs before mandibular growth is complete, growth of the affected .side of the mandible is inhibited

Differential Diagnosis:
.condylar tumor.neoplastic disease:Treatment
Joint mobility is improved by surgical removal of the osseous bridge or
creation of a pseudarthrosis

THANK YOU
SAEED ALYAFAWY
AND
DEENA RAMADAN