TMJ Imaging Anatomy and Lesions

Imaging Anatomy and Lesions of the
Temporomandibular Joint (TMJ)
DR KOLADE-YUNUSA HO MBBS, FMCR
LECTURER AND CONSULTANT RADIOLOGIST
UNIVERSITY OF ABUJA/ UNIVERSITY OF ABUJA TEACHING HOSPITAL (UATH),
ABUJA
KOLADE-YUNUSA HO, WACS REVISION

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Outline
Introduction
Imaging anatomy
Lesions of TMJ
Conclusion

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Introduction
The temporomandibular joint (TMJ) is a synovial

hinge joint between the condyle of the mandible and
the temporal bone.

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Articular surfaces
UPPER ; Articular eminence & mandibular fossa

Lower; Head of the mandible

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The temporal articulating surface consist of a fossa
posteriorly, the temporomandibular fossa, and a
prominence anteriorly, the articular tubercle.
The head of the mandible sits in the fossa at rest and
glides anteriorly on the articular tubercle when fully
open.

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The articular surfaces are covered with fibrous
cartilage.
A fibrocartilaginous disc divides the joint into
separate smaller upper and larger lower
compartments, each lined by a synovial membrane.
The disc is described as having anterior and
posterior bands with a thin zone in the middle and is
attached to the joint capsule.

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The anterior band is also attached to the lateral
pterygoid muscle.
The posterior band is attached to the temporal bone
by bands of fibers called the translational zone or
bilaminar zone
No communication between the joint compartments
is possible unless the disc is damaged.

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LIGAMENTS
Temporomandibular
Stylomandibular
Sphenomandibular
Fibrous capsule: attached above to the circumference
of the mandibular fossa, to the articular tubercle
immediately in front and, below, to the neck of the
condyle of the mandible.

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Nerve supply
The TMJ is supplied from the mandibular nerve by

twigs from its auriculotemporal and masseteric
branches.
Blood supply
 Middle meningeal artery, a branch of the maxillary
artery
Superficial temporal artery

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Movements
Movements Muscles
Elevation (close mouth) Temporal, Masseter and Medial

pterygoid
Depression (open mouth) Lateral pterygoid, Infrahyoid and

Suprahyoid muscles
Protrussion (Protrude chin) Lateral pterygoid, Masseter and Medial

pterygoid
Retrussion (Retrude chin) Temporal and Masseter
Lateral movts (grinding and Temporal of same side, Pterygoid of

chewing) opposite side and Masseter
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Upper compartment is involved in translational
movements-gliding side to side,protraction and
retraction
Lower compartment rotational movement- opening
and closing

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Biomechanics of the TMJ
Jaw movement involves a high level of interaction

and coordination between bilateral mandibular
condyles, disk, muscles, and ligaments of the joints.
 The functional interactions within the TMJ are
complex and incompletely understood
A simplistic view of the complex interactions in open
and closed mouth positions is described below.

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Closed mouth position
In the closed mouth position, the disk is interposed

between the condyle inferiorly and the mandibular
fossa superiorly. The articular eminence is anterior
to the disk.
 The normal disk is positioned such that the anterior
band is in front of the condyle and the junction of the
posterior band and bilaminar zone lie immediately
above the condyle near the 12 o’clock position

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Open mouth position
. When the mouth is open, the condyle moves

anteriorly under the centre of the articular eminence.
In a normal joint, the thin intermediate zone of the
disk is always interposed between the condyle and
the temporal bone in both the closed-mouth and
open-mouth positions. This is for the prevention of
articular damage.
The posterior band is against the posterior surface of
the condyle

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Imaging anatomy
The imaging anatomy of the TMJ is studied using

the below modalities
 Plain radiography
 CT Scan
 MRI
 Arthrography ( convectional, MRI,CT)
 Ultrasound +doppler
 Tomography
 Nuclear medicine

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Plain radiograph
The articulating bones appear opaque

The joint space will appear radiolucent
Fats will also appear lucent
The ligaments, disc and capsule are not visualized
but their positions can inferred.

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1-Articular tubercle 2-Temporal bone 3-Articular disc in
mandibular fossa 4-Head of mandible 5-External acoustic meatus
6-Region occupied by head of mandible when mouth is closed

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CT Scan
High resolution CT is used in the assessment of

theTMJ.
The bones are hyperdense
Muscles, ligaments and disc are hypodense.

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Coronal CT bone window, demonstrating the Rt and Lt
Temporomandibular joints

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MRI
MRI is excellent for the demonstration of the

internal anatomy of the TMJ
The anterior, posterior bands and thin zone of the

disc its attachments are identifiable.

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The cortex of the bone is signal void while the
medulla is hyperintense on both T1W and T2W
images.
The disc is biconcave in shape low signal intensity
on both T1W and T2W images
The muscles, capsule, and ligaments are hypointense
on all sequences.

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T1-Weighted sagittal
magnetic resonance
images in (a) closed-
and (b) open-mouth
positions showing
normal disc positions
(arrows)

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Sagittal proton density weighted closed
mouth( A) and open mouth view (B) of
magnetic resonance imaging.
Normal anatomy. Sagittal proton density

weighted closed mouth and open mouth
view of magnetic resonance imaging.
A: On the closed mouth view, the disk is

located posterior to the articular eminence
(the letter, a). It can be noted that the “bow-
tie” shape of the disk: Thicker anterior band
(red arrow) and posterior band (white
arrow) with a thinner central zone (orange
arrow). Bilaminar zone (BZ) is located
posterior to the posterior band. It can also
be noted that the inferior joint compartment
(white arrowhead) between the disk and the
mandibular condyle (the letter, b) and
superior joint compartment (red
arrowhead) between the articular eminence
and the disk;
B: On the open mouth view (in a different

patient), the thinner intermediate zone (red
arrow) of the disk is interposed between the
articular eminence (the letter, a) and the
condylar head (the letter, b) in a “bow-tie”
fashion. Orange arrowhead demonstrates
temporal lamina and black arrowhead
indicate inferior lamina.

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Arthrography
Arthrography of the TMJ may also be performed

where radio-opaque contrast is injected directly into
the synovial spaces.
The synovial cavity of the joint is outlined.
Contrast should not pass from one synovial
compartment to the other.

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uss
 On the sonogram, the disc is visualized as a thin,

homogeneous, hypo- to isoechoic band lying
(superiorly) to the mandibular condyle.
 The bony landmarks of the mandibular condyle and
the articular eminence are visualized as echogenic
lines.

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USS

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Lesions of the TMJ joint
Congenital/developmental
Acquired

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Congenital /developmental
Bifid condyle
Foramen of Huschke
Condylar hypoplasia
Idiopathic condylar resorption
Condylar hyperplasia
Extensive pneumatization

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Acquired
 TMJ arthritis
 Tumour-like conditions of the TMJ
Synovial chrondromatosis
Pigmented villnodular synovitis
 Internal derangement of TMJ
TMJ dysfunction
Peforated disc
Struck disc
Pseudodisc
Thickening of lateral pterygoid muscle attachment (double disk
sign)

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 TMJ dislocation
 Ankylosis
 Primary and secondary neoplasms
 TMJ trauma
 TMJ effusion
 Osteochondritis dissecans
 avascular necrosis

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TMJ ARTHRITIS
Similar to other synovial joints in body, the TMJ is

frequently involved in different inflammatory
arthritides.
 Degenerative arthritis and arthritis secondary to
systemic, metabolic, endocrine, crystalline
deposition disease, infection and trauma are also
common in TMJ.

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 Inflammatory arthritis
Rheumatoid arthritis (RA) : is by far the most
common
Juvenile idiopathic arthritis

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 Osteoarthritis
 ankylosing spondylitis
 calcium pyrophosphate deposition disease (CPPD)
 gout
 psoriatic arthritis
 systemic lupus erythematosus (SLE)

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 Infectious /septic arthritis
Connective tissue
Marfans syndrome
Ehlers-Danlos syndrome
Sticklers syndrome

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Rheumatoid arthritis (RA)
 Is a chronic inflammatory disorder that predominantly

affects the periarticular tissue such as synovial membrane,
joint capsules, tendon, tendon sheaths and ligaments.
 is a slowly progressive disease of insidious onset with
progressive destruction of the articular/periarticular soft
tissue and the adjacent bones resulting in joint deformity.
female predominance.
The peak onset of disease is 40-60 years and
approximately 50%-75% of patients with RA have TMJ
involvement

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The TMJ is involved at a later stage of disease
CF : causes deep, dull aching pain in the preauricular
area, especially during chewing. Limited range of
motion and morning stiffness can be present. The
mandibular condyle gradually resorbs as the disease
progresses.

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Radiogical features of RA
Early signs on MRI
Synovial proliferation is an early process in RA and
can distinguish it from other types of arthritis.
Synovial hyperemia and swelling
Pannus=tumourlike focal proliferation of
inflammatory tissue with destruction of cartilage and
bone
Joint effusion

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 Widened joint space from effusion and synovial
swelling
Bone marrow edema
Joint space narrowing (due to destruction of
cartilage, fibrosis and scar tissues)
condylar : Irregularity, erosion, flattening
destruction
There may be flattening of the articular eminence
and erosion of the glenoid fossa.
Bone ankylosis

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Osteoarthritis
Osteoarthritis is the most common joint pathology

affecting the TMJ.
 Predominantly non-inflammatory degenerative
disease that characteristically affects the articular
cartilage of synovial joints
and is associated with simultaneous remodeling of
the underlying subchondral bone with secondary
involvement of the synovium.

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Clinical features
pain especially during chewing. Fatigue of
masticator muscles, trismus, decreased range of
motion, difficulty opening the mouth and joint
crepitations.

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Radiologic features
Changes are usually more evident on the condylar
side of the joint
articular surface cortical bone irregularity, sclerosis,
joint space narrowing, subchrondral cyst, erosion,
osteophyte formation and loose body.
Osteophyte formation typically occurs at a later stage
in the disease

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osteoarthritis
Sagittal reformation of
the TMJ demonstrates
deformity of the
mandibular condyle
(the letter, c), extensive
sclerosis of the articular
eminence (the letter, a)
and severe loss of joint
space

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crystalline arthropathies
Calcium pyrophosphate dehydrate deposition disease

(CPPD)
 caused by the deposition of calcium pyrophosphate
dehydrate crystals in and around joints, especially
within the articular cartilage and fibrocartilage
The spectrum of TMJ involvement ranges from
asymptomatic disk calcification to a marked
destruction of the joint with erosive changes in the
mandibular condyle and the adjacent skull base.

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Common symptoms include pain and preauricular
swelling with occasional hearing loss. Chewing can
exacerbate the pain. Other less common symptoms
include TMJ clicking, tinnitus, and malocclusion.
The radiographic appearance of CPPD is variable.
Computed tomography demonstrates calcium
deposition in the disk or periarticular tissue.
On MRI, CPP deposits typically appear as
hypointense material both on T1 and T2 weighted
sequences.

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 CT and MRI show erosions near both the condyle
and fossa with adjacent CPP deposits. Involvement
of other joints with chondrocalcinosis is a clue to the
diagnosis.
The differential diagnosis includes synovial
chondromatosis, synovial osteochondroma, and
osteosarcoma .

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Calcium pyrophosphate
dehydrate deposition disease.
Coronal reformation of
the TJM demonstrates
destruction of the
temporomandibular
joint with erosion and
deformity of both the
mandibular condyle and
the glenoid fossa. There
is extensive calcium
pyrophosphate
dehydrate deposition
disease medial to the
joint space (arrow).

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Ankylosis of TMJ
It can occur as a sequel of previous infection,
trauma,surgery and in patients with juvenile
idiopathic arthritis or bifid mandibular condyles.
can be due to fibrous adhesions or a bony fusion
Bilateral or unilateral
MR arthrography is useful for the evaluation of
fibrous adhesions

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Ankylosis.
Coronal reformation of
the axial dataset
demonstrates complete
ankylosis of the right
temporomandibular
joint (TMJ) and near
complete ankylosis of
the left TMJ with subtle
residual joint space at
the center (black
arrow).

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TUMOUR-LIKE CONDITIONS OF THE TMJ
Synovial chondromatosis
a benign condition with chondrometaplasia of the
synovial membrane and formation of cartilaginous
nodules.
These nodules can become detached and form loose
bodies which later calcify.
Synovial chondromatosis typically involves large
joints, such as the knee, hip, and elbow. It is
uncommon for the temporomandibular joint to be
affected by SC

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 Typically involves the superior compartment of
TMJ. Inferior compartment is rare and secondary to
perforation of the articular disc.
pain, swelling, and limitation of motion.
The diagnosis of is difficult since it is a rare disease
and can have similar findings to more common
diseases, such as chondrocalcinosis, osteoarthritis,
and chondrosarcoma.

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The radiologic findings
 calcified loose bodies, soft tissue swelling, widening
of the joint space, irregularities of the joint surface,
and sclerosis of the glenoid fossa and/or mandibular
condyle.
CT typically shows calcified nodules surrounding the
mandibular condyle with degenerative changes of
the condyle

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Synovial chondromatosis.
Sagittal reformation of
the TMJ demonstrates
extensive cloud-like
calcification (arrows)
filling and expanding
the joint space anterior
to the mandibular
condyle (the letter, c).
Calcification is also
present posterior to the
mandibular condyle.

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MRI
ability to detect non-calcified loose bodies
The calcified nodules are T1/T2 hypointense with a
surrounding T2 hyperintense effusion and
proliferative synovium, which enhances after
contrast administration.

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Primary and secondary neoplasms
Benign primary bone neoplasms of TMJ,

Osteochrodroma: Most common
Less common: chondroblastoma, osteoma, osteoid
osteoma, osteoblastoma, ossifying fibroma, simple
bone cysts and aneurysmal bone cyst
Malignant primary bone neoplasms are extremely rare
in TMJ :
chondrosarcoma and osteosarcoma.

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Reported metastasis to TMJ includes breast, renal,
lung, colon, prostate, thyroid, and testes.
 Extension of tumours from adjacent structures into
the TMJ. Tumours from the external ear and parotid
gland can extend into the TMJ.

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Osteochrondroma
Osteochrondroma
 Common benign bone tumour of the TMJ
Affects 20-30 years old
CF: limited mouth opening, facial asymmetry, jaw
deviated to opposite side, maloccusion
Radiological features
Bone outgrow pointing away from the joint with
continuity of bone cortex and medulla with host bone
Enlarged condyle with irregular outline
 Hyaline cartilaginous -cap with arc/rings calcification

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MRI
Cortical and medullary continuity
Hyaline cartilage cap hyperintense on T2WI of low
to intermediate intensity on T1WI
Hypointense mineralized areas of cartilage

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TMJ dysfunction/disc displacement
 an abnormal relationship between the disc and the

adjacent articular surfaces (condyle below with
mandibular fossa and articular eminence above).
is far more common in women (F:M 8:1).
characterised by pain, clicking and functional
restriction.
the disc is displaced and does not maintain a normal
relationship to the articular surfaces throughout the
normal range of motion

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 Normally the disc is biconcave structure, and its
posterior band is located at 12 o'clock position with
the angle between its posterior limit and vertical
orientation of the condyle doesn't exceed 10o.
Types of disc displacement
 Anterior disc displacement -commonest
1. anterior disc displacement in closed mouth that
reduces in open mouth (ADR)
2. and a non reduced anterior displacement (ADNR).

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 Posterior disc displacement occurs when the
posterior band is displaced posteriorly and exceeds 1
o'clock position.
 Anteriormedial and anteriolateral disc
displacemment

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Anterior displacement with
reduction.
A:Sagittal proton density

weighted magnetic
resonance imaging (MRI) in
the closed mouth position
demonstrates anterior
displacement of the disk
(arrow) in front of the
mandibular condyle (the
letter, c);
B: Sagittal proton density

weighted MRI in the open
mouth position
demonstrates reduction of
the disk (arrow) between the
articular eminence (the
letter, a) and the mandibular
condyle (the letter, c).

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Anterior displacement with no
reduction.
A: Sagittal proton density

weighted magnetic resonance
imaging (MRI) in the closed
mouth position demonstrates
anterior displacement of the
disk (arrow) related to the
articular eminence (the letter,
a) and anterior to the
mandibular condyle (the
letter c);

no reduction of the disk
(arrow) between the articular
eminence (the letter, a) and
the mandibular condyle (the
letter, c).

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Stuck disc
 occurs when the disc fails to displace in open or
closed mouth position and becomes fixed to the
temporal bone due to adhesion. Sagittal oblique cine
imaging is particularly useful in evaluation of stuck
disk.

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Stuck disk.
A: Sagittal proton density

weighted magnetic resonance
imaging (MRI) in the closed
apparently normal position of
the disk (arrow) in relation to
the mandibular condyle (the
letter, c). The letter “a”
demonstrates the articular
eminence;

no anterior movement of the
disk (arrow) with the
mandibular condyle (the letter,
c), i.e., “stuck” to the glenoid
fosssa. The articular eminence
is denoted with letter “a”.

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Perforated disc
Disc perforation is reported in 5% to 15% of
deranged joints disc displacements.
It is more common in patients with ADNR than in
ADR
is usually seen in patients with advanced arthrosis.
The prevalence of a perforated disc is higher in
women than in men and prevalent in individuals
over 80 years of age

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MRI findings of disc perforation include
disc deformity (100%)-rounded, flattened , buckled
 disc displacement (81%),
condylar bony changes (68%),
joint effusion (23%)
 non-visualization of temporal posterior attachment (TPA)
of the disc (65%-68%)
Conventional and MR arthrogram can be helpful in the
diagnosis of a disc perforation by demonstrating
opacification of both the joint compartments from a single
lower compartment injection.

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Disc perforation and features of
degenerative joint disease
Oblique sagittal fat

suppressed proton
density-weighted image
in the open mouth
position of the right
TMJ. The condylar head
is slightly deformed
with small anterior
osteophytes
(arrowhead). A small
central perforation of
the intermediate zone of
the articular disc is seen
(arrow).

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Sagittal T2-weighted
magnetic resonance
image shows fluid
effusion in superior
joint cavity (arrow) and
anterior displacement
and folded deformity of
articular disc
(arrowhead)

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Double disk sign (thickening of
the lateral pterygoid muscle).
Sagittal closed mouth

proton density image
demonstrates anterior
displacement of the disk
(arrow head). The
thickened lateral
pterygoid muscle near the
mandibular condylar (the
letter, a) attachment
appear as linear
hypointense structure
(white arrow) inferior to
the disk in the same
orientation giving the
appearance of “double
disk”. The articular
eminence is denoted with
letter “b”

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TMJ dislocation
 The condyle of the mandible being abnormally

displaced, with a loss of the normal articulation with
the glenoid fossa.
Very common
 can occur at any age but are most common between
20-40 years of age

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Types of dislocation
 anterior dislocation (common)
 cranial dislocation (uncommon)
 posterior dislocation (rare)

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TMJ fracture
condylar process fractures

temporomandibular joint dislocation
fracture of the mandibular fossa

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TMJ effusion
are unusual in asymptomatic patients, and thus

should trigger a careful search for underlying
pathology.
It usually precedes osteoarthritis of the TMJ.
Effusions are seen in:
 TMJ dysfunction
 septic arthritis
 rheumatoid arthritis (RA)

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MRI
On PD/ T2 weighted sequences, both synovial
proliferation and effusions can be high on signal. If
necessary they two can be distinguished by
administering gadolinium.

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Congenital and developmental lesions of TMJ
Bifid condyle
A bi-lobed or duplicated mandibular head is an
infrequently encountered incidental imaging finding.
While the etiology is unknown, theories include
reminiscence of congenital fibrous septum or early
childhood trauma.

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Bifid condyle.
Coronal reformatted
computed tomography
image through the
temporomandibular
joint (TMJ)
demonstrates bifid left
mandibular condyle. It
can be noted that one of
the condyles (arrow) is
smaller than the other.
Advanced degenerative
changes are noted in
bilateral TMJ.

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Idiopathic condylar resorption
also known as condylysis or “cheerleader syndrome”)
is primarily a disease of TMJ affecting teenage girls.
There is rapidly progressive condylar erosion
resulting in widening of the joint space with the chin
becoming less prominent from retrognathia
 Many causes have been hypothesized including
estrogen influence on osteogenesis, avascular
necrosis, and TMJ internal derangement.

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Idiopathic condylar resorption.
Coronal reformatted
computed tomography
image through the
temporomandibular
joint of a young patient
demonstrates bilateral
severe condylar
resorption (arrows)
without any evidence of
degenerative changes
within the joint.

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Condylar hyperplasia
A rare disorder characterized by increased volume of the
mandibular condyle, and is frequently associated with
increased volume of the ramus and mandibular body
 usually a unilateral process.
This disease presents in the second and third decades of
life during brisk periods of osteogenesis suggesting a
hormonal influence upon the growth disturbance.
Trauma has also been implicated in asymmetric condylar
hyperplasia due to hypervascularity during healing
producing inducing excessive osteogenesis.

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Condylar hyperplasia.
Panoramic reformation
of the computed
tomography ncluding
both the
temporomandibular
joints of a young patient
demonstrates
hyperplasia of the left
condyle (arrowhead) in
comparison to the right
side. Associated
hypertrophy of the
ramus and the neck
(arrow) of the left hemi-
mandible is also noted

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Extensive pneumatization
Extensive pneumatization of the mastoid bone can
involve the glenoid fossa and articular eminence.
Knowledge of extensive pneumatization is necessary
prior to surgery to prevent perforations.
 Pneumatization can also provide a path of minimal
resistance and facilitate the spread of pathological
tumors, inflammation, infection or fracture into the
joint

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Extensive pneumatization.
Coronal reformatted
computed tomography
image through the right
temporomandibular
joint demonstrates
almost complete
pneumatization of the
glenoid fossa except the
central part

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CONCLUSION
Imaging of TMJ should be performed on a case by

case basis depending upon clinical signs and
symptoms.
MRI is the diagnostic study of choice for evaluation
of disk position and internal derangement of the
joint.
CT scan for evaluation of TMJ is indicated if bony
involvement is suspected

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CONCLUSION
Understanding of the TMJ anatomy, biomechanics,

and the imaging manifestations of diseases is
important to accurately recognize and manage these
various pathologies.

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REFERENCES CONT
McIvor J. Maxillofacial Radiology, In: Grainger &

Allisons Diagnostic Radiology. A Textbook of
Medical Imaging. 3rd Ed. Sheffield & London.
1997;Section 10, Chapter 103
Philip W. Ballinger. Facial bones, In: Merrill`s
Atlas of Radiographic Positions and Radiologic
Procedures Volume II. 6th Ed. Toronto. 1986;
P358-369
Whitley A S, Sloane C, Moore A D, Hoadley G,
Alsop C W. The Skull, In: Clark`s Positioning in
Radiography. 12th Ed.London.2005; P274
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Asim K Bag, Santhosh Gaddikeri, Aparna
Singhal, Simms Hardin, Benson D Tran, Josue A
Medina, and Joel K Curé. Imaging of the
temporomandibular joint: An update. World J
Radiol 2014; 6(8): 567–582.

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
Thank you

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TMJ Imaging Anatomy and Lesions

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Imaging Anatomy and Lesions of the

Temporomandibular Joint (TMJ)

DR KOLADE-YUNUSA HO MBBS, FMCR

LECTURER AND CONSULTANT RADIOLOGIST

UNIVERSITY OF ABUJA/ UNIVERSITY OF ABUJA TEACHING HOSPITAL (UATH),

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The temporomandibular joint (TMJ) is a synovial

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UPPER ; Articular eminence & mandibular fossa

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The TMJ is supplied from the mandibular nerve by

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Elevation (close mouth) Temporal, Masseter and Medial

Depression (open mouth) Lateral pterygoid, Infrahyoid and

Protrussion (Protrude chin) Lateral pterygoid, Masseter and Medial

Retrussion (Retrude chin) Temporal and Masseter

Lateral movts (grinding and Temporal of same side, Pterygoid of

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Jaw movement involves a high level of interaction

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In the closed mouth position, the disk is interposed

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. When the mouth is open, the condyle moves

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The imaging anatomy of the TMJ is studied using

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The articulating bones appear opaque

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High resolution CT is used in the assessment of

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MRI is excellent for the demonstration of the

The anterior, posterior bands and thin zone of the

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Normal anatomy. Sagittal proton density

A: On the closed mouth view, the disk is

B: On the open mouth view (in a different

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Arthrography of the TMJ may also be performed

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 On the sonogram, the disc is visualized as a thin,

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Similar to other synovial joints in body, the TMJ is

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 Is a chronic inflammatory disorder that predominantly

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