Diagnostic Imaging of the

Temporomandibular Joint
Fares H. Hanafieh & Fahad F. Salehi

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

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


MANDIBULAR FOSSA: Composed of the glenoid fossa and
atricular eminence.

INTERARTICULAR DISK: - Between condylar head and

mandibular fossa
- Biconcave shape

Disorders of the temporomandibular joint are

abnormalities that interfere with the normal form or
function of the joint

Disorders of the

Temporomandibular Joint
1- Developmental Abnormalities
2-

Soft Tissue Abnormalities

Developmental Abnormalities:
1- Condylar Hyperplasia
2- Condylar Hypoplasia
3- Juvenile Arthrosis
4- Coronoid Hyperplasia
5- Bifid Condyle

1- Condylar Hyperplasia:
- Enlargement and deformity of the condylar head
- Secondary effect on the mandibular fossa as it remodels to
accommodate 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

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

Treatment:
Orthodontics combined with orthognathic surgery

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

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

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

 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

4- Coronoid Hyperplasia:
- acquired or developmental
- elongation of the coronoid process
- developmental -> bilateral
acquired -> uni or bilateral
- inability to open mouth
- painless

 - 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

5- Bifid Condyle:
Vertical depression,
notch, or deep cleft
in 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

D/D: Vertical fracture through the condylar head

Treatment: Not indicated unless pain or functional
impairment is present

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

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.

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

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

 - 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)

 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

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

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

 D/D: severe DJD and psoriatic arthritis and osteopenia

Treatment:
- pain relief (analgesics)
- anti inflammatory drugs
- physiotherapy
- surgery (joint replacement)

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

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

Psoriatic Arthritis and

Akylosing Spondylitis
Septic Arthritis: Infection and inflammation of a joint that can result in joint
destruction

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

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

 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

Articular Loose Bodies

Radiopacities of varying origin located in the joint synoviom, within the

capsule in the joint spaces, or outside in soft tissue

1- 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

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 loose
bodies and resection of abnormal synovial tissue

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

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

Trauma
1- 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

Radiographic Features:
Commonly seen in conjunction with internal
derangements
Joint space is widened
* D/D: septic arthritis
* Treatment:
Anti-inflammatory drugs
Surgical drainage

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

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

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: Towns view panorama is taken to view fractures
* Treatment: Reduced surgically

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 and
orthognathic surgery

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

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

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

* 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 condylar
hyperplasia because of condylar enlargement although it
might be irregular in appearance
* Treatment: Surgical excision of tumor and occasionally
excision of condylar head or coronoid process

2- Malignant Tumors:
A- Primary (rare): - Intrinsic
- Extrinsic
Intrinsic: Chondrosarcoma
Osteogenic sarcoma
Senovial sarcoma
Fibrosarcoma
Extrinsic: Direct extension of adjacent parotid salivary gland
malignancies

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

Thank you