TMJ Anatomy and pathology Schuknecht
Transcript of TMJ Anatomy and pathology Schuknecht
03/11/2020
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Temporo-mandibular joint
Anatomy and pathology
Bernhard Schuknecht
Medical Radiological Institut Zurich
European Course in Head and Neck Neuroradiology Nov 4‐6, 2020
Anatomy osseous jointMandible : condylar process
Temporal fossa: fossa mandibularis – glenoid fossa concave
articular emenince convex
Articular surface fibrocartilage (type II collagen)
Surface area: Condylus ‐ glenoid fossa 200 : 420 mm2 (Lang J 1977)
Proc. zygomaticus
Condylus shape variable: Condylar polymorphism
Anatomy: capsule
Capsula articularisrelativ thin, anterior thicker
Membrana fibrosacollagen fibers
Membrana synovialissynovial villi, vessels, nervs
Art. disco‐temporalis Art. disco‐mandibularis
ap lt
Joint capsule u lateral capsular disc attachment
DESS 0.7mm cor
Star Vibe gd 0.5
muscle anterior + posterior joint recess
Anatomy: disc
• type I collagen ap orientation
• fibrous tissue
• proteoglykan (visco‐elastic)
medial lateral
Function: distribution of loadfriction↓ sliding
2‐ 3mm
1‐2 mm
3‐4mm
M. pterygoid sup. head: → disc –joint capsuleinf. head: → condyle
sup head
inf. head
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Anatomy: bilaminar Zone • Stratum superius: elastic fibers ‐ horizontal
Fiss tymp.‐petrosquamosa + external auditory canal
• Genu vasculosum: vascular spaces, loose connective tissue, fat
• Stratum inferius: fibrous collagen, oblique‐ post. condyle
.
Left
Right
Ligamentous cause of movement dependent pain
Lt TMJ pain markedly exacerbated during opening ff dental tx
T1gd fs 3mm closed open
closed open
TMJ: principle pats complaints
• painspontaneous, in movement
• noiseclicking, snapping, friction
• limitation of movement
mouth opening, closing. deviation ….
Research Diagnostic criteriafor temporomandibular disorders
3 examiners reliability () : OPT CT MRI
osteoarthritis 0.16 0.71 (0.46)
% agreement pairwise rating:
osteoarthritis 19% 84% 59%
disc displacement w/wo red 0.78/0.94 %
any disc disease 95%
effusion 81%
Ahmad M et al. Oral Surg Oral med Oral patho Oral radiol Endod 2009;107:844‐860
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TMJ protocol/ sequences /planes
Coil 4 chanal diameter 12 cm 1.5 T
t2 trufi sag dynTA 0.36 Measurements 90Voxel Size 0.8x0.8x4.5 mmFoV 150 mm FoV phase 100%Slice thikness 4.5 mmTR 4.65 TE 1.81Flip Winkel 60Time resolution 0.4s
t2 3d DESS cor obl along ascending ramusTA 4.27Voxel size 0.5x0.5x0.7 mmFoV 160 mm FoV phase 100%Slice thickness 0.7 mmTR 19.49 TE 7.09Flip Winkel 25Silces per slab 80
t2 fs Dixon axial including lower jaw ,parotid and sm gland 3.5mm
pd tse corTA 2.32Voxel size 0.3x0.3x0.2 mmFoV 200 mm FoV phase 100%Slice thickness 2 mmTR 2000 TE 14Flip Winkel 180
pd tse sag obliqueTA 3.54Voxel size 0.2x0.2x3 mmFoV 180mm FoV phase 100%Slice thickness 3 mmTR 1990 TE 12Flip Winkel 180
DESS‐ plane
PD cor obl plane
pd tse sag obliquet2 trufi sag dyn
CTMROsseous structure of condyle
CT vs MR (4 channel TMJ surface)
compacta = cortical bone + cancellous bone
PD sag obl 3mm
PD cor obl 2mm
cor DESS 0.7mm
adult
adolescent 15 y
MR → cortical + cancellous bone 12y
13.5 y
growth plate
condylolysis
overuse / bone bruise
52y
T1gd fs 3mm
0.7mm
cor obl PD 2mm
changes invisible by CT/CB –CT:
changes visible by CT/CB –CT→ avoid radiation exposure !
cor DESS
TMJ : Anatomy and function
closed
open
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Quantification→ anterior disc dislocation
Normal 11:00‐12:00 disco‐ bilaminar
transition zone
Pathologic< 10:30
9:00
7:00
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Anterior disc position10:30‐11:00
lt closed lt open
Anterior disc dislocation (ADD) with reduction
thickened disco‐bilaminar transition zone, slight effusion disco‐temporal + disco‐mandibulardisc intactlateral capsular attachment maintained (cor obl.)
10.2017 rt closed
rt open
9.2020 rt closed rt open
ADD with reduction (2017)
→ ADD without reduction (2020)
10.2017
9.2020
offenrt open
condylar edema
small ant. Recess‐ limitation of mouth opening
rt closed
Movie
Anterior disc dislocationwithout reduction (=fixed ADD)
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ltold
RTrecent
fixed ADD: recent vs old + f‐up
effusion‐ disc and bilaminar zone intact
rt closed rt open
bilaminar zone connection lost, osteoarthrosis
10. 2019 10. 2020Lt open Lt open
Elongation of lateral capsular attachment
rt closed lateral rt closed medial
Medial disc dislocation (very rare)
lt closed lateral
Posterior disc dislocation (very rare)
Ruptured tendinous insertion + effusion
Disc‐ perforation
closed
open
open
closed
+ posterior disc displacement
acute! pain + effusion – rare but symptomatic !
usually asymptomatic !!!
Pat SA
PAT SB
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Oct 2013medial
lateral
July 2014 mediallateral
Fixed ADD: pain and clicking oct 2013 f‐up (for contralat. side) after tx with oral splint
remodelling capacity of bone
OsteoarthrosisCondylar deconfiguration, joint space ↓
cortical bone thickeninganterior osteophyte, subchondral sclerosis + cystglenoid fossa + articular eminence flattening
rt closed lt closed
usually asymptomatic unless inflamed !!!
Activated osteoarthrosis
rt closed rt open
Synovial proliferation, slight effusion‐ joint space widening
Synovitis
closed open
effusion + synovial Gd uptake due to ID = internal derangement /disc displacementosteoarthrosis / autoimmun inflammatory disease
T1 Gd fsT1gd fs
Synoviocytes secrete proinflammatory cytokines (IL1β and TNF α)
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Idiopathic juvenile arthritis
most common rheumatic disease approximately 1 of 1000 childrenTMJ affected in ~ 50% of patsTx→ control inflammation +prevent joint damage → preserve normal growth
14 y
PD T1gd fs
Bilaminar zone
condyle
synovitis
F‐up 17 y arthritis
osteoarthrosis – asymptomatic
PD
courtesy Dr Dr D. Zweifel
offen
Chondrocalcinosis
tophous ‐ pseudotumoral type
closed
linear or fleck like calcificationsrarely ~ w acute or chronic pain, prevalence 18% (CT) in pats w wrist/ knee ch.
classical
Zweifel D, Ettlin D, Schuknecht B Obwegeser O Journal of Oral and Maxillofacial Surgery 2012; 70:60‐67.
Differential D.: osteochondrosis dissecans
Synovial chondromatosis
Cor T2
synovial metaplasia of unclear etiology leading to cartilaginous nodules → break free, mineralize, and even ossify
T2 cor lt
Conclusion
OPG basic diagnostic tool: occlusion dental status„the panoramic does not show detailed abnormalities of the TMJ “
CBT/CT ossoeus Δ: trauma, degenerative, (neoplasm)
MR internal derangement (disc….,perforation, ), ligament Δ : lateral capsular, bilam. zone )effusion, synovial inflammation- metaplasiaosseous changes: growth plate, bonebruise, condylolysis, arthritis (early invisible CT/CBTosteoarthrosis inactive vs active
functional trufi sequ. → TMJ function
Clinical findings and Imaging
→ basis for correct diagnosis and effective Tx !
Decision for choice of correct imagingBased on history, clinical findings and therapeutic consequences
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