Download Multiple inflammatory arthropathies can affect the TMJ

TMJ imaging beyond TMD
Margaret N. Chapman MD1, Vanesa Carlota Andreu MD1,
Qamar Mala’Beh MD1, Khairuddin Memon MD2,
Benjamin P. Liu MD2, Osamu Sakai MD, PhD1
1Boston
Medical Center, Boston University School of Medicine
2Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University
Contact information: [email protected]
Disclosures
There are no conflicts of interest to disclose
2
Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Introduction
• Temporomandibular joint (TMJ) imaging is most often performed
to evaluate temporomandibular joint disorder (TMD), specifically
to evaluate disc morphology and location, condylar morphology,
range of motion, and dynamic function.
• Standard MRI sequences including oblique sagittal proton density
weighted imaging in closed and open mouth positions are the key
sequences at most institutions.
• Although the clinical symptoms are similar or almost identical to
TMD, the TMJ may be affected by a variety of other conditions.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Introduction
• Dedicated TMJ MR imaging precisely depicts abnormality of
disc location and morphology, osteoarthritic changes,
abnormal dynamic function and range of motion, and joint
effusions.
• Disadvantages of dedicated TMJ MR imaging includes limited
field of view and limited sequences, and pathologies outside of
the TMJ may be missed.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Introduction
• CT and MR imaging performed for other reasons often show TMJ
abnormalities such as:
•
•
•
•
•
•
degenerative changes
fracture
infection
congenital anomalies
synovial osteochondromatosis
inflammatory conditions such as rheumatoid arthritis (RA) and calcium
pyrophosphate dihydrate deposition (CPPD)
• malignancy - primary and metastases
• Marrow abnormalities are often seen in patients with systemic
disorders/hematological disorders, including anemia, sickle cell
disease, leukemia, and chemotherapy.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Purpose
• Review the imaging anatomy of the TMJ
• Illustrate the current MR imaging technique of the TMJ
• Through an illustrative case based review, discuss various
pathologies that can affect the TMJ
• Discuss other conditions that can mimic TMD syndrome
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Anatomy
The TMJ is a synovial joint comprised of the articulation of the
mandibular condyle with the articular fossa of the temporal bone.
Bone
Disc
1.
2.
Positioned between the mandibular
condyle and glenoid fossa
1.
Mandibular Condyle
•
1.
Glenoid Fossa
1.
Articular Eminence
Superior and inferior
compartments
Biconcave with three segments:
•
Anterior band, intermediate zone,
posterior band
Muscles
1.
Lateral pterygoid  opening
2.
Temporalis, medial pterygoid,
masseter  closing
Joint
1.
Articular capsule: attaches to the
edges of the glenoid fossa and to
the neck of the mandible
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Introduction
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Anatomy
Imaging Protocol
Cases
Conclusion
References
Disc Anatomy in More Detail
•
The articular disc is a biconcave
avascular fibrocartilaginous structure
with three segments:
•
•
•
•
•
•
Anterior band (AB), intermediate zone
(IZ), and posterior band (PB)
The thicker peripheral AB and PB are
connected by the thinner IZ.
AB: smaller; attaches to the capsule,
condylar head, and lateral pterygoid
PB: larger; continuous with the bilaminar
zone (BZ)
BZ: rich neurovascular collagen fibers and
fibroelastic tissue, provides stability to disc
during motion
As the disc is made of fibrous tissue, it
is hypointense on all MR sequences,
although the IZ may be slightly higher
in signal
AE
MC
Sagittal proton density (PD)-weighted image
of the TMJ in the closed mouth position. The
disc is biconcave, with the thicker anterior and
posterior bands (blue arrows), separated by
the intermediate zone.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
CT Anatomy
GF
MC
MC
Coronal and axial CT images in bone window. Note the symmetric appearance of the the mandibular
condyles with smooth cortical margins. There is absence of subcortical sclerosis, cysts, and osteophytic
changes. There is symmetric articulation with the glenoid fossa, with no asymmetric joint space widening
or narrowing. GF: glenoid fossa, MC: mandibular condyle
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
MR Anatomy
GF
AE
MC
LPM
Sagittal PD-weighted image in the closed mouth position demonstrates normal
anatomic structures: GF: The glenoid fossa should be concave AE: Smooth cortical
margin MC: Mandibular condyle with smooth cortical margin and no abnormal
bone marrow signal LPM: Lateral pterygoid muscle with normal signal.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Biomechanics
• The TMJ is a hinge and glide joint with anterior translation of the
mandibular condyle with respect to the temporal bone, and also side
to side motion
• The muscles of mastication are responsible for opening and closing
the jaw
• Jaw opening: lateral pterygoid, stylohyoid, mylohyoid and geniohyoid
• Jaw closing: temporalis, medial pterygoid, and masseter muscles
• Anterior translation: lateral pterygoid, masseter, and medial pterygoid
• Closed mouth: condyle is centered in the glenoid fossa, with the disc
interposed between the two.
• Normal disc position: anterior band is in front of the condyle, and the posterior
margin of the posterior band is immediately superior to the condylar head in
the 12 o’clock position
• Open mouth: the condyle lies immediately below the apex of the articular
eminence with disc centered between the two.
• Intermediate zone is always positioned between the condyle and
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temporal bone.
Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Closed Mouth
AE
AE
MC
MC
Sagittal PD (A) and T2 (B) weighted images of the TMJ in the closed mouth position. The disc is
biconcave, with the thicker anterior and posterior bands (blue arrows), separated by the intermediate
zone. Note the position of the disc, with the posterior band centered at the 12 o’clock position.
Condylar position: should be centered in the glenoid fossa
Disc position: The posterior margin of the posterior band should be
located near the 12 o’clock position
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Opened Mouth
AE
MC
AE
MC
Sagittal PD (A) and T2 (B) weighted images of the TMJ in the open mouth position. The disc is biconcave,
with the thicker anterior and posterior bands (blue arrows), separated by the intermediate zone. Note
the position of the disc, centered between the mandibular condyle and apex of the articular eminence.
Condylar position: translate anteriorly, and lie below the apex of the
articular eminence
Disc position: should be centered between the two
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Imaging Protocol
• MRI:
• Survey in coronal and axial planes
• Sagittal T1 survey
• Sagittal oblique T2/PD weighted images in open and closed mouth
positions
• Coronal T1 weighted images
• CT:
• Usually imaged as part of a maxillofacial CT examination.
• 1.25 mm axial images without contrast
• Coronal and sagittal reformations
• Cone beam CT:
• Comparable osseous detail to CT
• Lower dose
• Increased noise
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Imaging Interpretation
Calcified Loose Bodies
Surgical
Reconstruction
CT
Internal Derangement
Trauma Marrow
MRI
Effusion/
Inflammation
Degenerative
OA
Degenerative
OA
Complementary
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Imaging Checkpoints
Disc
1.
Location:
1.
Synovium
Morphology:
2.
Capsule
a.
b.
3.
Fluid
4.
Loose Bodies
a.
2.
3.
Joint
Anterior, posterior, medial, lateral
Shape
Thinning, desiccation, volume
Function:
a.
b.
Recapture
Condylar translation
Bone
Muscle
1.
Signal
1.
Condylar Shape
2.
Space occupying lesion
2.
Marrow Signal
3.
Traumatic injury
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Temporomandibular Joint Disorder (TMD)
• Idiopathic process describing acute and chronic inflammation
and/or dysfunction of the TMJ
• TMD is the second most common musculoskeletal and
neuromuscular disorder
• Prevalence 5-12%
• Most common in women in their 2nd through 4th decades of
life
• Female: Male – 2 to 8: 1
• Internal derangement is the MOST COMMON TMJ disorder
• “Risk” factors include trauma, altered anatomy or physiology, and
psychosocial factors
• Symptoms: jaw pain and dysfunction, earache, headache, and
facial pain
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Internal Derangement
Abnormal position and functional relationship between the disc and
condyle, articular eminence and glenoid fossa
• Described as a mechanical process preventing smooth motion
and function of the joint
• The disc is usually dislocated anteriorly, and is often recaptured
with mouth opening
• Often associated with clicking, crepitus, and locking
• In more severe cases, no recapture is observed
• Limited range of motion, with diminished anterior translation
• The disc can be dislocated in any position (medial, lateral, and
posterior), although lateral and posterior disc dislocation are
rare
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Anterior subluxation with recapture
Closed
Opened
Sagittal PD-weighted images of the TMJ in the closed and open mouth positions. In the closed mouth
position the mandibular condyle is concentrically seated within the glenoid fossa. However, the posterior
margin of the posterior disc is situated far anterior to the 12 o’clock position (arrow), and the anterior
band is located inferior to the articular eminence (arrow). The intermediate zone is also located
anteriorly to the condyle. In opened mouth position, there is adequate anterior translation of the
condyle, located inferior to the apex of the articular eminence. The disk is anatomically positioned.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Anterior subluxation without recapture
Closed
Opened
Sagittal PD-weighted images in open and closed mouth positions. Note the anterior subluxation of the
disk with the posterior band located at the 8-9 o’clock position with respect to the mandibular condyle
(arrows). With mouth opening, there is limited range of motion of the condyle which is situated slightly
posterior to the articular eminence. The disc remains anteriorly positioned with respect to the condyle,
with posterior margin remaining at the 9 o’clock position, indicative of no recapture.
Images courtesy of Takashi Kaneda, DDS, PhD
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
“Stuck disc”
Closed
Opened
Sagittal oblique T2-weighted images of the TMJ. The mandibular condyle is anatomically situated within
the glenoid fossa in the closed mouth position. Note the normal location of the disc, with the posterior
margin of the posterior band at the 12 o’clock position (arrow). On open mouth position, there is mildly
limited anterior translation, with the mandibular condyle posterior to the articular eminence. The
position of the disc remains the same on mouth opening, with the posterior band at 12 o’clock. Note
also the irregular appearance of the condylar head with mild cortical thickening.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Osteoarthritis (OA)
• TMJ osteoarthritis often results from chronic internal
derangement or trauma
• Present in up to 20% of patients with internal derangement
• OA is the second most common cause of TMD
• The presence of osteoarthritis may not correlate with joint
function or clinical symptoms
• Older patients with imaging features of OA may be asymptomatic
• Signs: joint space narrowing, sclerotic change, osteophyte
formation, and subcortical cysts
• CT is the best imaging modality to evaluate the osseous
structures.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Osteoarthritis
A
B
Axial (A) and coronal (B) CT images through the TMJs. There is extensive osteophyte formation of the
mandibular condyle and glenoid fossa. Additional findings of OA include loss of joint space, cortical
sclerosis and irregularity, and subcortical cysts. There is no osseous erosion or joint space widening to
suggest a joint effusion.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Congenital Anomalies – Bifid condyle
• Congenital processes or syndromes may affect the TMJ
• Condylar aplasia/hypoplasia
• Condylar hyperplasia
• Bifid condyle: etiology unknown, but likely congenital. Characterized
by abnormal morphology of the condyle with a “double-headed”
appearance.
• Asymptomatic incidental diagnosis, with no clinical significance
• Imaging normal aside from abnormal contour of the condyle
• Syndromes: Hemifacial microsomia, Goldenhar syndrome, Treacher
Collins, Morquio syndrome, and auriculocondylar syndrome
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Introduction
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Anatomy
Imaging Protocol
Cases
Conclusion
References
Congenital Anomalies – Bifid condyle
A
B
Coronal CT through the condyles (A) demonstrates a double headed appearance with a central notch.
Coronal T1-weighted image (B) through the condyle shows a similar morphology. Note the absence of
degenerative changes (including osteophytes, subcortical cysts) and normal bone marrow signal on the
MR image.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Congenital Anomalies
A
B
C
Nager Syndrome. Rare inherited disorder characterized by craniofacial malformations and abnormalities
of the thumb and forearm. Craniofacial abnormalities include micrognathia and mandibular hypoplasia.
Affected individuals may develop TMD due to the abnormal development of the condyle and altered
biomechanics.
In this case of a 12 year old girl with Nager Syndrome and micrognathia, axial (A), sagittal (B), and coronal
(C) CT images demonstrate abnormal morphology of the condyle and flattening of the glenoid fossa.
There is ankylosis across the TMJs bilaterally, best seen on the coronal reformatted CT image (arrows).
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Inflammatory Conditions
Multiple inflammatory arthropathies can affect the TMJ
• Rheumatoid arthritis (RA): autoimmune inflammatory disease that
affects multiple organ systems and involves soft tissues and bones.
• TMJ is affected in > 20% of patients with RA.
• Inflammatory soft tissue (pannus) results in destruction of the disk,
which can be abnormally positioned or destroyed.
• Joint effusions are often seen, although nonspecific, as an effusion can
be seen with internal derangement, OA, or other inflammatory
processes.
• Imaging Findings: osseous erosion, secondary arthritic changes,
synovial proliferation, joint effusion
• Symptoms: pain, tenderness, swelling, and limited range of motion
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Rheumatoid Arthritis (RA)
A
B
C
Axial STIR image (A) through the TMJs demonstrates hyperintense signal centered within the joints
bilaterally (arrows). On a coronal PD-weighted image(B) through the left TMJ, there is extensive
hypointense signal within the joint space due to effusion and synovial proliferation (arrowheads). Note
the flattening and and abnormal bone marrow signal in the mandibular condyle (arrow). A sagittal
oblique PD-weighted image (C) also shows the deformity of the condylar head, as well as flattening of
the articular eminence. Note the thickened and globular disc, anteriorly displaced (arrow).
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Images courtesy of Takashi Kaneda, DDS, PhD
Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Inflammatory Conditions
Multiple inflammatory arthropathies can affect the TMJ
• Calcium pyrophosphate dihydrate deposition (CPPD): caused by
the deposition of of calcium pyrophosphate dihydrate crystals in the
articular cartilage and periarticular soft tissues
• May deposit in the synovium, joint capsule, tendons, ligaments, in
addition to the cartilage
• Imaging findings:
• CT: best modality to identify chondrocalcinosis in the joint or adjacent
soft tissues, adjacent secondary arthritic changes including joint space
narrowing, subcortical cysts, and osteophytes, and erosive changes
• MRI: T2 hypointense periarticular masses with heterogeneous
enhancement can be seen
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Introduction
Purpose
Anatomy
Imaging Protocol
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Conclusion
References
CPPD
A
B
C
Axial CT image in bone window (A) shows amorphous calcification involving the left TMJ, both the
condyle and glenoid fossa (arrows). There is expansion and multiple lucent lesions seen in the left
condyle. Coronal T2-weighted image (B) shows heterogeneous signal in the condyle with several small T2
hyperintense cystic lesions (arrowhead). Note the expanded joint capsule with heterogeneous, mostly
low signal, material (arrow). The coronal T1-weighted image (C) also demonstrates hypointense material
filling the expanded joint capsule (arrow). Compare the abnormal marrow signal in the left mandibular
condyle (arrowhead) with the normal fatty marrow signal on the right.
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Inflammatory Conditions
Multiple inflammatory arthropathies can affect the TMJ.
• PVNS: rare proliferative disorder affecting the synovium
• Usually a monoarticular inflammatory process involving large joints of
the extremities
• Locally aggressive with osseous erosion or destruction, and potential
for extracapsular extension of the inflammatory process
• Imaging findings:
• MRI: heterogeneous low signal areas on T2 images due to hemosiderin
deposition, regions of increased T2 signal may represent joint effusion
• CT: osseous erosion and cyst formation in the condyle, soft tissue masses
• Symptoms: slowly growing non-tender swollen joint, often affect
individuals in the 2nd through 3rd decade of life
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Introduction
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Anatomy
Imaging Protocol
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Conclusion
References
Pigmented Villonodular Synovitis (PVNS)
A
B
C
Axial T2-weighted image (A) through the TMJ. There is decreased T2 signal within and surrounding the
left TMJ (arrow). Axial T1-weighted image (B) also shows heterogeneous decreased signal within and
surrounding the TMJ (arrow). Post-contrast axial T1-weighted image (C) demonstrates enhancement of
the joint space surrounding the left mandibular condyle (arrows).
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Inflammatory Conditions
• Infection: rare in the TMJ
• Usually a monoarticular process resulting from hematogenous spread
of distant infection or direct inoculation from trauma
• In the TMJ, infection usually results from post-traumatic or iatrogenic
causes, or secondary to other infections in the head and neck
• Staphylococcus aureus is the most commonly reported pathogen
• Predisposing factors: immunocompromised state, corticosteroid therapy,
diabetes, IV drug use
• Symptoms: pain and trismus
• Imaging findings:
• CT: joint effusion and enhancement, osseous changes that may represent
osteomyelitis, and adjacent inflammatory changes
• MRI: joint effusion, synovial enhancement, adjacent bone marrow
changes including reactive edema or osteomyelitis, adjacent soft tissue
inflammation
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Introduction
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Anatomy
Imaging Protocol
Cases
Conclusion
References
Infection
A
B
Coronal STIR image (A) demonstrates abnormal hyperintense signal within the right mandibular condyle
(arrow), compared with the normal signal in the left mandibular condyle. There is additionally high signal
within the joint capsule, consistent with an effusion (arrowhead). The axial post-contrast fat-suppressed
T1-weighted image (B) demonstrates extensive avid enhancement within the right mandibular condyle
and TMJ (arrow), and in the right masticator space including the lateral pterygoid and temporalis
muscles. The small non-enhancing area within the joint may represent the effusion (arrowhead).
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Neoplastic Processes
Neoplastic processes of the TMJ can arise from the osseous
structures or adjacent soft tissues
• Primary bone tumors include:
• Osteochondroma (most common)
• Osteoma, fibrous dysplasia, giant cell tumors, non-ossifying fibromas
• Malignant bone tumors: osteosarcoma, chondrosarcoma
• Synovium: synovial osteochondromatosis
• Muscle/masticator space: primary tumors or metastases
including from perineural spread of head and neck cancer
• Metastases
• Plasmacytoma
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Synovial Osteochondromatosis
Uncommon benign condition of synovial neoplasia with
intraarticular proliferation of cartilaginous nodules arising from the
synovial membrane
• The nodular proliferation breaks off into the joint where the fragments
can grow, calcify, and ossify.
• Rare, presents more often in women in their 4th through 6th decades of
life
• Symptoms: pain, swelling, crepitus, limited range of motion
• Imaging findings:
• CT and MRI are complementary in evaluate for more aggressive
changes including extracapsular and intracranial extension
• CT: Expansion of the joint capsule, with multiple calcified or ossified
fragments, joint effusion, soft tissue swelling, and irregular joint surfaces
• MRI: better depicts joint effusion and adjacent soft tissue inflammation,
the multiple loose bodies are hypo- to isointense on MRI
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Introduction
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Anatomy
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Cases
Conclusion
References
Synovial Osteochondromatosis
A
B
C
Axial CT image (A) through the right mandibular condyle demonstrates multiple osseous fragments
within the right TMJ capsule (arrow). Note that there is also widening of the joint space, suggesting an
effusion (arrow). Sagittal T2 GRE image (B) through the right TMJ in open mouth position demonstrates
the joint effusion (arrows) with multiple internal foci of susceptibility artifact, correlating with the
osseous bodies. A coronal T2-weighted image (C) also depicts the effusion and loose bodies very well
(arrows).
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Introduction
Purpose
Anatomy
Imaging Protocol
Cases
Conclusion
References
Metastases
• Metastatic disease accounts for 32.7% of the malignant tumors
involving the TMJ
• Second most common after sarcomas
• The mandible is susceptible to metastatic tumors due to its abundant
bone marrow
• Most commonly located in the mandibular body and angle, but can be seen in
the condyle
• Most lesions are osteolytic, but they can also be sclerotic, expansile,
depending on the pathology of the primary tumor
• Can present as pathologic fracture
• Imaging findings:
• CT: osteolytic or osteoblastic lesions, pathologic fractures
• MRI: demonstrates abnormal bone marrow signal, extraosseous extension of
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lesion
Introduction
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Anatomy
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Cases
Conclusion
References
Metastases
A
B
C
Axial T1 MPRAGE image (A) performed during a contrast enhanced brain MRI in a patient with metastatic
neuroendocrine tumor demonstrates abnormally low signal within the left mandible near the condyle
(arrow). The axial fat-suppressed T2-weighted image (B) demonstrated corresponding hyperintense
signal (arrow). There was also restricted diffusion with hyperintense signal on the b1000 DWI image (C,
ADC not shown, arrow). There was associated enhancement (not shown). Note the absence of
surrounding inflammatory changes.
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Introduction
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Anatomy
Imaging Protocol
Cases
Conclusion
References
Hematologic Disorders
Marrow abnormalities can be seen in patients with systemic
disorders/hematological disorders, including anemia, sickle cell disease,
leukemia, and chemotherapy
A
B
C
Bone infarct and subperiosteal hemorrhage in the setting of sickle cell disease. Axial unenhanced CT
image through the mandibles (A) shows an ill-defined hypodense region adjacent to the left mandible
(arrows). On the corresponding fat-suppressed T2-weighted image (B), there is fluid signal adjacent to
the mandible (arrow). Note also the heterogeneous mildly increased signal and cortical irregularity in the
mandible, consistent with a bone infarct (arrowhead). The axial T2 FFE image (C) shows susceptibility
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artifact in the region of the fluid, consistent with hemosiderin from subperiosteal hemorrhage.
Introduction
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Cases
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References
Conclusion
• TMD is not the only condition that affects the TMJ.
• TMD is most often caused by internal derangement and
osteoarthritis, the most common processes that affect the TMJ.
• TMJ abnormalities are seen often on studies performed for other
reasons.
• Multiple neoplastic, inflammatory, congenital, and hematologic
processes can involve the TMJ.
• Incidentally found TMJ abnormalities may be a clue for
unrevealed, serious underlying diseases or conditions.
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Introduction
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References
References
• Morales H, Cornelius R. Imaging Approach to Temporomandibular Joint Disorders. Clin
Neuroradiol. 2015 Sep 15. [Epub ahead of print]
• Aiken A, Bouloux G, Hudgins P. MR imaging of the temporomandibular joint. Magn Reson
Imaging Clin N Am. 2012 Aug;20(3):397-412.
• Petscavage-Thomas JM, Walker EA. Unlocking the jaw: advanced imaging of the
temporomandibular joint. AJR Am J Roentgenol. 2014 Nov;203(5):1047-58.
• Bag AK, Gaddikeri S, Singhal A, Hardin S, Tran BD, Medina JA, Curé JK. Imaging of the
temporomandibular joint: An update. World J Radiol. 2014 Aug 28;6(8):567-82.
• Makdissi J, Pawar RR, Radon M, Holmes SB. Incidental findings on MRI of the
temporomandibular joint. Dentomaxillofac Radiol. 2013;42(10):20130175.
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