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

07-3121101~2755 [email protected]

學 習 目 標

Normal anatomy of TMJ Investigations available for TMJ Pathological conditions that can affect TMJ References 1. Eric Whaites: Essentials of dental radiography & radiology 3rd edition, Chapter 29, p. 371-388 2. Eric Whaites: Essentials of dental radiography & radiology 1st edition, Chapter 28, p. 297-323.

3. Rosenberg et al, Aust Dent J 1999;44:106 4. Kaohsiung Medical University, Oral Pathology Department

Subtopics

Normal anatomy of TMJ Investigations available for TMJ Pathological conditions that can affect TMJ

Ref. 1

Normal

Anatomy Basics components of the TMJ: Mandibular component : condyle head (Hard tissue) Disc (Soft tissue) Temporal component : glenoid fossa & articular eminence (Hard tissue) Capsule surround the joint (Soft tissue) Glenoid fossa Ext. auditory meatus Condyle head Upper joint space Disc/meniscus Lower joint space Lateral pterygoid attachment

Normal anatomy - Dry skull Anterior Lateral Ref. 1 Base

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

Investigations available for TMJ (1) The clinical indications How each investigation is performed: how the patient is positioned in relation to the film and X-ray tubehead , and whether the patient’s mouth needs to be opened or closed

Investigations available for TMJ (2) What information from each investigation The limitations and shortcomings of each investigation

Investigations

Conventional radiographic projections Transpharyngeal Panoramic Reverse Town’s Transorbital Tomography, linear

Summary of different parts of TMJ shown by the conventional projections Transcranial Lateral aspect of: Glenoid fossa Articular eminence Joint space Condylar head Reverse Towne’s Posterior view of: both condylar head & necks Transorbital Anterior neck view of: Condylar head & Transpharyngeal Lateral view of: Condylar head & neck Articular eminence Articular eminence Tomography All aspects of: Glenoid fossa Dental panoramic Lateral view of tomograph both condylar heads Articular eminence Joint space Condylar head Ref. 1

Transcranial

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

Transcranial Centric occlusion Mouth close Radiological term joint space: RL zone between condylar head & glenoid fossa, which includes discs & upper & lower anatomical joint spaces Right Mouth open Mouth close Ref. 1 Right Mouth open

Transcranial Closed view

Diagnostic

information 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 The range and type of movement of the condyle Open view A comparison of the degree of movement on both sides

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

Ref. 1 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

Dental panoramic tomograph 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

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

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 Mouth open Ref. 1

Ref. 1 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

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 due to 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

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

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

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

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

Other techniques & investigations

Arthrography AP view

為：

Computed tomography Magnetic resonance imaging C. Transorbital D. Modified Town’s view Main indications Diagnostic information

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

Arthrography Ref. 1 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

Computed tomography Main indications 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

Ref. 4 Computed tomography

Ref. 4

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

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

Ref. 3

Arthroscopy

1. Upper joint space 2. Lower joint space 3. Disc 4. Prolene suture 5. Yeates drain 6. External auditory meatus

Ref. 4

Arthroscopy

Fibrillation Adhesion Disc Disc

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

Main pathological conditions affecting the TMJ

(A) 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

Summaries

Knowing: Normal anatomy of TMJ What investigations are available for TMJ Main pathological conditions that can affect TMJ