Temporomandibular Joint Radiography
陳玉昆教授 : 高雄醫學大學 口腔病理科
07-3121101~2755 yukkwa@kmu.edu.tw

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

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

Ref. 1
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

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 view of:
Condylar head & neck
Transpharyngeal Lateral view of:
Condylar head & neck
Articular eminence
Articular eminence
Tomography All aspects of:
Glenoid fossa
Dental panoramic Lateral tomograph view of both condylar heads
Articular eminence
Joint space
Condylar head
Ref. 1

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
<N.B.> 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
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
Open view The range and type of movement of the condyle
A comparison of the degree of movement on both sides

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

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

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

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

Arthrography
AP view 為：
Computed tomography
Magnetic resonance imaging
C. Transorbital
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
Main indications
When diagnosis of internal derangements is in doubt
As a preoperative assessment before disc surgery
Anterior displaced disc
Condylar head

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

Ref. 4
Fibrillation( 顫動 )
Adhesion
Disc
Disc

Main pathological conditions affecting the TMJ
TMJ pain dysfunction syndrome
Internal derangements
Osteoarthritis
( 史迪爾氏症 )
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