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Diagnostic Imaging of theTemporomandibular Joint          Fares H. Hanafieh & Fahad F. Salehi
 What is the Temporomandibular joint? Unique in that it constitutes of two separate joints  anatomically and they functi...
 CONDYLE:-   Shape of condyle varies considerably-    Superior aspect maybe flattened,     rounded or markedly convex-   ...
 MANDIBULAR FOSSA: Composed of the glenoid fossa and atricular eminence. INTERARTICULAR DISK: - Between condylar head an...
Disorders of the temporomandibular joint areabnormalities that interfere with the normal form or                function o...
Disorders of the      Temporomandibular Joint1- Developmental Abnormalities2-   Soft Tissue Abnormalities
 Developmental Abnormalities:1- Condylar Hyperplasia2- Condylar Hypoplasia3- Juvenile Arthrosis4- Coronoid Hyperplasia5- ...
1- Condylar Hyperplasia:  - Enlargement and deformity of the condylar head  - Secondary effect on the mandibular fossa as ...
   Radiographic Features:   May appear normal but symmetrically enlarged   Maybe more radiopaque due to additional bone...
 Treatment: Orthodontics combined with orthognathic surgery
 2- Condylar Hypoplasia Failure of the condyle to attain normal size because of  congenital and developmental abnormalit...
 Radiographic Features: The condylar neck and coronoid process usually are very slender  and are shortened or elongated ...
 3- Juvenile Arthrosis: Manifests as hypoplasia and characteristic morphologic  abnormalities May be a form of condylar...
 Radiographic appearance: Condylar head develops a characteristic “toadstool” appearance Condylar neck is shortened or ...
 4- Coronoid Hyperplasia: - acquired or developmental - elongation of the coronoid process - developmental -> bilatera...
 - Radiographic features: Best seen in panoramic,  Waters, and lateral tomographic views and on CT scans TMJs usually a...
 5- Bifid Condyle: Vertical depression,  notch, or deep cleftin the center of the condylar head Rare, often unilateral...
 D/D: Vertical fracture through the condylar head Treatment: Not indicated unless pain or functional  impairment is pres...
Soft Tissue Abnormalities Internal Derangements - abnormality in the articular disc and  may interfere with normal functi...
 Radiographic Features: - MRI is the technique of choice Disc Displacement: - Anterior displacement is most common - ...
 Perforation and Deformities: - perforations between the superior and inferior joint spaces  most commonly occur in the ...
Remodeling and Arthritic conditions 1- Remodeling: - Adaptive response of cartilage and osseous tissue to forces  applie...
 - Radiographic Features: - flattening - cortical thickening of articulating surfaces - subchondral sclerosis -D/D: f...
   2- Degenerative joint disease (osteoarthritis):   - non inflammatory disorder of the     joints characterized by     ...
 D/D: - Erosive appearance  inflammatory arthritides (rheumatoid  arthritis) - Proliferative appearance with extensive...
 3- Rheumatoid Arthritis: - Synovial membrane inflammation - Patients with TMJ involvement complain of swelling, pain, ...
 D/D: severe DJD and psoriatic arthritis and osteopenia Treatment: - pain relief (analgesics) - anti inflammatory drug...
 4- Juvenile Arthritis: - Inflammatory disease that is characterized by chronic, intermittent  synovial inflammation - ...
 Radiographic features: - Osteopenia (decreased density) maybe only an initial  radiographic finding - Impaired mandibu...
Psoriatic Arthritis and                               Akylosing SpondylitisSeptic Arthritis: Infection and inflammation of...
 Radiographic Features:- No radiographic signs may be present in early stages of  the disease- Osteopenic (radiolucent) c...
 D/D: radiographic changes caused by septic arthritis  may mimic those of severe DJD or RA Treatment:- Antimicrobial the...
Articular Loose Bodies-   Radiopacities of varying origin located in the joint synoviom, within the    capsule in the join...
 Radiographic Features:- Osseous components may appear normal or may exhibit  osseous changes similar to those in DJD- Sc...
2- Chondrocalcinosis:- Characterized by acute or chronic synovitis and  precipitation of calcium pyrophosphate dihydrate  ...
 Radiographic Features:-   May simulate synovial chondromatosis-   Bone erosions and severe increase in condylar bone den...
Trauma1- Effusion:- Influx of fluid into the joint as a result of trauma  (hemorrhage or inflammation)- Swelling over affe...
 Radiographic Features:- Commonly seen in conjunction with internal  derangements- Joint space is widened* D/D: septic ar...
2- Dislocation:- Abnormal positioning of the condyle out of the mandibular fossa  but within the joint capsule- Unable to ...
3- Fracture:- Usually occur at condylar neck and often are  accompanied by dislocation of the condylar head- Unilateral fr...
 Radiographic features:- Radiolucent line limited to the outline of the neck is  visible- If bone fragments overlap, an a...
4- Neonatal Fracture:- Use of forceps during delivery of neonates may result in  fracture and displacement of the rudiment...
5- Akylosis:-    Condition in which condylar movement is limited by a mechanical problem in     the joint or by a cause no...
Tumors- Intrinsic or extrinsic- Intrinsic develop in condyle, temporal bone or coronoid  process- Extrinsic tumor may affe...
1- Benign Tumors:- Osteoma, osteochondroma, Langerhans histocytosis and osteoblastomas- Chondroblastomas, fibromyxomas, be...
* Radiographic Features:- Condylar tumors  condylar enlargement with irregular  outline- Osteoma and osteochondroma appea...
2- Malignant Tumors:A- Primary (rare): - Intrinsic                       - ExtrinsicIntrinsic: Chondrosarcoma           Os...
B- Metastatic (more common)-   May be asymptomatic or patients may have symptoms of TMJ dysfunction    (pain, limited mand...
Thank you
Radiographic imaging of TMJ
Radiographic imaging of TMJ
Radiographic imaging of TMJ
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Radiographic imaging of TMJ

Radiographic imaging of TMJ. Dia

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Radiographic imaging of TMJ

  1. 1. Diagnostic Imaging of theTemporomandibular Joint Fares H. Hanafieh & Fahad F. Salehi
  2. 2.  What is the Temporomandibular joint? Unique in that it constitutes of two separate joints anatomically and they function together as a single unit Consists of: Condyles Articular Disc Mandibular Fossa Has a fibrous capsule that surrounds and encloses the joint
  3. 3.  CONDYLE:- Shape of condyle varies considerably- Superior aspect maybe flattened, rounded or markedly convex- Mediolateral contour is usually slightly convex- Variations in shape may cause difficulty with radiographic interpretation- Extreme aspects of the condyle are the medial pole and lateral pole
  4. 4.  MANDIBULAR FOSSA: Composed of the glenoid fossa and atricular eminence. INTERARTICULAR DISK: - Between condylar head and mandibular fossa - Biconcave shape
  5. 5. Disorders of the temporomandibular joint areabnormalities that interfere with the normal form or function of the joint
  6. 6. Disorders of the Temporomandibular Joint1- Developmental Abnormalities2- Soft Tissue Abnormalities
  7. 7.  Developmental Abnormalities:1- Condylar Hyperplasia2- Condylar Hypoplasia3- Juvenile Arthrosis4- Coronoid Hyperplasia5- Bifid Condyle
  8. 8. 1- Condylar Hyperplasia: - Enlargement and deformity of the condylar head - Secondary effect on the mandibular fossa as it remodels toaccommodate the abnormal condyle Etiology: Trauma, infection, hereditary More common in males Self limiting Progresses slowly or rapidly Mandibular asymmetry Chin deviated to the affected side
  9. 9.  Radiographic Features: May appear normal but symmetrically enlarged Maybe more radiopaque due to additional bone present Condylar neck may be elongated Glenoid fossa may also be enlarged Ramus and mandibular body on the affected side also may be enlarged, resulting in a characteristic depression of the inferior mandibular border The affected ramus may have increased vertical depth and may be thicker in the anteroposterior dimension D/D: - Osteochondroma - Condylar osteoma or osteophyte that occurs in chronic degenerative joint disease
  10. 10.  Treatment: Orthodontics combined with orthognathic surgery
  11. 11.  2- Condylar Hypoplasia Failure of the condyle to attain normal size because of congenital and developmental abnormalities or acquired diseases that affect condylar growth. The condyle is small, but condylar morphology is normal Underdeveloped ramus and occasionally mandibular body Unilateral or bilateral
  12. 12.  Radiographic Features: The condylar neck and coronoid process usually are very slender and are shortened or elongated in some cases The ramus and mandibular body on the affected side may also be small, resulting in a mandibular asymmetry and occasional dental crowding, depending on the severity of mandibular underdevelopment D/D: Juvenile rheumatoid arthritis and arthritic conditions Treatment: orthognathic surgery bone grafts orthodontic therapy maybe required
  13. 13.  3- Juvenile Arthrosis: Manifests as hypoplasia and characteristic morphologic abnormalities May be a form of condylar hypoplasia It affects children and adolescents during the of mandibular growth More common in females Incidental finding in a panoramic projection
  14. 14.  Radiographic appearance: Condylar head develops a characteristic “toadstool” appearance Condylar neck is shortened or even absent in some cases D/D: developmental hypoplasia rheumatoid arthritis* Treatment: orthrognathic surgery orthodontic therapy
  15. 15.  4- Coronoid Hyperplasia: - acquired or developmental - elongation of the coronoid process - developmental -> bilateral acquired -> uni or bilateral - inability to open mouth - painless
  16. 16.  - Radiographic features: Best seen in panoramic, Waters, and lateral tomographic views and on CT scans TMJs usually appear normal -D/D: Unilateral cases should be differentiated from a tumor of the coronoid process (osteochondroma or osteoma) Unlike coronoid hyperplasia, tumors have an irregular shape -Treatment: surgical removal or the coronoid process and postoperative physiotherapy
  17. 17.  5- Bifid Condyle: Vertical depression, notch, or deep cleftin the center of the condylar head Rare, often unilateral Incidental finding Some patients may have sings of TMDs (noises + pain) Radiographic Features: Depression on the superior condylar surface giving a heart shape
  18. 18.  D/D: Vertical fracture through the condylar head Treatment: Not indicated unless pain or functional impairment is present
  19. 19. Soft Tissue Abnormalities Internal Derangements - abnormality in the articular disc and may interfere with normal function - Cause is unknown - Internal derangements can be diagnosed by MRI Clinical Features: - found in both symptomatic and healthy pts - symptomatic pts may have a decreased range of mandibular motion -displacements may be unilateral or bilateral
  20. 20.  Radiographic Features: - MRI is the technique of choice Disc Displacement: - Anterior displacement is most common - The articular disc is located anterior to the condylar head Disk reduction and nonreduction: - reduction is when an anteriorly displaced disk may reduce to a normal relationship with the condylar head during any part of the mouth opening movement - nonreduction is when the disk remains anteriorly displaced and will undergo permanent deformation.
  21. 21.  Perforation and Deformities: - perforations between the superior and inferior joint spaces most commonly occur in the retrodiskal tissue, just behind the posterior band of the disk - Not reliably detected with MRI Fibrous Adhesions and Effusion: - Fibrous adhesions are masses of fibrous or scarred tissue that form in the joint space, particularly after TMJ surgery - Joint Effusion means fluid in the joint and is considered to be and early change that may precede degenerative joint disease - Both can be detected by MRI
  22. 22. Remodeling and Arthritic conditions 1- Remodeling: - Adaptive response of cartilage and osseous tissue to forces applied to the joint that maybe excessive, resulting in alteration of the shape of the condyle and articular eminence - no destruction or degeneration of articular soft tissue occurs - occurs throughout adult life - considered abnormal only if it is accompanied by clinical signs and symptoms of pain or dysfunction
  23. 23.  - Radiographic Features: - flattening - cortical thickening of articulating surfaces - subchondral sclerosis -D/D: flattening and subchondral sclerosis maybe difficult to differentiate from early degenerative joint disease - Treatment: - Only indicated when signs and symptoms are present. (ex. Splint therapy)
  24. 24.  2- Degenerative joint disease (osteoarthritis): - non inflammatory disorder of the joints characterized by joint deterioration and proliferation - can occur at any age (incidence increases with age) - female predominance - asymptomatic or pts may complain of signs + symptoms of TMJ dysfunction - Radiographic features: - more accurately seen in CT but gross osseous changes maybe evident in MRI studies At the maximum intercuspation joint space may be narrow or absent Loss of cortex or erosions of the articulating surfaces of the condyle or temporal component are characteristics of this disease
  25. 25.  D/D: - Erosive appearance  inflammatory arthritides (rheumatoid arthritis) - Proliferative appearance with extensive osteophyte formation  benign tumor  osteoma or osteochondroma Treatment: - Relieving joint stress (e.g. Splint therapy) - relieving secondary inflammation with anti-inflammatory drugs - Increasing joint mobility and function  physiotherapy
  26. 26.  3- Rheumatoid Arthritis: - Synovial membrane inflammation - Patients with TMJ involvement complain of swelling, pain, tenderness, stiffness on opening, limited range or motion, and crepitus - Radiographic Features: - Osteopenia (decreased density) of the condyle and temporal component - erosion of anterior and posterior condylar surfaces if erosion is severe  condylar head is destroyed
  27. 27.  D/D: severe DJD and psoriatic arthritis and osteopenia Treatment: - pain relief (analgesics) - anti inflammatory drugs - physiotherapy - surgery (joint replacement)
  28. 28.  4- Juvenile Arthritis: - Inflammatory disease that is characterized by chronic, intermittent synovial inflammation - results in: synovial hypertrophy, joint effusion, and swollen, painful joints -pain and tenderness of affected joint or joints - can be asymptomatic - unilateral is common - facial appearance known as “bird face” - possible mandibular asymmetry if one side is more severely affected
  29. 29.  Radiographic features: - Osteopenia (decreased density) maybe only an initial radiographic finding - Impaired mandibular growth - Severe cases: only pencil shaped small condyle remains - Abnormal disk shape is often observed in patients with TMJ involvement
  30. 30. Psoriatic Arthritis and Akylosing SpondylitisSeptic Arthritis: Infection and inflammation of a joint that can result in jointdestruction- Affects any age- No sex predilection- Occurs unilaterally- Redness and swelling over joint- Trismus- Severe pain on opening- Inability to occlude the teeth- Large, tender cervical lymph nodes- Fever and malaise
  31. 31.  Radiographic Features:- No radiographic signs may be present in early stages of the disease- Osteopenic (radiolucent) changes of the joint components and mandibular ramus may be evident (7-10 days after onset of clinical symptoms)- Osseous ankylosis may occur after infection subsides
  32. 32.  D/D: radiographic changes caused by septic arthritis may mimic those of severe DJD or RA Treatment:- Antimicrobial therapy- Drainage of effusion and joint rest- Physiotherapy
  33. 33. Articular Loose Bodies- Radiopacities of varying origin located in the joint synoviom, within the capsule in the joint spaces, or outside in soft tissue1- Synovial Chondromatosis:- Uncommon disorder characterized by metaplastic formation of multiple cartilaginous and osteocartilaginous nodules within connective tissue of the synovial membrane of joint- Asymptomatic- May complain of preauricular swelling, pain, and decreased range of motion- Some patients have crepitus or other joint noises
  34. 34.  Radiographic Features:- Osseous components may appear normal or may exhibit osseous changes similar to those in DJD- Sclerosis of glenoid fossa and condyle may be seen (chronic bone reaction to an active lesion)- MRI may be useful in defining the tissue planes between the synovial chondromatosis and surrounding soft tissue* D/D: DJD with joint mice or chondrosarcoma or osteosarcoma* Treatment: Arthroscopic or open joint surgery  remove loosebodies and resection of abnormal synovial tissue
  35. 35. 2- Chondrocalcinosis:- Characterized by acute or chronic synovitis and precipitation of calcium pyrophosphate dihydrate crystals in the joint space- Most commonly affected joints are knee, wrist, shoulder, and elbow- TMJ involvement uncommon- Unilaterally and more common in males- Asymptomatic or complaints of pain and joint swellings
  36. 36.  Radiographic Features:- May simulate synovial chondromatosis- Bone erosions and severe increase in condylar bone density- Erosions of the glenoid fossa may be present (detected with CT)- Soft tissue swelling and edema of the surrounding muscles may be seen with MRI* D/D: DJD with joint mince or chondrosarcoma or osteosarcoma* Treatment:- Surgical removal of crystalline deposits- Steroids, aspirin, and non steroidal anti inflammatory agents may provide relief
  37. 37. Trauma1- Effusion:- Influx of fluid into the joint as a result of trauma (hemorrhage or inflammation)- Swelling over affected joint- Pain in TMJ, preauricular region, and limited range of motion
  38. 38.  Radiographic Features:- Commonly seen in conjunction with internal derangements- Joint space is widened* D/D: septic arthritis* Treatment:- Anti-inflammatory drugs- Surgical drainage
  39. 39. 2- Dislocation:- Abnormal positioning of the condyle out of the mandibular fossa but within the joint capsule- Unable to close mandible to maximal intercuspation* Radiographic Features:- In bilateral cases, both condyles are located anterior and superior to summits of articular eminentia* Treatment:- Manual manipulation to reduce the dislocation- Surgery in the case of fracture dislocation
  40. 40. 3- Fracture:- Usually occur at condylar neck and often are accompanied by dislocation of the condylar head- Unilateral fractures more common- May be accompanied by parasymphyseal or mandibular body fracture on contralateral side- Swelling over TMJ- Limited range of motion
  41. 41.  Radiographic features:- Radiolucent line limited to the outline of the neck is visible- If bone fragments overlap, an area of increase in radiopacity may be seen* D/D: Town’s view panorama is taken to view fractures* Treatment: Reduced surgically
  42. 42. 4- Neonatal Fracture:- Use of forceps during delivery of neonates may result in fracture and displacement of the rudimentary condyle- Severe mandibular hypoplasia* D/D: Developmental hypoplasia* Treatment: Combination of orthodontic andorthognathic surgery
  43. 43. 5- Akylosis:- Condition in which condylar movement is limited by a mechanical problem in the joint or by a cause not related to joint components- Restricted jaw opening or limited jaw opening* Radiographic Features:- In fibrous ankylosis articulating surfaces are usually irregular because of erosions- In bony ankylosis joint space may be partly or completely obliterated by the osseous bridge- Coronal CT images are the best to evaluate ankylosis* D/D: Condylar Tumor* Treatment:- Surgical removal of osseous bridge- Creation of pseudoarthrosis
  44. 44. Tumors- Intrinsic or extrinsic- Intrinsic develop in condyle, temporal bone or coronoid process- Extrinsic tumor may affect the morphology, structure and function of the joint without invading the joint itself
  45. 45. 1- Benign Tumors:- Osteoma, osteochondroma, Langerhans histocytosis and osteoblastomas- Chondroblastomas, fibromyxomas, benign giant cell lesions and anneurysmal bone cysts also occur- Benign tumors and cysts of the mandible may involve the entire ramus and condyle- Grow slowly- TMJ swelling- Pain and decrease in range of motion- Tumors of coronoid process are painless but may complain of progressive limitation of motion
  46. 46. * Radiographic Features:- Condylar tumors  condylar enlargement with irregular outline- Osteoma and osteochondroma appear as abnormal, pedunculated mass attached to the condyle* D/D: Condylar neoplasms may simulate condylarhyperplasia because of condylar enlargement although itmight be irregular in appearance* Treatment: Surgical excision of tumor and occasionallyexcision of condylar head or coronoid process
  47. 47. 2- Malignant Tumors:A- Primary (rare): - Intrinsic - ExtrinsicIntrinsic: Chondrosarcoma Osteogenic sarcoma Senovial sarcoma FibrosarcomaExtrinsic: Direct extension of adjacent parotid salivary glandmalignancies
  48. 48. B- Metastatic (more common)- May be asymptomatic or patients may have symptoms of TMJ dysfunction (pain, limited mandibular opening, mandibular deviation and swelling)* Radiographic Features:- Variant degree of bone destruction with ill defined, irregular margins- CT modality of choice- MRI useful for displaying extent of involvement into surrounding tissues* D/D: Osseous destruction of bone seen in severe DJD* Treatment:- Wide surgical removal of tumor- May include radiotherapy and chemotherapy
  49. 49. Thank you

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