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Imaging oftheCommon Conditions oftheTemporomandibular Joint
ab c
def
81
Fig. 14 Sagittal cross-section images show joint effusion. T2WI image (a) in closed position reveals mild to
moderate joint effusion in the anterior recess of the superior compartment. MERGE image (b) in closed position
shows the presence of synovial uid within the anterior
recess of the superior compartment, delineating the contours of the disc and its posterior attachment. In the
MERGE image (c) of the same patient upon mouth open-
ing, the uid migrates to the posterior recess of the superior compartment. PD FS (d) and T2 STIR (e) images of a
patient in open position illustrate mild joint effusion in the
anterior recess of the superior compartment and limited
condylar movement. MERGE image (f) of a different
patient in closed position shows moderate joint effusion in
the anterior recess of the superior compartment
abc
Fig. 15 CBCT sagittal cross-sectional images (a and b)
and 3D volume rendering (c) show hypermobility. In the
closed-mouth position (a), the condyle is located posteri-
that responds to functional needs and does not
necessarily signify any pathology or
dysfunction.
orly within the fossa, while in the open-mouth position
(b), the condyle translates to a point anterior and superior
to the crest of the eminence (b and c)
3.2.5 Degenerative Joint Disease
The terms degenerative joint disease (DJD),
osteoarthritis, and osteoarthrosis are frequently
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H. Demirturk and A. Potluri
Fig. 16 PDWI sagittal views show hypomobility in the
left TMJ. (a) In the closed position, the condyle is posteriorly positioned in the fossa, and the disc is anterior to the
condyle (arrow). (b) In the open position, the position of
the disc remains relatively unchanged relative to the fossa
(arrow), while the condyle translates to the intermediate
zone of the disc. These observations suggest adhesion in
the superior compartment of the TMJ
a b
Fig. 17 CBCT axially corrected sagittal and coronal views
demonstrate mild attening on the anterosuperior aspect of
the left condyle consistent with functional remodeling. This
process represents the bone’s effort to enlarge its surface
area in order to distribute and manage increased loads on
the joint surface. Sagittal (a) and coronal (b) views
used interchangeably. DJD is a noninammatory
degenerative condition that can develop in the
TMJ.DJD occurs when the functional demands
on the articular tissues exceed their remodeling
capacity, leading to the destruction of these tissues. It can affect either a single joint or both
joints bilaterally, and the progression of this condition may also vary between the two joints, leading to alterations in the shape and functionality of
the mandible.
In the context of TMJs, primary DJD is considered idiopathic. Secondary DJD is generally
ab
Imaging oftheCommon Conditions oftheTemporomandibular Joint
83
assumed to occur after the displacement of the
disc when there is bony contact between the condyle and the articular fossa. However, there have
been reports suggesting that DJD can develop
phytes, surface erosion, and subcortical pseudocysts. These features are illustrated in Figs.9,
18, 19, 20, 21, and 22 and are described as
follows:
before disc displacement occurs.
DJD is typically diagnosed radiographically,
as clinical signs and symptoms often have limited validity. Three key radiographic features
indicative of a diagnosis of DJD include osteo-
• Osteophyte is characterized by marginal
hypertrophy with sclerotic borders and angular, exophytic, osseous formation from the
surface.
c d
Fig. 18 Coronal (a and b) and sagittal (c and d) cross
sections of right (a and c) and left (b and d) TMJs with
active degenerative joint disease. Erosion and decortication are seen on anterosuperior articular surface of both
condyles (white arrow), with visible hint of recortication
and fuzzy appearance on the left (black arrow), indicative
of healing process
84
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H. Demirturk and A. Potluri
c d
Fig. 19 Coronal (a and b) and sagittal (c and d) cross
sections of right (a and c) and left (b and d) TMJs with
severe degenerative joint disease. Bilateral condyles,
articular eminences, and mandibular fossae show signicant volume loss, severe attening, and sclerosis. Notably,
there is subchondral cyst on the right condyle (thin white
arrow) close to proximal surface, thickening of the left
mandibular fossa roof, vertical height loss in both condyles, and shallower mandibular fossae. Erosion and
decortication on the superior articular surface of right
condyle (white arrow) are consistent with active phase of
the disease. Recortication and osteophyte on the anterior
aspect of the left condyle (black arrow) showing that the
disease has reached the stable stage
Imaging oftheCommon Conditions oftheTemporomandibular Joint
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85
Fig. 20 Visualization of a subchondral bone cyst (arrows)
using various MRI protocols on the same condyle; signal
variations can be seen across different imaging sequences:
(a) T1WI (b) PDWI, (c) MERGE. (Courtesy T.Gokdeniz,
DDS and K.Orhan, DDS)
abc
Fig. 21 Coronal (a) and sagittal (b and c) cross sections
of the right TMJ show degenerative joint disease with signicant vertical height and volume loss in the condyle and
possible irregular cortical break on the mandibular fossa
• Surface erosion refers to the loss of continuity
in the articular cortex, which can occur in the
condyle, fossa, or both.
• Subcortical pseudocyst (subchondral bone
cyst, Ely cyst) is a cavity beneath the articular
surface that deviates from normal marrow pattern. It is not a true cyst but rather represents
the loss of trabecular bone structure in that
area.
roof (a and b). Note large osteophyte in the anterior aspect
of the condyle (c). The disease has not yet reached the
stable phase
Additional radiographic ndings associated
with potential osseous remodeling include articular surface attening and subcortical sclerosis.
These can be challenging to denitively diagnose
as DJD because they may arise due to various
factors, including aging, functional remodeling
of the joints, or precursors to DJD. Over time,
attening and sclerosis can progress to DJD; as
such, it would represent regressive remodeling or
remain stable, reecting adaptive remodeling
The above radiographic features play a critical
(Fig.17).
role in diagnosing DJD.
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H. Demirturk and A. Potluri
• Surface attening refers to losing the rounded
contour of the condyle or the articular eminence. It is important to note that this feature
can be observed in normal, healthy joints and
be a variation of the normal anatomy.
• Subcortical sclerosis is described as an
increase in the thickness of the cortical plate
in areas that bear the load in relation to adjacent non-load-bearing areas. This is often
associated with increased loading of the joint
or can occur with normal loading when there
is disc displacement.
The initial phase of DJD begins on the supe-
rior surface of the mandibular condyle. It may be
observed in axially corrected sagittal crosssection images as a disruption of the cortical outline and loss of trabecular structure beneath the
surface (Figs. 18, 19, and 21). This stage is
referred to as “active DJD.” As the erosions go
through a healing process and recorticate, the
condyle undergoes a reduction in size, resulting
in a loss of both vertical height and volume
(Figs. 19 and 22). The process of recortication,
whether partial or complete, on the articular sur-
face is regarded as a component of the healing
stage (Fig.18).
When recortication is fully accomplished,
DJD is considered in a “stable” phase (Figs.19
and 22). Additional radiographic indicators of
stable DJD include osteophytes, generally on
the anterior aspect of the condyle, and loose
articular bodies known as “joint mice,” which
can be considered synovial chondromatosis secondary to DJD (Fig.23). It is important to note
that if excessive forces are reintroduced, the
entire process may reactivate, potentially leading to further erosion and loss of condylar volume. Reapplication of excessive forces can
potentially reactivate the entire process, leading
to new erosion and further loss of condylar
volume.
3.2.6 Inammatory Disorders
Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic inammatory autoimmune condition with an unknown etiology. It is characterized by joint tenderness,
swelling, and progressive destruction of synovial
Fig. 22 The sagittal cross-sectional CBCT images (a and
b) illustrate characteristic features of TMJ degenerative
joint disease, including severe condylar attening, vertical
height loss, subchondral sclerosis, and presence of a large
osteophyte. Recortication, more prominent on the left, is
suggestive of a stable phase. The mandibular fossa and
articular eminences are shallow and exhibit sclerosis, and
attening indicating the advanced nature of the disease
Imaging oftheCommon Conditions oftheTemporomandibular Joint
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87
Fig. 23 CBCT sagittal (a and c) and axial (b) cross sec-
tions illustrate loose articular bodies (arrows) secondary
to degenerative joint disease, also referred to as “secondary synovial chondromatosis” or “joint mice.” While the
joints. This can result in severe disability and an
increased risk of premature mortality. RA can
result in synovitis, which, in turn, can lead to the
formation of synovial granulation tissue, commonly referred to as pannus.
Joint involvement in RA typically follows a
polyarticular distribution and often presents with
symmetrically bilateral. Patients commonly
experience chronic episodes of are-ups and
periods of remission. TMJ involvement in RA is
rare despite the widespread polyarticular nature
of the disease.
Juvenile idiopathic arthritis (JIA), also known
as juvenile RA or Still’s disease, is an autoimmune pediatric rheumatic condition. In JIA
patients, TMJ involvement can be remarkably
high, with rates reported as high as 87%, and
TMJ can be the sole joint affected by JIA.Patients
may be asymptomatic or show restricted jaw
movement, mandibular asymmetry, and a class II
malocclusion due to irreversible condylar
resorption.
Imaging
The most frequent nding of RA is the erosion of
the condylar head on a panoramic radiograph and
attening of the articular eminence, subchondral
cyst, erosion, and reduced joint space on CT.On
MRI, the most common ndings are the abnormal (increased) signal intensity of the condylar
osseous components of the TMJ exhibit degenerative joint
disease changes, there is no mass effect typically associated with primary synovial chondromatosis
bone marrow, high signal intensity in the joint
space due to the uid (synovitis), erosion of the
condylar cortex, and resorption that may extend
to more than half of the condylar head. The pannus usually exhibits an intermediate signal intensity on both T1- and T2WI.In JIA, CBCT can
show bilateral at and signicantly misshapen
condyles, often accompanied by a widened glenoid fossa, elongated and superiorly positioned
coronoid processes, and clockwise rotation of the
mandible, which can be attributed to the shortened condyles (Fig.24).
In RA, there are some key differences com-
pared to DJD:
• Disc position: In RA, the disc can remain in a
normal position even in the presence of
signicant osseous changes. In contrast, in
DJD, disc displacement is more common.
• Osteophyte formation: Osteophyte (bone
spur) formation is not common in RA but is
more frequent in DJD.
• Effusion: RA patients tend to have a higher
frequency of joint effusion (accumulation of
uid in the joint) than patients with DJD.
• Condylar shape: The characteristic appearance of a condyle affected by RA resembles a
“sharpened pencil.” In DJD, the erosions on
the condyle tend to display a pattern of focal
erosions and subsequent loss of volume.
88
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H. Demirturk and A. Potluri
a
b
Fig. 24 CBCT reconstructions reveal marked changes in
the bilateral TMJs in a young patient suspicious for juvenile rheumatoid arthritis and juvenile degenerative joint
disease (idiopathic condylar resorption): panoramic
reconstruction (a) demonstrates prominent antegonial
notch (arrow), steep mandibular plane (thin arrow), and
notably short mandibular rami. In a sagittal oblique view
• Joint involvement: RA often affects TMJs
bilaterally due to being a systemic autoimmune condition involving multiple joints
throughout the body. DJD can affect either a
single joint or both joints.
In certain instances, both conditions can coex-
ist when there is a displacement of the disc and
DJD develops simultaneously.
Synovial Chondromatosis
Synovial chondromatosis (SC) is a rare benign
condition characterized by the proliferation of
of the right mandible (b) and volume renderings of the
right (c) and left (d) mandible, notable features include a
condylar stump (white arrow), underdeveloped mandibular fossa, and eminence (black arrows) suggesting that this
condition likely started earlier in life, prior to their full
development and long coronoid process (thin arrows)
compared to the condylar process
nodular cartilaginous or osteocartilaginous entities within the synovium of a joint. Over time,
these entities ossify, detach, and are observed as
loose bodies oating in the joint space.
Imaging
Panoramic radiographs can reveal signs of SC
once the cartilage undergoes ossication.
However, for a comprehensive diagnosis and
treatment planning, CT and MRI are advised.
MRI is particularly useful as it can display
multiple nodular entities, whether cartilaginous
or osseous in nature and joint effusion. On T1WI,
Imaging oftheCommon Conditions oftheTemporomandibular Joint
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89
Fig. 25 Sagittal (a), coronal (b), and 3D volume-
rendering (c) CBCT images illustrating primary synovial
chondromatosis in the right (TMJ), displaying multiple
well-dened calcied structures with low-density centers,
heterogeneous and hypointense loose bodies are
observed in the superior joint space. On T2WI,
hyperintense effusion± expansion and a “ringlike” signal caused by hyperintense uid surrounding a group of hypointense loose bodies are
commonly seen. These ndings are indicative of
the condition. On CT or CBCT, irregular joint
surface, limited motion, widened joint space, calcied loose bodies, sclerotic mandibular condyle,
and glenoid fossa can be seen (Fig.25).
4 Summary
Imaging is a fundamental element in the assessment of the patient with suspected TMJ dysfunction and/or craniofacial pain. There are many
imaging options available to characterize TMJ
dysfunction, whether caused by congenital
abnormalities or internal derangements.
Proceeding directly to imaging should be
avoided. A thorough physical exam is crucial for
the formulation of a proper differential diagnosis
and ordering of appropriate radiology.
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