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Index
terms:
Imaging
Computed
MUSCULOSKELETAL
Head and neck imaging FACIAL BONES
of the joint
umuIatIve
Joints, Joints, Joints,
Eberhard
Walter,
M.D.*
WA. Kalender,
Through The medium of selected case reports, the authois present their experience with sectional imaging of tho TMJ. The complementary roles of CT and MRI are emphasized.
THIS EXHIBIT WAS DISPLAYED AT THE 72ND SCIENTIFIC ASSEMBLY AND ANNUAL MEETING OF THE RADIOLOGICAL SOCIE1Y OF NORTH AMERICA NOVEMBER 30-DECEMBER 5, 1986, CHICAGO, ILLINOIS. IT WAS RECOMMENDED BY THE NEURORADIOLOGY PANEL AND WAS ACCEPTED FOR PUBLICATION AFTER PEER REVIEW AND REViSION ON AUGUST 28. 1987.
Introduction The temporomandibular joint is anatomically a very small but cornplex articulation (Figure 1). Moreover, physiologic and pathologic alterations in the joint are extremely variable (Figures 2 and 3). For these reasons, complex imaging procedures are needed if one is to visualize the articular structures adequately. It is the purpose of this article to present our experience with the use of computed tomography and magnetic resonance imaging In the evaluation of the temporomandibular Joint. Specifically, we will note the CT and MRI techniques that we have found most useful and will enumerate the advantages and disadvantages of the Iwo methods. In the clinical part of our presentation, we will specify indications for CT or MRI in the examination of the TMJ and will comment on the relative diagnostic usefulness of the two methods. Our experiences will be Hlustrated with 5 representative cases.
TUbingen, Roentgenweg
74000 TUbingen,
11,
West Germany.
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I
Figure 3
Diskless, sliding joint resulting from advanced joint destruction. C = condyle E= articular eminence
Subjects
In the past few years, we have examined
and Imaging
Methods
Standard Transaxia! Scanning
approximately 400 patients who had functional or structural disorders of the TMJ using CT. About
100 of these were also in 29 patIents, surgical examined with MRI, and findings were available
for comparison
MRI findings.
A series of 20 to 25 contiguous, I mm slices parallel to the infraorbital-tragus (orbitomeatal) plane is generated at 450 mAs. Two types of reconstruction are performed: 1. Reconstruction using a high resolution algorithm and a zoom factor of 2.5 (pixel size 0.4 mm) for gross orientation and left to right
All CT examinations
31M
were
.
carried
-
out
on a
Siemens SOMATOM DR The complete procedure described below (Steps I 3) can be carned out in less than 60 minutes, but in clinical practice, it usually requires longer (up to 90 mmutes).
zoom factor of 10 (pixel size 0.1 mm). Images are reformatted in sagittal, coronal and arbitrary
paraxial planes (Figure 5) as indicated.
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Figure 4
Normal standard transaxial CT scan Slice thickness=1 mm. Air cells are seen in the articular eminence on the right side (open arrow). C=condyle
Figure 5
Reconstruction from enlarged transaxial scans The reconstruction has been made in the long axis of the condyle (see bottom left).
Direct Sagittai Scanning Three scans per joint are generated in different phases of mouth opening (closed, half and fully open) with 2 mm slice thickness at 450 mAs. Reconstruction is with the standard head kernel (algorithm) and images are displayed with bone and soft tissue window settings (Figure 6).
3-D Bone Imaging dimensional images of both joints are from the transaxial images for lateral views, using the standard 3-D option For TMJ reconstruction, we use a bone of 150 HU and display with a shading
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iure 6
-:t sagiffal CT scans displayed with tissue (A) and bane window setS (B). In this case the articular disk ?monstrated. Large arrow= anterior ? of disic small arrows= posterior ,? of disk. C = condyle E= articular minence
Figure 7
Three dimensional reconstruction from enlarged transaxial CT scans (oblique lateral view) A=external auditory canal C = condyle E= arficular eminence
.
I
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B. MRI TECHNIQUES
Examinations were carried out on a Siemens MagnetomTM at a field strength of 1.0 1. The body coil was used as transmitter coil; the signal was received by a surface coil positioned horizontally adjacent to the TMJ with the patients head in the lateral position (turned 90#{176} the side from to the anatomic position).
Gradient
With time
Echo Sequences
sequences, the the acquisition repetitime
tion
can
be considerably
shortened.
A sequence
with a repetition time of 40 msecs and echo time of 12 to 16 msecs is used. The pulse angle is an additional factor that can be varied in this
Standard
Examinaion
sequence,
Figure
is our preference.
echo image, gener-
9 shows
Three transaxial slices are obtained for orientation. This requires one minute imaging time. Several sagittal slices are then produced through the TMJ with constant parameters: Spin echo sequence! multislice imaging; TR = 800
ated
time
with 8 acquisitions
of 1.5 minutes.
in a total
acquisition
3-D Measurements
Short repetition times make 3-D sequences possible in reasonable acquisition times. We use a 3-D sequence with a repetition time of 40 msecs and a total slice thickness of 2 cm. Sixteen partitions are calculated, each with a thickness of 1.25 mm. The imaging time for this sequence is 10 minutes. Figure 10 shows four parallel slices at different postions of the TMJ.
msec, TE
28 msec;
matrix
view 15 x 15 cm ( pixel slice thickness 5 mm; acquisitions; imaging shows an example of ceived, zoomed to a
size 0.6 mm x 0.6 mm); 2-3 contiguous slices; 2 time 6.8 minutes. Figure 8 an image as originally refield of view of 7.5 x 7.5 cm.
of
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ii
In this diskless, sliding joint the condyle, C, with osfeophytic lipping (arrowhead) is seen. (Compare with Figure 3) E= articular eminence
Figure 10
sagittal MR slices delineate the articular disk (arrowheads) which is anteriorly displaced. (A) = lateral (B) = laterocentral (C) = mediocenfral (D) medial
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Advantages
Both CT and
In demonstrating
and Disadvantages
advantages
of the
of CT and MRI
in direct
of cases.
MRI have
the
specific
monstrated
about 60%
sagittal
scanning
in only
can be
anatomic
structures
This disadvantage
TMJ and the surrounding tissue. CT, for example, delineates the bones and soft tissue structures around the TMJ, but the articular disk can be de-
overcome by using MR imaging. The advantages and disadvantages of both techniques are listed in Table I.
Table I
of CT:
transaxial scan-
(b) Advantages of MRI: C ideal method for delineation of the articular disk and its associated soft
ning
C
tissue structures
C
agreement findings)
C
with surgical
of soft tissues
Adequate
information
can be generated
in short acquisition
even
times
Assessment
relevant to TMJ function (for example, the lateral pterygold muscle) AbIlIty to generate patient
specIfic
In
reconstructions
Time consuming
3-D Images of The joint and views from any desired angle to facilitate scanning
surgical planning
Direct sagittal
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Clinical
On the basis of our experience
MRI in imaging the TMJ, we are listed have in Table
Results
tions of CT and
5 permit individual one
with CT and
developed II. Five clini-
Cases findings
3 to in error
to relate To date,
accuracy proved
discrete
techniques.
indications
These
to the surgical
in the surgically
cal cases have been selected to illustrate the distinct indications for, and diagnostic applica-
Indications
Table II for CT and MRI Examinations of the joint and the facial skeleton
degenerative joint disease with pain
refractory to therapy (Case 5) I Coronoid-blocking syndrome (Case 2) C Therapy refractory posttraumatic arthropathy (Case 3) and ankylosis . Rheumatoid arthritIs, osteomyelitls C Postoperative foilowup MR Indications: Chronic internal derangements
Limitation of mouth opening, usually secondary
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Case
History: For 20 years, this 44 year
Malformation
old woman
of the condyle MRI findings: The articular disk is seen to occupy a normal position both when the mouth is closed and when it is open (Figures 14 and 15).
In similar clinical cases, anterior subluxation disk displace-
had suffered
dibular mouth. motion
from
when
painless
restriction
she attempted
CT findings:
The transaxial
CT scan shows
ment
limitation
is usually
found
to be responsible
for the
(Figures 16
of mandibular
degenerative is particularly
reconstruction
joint disease (Figure 11). This finding apparent on the three dimensional
(Figure 12). The sagittal CT scan
is opened. With soft tissue window settings 13), disk displacement is not identified.
17). Comment: Unlike most such cases, MRI demonstrates here that the restricted opening of the mouth is not due to anterior displacement of the disk. Rather, it suggests that the deformity of the lateral aspect of the condyle, which is probably developmental, is the cause.
and
A Figure 11
Transaxial CT scan (A) showing the enlargement of the lateral aspect of the right condyle (curved arrows) Compare the right with the left condyle (B) which shows thickening of the anterior cortical bone (straight arrows).
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Figure 12
Enlarged three dimensional representation condyle (oblique posterior view) of the left
A Figure 13
No clear anterior displacement of the disk (arrowheads) is seen in this direct, sagittal CT scan through the medial part of the condyle. Soft tissue (A) and bone window (B) images are shown.
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MRI demonstrates the articular disk (arrowheads) in its normal location in the mouth closed position. C = condyle
Figure 15
MRI shows the disk (arrowheads) in normal location in the open mouth position. There has been limited translation of the condyle. C = condyle
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Figures 16 and 17 are not from Case I. They are included here to illustrate anterior displacement of the articular disk, the usual cause of restricted motion at the TMJ. Compare with Figures 14 and 15.
Figure 16
This sagittal MR image shows anterior disk displacement in the closed mouth position. In addition, the disk (curved arrow) is deformed. Arrowheads articular capsule
F,
17
in
This sagittal MR scan shows anterior disk displacement the open mouth position. Arrows = articular disk
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Case
History: this 26 year For many years,
Coronoid
blocking
syndrome
old man has noted that his ability to open his mouth was limited. The complaint has been constant but has not been associated
pain.
with
The survey transaxial section (Figure 18) shows local hyperplasia on the
Internal aspects of the zygomatic arches. When the
CT findings:
mouth is opened, the coronoid processes bilaterally impinge on the hyperplastic zygomatic arches (Figure 19). No pathoIoic findings were seen in the TMJ proper.
MPI provided information. no additional
Comment: In such a case, MRI is unnecessary; the malformation justified abnormality is well only demonstrated
by CT alone.
MRI would
if there within were the
be
Figure 18
This transaxial CT scan shows local hyperplasia on the interior aspects of the zygomatic arches (open arrows). C = coronoid process
reason to suspect
an additional
TMJ.
#{149}: :: .
Figure 19
The coronoid process, C, impinges on the hyperplastic bone structure when the mouth is opened (arrowheads). (A) = open mouth (B) = closed mouth
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Case History: This 31 year old woman suffered from increasingly more limited ability to open her mouth and had an occlusal disorder. CT findings: A reformatted image in a paraxial plane shows an old fracture of the condyle which had healed
with the articular process in
Posttraumatic
arthropathy
poor
direct
position
sagittal
(Figure
CT scan
20). A
demon-
strates ossified fragments of cartilage on the dorsal aspect of the condyle (Figure 21).
Figure 20
A reformatted image from enlarged transaxial CT scans shows a fracture healed in poor position. C = condyle S=fractured segment
Figure 21
This direct sagittal CT scan demonstrates ossified fragments (arrowheads) posterior to the condyle. There is restricted translation of the condyle. P = posterior
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firmed
conex-
posed during the procedure, demonstrates both the deformity of the articular process and the presence of multiple small ossified fragments. Comment: Multiplanar CT reconstructions in paraxial planes ideally demonstrated the malposition of the fragments. The CT scans provided
unequivocal evidence of the old injury and excluded the presence of a neoplasm, which had been the primary clinical diagnosis prior to the imaging study.
In response to detailed questioning, the pa-
tient stated
cranial
injury
at the
The small ossified cartilage fragments (curved arrows) are seen posterior to the condyle. A= antenor C = condyle P = posterior S=fractured segment
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Case
Internal
with
derangement
disk perforation
of the TMJ
This 45 year
old woman
had fully.
suffered
articular
her
TMJ pain
mouth
associated
to open
A transaxial CT scan and a paraxial reconstruction through the plane of the condylar process demonstrate osteophytes and
CT findings:
penetrating detritus cysts indicating articular degeneration (Figure 23). No clear information concerning the position and integrity of the disk was obtained from CT images optimized for demonstration of the soft tissues.
Figure 23
Transaxial CT scan (B) and paraxial reconstruction (A) demonstrate osteophytes and penetrated, detritus filled cysts (arrow)
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MRI findings:
mouth open (Figure
Paraxial
24) and
MR images
shut (Figure
generated
25), show
with the
a wide per-
foration
in the central
disk.
Figure 24
A sagittal MR scan shows the disk in two discrete parts (arrows) in the mouth open position. This suggests perforation of the disk. C = condyle with osteophytic lipping
Figure 25
This sagittal MR scan with the mouth closed shows the disk (arrowhead) to be anteriorly displaced. C = condyle
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Surgical during
findings:
At surgery,
of the
articular
as shown
in Figure
26, which
was exposed
displayed only the changes in bony structures, while MRI identified the perforation and displacement of the articular disc. Treatment in this case consisted of reconstructive diskoplasly.
Ir\
Lf
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Case
Degenerative
Joint disease
History: woman
joint pain
this period. CT findings: A bony spur is demonstrated anteriorly on the lateral aspect of the mandibular condyle (Figure 27). Surgical findings: At surgery, the osteophyte was apparent on gross inspection; histologic examination revealed reactive inflammatory changes in the adjacent tissues. The latter changes were not identified either by CT or
MRI. In addition, detritus filled
her mouth
during
Figure 27
This transaxial CT scan demonstrates the bony spur (arrow).
cysts and
the bony
local
alterations
further
of
evi-
structures,
Figure 28
Surgical findings Deformily of the condyle (arrow) are seen. A= anterior
and the spur
generative
process.
of
shaving,
symptom
free.
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Figure 29
A transaxial CT scan shows an osteophyte (open arrows) in the condyle as well as degenerative cysts
of
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Conclusion Computed tomography and magnetic resonance imaging ideally complement each other for the thorough examination of the structures of the temporomandibular joint. This is suggested by the comparison of CT, MRI and surgical findings in cases such as Case 4 presented here. At
it is refractory
therapy. Arthrography may be indicated rare cases when CT and MRI diagnoses consistent with clinical findings.
Suggested
1. Dolwick MF, Sanders C. Richardson B. TMJ internal derangement W. Nuclear and mag-
Readings
9. Manzione JV, Katzberg RW. Brodsky GL. Selizer SE. Mellins
arthrosis.
2. Helms
1985.
K, Ware
M, Moon
HZ. Internal derangements of the temporomandibular joint: Diagnosis by direct sagittal computed tomography.
Radiology 1984; 150:111.
tomographische
Stadienienteilung
des dysfunktionellen
Gelenkkopfumbaus. Dtsch Zahndrztl Z 1985; 40:37. 4. HUls A Walter E. Schulte W, S#{252}ss Zur Darstellung Ch. des Discus articularis rn Computeromogramm. Dtsch ZanOrztl z 1985; 40:236. 5. H#{252}Is Kuper K, Walter E. Engel E. Kernspintomographie A des Kiefergelenks. Dtsch Zanndrztl Z 1986; 41:1053. 6. HUIs A Walter E. Klose U. Engel E. Dos Internal Derangement des Kiefergelenks und seine Darstellung im Kernspintomogramm. Fortschr Kiefer-Gesichts-chir 1987; 11:328. 7. Katzberg RW, Schenk J, Roberts D, et al. The magnetic resonance imaging of the temporomandibular joint meniscus. Oral Surg 1985; 59:332. 8. Kubein-Meesenburg D. Die kraniale Grenzfunkion des stomatognathen Systems des Munich: Carl Hander, 1985.
10. Petrilli A Tomography of the temporomandibular joint. J Am Dent Ass 1939; 26:218. 11. Reich R, Dolwick M. Kiefergelenkbeschwerden bei Formund Lageveranderungen des Discus articularis. Dtsch Zahn-Mund-Kiefer-Gesichtschir 1984; 8:317. 12. Thompson JR. Christiansen E. Sauser D, Hasso A, Hinshaw D. Dislocation of the temporomandibular joint meniscus: Contrast arthrography vs. computed tomography. AJNR 1984; 5:747. 13. Westesson PL. Double contrast arthrotomography of the temporomandibular joint: Introduction of an arthrographic technique for visualization of the disc and the
articular surfaces, J Oral Maxillofac Surg 1983; 41:163-72. 14. Wilkes CH. Arthrography of the temporomandibular joint in patients with the TMG pain-dysfunction syndrome. Minn Med 1978; 61:645.
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