M. Gonzalez Vazquez; M.Costas; R.Prada; R.Oca; A. Villanueva and G. Tardaguila de la Fuente

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1 M. Gonzalez Vazquez; M.Costas; R.Prada; R.Oca; A. Villanueva and G. Tardaguila de la Fuente

2 A) Anatomy of temporomandibular joint. closed-mouth position Glenoid fossa Intermediate zone Posterior band Articular eminence Lateral pterygoid muscle Anterior band The disc divides the cavity into an upper and lower compartments. The anterior band is continuous with lateral pterygoid muscle fiber and the posterior band is continuous with the posterior attachment or bilaminar zone. The bilaminar zone is composed of fibroelastic tissue and collagen fibers and fills the posterior half of the glenoid fossa Mandibular condyle Bilaminar zone The joint is formed by the glenoid fossa and articular eminence of temporal bone, and by the head of the mandibular condyle. These articular surfaces are covered by fibrocartilage and including articular disc or meniscus, which is a biconcave structure of a fibrous nature, formed by a anterior band and a posterior band joined by an intermediate zone, which divides the cavity into an upper and lower compartments

3 A) Anatomy of temporomandibular joint. opened-mouth position Articular eminence Lateral pterygoid muscle Mandibular condyle Glenoid fossa Bilaminar zone ØThe joint is thus referred to as ginglymodiarthrodial : a combination of the terms ginglymoid (rotation) and arthrodial (translation) ØThe elastic tissue of the bilaminar zone allows for the motion of the disc and condyle translate anteriorly, it s positioned directly under to the articular eminence

4 B)Pathophysiology and biomechanic of intracapsular disorders in temporomandibular joint Infectious Traumatic Inmunologic Degenerative MULTIFACTORIAL ETIOLOGY Metabolic Internal derangement and osteoartrosis are the most frequently encountered articular disorders: Ø Internal derangement is defined as an abnormal positional relation ship of the disc relative to the mandibular condyle and the articular eminence Ø Osteoartrosis is characterized by structural damage of the cartilage in early stages and subcondral bone and osteophytes in late stages

5 B)Pathophysiology and biomechanic of intracapsular disorders in temporomandibular joint Internal derangement of the TMJ is associated with formation of: - Disc displacements - Disc perforations - Intra-articular adhesions, that consists of fibrous connective tissue with fibroblastos To result from dysfunctional remodeling, due to a decreased host-adaptive capacity of the articulating surfaces and/or functional overloading of the joint that exceeds the normal adaptive capacity Wilkes promotes the theory that internal derangement logically progresses to degenerative joint disease in his classification system

6 C) Technical procedure of MRI- arthography : Intraarticular contrast injection under ultrasound guidance in the posterosuperior compartment of the joint. The point of injection is located along the line from the tragus to outer canthus of eye, 10 mm from middle of tragus and 2 mm below the line. Doppler us is useful to visualizate pretragal vascular band ( superficial temporal artery and vein). Patient position : Lateral decubitus on the side that will be not studied Volume : ml ( sterile saline containing 1% of gadolinium based contrast agent) Needle : 25 GA x 5/8 in ( 0.5 x 16mm)

7 TECHNICAL PROCEDURE 1 cm 2mm ØThe point of injection is located along the line from the tragus to outer canthus of eye, 10 mm from middleof tragus and 2 mm below the line. Temporal eminence and glenoid cavity Mandibular condyle Articular space

. Unfortunately, the clinical problem described globally as a TMD has several different and overlapping pathophysiologic disease processes, and a traditional clinical examination does not provide

8 C) Technical procedure of MRI- arthrography :Indications, contraindications and possible complications. Indications: Patients with clinical suspected of intracapsular pathology of temporomandibular joint: reduced jaw opening, pain, tenderness, noises.. Unfortunately, the clinical problem described globally as a TMD has several different and overlapping pathophysiologic disease processes, and a traditional clinical examination does not provide highly tissue-specific pathologic information Only in patients eligible for surgery because there is a minimally invasive technique * Patients who fail these 2 criteria would be excluded Contraindications: Infections in the preauricular region / acute joint infection Advanced resorption of the glenoid fossa MRI contrast agents adverse reactions, renal insufficiency Metallic implants, pacemakers, cochlear implants.. Pregnancy, claustrophobia

9 C) Technical procedure of MRI- arthrography :Indications, contraindications and possible complications. Complications: Common Contrast medium extravasation into the capsule and soft tissues around the joint, causing pain and discomfort. It s the complications most frecuent, but the contrast is resorbed within hours without other complications Vagal reaction Hematoma : Especially in patients with coagulation disorders Uncommon Infection, septic arhritis: It is important to perform the technique under aseptic conditions to avoid them Transient facial paralysis : may result from too vigorous infiltration of lidocaine, but in the majority of the cases the procedure is well tolerated by the patient without anesthesia or by using a very small amount of lidocaine Intravasation of contrast material infrequently occurs

10 Contrast medium extravasation into the capsule and soft tissues around the joint

chondromalacia than MRI -It has been demonstrated disc perforations and intraarticular adhesions or fibrosis that they are not displayed on

11 C) Technical procedure of MRI- arthrography : Advantagesand disadvantages. ADVANTAGES DISADVANTAGES -Provides information shape and position of the articular disk - To permit detect more early states of chondromalacia than MRI -It has been demonstrated disc perforations and intraarticular adhesions or fibrosis that they are not displayed on MRI - It may be a therapeutic method to lisis intraarticular adhesions -It is an minimally invasive technique due to contrast injection into the TM joint - MRI findings of disc perforations may be difficult to interpret

C) Technical procedure of MRI- arthography : MRI

T1 FFE SPIR WATS 3D: Sagital plane and closed mouth DP

Sagital plane and dynamic study with 4 degrees of

12 C) Technical procedure of MRI- arthography : MRI sequencesprotocol 1,5 Teslas MRI : Phillips, Ingenia T1 FFE SPIR WATS 3D: Sagital plane and closed mouth DP TSE: Sagital plane and closed mouth T1 FFE SPIR: Sagital plane and dynamic study with 4 degrees of mouth opening ( cine images) T2 Dixon: Coronal plane and closed mouth

D) Diagnostic imaging findings: 1. Disk position and morphology: Ø Position: Normal Anterior displacement is the most frecuent Anormal: anterior, posterior, medial and lateral displacement.

13 D) Diagnostic imaging findings: 1. Disk position and morphology: Ø Position: Normal Anterior displacement is the most frecuent Anormal: anterior, posterior, medial and lateral displacement. Anteriorly displaced with reduction Anteriorly displaced without reduction. Ø Morphology: flattened, thickened, buckled and folded disk. The evaluation of the morphology of the disc should be done with the patient mouth closed position not with opened mouth. Sagital DP with mouth closed position show anterior luxation and buckled disk.

14 MOUTH CLOSED: sagital DP TSE MOUTH OPENED: Sagital T1 FFE Temporal eminence and glenoid cavity Mandibular condyle Articular disk ( anterior displacement without reduction) Posterior attachment and bilaminar zone

15 D) Diagnostic imaging findings: 2. Disc or discal attachment perforations: Contrast injection in the posterosuperior compartment of TM joint go to lower compartment MRI-arthrography findings: Contrast material appears in superior and lower compartments Perforations are often easier to visualize in the open mouth position and by the presence of intraarticular contrast distending the jointcapsule Perforations are more frecuent in anterior displacement without reduction than in anterior displacement with reduction Perforations in the posterior attachment or posterior band of the disc are more frecuent than in the central or intermediate zone

16 Ø Perforation in the posterior attachment of the disk, with passage of contrast between the upper and lower compartment with open mouth position and that it was confirmed by arthroscopy.

contrast in the articular space exists a limited

MRI-arthrography findings: Hypointense lineal bands in

study The majority of adhesions are in the upper

17 D) Diagnostic imaging findings: 3. Intraarticular adhesions or fibrosis When youintroduce contrast in the articular space exists a limited distensibility that difficults the entry of contrast MRI-arthrography findings: Hypointense lineal bands in the articular capsule that limit mouth opening in dynamic study The majority of adhesions are in the upper compartment of the joint This is the reason for choosing the superior compartment for the contrast injection

19 Ø Intraarticular adhesions

20 D) Diagnostic imaging findings: 4. Cartilage degeneration (chondromalacia) :affecting both the condyle and the temporal eminence. Ø MRI-arthrography findings : Cartilage signal alterations and chondral ulcerations ( the contrast is introduced in the ulcerations) Osteochondral lesions, sclerosis Marginal osteophytes *MRI athrography permit to detect more early states of chondromalacia than MRI

Care to eliminate air bubbles when youinjected into the joint space because the may simulate loose bodies Ø MRI- arthrography permit to

21 D) Diagnostic imaging findings: 5. Intraarticular loose bodies Ø It is easier to detect intraarticular loose bodies when you introduce contrast and distend synovial capsule. Care to eliminate air bubbles when youinjected into the joint space because the may simulate loose bodies Ø MRI- arthrography permit to delineate loose bodies a b Synovial chondromatosis of left temporomandibular joint: a) axial plane T2 TSE sequence and b) sagittal plane mri-arthrography that show contrast in the synovial of articular space with multiple intra-articular loose bodies

22 E) Treatment planning: conservative, interventional, arthroscopy or by open surgery MRI- arthrography is useful: To detect disc displacement To visualizate disc perforations, being the treatment with arthroscopy in small perforations and open surgery in larger perforations. To permit detect early states of degenerative changes with conservative management To lisis intraarticular adhesions or fibrosis like a therapeutic method and not only a diagnosis method

CONCLUSIONS Ø MRI-arthrography of temporomandibular joint may be useful in determinate cases for diagnosis of intracapsular disorders, especially for

23 CONCLUSIONS Ø MRI-arthrography of temporomandibular joint may be useful in determinate cases for diagnosis of intracapsular disorders, especially for perforations and adhesions Ø In the future, MRI- arthrography couldallow better correlation with arthroscopy versus MRI, as occurs in other joints like shoulder or wrist

24 REFERENCES: 1. G Venetis, M Pilavaki, K Triantafyllidou, A Papachristodoulou, N Lazaridis, and P Palladas. The value of magnetic resonance arthrography of the temporomandibular joint in imaging disc adhesions and perforations. Dentomaxillofac Radiol Feb; 40(2): Liu XM, Zhang SY, Yang C, Chen MJ, Y Cai X, Haddad MS, Yun B, Chen ZZ. Correlation between disc displacements and locations of disc perforation in the temporomandibular joint. Dentomaxillofac Radiol Mar;39(3): doi: /dmfr/ Rao VM, Farole A, Karasick D. Temporomandibular joint dysfunction: correlation of MR imaging, arthrography, and arthroscopy. Radiology Mar;174(3 Pt 1): X. Alomar, MD, J. Medrano, MD,J. Cabratosa, MD,J.A. Clavero, MD, M. Lorente, MD,I. Serra, MD,J.M. Monill, MD and A. Salvador, MD. Anatomy of temporomandibular Joint. Semin Ultrasound CT MRI 28: Elsevier Inc. 5. Francesco Molinari, MD,Paolo Francesco Manicone, MD,Luca Raffaelli, MD,Renzo Raffaelli, MD,Tommaso Pirronti, MD,and Lorenzo Bonomo, MD. Temporomandibular Joint Soft-Tissue Pathology, I: Disc Abnormalities. Semin Ultrasound CT MRI 28: , 2007 Elsevier Inc. 6. Kathleen Herb, DMD, MD, Sung Cho, DMD, and Marlind Alan Stiles, DMD. Temporomandibular Joint Pain and Dysfunction. Current Pain and Headache Reports 2006, 10: Current Science Inc. ISSN E. Tanaka, M.S. Detamore, and L.G. Mercuri. Degenerative Disorders of the Temporomandibular Joint: Etiology, Diagnosis, and Treatment. J Dent Res 87(4): , 2008.

The Temporomandibular joint: Anatomy, Mechanics, Pathology. Aditya Bahel, DO

The Temporomandibular joint: Anatomy, Mechanics, Pathology Aditya Bahel, DO Outline Anatomy Mechanics and function Indications for TMJ imaging MR Protocols and pitfalls Pathology Treatment options Anatomy