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牙科放射線學 (2). Temporomandibular Joint Radiography. 顳顎關節放射線攝影術. 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw. 學 習 目 標. The normal anatomy of the TMJ What investigations are available Common pathological conditions that - PowerPoint PPT Presentation
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牙科放射線學 (2)
陳玉昆教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw
Temporomandibular Joint Radiography
顳顎關節放射線攝影術
Normal anatomy of TMJ
Investigations available for TMJ
Pathological conditions that can affect TMJ
學 習 目 標
1. Eric Whaites: Essentials of dental radiography & radiology 3rd edition, Chapter 29, p. 371-3882. Eric Whaites: Essentials of dental radiography & radiology 1st edition, Chapter 28, p. 297-323.
References
3. Rosenberg et al, Aust Dent J 1999;44:1064. Kaohsiung Medical University, Oral Pathology Department
Normal anatomy of TMJ
Investigations available for TMJ
Pathological conditions that can affect TMJ
Subtopics
Condyle head
Disc/meniscus
Glenoid fossa
Lateral pterygoidattachment
Upper joint space
Lower joint space
Ext. auditory meatus
Ref. 1
Basics components of the TMJ:Mandibular component: condyle head (Hard tissue) Disc (Soft tissue)Temporal component: glenoid fossa & articular eminence (Hard tissue)Capsule surround the joint (Soft tissue)
Normal Anatomy
Lateral Anterior
Base
Normal anatomy - Dry skull
Ref. 1
Rotatory and translatory movements of condyle during normal mouth opening
Restposition
Mouthclosed
Primaryrotation
Mouthopened
Translation
Mouth openedinitially
Mouth openedwidely
Secondaryrotation
Ref. 1
Investigations available for TMJ (1)
The clinical indicationsHow each investigation is performed:how the patient is positioned in relation tothe film and X-ray tubehead, and whetherthe patient’s mouth needs to be opened or closed
Investigations available for TMJ (2)
What information from each investigationThe limitations and shortcomings of eachinvestigation
Conventional radiographic projections Other techniques and investigations
Investigations
Transcranial Transpharyngeal Panoramic Reverse Town’s Transorbital Tomography, linear
Summary of different parts of TMJshown by the conventional projections
Ref. 1
Transcranial Lateral aspect of: Glenoid fossa Articular eminence Joint space Condylar head
Transpharyngeal Lateral view of: Condylar head & neck Articular eminence
Dental panoramic Lateral view of tomograph both condylar heads
Reverse Towne’s Posterior view of: both condylar head & necks
Transorbital Anterior view of: Condylar head & neck Articular eminence
Tomography All aspects of: Glenoid fossa Articular eminence Joint space Condylar head
Transcranial
TMJ pain dysfunction syndrome – pain,clicking & mouth opening limitationTo investigate the size & position of thedisc (joint space)To investigate range of movement in thejoints
Main indications
Mouth openMouth close
Mouth open
Right
Mouth close Right
Transcranial Centric occlusion
Ref. 1
<N.B.>Radiological term joint space: RL zone between condylar head & glenoid fossa, which includes discs & upper & lower anatomical joint spaces
Diagnostic informationClosed view
Open view
Transcranial
The size of the joint space – provide indirectinformation about the position and shape ofthe discThe position of the head of the condyle withinthe fossaThe shape and conditions of the glenoid fossa &articular eminence (on the lateral aspect only)The shape of the head of the condyle & the condition of the articular surface (on the lateralaspect only)A comparison of both sidesThe range and type of movement of the condyle
A comparison of the degree of movement onboth sides
Main indications
Transpharyngeal
TMJ pain dysfunction syndromeTo investigate the presence of joint disease,particularly osteoarthritis and rheumatoidarthritisTo investigate pathological conditionsaffecting the condylar head, including cysts ortumorsFractures of the neck and head of the condyle
Diagnostic information The shape of the head of condyle and condition of the articular surface from lateral aspect A comparison of both condylar heads
Transpharyngeal
Ref. 1
Dental panoramic tomograph Main indicationsMain indications TMJ pain dysfunction syndrome To investigate disease within the joint To investigate pathological conditions affecting the condylar heads Fractures of the condylar head or neck Condylar hypo/hyperplasia
Diagnostic information The shape of the condylar head and condition of the articular surface from lateral aspect A direct comparison of both condylar heads
Dental panoramic tomograph
Transcranialview taken frompanoramicmachine
Right close Right open Left open Left close
Ref. 4
To investigate the articular surface of the condyles and disease within the joint Fractures of the condylar heads and necks Condylar hypo/hyperplasia
Main indications Reverse Towne’s
Mouth openRef. 1
Diagnostic information The shape of the condylar heads and condition of the articular surfaces from the posterior aspect A direct comparsion of both condyles
Reverse Towne’s
Ref. 1
Transorbital (Zimmer’s view)
To investigate the articular surface of the condyle and disease within the joint High fractures of the condylar neck to show medio-lateral displacement
This view is rarely used due tothe risk of damage to the lens ofeye from radiationHowever, it provides an AP view ofthe condylar head-an aspect notshown by other radiographs
Mouth openRef. 2
Main indications
Transorbital
Ref. 2
The shape of the condylar head and neck from the anterior aspect The condition of the articular surface from the anterior aspect
Diagnostic information
Tomography Main indications Full assessment of the whole of the joint to determine the presence and site of any bone disease or abnormality To investigate the condyle and articular fossa when the patient is unable to open the mouth Assessment of fractures of the articular fossa and intracapsular fractures
Lateral
Anterior15o20o25o30o
Tomography
Ref. 1
Diagnostic information The size of the joint space The position of the head of the condyle within the fossa The shape of the head of the condyle and condition of the articular surface including the medial and lateral aspects The shape and condition of the articular fossa and eminence Information on all aspects of the joints The positions and orientation of the fracture fragments
Tomography
Other techniques & investigations
Arthrography Computed tomography Magnetic resonance imaging Artheroscopy
Main indications Diagnostic information
下列何者是 AP view為:A. Panoramic radiographyB. Transcranial projectionC. TransorbitalD. Modified Town’s view
Arthrography
Main indications Longstanding TMJ pain dysfunction unresponsive to simple treatments Persistent history of locking Limited opening of unknown etiology
Main contraindications Acute joint infection Allergy to iodine or contrast medium
Diagnostic information Dynamic information on the position of the joint components and disc as they move in relation to one another Static images of the joint components with the mouth closed and with the mouth open. Any anterior or anteromedial displacement of the disc can be observed The integrity of the disc, i.e. any perforationsNote: Outline the lower joint space usually provides more useful information on the disc
Arthrography
Ref. 1
Computed tomographyMain indications
Diagnostic information The shape of the condyle and the condition of the articular surface The condition of the glenoid fossa and eminence The position and shape of the disc The integrity of the disc and its soft tissue attachments The nature of any condylar head disease
It provides sectional or slice images of the joint It can produce images of the hard and soft tissues in the joint, including the disc, in different planes
Computed tomography
Ref. 4
Magnetic resonance imaging
Condylar head
Anteriordisplaceddisc
Main indications When diagnosis of internal derangements is in doubt As a preoperative assessment before disc surgery
Ref. 4
Arthroscopy
It gives direct visualization of the TMJ and allows certain interventional procedures to be performed, including Washing out the joint with saline Introduction of steroids directly into the joint Division of adhesions Removal of loose bodies from within the joint
Arthroscopy is considered as the last line of investigation before full surgical exploration ofthe joint is carried
Main indications
1. Upper joint space2. Lower joint space3. Disc4. Prolene suture5. Yeates drain6. External auditory meatus
Arthroscopy
Ref. 3
Fibrillation( 顫動 )
Disc
Adhesion
Disc
Arthroscopy
Ref. 4
Main pathological conditions affecting the TMJ
TMJ pain dysfunction syndromeInternal derangementsOsteoarthritisJuvenile rheumatoid arthritis (Still’s disease)AnkylosisTumorsFracturesDevelopmental anomalies
( 史迪爾氏症 )
Main pathological conditions affecting the TMJ
最可能的診斷為:A. AmeloblastomaB. Squamous cell carcinomaC. HemangiomaD. Central giant cell granuloma
(A) A multilocular radiolucency; (B), (C) Surgical specimen; (D) Costochondral graft;(E) Histological examination: bony trabeculae entrapped by multiple blood vessels
Knowing: Normal anatomy of TMJ
What investigations are available for TMJ
Main pathological conditions that can affect TMJ
Summaries
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