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Common abnormalities in temporomandibular joint imaging
Common Abnormalities in Temporomandibular Joint Imaging Tsukasa Sano, DDS, PhD,a Mika Yamamoto, DDS,a Tomohiro Okano, DDS, PhD,a Takehiko Gokan, MD, PhD,b and Per-Lennart Westesson, MD, PhD, DDSc
Magnetic resonance imaging has evolved as a prime diagnostic method for soft-tissue abnormalities of the temporomandibular joint. The most common temporomandibular joint abnormalities are internal derangement and osteoarthritis, but there are many other reasons for pain and dysfunction that are often overlooked. The purpose of this paper is to illustrate several of these more unusual and less well-recognized causes for temporomandibular joint pain and dysfunction. For example, internal derangement is often seen in asymptomatic individuals. Another purpose is to illustrate the difference in magnetic resonance imaging of asymptomatic and symptomatic internal derangement.
Improvements in diagnostic imaging of the temporomandibular joint (TMJ) (Fig 1) during the last 2 decades have shown that disk displacement is the most frequent abnormality in patients with pain and dysfunction. Magnetic resonance imaging (MRI) has evolved as a prime diagnostic method for soft-tissue abnormalities of TMJ, including internal derangements, since its clinical introduction in the mid-1980s.1,2 In diagnosing TMJ, more recent studies3,4 have demonstrated that MRI is equal or possibly better than standard tomography in diagnosing osseous abnormalities of TMJ. The etiology of TMJ pain is not completely understood. There are several possible sources of TMJ pain, such as disk displacement,1,2 osteoarthritis,5 bone-marrow alterations of the mandibular condyle,6 inflammatory changes in the retFrom the aDepartment of Radiology, Showa University School of Dentistry, Tokyo, Japan; bDepartment of Radiology, Showa University School of Medicine, Tokyo, Japan; cDepartment of Radiology, Division of Neuroradiology, University of Rochester Medical Center, Rochester, NY. Reprint requests: Tsukasa Sano, DDS, PhD, Department of Radiology, Showa University School of Dentistry, 2-1-1, Kitasenzoku, Ohta-ku, 145, Tokyo, Japan. E-mail: [email protected]. Curr Probl Diagn Radiol 2004;33:16-24. © 2004 Mosby, Inc. All rights reserved. 0363-0188/2004/$30.00 ⫹ 0 doi:10.1067/j.cpradiol.2003.09.001
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FIG 1. TMJ in sagittal section. The posterior band of the disk (D) is lying over the condyle (C). The disk is between upper (U) and lower (L) joint spaces. R, retrodiskal tissue; EAC, extraauditory canal; LPM, lateral pterygoid muscle.
rodiskal tissue,7-9 and inflammatory changes in the joint space resulting in joint effusion.10 The purpose of this paper is to illustrate several of these more unusual and less well-recognized causes for TMJ pain and dysfunction and also to illustrate the difference in MRI of asymptomatic and symptomatic internal derangement.
Disk Displacement Most asymptomatic individuals show normal disk position (Fig 2). Disk displacement (Figs 3 and 4) is found in approximately 80% of patients with symptoms.11 Several forms of disk displacement are also seen in as much as one third of asymptomatic volunteers.11-13 This may initially appear confusing, but asymptomatic volunteers demonstrate that most, if not all, the volunteers have early-stage disk displacement, whereas more later stages are seen in patients.14 Larheim et al14 reported that complete
Curr Probl Diagn Radiol, January/February 2004
FIG 2. Normal disk position with normal function. (A) In the protondensity closed-mouth image, the disk (arrow) is between the condyle and the articular eminence. (B) On opening, the disk (arrow) is also located between the condyle and the articular eminence during condylar movement, indicating normal disk position with normal function.
disk displacement was found in 46 (40%) of 115 joints in patients compared with 3 (2.4%) of 124 joints in asymptomatic volunteers, whereas partial disk displacement (Fig 5) occurred in 26 (22.6%) and 27 (21.8%) joints, respectively.
Curr Probl Diagn Radiol, January/February 2004
FIG 3. Anterior disk displacement with reduction. (A) In the protondensity closed-mouth image, the disk (arrow) is anterior to the condyle. (B) On opening, the disk (arrow) is located between the condyle and the articular eminence, indicating anterior disk displacement with reduction.
Osteoarthritis Osteoarthritis (Figs 6 and 7) has also been indicated as a source of the pain,5 but a recent study has indicated that there is no statistically significant difference in the degree
17
FIG 4. Anterior disk displacement without reduction. (A) In the proton-density closed-mouth image, the disk (arrow) is anterior to the condyle. (B) On opening, the disk (arrow) remains anterior to the condyle, indicating anterior disk displacement without reduction.
of pain in patients with osteoarthritis compared to those without.15 This is also in accordance with the findings that osteoarthritis in a large proportion of older individ-
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FIG 5. Partial anterior disk displacement. (A) In the lateral part of the joint, the disk (arrow) is anteriorly displaced on proton-density image. (B) In the medial part of the joint, the disk (arrow) is located in a normal superior position. This indicates a partial anterior disk displacement.
uals is completely asymptomatic.16-19 It is well recognized that symptoms of TMJ decrease with age and that it is often remitting and self-limiting.16-19
Curr Probl Diagn Radiol, January/February 2004
FIG 6. Osteoarthritis. (A) Proton-density closed-mouth image shows an anterior osteophyte of the condyle (arrows). This change is consistent with degenerative joint disease. (B) On opening, the disk remains anterior (arrow).
Joint Effusion
FIG 7. Osteoarthritis. (A) Proton-density closed-mouth image shows an erosion of the condyle (arrows). (B) On opening, the disk remains anterior (arrow).
Large accumulations of joint fluid are seen only in symptomatic patients (Fig 8). 20 Such effusions are best seen in T2-weighted MRI.
Curr Probl Diagn Radiol, January/February 2004
19
FIG 8. Large joint fluid (effusion) in painful joint. (A) In the closedmouth T2-weighted image, there is an increased signal area, indicating large effusion in the upper joint space (arrow). (B) On opening, the accumulation is moved to the posterior portion of the upper joint space (arrow). The disk with anterior displacement is not reduced (arrowheads).
Joint fluid is significantly more prevalent in painful joints than in nonpainful joints.10 Not all individuals with pain have joint effusion, but a significant accumulation of joint effusion is likely associated with pain and the status of the disk.20-22
20
FIG 9. Marrow abnormalities. Parasagittal (A) proton-density images show an intermediate signal from the bone marrow of the condyle (arrow). The disk is anteriorly displaced and deformed. Parasagittal (B) T2-weighted MRI shows an increased signal from the bone marrow of the condyle (arrow), suggesting bone-marrow edema. There are also small joint effusions in the upper and lower joint spaces.
Curr Probl Diagn Radiol, January/February 2004
FIG 10. Marrow abnormalities. Parasagittal (A) proton-density image shows a decreased signal from the bone marrow of the condyle (arrow). There is also an irregularity of the upper surface of the condyle and the temporal joint component that suggests osteoarthritis. The disk is anteriorly displaced and deformed. Parasagittal (B) T2-weighted image shows a decreased signal from the bone-marrow condyle (arrow), suggesting osteonecrosis, and there is a moderate effusion in both upper and lower joint spaces.
FIG 11. Marrow abnormalities. Parasagittal (A) proton-density MRI shows an area of low signal in the inferior portion of the condyle and an area of higher signal in the more superior medial portion of the condyle (arrow). There is also displacement and deformation of the disk and an anterial osteophyte of the condyle, indicating osteoarthritis. T2-weighted parasagittal (B) MRI shows an area of increased signal in the upper portion of the condyle (arrow) and decreased signal in the lower portion of the condyle. This is consistent with the combined edema and sclerotic pattern that suggests osteonecrosis.
Curr Probl Diagn Radiol, January/February 2004
21
FIG 12. Painful TMJ with increased T2-weighted signal intensity from retrodiskal tissue. On open-mouth proton-density image, the disk (arrow) is quite normal. On open-mouth T2-weighted image (B), however, the retrodiskal tissue shows an increased signal intensity (arrows), which may cause the TMJ pain.
Marrow Abnormalities of the Mandibular Condyle Multiple MRI studies have described abnormalities of the mandibular condyle similar to the appearance of osteonecrosis (aseptic necrosis) in the femoral head.23-27 One study used core biopsy to document that edema (Fig 9) and osteonecrosis (Figs 10 and 11) may occur in the marrow of the mandibular condyle.28 Histologic evidence of bone-marrow edema (Fig 9) was also found without evidence of osteonecrosis (Figs 10 and 11), suggesting that edema may be a precursor to osteonecrosis, as is known from investigation of other joints.28 A study has shown markedly greater pain in joints that have bone-marrow alterations in the mandibular condyle compared to joints with normal bone marrow.6
FIG 13. A decreased signal from retrodiskal tissue. A proton density image shows a decreased signal (arrow) in the upper portion of retrodiskal tissue.
22
Changes in the Retrodiskal Tissue On enhancement MR studies,7,8 TMJs with pain and dysfunction indicate a higher signal intensity in the retrodiskal tissue than those without. On a T2weighted MR study,9 Sano et al indicate a slightly increased signal intensity from the retrodiskal tissue in
Curr Probl Diagn Radiol, January/February 2004
painful joints when compared with nonpainful joints (Fig 12). These indicate a higher degree of vascularity in the retrodiskal tissue in the painful joints compared with the nonpainful joints. A decreased signal in the retrodiskal tissue (Fig 13) may or may not be associated with fibrous changes. It has been theorized that the decreased pain frequently observed in longstanding disk displacement is the result of fibrous changes in the retrodiskal tissue;29,30 however, the exact relationship between TMJ pain and a decreased signal in the retrodiskal tissue has not been fully elucidated.29,31
Other Pathological Conditions Most imaging evaluations are performed for possible internal derangements and their sequelae; however, many other types of pathology occasionally affect the TMJ and may cause pain and dysfunction. Tumors and tumor-like conditions include synovial chondromatosis,32-35 pigmented villonodular synovitis,36-42 osteochondroma, and calcium pyrophosphate dehydrate deposition disease (pseudogout).43-48 The TMJ is infrequently affected by tumors and tumor-like conditions. The most common neoplastic lesion affecting the TMJ is synovial chondromatosis.34,35 This tumor can be locally aggressive, and cases with intracranial extension have been described. Arthritides includes rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.49,50 The TMJ is involved in approximately 50% of patients with such rheumatoid diseases; however, MRI is not routinely used for such patients. Acute trauma to the mandible can be evaluated with plain films, panoramic examinations, or computer tomography. MRI may occasionally show fractures and effusions not seen on other imaging studies.
Conclusion The etiology of TMJ pain is not fully understood. There are also discrepancies between imaging findings and patient symptoms. Further studies using the latest imaging techniques will allow for a better understanding of the sources of joint pain and the discrepancy between imaging findings and patient symptoms.
REFERENCES 1. Farrar WB. Diagnosis and treatment of anterior dislocation of the articular disc. NY J Dent 1971;41:348-51.
Curr Probl Diagn Radiol, January/February 2004
2. Farrar WB, McCarthy WL Jr. Inferior joint space arthrography and characteristics of condylar paths in internal derangements of the TMJ. J Prost Dent 1979;41:548-55. 3. Kirk WS Jr. A comparative study of axial corrected tomography with magnetic resonance imagery in 35 joints. Oral Surg Oral Med Oral Pathol 1989;68:646-52. 4. Larheim TA, Smith HJ, Aspestrand F. Rheumatic disease of the temporomandibular joint: MR imaging and tomographic manifestations. Radiology 1990;175:527-31. 5. Heloe B, Heloe LA. Characteristics of a group of patients with temporomandibular joint disorders. Community Dent Oral Epidemiol 1975;3:72-9. 6. Sano T, Westesson PL, Larheim TA, et al. The association of temporomandibular joint pain with abnormal bone marrow of the mandibular condyle. J Oral Maxillofac Surg 2000;58: 254-7. 7. Suenaga S, Sonoda S, Oku T, et al. MRI of the temporomandibular joint disk and posterior disk attachment before and after nonsurgical treatment. J Comput Assist Tomogr 1997; 21:892-6. 8. Suenaga S, Hamamoto S, Kawano K, et al. Dynamic MR imaging of the temporomandibular joint in patients with arthrosis: relationship between contrast enhancement of the posterior disk attachment and joint pain. Am J Roentgenol 1996;166:1475-81. 9. Sano T, Westesson PL. Magnetic resonance imaging of the temporomandibular joint: increased T2 signal in the retrodiskal tissue of painful joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:511-6. 10. Westesson PL, Brooks SL. Temporomandibular joint: relationship between MR evidence of effusion and the presence of pain and disk displacement. Am J Roentgenol 1992;159:55963. 11. Tasaki MM, Westesson PL, Isberg AM, et al. Classification and prevalence of temporomandibular joint disk displacement in patients and symptom-free volunteers. Am J Orthod Dentofacial Orthop 1996;109:249-62. 12. Katzberg RW, Westesson PL, Tallents RH, et al. Orthodontics and temporomandibular joint internal derangement. Am J Orthod Dentofacial Orthop 1996;109:515-20. 13. Katzberg RW, Westesson PL, Tallents RH, et al. Anatomic disorders of the temporomandibular joint disc in asymptomatic subjects. J Oral Maxillofac Surg 1996;54:147-53. 14. Larheim TA, Westesson P, Sano T. Temporomandibular joint disk displacement: comparison in asymptomatic volunteers and patients. Radiology 2001;218:428-32. 15. Sano T, Yamamoto M, Takagi R, et al. Pain from bone change in joints with temporomandibular disorders [in Japanese]. Dental Radiol 1999;39:47. 16. Pereira FJ Jr, Lundh H, Westesson PL, Carlsson LE. Clinical findings related to morphologic changes in TMJ autopsy specimens. Oral Surg Oral Med Oral Pathol 1994;78:288-95. 17. Lundh H, Westesson PL, Kopp S. A three-year follow-up of patients with reciprocal temporomandibular joint clicking. Oral Surg Oral Med Oral Pathol 1987;63:530-3. 18. Rasmussen OC. Description of population and progress of symptoms in a longitudinal study of temporomandibular arthropathy. Scand J Dent Res 1981;89:196-203.
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19. Randolph CS, Greene CS, Moretti R, et al. Conservative management of temporomandibular disorders: a posttreatment comparison between patients from a university clinic and from private practice. Am J Orthod Dentofacial Orthop 1990;98: 77-82. 20. Larheim TA, Katzberg RW, Westesson PL, et al. MR evidence of temporomandibular joint fluid and condyle marrow alterations: occurrence in asymptomatic volunteers and symptomatic patients. Int J Oral Maxillofac Surg 2001;30:113-7. 21. Larheim TA, Westesson PL, Sano T. MR grading of temporomandibular joint fluid: association with disk displacement categories, condyle marrow abnormalities and pain. Int J Oral Maxillofac Surg 2001;30:104-12. 22. Rudisch A, Innerhofer K, Bertram S, et al. Magnetic resonance imaging findings of internal derangement and effusion in patients with unilateral temporomandibular joint pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:56671. 23. Schellhas KP, Wilkes CH, Omlie MR, et al. The diagnosis of temporomandibular joint disease: two-compartment arthrography and MR. Am J Roentgenol 1988;151:341-50. 24. Schellhas KP. Internal derangement of the temporomandibular joint: radiologic staging with clinical, surgical, and pathologic correlation. Magn Reson Imaging 1989;7:495-515. 25. Schellhas KP, Wilkes CH. Temporomandibular joint inflammation: comparison of MR fast scanning with T1- and T2-weighted imaging techniques. Am J Roentgenol 1989;153: 93-8. 26. Schellhas KP, Wilkes CH, Fritts HM, et al. MR of osteochondritis dissecans and avascular necrosis of the mandibular condyle. Am J Roentgenol 1989;152:551-60. 27. Schellhas KP. Temporomandibular joint injuries. Radiology 1989;173:211-6. 28. Larheim TA, Westesson PL, Hicks DG, et al. Osteonecrosis of the temporomandibular joint: correlation of magnetic resonance imaging and histology. J Oral Maxillofac Surg 1999; 57:888-98. 29. Westesson PL, Paesani D. MR imaging of the TMJ: decreased signal from the retrodiskal tissue. Oral Surg Oral Med Oral Pathol 1993;76:631-5. 30. Manzione JV, Tallents RH. “Pseudomeniscus” sign: potential indicator of repair or remodeling in temporomandibular joints with internal derangements. Radiology 1992;185:175 (abstr). 31. Sano T. Recent developments in understanding temporomandibular joint disorders. Part 2: changes in the retrodiscal tissue. Dentomaxillofac Radiol 2000;29:260-3. 32. Heffez LB. Imaging of internal derangements and synovial chondromatosis of the temporomandibular joint. Radiol Clin North Am 1993;31:149-62. 33. Nomoto M, Nagao K, Numata T, et al. Synovial osteochondromatosis of the temporo-mandibular joint. J Laryngol Otol 1993;107:742-5. 34. Quinn PD, Stanton DC, Foote JW. Synovial chondromatosis with cranial extension. Oral Surg Oral Med Oral Pathol 1992;73:398-402.
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35. Sun S, Helmy E, Bays R. Synovial chondromatosis with intracranial extension. A case report. Oral Surg Oral Med Oral Pathol 1990;70:5-9. 36. Rickert RR, Shapiro MJ. Pigmented villonodular synovitis of the temporomandibular joint. Otolaryngol Head Neck Surg 1982;90:668-70. 37. Lapayowker MS, Miller WT, Levy WM, et al. Pigmented villonodular synovitis of the temperomandibular joint. Radiology 1973;108:313-6. 38. Curtin HD, Williams R, Gallia L, et al. Pigmented villonodular synovitis of the temporomandibular joint. Comput Radiol 1983;7:257-60. 39. O’Sullivan TJ, Alport EC, Whiston HG. Pigmented villonodular synovitis of the temporomandibular joint. J Otolaryngol 1984;13:123-6. 40. Song MY, Heo MS, Lee SS, et al. Diagnostic imaging of pigmented villonodular synovitis of the temporomandibular joint associated with condylar expansion. Dentomaxillofac Radiol 1999;28:386-90. 41. Bemporad JA, Chaloupka JC, Putman CM, et al. Pigmented villonodular synovitis of the temporomandibular joint: diagnostic imaging and endovascular therapeutic embolization of a rare head and neck tumor. Am J Neuroradiol 1999;20:159-62. 42. Klenoff JR, Lowlicht RA, Lesnik T, et al. Mandibular and temporomandibular joint arthropathy in the differential diagnosis of the parotid mass. Laryngoscope 2001;111:2162-5. 43. Dijkgraaf LC, Liem RS, de Bont LG. Temporomandibular joint osteoarthritis and crystal deposition diseases: a study of crystals in synovial fluid lavages in osteoarthritic temporomandibular joints. Int J Oral Maxillofac Surg 1998;27:268-73. 44. Goudot P, Jaquinet A, Gilles R, et al. A destructive calcium pyrophosphate dihydrate deposition disease of the temporomandibular joint. J Craniofac Surg 1999;10:385-8. 45. Jibiki M, Shimoda S, Nakagawa Y, et al. Calcifications of the disc of the temporomandibular joint. J Oral Pathol Med 1999;28:413-9. 46. Olin HB, Pedersen K, Francis D, et al. A very rare benign tumour in the parotid region: calcium pyrophosphate dihydrate crystal deposition disease. J Laryngol Otol 2001;115:504-6. 47. Jordan JA, Roland P, Lindberg G, et al. Calcium pyrophosphate deposition disease of the temporal bone. Ann Otol Rhinol Laryngol 1998;107(11 Pt 1):912-6. 48. Vargas A, Teruel J, Trull J, et al. Calcium pyrophosphate dihydrate crystal deposition disease presenting as a pseudotumor of the temporomandibular joint. Eur Radiol 1997;7: 1452-3. 49. Larheim TA. Imaging of the temporomandibular joint in rheumatic disease. in Westesson PL, Katzberg RW, editors. Imaging of the Temporomandibular Joint (Cranio Clinics International). Baltimore, MD: Williams and Wilkins; 1991:pp 133-53. 50. Smith HJ, Larheim TA, Aspestrand F. Rheumatic and nonrheumatic disease in the temporomandibular joint: gadolinium-enhanced MR imaging. Radiology 1992;185:229-34.
Curr Probl Diagn Radiol, January/February 2004
Magnetic resonance imaging has evolved as a prime diagnostic method for soft-tissue abnormalities of the temporomandibular joint. The most common temporomandibular joint abnormalities are internal derangement and osteoarthritis, but there are many other reasons for pain and dysfunction that are often overlooked. The purpose of this paper is to illustrate several of these more unusual and less well-recognized causes for temporomandibular joint pain and dysfunction. For example, internal derangement is often seen in asymptomatic individuals. Another purpose is to illustrate the difference in magnetic resonance imaging of asymptomatic and symptomatic internal derangement.
Improvements in diagnostic imaging of the temporomandibular joint (TMJ) (Fig 1) during the last 2 decades have shown that disk displacement is the most frequent abnormality in patients with pain and dysfunction. Magnetic resonance imaging (MRI) has evolved as a prime diagnostic method for soft-tissue abnormalities of TMJ, including internal derangements, since its clinical introduction in the mid-1980s.1,2 In diagnosing TMJ, more recent studies3,4 have demonstrated that MRI is equal or possibly better than standard tomography in diagnosing osseous abnormalities of TMJ. The etiology of TMJ pain is not completely understood. There are several possible sources of TMJ pain, such as disk displacement,1,2 osteoarthritis,5 bone-marrow alterations of the mandibular condyle,6 inflammatory changes in the retFrom the aDepartment of Radiology, Showa University School of Dentistry, Tokyo, Japan; bDepartment of Radiology, Showa University School of Medicine, Tokyo, Japan; cDepartment of Radiology, Division of Neuroradiology, University of Rochester Medical Center, Rochester, NY. Reprint requests: Tsukasa Sano, DDS, PhD, Department of Radiology, Showa University School of Dentistry, 2-1-1, Kitasenzoku, Ohta-ku, 145, Tokyo, Japan. E-mail: [email protected]. Curr Probl Diagn Radiol 2004;33:16-24. © 2004 Mosby, Inc. All rights reserved. 0363-0188/2004/$30.00 ⫹ 0 doi:10.1067/j.cpradiol.2003.09.001
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FIG 1. TMJ in sagittal section. The posterior band of the disk (D) is lying over the condyle (C). The disk is between upper (U) and lower (L) joint spaces. R, retrodiskal tissue; EAC, extraauditory canal; LPM, lateral pterygoid muscle.
rodiskal tissue,7-9 and inflammatory changes in the joint space resulting in joint effusion.10 The purpose of this paper is to illustrate several of these more unusual and less well-recognized causes for TMJ pain and dysfunction and also to illustrate the difference in MRI of asymptomatic and symptomatic internal derangement.
Disk Displacement Most asymptomatic individuals show normal disk position (Fig 2). Disk displacement (Figs 3 and 4) is found in approximately 80% of patients with symptoms.11 Several forms of disk displacement are also seen in as much as one third of asymptomatic volunteers.11-13 This may initially appear confusing, but asymptomatic volunteers demonstrate that most, if not all, the volunteers have early-stage disk displacement, whereas more later stages are seen in patients.14 Larheim et al14 reported that complete
Curr Probl Diagn Radiol, January/February 2004
FIG 2. Normal disk position with normal function. (A) In the protondensity closed-mouth image, the disk (arrow) is between the condyle and the articular eminence. (B) On opening, the disk (arrow) is also located between the condyle and the articular eminence during condylar movement, indicating normal disk position with normal function.
disk displacement was found in 46 (40%) of 115 joints in patients compared with 3 (2.4%) of 124 joints in asymptomatic volunteers, whereas partial disk displacement (Fig 5) occurred in 26 (22.6%) and 27 (21.8%) joints, respectively.
Curr Probl Diagn Radiol, January/February 2004
FIG 3. Anterior disk displacement with reduction. (A) In the protondensity closed-mouth image, the disk (arrow) is anterior to the condyle. (B) On opening, the disk (arrow) is located between the condyle and the articular eminence, indicating anterior disk displacement with reduction.
Osteoarthritis Osteoarthritis (Figs 6 and 7) has also been indicated as a source of the pain,5 but a recent study has indicated that there is no statistically significant difference in the degree
17
FIG 4. Anterior disk displacement without reduction. (A) In the proton-density closed-mouth image, the disk (arrow) is anterior to the condyle. (B) On opening, the disk (arrow) remains anterior to the condyle, indicating anterior disk displacement without reduction.
of pain in patients with osteoarthritis compared to those without.15 This is also in accordance with the findings that osteoarthritis in a large proportion of older individ-
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FIG 5. Partial anterior disk displacement. (A) In the lateral part of the joint, the disk (arrow) is anteriorly displaced on proton-density image. (B) In the medial part of the joint, the disk (arrow) is located in a normal superior position. This indicates a partial anterior disk displacement.
uals is completely asymptomatic.16-19 It is well recognized that symptoms of TMJ decrease with age and that it is often remitting and self-limiting.16-19
Curr Probl Diagn Radiol, January/February 2004
FIG 6. Osteoarthritis. (A) Proton-density closed-mouth image shows an anterior osteophyte of the condyle (arrows). This change is consistent with degenerative joint disease. (B) On opening, the disk remains anterior (arrow).
Joint Effusion
FIG 7. Osteoarthritis. (A) Proton-density closed-mouth image shows an erosion of the condyle (arrows). (B) On opening, the disk remains anterior (arrow).
Large accumulations of joint fluid are seen only in symptomatic patients (Fig 8). 20 Such effusions are best seen in T2-weighted MRI.
Curr Probl Diagn Radiol, January/February 2004
19
FIG 8. Large joint fluid (effusion) in painful joint. (A) In the closedmouth T2-weighted image, there is an increased signal area, indicating large effusion in the upper joint space (arrow). (B) On opening, the accumulation is moved to the posterior portion of the upper joint space (arrow). The disk with anterior displacement is not reduced (arrowheads).
Joint fluid is significantly more prevalent in painful joints than in nonpainful joints.10 Not all individuals with pain have joint effusion, but a significant accumulation of joint effusion is likely associated with pain and the status of the disk.20-22
20
FIG 9. Marrow abnormalities. Parasagittal (A) proton-density images show an intermediate signal from the bone marrow of the condyle (arrow). The disk is anteriorly displaced and deformed. Parasagittal (B) T2-weighted MRI shows an increased signal from the bone marrow of the condyle (arrow), suggesting bone-marrow edema. There are also small joint effusions in the upper and lower joint spaces.
Curr Probl Diagn Radiol, January/February 2004
FIG 10. Marrow abnormalities. Parasagittal (A) proton-density image shows a decreased signal from the bone marrow of the condyle (arrow). There is also an irregularity of the upper surface of the condyle and the temporal joint component that suggests osteoarthritis. The disk is anteriorly displaced and deformed. Parasagittal (B) T2-weighted image shows a decreased signal from the bone-marrow condyle (arrow), suggesting osteonecrosis, and there is a moderate effusion in both upper and lower joint spaces.
FIG 11. Marrow abnormalities. Parasagittal (A) proton-density MRI shows an area of low signal in the inferior portion of the condyle and an area of higher signal in the more superior medial portion of the condyle (arrow). There is also displacement and deformation of the disk and an anterial osteophyte of the condyle, indicating osteoarthritis. T2-weighted parasagittal (B) MRI shows an area of increased signal in the upper portion of the condyle (arrow) and decreased signal in the lower portion of the condyle. This is consistent with the combined edema and sclerotic pattern that suggests osteonecrosis.
Curr Probl Diagn Radiol, January/February 2004
21
FIG 12. Painful TMJ with increased T2-weighted signal intensity from retrodiskal tissue. On open-mouth proton-density image, the disk (arrow) is quite normal. On open-mouth T2-weighted image (B), however, the retrodiskal tissue shows an increased signal intensity (arrows), which may cause the TMJ pain.
Marrow Abnormalities of the Mandibular Condyle Multiple MRI studies have described abnormalities of the mandibular condyle similar to the appearance of osteonecrosis (aseptic necrosis) in the femoral head.23-27 One study used core biopsy to document that edema (Fig 9) and osteonecrosis (Figs 10 and 11) may occur in the marrow of the mandibular condyle.28 Histologic evidence of bone-marrow edema (Fig 9) was also found without evidence of osteonecrosis (Figs 10 and 11), suggesting that edema may be a precursor to osteonecrosis, as is known from investigation of other joints.28 A study has shown markedly greater pain in joints that have bone-marrow alterations in the mandibular condyle compared to joints with normal bone marrow.6
FIG 13. A decreased signal from retrodiskal tissue. A proton density image shows a decreased signal (arrow) in the upper portion of retrodiskal tissue.
22
Changes in the Retrodiskal Tissue On enhancement MR studies,7,8 TMJs with pain and dysfunction indicate a higher signal intensity in the retrodiskal tissue than those without. On a T2weighted MR study,9 Sano et al indicate a slightly increased signal intensity from the retrodiskal tissue in
Curr Probl Diagn Radiol, January/February 2004
painful joints when compared with nonpainful joints (Fig 12). These indicate a higher degree of vascularity in the retrodiskal tissue in the painful joints compared with the nonpainful joints. A decreased signal in the retrodiskal tissue (Fig 13) may or may not be associated with fibrous changes. It has been theorized that the decreased pain frequently observed in longstanding disk displacement is the result of fibrous changes in the retrodiskal tissue;29,30 however, the exact relationship between TMJ pain and a decreased signal in the retrodiskal tissue has not been fully elucidated.29,31
Other Pathological Conditions Most imaging evaluations are performed for possible internal derangements and their sequelae; however, many other types of pathology occasionally affect the TMJ and may cause pain and dysfunction. Tumors and tumor-like conditions include synovial chondromatosis,32-35 pigmented villonodular synovitis,36-42 osteochondroma, and calcium pyrophosphate dehydrate deposition disease (pseudogout).43-48 The TMJ is infrequently affected by tumors and tumor-like conditions. The most common neoplastic lesion affecting the TMJ is synovial chondromatosis.34,35 This tumor can be locally aggressive, and cases with intracranial extension have been described. Arthritides includes rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.49,50 The TMJ is involved in approximately 50% of patients with such rheumatoid diseases; however, MRI is not routinely used for such patients. Acute trauma to the mandible can be evaluated with plain films, panoramic examinations, or computer tomography. MRI may occasionally show fractures and effusions not seen on other imaging studies.
Conclusion The etiology of TMJ pain is not fully understood. There are also discrepancies between imaging findings and patient symptoms. Further studies using the latest imaging techniques will allow for a better understanding of the sources of joint pain and the discrepancy between imaging findings and patient symptoms.
REFERENCES 1. Farrar WB. Diagnosis and treatment of anterior dislocation of the articular disc. NY J Dent 1971;41:348-51.
Curr Probl Diagn Radiol, January/February 2004
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