1. Temporomandibular Joint Radiography
牙科放射線學(2)
Temporomandibular Joint Radiography
顳顎關節放射線攝影術
陳玉昆副教授: 高雄醫學大學 口腔病理科
~2755

2. 學 習 目 標 The normal anatomy of the TMJ
What investigations are available
Common pathological conditions that
can affect the joints
References
1. Eric Whaites: Essentials of dental radiography & radiology 3rd edition,
Chapter 29, p
2. Eric Whaites: Essentials of dental radiography & radiology 1st edition,
Chapter 28, p
3. Rosenberg et al, Aust Dent J 1999;44:106
4. Kaohsiung Medical University, Oral Pathology Department

3. Subtopics The normal anatomy of the TMJ
What investigations are available
Common pathological conditions that
can affect the joints

4. Normal Anatomy (Hard tissue) (Soft tissue) (Hard tissue) (Soft tissue)
Condyle head
Disc/meniscus
Glenoid fossa
Lateral pterygoid
attachment
Upper joint space
Lower joint space
Ext auditory
meatus
Ref. 1

5. Lateral
Anterior
Normal
anatomy
- Dry skull
Base
Ref. 1

6. Rotatory and translatory movements of condyle
during normal mouth opening
Rest
position
Mouth
closed
Primary
rotation
opened
Translation
initially
widely
Secondary
Ref. 1

7. What investigations are available (1)
The clinical indications
How each investigation is performed, i.e.
how the patient is positioned in relation to
the film and X-ray tubehead, and whether
the patient’s mouth needs to be open or
closed

8. What investigations are available (2)
What information each investigation
The limitations and shortcomings of each
investigation

9. Investigations Conventional radiographic projections
Other techniques and investigations
Transcranial
Transpharyngeal
Panoramic
Reverse Town’s
Transorbital
Tomography, linear

10. Summary of different parts of TMJ
shown by the conventional projections
Ref. 1

11. Transcranial Main indications TMJ pain dysfunction syndrome – pain,
clicking and limitation in opening
To investigate the size & position of the
disc (joint space)
To investigate range of movement in the
joints
Main indications

12. Transcranial Centric occlusion Mouth close Mouth open
<N.B.>The radiological term joint space: radiolucent zone between condylar head & glenoid fossa, which includes discs & upper & lower anatomical joint spaces
Mouth close
Right
Mouth open
Right
Ref. 1

13. Diagnostic information
Closed view
The size of the joint space – provide indirect
information about the position and shape of
the disc
The position of the head of the condyle within
the fossa
The shape and conditions of the glenoid fossa &
articular eminence (on the lateral aspect only)
The shape of the head of the condyle & the
condition of the articular surface (on the lateral
aspect only)
A comparison of both sides
Transcranial
Open view
The range and type of movement of the condyle
A comparison of the degree of movement on
both sides

14. Transpharyngeal Main indications TMJ pain dysfunction syndrome
To investigate the presence of joint disease,
particularly osteoarthritis and rheumatoid
arthritis
To investigate pathological conditions
affecting the condylar head, including cysts or
tumors
Fractures of the neck and head of the condyle

15. Diagnostic information
Transpharyngeal
Diagnostic information
The shape of the head of condyle and condition
of the articular surface from lateral aspect
A comparison of both condylar heads
Ref. 1

16. Dental panoramic tomograph
Main indications
Main indications
TMJ pain dysfunction syndrome
To investigate disease within the joint
To investigate pathological conditions affecting
the condylar heads
Fractures of the condylar head or neck
Condylar hypo/hyperplasia
Diagnostic information
The shape of the condylar head and
condition of the articular surface from
lateral aspect
A direct comparison of both condylar
heads

17. Dental panoramic tomograph
Right close
Right open
Left open
Left close
Transcranial
view taken from
panoramic
machine
Ref. 4

18. Reverse Towne’s Main indications
To investigate the articular surface of the
condyles and disease within the joint
Fractures of the condylar heads and necks
Condylar hypo/hyperplasia
Main indications
Mouth open
Ref. 1

19. Diagnostic information
Reverse Towne’s
Diagnostic information
The shape of the condylar heads and condition
of the articular surfaces from the posterior aspect
A direct comparsion of both condyles
Ref. 1

20. Transorbital (Zimmer’s view)
Main indications
To investigate the articular surface of the
condyle and disease within the joint
High fractures of the condylar neck to show
medio-lateral displacement
This view is rarely used because of the risk of
damage to the lens of eye from radiation.
However, it provides an AP view of the condylar head-
an aspect not shown by other radiographs
Mouth open
Ref. 2

21. Diagnostic information Transorbital
The shape of the condylar head and neck from
the anterior aspect
The condition of the articular surface from the
anterior aspect
Ref. 2

22. Tomography Main indications
Full assessment of the whole of the joint to
determine the presence and site of any
bone disease or abnormality
To investigate the condyle and articular
fossa when the patient is unable to open
the mouth
Assessment of fractures of the articular
fossa and intracapsular fractures

23. Tomography
15o
20o
25o
30o
Lateral
Anterior
Ref. 1

24. Diagnostic information
Tomography
Diagnostic information
The size of the joint space
The position of the head of the condyle within
the fossa
The shape of the head of the condyle and
condition of the articular surface including the
medial and lateral aspects
The shape and condition of the articular fossa
and eminence
Information on all aspects of the joints
The positions and orientation of the fracture
fragments

25. Other techniques & investigations
下列何者是AP view為： A. Panoramic radiography
B. Transcranial projection C. Transorbital
D. Modified Town’s view
Arthrography
Computed tomography
Magnetic resonance imaging
Artheroscopy
Main indications
Diagnostic information

26. Main contraindications
Arthrography
Main indications
Longstanding TMJ pain dysfunction
unresponsive to simple treatments
Persistent history of locking
Limited opening of unknown etiology
Main contraindications
Acute joint infection
Allergy to iodine or contrast medium

27. Diagnostic information
Arthrography
Diagnostic information
Dynamic information on the position of the
joint components and disc as they move in
relation to one another
Static images of the joint components with the
mouth closed and with the mouth open. Any
anterior or anteromedial displacement of the
disc can be observed
The integrity of the disc,
i.e. any perforations
Note: Outline the lower joint space usually
provides more useful information on the disc
Ref. 1

28. Computed tomography Main indications Diagnostic information
It provides sectional or slice images of the joint
It can produce images of the hard and soft
tissues in the joint, including the disc, in different
planes
Diagnostic information
The shape of the condyle and the condition of
the articular surface
The condition of the glenoid fossa and eminence
The position and shape of the disc
The integrity of the disc and its soft tissue attachments
The nature of any condylar head disease

29. Computed tomography
Ref. 4

30. Magnetic resonance imaging
Main indications
When diagnosis of internal derangements is
in doubt
As a preoperative assessment before disc surgery
Anterior
displaced
disc
Condylar
head
Ref. 4

31. Arthroscopy Main indications It gives direct visualization of the TMJ
and allows certain interventional procedures
to be performed, including
Washing out the joint with saline
Introduction of steroids directly into the joint
Division of adhesions
Removal of loose bodies from within the joint
Arthroscopy is considered as the last
line of investigation before full surgical
exploration of the joint is carried

32. Arthroscopy Upper joint space Lower joint space Disc Prolene suture
Yeates drain
External auditory meatus
Ref. 3

33. Disc
Adhesion
Arthroscopy
Fibrillation
Disc
Ref. 4

34. Main pathological conditions affecting the TMJ
TMJ pain dysfunction syndrome
Internal derangements
Osteoarthritis
Juvenile rheumatoid arthritis (Still’s disease)
Ankylosis
Tumors
Fractures
Developmental anomalies

35. Main pathological conditions affecting the TMJ
A multilocular radiolucency; (B), (C) Surgical specimen; (D) Costochondral graft;
(E) Histological examination: bony trabeculae entrapped by multiple blood vessels
最可能的診斷為： A. Ameloblastoma
B. Squamous cell
carcinoma C. Hemangioma
D. Central giant cell
granuloma

36. Summaries Knowing: The normal anatomy of the TMJ
What investigations are available
Common pathological conditions that
can affect the joints

37. remember these three points
The End
Revision
Have you already
remember these three points
(red, yellow & green)?
What are the key points
of this lecture?