Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1996e2002

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Journal of Cranio-Maxillo-Facial Surgery

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The prevalence of pneumatized articular eminence in the temporal

bone. Do we need a high resolution computed tomography-based
novel risk classification for eminectomy?
Nils Heim a, *, Werner Go
€tz b, Rudolf H. Reich a, Anton Faron c
a
University of Bonn, Department for Oral & Cranio-Maxillo and Facial Plastic Surgery (Head: Prof. Dr. Dr. Rudolf H. Reich), Germany
b
University of Bonn, Department of Orthodontics, Dental Hospital of the University of Bonn, Head of the Oral Biology Laboratory, Germany
c
University of Bonn, Department for Radiology, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Besides mastoid air filled cells, pneumatizations (PN) occasionally occur in the articular
Paper received 19 June 2018 eminence (AE) of the temporomandibular joint (TMJ). These findings represent no pathological character
Accepted 20 September 2018 but may increase the risk of perforating the AE during eminectomy with potential harming the skull base.
Available online 25 September 2018
Various classifications catagorize the degree of temporal PN without focussing solely on the AE. Pano-
ramic radiograph (PR) and computed tomographie (CT) are both described as suitable for diagnosing PNs.
Keywords:
Are the common ways of imaging capable for precise diagnosis and do we need a risk pattern for
Articular eminence
eminectomy?
Pneumatization
Air cells
Methods: A 4-year retrospective study evaluated high resolution computed tomographie (HRCTs) of 300
Eminectomy patients. We screened digitalized skull images for PN of the AE. The frankfort horizontal was determined
TMJ as the reference mark for measurements. Images were assessed by a craniomaxillofacial surgeon and a
radiologist.
Results: 300 patients (600 AEs) were investigated. We detected 60 PNs (10% of all AEs) in 44 patients
(14.7%). We subdevided the findings according to the extent of PN. 10 AEs showed PNs of less than 20%
(type 1); n¼18: 21-40% (type 2); n¼18: 41-70% (type 3). n¼14: 71 to 100% (type 4). In 32 cases (72.7%)
with 42 PNs a PR existed. Of the 42 AEs, corresponding PN could be detected in 21 cases (50%).
Discussion: PNs are a potential threat when performing TMJ surgery. Sufficient preoperative imaging is
required to avoid severe endangerment for the patient. CT imaging is most suitable detecting PNs. PR
seem to fail in diagnosing PNs of different degree. Our novel HRCT-based classification shows the dis-
tribution of PNs and provides a risk pattern.
Conclusion: HRCT exceeds the diagnostic accuracy of PR in detecting pneumatized AEs. PR is not capable
for detecting PNs of different degree. A novel classification may increase the prediction of perforation
risk. Restricting eminectomy to reduce height only to a certain amount reduces the risk of complications.
© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction process of the temporal bone (Orhan et al., 2005). Mastoid

During skull development, numerous bone-enclosed air-filled
cavities, also referred to as pneumatizations, arise in many
distinct locations (Lang, 1992). One of them is the zygomatic
* Corresponding author. Abteilung für Mund, Kiefer und Plastische Gesicht-
schirurgie, Universit€ atsklinikum Bonn, Sigmund-Freud-Strasse 25, Haus 11, 2. OG,
D-53127, Bonn, Germany. Fax: þ49 0 228 287 22604.
E-mail addresses: nils.heim@ukbonn.de (N. Heim), wgoetz@uni-bonn.de
(W. Go€ tz), rudolf.reich@ukbonn.de (R.H. Reich), anton.faron@ukbonn.de (A. Faron).
pneumatizations are well-known entities and considered as
common findings on computed tomography (CT) scans. However,
air-filled cavities are potentially imperiled anatomic structures
due to infections, trauma, tumor and cancer therapies such as
radiation, as solidity and resistance of regular bone is not given
(Walker et al., 2011). Similar to mastoid air cells, pneumatized
articular eminences (PAE) of the temporal bone are asymptomatic
air-filled cavities, but with only occasional occurrence and a re-
ported prevalence between 1.03% and 6.2% (Yavuz et al., 2009;
Shokri et al., 2013; Bohra et al., 2015) in panoramic radiographs

https://doi.org/10.1016/j.jcms.2018.09.021
1010-5182/© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
 N. Heim et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1996e2002
(PRs). PAEs are likewise other pneumatizations, a non-pathologic
finding that require no further treatment. Admittedly, air cells
(ACs) may form a potentially hazard in the course of surgical
procedures of the temporomandibular joint (TMJ) (Da costa
Ribeiro et al., 2014). Against the backdrop of reported cases with
perforated cavities in the articular eminence (Kulikowski et al.,
1982), radiological imaging must be performed before indicating
surgical procedures (Undt, 2011). Furthermore, air cells of the
zygomatic process seem to occur more frequently in patients with
temporomandibular joint (TMJ) problems and dysfunction (Gupta
et al., 2014; Hasnaini and Ng, 2000). Besides total joint replace-
ment of the TMJ, which involves inserting screws into the glenoid
fossa and the articular eminence (AE), when fixing the fossa
component (Granquist and Quinn, 2011; Giannakopoulos et al.,
2012), eminectomy represents a high risk of complications in
patients with pneumatized articular eminence due to the
anatomic vicinity of the lateral skull base. Eminectomy was
initially delineated by Myrhaug (1951) as a surgical method for
the treatment of habitual dislocation of the mandible. Myrhaug
was convinced that a reduction of bone mass of the eminence
enhances the unimpeded movement of the condyle back into the
glenoid fossa. Subsequently, eminectomy was suggested for the
treatment of closed lock of the TMJ (Nitzan and Dolwick, 1991)
and internal derangement (Weinberg, 1984). Several methods of
eminectomy, in many instances altered from the traditional form
(Pogrel, 1987), have been described by numerous authors (Reich,
1987, Sato et al., 2003; Vasconcelos et al., 2009). Not all authors
propose the resection of the same part of the eminence to
enhance the appropriate guidance of the condylar movement.
However, ablating bone from the eminence is a common approach
of each surgical technique with the subsequent risk of perforating
potential air cells.
A widespread discordance regarding the prevalence of pneu-
matization of the zygomatic process and the eminence complicate
the clinician's decision of proceeding with diagnosing and appro-
priate therapy. Furthermore, great disparities between radiological
findings of PR and CT scans outline a large scope for interpretation
of the presented data in the literature (Khojastepour et al., 2015;
Bronoosh et al., 2014; Shamshad et al., 2018). Layer thickness of
the analyzed CT data and accuracy of PR is an additional crucial
issue in assessing the study results. Inconclusive assertions as to
whether a small air cell should be regarded as a pneumatization of
the eminence, and therefore is or is not an endangerment for per-
forming eminectomy, makes the clinician decisions even more
difficult.
The aim of this study is to determine the prevalence of pneu-
matized articular eminences by evaluating high-resolution CT
(HRCT) scans and using these data to develop a novel risk classifi-
cation aiming at sustaining clinician decisions was to whether to
perform or not perform eminectomy on a given patient. Addition-
ally, we compared HRCT scans with corresponding PR to determine
their value in detecting air cells.
2. Materials and methods
2.1. Patients
A 4-year retrospective study evaluated HRCTs of 300 patients. All
patients received medical attention from the Department of Oral
and Maxillofacial Plastic Surgery of the University of Bonn, Germany.
Inclusion criteria for the study were recently performed HRCTs with
faultless representation of both AEs in all planes. Exclusion criteria
were any trauma or pathologies of the TMJ with possible involve-
ment of the AE. Patients’ clinical data were reviewed, including age,
sex and diagnosis leading to inpatient treatment.
1997
2.2. Image analysis
We screened digitalized skull images for pneumatizations for
the AE. CT scans were performed by a Philips iCT, 256-slice CT
scanner. Images were obtained from the local Picture Archiving and
Communication System (PACS) and reviewed on a conventional
radiologic workstation (Barco Mio. for multiplanar reformation the
extended multi-planar reconstruction tool of the Agfa Impax
Application [AGFA, Belgium] was used). Images were viewed in the
axial plane, the coronal plane and the sagittal plane. The Frankfort
horizontal was determined as the reference mark for all measure-
ments of AE in HRCT (Fig. 1). Images were assessed by a cranio-
maxillofacial surgeon and a radiologist.
2.3. Statistical analyses
All information was arranged electronically and analyzed
(Microsoft Excel, version: 12.3.6; Microsoft Corporation, Redmond,
WA, USA). Measurements were described by the means and cor-
responding standard deviations (SDs).
3. Results
A total of 300 subjects with 600 AEs (107 female and 193 male)
from 7 to 98 years of age were enrolled in the study. The patients’
mean age was 50.9 years (±20.3 SDs). Every patient received
inpatient treatment in our department and HRCT scan. Above all,
causative diagnosis for performing HRCTs and inpatient treatment
were fractures (n ¼ 193; 64.4%) and cancer (n ¼ 68; 22.7%). The
distribution of all diagnoses is illustrated in Fig. 2.
We detected 60 pneumatizations (10% of all investigated AEs) of
AEs in 44 patients (14.7% of all patients) of different sizes. Ten of the
pneumatizations were detected on the right side, 18 on the left side
and 16 on both sides of the patients. The group of patients with
pneumatizations of the AE (pnþ) had a mean age of 50.4 (±21.8)
years. Among patients without pneumatized AEs (pn), patient age
was a mean of 51.1 (±21.1) years.
In the pn þ group, we subdivided the findings according to the
extent of pneumatization in every AE. Accordingly, 10 AEs were
detected with single air cells (AC) or pneumatizations of less than
20% of the AE (type 1). In all, 18 sites presented with
Fig. 1. Reference line for all measurements. FH ¼ Frankfort horizontal.
1998 N. Heim et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1996e2002
Fig. 2. Distribution of the patients' diagnoses and reasons for CT scan.
pneumatizations between 21% and 40% (type 2). Another 18 sites
presented pneumatizations of 41%e70% of the AE (type 3). In 14 AEs
a pneumatization of 71%e100% (complete pneumatization, type 4)
was detected (Fig. 3). In three cases (6.8%) we investigated AC or
pneumatization (1 ¼ type 1; 2 ¼ type 2) with no discernible
anatomic connection with other pneumatizations of the temporal
bone.
In 32 cases (72.7%) of the pn þ group (n ¼ 44) a conventional
panoramic radiograph (PR) of the patient existed. We analyzed all
PRs regarding the occurrence of appending appearances of pn or AC
in HRCT and PR. In all, 42 pneumatizations were detected by HRCT
scans in the 32 patients (HRCT þ PR available). Of these 42 AEs,
corresponding pneumatizations could be detected in 21 cases
Fig. 3. Classification for pneumatized articular eminence (AE) and risk of perforation when performing eminectomy.
(50%). In the other half of the cases, the findings of pneumatization
of AE in HRCT scan could not be endorsed by the PR findings. We
categorized the PR-undetectable AEs in the type of pneumatization.
Of the 21 cases with disparate findings in the distribution, 2 cases of
type 1 pns with a mismatch (33.3%) were detected; 9 cases of type 2
showed a mismatch (75%); 5 cases of type 3 showed a mismatch
(38.5%); 5 cases of type 4 showed a mismatch (45.5%) in PR (Fig. 4).
Fig. 5 provides samples of matching and mismatching findings of
corresponding HRCT and PR imaging.
4. Discussion
In our retrospective study, we investigated HRCTs of 300 pa-
tients who had undergone examination for various purposes
(Fig. 2). We documented a male predominance (193 male, 64.3%;
107 females, 35.7%). The mean age of the patients was 50.9 years
(±20.3), ranging from 7 to 98 years of age. Other studies present
similar data for both gender balance and age (Friedrich et al., 2016).
We detected a laterality imbalance of pneumatized AE with a
higher incidence on the left side (left: n ¼ 18; right: n ¼ 10; bilat-
eral: n ¼ 16). Despite the fact that our data resemble those of
previous studies (Friedrich et al., 2016), we have no traceable
explanation for an outbalancing left side. We assume that the
limited number of analyzed HRCTs erroneously create the impres-
sion of unbalanced laterality, which may be leveled by a greater
number of analyzed patients.
Myrhaug originally introduced eminectomy as a surgical pro-
cedure for the treatment of habitual dislocation (Myrhaug, 1951).
He was convinced that ablating the eminence leads to an easy
reposition of the habitually dislocating condyle into the glenoid
fossa. Other authors subsequently promoted eminectomy for the
treatment of different TMJ pathologies, such as closed lock of the
TMJ (Nitzan and Dolwick, 1991; Stassen and Currie, 1991) and in-
ternal derangement of the TMJ (Hall et al., 1984; Weinberg, 1984). In
the treatment of recurrent dislocation, eminectomy is indicated
after failed conservative options such as training of the masticatory
muscles, physiotherapy, sufficient prosthetic restauration, and
modification in the drug therapy of patients with extrapyramidal
motor disorders (Undt, 2011). Besides infections of the auditory
region with the potential of spreading into the TMJ (Thomson,
1989), degenerative joint diseases may destroy joint surfaces,
debilitate the bony mass of the AE and increase the risk of damage
 N. Heim et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1996e2002 1999

Fig. 4. Distribution of pneumatized articular eminences (AEs) and matching/mismatching with panoramic radiographs.

Fig. 5. Samples of high-resolution CT imaging and correlating panoramic radiographs with matching and nonmatching results.

to the skull base during TMJ surgery (Al-Faleh and Ibrahim, 2005).
These threats are greatly increased in patients with pneumatized
AEs, because the bony mass of the AE, as a natural barrier between
the TMJ and skull base, is missing. Therefore, sufficient imaging of
the AE prior to surgical procedures in this area is of utmost
importance (Demirel et al., 2014). During the recent decades, many
investigators performed eminectomy for treatment of mandibular
luxation and reported their experiences (Irby, 1957; Hale, 1972;
Reich, 1987; Undt et al., 1997; Klüppel et al., 2010). However
there is dissent within the group of authors as to which amount of
bone should be removed when performing eminectomy. Many
authors postulate that most of the eminence, including the medial
parts, should be removed radically to achieve pain reductional and
better disc replacement and to prevent recurrence (Goode and
Linehan, 1973; Helman et al., 1984; Gay-Escoda, 1987). Other au-
thors propose to restrain the procedure and only ablate parts of the
2000 N. Heim et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1996e2002
eminence, including the lateral part of AE (Baumstark et al., 1977;
Cherry and Frew, 1977; Reich, 1987).
Alongside general risks of open joint surgery such as perfora-
tion of the outer ear channel, damaging hard and soft tissue of the
glenoid fossa and vessels and nerves, pneumatization of the AE
can lead to severe problems during and after surgery (Kulikowski
et al., 1982). Depending on the degree of AE pneumatization, an
intraoperative perforation of a pneumatized eminence or AC in AE
increases the risk of damaging the skull base. Therefore it is
necessary to perform sufficient imaging in order to avoid surgery
on the PAE. Many authors have investigated the prevalence of AC
in the temporal bone, presenting a broad range of results between
1.02% and 6.2% in PR (Kaugars et al., 1986; Shokri et al., 2013) and
1e38.3% in CT (Ladeira et al., 2013; Nascimento et al., 2015). A
Fig. 6. Accumulated prevalence of all articular eminences (AEs) found in the study.
Low (green) ¼ rarely occurring PNs; high (red) ¼ frequently occurring PNs. Direction of
pneumatization. PNs extend from the mastoid over the glenoid fossa into the AE.
large study of Yavuz et al. (2009) investigated PRs of 8107 pa-
tients. ACs were detected in only 1.03% of the cases. Analyzing
HRCTs, we detected pneumatizations of the AE in 44 patients
(14.7%). Sixteen patients presented with bilateral pneumatiza-
tions, hence 10% (n ¼ 60) of all AEs showed pneumatizations of
different degree (Fig. 5). Our findings show a significantly higher
number of pneumatized AEs than all studies using PRs (Friedrich
et al., 2016). We assume that HRCT is much more suitable for
achieving sufficient resolution to detect pneumatizations. Thus,
we found PRs in 32 patients (72.7%); 44 AEs previously diagnosed
with PAE. We compared our findings from HRCT with correlating
PR imaging (Fig. 5) and discovered that pneumatizations could be
verified in PR in only 21 cases (50%). The other half of PAE could
not be detected by PR (Fig. 4). However, our data also show a
higher prevalence of pneumatization compared to studies using
CT or CBCT (Friedrich et al., 2016). Possible reasons for differing
results could be a higher resolution of the HRCT scan that we used,
compared to lower resolutions used in other studies with
concomitant detectability of ACs. Another reason may be different
investigated areas of the temporal bone, while we defined the
Frankfort horizontal as a strict reference (Fig. 1).
In most of the cases of PAE, we detected a connection to the
mastoid air cell system (92.2%). These findings are consistent with
the theory that pneumatization of the mastoid may spread above
the glenoid fossa into the AE (Koc et al., 2004). Further we analyzed
the prevalence of pneumatized AE regions and determined the
posterior and cranial parts of the fossa, close to the mastoid, to be
the most frequent pneumatized sites (Fig. 6). This detection of the
distribution of pneumatized parts of the AE supports the theory of
spreading ACs from the mastoid. However there is dissent in the
literature about the beginning of the development of air-filled ca-
nals and cavities. Some authors assert that pneumatization can be
detected at birth, whereas others claim that it can be observed at
the 24th week of gestation (Virapongse et al., 1985).
Over the years, various investigators have developed different
classifications categorizing pneumatizations according to their lo-
calizations. Allam divided air-filled bony structures according to
their localizations: middle ear, mastoid petrous apex, perilabyrinth
and accessory regions (subdivided into: zygomatic, styloid, occip-
ital and squamos (Allam, 1969)). Carter et al. classified air-filled
structures according to their appearance in PRs into unilocular,
multilocular and trabecular (Carter et al., 1999). HRCT was used in a
study of Groell and Fleischmann. Air-filled cavities were also clas-
sified by their localizations. The AE was again only a single locali-
zation beside peritubal, roof of the fossa and zygomatic process
(Groell and Fleischmann, 1999).
None of those classifications were solely referring to the AE,
but to more than one region of the temporal bone and thus do
not meet the requirements needed for the development of a risk
pattern for eminectomy in PAEs. We developed a simple classi-
fication for categorizing the pneumatization of AEs and the risk
of perforation when performing eminectomy. Referring to the
Frankfort horizontal, Type I shows single ACs or pneumatization
20% or less, equating no risk or low risk for perforation. In Type 2
pneumatizations, 21%e40% of the volume of the AE is pneuma-
tized and presents an increased risk for perforation. Type 3
(41%e70% of AE pneumatization) correlates with a high risk for
perforation. Type 4 (71%e100% of pneumatized bone) is consid-
ered to be a contraindication to AE surgery. Fig. 3 illustrates all
types, risks and selected example illustrations. We applied the
classification to the HRCTs correlating with PRs and discovered
that PR failed in 33% (n ¼ 2) of visualizing pneumatizations in
Type 1. Furthermore there was a 75% (n ¼ 9) visualization failure
in Type 2, a 38.5% (n ¼ 5) failure in Type 3 and a 45.5% (n ¼ 5)
failure in Type 4. Samples for matching and mismatching images
 N. Heim et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1996e2002
are given in Fig. 5. Other authors reiterated in their studies that
PR is limited in diagnosing pneumatizations due to superimpo-
sitions in complex three-dimensional bony structures (Demirel
et al., 2014). We assume that the marked differences in the
prevalence of PAEs between our data and PR studies are pri-
marily explainable by a lack of visualization of pneumatizations
in PR, due to superimpositions.
Although some authors support the use of PRs in diagnosing PAE
(Orhan et al., 2005), our data present a mismatch between HRCT
and PR diagnosis in half of the cases and therefore lead to the
assumption that PR may not be a reasonable method for operation
planning in TMJ surgery (Crow et al., 2005). Carefully weighing both
options, the detrimental aspects of CT are increased radiation
exposure and higher costs than with PR. Apart from that, CT ex-
ceeds the representability of three-dimensional bony structures, in
comparison to plain radiographs, by far (Yavuz et al., 2009).
However, our study has two major limitations. First of all, we
only investigated 300 HRCTs (600 AEs), by contrast to PR studies
investigating more than 8000 PRs (Yavuz et al., 2009). Additionally,
correlating PRs were only present in 72.7% of the diagnosed
pneumatizations in HRCT. Comparing these numbers is statistically
not fully feasible. Furthermore we only investigated PRs with pre-
viously confirmed diagnosis of pneumatization in HRCT. Other PRs
were not taken into consideration, due to the assumption that
HRCT exceeds diagnostic accuracy of PR.
5. Conclusion
HRCT exceeds the diagnostic accuracy of PR in visualizing three-
dimensional bony structures, detecting pneumatized AEs and
planning TMJ surgery. PR is not capable of detecting PAEs of
different degrees. A novel classification of PAT may increase the
prediction of perforation risk, and thus the endangerment of the
skull base during eminectomy. By restricting eminectomy to reduce
height only to a certain amount or by ablating the lateral parts of
the AE, the risk of perforation is considerably reduced, especially in
Type 2 and 3 pneumatizations.
Financial disclosure
There are no financial disclosures or commercial interests from
any authors.
Conflicts of interest
There were no conflicts of interest.
Acknowledgments
This study is dedicated to Professor Dr. Dr. R. H. Reich as a small
recognition for decades of effort in clinical and scientific work, inter
alia, TMJ surgery and sharing of his broad knowledge.
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