MRI TMJ TUTORIAL.pps

8/19/2019 MRI TMJ TUTORIAL.pps

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MRI TMJ TUTORIALMRI TMJ TUTORIAL

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• AbstractAbstract

• AnatomyAnatomy

• PhysiologyPhysiology

• Disk or Meniscus. MorphologyDisk or Meniscus. Morphology

• Disk Displacement. Closed-mouth positiDisk Displacement. Closed-mouth positi

onon

• Disk Displacement. pen-mouth positioDisk Displacement. pen-mouth positio

nn

• !oint "ffusion!oint "ffusion• #etrodiscal#etrodiscal $issue$issue

• %nsertion of the &ateral %nsertion of the &ateral PterygoidPterygoid MuscleMuscle

• steoarthriticsteoarthritic ChangesChanges

• #eferences#eferences

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Mail to (irst Author )$omas *+Mail to (irst Author )$omas *+

Browsing AreaBrowsing Area

Dear ,uest: All $M! figures of this "ducational "'hibit are intellectual property of *aier $MA/ MD )*$omas+. Copy or duplication areformally forbidden without preious author0s agree. $hank you ery much for your attention/ and % hope that you en1oy it 22

mailto:[email protected]?subject=TMJ%20TUTORIAL%20RSNA


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MRI TMJ TUTORIALMRI TMJ TUTORIAL Abstract Abstract

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&"A#3%3, 4!"C$%5"&"A#3%3, 4!"C$%5"

6. $o describe the basic concepts of temporo-mandibular 1oint M# imaging.

7. $o reiew the role of M# imaging in the assessment of temporo-mandibular 1ointdysfunction. pecial emphasis is placed on new indirect signs of dysfunction.

8. $o correlate M# imaging features with clinical symptoms.

A4$#AC$A4$#AC$

Dysfunction of the $M! is a fre9uent disease which/ in some studies/ may affect up to7 ; of the population. %n recent years/ M#% has been confirmed as the imagingtechni9ue of choice in the study of $M! meniscal displacement in patients. Despite of/a high fre9uency of disk displacement appears in asymptomatic olunteers. (urtherstudies using the latest techni9ues allow a better understanding of the sources of 1ointpain and the discrepancy between imaging findings and patient symptoms.


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MRI TMJ TUTORIALMRI TMJ TUTORIAL Anatomy Anatomy

6. Condyle6. Condyle7. $emporal 4one. Articular eminence7. $emporal 4one. Articular eminence

8. $emporal bone. Mandibular fossa8. $emporal bone. Mandibular fossa

>. Disk. Anterior band )A4+>. Disk. Anterior band )A4+

?. Disk. %ntermediate =one )%@+?. Disk. %ntermediate =one )%@+

. Disk. Posterior band )P4+. Disk. Posterior band )P4+

B. 4ilaminar =one. uperior retrodiscal layerB. 4ilaminar =one. uperior retrodiscal layer

.. 4ilaminar =one4ilaminar =one. %nferior retrodiscal layer. %nferior retrodiscal layer

. 4ilaminar =one. 5asculo-nerous structures. 4ilaminar =one. 5asculo-nerous structures

6. Capsular superior attachment6. Capsular superior attachment

66. Capsular inferior attachment66. Capsular inferior attachment

67. uperior 1oint space67. uperior 1oint space68. %nferior 1oint space68. %nferior 1oint space

6>. &ateral superior pterygoid muscle )&P+6>. &ateral superior pterygoid muscle )&P+

6?. &ateral inferior pterygoid muscle )%&P+6?. &ateral inferior pterygoid muscle )%&P+

6. %nterpterygoid space6. %nterpterygoid space

6B. "'ternal auditory canal6B. "'ternal auditory canal

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MRI TMJ TUTORIALMRI TMJ TUTORIALDisk or Meniscus Mor!hologyDisk or Meniscus Mor!hology

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4iconcae.4iconcae. 3ormal disk in a sagittal3ormal disk in a sagittalsection in closed-mouth positionsection in closed-mouth position(upper image)(upper image) .. $he margins of disk$he margins of disk)bands+/ are thick/ and the center)bands+/ are thick/ and the center))arrow; intermediate zonearrow; intermediate zone++ is thin.is thin.

P4 and retrodiscal tissue are bestP4 and retrodiscal tissue are bestdepicted in open-mouth position E6Fdepicted in open-mouth position E6F(arrow; lower image).(arrow; lower image). 3ormal signal3ormal signalintensity use to be hypointense in 4Aintensity use to be hypointense in 4Aand @%/ and slightly hyperintense inand @%/ and slightly hyperintense inP4G hypointense signal intensity inP4G hypointense signal intensity inP4 is more fre9uent in patients withP4 is more fre9uent in patients withdisk pathology E7F.disk pathology E7F.

4ulge A4.4ulge A4. ome authors haeome authors haedescribed this morphologydescribed this morphology as aas anormal ariant of disk E8-?F.normal ariant of disk E8-?F.


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MRI TMJ TUTORIALMRI TMJ TUTORIAL RSNA´04

%rregular%rregular $he disk$he disk (arrow; left(arrow; leftupper figure)upper figure) has lost its typicalhas lost its typicalbiconcae morphology/ gettingbiconcae morphology/ gettingcrumpled.crumpled.

#ounded#ounded (arrow; right upper(arrow; right upperfigure).figure). %rregular and rounded%rregular and roundedmorphologies are uniersallymorphologies are uniersallyconsidered pathologic conditionsconsidered pathologic conditionsE-FE-F

(lat(lat (arrow; left bottom figure).(arrow; left bottom figure).

%n the study of the first author/%n the study of the first author/this morphology appeared as athis morphology appeared as apathologic finding EFpathologic finding EF

Central perforationCentral perforation (arrow; right(arrow; rightbottom figure).bottom figure). AbnormalAbnormal

condition.condition.

Disk or Meniscus Mor!hologyDisk or Meniscus Mor!hology


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MRI TMJ TUTORIALMRI TMJ TUTORIALDisk Dis!lacement "lose#$mouth !ositionDisk Dis!lacement "lose#$mouth !osition

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67-o0clock position of the condyle in67-o0clock position of the condyle insagittal-obli9ue plane.sagittal-obli9ue plane. PathologicPathologiccondition has been considered if thecondition has been considered if theangle between P4 and 67-o0clock line isangle between P4 and 67-o0clock line isoer HI- 6Joer HI- 6J E6-67FE6-67F (upper figure).(upper figure). ther studies hae shown that/ in thisther studies hae shown that/ in this

way/ a large number )88;+ ofway/ a large number )88;+ ofasymptomatic olunteers presented diskasymptomatic olunteers presented diskdisplacement E68-6>Fdisplacement E68-6>F ..

Discal %ntermediate @one as point ofDiscal %ntermediate @one as point ofreference.reference. Kelms and Laplan emphasi=eKelms and Laplan emphasi=ethe interposition of %@ between condylethe interposition of %@ between condyle

and temporal boneG 67-o0clock position isand temporal boneG 67-o0clock position isnot considered E6?F.not considered E6?F.An important disk displacement in closed-An important disk displacement in closed-mouth position is showed here/ in amouth position is showed here/ in apatient with $M! dysfunctionpatient with $M! dysfunction (lower(lowerfigure).figure). %@%@ (arrow)(arrow) is clearly beyond ofis clearly beyond ofcondyle. $he angle between P4 and 67-ocondyle. $he angle between P4 and 67-o0clock line is close to ?J.0clock line is close to ?J.

-H


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6-to-7 o0clock position.6-to-7 o0clock position.#ammelsberg hae recommended this#ammelsberg hae recommended thismodification to better correlate discmodification to better correlate discdisplacement with clinical symptoms todisplacement with clinical symptoms to$M! dysfunction.


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Posterior disk displacement.Posterior disk displacement.$his rare pathologic entity has an oerall$his rare pathologic entity has an oerallincidence between .6 to .6 of $M!incidence between .6 to .6 of $M!disorders E6/6F. $he main clinical signdisorders E6/6F. $he main clinical signis sudden molar open bite. M#% shows ais sudden molar open bite. M#% shows aposterior band located anywhere lessposterior band located anywhere less

than at one o0clock position. (iguresthan at one o0clock position. (iguresdepict a P4 posteriorly displaced indepict a P4 posteriorly displaced inclosedclosed (upper left figure)(upper left figure) and open-and open-mouth positionmouth position (arrow; upper left(arrow; upper leftfigure).figure). !aw is nearly locked in this!aw is nearly locked in thiscase. %n other patient P4 remains closecase. %n other patient P4 remains closeto the mandibular fossa in closeto the mandibular fossa in close (arrow;(arrow;

lower left figure)lower left figure) and open-mouthand open-mouthpositionposition (arrow; lower right figure);(arrow; lower right figure); openopen 1aw was seriously limited. 1aw was seriously limited.


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MRI TMJ TUTORIALMRI TMJ TUTORIALDisk Dis!lacement O!en$mouth !ositionDisk Dis!lacement O!en$mouth !osition

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3ormal disk displacement.3ormal disk displacement. $he$hedisk preseres its normaldisk preseres its normalposition/ between the condyleposition/ between the condyleand temporal bone/ centered inand temporal bone/ centered in

the intermediate =one/ inthe intermediate =one/ inclosedclosed (arrow; upper figure)(arrow; upper figure) and open-mouth positionand open-mouth position(arrow; bottom figure),(arrow; bottom figure), duringduringcondylar moement. $hiscondylar moement. $hisinterposition aoids abnormalinterposition aoids abnormal

contact between osseous 1ointcontact between osseous 1ointsurfaces.surfaces.


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MRI TMJ TUTORIALMRI TMJ TUTORIALDisk Dis!lacement O!en$mouth !ositionDisk Dis!lacement O!en$mouth !osition

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%nternal derangement with%nternal derangement withreduction.reduction. $he disk returns to the$he disk returns to thenormal position/ between thenormal position/ between thecondyle and temporal bone/ duringcondyle and temporal bone/ during 1aw moement 1aw moement (arrow; upper(arrow; upper

figures),figures), generally producing a noisegenerally producing a noise)clicking or popping+ E7F.)clicking or popping+ E7F.

%nternal derangement without%nternal derangement withoutreduction.reduction. $he disk remains$he disk remainsdisplaced from its normal location indisplaced from its normal location inclosed-mouthclosed-mouth (arrow; lower left(arrow; lower leftfigure)figure) and open-mouth positionand open-mouth position(arrow; lower right figure).(arrow; lower right figure). (urthermore/ disk shows an(urthermore/ disk shows anabnormal morphology.abnormal morphology.


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MRI TMJ TUTORIALMRI TMJ TUTORIALRetro#iscal TissueRetro#iscal Tissue

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#etrodiscal layers.#etrodiscal layers. Collagen fibers form theCollagen fibers form theinferior retrodiscal layer and elastic fibersinferior retrodiscal layer and elastic fibersthe superior retrodiscal layerthe superior retrodiscal layer (arrow; upper(arrow; upperfigures).figures). $hese structures play an important$hese structures play an importantrole in normal disk displacement. #& fibersrole in normal disk displacement. #& fibersrupture can produce an important diskrupture can produce an important disk

instability. $his sign can be shown in twoinstability. $his sign can be shown in twodifferent patients with seere non-reducteddifferent patients with seere non-reducteddisk displacementdisk displacement (arrow; lower figures).(arrow; lower figures). %n%nour knowledge/ this sign has not beenour knowledge/ this sign has not beenpreiously described.preiously described.

5asculo-nerous structures.5asculo-nerous structures. A higher $7-A higher $7-weighted signal intensity/ due to a higherweighted signal intensity/ due to a higher

degree of ascular supply/ hae seen founddegree of ascular supply/ hae seen foundin the retrodiscal tissue of painful 1ointsin the retrodiscal tissue of painful 1ointscompared with the non-painful 1ointscompared with the non-painful 1ointsE78/7>F. 4y the other side/ a decreasedE78/7>F. 4y the other side/ a decreasedsignal may be associated with fibroussignal may be associated with fibrous

changes E7?F.changes E7?F.


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MRI TMJ TUTORIALMRI TMJ TUTORIALInsertion o& the Lateral Pterygoi# MuscleInsertion o& the Lateral Pterygoi# Muscle

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(unction of &PM.(unction of &PM. $his muscle has two$his muscle has twobellies: superior )P&+ and inferior )%P&+.bellies: superior )P&+ and inferior )%P&+.

ome authorsome authors E7/7BFE7/7BF beliee that thosebeliee that thosebellies are really two differenciated muscles.bellies are really two differenciated muscles.$he %&P muscle may become hyperactie in$he %&P muscle may become hyperactie inspecific positions to help in stabili=ing andspecific positions to help in stabili=ing andpositioning the condyle and the disk in casespositioning the condyle and the disk in caseswith $M! internal derangement. $emporaliswith $M! internal derangement. $emporalisand the masseter muscles are notand the masseter muscles are nothyperactie in $M! internal derangementhyperactie in $M! internal derangement

E7-8F.E7-8F.

&PM 3ormal M# %maging.&PM 3ormal M# %maging. $hin insertional$hin insertional

area of %&Parea of %&P (arrow; upper left figure),(arrow; upper left figure), 1ust 1ustbelow of the disk. $hin insertional area ofbelow of the disk. $hin insertional area of&P&P (arrow; upper right figure),(arrow; upper right figure), 1ust in front 1ust in frontof the disk. During open-mouth position/of the disk. During open-mouth position/because of contraction of the muscle/because of contraction of the muscle/insertional area of %&P growsinsertional area of %&P grows (arrow; bottom(arrow; bottomleft figure),left figure), respect to closed-mouth positionrespect to closed-mouth position

(arrow; bottom right figure).(arrow; bottom right figure).


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&PM Pathologic M# %maging.&PM Pathologic M# %maging. A M#%A M#%study of first author/ comparing study of first author/ comparing patients suffering $M! dysfunctionpatients suffering $M! dysfunctionand 67 normal olunteers/ found thatand 67 normal olunteers/ found thatthe mean diameter of the insertion ofthe mean diameter of the insertion of

P& and %P& was higher in patientsP& and %P& was higher in patientsthan in the control group.than in the control group.(urthermore/ the diameter of %P&(urthermore/ the diameter of %P&showed a parallel increase in respectshowed a parallel increase in respectto disk displacement degreeto disk displacement degree (diagram(diagramshows significative relationshipshows significative relationship

between diameter of IPL in mm. andbetween diameter of IPL in mm. and

disk displacement in degrees.disk displacement in degrees.tatistic !ltman "est was done)tatistic !ltman "est was done) EF.EF. %n our knowledge/ these findings%n our knowledge/ these findingshae been preiously described onlyhae been preiously described onlyin isolated patients E86F/ but notin isolated patients E86F/ but notsystematically analy=ed.systematically analy=ed.


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&PM Pathologic M# %maging. (igures.&PM Pathologic M# %maging. (igures.ymptomatic $M! of a patient.ymptomatic $M! of a patient.Complete disk displacement.Complete disk displacement.%nsertional area of &P%nsertional area of &P (arrowhead)(arrowhead) and %&Pand %&P (arrow; upper left figure)(arrow; upper left figure) areare

really thicker that in oppositereally thicker that in oppositeasymptomatic $M! in the sameasymptomatic $M! in the samepatient/ where a subtle diskpatient/ where a subtle diskdisplacement/ with minimum thickdisplacement/ with minimum thickinsertional area of &Pinsertional area of &P (arrowhead)(arrowhead) and %&Pand %&P (arrow; upper right figure)(arrow; upper right figure) are shown. ymptomatic $M! in otherare shown. ymptomatic $M! in othertwo patients. Complete disktwo patients. Complete diskdisplacement. $hick insertional areadisplacement. $hick insertional areaof %&Pof %&P (arrow; lower figures),(arrow; lower figures), thatthatruns parallel to disk )runs parallel to disk )arrowhead arrowhead +/+/conforming a new conforming a new double-disk signdouble-disk signN.N.


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MRI TMJ TUTORIALMRI TMJ TUTORIALOsteoarthritic "hangesOsteoarthritic "hanges

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Clinical %mpact.Clinical %mpact. steoarthriticsteoarthriticchanges use to be the last e'pressionchanges use to be the last e'pressionof $M! dysfunction. $hese pathologicof $M! dysfunction. $hese pathologicchanges deelops when diskchanges deelops when disk

displacement is well stablisheddisplacement is well stablished E6F.E6F.

$hese changes can be seen in young$hese changes can be seen in youngpatients.patients.

M# %maging.M# %maging. $here are four imaging$here are four imagingsigns: condylar flatteningsigns: condylar flattening (arrow;(arrow;upper left figure),upper left figure), osteophytesosteophytes(arrow; upper right figure),(arrow; upper right figure), sclerosissclerosis

and erosionsand erosions (lower figures).(lower figures). $he$heauthor found that flattening andauthor found that flattening andosteophytes were significantlyosteophytes were significantlycorrelated with $M! dysfunctioncorrelated with $M! dysfunction EF.EF. $he other two signs could be more$he other two signs could be moredifficult to detect/ due to M#%difficult to detect/ due to M#%

techni9ues applied.techni9ues applied.


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MRI TMJ TUTORIALMRI TMJ TUTORIALRe&erencesRe&erences

6.6. KelmsKelms CA/ CA/ LabanLaban &4/ &4/ Mc3eillMc3eill C/ C/ DodsonDodson $.$. $emporomandibular 1oint: morphology$emporomandibular 1oint: morphologyand signal intensity characteristics of the disk at M# imaging. #adiology. 6and signal intensity characteristics of the disk at M# imaging. #adiology. 6epG6B7)8+:6B-7.epG6B7)8+:6B-7.

7.7. Drace !"/ Ooung


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.. MurakamiMurakami / / $akahashi$akahashi A/ A/ 3ishiyama3ishiyama K/ K/ (u1ishita(u1ishita M/ M/ (uchihata(uchihata K.K. MagneticMagnetic

resonance ealuation of the temporomandibular 1oint disc position and configuration.resonance ealuation of the temporomandibular 1oint disc position and configuration.Dentoma'illofac #adiol. 68 3oG77)>+:7?-B.Dentoma'illofac #adiol. 68 3oG77)>+:7?-B.

'' Tomas ( Tomas ( %stu#io !or resonancia magn)tica* me#iante secuencias +% T, -&lash ,D. y /% T0* #e%stu#io !or resonancia magn)tica* me#iante secuencias +% T, -&lash ,D. y /% T0* #e

la #etecci1n #e !atolog2a #is&uncional a ni3el #e la articulaci1n tem!oroman#ibular Doctoralla #etecci1n #e !atolog2a #is&uncional a ni3el #e la articulaci1n tem!oroman#ibular Doctoral

Thesis Uni3ersity o& Barcelona* 0''' "o#e 45'6 -,666.Thesis Uni3ersity o& Barcelona* 0''' "o#e 45'6 -,666.6.6. DraceDrace !"/ !"/ "n=mann"n=mann D#.D#. Defining the normal temporomandibular 1oint: closed-/Defining the normal temporomandibular 1oint: closed-/

partially open-/ and open-mouth M# imaging of asymptomatic sub1ects.partially open-/ and open-mouth M# imaging of asymptomatic sub1ects.#adiology. 6 ctG6BB)6+:B-B6.#adiology. 6 ctG6BB)6+:B-B6.

66.66. KarmsKarms "/ "/ 7.

67.67. $akebayashi$akebayashi / / $akama$akama $/ $/ kadakada / / MasudaMasuda ,/ ,/ MatsubaraMatsubara .. M#% of the $M! disc withM#% of the $M! disc with

intraenous administration of gadopentetate dimeglumine. ! Comput Assist $omogr.intraenous administration of gadopentetate dimeglumine. ! Comput Assist $omogr.6B Mar-AprG76)7+:7-6?.6B Mar-AprG76)7+:7-6?.

68.68. Lat=bergLat=berg #B-?8G discussion 6?8-?.

RSNA´04

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