Radiooraphlcs

Index

terms:
Imaging

Computed

tomography HEAD AND NEC1( Magnetic resonance

MUSCULOSKELETAL
Head and neck imaging FACIAL BONES

CT and MR imaging temporomandibular

of the joint

umuIatIve
Joints, Joints, Joints,

Index terms: CT MR studies temporomandibuiar

Eberhard

Walter,

M.D.*

A. HUls, D.M.D.t P. Schmelzle,

D.M.D.t

U. Klose, DipI. Phys. K. Kuper,

M.D.* Ph.D.t

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.

From the Medizinisches Strahleninstitut (1 and the Zentrum

f#{252}r Zahn-, Mund- and

Kieferheilkunde (t), University of Tubingen, Tubingen, West

Germany and Siemens Medical Systems (t) Erlangen, West Germany.

Address reprint requests E. Walter, M.D., Medlzinisches Strahleninstitut, Universitat to

TUbingen, Roentgenweg
74000 TUbingen,

11,

West Germany.

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CT and MR imaging
0
.

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:i

Figure 1 Intact mandibular joint

The disk, D, is in the normal position. C = condyle E= articular eminence Figure 2

The disk, D, is displaced anteriorly and has lost its normal biconcave form. The posterior part is thickened and deformed (open arrows).

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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

with the CT and

A. CT TECHNIQUES

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).

comparison (Figure 4). 2. Separate reconstructions

right TMJ with a high resolution

of the left and

algorithm and a

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).

Three generated or oblique (Figure 7). threshold

filter.

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

gradient echo and, therefore,

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

and a 15#{176} angle

a gradient

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.

256 x 256; field

of

#{149}1 Figure 8 Delineation ofthe normal biconcave disk (arrowheads) by MR imaging

The original MR image has been zoomed to a field of view of 7.5 x 7.5 cm. C=condyle E=articular eminence

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ii

Figure 9 Gradient echo MR image

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

Advantages and Disadvantages of CT and MRI In TMJ Imaging (a) Advantages

Standard

of CT:
transaxial scan-

(b) Advantages of MRI: C ideal method for delineation of the articular disk and its associated soft

ning
C

Detailed delineation of bony structures (100%

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

(c) Disadvantages of CT and MRI: . Costly examinations

C

reconstructions

Time consuming

coronal, sagittaI or paroxial planes as mdicated

C

3-D Images of The joint and views from any desired angle to facilitate scanning

surgical planning
Direct sagittal

. Information about posiflon of the articular disk

In varIous phases of mouth opening (reliable Information obtained In about 60% of all cases) . Determination of condy-

br position in various phases of mouth opening

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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-

MRI in TMJ imaging.

the diagnostic

Cases findings

3 to in error

to relate To date,

accuracy proved

discrete
techniques.

indications
These

for the use of the Iwo

of CT and MRI studies

cases.

to the surgical
in the surgically

cal cases have been selected to illustrate the distinct indications for, and diagnostic applica-

cases, we have encountered no diagnostic in the interpretation of CT and MR images.

Indications

Table II for CT and MRI Examinations of the joint and the facial skeleton
degenerative joint disease with pain

CT indications: Malformation (Case 1)

. Advanced

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

to nonreducing anterior disk displacement (Case 4) . Postoperative followup

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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

of manto open her

she attempted

CT findings:

The transaxial

CT scan shows

ment
limitation

is usually

found

to be responsible

for the
(Figures 16

enlargement of the lateral condyle on the right, with

pole of the mandibular osteophytes indicating

of mandibular

degenerative is particularly
reconstruction

joint disease (Figure 11). This finding apparent on the three dimensional
(Figure 12). The sagittal CT scan

demonstrates the condylar

mouth (Figure

that the condyle does fossa (sublux) completely

not leave when the

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

Surgical findings: The CT findings were at surgery. Figure 22, a photograph

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

that she had suffered

cranial

injury
at the

in early childhood, but time to have sustained

was not thought a fracture.

Figure 22 Surgical findings

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

HIstory: with inability

This 45 year

old woman

had fully.

suffered

for a year from

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

third of the articular

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,

perforation of the joint.

of the

articular

disk was confirmed

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.

the surgical exploration Comment: CT in this case

Ir\

Lf

Figure 26 Surgical findings

foration. A= anterior

The instrument traverses the disk perE= eminence P = posterior

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Case

Degenerative

Joint disease
History: woman
joint pain

This 48 year old had suffered from TM

for nine months

prior to the CT examination and had noted increasing

restriction in her ability to open

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,

dence of degenerative joint disease, were encountered

(Figures 29 and 30).

Comment: High resolution CT permits the display of even

Figure 28
Surgical findings Deformily of the condyle (arrow) are seen. A= anterior
and the spur

small bony spurs such as those usually caused by a de-

generative

process.
of

After surgical removal

the spur and condylar

the patient was clinically

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

Figure 30 Surgical findings This photograph

the joint confirms the presence

exposed during surgical exploration of degenerative cysts (arrows)

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

our institution, CT and MRI have placed conventional techniques

TMJ pain syndrome when

completely tein diagnosing

to

it is refractory

therapy. Arthrography may be indicated rare cases when CT and MRI diagnoses consistent with clinical findings.

in very are not

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

St. Louis: Mosby,

1985.
K, Ware

M, Moon

HZ. Internal derangements of the temporomandibular joint: Diagnosis by direct sagittal computed tomography.
Radiology 1984; 150:111.

netic resonance joint: Preliminary

1984; 2:220. 3. H#{252}Is Walter A

imaging of the temporomandibular observation. J Craniomandib Pract

E. Schulte W. Freesmeyer W. computer-

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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