internal derangement of the temporomandibular joint rosalyn cheng.pdf · references • sommer, j,...
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Internal Derangement of the
Temporomandibular Joint
Rosalyn Cheng
April 3, 2008
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Objectives
• Clinical significance
• Imaging using MRI
• Normal anatomy of the
temporomandibular joint
• MRI findings of TMJ internal derangement
• Review examples
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20-30% of population
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Internal derangement and clinical
significance
• Most frequent disorder of the TMJ
• Abnormal positional and functional
relationship between the articular disk and
its articulating surfaces
• F:M= 3-5:1
• Fourth decade
• Bilateral abnormalities 60-70%
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Internal derangement and clinical
significance
• Disk position can be abnormal in up to 33% of
asymptomatic individuals
• 82% of patients presenting with pain and
functional disturbance have displaced disks on
MRI
• Progressive disorder eventually resulting in
ankylosis and osteoarthrosis of varying severity
• Symptoms become quiescent over a period of 6-
10 years
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Etiology?
• Not understood
• Trauma
• Iatrogenic
• Ligamentous laxity
• Organic changes in the teeth, malocclusion,
bruxism
• Changes in composition of synovial fluid
• Improper activity of lateral pterygoid muscle
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Imaging of the TMJ:
• Transcranial radiography
• Panorex
• SPECT using 99mTc MDP/HMDP
• Ultrasound
• CT
• Arthrography
• MRI
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Imaging TMJ- MRI
• T1 spin echo coronal or axial localizer
• PD or T1 and T2 sagittal and coronal in closed-
and open-mouth positions
Sommer, O. J. et al. Radiographics 2003;23:14
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Imaging TMJ- MRI
• 3 mm slice thickness with a spacing of 0.5
or 1 mm
• FOV 12-14 cm
• Matrix 256 x 192
• Small surface coils; dual
• Gradient echo- pseudodynamic; static
images at progressive increments of
mouth opening
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Temporomandibular joint
• Craniomandibular
articulation
• Ginglymoarthrodial joint
• Joint surfaces covered by
fibrocartilage instead of
hyaline cartilage
• Synovial membrane lines
parts of the joint not
covered by fibrocartilage
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Anatomy-Osseous components
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Mandibular component
• Condylar head atop
mandibular neck
• Lateral pole and
medial pole
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Mandibular component
• Morphology of
condyle variable
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Anatomy- Temporal bone
component• Articular eminence
• Articular tubercle
• Preglenoid plane
• Glenoid fossa
• Postglenoid process
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Alomar X, et al. Sem Ultrasound, CT, MRI.
2007; 28(3):170-183.
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Aloma X, et al. Sem Ultrasound, CT, MRI.
2007; 28(3):170-183.
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Anatomy- Articular Disk
• Biconcave fibrocartilagous disc
• Divides joint into larger upper and smaller
lower compartments
• Firmly attached to articular capsule
circumferentially except for medially and
laterally where it is attached to medial and
lateral poles of condyle by collateral
condylodiskal ligaments
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Articular Disk
• Anterior band
• Intermediate band
• Posterior band
• Retrodiskal tissue
(bilaminar zone)
– 2 laminae
– Neurovascular
structures
Sommer, O. J. et al. Radiographics 2003;23:14
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Normal superior lamina (elastic fibers) Normal inferior lamina (collagen fibers)
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Alomar X et al. Sem Ultrasound, CT, MRI.
2007; 28(3):170-183.
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Biomechanical Properties of the
Disc
• Disc has to be able to absorb peak loads,
distribute force
• Inhomogeneous distribution of collagen,
elastin ,proteoglycans and fluid
• Plastic deformation, local and
progressively
• Adaptative response
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TMJ Disc Collagen Fiber
Organization
Scapino, et al. Cell Tissues Organs 2006; 182: 201-225
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Collateral LigamentsStrong lateral ligament
• 2 layers:
1) superficial
-fan-shaped
-oblique course
-taut in protraction
2) deep
-narrow
-anteroposterior course
-taut in retraction
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Alomar X, et al. Sem Ultrasound, CT, MRI.
2007; 28(3):170-183.
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Muscles
• Muscles of mastication:
– Abductors (jaw opener)
• Lateral pterygoid
– Adductors (jaw closers)
• Temporalis, masseter, and medial pterygoid
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Lateral pterygoid
• Superior belly:
– Pass through joint capsule
connecting with anterior
band of disk
– Responsible for proper disk
movement in coordination
with movement of lower
jaw especially during
closing and ipsilateral
movements
• Inferior belly:
– Pulls condyles forward
during opening
– Alternate contracting allows
contralateral movement
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http://www.herkules.oulu
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Alomar X, et al. Sem Ultrasound, CT, MRI.
2007; 28(3):170-183.
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Copyright ©Radiological Society of North America, 2006
Tomas, X. et al. Radiographics 2006;26:765-781
Figure 1. Drawing illustrates the anatomy of the TMJ
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What is normal?
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Molinari et al. Sem Ultrasound, CT, and
MRI. 2007; 28(3):192-204. Sano et al. Current problems in
Diagnostic Radiology 33(1); 2004
16-24.
Closed
Open
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Sommer, OJ et al. Radiographics 2003;23:14
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Molinari et al. Sem Ultrasound, CT, and
MRI. 2007; 28(3):192-204.
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Normal TMJ motion
• Opening-two different motions:
1) Rotation around a horizontal axis through
the condylar heads
2) Translation
condyle and meniscus move together
anteriorly beneath the articular eminence;
intermediate zone of the meniscus becomes the
articulating surface between the condyle and the
articular eminence
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Protraction
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Retraction
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Classifications of Internal Derangement-
Direction
• Direction of displacement (ant, med, lat, posterior, anteromedial, anterolateral)
• Multidirectional displacements more frequent than unidirectional ones
• Posterior displacement rare
• Oblique orientation of lateral pterygoid muscle and angulation of condyle direct most meniscal displacements in anteromedial path
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Classification –Direction plus
altered motion
• Anterior displacement with reduction
during opening
• Anterior displacement without reduction
during opening
• Anterior displacement with perforation of
the disk
• Stuck disk, adhesions
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Closed Open
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Sano et al. Current problems in
Diagnostic Radiology 2004; 33(1):
16-24.
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Sano et al. Current problems in
Diagnostic Radiology 33(1); 2004
16-24.
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Anterolateral displacement
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Secondary signs
• Morphology of disc- biconvex, rounded, irregular
or flat usually indicates more advanced disease
• Presence of joint effusion
• Rupture of retrodiscal ligaments
• Decreased signal intensity of the disc
• Increased T2 SI of retrodiscal tissue- due to
higher degree of vascular supply
• Lateral pterygoid muscle: hypertrophy, atrophy
or contracture
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Abnormal morphology
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Joint Effusions
• Significantly more prevalent in painful vs.
nonpainful joints
• Large joint effusions seen only in
symptomatic patients
• Presence of joint effusion unusual sign in
asymptomatic individuals
• Generally seen surrounding anterior band
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Tomas X, et al. Semin Ultrasound CT MRI 2007; 28:205-212.
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Tomas X, et al. Semin Ultrasound CT MRI 2007; 28:205-212.
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Sano et al. Current problems in
Diagnostic Radiology 33(1); 2004
16-24.
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Changes in retrodiskal tissue
• TMJs with pain and dysfunction have
higher signal intensity in retrodiskal tissue
than those without
• Indicates higher degree of vascularity in
RDT in painful vs nonpainful
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Sano et al. Current problems in
Diagnostic Radiology 200; 33(1):
16-24
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Abnormal
enhancement of
RT
Normal side
Tomas X, et al. Semin Ultrasound CT MRI
2007; 28:205-212.
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http://www.herkules.oulu
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Osteoarthrosis
• Second most common abnormality of TMJ
• 20% of patients with internal derangement have
OA at time of initial presentation
• Rare in joints with normal disk position
• OA in large proportion of older individuals
completely asx
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Osteoarthrosis
• Flattening, irregularity
of articular surfaces,
subchondral
decreased signal,
subchondral cystic
change,
osteophytosis,
erosions
Sano et al. Current problems in Diagnostic Radiology
2004; 33(1):16-24.
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Treatment of Internal Derangement
• 1st line: conservative
and reversible
approaches
• NSAIDS, muscle
relaxants
• splints, home care
procedures
• cognitive-behavioral
information program
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Treatment of Internal Derangement
• Surgery:
• Diskal plication with
repositioning
• Arthroscopy with lysis
of adhesions
• Diskectomy and
alloplastic disc
implant or autograft
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Postoperative
• Failed implants resulting from foreign body
reaction- bone erosions similar to septic
arthritis and RA
• Clinical findings and MRI appearances
correlate poorly
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Case review:
• Position and mobility
• OA changes
• Effusion
• Morphology
• Signal intensity (disk and retrodiskal
tissue)
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Closed mouth
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Open mouth
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Closed mouth Coronal
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Closed mouth Coronal
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Right Closed Left Closed
27 y.o with left TMJ pain
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Left OpenRight Open
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Left ClosedRight Closed
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CLOSED LOCK
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Anterior disc displacement
without reduction
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Posterior band rupture
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Copyright ©Radiological Society of North America, 2006
Tomas, X. et al. Radiographics 2006;26:765-781
Normal
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Lateral displacement
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Styles C, Whyte A. Brit J of Oral and Maxillofacial
Surgery (2002) 40:220-228.
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Copyright ©Radiological Society of North America, 2006
Tomas, X. et al. Radiographics 2006;26:765-781.
Posterior displacement
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Anterior dislocation without recapture and
perforation posterior attachment
Styles C, et al. Brit J of Oral and Maxillofacial
Surgery. 2002; 40:220-228.
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Stuck disk
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Anterior dislocation without reduction upon
opening
http://www.herkules.oulu
35 y.o. F pain on jaw movement; difficult
with mouth opening x past two years
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Summary
• Internal derangement most common abnormality affecting the TMJ
• MRI modality of choice
• Symptomatology may not correlate with imaging findings
• Frequently sequential progression:
– ADDWR
– ADDWOR
– Perforation
– Stuck
• POEMS: (position and mobility, OA, effusion, morphology, signal intensity)
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Thanks to Christine and Tudor!
The End
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References:• Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I,Monill J, Salvador
A. Anatomy of the Temporomandibular Joint. Semin Ultrasound CT MRI. 2007; 28(3):170-183.
• Helms CA, Kaban LB, McNeill C, Dodson T. Temporomandibular Joint: Morphology and Signal Intensity Characteristics of the Disc at MR ImagingTemporomandibular. Radiology 1989; 172:817-820.
• Katzenberg TW. Temporomandibular joint imaging. Radiology 1989; 170:297-307.
• Larheim TA, Westesson P, Sano T. Temporomandibular Joint Disk Displacement: Comparison in Asymptomatic Volunteers and Patients. Radiology 2001; 218:428-432.
• Murphy WA, Kaplan PA. Resnick D. Temporomandibular joint. In: Resnick D, eds. Diagnosis of bone and joint disorders. Saunders, 2002; 1707-1751.
• Molinari F, Manicone PF, Raffaelli L, Raffaelli R, Pirronti T, Bonomo L. Temporomandibular Joint Soft-Tissue Pathology, I: Disc Abnormalities. Semin Ultrasound CT MRI 2007; 28(3):192-204.
• Rao VM. Imaging of the Temporomandibular Joint. Semin Ultrasound CT MRI. 1995; 16(6):513-526.
• Sano T, Yamamoto M, Okano T, Gokan, T, Westesson P, et al. Common abnormalities in temporomandibular joint imaging. Current problems in Diagnostic Radiology 2004; 33:16-24.
• Sano T, Otonari-Yamamoto M, Otonari T, Yajima A. Osseous Abnormalities Related to the Temporomandibular Joint. Semin Ultrasound CT MRI 2007; 28(3):213-221.
• Scapino RP, Obrez A, Greising D. Organization and function of the Collagen Fiber System in the Human Temporomandibular Joint Disk and Its Attachments. Cells Tissues Organs. 2006; 182:201-225.
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References
• Sommer, J, et al.: Cross-sectional and Functional Imaging of the Temporomandibular Joint: Radiology, Pathology, and Basic Biomechanics of the Jaw. Radiographics; 2003; 23-25.
• Styles C, Whyte A. MRI in the assessment of internal derangement and pain within the temporomandibular joint: a pictorial essay. Brit Journal of Oral and Maxillofacial Surgery 2002; 40:220–228
• Tomas X, Pomes J, Berenguer J. Mercader JM, Pons F, Donoso L. Temporomandibular Joint Soft-Tissue Pathology, II: Nondisc Abnormalities. Semin Ultrasound CT MRI 2007; 28(3):205-212.
• Tomas X, Pomes J, Berenguer J, Quinto L, Nicolau C, Mercader JM, Castro V. MR Imaging of Temporomandibular Joint Dysfunction: A Pictorial Review. RadioGraphics 2006; 26:765-781.
• http://www.johnsdental.com
• http://www.learningfile.com
• http://uwmsk.org/tmj/anatomy.html