Diagnosis of Temporomandibular Joint Disorders: Indication of Imaging

Home , Sialadenitis, Sialolithiasis

Braz J Otorhinolaryngol. 2016;82(3):341---352

Brazilian Journal of OTORHINOLARYNGOLOGY

www.bjorl.org

REVIEW ARTICLE

Diagnosis of temporomandibular joint disorders:

ଝ

indication of imaging exams

a,b,c,d,∗ e,f,g h

Luciano Ambrosio Ferreira , Eduardo Grossmann , Eduardo Januzzi ,

i,j d

Marcos Vinicius Queiroz de Paula , Antonio Carlos Pires Carvalho

Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil

Faculdade Sete Lagoas (FACSETE), Sete Lagoas, MG, Brazil

Hospital Maternidade Therezinha de Jesus-HMTJ/JF, Suprema-Faculdade de Ciências Médicas e da Saúde,

Juiz de Fora, MG, Brazil

Department of Radiology, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS, Brazil

Universidade Estadual de Maringá, Maringá, PR, Brazil

Department of Morphology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

Postgraduate Course in Temporomandibular Joint Dysfunction and Orofacial Pain, Faculdade Sete Lagoas (FACSETE), Sete

Lagoas, MG, Brazil

Discipline of Propaedeutic and Dental Radiology, Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil

Postgraduate Course in Dental Radiology and Imagenology, Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, MG, Brazil

Received 23 October 2014; accepted 16 June 2015

Available online 8 January 2016

KEYWORDS Abstract

Temporomandibular Introduction: Knowledge of the different imaging tests and their appropriate indications is

joint disorders; crucial to establish the diagnosis of temporomandibular disorders, especially in patients with

Diagnostic imaging; overlapping signs and symptoms.

Temporomandibular Objective: To present and assess the main diagnostic imaging tests for temporomandibular

joint; disorders and rationally discuss their indication criteria, advantages, and disadvantages.

Magnetic resonance Methods: Literature review in the Web of Knowledge, PubMed and SciELO databases, as well

imaging; as manual search for relevant publications in reference lists of the selected articles.

X-ray computed Results: Computed tomography and magnetic resonance imaging were considered the gold

tomography; standard assessments for the temporomandibular joint to evaluate hard and soft tissues, respec-

Radiography tively. Each diagnostic method exhibited distinct sensitivity and speciﬁcity for the different

subtypes of joint dysfunction.

ଝ

Please cite this article as: Ferreira LA, Grossmann E, Januzzi E, de Paula MVQ, Carvalho ACP. Diagnosis of temporomandibular joint

disorders: indication of imaging exams. Braz J Otorhinolaryngol. 2016;82:341---52. ∗

Corresponding author.

E-mail: [email protected] (L.A. Ferreira).

http://dx.doi.org/10.1016/j.bjorl.2015.06.010

342 Ferreira LA et al.

Conclusion: Selecting an evaluation examination based on its accuracy, safety, and clinical

relevance is a rational decision that can help lead to an accurate diagnosis and an optimum

treatment plan.

PALAVRAS-CHAVE Diagnóstico das disfunções da articulação temporomandibular: indicação dos exames

Transtornos da por imagem articulac¸ão

temporomandibular; Resumo

Introduc¸ão: O conhecimento dos distintos exames de imagem e sua correta indicac¸ão é funda-

Diagnóstico por

imagem; mental para elaborac¸ão do diagnóstico das disfunc¸ões temporomandibulares, principalmente

Articulac¸ão em pacientes com grande sobreposic¸ão de sinais e sintomas.

temporomandibular; Objetivo: Apresentar e avaliar os principais exames de diagnóstico por imagem das disfunc¸ões

temporomandibulares, além de discutir racionalmente os seus critérios de indicac¸ão, vantagens Imagem por

ressonância e desvantagens.

magnética; Método: Revisão da literatura nas bases de dados Web of Knowledge, PubMed e SciELO, além

Tomograﬁa de busca manual por publicac¸ões relevantes nas listas de referências dos artigos selecionados.

Resultado: Os exames de tomograﬁa computadorizada e ressonância magnética foram con-

computadorizada por

siderados ‘‘padrão-ouro’’ para a avaliac¸ão dos tecidos duros e moles, respectivamente, da

raios X;

Radiograﬁa articulac¸ão temporomandibular. Cada método de diagnóstico pesquisado apresentou sensibili-

dade e especificidade distintas para os diferentes subtipos de disfunção da articulação.

Conclusão: Considera-se como racional a indicac¸ão fundamentada na acurácia, seguranc¸a e

relevância clínica do exame a ser solicitado, o que implica na adequada determinac¸ão do

diagnóstico e do plano de tratamento.

6,8,12

The etiology of TMJD is not fully understood and is

Introduction related to the presence of risk factors such as trauma, para-

functional habits, postural condition, occlusal microtrauma,

The temporomandibular joint (TMJ) is a composite systemic predisposition, sleep disorders, and deleterious

6---8,11,13

ginglymus-arthrodial joint, whose components are the psychosocial alterations.

condyle, glenoid cavity and articular tubercle, articu- The diagnosis of TMJD is achieved by evaluating the

6,8,14

lar disc, retrodiscal tissue, synovial membrane, and joint medical history and by physical examination. However,

capsule. It is the most frequently used joint of the human diagnostic TMJ imaging methods are used to assess the

body and has simultaneous bilateral capacity to move the integrity of its components and their functional association,

2,3

mandible. to conﬁrm the extent or progression of an existing disease,

Its components often undergo remodeling and adaptation and to assess and document the effects of an already estab-

9,15

processes. In the presence of temporomandibular disorders lished treatment. They are essential for assessment in

(TMD), structural alterations and functional disorders are cases of trauma, occlusal alterations and sudden limitation

2,3

commonly observed. of mouth opening, presence of joint noises, systemic joint

In most cases, symptoms are diffuse and imprecisely diseases, infection and failure of conservative treatments.

manifested as masticatory myalgia, arthralgia, headache,

4 --- 8

otalgia, and neck pain, among others. Pain in more than Objectives

one area is common and often leads patients to seek evalu-

ation from various medical and dental specialists, including

This study discusses the main imaging techniques for the

otorhinolaryngologists.6,8

assessment of TMJ and adjacent structures and their indi-

For instructional purposes, the American Academy of

cations for the diagnosis of joint alterations, rationally

Orofacial Pain (AAOP) has classiﬁed TMD into two major

9 evaluating their advantages and disadvantages.

groups: muscle and joint pain. It is estimated that

temporomandibular joint disorders (TMJD) affect approx-

imately 30% of the population in asymptomatic form, as Method

internal joint derangement, comprising disc dislocation

and structural changes resulting from osteoarthritis and Using the ISI Web of Knowledge, PubMed, and SciELO

2,10,11

osteoarthrosis. The diagnostic subtypes TMJD can be databases, a search was carried out for literature arti-

seen in Table 1. cles published and made available in the years 2004---2014,

Diagnosis of TMD: indication of imaging exams 343

Table 1 Diagnostic classiﬁcation proposed by the AAOP.

Congenital or developmental disorders Aplasia Hypoplasia Hyperplasia Dysplasia

Acquired disorders Neoplasias

Disorders of disc derangement Disc displacement with reduction

Disc displacement without reduction

TMJ displacement (dislocation)

Inﬂammatory disorders Synovitis and capsulitis

Polyarthritis

Non-Inﬂammatory disorders Primary osteoarthritis

Secondary osteoarthritis

Ankylosis

Fracture (condylar process)

AAOP, American Academy of Orofacial Pain.

in English or Portuguese, that contained the keywords Panoramic radiography

‘‘temporomandibular joint disorder’’ and ‘‘diagnostic imag-

ing test.’’ As it provides a maxillary overview, it is useful in the differ-

There were 51 articles found in the ISI Web of Knowledge ential diagnosis of odontogenic alterations whose symptoms

13,18

database, 117 in PubMed, and 25 in SciELO. Basic research overlap with TMJD. It can reveal advanced bone alter-

experimental articles, letters to the editor, and isolated case ations in the condyle, such as asymmetries, erosions,

reports were excluded. A total of 23 articles, characterized osteophytes, fractures, changes in size and shape, degen-

as clinical trials, comparative studies, reviews, and case erative and inﬂammatory processes, growth alterations,

1,13,15,16

group studies comprised the ﬁrst stage of the research. maxillary tumors, metastases, and ankylosis. How-

Then, based on the same inclusion criteria, a literature ever, it does not provide functional information on condylar

search was performed in the ﬁve most frequently cited radi- excursion. Also, only gross alterations in the articular

ology journals for the years 2004---2014. In this search, six tubercle morphology can be seen because of the super-

new references were found in addition to the previously imposition of images of the skull base and the zygomatic

3,14,16,18

selected articles. Four other relevant publications cited in arch. This technique is useful as a screening tool, as it

the selected articles’ lists of references were added, includ- allows the initial diagnosis and assessment of TMJ alterations

ing historical ones dated prior to 2004. that are not so subtle. It is also indicated when the patient

According to the requirements deﬁned in CNS Resolu- has reduced mouth opening and the differential diagnosis of

1,3

tion 196/96, this study was submitted to the Research fracture is considered.

Ethics Committee, approved under No. 133/2009, designed

to demonstrate the major changes in the TMJ as disclosed

by imaging tests.

Planigraphy (or panoramic radiography with

programs for TMJ)

Temporomandibular joint imaging assessment

This method provides considerable accuracy and produces

Radiographic examinations images without much overlap. It visualizes the articular

boney detail and reveals any anatomical abnormalities in

TMJ radiographs provide information on the morphological structures adjacent to the TMJ, such as the styloid process,

3,15

characteristics of osseus components of the joint and cer- mastoid process, and zygomatic arch. It can be obtained

tain functional associations between the condyle, articular in the sagittal and coronal planes, documenting the rela-

tubercle and fossa, but are inefﬁcient for evaluating the soft tionship of the condyle with the articular fossa in maximum

1,14,16

tissues. habitual intercuspation (MHI) and the excursion extension

Several anatomical and technical factors can prevent a during maximal mouth opening (MMO). It provides a direct

16,17

clear and unobstructed radiographic image of the TMJ. comparison of both sides regarding the hypo-, normo-, or

When choosing TMJ radiography, one needs to consider hyperexcursion of the condyle, which is useful in conﬁrming

1,3

the identiﬁcation of boney structural details, the speciﬁc a clinical suspicion of hypermobility.

suspected clinical disorder, the amount of symptomatic In spite of the relative identiﬁcation of the TMJ boney

information clinically available for the diagnosis, the cost structures, it does exhibit some magniﬁcation that is inher-

3,14

of these examinations, and their radiation dose. The ent to the technique. However, it is useful for functional

radiographic techniques most often used in the routine assessment of mouth opening, evaluation of morphologi-

management of TMJD are panoramic radiography, planigra- cal alteration and the joint spaces, analysis of dimension,

1,3,13,15 3

phy, and transcranial radiography (Fig. 1). fractures, and ankylosis.

344 Ferreira LA et al.

Figure 1 Radiographic assessments of different TMDs. (a---c) Close-up in panoramic image showing mandibular condyle hypoplasia

(a), horizontal impaction of the third molar (a, b) fracture line in the region of gonial angle (b) and elongated styloid process.

The transcranial images (d---f) show the presence of osteophytes (d), preservation of joint spaces in maximum habitual intercus-

pation (MHI) (e) and the identiﬁcation of condylar hyperexcursion (f). The planography techniques (g---j) demonstrate: mandibular

neck fracture and ankylosis (g) elongated styloid process (h), advanced remodeling process, superior-anterior ﬂattening, cortical

irregularities, and osteophyte formation (i) in addition to mandibular head hyperexcursion, deﬁning TMJ hypermobility (j).

Transcranial radiography also requires the use of a speciﬁc cephalostat for standard-

1,13,14,17

ization, usually requiring complex positioning.

Similarly to the planigraphy, this evaluation provides good

anatomical assessment of the condyle, fossa, and articular

1,14,17

tubercle. In this technique, an X-ray beam is obliquely Arthrography

directed through the skull to the contralateral TMJ, produc-

ing a sagittal view. Thus, the central and medial portions Arthrography is a variant of the radiographic technique

of the condyle are projected inferiorly and only the lat- for TMJ, which aims to assess the TMJ soft tissues. In

eral joint contour is displayed. It is useful to identify bone the 1970s and 1980s, arthrography was the method of

14,15,19

alterations and displaced fractures of the head and neck of choice for the identiﬁcation of disc displacement. Disc

the mandibular condyle, as well as to assess excursion and morphology, positioning, and function were indirectly iden-

3,14,17

to determine radiographic joint spaces. tiﬁed by contrast injection into the superior and/or inferior

This type of projection is limited by the fact that it joint spaces. After the injection, dynamic images were

produces an image with a large overlap of the skull bones; it obtained, recording mandibular movements.

Diagnosis of TMD: indication of imaging exams 345

Even though it is useful for disc position identiﬁca- Fig. 2 shows morphological alterations in joint bone com-

tion, arthrography is not currently recommended as it is ponents diagnosed by the CBCT technique.

an invasive procedure and carries a risk of iatrogenic disc

perforation and facial nerve damage. There are also the

Magnetic resonance imaging (MRI)

risks of radiation to radiosensitive structures (crystalline and

thyroid), pain and limitation of movement after the injec-

MRI has been the method of choice to study disease pro-

tions, infections, allergies to the injected dye, and it is an 2,20,23

1,14,15,20 cesses involving the TMJ soft tissues, such as the

examination that is considered difﬁcult to perform.

articular disc, ligaments, retrodiscal tissues, intracapsular

synovial content, adjacent masticatory muscles, as well as

Other combined radiographic techniques 1,3,15,22

cortical and medullary integrity of bone components.

The technique allows three-dimensional analysis in the

Due to the two-dimensional radiographic visualization

axial, coronal, and sagittal planes. It is considered the gold

of the TMJ, the combined use of different techniques is

standard for assessing disc position and is highly sensitive

necessary to provide an accurate diagnosis and location of 3,20,23

for intraarticular degenerative alterations.

the alterations. The evaluation of the structures in different

The clinical conditions that suggest its use include per-

planes illuminates fracture extension, degenerative joint

3 sistent symptoms of joint or pre-auricular pain, presence of

disease, postoperative status, ankylosis, and neoplasms.

clicking and crepitation noises, functional alterations such

Additionally, the anatomic relations of areas adjacent to the

as lateral projections of the condyle during mouth open-

lesion can be studied with greater diagnostic accuracy, pro-

15 ing, frequent subluxations and dislocations, limited mouth

viding more efﬁcient surgical and therapeutic planning.

opening movement with terminal stiffness, suspected neo-

The main combined views are submental (or submento-

plastic processes, and presence of osteoarthritic symptoms

vertex), transpharyngeal, transmaxillary, reverse Towne, 1,2,13,15

3,13,15 or asymptomatic osteoarthrosis.

posterior---anterior, and lateral teleradiography.

This diagnostic test protocols usually include the recor-

Despite their lower cost, technical simplicity, and lower

ding in the MHI and MMO position, using weighted T1, T2,

levels of radiation, the use of combined radiographic images 15

and proton density (PD), in the sagittal and coronal planes.

has become less common due to increasing use and avail-

With T1-weighted images, it is possible to obtain excellent

ability of accurate images such as cone-beam computed

anatomic detail; proton density results in satisfactory spatial

tomography, which assess hard tissues in the three anatom-

13,15 resolution of joint disc injuries, and is an excellent choice for

ical planes and are widely used in dental diagnosis. 20

the evaluation of medial and lateral disc displacements.

T2-weighted images record the presence of joint effusion

Computed tomography (CT) 2,3,20

and medullary bone edema.

The main advantages include detecting soft tissue alter-

CT comprises a set of images obtained through a sophisti-

ations, necrosis, edema, presence or absence of invasion,

cated and highly accurate technique, compared to plane 2,3,15,16,20

2 and lack of exposure to ionizing radiation.

radiographs. Recently, cone-beam computed tomography

MRI is also indicated for the assessment of the

(CBCT) technology has been used for dental diagnosis due

3,21 integrity and anatomical relation of neural structures,

to its speciﬁc use for the maxillofacial region. Its main

which, when compressed by tumor or vascular pro-

advantage is the observation of boney joint structures in

1,21 cesses, can produce orofacial pain by demyelination and

the sagittal, coronal, and axial planes, in addition to deafferentation.2,3,13,14,16

the possible image manipulation at different depths and

14,21 Its disadvantages are related to the high cost and the

three-dimensional reconstruction through speciﬁc soft-

need for sophisticated facilities. It is contraindicated in

ware. The examination time varies between 10 and 70 s, and

claustrophobic patients, those with pacemakers and metal-

the radiation dose is much lower compared to the helical

3,21 lic heart valves, ferromagnetic foreign bodies, and pregnant

technique. women.14,15,23

The main indications of CBCT include structural assess-

Fig. 3 illustrates morphological joint disc and bone struc-

ment of bone components of the TMJ, which precisely

tures alterations diagnosed by MRI.

determines the location and extent of boney alterations:

fractures, neoplasms, and ankylosis; erosive degenera-

Other imaging techniques

tive, pseudocystic, and osteophytic alterations; presence of

asymptomatic bone remodeling; evaluation of post-surgical

conditions; hyperplasia of condylar, coronoid, and styloid Ultrasonography (US)

processes; persistent foramen of Huschke; as well as intraar-

ticular calciﬁcation derived from synovial chondromatosis or The use of US examination, especially by high-resolution

2,14,15

metabolic arthritis. imaging equipment, can be a useful option in the assess-

4,23

Hard tissues, teeth, and bones are well demonstrated ment of disc position in internal TMJ disorders. Although

and measured in their real morphological condition, with it has considerable diagnostic sensitivity, it has insufﬁcient

1,18,22

minimal noise and artifacts. However, few details are speciﬁcity to identify osteoarthrosis. The ﬁndings related to

provided on soft tissue and it is not possible to evaluate the morphological alterations show that the method still does

3,22

joint disc. not have accuracy for the cortical and articular disc morpho-

Signiﬁcant disadvantages are the cost of the examination logical diagnosis. However, the method is able to identify

and exposure to signiﬁcant levels of radiation compared to effusion in patients with inﬂammatory condition associated

1,14,15,18 23,24

conventional radiographic techniques. with pain, veriﬁed by MRI.

346 Ferreira LA et al.

a b c d e f g h

Figure 2 Cone-beam computed tomography (CBCT) assessment of different TMJs in the coronal (a, e) and parasagittal (b---d)

views. (a) Coronal view showing extensive erosion. Note the presence of bone sclerosis, cortical irregularities, and osteophytic

formation in (b), (c), and (e). The presence of subchondral cysts can be observed in (c) and (e). Advanced ﬂattening of bone

components and decreased joint space are recorded in (d). Advanced degenerative osteoarthritis alteration is observed in e. Three-

dimensional reconstructions (f---h) show osteophytes (f, g), advanced erosion (g) and hyperexcursion of the mandibular condyle (h).

(i) The coronal view of the right and left TMJ shows alteration of the mandibular condyle and hyperdense images in the joint spaces

compatible with synovial chondromatosis.

Even with limitations, it can become a useful option arthrocentesis, and viscosupplementation (Fig. 4a and b).

for the initial study of the internal dysfunctions of the It shows, dynamically and in realtime, the location of joint

15,23

TMJ, particularly in patients with contraindications to components, providing adequate lubrication and washing,

MRI. Moreover, it is less expensive, allows real-time visu- which are veriﬁed by the increase in joint space after

alization without the use of ionizing radiation, and is quick treatment. 4,23,24

and comfortable.

US assessment is commonly used in the differential diag- Nuclear medicine evaluation

nosis of glandular and adjacent structures alterations, such

as the TMJ and the masseter muscle. The symptoms present Nuclear medicine facilitates establishing a diagno-

in cases of sialadenitis and sialolithiasis can be mistaken sis by detecting minute concentrations of radioactive

for Eagle syndrome, TMD, myofascial pain, nerve pain, and pharmacological substances that determine osteometabolic

other orofacial pain conditions. alterations expressed in imaging exams.

Another indication of the US assessment is the cor- Bone scintigraphy is indicated to deﬁne neoplastic activ-

14,26,27

rect location of joint spaces for inﬁltrative therapies, ity, metabolic disorders, and bone growth, as well as

Diagnosis of TMD: indication of imaging exams 347

Figure 3 Different MRI assessments disclosing previous joint disc displacement, with no reduction in the parasagittal views. One

can observe compressive deformation of the joint disc in (a), also during dynamic comparison of the mandibular condylar movement

in (b) and (c). Osteophytic formations (d---f), subchondral cyst (d), and severe change in form (f) deﬁne the diagnosis of osteoarthritis

degenerative alterations in bone components. The presence of hyperintense T2-weighted images deﬁnes the diagnosis of effusion

in (b---f).

18 26

to evaluate synovitis and osteoarthritis. It is an exami- with 99m Tc-MDP) is largely employed. This technol-

nation with considerable sensitivity, low invasiveness, and ogy allows for multiplane image acquisition and 3-D

high organ speciﬁcity, with low levels of radiation. It has display. The radiotracer 99m Tc is able to reﬂect the

some advantages over radiographies, conventional CT, and local osteometabolic rate, while the anatomic mapping is

MRI because it provides an estimate of metabolic and inﬂam- obtained by tomographic technique. As in the PET, anatom-

26,27 28

matory activity. It can facilitate an early diagnosis and is ical and functional data are fused into a single image

less costly than CT and MRI. However, it does not differen- (Fig. 4c and d). Its main advantage is its sensitivity and

26,28

tiate among bone scar disorders, infections, osteoarthritic speciﬁcity.

manifestations, or tumors. Nuclear medicine examinations differ by the radiotrac-

Positron-emission tomography (PET) is usually indicated ers/radioisotopes used, image capture technique, radiation

for the assessment and staging of metastatic tumors. It dose, sensitivity, and presentation of results.

is able to provide accurate functional, morphological, and

metabolic information. Three-dimensional images facili-

tate anatomical visualization and can signiﬁcantly reduce Imaging test indication criteria in the diagnosis

the time required for diagnosis, in addition to prop- of temporomandibular joint disorders

erly direct treatments by ensuring that the therapies are

appropriate.15

One of the failures in diagnosis and treatment planning is an

Currently, single photon emission computed tomography

incorrect or unnecessary selection of unsuitable diagnostic

with technetium-99m methylene diphosphate (SPECT/CT

tests. This occurs because of a lack of knowledge on the

348 Ferreira LA et al.

Joint disc

Condyle

a b c d

Figure 4 Other imaging techniques. (a) Ultrasound examination of the TMJ used during the arthrocentesis assessment. Note

the arthrocentesis needle as a hyperechoic point (white arrow). (b) Ultrasound examination of the TMJ showing the joint disc and

condyle. (c) Tomographic axial view showing mass of soft tissue growth in the left TMJ region extending to the ipsilateral pterygoid

region. Infra-temporal space with absence of condylar process, the presence of hyperdense areas, swelling, and asymmetry. (d)

PET/CT assessment in axial view showing high metabolic activity in the left TMJ region. Images reproduced with permission of

25,28

the authors’ copyrights by Elsevier.

part of the professionals regarding the indications of the of joint noises are instruments of great diagnostic validity

29 6

applicable tests. when performed by trained and experienced professionals.

The correct indication of an imaging study should be However, the overlapping of muscle and joint symptoms can

based on the patient’s need for legal documentation, impair diagnostic accuracy, as both conditions show func-

his/her individual complaints, and the identiﬁed clinical tional impairment. In this case and in cases of non-speciﬁc

signs and symptoms obtained during history-taking and phys- symptoms (from, for example, inﬂammation, neoplasia, and

15,29,30

ical examination. The basic principle that should guide trauma), complementary imaging tests are essential for

the professional is that supplementary tests are only indi- diagnostic clariﬁcation and delineation of the appropriate

2,6

cated when the clinical assessment is not sufﬁcient to arrive therapy.

at a diagnosis and devise a treatment plan. Imaging tests, from the simplest to the most complex,

For TMJD, the physical examinations of palpation, mea- have varying degrees of sensitivity and speciﬁcity, properties

surement of movement, functional testing and evaluation that give them their diagnostic power.

Diagnosis of TMD: indication of imaging exams 349 1,3,13,14,16---18,20,29 Arthrography a a a --- c c a b ------d --- 1,3,13,14,16,18,29

Planigraphy ca c c a c c c ------c system.

stomatognathic

1,3,13,14,16---18,29 the

Transcranial c c c cc c ------ccb ------adjacent

structures

1,3,13,14,16,18,29

b bc cb a b b aa a bb b a bb b a cc c b cb c c a c ------alterations

and

TMD

and

line joint

ligaments,

masticatory MMO impaired

M M O ------

cortical

alteration periapical in clinical coronoid the

inﬂammation cortical

M M O ------

reduction increase

fracture

in in structure area, remodeling remodeling mandibular calciﬁcation growth ------

alteration

inﬂammation, x sign Panoramic diagnose form ratio edema of

processes

tumors, to locking, formation/destruction formation,

tissue disc

recapture

mastoid alteration, excursion perforation retrodiscal muscles capsular Metastasis tubercle disease diagnosis alteration, Assessed Absence Dimensional Dimensional Structural Soft Effusion, Bone Sialolithiasis, TMJ Condylar Alterations Uni-/bilateral, Bone tests

imaging

glands

process) Asymmetry, or

tissues Alterations form bone

excursion

process Elongation

salivary developmental conditions Cists,

soft disc disorders

osteoarthritis Indication

and (condylar

reduction No

styloid major condylar joint adjacent

2 reduction Recapture displacement Open

the the the the the adjacent derangement

Of Of Of Of (hypo/hyper) Aplasia Polyarthritis Polyarticular, structures With secondary Hypoplasia Hyperplasia Dysplasia Neoplasias Without TMJ Non-inﬂammatory disorders/primary Ankylosis Fracture Odontogenic Of Of Synovitis/capsulitis Disc Congenital Acquired Inﬂammatory Table Disorders

350 Ferreira LA et al. 13,14,26,28 joint.

medicine

Nuclear a a a a d d ------a a a ------c ------b a temporomandibular

TMJ,

4,5,15,23---25,30,33

opening; US a a a a c c a c ------a --- d ------c

mouth

maximal

MMO,

1---3,12,14,15,19,20,24,29,31---33

ultrasound; MRI c c c d d dc d c d c c a b d c c b d

US,

conﬁrm.

imaging.

planning.

required

are

resonance

treatment

1,15,16,18,21---23,29,32 tests

CT dcd d a d d a cc ad ------d d dc d dc d d b d d ------and

Other tests.

magnetic

MRI, location,

accurate

and

examination.

line staging,

ligaments,

the

masticatory MMO impaired

MMO

tomography; cortical

alteration periapical of in clinical coronoid the

inﬂammation cortical

MMO other

reduction increase

fracture

in in structure area, remodeling remodeling mandibular calciﬁcation growth

alteration

inﬂammation, x sign form ratio edema of

processes

tumors, locking, formation/destruction formation,

purpose tissue disc

measurement, computed recapture requires

perforation mastoid excursion tubercle retrodiscal muscles diagnosis disease alteration, Assessed Absence Dimensional Dimensional Structural Soft Metastasis Recapture No Open Effusion, Polyarticular, Bone Asymmetry, Cists, Elongation Sialolithiasis, TMJ Alterations alteration, capsular Alterations Uni-/bilateral, Bone Condylar CT, but

diagnostic

evaluation,

the

disorders;

condition, established.

)

not

glands

process) or

diagnostic

tissues form bone

excursion

diagnosed ﬁnding, process

salivary developmental conditions

soft diagnosis disc

disorders Continued

osteoarthritis (

and (condylar

reduction

standard

styloid major condylar joint adjacent

2 reduction displacement

temporomandibular

the the the the the adjacent derangement

Occasional Frequently Accurate Gold Without TMJ Fracture Odontogenic Of Of Of Of structures With secondary Hypoplasia Hyperplasia Dysplasia Neoplasias Polyarthritis Non-inﬂammatory disorders/primary Ankylosis Of Of (hypo/hyper) Synovitis/capsulitis Aplasia c a b d Inﬂammatory TMD, Congenital Acquired Disc Table Disorders

Diagnosis of TMD: indication of imaging exams 351

In general, MRI and CT are methods with higher accu- CT should only cautiously be chosen because of its higher

15,29

racy when compared to conventional radiology, due to the radiation absorption, although CBCT has shorter radia-

higher anatomical resolution they provide. CT is considered tion exposure time when compared to helical CT.

the gold standard for the assessment of boney structures Even if they pose some risk, tests that use higher doses

and the method of choice for facial trauma, whereas MRI is of radiation are needed for disease staging and are essential

1,2,16,23,29

similarly regarded for the study of soft tissues. The for deﬁning the treatment plan. Nuclear medicine exam-

two methods often complement each other in the study of inations, for instance, are indicated to assess metabolic

26---28

TMJ alterations, constituting important tools for muscle and alterations of growth and assessment of metastases.

joint differential diagnosis. Although able to diagnose all However, they still require conﬁrmation of the type of

bone alterations of the TMJ, MRI is considered limited when growth through speciﬁc tests, such as histopathological or

19,22 15

compared to the high accuracy of CT for hard tissue. immunohistochemical analysis.

However, low-technical-complexity tests may possess Table 2 lists and classiﬁes information that can be

high diagnostic accuracy, as in the case of radiographic obtained by several examination techniques through TMJ

records of condylar hyperexcursion in patients with the images, based on their indications, risks, and diagnostic

clinical presentation of terminal joint clicking. These power.

characteristics suggest a diagnosis of joint hypermobility,

veriﬁed by a simple transcranial or planigraphy image. In

this example, the image has great sensitivity, while clinical

data confer speciﬁcity, ruling out other diagnostic possibili- Conclusion

ties.

Similarly, morphological alterations of the styloid, coro- Individually, the several imaging tests have speciﬁc indica-

noid, and condylar processes can be evaluated with tions for the diagnosis of TMJD.

high diagnostic accuracy through low-cost and easy-to- Despite their lower sensitivity, radiographic techniques

perform radiographic examinations, such as planigraphy and have lower cost and employ lower radiation doses. They are

panoramic X-rays, even though the CT is the gold standard indicated for the early assessment of less complex symptoms

for assessment of these alterations. and the differential diagnosis between TMD and inﬂamma-

The decision in choosing the examination must consider tory dental-maxillofacial conditions.

its inﬂuence on the proposed diagnosis and therapy. If the Morphological, degenerative bone abnormalities, and

clinical indication is a conservative therapy that can con- fractures are precisely diagnosed, identiﬁed, and measured

trol symptoms in the short term, image requests can be by CT. Mainly, CBCT has a lower radiation dose and arti-

1,15

considered. Moreover, when conservative therapy has fact reduction, and is considered the gold standard for the

failed and an invasive therapy is indicated, highly sensitive assessment of maxillofacial hard tissues. Inﬂammatory alter-

15,31

diagnostic tests, such as CT and MRI are selected. ations, joint disc position, and other soft tissue structures

Elaborate treatment plans also require complete and are clearly identiﬁed and evaluated by MRI, that is safer than

29,31

accurate images, for example, suspected fractures, arthrography.

where the CT, in addition to establishing the diagnosis, US examination accurately identiﬁes the joint disc,

illustrates the exact location and size, and allows for the mainly when the MRI assessment is contraindicated. It is

selection of the appropriate surgical therapy. indicated for the differential diagnosis between TMD and

Similar reasoning is used for the assessment of neoplas- painful conditions of major salivary glands, as well as pre-

tic conditions. A study that compared the accuracy of and post-evaluation of inﬁltration therapies, such as visco-

imaging tests for bone tumor detection showed that the supplementation and arthrocentesis.

nuclear medicine diagnostic tests had greater sensitivity Nuclear medicine assessments are primarily indicated for

and speciﬁcity than CT scans, MRI, and radiographic assess- the assessment of metabolic and growth alterations, such as

ment, although the latter are useful in the initial clinical tumors and metastases.

26,28,29,32

investigations. Arthrography is an invasive intra-articular examination;

Especially for non-surgical joint conditions, one should its usual indication is the visualization of joint disc alter-

consider the risk of injuries and the safety of diagnostic ations. Due to the risk inherent to the technique, it has been

techniques. Although arthrography can effectively deter- replaced by MRI assessment.

mine disc position and perforation, it is considered an Factors that need to be evaluated for the selection of

invasive and potentially hazardous method. Thus, MRI has TMJ imaging tests include the following: the need to deter-

become the method of choice for such conditions. mine the presence of the disease and its prognosis, the

4,5,23---25,30

Similarly, recent studies have recommended quality and quantity of available clinical information; uncer-

US as a safe, noninvasive diagnostic technique with con- tainty in the differential diagnosis; determining the stage of

siderable accuracy for joint disc positioning, especially disease development; need for legal documentation; preop-

for patients with contraindication to MRI or submitted to erative preparation; evaluation of treatment evolution; and

real-time interventions, such as arthrocentesis and visco- the safety and accuracy of the proposed examination.

supplementation. In these techniques, the US examination

is especially appropriate for the identiﬁcation of the inferior

joint space. Its precise identiﬁcation and correct access are

factors that contribute to the technique’s success. Conﬂicts of interest

Long-term risks and tissue damage should also be consid-

ered for radiation exposure. As in conventional radiographs, The authors declare no conﬂicts of interest.

352 Ferreira LA et al.

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