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Temporomandibular joint arthrography: Negative pressure, nontomographic techniques
Temporomandibular joint arthrography: Negative pressure, nontomographic techniques Robert L. Campbell, D.D.S., * and John M. Alexander, D.D.S., * Richmond, Va. DIVISION VIRGINIA,
OF ORAL VIRGINIA
AND MAXILLOFACIAL COMMONWEALTH
SURGERY, UNIVERSITY
DEPARTMENT
OF SURGERY,
MEDICAL
COLLEGE
OF
A technique for temporomandibular joint arthrography with a 100 mm. camera rather than spot or tomogram radiographs is presented. The negative pressure within the joint space aids in the accurate placement of the Teflon catheter. Negative prints of the camera film are used for clarity in publication.
rthrography of the temporomandibular joint A (TMJ) was described by Norgaard’ and reviewed 25 years later by Agerberg and Lundberg,2 who reported on arthrographic findings of eleven patients. Toller3 studied 146 arthrograms, using transcranial radiographs which outlined both the upper and lower compartments. Proper angulation of the x-ray beam was important if one was to visualize the lower space with minimal overlap from the contrast medium injected into the upper space.Arthrotomography has been described by Campbell,“ Wilkes,5 and Dolwick and associates6who used multiple spot radiographs to minimize the overlap of soft tissue and bony structures which could lead to inaccurate interpretation. A scout tomogram of the condyle that clearly delineates the bony topography is taken, and after contrast medium is injected the repeat films are done in various stages of jaw opening. Norgaard used a steel needle to inject contrast material without consideration of the volume of the compartments. Toller evaluated forty-seven cases of arthrography and estimated that the upper and lower compartments could be passively filled with 1.2 ml. and 0.9 ml. of fluid, respectively. Pressuresand volume ranges were not documented and the question of distortion from “overfill” has not been adequately answered. Wilkes used a preauricular, percutaneous approach with an intracatheter thread over a 20-gauge needle which was then easily stabilized with adhesive tape. The contrast medium injection was then directly visualized, without the risk of perforation of the meniscus *Associate Professor. 0030~4220/83/020121
+06$00.60/O@
1983 The C. V. Mosby Co.
by a steel needle left in the upper or lower compartment. Other techniques have been described, including a modified butterfly needle from the preauricular approach and a 25-gauge 1%-inch needle placed into the lower joint space from a intrameatal puncture site. Some clinicians inject the contrast medium during fluoroscopic visualization but remove the needle from the joint space prior to taking of tomographic films. Some techniques describe the use of epinephrine diluted with the contrast medium to delay absorption from the space. The technical difficulties of arthrography, including accurate placement of the contrast medium and the necessity of clear tomographic films, have discouraged many clinicians from using arthrography. Since the clicking, popping joint has been associated with anterior subluxation of the meniscus and arthrography seems to have supported this explanation, the necessity for arthrography has also been questioned. However, several other possible pathologic entities can be associated with the clicking joint, including (1) posterior and anterior attachment perforations, (2) central articulating surface perforation, (3) folding of the central articulating surface from chronic obstruction of the anterior movement of the meniscus between the eminence and the condylar head, (4) osteochondritis of the disc (calcified material within the meniscus), (5) stretching of the posterior bilaminar attachment from chronic trauma or muscle spasm resulting in anterior displacement of the meniscus, and (6) hydrostatic pressure changesassociated with reduced synovial fluid within the joint spaces. If standardized arthrography techniques were established, simplified, and placed into the 121
122
Campbell and Alexander
Oral
Surg.
February, 1983
;-
Fig. 1. Illustration of the anteroposteriorview of the condyle and lateral meniscusattachment;penetrationof the upper spacecan occur if the needle placementis superiorto the attachmentof the meniscusto the capsular ligament.
hands of knowledgeable radiologists, an accurate assessment of the exact pathosis and a planned surgical procedure could be considered. There would be less “exploratory” temporomandibular joint surgery and perhaps more justification for high condylar shave, eminectomy, or both. We will present a technique which, along with other technical considerations previously reported, has simplified arthrography. By the establishment of guidelines for the accurate placement of a catheter into the upper or lower compartments, teaching of the technical skills has been simplified. TECHNIQUE
Spasm of the lateral pterygoid muscle causes limitation of full translation movement and perhaps may result in anterior positioning of the meniscus. If this occurs, the elimination of pain during the processof opening the mouth appears to be clinically important for an adequate assessmentof the meniscus and pterygoid muscle function. An intraoral injection of 2 C.C.of 3 percent Carbocaine into the posterior superior alveolar area adjacent to the lateral pterygoid plates will significantly reduce (greater than 75 percent) or eliminate the pain during function in patients suffering from myofascial pain dysfunction. The presence of clicking prior to
the injection which becomesgreatly diminished after local anesthesia may indicate that the muscle spasm is the cause of anterior meniscus displacements. Muscle paresis and the resulting deviation of the mandible toward the injected side during opening may occur after anesthesia. An accurate assessment of the amount of incisal opening is made before and after the anesthetic injection. The full opening should be measured in millimeters or “fingerbreadths.” If, during the filling of the upper and lower joint spaces,there appears to be a decreasein the maximum opening, overfilling of the compartments should be suspected. If the same clicking or popping sound is still present after the local anesthetic is administered, an accurate arthrogram can be expected. An extraoral injection of local anesthetic with a vasoconstrictor is then made sufficiently deep to anesthetize the skin, subcutaneous tissue, and capsular ligament, but no attempt is made to touch the condylar head. A 20-gauge 1%-inch angiocatheter is directed perpendicular to the skin to the depth of the condylar and the exact position of the tip is visualized fluoroscopically. If the angiocatheter is placed through the skin too far superiorly and angled inferiorly, both the superior and inferior compartments may be accidently penetrated (Fig. 1, arrow). If the needle and catheter are visualized at the proper position (Fig. 2) the lateral, superior, posterior surface of the condylar head is then engaged. The catheter must be completely filled with the local anesthetic solution, not air, as the needle touches the bone. The needle and catheter are directed slightly cephalad. When the patient opens the mouth, the needle is “walked off’ the posterior surface. Simultaneous with the downward and forward movement of the condyle, the negative pressure within the inferior compartment will “suck in” some of the anesthetic solution and the proper position can be verified by the descending meniscus column (Fig. 3). The meniscus column will usually descend approximately 3 to 5 mm., depending upon how far the patient opens the mouth. If the needle is not within the compartment, the column may fluctuate down and then up during opening and closing, respectively. However, a pronounced drop of about 5 mm. in the solution is seen on opening, and this column of anesthetic solution is “sucked into the space” and does not rise up the needle upon closure. The local anesthetic syringe is reattached and a small amount of local is reinjected to expand the lower compartment. If the fluid enters the spacewith no resistance to injection, this is a reaffirmation that the joint
Volume Number
55 2
Temporomandibular joint arthrography
123
Fig. 2. Illustration of the proper position of the needle from the lateral view; palpation of the condyle head with the needle tip as the posterior surface of the condyle head moves anteriorly.
space has been cannulated. The catheter is then advanced over the needle and stabilized, and the syringe with contrast material and extension tubing is attached. A three-way stopcock is attached between the 3 C.C.plastic syringe and the extension tubing. After the contrast medium is injected, the stopcock is closed to prevent the fluid from backing up into the syringe during the study. Fluoroscopy is used to observe the movement of contrast solution through the catheter and into the joint space. If the inferior compartment has been entered, filling posterior or the condylar head can be seen. The patient is asked to move the jaw laterally or to open the mouth in order that the movement of the solution may be followed. Small increments are injected until the contrast material can be observed both anterior and posterior to the condylar head. During the movement of the condyle down the eminence, the patient is asked if the clicking sounds are still present. Often very subtle, soft clicks are barely perceptible on fluoroscopy and are occasionally eliminated after “lubrication” of the inferior and/or the superior compartments. The patient is asked to open and close the mouth to the maximum extent and instructed to report if this cannot be done. Overfilling should be suspectedif the patient cannot
open the mouth as well as prior to placement of the catheter. DISCUSSION
There are several potential cavities in the body, including the intrapleural and subarachnoid spaces, which have negative pressures. This has not been described previously as existing in the temporomandibular joint compartments. With the previously described arthrography techniques, the local anesthetic or radiopaque dye has been injected as the needle penetrates the joint space and touches the condylar head. Entrance into the inferior or superior compartments was determined by sliding off the condylar head and injecting fluid without resistance into a compartment capable of occupying a volume of 0.9 to 1.2 ml. of fluid. If resistance to injection of local anesthetic is encountered, it is likely that needle is outside the joint spaceand subsequent injection of contrast material would most likely be seen in the interstitial tissue posterior or inferior to the lower compartment. The apparent negative pressure in the TMJ is a useful guide and has significantly decreased the failure rate of a catheter technique. If injection into the interstitial tissue posterior and below the inferior
124
Campbell and Alexander
Fig. 3. The needle is directed perpendicular surface with the fluid meniscus visible.
Oral Surg. February. I983
to the skin
joint space occurs, reintroduction of the catheter through the skin at a more superior level is usually successful.The negative pressure can still be used as a guide unless contrast medium or local anethetic solution has been inadvertently introduced into the compartment. If interstitial infiltration occurs, Renografin-60 will become absorbed more quickly than the more concentrated media. Usually, within 15 minutes the dye has become reabsorbed and a second attempt at catheterization of the TMJ compartments can be made. After injection of the inferior space (Fig. 4), movement of the majority of the contrast material anterior to the condyle indicates a subluxation of the meniscus. Upon opening, a click can be visualized on the fluoroscope and confirmed by the patient. If there appears to be an equal balance of dye anterior and posterior to the condyle in the lower compartment without a click on opening, this represents a normal arthroram (Fig. 5). The image of the meniscus can be seen between the condylar head and the eminence as the mouth is gradually opened (Fig. 6). If the patient can open the mouth completely without limitation, the contrast material in the lower joint
Fig. 4. Abnormal inferior compartment in the closed position. A 26-year-old woman with a history of closed lock shows an overfill anterior to the condyle compared to the posterior joint space.
space will normally curve downward anteriorly (Fig. 7). Many investigators have not found the need to inject the upper compartment. If the lower compartment is clearly abnormal, we do not usually recommend injection of the superior joint space. However, if a borderline abnormal inferior compartment has been demonstrated by either an unequal amount of contrast material anterior to the condylar head or the continued presenceof a click, the superior compartment can be injected for more accurate location of the meniscus. Usually this does not result in more information, but occasionally the injection of the upper compartment will temporarily eliminate the click and has been therapeutic in a few patients. Multiple spot films were originally attempted, but these were often of poor quality becauseof overlapping anatomic structures, and the contrast medium on the lateral and medial surfaces of the condylar produced unacceptable shadows (Fig. 8). It was
Volume Number
55 2
Temporomandibular joint arthrography
125
Fig. 5. Normal inferior and superior compartments in the closed position. A 40-year-old woman with early clicking shows an equal balance of contrast medium in the lower space in the closed position.
Fig. 6. The meniscus can be visualized with the central articulating surface beneath the arrow in the partially open position.
Fig. 7. Downward deflection of the dye anteriorly (arrow) and smooth curvature at the posterior surface of the lower compartment indicate a normal full open position.
126
Campbell and Alexander
Oral Surg. February, 1983
SUMMARY
Fig. 8. Arthrogram of the upper and lower compartments on a standard lateral projection. The overlapping shadows are evident.
found that the 100 mm. camera attached to the fluoroscope produced a more detailed outline of the inferior compartment. The image on the fluoroscope is exactly what is recorded by the camera. Head position can be adjusted to eliminate the overlap of the petrous bone onto the temporomandibular joint area. The camera film can be exposed in multiple frames per second if necessary,but this may lead to more radiation exposure from the fluoroscopy. The major advantages to the use of the camera are (1) it is not necessaryto move the patient, with a catheter in place, to another area; (2) greater detail than on spot films and often better than tomograms; (3) small, compact films which can still be developed rapidly. The disadvantagesof the camera include (1) the necessity of taking several pictures in order to avoid wasting a complete roll of film and (2) slightly more radiation exposure to the patient from the fluoroscope during actual exposure of the film. Despite the disadvantages stated, the increased detail and the capability of completing the study without the risk of dislodgment of the catheter facilitate use of the 100 mm. camera.
The injection of contrast material through a catheter under direct fluoroscopic vision seems to be more informative than blind injection technique. Injection of a controlled amount of Renografin can diminish the likelihood of overfill and allow more complete opening of the mouth. If overfilling is suspected, after waiting approximately 15 minutes for absorption, the patient will then be able to move his condyle more freely. The use of a 100 mm. camera will provide good films and eliminate the need for tomograms. A catheter is preferred over a steel needle, and its position is more accurately assessedby using the negative pressure technique. Catheterization of the superior joint space is not done if the lower compartment injection shows obvious anterior subluxation of the meniscus. In certain borderline cases,the upper compartment filling may yield more positive diagnotic information. It is within the scopeof this article to present a technique, not to indicate the usefulness or necessity of TMJ arthrography or tomography. The role of arthrography in the diagnosis and subsequent decision as to whether surgical or nonsurgical modalities should be performed will become evident only when the state of the art is defined. REFERENCES I Norgaard, F.: Temporomandibular Arthrography, Thesis, Munksgard, Copenhagen, 1947. 2. Agerberg. G., and Lundberg, M.: Changes in the Temporomandibular Joint After Surgical Treatment, ORAL SURG. 32: X65-875, I97 I 3. Toiler, P. A.: Opaque Arthrography
of the Temporomandibular Joint, Int. J: URAL SURG. 3: 17-28, 1974. 4. Camobell. W.: Clinical Radiological Investigation of the Temporomandibular Joints, J. Radio1 38: 401-42 1, 1965. 5. Wilkes, C.: Arthrography of the Temporomandibular Joint in Patients With the TMJ Pain Dysfunction Syndrome, Minn. Med. 61: 645. 1978. 6. Dolwick. M. F.. et al.: Arthrotomographic Evaluation of the Temporomandibular Joint, J Oral Surg. 37: 793-799, 1979.
Reprint
requests
to:
Dr. Robert L. Campbell BOX 566, MCV Station Richmond, Va. 23298
OF ORAL VIRGINIA
AND MAXILLOFACIAL COMMONWEALTH
SURGERY, UNIVERSITY
DEPARTMENT
OF SURGERY,
MEDICAL
COLLEGE
OF
A technique for temporomandibular joint arthrography with a 100 mm. camera rather than spot or tomogram radiographs is presented. The negative pressure within the joint space aids in the accurate placement of the Teflon catheter. Negative prints of the camera film are used for clarity in publication.
rthrography of the temporomandibular joint A (TMJ) was described by Norgaard’ and reviewed 25 years later by Agerberg and Lundberg,2 who reported on arthrographic findings of eleven patients. Toller3 studied 146 arthrograms, using transcranial radiographs which outlined both the upper and lower compartments. Proper angulation of the x-ray beam was important if one was to visualize the lower space with minimal overlap from the contrast medium injected into the upper space.Arthrotomography has been described by Campbell,“ Wilkes,5 and Dolwick and associates6who used multiple spot radiographs to minimize the overlap of soft tissue and bony structures which could lead to inaccurate interpretation. A scout tomogram of the condyle that clearly delineates the bony topography is taken, and after contrast medium is injected the repeat films are done in various stages of jaw opening. Norgaard used a steel needle to inject contrast material without consideration of the volume of the compartments. Toller evaluated forty-seven cases of arthrography and estimated that the upper and lower compartments could be passively filled with 1.2 ml. and 0.9 ml. of fluid, respectively. Pressuresand volume ranges were not documented and the question of distortion from “overfill” has not been adequately answered. Wilkes used a preauricular, percutaneous approach with an intracatheter thread over a 20-gauge needle which was then easily stabilized with adhesive tape. The contrast medium injection was then directly visualized, without the risk of perforation of the meniscus *Associate Professor. 0030~4220/83/020121
+06$00.60/O@
1983 The C. V. Mosby Co.
by a steel needle left in the upper or lower compartment. Other techniques have been described, including a modified butterfly needle from the preauricular approach and a 25-gauge 1%-inch needle placed into the lower joint space from a intrameatal puncture site. Some clinicians inject the contrast medium during fluoroscopic visualization but remove the needle from the joint space prior to taking of tomographic films. Some techniques describe the use of epinephrine diluted with the contrast medium to delay absorption from the space. The technical difficulties of arthrography, including accurate placement of the contrast medium and the necessity of clear tomographic films, have discouraged many clinicians from using arthrography. Since the clicking, popping joint has been associated with anterior subluxation of the meniscus and arthrography seems to have supported this explanation, the necessity for arthrography has also been questioned. However, several other possible pathologic entities can be associated with the clicking joint, including (1) posterior and anterior attachment perforations, (2) central articulating surface perforation, (3) folding of the central articulating surface from chronic obstruction of the anterior movement of the meniscus between the eminence and the condylar head, (4) osteochondritis of the disc (calcified material within the meniscus), (5) stretching of the posterior bilaminar attachment from chronic trauma or muscle spasm resulting in anterior displacement of the meniscus, and (6) hydrostatic pressure changesassociated with reduced synovial fluid within the joint spaces. If standardized arthrography techniques were established, simplified, and placed into the 121
122
Campbell and Alexander
Oral
Surg.
February, 1983
;-
Fig. 1. Illustration of the anteroposteriorview of the condyle and lateral meniscusattachment;penetrationof the upper spacecan occur if the needle placementis superiorto the attachmentof the meniscusto the capsular ligament.
hands of knowledgeable radiologists, an accurate assessment of the exact pathosis and a planned surgical procedure could be considered. There would be less “exploratory” temporomandibular joint surgery and perhaps more justification for high condylar shave, eminectomy, or both. We will present a technique which, along with other technical considerations previously reported, has simplified arthrography. By the establishment of guidelines for the accurate placement of a catheter into the upper or lower compartments, teaching of the technical skills has been simplified. TECHNIQUE
Spasm of the lateral pterygoid muscle causes limitation of full translation movement and perhaps may result in anterior positioning of the meniscus. If this occurs, the elimination of pain during the processof opening the mouth appears to be clinically important for an adequate assessmentof the meniscus and pterygoid muscle function. An intraoral injection of 2 C.C.of 3 percent Carbocaine into the posterior superior alveolar area adjacent to the lateral pterygoid plates will significantly reduce (greater than 75 percent) or eliminate the pain during function in patients suffering from myofascial pain dysfunction. The presence of clicking prior to
the injection which becomesgreatly diminished after local anesthesia may indicate that the muscle spasm is the cause of anterior meniscus displacements. Muscle paresis and the resulting deviation of the mandible toward the injected side during opening may occur after anesthesia. An accurate assessment of the amount of incisal opening is made before and after the anesthetic injection. The full opening should be measured in millimeters or “fingerbreadths.” If, during the filling of the upper and lower joint spaces,there appears to be a decreasein the maximum opening, overfilling of the compartments should be suspected. If the same clicking or popping sound is still present after the local anesthetic is administered, an accurate arthrogram can be expected. An extraoral injection of local anesthetic with a vasoconstrictor is then made sufficiently deep to anesthetize the skin, subcutaneous tissue, and capsular ligament, but no attempt is made to touch the condylar head. A 20-gauge 1%-inch angiocatheter is directed perpendicular to the skin to the depth of the condylar and the exact position of the tip is visualized fluoroscopically. If the angiocatheter is placed through the skin too far superiorly and angled inferiorly, both the superior and inferior compartments may be accidently penetrated (Fig. 1, arrow). If the needle and catheter are visualized at the proper position (Fig. 2) the lateral, superior, posterior surface of the condylar head is then engaged. The catheter must be completely filled with the local anesthetic solution, not air, as the needle touches the bone. The needle and catheter are directed slightly cephalad. When the patient opens the mouth, the needle is “walked off’ the posterior surface. Simultaneous with the downward and forward movement of the condyle, the negative pressure within the inferior compartment will “suck in” some of the anesthetic solution and the proper position can be verified by the descending meniscus column (Fig. 3). The meniscus column will usually descend approximately 3 to 5 mm., depending upon how far the patient opens the mouth. If the needle is not within the compartment, the column may fluctuate down and then up during opening and closing, respectively. However, a pronounced drop of about 5 mm. in the solution is seen on opening, and this column of anesthetic solution is “sucked into the space” and does not rise up the needle upon closure. The local anesthetic syringe is reattached and a small amount of local is reinjected to expand the lower compartment. If the fluid enters the spacewith no resistance to injection, this is a reaffirmation that the joint
Volume Number
55 2
Temporomandibular joint arthrography
123
Fig. 2. Illustration of the proper position of the needle from the lateral view; palpation of the condyle head with the needle tip as the posterior surface of the condyle head moves anteriorly.
space has been cannulated. The catheter is then advanced over the needle and stabilized, and the syringe with contrast material and extension tubing is attached. A three-way stopcock is attached between the 3 C.C.plastic syringe and the extension tubing. After the contrast medium is injected, the stopcock is closed to prevent the fluid from backing up into the syringe during the study. Fluoroscopy is used to observe the movement of contrast solution through the catheter and into the joint space. If the inferior compartment has been entered, filling posterior or the condylar head can be seen. The patient is asked to move the jaw laterally or to open the mouth in order that the movement of the solution may be followed. Small increments are injected until the contrast material can be observed both anterior and posterior to the condylar head. During the movement of the condyle down the eminence, the patient is asked if the clicking sounds are still present. Often very subtle, soft clicks are barely perceptible on fluoroscopy and are occasionally eliminated after “lubrication” of the inferior and/or the superior compartments. The patient is asked to open and close the mouth to the maximum extent and instructed to report if this cannot be done. Overfilling should be suspectedif the patient cannot
open the mouth as well as prior to placement of the catheter. DISCUSSION
There are several potential cavities in the body, including the intrapleural and subarachnoid spaces, which have negative pressures. This has not been described previously as existing in the temporomandibular joint compartments. With the previously described arthrography techniques, the local anesthetic or radiopaque dye has been injected as the needle penetrates the joint space and touches the condylar head. Entrance into the inferior or superior compartments was determined by sliding off the condylar head and injecting fluid without resistance into a compartment capable of occupying a volume of 0.9 to 1.2 ml. of fluid. If resistance to injection of local anesthetic is encountered, it is likely that needle is outside the joint spaceand subsequent injection of contrast material would most likely be seen in the interstitial tissue posterior or inferior to the lower compartment. The apparent negative pressure in the TMJ is a useful guide and has significantly decreased the failure rate of a catheter technique. If injection into the interstitial tissue posterior and below the inferior
124
Campbell and Alexander
Fig. 3. The needle is directed perpendicular surface with the fluid meniscus visible.
Oral Surg. February. I983
to the skin
joint space occurs, reintroduction of the catheter through the skin at a more superior level is usually successful.The negative pressure can still be used as a guide unless contrast medium or local anethetic solution has been inadvertently introduced into the compartment. If interstitial infiltration occurs, Renografin-60 will become absorbed more quickly than the more concentrated media. Usually, within 15 minutes the dye has become reabsorbed and a second attempt at catheterization of the TMJ compartments can be made. After injection of the inferior space (Fig. 4), movement of the majority of the contrast material anterior to the condyle indicates a subluxation of the meniscus. Upon opening, a click can be visualized on the fluoroscope and confirmed by the patient. If there appears to be an equal balance of dye anterior and posterior to the condyle in the lower compartment without a click on opening, this represents a normal arthroram (Fig. 5). The image of the meniscus can be seen between the condylar head and the eminence as the mouth is gradually opened (Fig. 6). If the patient can open the mouth completely without limitation, the contrast material in the lower joint
Fig. 4. Abnormal inferior compartment in the closed position. A 26-year-old woman with a history of closed lock shows an overfill anterior to the condyle compared to the posterior joint space.
space will normally curve downward anteriorly (Fig. 7). Many investigators have not found the need to inject the upper compartment. If the lower compartment is clearly abnormal, we do not usually recommend injection of the superior joint space. However, if a borderline abnormal inferior compartment has been demonstrated by either an unequal amount of contrast material anterior to the condylar head or the continued presenceof a click, the superior compartment can be injected for more accurate location of the meniscus. Usually this does not result in more information, but occasionally the injection of the upper compartment will temporarily eliminate the click and has been therapeutic in a few patients. Multiple spot films were originally attempted, but these were often of poor quality becauseof overlapping anatomic structures, and the contrast medium on the lateral and medial surfaces of the condylar produced unacceptable shadows (Fig. 8). It was
Volume Number
55 2
Temporomandibular joint arthrography
125
Fig. 5. Normal inferior and superior compartments in the closed position. A 40-year-old woman with early clicking shows an equal balance of contrast medium in the lower space in the closed position.
Fig. 6. The meniscus can be visualized with the central articulating surface beneath the arrow in the partially open position.
Fig. 7. Downward deflection of the dye anteriorly (arrow) and smooth curvature at the posterior surface of the lower compartment indicate a normal full open position.
126
Campbell and Alexander
Oral Surg. February, 1983
SUMMARY
Fig. 8. Arthrogram of the upper and lower compartments on a standard lateral projection. The overlapping shadows are evident.
found that the 100 mm. camera attached to the fluoroscope produced a more detailed outline of the inferior compartment. The image on the fluoroscope is exactly what is recorded by the camera. Head position can be adjusted to eliminate the overlap of the petrous bone onto the temporomandibular joint area. The camera film can be exposed in multiple frames per second if necessary,but this may lead to more radiation exposure from the fluoroscopy. The major advantages to the use of the camera are (1) it is not necessaryto move the patient, with a catheter in place, to another area; (2) greater detail than on spot films and often better than tomograms; (3) small, compact films which can still be developed rapidly. The disadvantagesof the camera include (1) the necessity of taking several pictures in order to avoid wasting a complete roll of film and (2) slightly more radiation exposure to the patient from the fluoroscope during actual exposure of the film. Despite the disadvantages stated, the increased detail and the capability of completing the study without the risk of dislodgment of the catheter facilitate use of the 100 mm. camera.
The injection of contrast material through a catheter under direct fluoroscopic vision seems to be more informative than blind injection technique. Injection of a controlled amount of Renografin can diminish the likelihood of overfill and allow more complete opening of the mouth. If overfilling is suspected, after waiting approximately 15 minutes for absorption, the patient will then be able to move his condyle more freely. The use of a 100 mm. camera will provide good films and eliminate the need for tomograms. A catheter is preferred over a steel needle, and its position is more accurately assessedby using the negative pressure technique. Catheterization of the superior joint space is not done if the lower compartment injection shows obvious anterior subluxation of the meniscus. In certain borderline cases,the upper compartment filling may yield more positive diagnotic information. It is within the scopeof this article to present a technique, not to indicate the usefulness or necessity of TMJ arthrography or tomography. The role of arthrography in the diagnosis and subsequent decision as to whether surgical or nonsurgical modalities should be performed will become evident only when the state of the art is defined. REFERENCES I Norgaard, F.: Temporomandibular Arthrography, Thesis, Munksgard, Copenhagen, 1947. 2. Agerberg. G., and Lundberg, M.: Changes in the Temporomandibular Joint After Surgical Treatment, ORAL SURG. 32: X65-875, I97 I 3. Toiler, P. A.: Opaque Arthrography
of the Temporomandibular Joint, Int. J: URAL SURG. 3: 17-28, 1974. 4. Camobell. W.: Clinical Radiological Investigation of the Temporomandibular Joints, J. Radio1 38: 401-42 1, 1965. 5. Wilkes, C.: Arthrography of the Temporomandibular Joint in Patients With the TMJ Pain Dysfunction Syndrome, Minn. Med. 61: 645. 1978. 6. Dolwick. M. F.. et al.: Arthrotomographic Evaluation of the Temporomandibular Joint, J Oral Surg. 37: 793-799, 1979.
Reprint
requests
to:
Dr. Robert L. Campbell BOX 566, MCV Station Richmond, Va. 23298