牙科放射線學 (2)
陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 [email protected]
Temporomandibular Joint Radiography
顳顎關節放射線攝影術
The normal anatomy of the TMJ
What investigations are available
Common pathological conditions that can affect the joints
學 習 目 標學 習 目 標
1. Eric Whaites: Essentials of dental radiography & radiology 3rd edition, Chapter 29, p. 371-3882. Eric Whaites: Essentials of dental radiography & radiology 1st edition, Chapter 28, p. 297-323.
References
3. Rosenberg et al, Aust Dent J 1999;44:106
4. Kaohsiung Medical University, Oral Pathology Department
Subtopics
The normal anatomy of the TMJ
What investigations are available
Common pathological conditions that can affect the joints
Condyle head
Disc/meniscus
Glenoid fossa
Lateral pterygoidattachment
Upper joint space
Lower joint space
Ext auditory meatus
Normal Anatomy
(Hard tissue)
(Hard tissue)
(Soft tissue)
(Soft tissue)
Ref. 1
Lateral Anterior
Base
Normal anatomy- Dry skull
Ref. 1
Rotatory and translatory movements of condyle during normal mouth opening
Restposition
Mouthclosed
Primaryrotation
Mouthopened
Translation
Mouth openedinitially
Mouth openedwidely
Secondaryrotation
Ref. 1
What investigations are available (1)
The clinical indicationsHow each investigation is performed, i.e.how the patient is positioned in relation tothe film and X-ray tubehead, and whetherthe patient’s mouth needs to be open or closed
What investigations are available (2)
What information each investigationThe limitations and shortcomings of eachinvestigation
Conventional radiographic projections Other techniques and investigations
Investigations
Transcranial Transpharyngeal Panoramic Reverse Town’s Transorbital Tomography, linear
Summary of different parts of TMJshown by the conventional projections
Ref. 1
Transcranial
TMJ pain dysfunction syndrome – pain,clicking and limitation in openingTo investigate the size & position of thedisc (joint space)To investigate range of movement in thejoints
Main indications
Mouth openMouth close
Mouth open
Right
Mouth close Right
Transcranial Centric occlusion
Ref. 1
<N.B.>The radiological term joint space: radiolucent zone between condylar head & glenoid fossa, which includes discs & upper & lower anatomical joint spaces
Diagnostic informationDiagnostic informationClosed view
Open view
Transcranial The size of the joint space – provide indirectinformation about the position and shape ofthe discThe position of the head of the condyle withinthe fossaThe 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 lateralaspect only)A comparison of both sides
The range and type of movement of the condyle
A comparison of the degree of movement onboth sides
Main indicationsMain indications
Transpharyngeal
TMJ pain dysfunction syndromeTo investigate the presence of joint disease,particularly osteoarthritis and rheumatoidarthritisTo investigate pathological conditionsaffecting the condylar head, including cysts ortumorsFractures of the neck and head of the condyle
Diagnostic informationDiagnostic information The shape of the head of condyle and condition of the articular surface from lateral aspect A comparison of both condylar heads
Transpharyngeal
Ref. 1
Dental panoramic tomograph
Main indicationsMain 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
Transcranialview taken frompanoramicmachine
Right close Right open Left open Left close
Ref. 4
To investigate the articular surface of the condyles and disease within the joint Fractures of the condylar heads and necks Condylar hypo/hyperplasia
To investigate the articular surface of the condyles and disease within the joint Fractures of the condylar heads and necks Condylar hypo/hyperplasia
Main indications
Reverse Towne’s
Mouth openRef. 1
Diagnostic informationDiagnostic information The shape of the condylar heads and condition of the articular surfaces from the posterior aspect A direct comparsion of both condyles
Reverse Towne’s
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
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 because of the risk ofdamage 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
Diagnostic informationDiagnostic information The shape of the condylar head and neck from the anterior aspect The condition of the articular surface from the anterior aspect
The shape of the condylar head and neck from the anterior aspect The condition of the articular surface from the anterior aspect
Transorbital
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
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
Lateral
Anterior15o20o25o30o
Tomography
Ref. 1
Diagnostic informationDiagnostic 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
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
Tomography
Other techniques & investigations
Arthrography Computed tomography Magnetic resonance imaging Artheroscopy
Arthrography Computed tomography Magnetic resonance imaging Artheroscopy
Main indicationsMain indicationsDiagnostic informationDiagnostic information
下列何者是 AP view為:A. Panoramic radiographyB. Transcranial projectionC. TransorbitalD. Modified Town’s view
下列何者是 AP view為:A. Panoramic radiographyB. Transcranial projectionC. TransorbitalD. Modified Town’s view
Arthrography
Main indicationsMain indications
Longstanding TMJ pain dysfunction unresponsive to simple treatments Persistent history of locking Limited opening of unknown etiology
Longstanding TMJ pain dysfunction unresponsive to simple treatments Persistent history of locking Limited opening of unknown etiology
Main contraindicationsMain contraindications
Acute joint infection Allergy to iodine or contrast medium
Acute joint infection Allergy to iodine or contrast medium
Diagnostic informationDiagnostic 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
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 perforationsNote: Outline the lower joint space usuallyprovides more useful information on the disc
Arthrography
Ref. 1
Computed tomography
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
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
Main indicationsMain indications
Diagnostic informationDiagnostic 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
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
Condylar head
Anteriordisplaceddisc
Main indications
When diagnosis of internal derangements is in doubt As a preoperative assessment before disc surgery
When diagnosis of internal derangements is in doubt As a preoperative assessment before disc surgery
Ref. 4
Arthroscopy
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 lastline of investigation before full surgicalexploration of the joint is carried
Main indications
1. Upper joint space2. Lower joint space3. Disc4. Prolene suture5. Yeates drain6. External auditory meatus
1. Upper joint space2. Lower joint space3. Disc4. Prolene suture5. Yeates drain6. External auditory meatus
Arthroscopy
Ref. 3
Fibrillation
Disc
Adhesion
Disc
Arthroscopy
Ref. 4
Main pathological conditions affecting the TMJ Main pathological conditions affecting the TMJ
TMJ pain dysfunction syndromeInternal derangementsOsteoarthritisJuvenile rheumatoid arthritis (Still’s disease)AnkylosisTumorsFracturesDevelopmental anomalies
Main pathological conditions affecting the TMJ Main pathological conditions affecting the TMJ
最可能的診斷為:A. AmeloblastomaB. Squamous cell carcinomaC. HemangiomaD. Central giant cell granuloma
最可能的診斷為:A. AmeloblastomaB. Squamous cell carcinomaC. HemangiomaD. Central giant cell granuloma
(A) A multilocular radiolucency; (B), (C) Surgical specimen; (D) Costochondral graft;(E) Histological examination: bony trabeculae entrapped by multiple blood vessels
Knowing: The normal anatomy of the TMJ
What investigations are available
Common pathological conditions that can affect the joints
SummariesSummaries