Gomputed tomography of the normal temporomaandibular joint

Gomputed tomography of the normal temporomaandibular joint EDWIN h. GHRISTiANSENi, TERENCE T: CHAN^, JOSEPH R. THOMPSON^ ANTON N. HASSO', DAVID B. HINSHAW JR' AND SIGVARD KOPP* ^Department of Endodontics^ School of Dentistry,, Loma Linda University, '^Department of Radiation Sciences, 'Section of Neuroradiology, Lima Linda University Medical Center, Loma Linda, California, USA, 'Department of Stomatognathic Physiology, School of Dentistry, University of Lund, Malmo, Sweden Christiansen EL, Chan TT, Thompson JR, Hasso AN, Hinshaw DB Jr, Kopp S: Computed tomography of the normal temporomandibular joint. Scand J Dent Res 1987; 95: 499-309. Abstract - A study was made in two parts, retrospective (I) and prospective (II), on two samples of 36 and 17 individuals, respectively, who had temporal bone CT studies for reasons unrelated to TMJ pain and dysfunction. Groups I and II had no radiographic signs of TMJ disease and Group II had neither radiographic nor clinical signs of TMJ disease. Both groups were considered to have normal joints. Joint morphometrics for the two groups () were as follows; transverse condylar dimensions were 18.5/18.1 mm. Condylar angulation averaged 24''/25 and intercondylar distance averaged 83/83 mm while extra condylar distance averaged 118/118 mm. The condyle in the sagittal plane showed a smooth and rounded form with anterior-superior joint space averaging 1.9/1.7 mm while the central-superior joint space averaged 2.3/2.2 mm. The medial-horizontal joint space averaged 3.9/3.7 mm. The slope of the central portion of the articular eminence averaged GO'/eO" in the sagittal plane. Key words: anatomy; computed tomography; mandible; temporomandibular joint. Edwin L. Christiansen, Department of Endodontics, School of Dentistry, Loma Linda, California 92350, USA. Accepted for publication 17 February 1987. Pain and dysfunction of the temporoman- CT appearance of the normal TMJ. Our dibular joints (TMJ) are not uncommon review of the literature has shown that while cohiplaints in patients presenting at dental references have been made to the normal CT and medical clinics. Thin section computed appearance of the TMJ, no stibstantiating tomography (CT) has provided new diag- morphometrics are presented (1, 2). Since nostic possibilities for this large group of pa- the first paper by SOARES etal. (3), interest in tients. The purpose of this retrospective TMJ CT has concentrated on scan protocols study was to describe the normal TMJ as it and imaging of the meniscus {4 10). Several is depicted with computed tomography. papers presented case reports, CT for facial To evaluate the CT appearance of the fractures and specific research topics abnormal TMJ it is necessary to define the (11 15). Obvious variations of TMJ

500 CHRISTIANSEN ET AL. Table 1 Age distribution in tmmber of individuals for Groups J and II by sex separated in three classes of approximately 20y width. The mean (M) and standard deviation (SD) of age in years are induded Groups Women Men Total 21-40 4/1 6/2 10/3 41-60 9/4 5/4 14/8 61-83 9/4 3/2 12/6 M 54/55 47/50 SD 18/16 15/15 omy and the absence of a morphometric GT description of the normal joint has led us to undertake this study. Material and metiiods Axiai plane close sequence CT studies of two groups (I, II) of individuals that induded the temporoman dibular joints form the basis for this study. Group 1 {K = 36) represents, a retrospective Fig. J. Direct sagittal view of right TMJ showing level at which measurements were made in axial plane.

CT OF NORMAL TMJ study and Group II {n= 17) represents a prospective study of temporal bone scans which, for both groups, were not made specifically for the TMJ. Additionally, while there was no history taken nor any clinical examination made of Group I, Group II was. examined as to any past or present TMJ symptomatology^ such as pain, clicking or locking. For Group II, the position of the mandible (centric occlusion with light intercuspation) was. controlled whereas it was not controlled for Group I. The scans were loaded on a video display terminal (VDT) where they were evaluated for technical adequacy with respect to display of the joint elements, joint space and freedom from movement artifacts. Criteria for selection of the two groups were as follows: 1} the scans muse be in the axiai plane parallel to Reid's baseline, 2) the subjects must be '21 yr or older, 3) no-reports in the medical record of pain or dysfunction of the TMJ, 4) no reports of head trauma, 5) no radiographic signs, of TMJ disease and 6) no craniofacial neopiastic disease. The GT scan reports and the hospital records were reviewed for indications of trauma or neopiastic disease. The distribution of age and sex of the individuals for each group is shown in Table h AM patients were imaged wstb the General Electric 8800 CT/N scanner {General Electric Co., Medical Systems Operations, Milwaukee, WI;^ USA) with supine po.sitioning and axial, imaging planes. The scan parameters, most frequendy used included the adult head calibration file, 1.2 prospective soft tissue targeting, 1.6 retrospective bone targeting, 9.6 second scan times and i.5 mm sections. When the scan data was not retrospectively Reviewed (General Electric Co.), tbe extended scale video display function was selected for optimum visualization of bone. Morphometric analysis of the right and left joints of each group was identical. All measurements and assessments in the axial plane were made at the level of the summit of the articular eminence (Fig. 1) because this level most frequently corresponds, to maximum condylar dimensions. Furthermore, at this location, \'isualization of the soft tissue and osseous joint elements is maximized because there is no interference from adjacent bony structures^ particulariy the articular eminence. Assessments in the vertically reformatted coronal plane were made along the transverse axis of the condyle. Measurements in the vertically reformatted sagittal plane were perpendicular to the transverse axis of the condyle ai its visually estim.ated center. The antero-superior (AS) sagittal joint space was measured at the center of the condyle., as the shortest distance between the bony surfaces of the condyle and the articular eminence (Fig. 2A).. This joint space represents the thin central articular portion of the meniscus as it is normally positioned between the bony joint elements in the sagittally viewed closed mouth position (Fig. 2B). Coronal centro-superior (CS) joint space was measured from the central superior portion of the condyle' to the nearest point in the glenoid fossa (Fig. 2G). The medial-horizontal (MH) joint space was measured from the height of contour of the bony surface of the medial condylar pole, horizontally to the adjacent wall of the glenoid fossa. Condylar angulation was visually estimated, then measured by depositing the cursor at the medial and lateral poles of tbe magnified (4.0 times) axial image and reading to the nearest I / 10th degree directly from the VDT (Fig. 3A). Intercondylar and extracondylar distances were measured from the heights of contour of the respective condylar poles (Fig. 3B}. Condylar form, in the axial plancj was assessed as either ellipsoid, concavoconvex or ovoid (Fig. 4A-C). Condylar form i,n the coronal plan.e was tabulated as one of four types according to a previous study of dry skull material (16) (Fig. 5A D). Angulation of the articular eminence in tbe sagittal plane was measured directly from the film with a protractor along.a visually estimated line that provide a visual best-fit of tbe slope (Fig. 6). In most individuals the slope of tbe eminence was readily determined. In a few individuals the eminence was smoothly sigmoid over its entirety and estimating the slope was more difficult. In these cases, the slope was estimated by a tangent to the curve of the eminence. The length and angulation of the inferior bundle of the lateral pterygoid muscle in the axial plane were measured from the condylar center to the medial recess or antero-posterior midpoint of tbe lateral pter)'goid plate and read directly from the VDT (Figs. 7A, B), Differences between sides and sexes in this study were tested for statistical significance by Student's,(-test for comparing the means of two small samples and correlation to age was tested by Pearson's product-moment correlation coefficient (r).

502 CHRISTIANSEN ET AL.. sf-^' '"<$r^ POST BAND (LAMINAR ZONE / CENTRAL ARTICULAR PORTION

CT OF NORMAL TMJ 503 Fig. 2. a, vertically reformatted sagittal image along antero-posterior condylar axis for determination of antero-superior (AS) joint space, form and slope of articular eminence, b, drawing made from same GT section as A illustrating relation of normal meniscus, to osseousjoint elements, c, vertically reformatted coronal image along transverse condylar axis illustrating central-superior (CS) and medio-horizontal (MH) joint space. Results The results of this study are shown in Table 2 and Figs. 4 and 5. The average transverse dimensions of the condyles iti men (19.6 mm) and wonien (17.7 mm) in Group I were significantly different (P<0.02). The extracondylar distance in men and vv'omen in Group I and II was 121 mm and 115.6, respectively, and the diiference between these values was also significant (/'<0.05). No significant differences between right and left sides and no significant correlation to age was found for any of the variables investi-

504 CHRISTIANSEN ET AL.

CT OF NORMAL TMJ 505 ' I. * =/. K, i^i^. 5. a, axial section, bone detail images were utilized in determination of condylar angulation (AN) relative to coronal plane (XX). b, axial section demonstrating measurement of transverse condylar dimension, c^ axial section demonstrating extracondylar (line AB) and intercondylar (line CD) measurements. Discussion There is the possibility of a radiographically undetected and asymptomatic meniscal problem in Group I since no clinical examination of the TMJ was made of the individuals in this group. However, this possibility is greatly reduced in Group II, where the clinical examination should have disclosed such a problem of any clinical significance. We therefore consider the joints of the individuals in Group II to be normal from al! aspects. The radiographically normal joints in the asymptomatic individuals of Group I do not differ io morphometric pattern from Group II and there is no reason therefore to suspect an asymptomatic meniscal problem of any relevance for this study.

506 CHRISTIANSEN ET AL. o Fig. 4. Axial plane condylar form. Relative frequency is (A) 40% elliptical, (B) 40% concavoconvex and (C) 20%. ovoid. The average age of the individuals in this investigation is higher by 15 yr in women and 7 yr in men than what is seen on average in the TMJ clinic at this university. Rather than being a liability to the study, the age distribution of this population is presumed ^7000 A B C D Fig. 5. Coronal plane condylar form (according to YALE et al. (15) and relative frequency (%). I (A) 34%, II (B) 43%, III (C) 19% and IV (D) 9%.... '<. : Fig. 6. Slope and form of articular eminence was determined from verdcally reformatred images. Line AB illustrates slope of eminence.

CT OF NORMAL TMJ 507 Fig.. 7. a, ieiigth and angulation of inferior belly of lateral pterygoid muscle measured from condylar visual center (arrow) to lateral surface (arrow) of lateral pter^'goid plate, b, axial image, soft tissue detail of same subject as.a demonstrating deployment (dotted line) of inferior belly of lateral pterygoid muscle.

508 CHRISTIANSEN ET AL. Table 2 Distribution for Groups I {n 36) and JI (n~17) of mean (M), range (R) and standard deviation (SD) of condylar anguiation (degrees), transverse (TR) condylar dimension (mm), mttero-posterior (AP) condylar dimension (mm)j antero-superior (AS) sagittal plane joint space (mm)y centra-superior (CS) coronal plane joint space (mm), extracondylar distance (mm), slope of articular eminence (degrees), angle (degrees) and length (mm) of inferior belly of lateral pterygoid muscle Group TR condylar angnlation.'vp condylar dimension AS joint space CS joint space MH joint space Intercondylar distance Extracondyiar distance Eminence angulation Muscle angulation M 23.9/25.4 18.5/18.0 1.9/1.7 2.3/2.2 3.9/3.6 83.0/83.0' 118.5/117.5 59.6/60.0 37.8/37.9 R 30.9/22.6 9.2/8.0 2.5/2.1 5.3/3.2 6.0/4.0 22.6/22.6 28.8/28.8 55.0/47.0 14.9/14.2 SD 6.6/6.2 2.4/2.5 0.5/0.5 0.9/1.1 1.1/Ll 4.6/6.2 6.8/8.2 12.4/11.9 3.1/3.7 to provide a continuum of appearance of normal joints. The inferior crest of the articular eminence was selected as the location for measurements primarily because this is the site where we make many of the CT scan evaluations of TMJ patients. Determination of the slope of the articular eminence was the most subjective measurement in the study. The average error of measurement was estimated to be + 5 in those individuals where the slope was easily determined and + 10 where it was nat. The mean value for condylar angulation is comparable to studies using conventional radiographic techniques (17), however, the standard deviation is less by about 3 (a relative deerease of 33%), indicative of a more homogeneous group. Condylar angulation was not signiftcantiy correlated to age in these studies of normal individuals but has been found to be correlated to age in individuals with diseased TM-joints (18). We anticipated that we would fmd greater differences when we analyzed for differences between left and right sides and by sex. Surprisingly, there were significant differences in only two variables by sex, transverse condylar dimension and extra condylar distance. The results of this sttidy are consistent with previous reports of TMJ morphometrics for ' older-(19) and younger (20) adults, where the mean condylar transverse dimensions were 19.8 mm and 20.5 mm, respectively. Their description of coronal and axial condylar morphology is essentially the same as that reported in this study. It is understood that padents do not normally have CT head scans unless a disease process is suspected. However, the patients in these two samples are considered normal insofar as the temporomandibular joints are concerned and the parameters presented should therefore be valid as normal morphometric values. References 1. LARHEIM TA, KOLBENSTVEDT A. High resolution computed tomography of the osseou.s temporomandibulair joint, Acta Radiol Diagnosis 1984; 25: 465-9. 2. COHEN H, ROSS S, GORDON R. Computerized tomography as a guide in the diagnosis of temporomandihular joint disease. J Am Dent Assoc 1985; 110: 57-50.

CT OF NORMAL TMJ 509 3. SuAREs FR, BHUSSRY BR, HUANG KH, VAUGHN D. A preliminary study of computerized tomography for evaluation of the tennporomandibular joints. Compmd Contin Educ Dent 1980; 1: 217-22. 4. HELMS CA, MORRISH RB, KIRCOS LT, KATZ- BERG RW, DoLwicK MF. Computed tomography of the meniscus of the temporomandibular joint: preliminary observations. Radiology 1982; 145: 719-22., 5. MANZIONE JV, SELTZER SE, KATZBERG RW, HAMMERSCHLAG SB, CHIAKGO BF. Direct sagittal computed tomography of the temporomandibular joint. Am J Neuroradiol 1982; 3: 677-9. 6. HELMS CA, KATZBEBG RW, MOORISH R, DOLwiCK MF. Computerized tomography of the temporomandibular joint. J Oral Maxillofac Surg 1983; 41: 512-7. 7. MANZIONE JV, KATZBERG RW, BRODSKY GL, SELTZER SE, MELLING HZ. Internal derangements of the temporomandibular joint: diagnosis by direct sagittal computed tomography. Radiology 1984; 150: 111-5. 8. THOMPSON JR, CHRISTIANSEN EL, HASSO AN, HINSHAW DB JR. Dislocation of the Eemporomandibular joint disk demonstrated by CT, Am J Neuroradiol 1984; 5: 115-6. 9. THOMPSON JR, CHRISTIANSEN EL, HASSO AN, HINSHAW DB JR. Temporomandibular joints: high resolution computed tomographic evaluation. Radiology 1984; 150: 105-10. 10. HELMS CA, VOGLER JB, MOORISH RB. Diagnosis by computed tomography of temporomandibular joint meniscus displacement. J Prosthet Dent 1984; 51: 544-7. 11. DELBALSO AM, PYATT RS, BUSCH RF, HIRO- KAWA R, FiNK CS. Synovial cell sarcoma of the temporomandibular joint. Computed tomography fmdings. Areh Otolaryngol 1982; 108: 520-2. 12. KABAN LB, BERTOLAMI CN. The role of CT scan in diagnosis of TMJ ankylosis: report of case. J Oral Surg 1981; 39: 370-2. 13. Fujii N, YAHASHIRO M. Computed tomography for the diagnosis of facial fractures. J Oral Surg 19B1;39: 568-71. 14. HiGASHI T, KASHMIA I, KANNO M, TAKENAKE E, MoHDSE I, MARTIN MB. Experimental use of CT scan for definition of dentomaxillomandibular anatomy. J Oral Surg 1981; 39: 568-7 i. 15. HuLS AB. Kiefergeienk und Kaumuskulature im Computeftomogram vergleichmde klinisch-rontgenenologische Unterscuhungen zufunktionstsrungen stomatognathen System. Thesis, Tubingen: Eberhard- Karls Universitat, 1981. 16. YALE SH, CEEALLOS M, KRESNOFF CS, HAUPTFUEHRER JD. Some observations on the classification of the mandibular condyle types. Oral Surg 1963; 16: 572-7. 17. WILLIAMSON EH, W^ILSON CW, Use of a submentalvertex analysis for producing quality temporomandibular joint laminagraphs. Am J Orthodonl 1976; 70: 200-7. 18. CHRISTIANSEN EL, THOMPSON JR, KOPP SFO, HASSO AN, HINSHAW DB JR. Radiographic signs of temporomandibular joint disease: an investigation utilizing x-ray computed tomography, Dentomaxillofac Radiol 1985; 14: 83-92. 19. OBEKG T, CARLSSON GE, FAJERS CM, The temporomandibular joint: a morphologic study on human autopsy material. Acta Odontol Scand 1971; 29: 349-84, 20. SoLBERG WK, HANSSON T, NORDSTROM B, The temporomandibular joint in young adults at autopsy: a morphologic classibcation and evaluation. J Oral Rehabil 1985; 12: 303-21,

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