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
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
Subtopics
Normal anatomy of TMJ
Investigations available for TMJ
Pathological conditions that can affect
TMJ
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
Ref. 1
Upper joint space
Disc/meniscus
Lower joint space
Lateral pterygoid
attachment
Normal anatomy - Dry skull
Lateral
Ref. 1
Anterior
Base
Rotatory and translatory movements of condyle
during normal mouth opening
Mouth
closed
Rest
position
Mouth
opened
initially
Translation
Mouth
opened
widely
Secondary
rotation
Mouth
opened
Primary
rotation
Ref. 1
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
Other techniques and investigations
Transcranial
Transpharyngeal
Panoramic
Reverse Town’s
Transorbital
Tomography, linear
Summary of different parts of TMJ
shown by the conventional projections
Transcranial
Transpharyngeal
Dental panoramic
tomograph
Ref. 1
Lateral aspect of:
Glenoid fossa
Articular eminence
Joint space
Condylar head
Lateral view of:
Condylar head &
neck
Articular
eminence
Lateral view of
both condylar
heads
Reverse Towne’s
Posterior view of:
both condylar
head & necks
Transorbital
Anterior view of:
Condylar head &
neck
Articular
eminence
Tomography
All aspects of:
Glenoid fossa
Articular
eminence
Joint space
Condylar head
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
Centric occlusion
Transcranial
<N.B.>Radiological
term joint space: RL
zone between condylar
head & glenoid fossa,
which includes discs &
upper & lower
anatomical joint spaces
Mouth open
Mouth close
Right
Mouth close
Ref. 1
Right
Mouth open
Transcranial
Diagnostic information
Closed view
Open 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
The range and type of movement of the condyle
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
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
Dental panoramic tomograph
Main
Mainindications
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
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
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
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
30o
Ref. 1
25o
20o
15o
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
下列何者是AP view為：
Arthrography
A. Panoramic radiography
Computed tomography
B. Transcranial projection
Magnetic resonance imaging
C. Transorbital
Artheroscopy
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
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
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
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
Ref. 4
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
Arthroscopy
1.
2.
3.
4.
5.
6.
Ref. 3
Upper joint space
Lower joint space
Disc
Prolene suture
Yeates drain
External auditory meatus
Arthroscopy
Fibrillation
Adhesion
Disc
Disc
Ref. 4
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