M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

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Petscavage-Thomas and Walker

Advanced Imaging of the Temporomandibular Joint

Musculoskeletal Imaging
Review

Unlocking the Jaw: Advanced Imaging

Jonelle M. Petscavage-Thomas1
Eric A. Walker
Petscavage-Thomas JM, Walker EA
of the Temporomandibular Joint
OBJECTIVE. Temporomandibular joint (TMJ) dysfunction is a common condition, af-
fecting up to 28% of the population. The TMJ can be affected by abnormal dynamics of the
disk-condyle complex, degenerative arthritis, inflammatory arthritis, and crystal arthropathy.
Less commonly, neoplasms and abnormal morphologic features of the condyle are causes of
TMJ symptoms. Cross-sectional imaging is frequently used for diagnosis.
CONCLUSION. Knowledge of the normal imaging appearance of the TMJ, its appear-
ance on radiological examination, and interventional techniques are useful for providing a
meaningful radiologic contribution. This article will review normal TMJ anatomy; describe
the normal ultrasound, CT, and MRI appearances of TMJ; provide imaging examples of ab-
normal TMJs; and illustrate imaging-guided therapeutic TMJ injection.

Keywords: internal derangement, jaw, MRI, temporo-
mandibular joint
DOI:10.2214/AJR.13.12177
Received November 1, 2013; accepted without revision
December 5, 2013.
1
Both authors: Department of Radiology, Penn State
Hershey Medical Center, 500 University Dr, Hershey, PA
17033. Address correspondence to J. M. Petscavage-
Thomas (jthomas5@hmc.psu.edu).
This article is available for credit.
AJR 2014; 203:1047–1058
0361–803X/14/2035–1047
© American Roentgen Ray Society
T
emporomandibular disorder
(TMD) is common, affecting
28% of the population [1]. Me-
chanical issues are the most fre-
quent type of disorder, associated with
­abnormal anatomic relationships at the tem-
poromandibular joint (TMJ) [2]. Inflammato-
ry conditions, such as juvenile inflammatory
arthritis, rheumatoid arthritis, and psoriatic
arthritis, may also lead to symptomatic TMD.
Developmental abnormalities, crystalline dis-
ease, and neoplasms are less common sources
of TMD. Clinical symptoms of TMD, includ-
ing pain, decreased mandibular movement,
and mastication problems, can also occur in
non-TMJ disorders [3, 4].
Thus, imaging plays a key role in delineat-
ing the anatomic changes of the TMJ, assisting
in identifying the category of TMD, assessing
treatment response, providing therapeutic in-
tervention, and guiding surgical management.
This article will review the use of diagnostic
and therapeutic imaging of the TMJ.
Anatomy
The TMJ is a synovial joint formed by the
articulation of the mandibular condyle with
the articular fossa of the temporal bone [5, 6].
Interposed between the bones is a biconcave
fibrous articular disk. The disk contains
thick anterior and posterior bands and a thin
intermediate zone [7] (Fig. 1). It is devoid of
blood vessels and nerve fibers [8]. The disk
divides the joint into superior and inferior
compartments that do not communicate
unless there is disk compromise [9].
A bilaminar zone of connective tissue at-
taches the posterior band of the disk to the tem-
poral bone. Supporting ligaments include the
temporomandibular, sphenomandibular, and
stylomandibular [8]. The superior belly of the
lateral pterygoid muscle inserts onto the disk.
The inferior belly of the lateral pterygoid mus-
cle can insert onto the mandibular condyle, or
between the condyle, capsule, and disk [2, 8].
The inferior belly is active in jaw opening, pro-
trusion, and contralateral jaw movements.
Normal Biomechanics
The TMJ is a ginglymoarthrodial (meaning
“hinge and glide”) joint [8]. Both translation-
al and rotational motions are supported. With
a closed mouth, the condyle articulates with
the temporal fossa, and the posterior band of
the articular disk is at the 11–12 o’clock posi-
tion [2, 8] (Fig. 1A). When the jaw is open,
the mandibular condyle moves anteriorly be-
neath the articular eminence, and the central
part of the disk is interposed between the con-
dyle and the articular tubercle [2] (Fig. 1B).
Imaging
MRI
MRI is the reference standard for evalu-
ating the articular disk and soft-tissue struc-
tures of the TMJ [8]. The imaging technique

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includes sagittal oblique and coronal plane
images of 3-mm slice thickness or less. T1-
and proton density–weighted or T2-weighted
sequences with fat saturation are preferred
in both closed- and open-mouth positions [2,
10]. Gadolinium-based contrast material can
help determine the presence of an inflamed
synovium or arthropathy in select patients
[8]. A dual-surface coil is used to image both
TMJs in plane.
On sagittal images, a normal disk has a
biconcave or bow-tie configuration. In the
closed-mouth view, the posterior band of the
disk is located near the 11–12 o’clock position
[2, 8] (Fig. 2A). Normally, with mouth open,
the condyle translates anteriorly to articulate
with the articular eminence (Fig. 2B) and the
disk remains overlying the mandibular con-
dyle. The junction of the posterior band and
the intermediate-signal-intensity bilaminar
zone should fall within 10° of vertical [2, 11].
The disk is of intermediate to low signal in-
tensity on both T1-weighted and fluid-sensi-
tive sequences. On the coronal view, it should
not overhand the mandibular condyle medi-
ally or laterally. The bilaminar zone is of in-
termediate signal intensity with respect to the
muscle on all imaging sequences.
CT
CT is most useful for evaluating osseous
changes, such as erosions, fracture, postsurgi-
cal deformity, and the adjacent temporal bone
[12]. Westesson et al. [13] found a sensitivity
of 75% and specificity of 100% for the diag-
nosis of condylar osseous changes. The imag-
ing technique involves MDCT in closed- and
open-mouth positions, acquired of both TMJs
with thin slices (1- to 2.5-mm thickness).
Multiplanar reformations are performed in
coronal oblique (parallel to the long axis of
the condyle) and sagittal oblique planes using
both bone and soft-tissue algorithms [12]. CT
with 3D reconstructions can be useful for sur-
gical treatment planning.
Normally, the mandibular condyle has a
thin cortex with a smooth contour. The con-
dyle appears broader on coronal images (Fig.
2C). The anterior and posterior articular disk
bands are higher in attenuation than adjacent
soft tissues but lower in attenuation than the
lateral pterygoid muscle tendon [12]. The bi-
laminar zone and intermediate zones cannot
be seen without CT arthrography.
Sonography
Although it is used less commonly, ultra-
sound does have utility for pediatric patients
1048
Petscavage-Thomas and Walker
who cannot undergo an MRI. A 40-year re-
view of the literature showed ultrasound to
have a sensitivity of 13–100% for disk dis-
placement, 70–94% for condylar erosion,
and 70.6–83.9% for evaluation of joint ef-
fusion [14]. The article also showed vari-
ability in ultrasound technique, with linear
transducer frequency ranging from 5 to 20
MHz [14]. The transducer can be aligned
along the axis of the mandibular ramus at
the level of the zygomatic arch or parallel to
the axis of the zygomatic arch.
Normally, on ultrasound images, the artic-
ular eminence and mandibular condyle are
hypoechoic with a hyperechoic cortex due to
high reflection of sound waves. The disk may
be hyperechoic, hypoechoic, and isoecho-
ic, whereas the surrounding capsule, ptery-
goid muscle tissue, and retrodiscal tissues
are isoechoic (Fig. 2D). One caveat is that
changes in the incident angle of sound ener-
gy can lead to changes in disk echogenicity
that may not be pathologic.
Bone Scans
Bone scans are useful tools for the diag-
nosis of TMJ osteoarthritis or joint inflam-
mation. Kircos et al. [15] have reported that,
in patients with TMD, the sensitivity of bone
scan procedures was 93% and the specific-
ity was 86%. In another study, the sensitivity
of bone scans for diagnosis of osteoarthritis
was 72.2% and the specificity was 57.7%
[16]. Findings in TMD include increased up-
take ratios in the TMJ. Bone scans, however,
do not reveal the level of anatomic detail of
MRI and CT.
Imaging of Specific Disorders
Internal Derangement
Internal derangement is defined as an ab-
normal anatomic relationship of the disk
to the mandibular condyle [2]. Disk dis-
placement has been reported in 16–31% of
asymptomatic patients but is statistically
more common in patients with symptoms
[3, 17]. A displaced disk may be reduced
(“recaptured”) with mouth opening, and
this is often accompanied by an audible and
palpable click. As disease progresses, the
disk may be nonreducible, resulting in lim-
ited motion with the absence of an audible
click. The condition is three to five times
more common among women and typically
is seen at ages 20–40 years [8, 9]. Causes of
internal derangement include trauma, mal-
occlusion, bruxism, stress, and primary os-
seous abnormalities [18].
Disk Displacement With Reduction
Early in disease, MRI findings include an-
terior disk displacement in the closed-mouth
view, with reduction in the open-mouth view
(Figs. 3A and 3B). The most sensitive signs of
internal derangement are a rounded or bicon-
vex disk shape and abnormal disk position
[8]. The earliest finding may be increased T2
signal in the bilaminar zone. Disk degenera-
tion is seen as loss of T1 and T2 signal [18].
Additionally, the angle between the posterior
band and the vertical orientation of the con-
dyle exceeds 10° [19, 20].
Disk Displacement Without Reduction
With disease progression, increased laxity
of retrodiscal soft tissues results in disk dis-
placement without reduction [2] (Figs. 3C and
3D). There is further thickening of the pos-
terior band and reduced mass of the anterior
band. A folded or flattened shape is found in
more severe cases of internal disk derange-
ment [21]. A stuck disk is one that remains in
a fixed position in both the open- and closed-
mouth views. This is presumably due to the
formation of adhesions [2]. Although most
disk displacement occurs anteriorly, 30% of
cases are medial or lateral [15]. Posterior di-
rection of disk displacement is rare.
Other MRI findings of internal derange-
ment include high T2 signal of the retro-
discal tissues, indicating inflammation and
pain [22]. Alternatively, low T2 signal in
this region can be seen, indicating fibrosis
of a chronically displaced disk [23]. A non-
enhancing joint effusion is seen more often
in patients with disk displacement and pain
[24]. Associated cortical erosions, condylar
head flattening, osteophytes, subchondral
marrow edema, and low-signal sclerosis are
also reported in more severe cases with sec-
ondary osteoarthritis [8].
The inferior lateral pterygoid muscle is
hyperactive in internal derangement [25], re-
sulting in a thickened attachment that, when
parallel to the anteriorly displaced disk,
shows a “double-disk sign” [2, 26] (Fig. 3E).
The muscle may also be hypertrophied, atro-
phied, or fibrosed.
Inflammatory Arthritis
Rheumatoid arthritis—Rheumatoid arthri-
tis is a chronic inflammatory polyarticular
disease most common among women in their
40s [27]. Rheumatoid arthritis is the most
common inflammatory arthritis in adults to
affect the TMJ, with incidence ranging from
5% to 86% of patients [28]. Patients experi-
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Advanced Imaging of the Temporomandibular Joint
ence symptoms of pain, tenderness, swelling,
and limited jaw movement [29].
In rheumatoid arthritis, the inflammatory
synovial pannus destroys the articular disk
and bilaminar zone, resulting in abnormal
disk position (superior in > 50% of cases)
and biplanar morphologic features on cross-
sectional imaging [30] (Fig. 4A). There can
also be complete disk destruction. Joint effu-
sion is nonspecific for rheumatoid arthritis,
but an enhancing synovial proliferation sug-
gests active rheumatoid arthritis [31] (Fig.
4B). Synovial enhancement is often a precur-
sor to osseous changes. The osseous changes
include bony apposition, with destroyed in-
tervening soft tissues and secondary osteo-
arthritis [9], and 65% of cases show limited
condylar motion on both open- and closed-
mouth images [31]. MRI has the highest ac-
curacy (95%) for the diagnosis of rheumatoid
arthritis. MRI and CT have been shown to
similarly depict the osseous changes of con-
dylar and articular eminence erosions, sub-
chondral sclerosis, and bony apposition [32].
Lin et al. [33] developed grading catego-
ries of rheumatoid arthritis on MRI. Grade
0 is a normal condyle and joint. Grade 1 is
mild rheumatoid arthritis involvement, with
irregularity in the mandibular condyle, osse-
ous destruction, bone marrow changes, and
minimal joint space narrowing. Medium se-
verity, or grade 2, includes significant ero-
sion in the condyle, destruction, and joint
space narrowing. Grade 3 (severe) involves
complete destruction of the condyle and joint
space narrowing [33].
Psoriatic arthritis—Psoriatic arthritis is
a chronic inflammatory seronegative spon-
dyloarthropathy that occurs in 5–8% of pa-
tients with psoriatic skin disease [34]. It is
rarely associated with TMJ symptoms. Find-
ings are similar to those for rheumatoid ar-
thritis, including osseous erosions, condylar
head flattening, decreased jaw motion be-
tween open- and closed-mouth views, joint
effusion, and abnormal disk morpholog-
ic features and position [35] (Fig. 4C). CT
scans may also show resorption of the man-
dibular condyle with new bone formation
along and within the joint space [36].
Juvenile inflammatory arthritis—Juvenile
inflammatory arthritis is the most common-
ly diagnosed rheumatologic condition in chil-
dren, with about 300,000 affected children
in the United States and a female predilec-
tion [37]. Several factors are associated with
an increased risk of TMJ arthritis in juvenile
inflammatory arthritis, including longer dis-
AJR:203, November 2014
ease duration, young age at disease onset, and
polyarticular or systemic course [38]. The
rate of TMJ involvement differs significant-
ly among the seven juvenile inflammatory ar-
thritis subtypes, with 61% of cases associat-
ed with the extended oligoarticular subtype,
52% associated with the polyarticular rheu-
matoid factor–negative subtype, 50% associ-
ated with the psoriatic subtype, 36% associat-
ed with the systemic subtype, 33% associated
with the polyarticular rheumatoid factor–pos-
itive subtype, 33% associated with the persis-
tent oligoarticular subtype, 30% associated
with the unclassified juvenile inflammatory
arthritis subtype, and 11% associated with
enthesitis-related arthritis [39].
The TMJ is more susceptible than other sy-
novial joints to damage from arthritis because
of the close proximity of the growth plate of
the condylar head to the location of inflam-
mation or synovitis [38]. Early diagnosis and
treatment of TMJ synovitis are particularly
important in the pediatric population, because
acute and chronic inflammation in the TMJ
joint can lead to joint deformity and function-
al limitations. Physical examination of chil-
dren with TMJ arthritis is challenging, be-
cause there is often a paucity of TMJ signs or
symptoms, and pain is not a reliable indicator
of inflammation or damage in this population
[38, 40]. Despite the high prevalence of radio-
graphic evidence of TMJ disease in patients
with juvenile inflammatory arthritis, most of
the children have no TMJ signs or symptoms
at examination [41–43].
Ultrasound examination of the TMJ al-
lows dynamic evaluation of TMJ joint mo-
tion and fast detection of joint effusion, con-
dylar erosions, and increased power Doppler
flow due to synovitis (Fig. 4D). Sonography
is suboptimal at detecting medial or lateral
disk displacements [44]. CT findings include
condylar concavities, condylar flattening,
erosions, chronic hypoplasia or dysplasia of
the condyle, and joint effusion. The condy-
lar concavities can result in a bifid appear-
ance (Fig. 4E). MRI with gadolinium-based
contrast material is the most sensitive tool for
detecting TMJ arthritis in juvenile inflam-
matory arthritis [38]. The most common ab-
normal findings in the TMJ on MRI are (in
order of decreasing frequency) erosion of the
condylar head, synovial enhancement, artic-
ular surface flattening (Fig. 4F), abnormality
in jaw motion, subchondral sclerosis of the
articular eminence, joint effusion, deformed
or displaced disk in the open- or closed-
mouth position, bone marrow edema, scle-
rosis of the fossa, sclerosis of head, and the
presence of osteophytes [45].
Other Types of Arthritis and Related Conditions
Osteoarthritis—Osteoarthritis is the most
common arthropathy of the skeleton and in-
cludes both primary and secondary causes.
Primary osteoarthritis of the TMJ is more
common in older patients and is associated
with poor dentition. Secondary osteoarthritis
may be seen in patients with internal derange-
ment and other arthropathy. Imaging findings
on both CT and MRI are similar to those for
other joints in the body and include one or
more of the following: condyle flattening, os-
teophytes, erosions, joint space loss, and sub-
chondral sclerosis [46] (Fig. 5A). In more ad-
vanced cases, joint fusion may occur [8].
Avascular necrosis—Avascular necrosis
is a common but underrecognized condition
that involves the TMJ. It is more common in
patients with disk displacement without de-
struction. It is postulated that the anterior-
ly displaced disk mechanically compromis-
es the extraosseous and venous blood flow
to the condyle by compression of the lateral
pterygoid muscle insertion onto the mandibu-
lar condyle [47]. Avascular necrosis can lead
to osteoarthritis and condylar collapse [47].
CT images show sclerosis of the subchondral
bone and, as disease advances, subchondral
collapse (Fig. 5A). MRI may show decreased
T1 signal; decreased, increased, or variable
T2 signal; and abnormalities of condylar
morphologic features [48].
Calcium pyrophosphate dehydrate deposi-
tion disease—Calcium pyrophosphate dehy-
drate deposition disease is caused by deposition
of calcium pyrophosphate dehydrate crystals in
articular cartilage [49]. Typically, this involves
fibrocartilage and hyaline cartilage, but crys-
tals may also deposit in synovium, joint cap-
sule, tendon, and intraarticular ligaments [49].
In the TMJ, calcium pyrophosphate dehydrate
deposition disease is a rare condition of un-
known cause. On radiographs and CT, one can
see chondrocalcinosis of the fibrous disk and
adjacent osseous changes of joint space nar-
rowing, osteophytosis, and subchondral cyst
formation [50] (Fig. 5B). Crystal accumulation
can also mimic tumor or mass lesions because
of erosion of adjacent condyle and temporal
bone. MRI findings include low-signal-intensi-
ty periarticular masses on T2-weighted images
with inhomogeneous enhancement [50]. The
differential diagnosis for periarticular low-sig-
nal-intensity formation includes amyloid, gout,
and synovial chondromatosis.
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Septic arthritis—Septic arthritis is un-
common in the TMJ. It is most often the re-
sult of hematogenous spread of distant infec-
tion, including sexually transmitted diseases
and reactive arthritis [51]. Locally, septic ar-
thritis may result from local trauma, burns,
or spread of local infection. Typically, in-
fection is due to a bacterial pathogen, most
commonly Staphylococcus aureus [51]. Sep-
tic arthritis is most often seen in men pre-
senting with pain and trismus at a mean age
of 36 years [52].
On contrast-enhanced CT, findings include
a large joint effusion (Fig. 5C), synovial
enhancement, cortical breakdown, and, in
some cases, osteomyelitis [52]. MRI reveals
joint effusion with enhancing synovium and
adjacent bone marrow changes, ranging from
edema to erosions and findings of osteomyelitis.
Tumors and Tumorlike Conditions
Synovial chondromatosis—Synovial chon-
dromatosis is an uncommon benign condition
of synovial neoplasia with intraarticular pro-
liferation of cartilaginous nodules originating
from the synovial membrane [53]. It is a rare
entity in the TMJ and is present more often
in women aged 40–60 years. Clinically, pa-
tients present with pain, swelling, crepitation,
and limited jaw movements, which can be as-
sociated with cranial nerve dysfunction. It is
now thought that synovial chondromatosis is
a neoplasia, not a metaplasia.
Imaging findings include joint space wid-
ening, joint effusion, soft-tissue swelling, ir-
regular surfaces of the joint, and multiple cal-
cified loose bodies, which are seen as ossified
bodies on CT and as amorphous isointense
signal on MRI in up to 86.4% of cases [54]
(Fig. 6A). Low-signal-intensity nodules might
appear as both small round and punctate
forms, correlating with calcified and ossified
nodules on pathologic examination [55]. MRI
is helpful in assessing for skull base changes
that indicate a more aggressive course. Thus,
preoperative CT and MRI are very useful be-
cause synovial chondromatosis requires sur-
gery for treatment. In some cases, there is
extracapsular and intracranial extension and
malignant transformation [56].
Pigmented villonodular synovitis—Pig-
mented villonodular synovitis is another
uncommon but reported tumorous synovial
disease of the TMJ. It is typically a monoar-
ticular hyperplastic inflammatory process of
large joints of the extremities [57]. CT find-
ings in the TMJ include bone erosion and
cyst formation of the mandibular condyle
1050
Petscavage-Thomas and Walker
and soft-tissue masses with attenuation low-
er than that of adjacent skeletal muscle [57,
58]. MRI features include areas of low signal
on all imaging sequences due to hemosiderin
deposition. Areas of high T2 signal may rep-
resent loculated cysts of joint fluid [57, 58].
Tumors—Neoplasms are rare in the TMJ.
However, symptoms can be similar to those
of TMD. A meta-analysis of the literature
of 285 different reported tumorlike condi-
tions found that 81.8% of lesions were be-
nign [59]. However, when benign tumorlike
conditions, such as pseudotumors, synovi-
al chondromatosis, pigmented villonodu-
lar synovitis, and eosinophilic granuloma,
were excluded, 64.2% of cases were malig-
nant. The most common malignant tumors
are sarcoma (53.8%) and metastatic disease
(32.7%) (Figs. 6C and 6D). Malignant enti-
ties are more often a mixed lytic and soft-
tissue pattern involving the mandibular con-
dyle on CT, compared with radiolucency
without a soft-tissue component for benign
entities. Benign neoplastic entities reported
in the TMJ include aneurysmal bone cysts
and fibrous dysplasia, with imaging appear-
ances similar to those of other osseous sites
of involvement [59, 60].
Condylar Aplasia and Hypoplasia
Aplasia and hypoplasia—Condylar de-
ficiency can range from minimal to com-
plete absence of the mandibular condyle
and can be due to abnormal development
and growth of the TMJ [6]. Common
causes of aplasia include rheumatoid ar-
thritis, radiation therapy, and parathyroid
hormone–related processes affecting chondro­
cyte differentiation [61, 62]. Aplasia is
also associated with hemifacial micro­
somia, Goldenhar syndrome, Treacher
Collins syndrome, Proteus syndrome,
Morquio syndrome, and auriculo-condylar
syndrome [8]. Agenesis is associated with
external ear, auditory canal, and middle
and inner ear abnormalities [8], whereas
external ear deficiencies are not a feature
of condylar hypoplasia. On CT and MRI,
altered condylar shape is associated with a
shallow sigmoid notch, a short ramus and
mandibular body, and underdeveloped gle-
noid fossa (Fig. 7A).
Hyperplasia—Hyperplasia is typically
idiopathic, although it has been associated
with endocrine disturbances [63]. Patients
may have an elongated ramus and body (Fig.
7B), resulting in deviation of the chin to the
unaffected side [63]. The condyle may also
be morphologically normal or elongated and
may impinge on the zygomatic process [64].
Traumatic Conditions
Trauma to the TMJ includes condylar
process fracture, mandibular fossa fracture,
and TMJ dislocation.
Fractures—Mandibular fractures are typ-
ically the result of motor vehicle crashes and
assaults [65]. Condylar fractures account
for 25–50% of mandibular fractures and are
classified as condylar neck (low, medium, or
high) and condylar head (extra- or intracap-
sular) [65]. Fracture displacement is usual-
ly medial because of the action of the lateral
pterygoid muscle. CT is useful in multiplanar
reconstruction and assessment of adjacent
zygomatic process and external auditory ca-
nal injury (Fig. 8A).
Dislocation—Dislocation of the TMJ can
be traumatic or nontraumatic, such as that
precipitated by yawning, eating, dental treat-
ment, or oral intubation [66]. Dislocation
at the TMJ is defined as excessive forward
movement of the condyle beyond the articu-
lar eminence, with complete separation of the
articular surfaces and fixation of the condyle
in that position [67]. Dislocation can be seen
on imaging when there is persistent location
of the condyle under the articular eminence
in both open- and closed-mouth positions
(Fig. 8B). Associated condylar fractures may
be seen. Clinically, the patient cannot fully
close the mouth and has pain and difficulty
speaking and swallowing. There is increased
risk of dislocation in patients with shallow
articular fossa or connective tissue disease.
Therapeutic Joint Injection
Although arthroscopy is the primary
treatment for patients with internal derange-
ment, nonsurgical management can be at-
tempted. Fluoroscopically guided intraar-
ticular steroid injection has been shown to
increase active mouth opening by 10 mm
[68]. Therapeutic injection is often used for
patients with juvenile inflammatory arthri-
tis to maintain optimal joint function, reduce
orofacial symptoms, and avoid permanent
damage and unfavorable growth alterations
[68]. However, a systematic review of cor-
ticosteroid injection of TMJ in juvenile in-
flammatory arthritis found only limited con-
clusions on efficacy and no long-term effect
data on outcomes or effect on mandibular
growth alterations and or damage [69].
The imaging-guided technique involves
palpation of the lower edge of the zygoma
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Advanced Imaging of the Temporomandibular Joint
and posterior edge of the condyle of the man-
dible. The injection is done with the mouth
wide open. A 23- to 25-gauge needle is in-
serted almost vertically (directed slightly
forward) at the base of the tragus. The tip
of the needle lies intraarticularly at about
1.5 cm. Contrast material outlining the joint
space confirms the intraarticular location
(Fig. 9). Recent studies have shown that in-
jection of the inferior joint space or double
joint space results in greater maximal mouth
opening and alleviation of pain compared
with superior space injection [70].
Temporomandibular
Joint Arthroplasty
Another treatment option, particular-
ly for patients for whom therapeutic joint
injections and arthroscopy have failed, is
TMJ replacement. Both partial joint pros-
theses that replace the fossa eminence and
total joint prostheses are available. Partial
replacements may be composed of silastic
or metal material (Fig. 10). In total joint
replacement, the neurovascular structures
and disk are removed, and one of several
U.S. Food and Drug Administration–ap-
proved devices is implanted [71]. These
devices typically contain a metal condy-
lar component, mesh or metal fossa com-
ponent, and radiolucent ultra-high-molec-
ular-weight polyethylene material for the
articular surface.
In a study of 442 total TMJ replacements
in 288 patients, 69.5% had decreased inter-
ference with eating, 67.5% had less pain,
and 44.6% had increased incisal open-
ing at 3 years [72]. Another study of 103
joints showed improved pain, an increase
in maximal incisal opening of 22–33 mm,
and improved dietary score at 1-year fol-
low-up [73]. Potential complications of
TMJ arthroplasty include infection; foreign
body reaction to metal or polyethylene; fos-
sa wear-through; facial nerve dysfunction;
neuroma formation; dislocation, loosening,
or displacement of the implant; heterotopic
bone formation; screw fracture; and corro-
sion of joint surface or degenerative chang-
es resulting from implants.
Conclusion
Knowledge of normal TMJ anatomy,
expected cross-sectional imaging appear-
ance, pathologic appearance, and therapeu-
tic technique is important for a radiologist
to assist in the management of patients with
TMJ dysfunction.
AJR:203, November 2014
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(Figures start on next page)
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Advanced Imaging of the Temporomandibular Joint

Fig. 1—Normal temporomandibular joint (TMJ)

anatomy. (Illustrations by Walker EA)
A, Illustration of normal TMJ anatomy in closed-
mouth view shows mandibular condyle (C)
articulating with articular fossa (AF). Disk is
biconcave with thin intermediate zone. Posterior
band (P) is at 11–12 o’clock position of condyle.
Superior belly of lateral pterygoid muscle (SHLP)
inserts onto anterior band of disk (A), whereas
inferior belly (IHLP) can attach to disk or mandibular
condyle. Posterior band is connected to temporal
bone by connective tissue called bilaminar zone. AE =
articular eminence.
B, Illustration of normal TMJ anatomy in open-mouth
view shows condyle now articulates with articular
eminence of temporal bone. Disk remains between
eminence and condyle.

A B

A B

C D
Fig. 2—Three patients with normal temporomandibular joint imaging appearance.
A and B, 35-year-old woman. Closed-mouth proton density–weighted fat-saturated image (A) and open-mouth T1-weighted sagittal image (B) show hypoechoic
biconcave shaped disk with anterior (white arrow) and posterior (black arrow) bands. Posterior band of disk is at 11–12 o’clock position in closed-mouth view. Lateral
pterygoid muscle (LP) is anterior to condyle (C). AE = articular eminence, EAC = external auditory canal.
C, 45-year-old man. Coronal CT image in bone window shows rounded contour of mandibular condyle with thin cortex and normal disk space.
D, 15-year-old girl. Ultrasound image with 12-MHz linear transducer aligned along long axis of mandibular ramus at level of zygomatic arch shows articular eminence
(AE), hypoechoic disk (arrow), and erosion-free mandibular condyle.

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Petscavage-Thomas and Walker

A B C

D E
Fig. 3—Three patients with internal derangement.
A and B, 57-year-old woman with pain and clicking. Sagittal closed-mouth proton density–weighted fat-saturated image (A) shows disk is anteriorly displaced (white
arrow). There is also increased T2 signal (black arrow) in bilaminar zone and flattening of normal shape of disk. Sagittal open-mouth T1-weighted image (B) shows that
disk (arrow) reduces to normal position.
C and D, 45-year-old woman with internal derangement/temporomandibular dysfunction. Sagittal T1-weighted image (C) shows that disk (arrow) in closed-mouth
position is anteriorly displaced and slightly irregular in shape. Sagittal T1-weighted open-mouth view (D) shows no reduction of disk displacement (arrow) and globular
disk shape.
E, 39-year-old woman with internal derangement/temporomandibular dysfunction. Proton density–weighted fat-saturated image shows two hypoechoic horizontal
bands attaching to condyle. This represents double-disk sign of thickened inferior lateral pterygoid muscle (arrow) and anteriorly displaced disk.

A B C
Fig. 4—Four patients with inflammatory arthritides.
A and B, 33-year-old woman with rheumatoid arthritis. Sagittal proton density–weighted fat-saturated image (A) shows disk is anteriorly displaced and globular in
configuration (arrow). Condyle is also eroded and diminished in size. Coronal T1-weighted contrast-enhanced fat-saturated image of right temporomandibular joint (TMJ)
(B) shows joint effusion with enhancing synovitis, absence of normal appearing disk, and posterior pannus (arrow).
C, 45-year-old man with psoriatic arthritis. Sagittal T1-weighted fat-saturated gadolinium-enhanced image shows enhancing synovium, destroyed disk, and flat irregular
condyle with new bone formation.
(Fig. 4 continues on next page)

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Advanced Imaging of the Temporomandibular Joint

D E
Fig. 4 (continued)—Four patients with inflammatory
arthritides.
D, 17-year-old girl with juvenile inflammatory
arthritis. Ultrasound image of mandibular condyle
in long axis shows erosion of mandibular condyle
(arrow) and hypoechoic synovitis along TMJ.
E and F, 14-year-old boy with juvenile inflammatory
arthritis. CT coronal image in bone algorithm (E)
shows bifid appearance of condyle due to central
erosion. T1-weighted contrast-enhanced fat-
saturated image of patient’s other TMJ (F) shows
erosion and flattening of condyle, bone marrow
enhancement, and enhancing synovium with large
joint effusion. Normal disk is not apparent.

Fig. 5—Three patients with other types of arthritis and related conditions.
A, 55-year-old man with avascular necrosis. Coronal CT image in bone window of
both temporomandibular joints (TMJs) shows joint space narrowing of both, with
subchondral sclerosis and subchondral cystic change. Increased serpiginous
sclerosis in right mandibular condyle is due to avascular necrosis.
A (Fig. 5 continues on next page)

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Petscavage-Thomas and Walker

Fig. 5 (continued)—Three patients with other types

of arthritis and related conditions.
B, 58-year-old woman with calcium pyrophosphate
dehydrate deposition disease. Sagittal CT image in
soft-tissue window shows linear chondrocalcinosis
of TMJ, flattening of condyle, and subchondral cysts.
C, 35-year-old man with septic arthritis who
presented with fever and elevated erythrocyte
sedimentation rate. Axial contrast-enhanced CT
image in soft-tissue window shows joint effusion in
right TMJ (arrow) with enhancement. Joint aspiration
confirmed septic arthritis.

B C

A B

Fig. 6—Three patients with tumors and tumorlike

conditions.
A, 55-year-old woman with synovial chondromatosis.
Sagittal CT image in bone algorithm shows multiple
intraarticular ossified bodies, narrowing of left
temporomandibular joint (TMJ), and osseous erosion
and subchondral cyst.
B, 44-year-old woman with left TMJ dysfunction.
T2-weighted fat-saturated coronal image shows
multiple round and punctate low-signal-intensity
nodules with joint effusion (arrowhead) in left TMJ
overlying condyle (arrow), consistent with synovial
chondromatosis.
C and D, 64-year-old man with primary
adenocarcinoma of lung. Axial CT image in bone
algorithm (C) shows soft-tissue mass in TMJ with
lytic destruction of anterior aspect of mandibular
condyle. Axial fused PET/CT image (D) shows uptake
in left TMJ consistent with metastatic disease.
C D

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Advanced Imaging of the Temporomandibular Joint

Fig. 7—Two patients

with dysplasia.
A, 20-year-old man
with dysplasia.
Coronal CT image in
bone window shows
underdeveloped left
mandibular condyle
and shallow articular
fossa compared with
normal right side.
B, 22-year-old man
with dysplasia.
Coronal CT image
in bone window
shows hyperplasia
of mandibular
condyle (arrow),
with impingement on
adjacent temporal
bone and lateral
subluxation in respect
to articular fossa.

A B

Fig. 8—Two patients with trauma.

A, 25-year-old man with impaction fracture. Coronal CT image in bone window
shows impaction fracture of mandibular condyle, with bone fragment within joint
space (arrow). Condyle is also medially subluxated in respect to fossa.
B, 33-year-old man with dislocation due to yawning. Sagittal CT image in bone
window shows condyle is anteriorly dislocated in respect to articular eminence.
A

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Petscavage-Thomas and Walker

Fig. 9—25-year-old woman who received

therapeutic injection. Lateral fluoroscopic image
shows needle in disk space and contrast agent
outlining temporomandibular joint, consistent with
intraarticular location.

Fig. 10—65-year-old woman who underwent

temporomandibular joint (TMJ) arthroplasty.
A, Radiograph shows bilateral partial TMJ
replacement as metal articular fossa implants.
B, Sagittal CT image in bone window shows partial
articular fossa TMJ arthroplasty of metal. This acts
as spacer to maintain joint space, alleviate pain, and
allow jaw opening and eating functionality.
A

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