Diagnostic Imaging of

the SUSAN ROCHE, D.D.S., M.S.,

FAHS
Temporomandibular DEPARTMENT OF ORAL &
MAXILLOFACIAL SURGERY

Joint LOMA LINDA SCHOOL OF

DENTISTRY
Imaging

Selection of Imaging Techniques depends on:

1. Clarifying Clinical diagnosis esp. if unclear
2. Presence of unusual signs/symptoms & clinical exam
findings
3. Desire to image hard vs soft tissue
4. Diagnostic information provided from the imaging
technique (i.e. visualization of disc; or range of motion of
condyle, soft tissue, rule out pathology, stage diseases
affecting the orofacial region)
5. Availability of imaging
6. Radiation dose
7. Cost
Techniques for Imaging
Osseous Structures

 Projections:
 Panoramic
 Transcranial
 Transmaxillary
 Transorbital
 Transpharyngeal
 Submentovertex
 Tomography
 Computed Tomography (CT)
Techniques for Imaging Soft
Tissue

1. Magnetic Resonance Imaging (MRI)

2. Newer multidetector Computed Imaging
(MDCT)
3. Arthrography- rarely ordered
Plain Radiography

 Transcranial radiography:
 Used for screening.
 Useful in evaluating condylar translation & gross
degenerative changes.
 Image distortion of articular surfaces occurs.
 Superimposition of osseous structures occurs.
 Specific joint space measurements to determine
condylar position are not possible due to
distortion and superimposition.
Plain Radiography

 Transcranial or transorbital
techniques view the condyle in
anterior-posterior position.
 Helpful in assessing degenerative
pathological conditions involving
the condyles.
Panoramic Radiography:
Tomography

 Advantages:
 The maxilla and mandible are depicted in a
single film
 Broad anatomic region is imaged to screen
gross dental/periodontal pathology,
disorders of the maxilla and mandible, and
diseases
 May identify fractures, gross degenerative
changes in the TMJ, & gross pathological
changes of the maxilla & mandible.
Panoramic Radiography

 Advantages:
 Relatively low dose of radiation for patient.
 Simple and quick to perform.
 Ideal for patient who cannot open his/her
mouth.
 Images the maxilla and mandible in one
single film
Panoramic Radiography

 Disadvantages:
 Limitations include: magnification,
superimposition, & distortion.
 Lacks fine anatomical detail.
 Artifacts (“ghosts”) occurs as radiopaque
shadows superimposed over normal
anatomic structures. This results from
projection of x-ray beam through a dense
object (i.e. spinal column, hard palate).
Panorex demonstrates severe
degenerative changes R./L.
condyles
Panorex (edentulous patient)
W.F.

7-11-01
Hyperplasia

Transpharyngeal projection:
Condylar head is enlarged,
and the neck is thick.
Hypoplasia B.J. 15 y.o.
Female

Condylar Hypoplasia on R condyle resulting in loss of vertical height on

mandibular ramus. Hx of fracture of R condyle at age 6.
Fracture

Condylar Fracture:
The arrow points to the
overlapped fragments, as
evidenced by increased
radiopacity.
Panorex 1/23/2003
L.A.
Stylohyoid Calcification 82y.o.
male C.L.
Corrected Tomography

 Accurate radiographic imaging for

evaluating osseous changes in 2-D.
 High spatial resolution of skeletal structures in
3 views: ICP, protrusion, & open views.
 Can show narrowing of joint space
suggestive of disc displacement without
reduction.
 Excellent for evaluating condylar mobility.
 Depicts bony changes, joint spacing &
identification of osteoarthritic changes.
Lateral Corrected Tomogram
Lateral Corrected Tomogram
Hypoplasia Right side B.J. 15
y.o. Female
Computed Tomography (CT)
Medical

 X-ray tube & detector revolve around patient

and data is stored in computer
 Valuable for assessing pathology in sinuses, TMJ,
head and neck.
 Not useful in evaluation of disc displacement
due to poor reliability of imaging the disc and
superiority of MRI.
 Useful for evaluation of entire maxilla/mandible
 Pt receives a slightly higher dose of radiation
compared to dental CBCT due to larger Field of
view (FOV)
Mechanical Geometry
of CT Scanner
Computed Tomography (CT)

 ADVANTAGES:
 Eliminates superimposition of images
of structures superficial/deep to area
of interest
 Differentiates between tissues easily
due to high-contrast resolution
 Stored images are reconstructed in
axial, coronal & sagittal planes from a
single imaging procedure
3-D CT scan
3-D CT scan
Cone Beam Computed
Tomography- Dental

 Introduced in oral &  3-D visualization of hard

maxillofacial imaging in tissues
2000
 Limited visualization of soft
 Utilizes relatively low tissues
ionization radiation

Tetratis, S and White, S. A Decade of Cone Beam Computed

Tomography. CDA, Jan 2010, pg. 24-27.
Advantages of Cone Beam CT
(CBCT)

 Controlled magnification  Ease in data acquisition,

reconstruction & display
 Lack of superimposition
 Improved structure visualization &
 Absence of geometric
diagnostic efficacy
distortion
 Multiplanar & 3-D display
 Lower cost, higher
resolution & lower radiation
dose compared to
Medical CT

Tetratis, S and White, S. A Decade of Cone Beam Computed Tomography.

CDA, Jan 2010, pg. 24-27.
Disadvantages of Cone Beam
CT (CBCT) compared to
Medical CT (MDCT)

 Motion artifact potential

 Beam hardening
 Absence of soft tissue detail
 Cone Beam CT

figure 1. Normal TMJ in the closed position seen on corrected lateral (a),
coronal (b), and axial (c) CBCT sections.

figure 2. Bone remodeling on

lateral (a) and coronal (b ) CBCT
sections showing flattening and
cortical thickening of the antero-
superior surface of the condylar
head and glenoid fossa.
Barghan, S, Merrill, R and Tetratis. S. Cone Beam Computed Tomography Imaging in the Evaluation of the Temporomandibular Joint.
CDA Jan. 2010, pg. 33-39
 Right TMJ (closed position)

Axial

degeneration osteophyte Joint

mouse

Coronal Sagittal
 Right TMJ (open position)

Axial

Subchondral cyst

Coronal Sagittal
Patient Risk Related to Common Dental Radiographic Examinations: The Impact of 2007 International
Commission on Radiological Protection Recommendations Regarding Dose Calculation.
John B. Ludlow, DDS, MS, Laura E. Davies-Ludlow, BS and Stuart C. White, DDS, PhD
Arthrography

 Radiographic technique in which

radiographic dye is injected into the
inferior/superior joint space(s) that
outlines the articular disc and transcranial
or tomographic radiographs are taken.
 Useful in determining disc position,
perforation of articular disc, or fibrosis.
 Functioning of condyle/disc can be
assessed with use of fluoroscopy and
videotaping.
Arthrography

 Disadvantages:
 Invasive procedure
 Exposure to radiation
 Discomfort due to injection of
contrast medium
 Possible hypersensitivity to
contrast agent
Arthrography

 Limited use at present due to wide

availability of MRI which does not expose
patient to radiation.
 Causes patient discomfort & it is an invasive
technique.
 Use on selected patient cases when
dynamic imaging results will alter the course
of treatment or when indicated prior to joint
lavage.
 Most reliable method for identification of
perforation in the articular disc.
Arthrography
Arthrography
Arthrography

Leakage of dye indicates

perforation in disc
Arthrography

Leakage of dye

Disc
Magnetic Resonance Imaging
(MRI)

 Advantages:
 Current Gold Standard for imaging of soft tissues.
Reveals pathological conditions or abnormal
structures for soft tissue and osseous structures.
 Does Not use radiation.
 Useful for diagnosis of suspected articular disc
disorders, particularly disc displacement, edema,
perforation, condylar bone morphology, soft tissue
adhesions, inflammation (edema) & tumors.
 Dynamic images are possible with video (cine MRI).
Magnetic Resonance Imaging
(MRI)

 Disadvantages:
 Expensive
 Not well tolerated by claustrophobic
patients and anxiolytics (i.e. valium) are
required prior to imaging.
 Cooperation by patient is required and
may affect results.
Magnetic Resonance Imaging
(MRI)

 MRI results should be used in conjunction with clinical findings

to confirm differential diagnosis and should not solely be used
to dictate treatment plan.
 Poor reliability in depicting disc perforation.
Magnetic Resonance Imaging
(MRI)

 Useful for:
 diagnosis for insurance and medicolegal cases.
 oral surgeon prior to arthroscopy or arthrotomy.
 ruling out articular pathology in patients that have
failed multiple treatments.
MRI (Ant. Disc Displacement without
Reduction)

Disc remains anterior to

condyle
Nuclear Medicine Studies

 Demonstrates areas of altered bone metabolism.

 Radioactive isotope technetium is administered I.V. and
accumulates in areas of osteoblastic activity.
 Useful to determine bone growth activity in hyperplasia of the
TMJ condyles
 High activity takes place in areas of neoplasia &
inflammation due to reparative process of reactive bone
formation (i.e. infection, arthritis, malignancy/cancer).
 Can identify fractures
Radionuclide Imaging

 Rarely used in routine clinical practice of orofacial

pain except when malignancy is suspected or when
diagnosis is elusive.
Bone Scan L. Maxilla
osteomyelitis ? AMP

Increased bone activity

 Bone Scan AMP

Increased bone activity following extraction- used to help assess possible

osteonecrosis
Bone Scan
L. TMJ condylar resorption D.P.

Increased bone activity in L. TMJ

Lecture Learning Objectives

 Be familiar with the imaging techniques

available for assessing TMD and orofacial
pain.
 Know the advantages and disadvantages
of each technique.
 Know the imaging techniques most
appropriate for a screening examination
and for a particular diagnosis.
 Know which imaging techniques are most
appropriate for assessing: osseous tissue,
soft tissue, and metabolic activity.