Temporomandibular joint pathologies: pictorial review

Abstract

In this pictorial review, an introductory paragraph emphasizes the significance of some anatomical aspects for optimal imaging of the temporomandibular joint (TMJ). The most frequent pathologies: internal derangement (ID) and osteoarthritis (OA) are comprehensively discussed and illustrated. Less common conditions: ID and OA-like changes in children and adolescents, idiopathic condylar resorption, inflammatory arthritis, and juvenile idiopathic arthritis are briefly discussed. A short paragraph on differential diagnostics in young patients is included followed by a brief comment on expansile lesions that occasionally may occur in the TMJ.

Keywords: TMJ differential diagnostics in young patients; TMJ disorders; anatomy; expansile TMJ lesions; idiopathic condylar resorption; inflammatory arthritis; internal derangements; juvenile idiopathic arthritis; osteoarthritis.

Figure 1.

MRI (oblique sagittal, oblique coronal) (left column, upper and second row), corresponding autopsy specimen (middle column), and axial MRIs with cursor lines for optimal sectioning (right column). Normal articular surface outlines and biconcave articular disc (a). CT and MRI show normal structures with intact cortical outline. The “white” cortex on CT is thinner than the “black” outline on MRI. Fibrocartilage and cortex cannot be separated on MRI whereas only cortex is visualized on CT (b). During motion, combining gliding and rotation, the condyle and disc move intimately to the top of the eminence or close to it with the posterior band of the disc located posterior to the condyle (c). A stuck (fixed) disc with posterior band (arrow) normally located but not moving with the condyle, for comparison (d). The normal translatory movement of the condyle in a child is widely anterior to the articular eminence, illustrated in a case with JIA followed from 11 years (left column) via 13 years of age (middle column) to 33 years of age (right column). Both tomography at 11 years of age and MRI at 33 years of age are normal (e). Reprinted, with permission, from Larheim and Westesson.

Figure 2.

MRI and autopsy specimen: normal disc position (a), partial disc displacement (b), and complete disc displacement (c). MRI in upper row, autopsy specimen in lower. Disc is located with posterior band in normal superior position in all sections throughout the joint (a). Disc is displaced anteriorly in one portion of the joint, normally located in another portion and reduces to normal at open-mouth (b). Disc is displaced anteriorly in all sections throughout the joint and does not reduce to normal at open-mouth (c). Reprinted, with permission, from Larheim et al. and Larheim and Westesson.

Figure 3.

MRI: normal fluid (a) and joint effusion (b). Maximum amount found among asymptomatic volunteers (a). Joint effusion defined as more fluid, seen in anterior recess of upper compartment (left image, arrowhead) (lower row), laterally in the joint (middle image, arrowhead). Disc anteriorly displaced (left image, arrow). Joint effusion in upper and lower compartment, anterior and posterior recess, normal disc position but elongated disc, and condyle marrow oedema (right image, lower row). Reprinted, with permission, from Larheim et al.^,

Figure 4.

MRI: normal (a), joint effusion and disc displacement (b). Asymptomatic joint in volunteer with normal disc and normal bone. Post–contrast image (right, upper row) does not show enhancement or minimal enhancement in posterior attachment (a). Symptomatic disc displacement and areas of contrast enhancement (left image pre–contrast, right image post–contrast) corresponding to areas of fluid collections (middle T2W image) (c, condyle) (b). Reprinted, with permission, from Smith et al.

Figure 5.

CT and MRI: CT shows normal cortical bone (lateral, central, medial section) (upper row). MRI shows complete anterior disc displacement (lateral, central, medial section) without reduction (arrow) and effusion (arrowhead) throughout the joint (a). Other patient: disc severely displaced (arrow), marrow oedema in condyle (arrowhead) (b). Reprinted, with permission, from Larheim and Westesson.

Figure 6.

CT, MRI (female, 18 years): juvenile osteoarthritis. CT shows condylar erosion (arrowhead) in one joint, and condylar flattening and osteophyte (arrow) in contralateral. MRI shows anterior disc displacement without reduction (arrow). Similar disc condition in contralateral joint (not shown). Reprinted, with permission, from Larheim and Westesson.

Figure 7.

Autopsy specimen: osteoarthritis, CT: osteoarthritis. Autopsy: osteophyte, sclerosis, anteriorly displaced disc. CT: flattened articular surfaces, narrowed joint spaces, bone apposition in fossa, osteophyte (arrow), erosion in fossa (arrowhead), subcortical cyst, condylar erosion (arrowhead), and sclerosis (arrow). Reprinted, with permission, from Larheim and Westesson.

Figure 8.

Three cases of erosive osteoarthritis (upper row). CT (F 36 years at baseline) shows punched out erosions at baseline (arrows). Five years later the erosions have repaired with cortical outline (middle and right image, lower row). Reprinted, with permission, from Larheim and Westesson.

Figure 9.

MRI F 37 years (left image, upper row), F 33 years (middle image, upper row), F 48 years (right upper and lower row): osteoarthritis. Bone erosion, damaged disc (arrowhead), and sclerosis (arrow) (left image, upper row). Large joint effusion (black asterix), severe (generalized) sclerosis in condyle (white asterix), and anterior disc displacement (middle image, upper row). Bone erosion, sclerosis, anterior disc displacement (right images, upper and lower row) and joint effusion in entire upper joint compartment (right image, lower row). Core biopsy showed histologic evidence of necrosis in condyle marrow in this patient. Reprinted, with permission, from Larheim et al., Larheim and Westesson.

Figure 10.

CT and MRI (M 65 years): osteoarthritis. CT shows erosions (arrows), osteophyte (arrowhead), sclerosis, osteophyte (white arrowhead), and loose body (black arrowhead) (left and middle image, upper row). MRI shows loose body (white arrowhead) in front of the condyle at open-mouth (right image, upper row), joint effusion in anterior recess (small arrow), marrow oedema in condyle (large arrow) (left image, lower row). Pre– and post–contrast images (middle and right, lower row) show enhancement in condyle marrow (arrow). Reprinted, with permission, from Larheim and Westesson.

Figure 11.

MRI and histological examination (condylar core biopsies) (F 41 years, F 50 years, F 32 years): normal condyle marrow (a), osteoarthritis (condyle marrow sclerosis) (b), osteoarthritis (condyle marrow necrosis) (c). MRI shows small osteophyte and normal homogeneous intermediate signal in condyle marrow. Histology (haematoxylin eosin) (upper, same patient) shows normal haematopoietic elements interspersed with marrow fat and intact trabecular bone. Histology (lower) from hip for comparison shows similar normal appearance (a). MRI shows disc displacement and extensive sclerosis. Histology (haematoxylin eosin) shows replacement of marrow space by dense bony tissue and fibrous tissue, suggestive of a reparative process (b). MRI shows disc displacement at open-mouth, large osteophyte, and a combination of sclerosis pattern and oedema pattern (both low and high T2 signal from condyle marrow). Histology (upper) (haematoxylin eosin) shows loss of haematopoietic marrow and adiposed tissue consistent with osteonecrosis, and evidence of reactive bone formation. In addition, a prominent chronic inflammatory cell infiltrate is seen. Histology (lower) (reticulin fibre stain) shows marked increase of reticulin fibre deposit consistent with irreversible changes (c). Reprinted, with permission, from Larheim et al.

Figure 12.

CT and MRI (F 38 years): unilateral osteoarthritis and F (27 years): bilateral osteoarthritis. CT (oblique sagittal, upper) and oblique coronal (lower) show small erosions in eminence and condyle, and sclerosis. MRI shows joint effusion (arrowhead) and anterior disc displacement (arrow), and laterally displaced disc (arrow, right image, upper row). Pre–contrast MRI (left image, next row) and post–contrast images (middle and right) show enhancement in synovial membrane (arrow) around joint effusion (arrowhead) and after some minutes, contrast enhancement of entire effusion (arrowhead) (right image). CT and MRI (next row) show normal contralateral joint for comparison (a). CT shows flattened surfaces, sclerosis, and osteophyte. MRI (gradient echo, opened mouth) shows reduced condylar translation and non–reducing disc displacement (arrow). MRI (T2W) shows extensive joint effusion in upper joint compartment, anterior and posterior recess (arrows), and marrow oedema in condyle. Post–contrast MRI (next row) shows enhancement in synovium around joint effusion (arrow) and disc, and in condyle marrow. CT (next row) (contralateral joint) shows similar osteoarthritis, but not so flattened and sclerotic eminence. MRI shows similar abnormalities but not joint effusion. Patient has bilateral osteoarthritis but only one joint with active inflammation.

Figure 13.

F (21 years): juvenile osteoarthritis. Lateral view shows anterior bite opening (middle image, upper row). CT (upper and middle row) shows deformed condyle with double contour posteriorly due to bone apposition (remodelling) and flattening of fossa/eminence. MRI (lower row) shows anteriorly displaced disc at closed and opened mouth (arrow).

Figure 14.

F (11 years) (left image, upper row) with 1.3 years follow-up (right image, upper row). CBCT shows progression of condylar resorption (arrow). F (13 years) (second row) with 4 years follow-up (right image), F (15 years) (third row) with 6 years follow-up (right image), F (18 years) (fourth row) with 5 years follow-up (right image), all showing improvement of the condylar resorption. Cases in third and fourth row has “repaired” with intact cortical outline and somewhat deformed condyles.

Figure 15.

Autopsy: known longstanding rheumatoid arthritis (left image, upper row). F (31 years) with psoriatic arthritis (a), M (41years) with rheumatoid arthritis (b). Autopsy shows no disc structure but pannus and punched out erosion in condyle (arrow). MRI (right image, upper row) shows reduced translation and normal disc position. CT shows punched out erosion in condyle (second row). Pre– and post–contrast MRI (middle and right joint) shows enhancement in the condyle erosion and joint in general (a). CT shows punched out erosion and MRI shows erosive condyle, flattened fossa/eminence and destroyed disc. Pre– and post–contrast MRI (left and middle image, lower row) shows contrast enhancement in entire joint (pannus), only disc remnants, and no joint effusion (b). Reprinted, with permission, from Larheim and Westesson.

Figure 16.

F (33 years): rheumatoid arthritis. MRI (T2W) (left image, upper row) shows effusion in anterior recess of upper and lower compartment (arrows) (c=condyle). Pre–contrast MRI (middle image, upper row) shows anteriorly displaced disc and fluid-filled bulging joint compartment of intermediate signal intensity. Post–contrast MRI shows synovial enhancement on both sides of the disc (arrows) (right image, upper row). Effusion in lower compartment is still of intermediate signal intensity (area below layer of enhancement). Pre– and post–contrast MRI and T2W MRI 1.5 years after synovectomy and discectomy show large areas of effusion, most prominent in the anterior recess (=ar) (c=condyle) (middle row). Post–contrast MRI shows enhancement in synovium in the periphery of the effusion (arrows, lower row) (c=condyle) and more enhancement after some minutes (right image, lower row). Reprinted, with permission, from Smith et al.

Figure 17.

M (66 years): destructive arthritis, possibly reactive (severe ENT symptoms), with punched-out erosions (left and middle image, upper row) developing into bone-productive osteoarthritis (with osteophyte) within 2 years, without any treatment (upper and lower right images).

Figure 18.

F (13 years): juvenile idiopathic arthritis (JIA) (left and middle image, upper row), F (59 years): rheumatoid arthritis (RA) (right image, upper row), F (11 years): JIA (lower row). CT shows normal joint (left image, upper row), JIA—involvement with flattened eminence and condyle, increased condyle in antero-posterior direction due to remodelling/growth disturbance within the joint, no erosions (middle image, upper row). Punched-out erosion in adult RA (right image, upper row). MRI shows reduced signal in condyle marrow on T1W image (left, lower row) and high signal on T2W image (middle, lower row), and contrast enhancement (right image) consistent with marrow oedema. There is contrast enhancement in upper and lower joint space consistent with synovitis (and minimal fluid). Disc is flattened, perforated in centre, and elongated. Reprinted, with permission, from Larheim and Westesson.