Computed tomography of the temporomandibular joint

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1 s_s_nner Journl of Medicl Imging nd Rdition Oncology 57 (2013) RADIOLOGY PICTORIAL ESSAY Computed tomogrphy of the temporomndiulr joint Rudolf Boeddinghus nd Andy Whyte Perth Rdiologicl Clinic, Suico, Perth, Western Austrli, Austrli R Boeddinghus MBChB, FCRd(SA), FRANZCR, FRCR; A Whyte BDS(Hons), MBChB, FDSRCS, DDR RCR, FRCR, FRANZCR. Correspondence Dr Rudolf Boeddinghus, Perth Rdiologicl Clinic, 127 Hmersley Rod, Suico, Perth, WA 6008, Austrli. Emil: roeddinghus@perthrdclinic.com.u Conflict of interest: None. Summry We present pictoril review of the spectrum of temporomndiulr joint (TMJ) pthology dignosed with CT. Although MRI is the modlity of choice for most TMJ pthology, CT is useful when MRI is contrindicted or not ccessile. With ttention to technique nd viewing conditions, CT is cple of showing internl disc derngement, rthritis, neoplsms nd non-tmj regionl pthology t reltively low rdition dose. Key words: nkylosis; rticulr disc; computed tomogrphy; osteorthritis; temporomndiulr joint. Sumitted 27 April 2012; ccepted 14 Septemer doi: / Introduction Temporomndiulr disorders (TMDs) re common, ffecting up to 28% of the popultion t some time in their lives. 1 They re heterogeneous group of disorders, usully clssified into myogenous nd rthrogenous groups, lthough there is often overlp. Articulr cuses of TMD include internl derngement of the rticulr disc (meniscus), inflmmtory nd degenertive rthropthies, nd less commonly nkylosis nd neoplstic conditions. Mgnetic resonnce imging is the imging technique of choice for the evlution of suspected temporomndiulr joint (TMJ) disorders. 2 However, it is contrindicted in some ptients nd is not tolerted ecuse of clustrophoi in others, nd its ccessiility is reltively limited. Multidetector CT (MDCT) is more widely ville nd etter tolerted. Computed tomogrphy hs een used to detect ony normlities of the TMJ 3 nd in rre conditions such s synovil osteochondromtosis. 4 It hs lso previously een used for the dignosis of internl disc derngement. 5 We hve found MDCT to e useful imging investigtion in the relile detection of internl disc derngement, rthritis nd other miscellneous conditions of the TMJ. We present review of the technique nd of the rnge of imging normlities encountered. Computed tomogrphy technique nd ntomy MDCT (16- to 64-detector row) is performed in the closed- nd open-mouth positions, without the use of intrvenous or intr-rticulr contrst medium. Multiplnr reconstructions re performed in the coronl olique (i.e., prllel to the long xis of the mndiulr condyle) nd in the sgittl olique (i.e., perpendiculr to the long xis of the mndiulr condyle) plnes using oth one nd soft-tissue reconstruction lgorithms. Using currently ville low-dose itertive reconstruction lgorithms, the dose-length product (DLP) of the exmintion cn e reduced to s low s 540 mgy cm, resulting in n effective dose (ED) of pproximtely 1.2 msv (if the ED/DLP rtio of 2.2 for CT of the hed is used). 6 The multiplnr reconstructions re viewed y the rdiologist on DICOM viewer, which llows window width nd window level to e djusted, to optimise visulistion of the rticulr disc. The source xil imges re lso reviewed to detect ny normlities in the imged volume, which my e incidentl or which my e the source of symptoms mimicking TMJ dysfunction. Disc displcements my lso e visile on the xil imges. The TMJ is synovil joint tht is divided into superior nd inferior comprtments y the firocrtilginous iconcve disc (meniscus) (Fig. 1). The disc hs thick nterior nd posterior nds, nd thinner intermedite zone: the ltter is normlly positioned etween the nterosuperior spect of the mndiulr condyle nd the rticulr surfce of the squmous temporl one. The rticulr disc hs higher ttenution thn the surrounding soft tissues ut lower ttenution thn the djcent tendon of the lterl pterygoid muscle. The nterior nd posterior nds cn e seen, lthough the thinner intermedite nd ilminr zones re not generlly visile on CT. 448 Journl of Medicl Imging nd Rdition Oncology 2012 The Royl Austrlin nd New Zelnd College of Rdiologists

2 CT of the TMJ c d Fig. 2. Reducing nterior disc displcement. () Sgittl olique soft-tissue reconstruction shows moderte nterior disc displcement (etween rrowheds). () With mouth opening, the disc is reduced (nterior nd: lck rrowhed; posterior nd: white rrowhed). There is mild hypermoility, with nterior trnsltion of the condyle well nterior to the summit of the rticulr eminence. Internl disc derngement Fig. 1. Norml CT ntomy of the temporomndiulr joint. () Olique sgittl reconstruction t one window nd using one reconstruction lgorithm, showing the mndiulr condyle (C) seted within the glenoid foss (gf) of the temporl one. The rticulr eminence (e) of the temporl one is nterior nd the externl uditory cnl (ec) is posterior. () Olique coronl reconstruction t one window using one reconstruction lgorithm. The condyle is rod in its coronl dimension. Lterlly is the root of the zygomtic process (rz). (c) Olique sgittl reconstruction in the closed-mouth position t softtissue windows nd using soft-tissue reconstruction lgorithm. The nterior nd (thick rrow) nd posterior nd (rrowhed) re clerly visile. The thin intermedite zone (thin rrow) is situted t the nrrowest prt etween the condyle nd the rticulr eminence. The posterior mrgin of the posterior nd is normlly positioned t pproximtely the 12 o clock position. (d) Softtissue olique sgittl reconstruction in the open-mouth position. There hs een nterior trnsltion of the condyle onto the rticulr eminence, with concomitnt nterior movement of the disc. Anterior nd (thick rrow), posterior nd (rrowhed) nd intermedite zone (thin rrow) gin shown. Internl derngement is interference with joint s smooth function, nd in the TMJ this is usully due to displcement of the disc. Disc displcement is common, especilly in women, nd hs een descried in symptomtic volunteers. 7 Postulted cuses include ligmentous lxity (there is frequently n ntecedent history of trum or prolonged mouth opening for dentl procedures), ruxism nd norml ctivity of the lterl pterygoid muscle. 8 A displced disc my e reduced ( recptured ) with mouth opening (Fig. 2), nd reduction is ccompnied y n udile nd plple click. In more dvnced cses, displced disc my remin displced in opening the mouth (the so-clled closed lock ) (Fig. 3), in which cse there is usully restriction of mouth opening, nd sence of click. The disc my e deformed, nd there my e ssocited synovitis (predominntly in the inferior joint comprtment) nd osseous erosions (usully ffecting the condyle). Remodelling nd osteorthritis my follow (Fig. 4). Disc displcement is most commonly nterior (see Figs 2,3) or nterolterl 9 (Fig. 5). The disc my lso e displced nteromedilly. Pure medil (Fig. 6) nd pure lterl displcement re uncommon, nd posterior disc c Fig 3. Non-reducing nterior disc displcement with superior comprtment effusion, inferior comprtment synovitis nd erly condylr erosion. () Sgittl olique soft-tissue reconstruction shows mrked nterior displcement of the disc (etween rrowheds). The disc ppers slightly deformed. There is significnt superior comprtment effusion (thick rrow), nd there is evidence of synovitis in the inferior comprtment (thin rrow, higher ttenution thn the effusion in the superior comprtment). () With mouth opening, the disc is not recptured (rrowheds) nd nterior condylr trnsltion is limited. This corresponds with closed lock cliniclly, with no click ut with pinful restriction of mouth opening. (c) Coronl olique one reconstructions show smll superior condylr corticl erosion (rrow). Journl of Medicl Imging nd Rdition Oncology 2012 The Royl Austrlin nd New Zelnd College of Rdiologists 449

3 R Boeddinghus nd A Whyte Fig. 4. Non-reducing nterior disc displcement with ssocited osteorthritis. () Soft-tissue sgittl olique reconstruction shows mrked nterior displcement of mildly deformed disc (rrows), with smll ssocited superior comprtment effusion nd prole inferior comprtment synovitis. () Bone sgittl olique reconstruction shows condylr flttening, irregulrity nd sclerosis (lrge rrow), nd smll nterolterl osteophytes (smll rrows). displcement is rre. Associted disc deformity, joint effusions, synovitis nd erosions re visile on CT (see Fig. 3). Erosive rthritis Osseous erosions re frequently seen in ssocition with disc displcement, usully ffecting the mndiulr condyle (see Fig. 3c). Less commonly, TMJ erosions re seen s prt of systemic inflmmtory rthropthy, such s juvenile chronic rthritis, rheumtoid rthritis, nkylosing spondylitis nd psoritic rthritis (Fig. 7). Fig. 7. Primry erosive rthritis in young mn with severe ilterl temporomndiulr joint pin. Coronl olique () nd sgittl olique () one reconstructions demonstrte lrge ctive condylr erosions (lck rrows) nd periostel new one formtion long the right condylr neck (white rrow). Similr chnges were present on the left. Appernces re consistent with psoritic rthritis. Idiopthic condylr resorption A more severe form of condylr erosion ssocited with high grde internl derngement is recognised in teenge girls who hve reltively smll mndile (retrognthism). It hs een referred to s cheerleder s syndrome ecuse of the demogrphic primrily ffected. On imging, there is firly rpid progression from non-reducile displced meniscus to progressive condylr erosion nd resorption (Fig. 8). The glenoid foss is norml, the joint spce progressively widens nd Fig 5. Anterolterl disc displcement. () Sgittl olique soft-tissue reconstruction shows nterior displcement of deformed, crumpled disc (rrows). () Coronl olique reconstruction est shows the lterl component of disc displcement (rrow), lthough this is lso esily pprecited y scrolling through sgittl olique nd xil imges (not shown). Fig. 6. Pure medil disc displcement is unusul. () Coronl olique reconstruction shows the medil mrgin of the medilly displced disc (white rrow). () Review of xil soft-tissue imges demonstrtes the medilly displced disc (etween the rrowheds). Fig. 8. Idiopthic condylr resorption. Sgittl olique one-lgorithm CT reconstruction showing resorption of the nterosuperior spect of the condyle (rrow). The temporl one rticulr surfces re unffected. Soft-tissue CT reconstructions nd MRI (not shown) lso demonstrted non-reducing nteriorly displced disc, with condylr mrrow oedem lso visile on the MRI. 450 Journl of Medicl Imging nd Rdition Oncology 2012 The Royl Austrlin nd New Zelnd College of Rdiologists

4 CT of the TMJ Fig. 9. Osteorthritis. Axil CT imge () shows mild osteorthritis, with joint spce nrrowing nterolterlly (rrow), the usul site of erly chnges. Sgittl olique one reconstruction () in different ptient showing severe osseous sclerosis, rticulr surfce flttening nd irregulrity, n nterior condylr osteophyte nd clcified joint ody (rrow). eventully only the stump of the resored condyle remins. It is usully ilterl ut my e symmetric. There is significnt dete s to whether orthodontic tretment is n etiologicl or excerting fctor in this condition. Severl uthors hve proposed tht vsculr necrosis of the condyle is the likely pthogenesis. Tretment is difficult nd some ptients will need corrective jw (orthognthic) surgery to correct their skeletl deformity with or without deridement of the TMJs once the condition hs stilised, usully t the end of puerty. Fig. 10. Intr-rticulr nkylosis. Coronl reformtted CT showing ony nkylosis on the right nd likely firous nkylosis on the left. There ws remote history of temporomndiulr joint septic rthritis. firous nkylosis, there is mrked joint spce nrrowing with reciprocl rticulr surfce irregulrity often giving sw-tooth ppernce. Extr-rticulr nkylosis is rre. Firous nkylosis cn follow hemorrhge or infection in the muscles of mstiction, some of these cses representing typicl myositis ossificns. Bony nkylosis or development of pseudo-rthrosis cn occur in ptients with developmentl coronoid hyperplsi or post-trumtic depression of the zygomtic rch. In oth cses, there is nkylosis or pseudo-rthrosis etween the coronoid process nd the medil mrgin of the rch (Fig. 11). Osteorthritis Osteorthritis is usully seen in n older ge group thn internl derngement. Most ptients with TMJ osteorthritis hve history of preceding internl derngement, nd ville evidence suggests tht ptients with severe internl derngement cn progress to osteorthritis fter vrile intervl, often severl yers. The chnges of osteorthritis seen in the TMJ re identicl to those seen in other ffected joints: joint spce loss, rticulr surfce remodelling nd flttening, corticl sclerosis nd thickening, sucorticl cysts, osteophytes nd clcified intr-rticulr odies (Fig. 9) As is typicl of this condition, the chnges seen on imging do not lwys correlte with symptoms. Mny ptients my e pinfree despite dvnced osteorthritis nd the only complint is of joint noises or grting. Ankylosis Mrked restriction of mouth opening nd condylr movement is uncommonly due to nkylosis of the TMJ, which my e intr- or extr-rticulr in loction nd firous or ony in nture. Intr-rticulr nkylosis usully results from prior trum (such s intr-cpsulr condylr frcture), cusing hemrthrosis or prior septic rthritis (Fig. 10). Osseous union my e prtil or totl. In Fig. 11. Extr-rticulr cuse of pprent temporomndiulr joint (TMJ) nkylosis. Computed tomogrphy ws performed for suspected TMJ internl derngement in this 67-yer-old mn with severely limited mouth opening. The TMJs hd norml ppernces. Axil one-lgorithm CT demonstrtes pseudo-rthrosis etween the hyperplstic right coronoid process nd n exostosis rising from the medil mrgin of the zygomtic rch (rrowhed). Tip of norml left coronoid process (rrow) for comprison. Journl of Medicl Imging nd Rdition Oncology 2012 The Royl Austrlin nd New Zelnd College of Rdiologists 451

5 R Boeddinghus nd A Whyte Fig 12. Temporomndiulr joint frctures. () Axil imge showing severely displced condylr neck frcture, the condylr hed (white rrow) eing displced inferiorly, nterior nd medilly y the pull of the lterl pterygoid muscle. There is lso tympnic plte frcture with sucutneous emphysem deep to the skin of the nterior externl uditory cnl (lck rrow). This is occsionlly seen s n isolted frcture. Coronl CT reconstruction in different ptient () showing old ilterl condylr frctures, with ifid deformity of the condyles nd secondry osteorthritis with clcified joint odies. Condylr frctures Frctures of the mndiulr condyle re common nd usully occur following low to the contrlterl side of the mndile. They my e the sole injury s the condylr neck is reltively thin ut lso occur in conjunction with frctures of the contrlterl mndiulr ngle or ody. A low to the symphysis my result in ilterl condylr frctures, especilly in elderly ptients with resored mndile. Most condylr frctures re extr-cpsulr, running oliquely through the thin neck. The pull of the lterl pterygoid muscle tht ttches to oth the condyle nd disc results in nteromedil displcement of the condyle from the glenoid foss with the disc mintining norml ntomicl reltionship to the displced condyle (Fig. 12). If these frctures occur efore growth is complete, growth of neo-condyle my occur, replcing the displced condyle within the glenoid foss nd producing doule condyle ppernce (Fig. 12). Intrcpsulr frctures re much less common nd my e undisplced nd occult on plin rdiogrphs. A vrint of this injury is tympnic plte frcture involving the posterior wll of the glenoid foss (i.e., the nterior wll of the ony externl uditory cnl) (see Fig. 12). Firous dysplsi This my ffect the temporl surfces of the TMJ or the condyle itself. Its ppernces re chrcteristic, with expnsion of ffected one, ground glss texture nd loss of the norml corticomedullry differentition. Osteochondrom This enign one tumour (crtilge-cpped exostosis) is the most common neoplsm ffecting the TMJ. It cn c Miscellneous neoplstic nd hyperplstic TMJ conditions Condylr hyperplsi This is n idiopthic developmentl condition more common in mles nd generlly mnifesting in the teenge yers nd stilising t skeletl mturity. Unilterl overgrowth of mndiulr condyle results in mndiulr symmetry; the condylr neck my lso e enlrged, nd there my e n ipsilterl posterior open ite. There is commensurte enlrgement of the glenoid foss (Fig. 13). Fig. 13. Condylr hyperplsi. Sgittl olique reconstruction of the right temporomndiulr joint () in young womn with mndiulr symmetry nd right posterior open ite shows n enlrged nd slightly irregulr condyle nd condylr neck compred with the norml left side (). Coronl mximum intensity projection thick sl reconstruction (c) shows the symmetry nd chrcteristic prominence of the lterl spect of the ffected condylr neck (rrow). 452 Journl of Medicl Imging nd Rdition Oncology 2012 The Royl Austrlin nd New Zelnd College of Rdiologists

6 CT of the TMJ Fig. 14. Tumours of crtilge origin. Axil CT () shows smll osteochondrom rising from the nterolterl spect of the left mndiulr condyle; this presented s suspected internl disc derngement. Sgittl olique one () nd postcontrst soft-tissue (c) reconstructions in different ptient show n expnsile enhncing tumour centred in the rticulr eminence with corticl expnsion, thinning nd dehiscence (rrows). This proved to e chondrolstom. c rise from the condylr neck or hed nd cn interfere with the norml joint movements of the TMJ (Fig. 14). Other neoplsms of chondrl origin re fr less common (Fig. 14,c). Synovil chondromtosis Although the synovil prolifertion ssocited with dvnced internl derngement occurs in the lower joint spce, other rre synovil prolifertive disorders predominte in the upper joint spce. Of these, synovil chrondromtosis is the most common. The upper joint spce is distended y synovil prolifertion nd smll intr-rticulr odies, either chondrl or ossified (Fig. 15). Chondrl odies my e missed on CT, eing more clerly demonstrted y MRI. Nevertheless, the dignosis of synovil osteochondromtosis should e suggested in ptient with symptoms of internl derngement, normlly positioned disc nd significntly distended upper joint spce, with or without rticulr surfce erosions. Metstses Metstses nd other ggressive neoplstic lesions my ffect the condyle nd my present cliniclly s TMJ pin (Fig. 16). Regionl pthology Temporl one Otlgi cn e difficult to differentite from pin of TMJ origin. The nterior wll of the ony segment of the externl uditory cnl (tympnic plte) lso forms the posterior ony mrgin of the glenoid foss of the TMJ. In ddition, the uriculotemporl nerve, rnch of V3, provides the min innervtion to the TMJ s well s portion of the externl uditory cnl, the lterl spect of the tympnic memrne, uricle nd skin in the temporl region. Otomstoid inflmmtory disese nd destructive processes re optimlly ssessed on the volumetric dt set provided y MDCT of the TMJ. Protid glnd Protitis, mlignnt slivry glnd tumours nd metsttic crcinoms to the intr-protid lymph nodes my ll cuse pin referred to or within the TMJ. The uriculotemporl nerve provides secretomotor supply to the protid glnd, thus providing link etween the Vth nd VIIth crnil nerves. It my e involved y the Fig. 15. Synovil chrondromtosis. Sgittl olique CT reconstruction on softtissue lgorithm nd windows () shows distended superior joint spce with fluid nd sutle clcified foci (rrow). Sgittl olique T2-weighted ft sturted MRI () confirms fluid nd smll joint odies consistent with chondrl joint odies. The dignosis ws confirmed t rthroscopy. Fig. 16. Destructive one lesions. Sgittl olique one reconstruction () demonstrtes n ggressive lucent lesion in the condylr neck nd posterosuperior rmus, with pthologicl frcture (rrows); this proved to e metstsis from lung crcinom. Coronl one reconstruction () in different ptient shows loulr lucent lesion in the right mndiulr condyle, which proved to e Lngerhns cell histiocytosis (eosinophilic grnulom). Journl of Medicl Imging nd Rdition Oncology 2012 The Royl Austrlin nd New Zelnd College of Rdiologists 453

7 R Boeddinghus nd A Whyte pituitry neoplsms, cholestetom, otosclerosis nd other temporl one pthology. Conclusion Fig. 17. Regionl pthology cliniclly simulting temporomndiulr joint (TMJ) disese. Axil non-contrst soft-tissue lgorithm CT () in ptient with right TMJ region pin, demonstrting n irregulr tumour (rrowheds) in the protid glnd, with evidence of proximl perineurl tumour spred long the right fcil nerve (rrow): nplstic crcinom. Axil post-contrst CT () in different ptient with right TMJ pin nd limited mouth opening, showing inflmmtory chnge nd smll scess in the right medil pterygoid muscle, which is enlrged nd enhnces heterogeneously, with smll locules of gs (rrow); this ws secondry to peripicl sepsis in severl right mndiulr molrs; the TMJs ppered norml. perineurl tumour spred tht cn sometimes e visulised on non-contrst MDCT in the ftty protid glnds viewed on soft-tissue window (Fig. 17). Mstictor spce Inflmmtory or neoplstic processes in the mstictor spce cn produce pin in the region of the TMJ s well s restricted mouth opening, mimicking TMJ disorders (Fig. 17). Skull se Neoplstic involvement of the V3 from Meckel s cve to the inferior lveolr cnl in the mndile could potentilly produce pin within or close to the TMJ. Asymmetric expnsion of the formen ovle nd thickening of the V3 nerve cn e pprecited on non-contrst MDCT. Uncommonly, primry tumours or metstses involving one or the meninges of the floor of the middle crnil foss my cuse pin in the vicinity of the TMJ. Furthermore, even if not responsile for the presenting symptoms, significnt incidentl lesions my e seen within the scnned volume, including posterior foss nd Although CT hs een trditionlly viewed s modlity for ssessing only ony pthology nd clcifiction of the TMJs, with ttention to technique nd interctive reding with DICOM viewer, it is n excellent modlity for viewing the full rnge of TMJ pthology nd cn e used insted of MRI when MRI is contrindicted or not ccessile. In the setting of trum nd primry one lesions, it is the modlity of choice. References 1. Gurlnick W, Kn LB, Merrill RG. Temporomndiulr joint fflictions. N Engl J Med 1978; 299: Toms X, Pomes J, Berenguer J et l. MR imging of temporomndiulr joint dysfunction: pictoril review. Rdiogrphics 2006; 26: Brooks SL, Brnd JW, Gis SJ et l. Imging of the temporomndiulr joint: position pper of the Americn Acdemy of Orl nd Mxillofcil Rdiology. Orl Surg Orl Med Orl Pthol Orl Rdiol Endod 1997; 83: Blliu E, Medin V, Villnov JC et l. Synovil chondromtosis of the temporomndiulr joint: CT nd MRI findings. Dentomxillofc Rdiol 2007; 36: Simon DC, Hess ML, Smilk MS, Beltrn J. Direct sgittl CT of the temporomndiulr joint. Rdiology 1985; 157: Hud W, Ogden KM, Khorsni MR. Converting dose-length product to effective dose t CT. Rdiology 2008; 248: Lrheim TA, Westesson PL, Sno TS. Temporomndiulr joint disk displcement: comprison in symptomtic volunteers nd ptients. Rdiology 2001; 218: Molinri F, Mnicone PF, Rffelli L et l. Temporomndiulr joint: soft-tissue pthology, I: disc normlities. Semin Ultrsound CT MR 2007; 28: Whyte AM, McNmr D, Rosenerg I, Whyte AW. Mgnetic resonnce imging in the evlution of temporomndiulr joint disc displcement review of 144 cses. Int J Orl Mxillofc Surg 2006; 35: Journl of Medicl Imging nd Rdition Oncology 2012 The Royl Austrlin nd New Zelnd College of Rdiologists

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