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