6 TMJ Arthritis

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Temporomandibular Joint: Review of the Anatomy, Pathology, and Magnetic Resonance Imaging…

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coma, and metastatic tumors. In chondrosarcoma, MRI typically shows a lobulated mass with heterogeneous signal intensity on T1- and T2-weighted images. The mass is usually hypointense on T1-weighted images and hyperintense on T2-weighted images. In osteosarcoma, MRI typically shows a large, lobulated mass with heterogeneous signal intensity on T1and T2-weighted images. The mass is usually hypointense on T1-weighted images and hyperintense on T2-weighted images. In metastatic tumors, MRI typically shows a mass with heterogeneous signal intensity and variable enhancement [1].

5.3 MR inEvaluation ofTumor Extent

MRI is valuable in the evaluation of tumor extent and involvement of adjacent structures. It can help to determine the involvement of the condyle, articular disc, and adjacent soft tissue structures. MRI can also help to identify the presence of metastases in adjacent bones and soft tissues [50].

5.4 MR inTreatment Planning

MRI is useful in treatment planning for tumors and tumorlike conditions of the TMJ.It can help to determine the extent of surgical resection and to plan for reconstruction of the TMJ.MRI can also help to guide biopsy and to monitor response to therapy [50].

MRI is a valuable tool in the evaluation of tumors and tumorlike conditions of the TMJ.It provides excellent soft tissue contrast and multiplanar imaging capabilities, which make it useful in the diagnosis and management of these conditions. MRI can help to determine the extent of disease, involvement of adjacent structures, and response to therapy. Further research is needed to improve our understanding of the role of MRI in the diagnosis and management of tumors and tumorlike conditions of the TMJ [25, 26].

6 TMJ Arthritis

The TMJ, like other synovial joints in the body, is susceptible to various inammatory arthritic conditions. In addition to degenerative arthritis, which is a common occurrence in the TMJ, arthritis resulting from crystalline deposition diseases is also prevalent. Furthermore, TMJ arthritis can be secondary to infection or trauma. It is important to discuss arthritis of the TMJ based on the underlying pathophysiological mechanisms involved in its development. By understanding the specic mechanisms at play, clinicians can better diagnose, treat, and manage TMJ arthritis to alleviate symptoms and improve the overall function of the joint [24, 27].

6.1 Degenerative Disease (Osteoarthritis)

Osteoarthritis (OA) is a chronic degenerative disease that primarily affects the articular cartilage of synovial joints. It involves the remodeling of the underlying subchondral bone and can also affect the synovium. Among all joint pathologies, TMJ is commonly affected by osteoarthritis. Interestingly, there is often a discrepancy between radiographic evidence of OA and presence of symptoms, a classic phenomenon in OA, known as clinical-radiological dissociation. Populationbased studies have shown that up to 35% of asymptomatic individuals exhibit minimal condylar attening on radiographs, while approximately 11% of patients experience TMJ symptoms related to OA [51].

The most prevalent symptom of TMJ OA is pain during chewing. Typically, the pain originates from the periarticular soft tissues and masticator muscles, which can be in a protective reex spasm. Other common symptoms include masticator muscle fatigue, trismus (limited mouth opening), decreased range of motion, difculty opening the mouth, and joint crepitations [9, 20].

Radiographically, TMJ OA is characterized by specic features such as irregularities in the cortical bone of the articular surface, erosion, and formation

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of osteophytes (Fig. 21). Erosion refers to focal areas of decreased density along the cortical margin of the mandibular condyle’s articular surface and the subchondral region (Fig. 22). Osteophyte formation usually occurs in the later stages of the dis-

ease and is an attempt by the joint to stabilize and increase its surface area to better withstand axial loading forces. Various imaging modalities have been utilized to assess TMJ OA, with CT and MRI being the most indicated [24, 51].

Fig. 21 Degenerative changes. Coronal (a) and sagittal reformation (b) of multislice computed tomography (CT) demonstrates deformity and osteophytosis of the mandib-

ular condyle (c), subchondral sclerosis of the mandibular condyle and of the articular eminence (a), and asymmetrical loss of joint space

Fig. 22 Degenerative changes. Coronal proton densityweighted (a) and (b) and sagittal T1-weighted (c) magnetic resonance imaging (MRI) of three different patients

demonstrates sclerosis and osteophytosis of the mandibular condyle (c), subchondral cysts (arrowheads in b) of the mandibular condyle, and loss of joint space

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6.2 Inammatory Arthritis

6.2.1 Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is the most prevalent rheumatic disease in childhood, affecting girls more frequently than boys. The condition primarily affects synovial joints, and its onset typically occurs in two peaks: the rst between 1 and 3 years of age, and the second between 8 and 12 years. TMJ involvement is observed in 17–87% of JIA patients. JIA can manifest as systemic, polyarticular, or periarticular forms, with the TMJ being more commonly affected in those with polyarticular joint involvement. Symptoms of TMJ involvement in JIA often include pain, joint tenderness, crepitation, stiffness, and reduced range of motion. In some cases, late-stage disease may lead to the development of bony ankylosis [49, 52, 53].

Various imaging techniques such as orthopantomography, CT, MRI, and ultrasound have been utilized to evaluate TMJ involvement in JIA. Orthopantomography and CT are particularly useful in detecting bony erosions secondary to TMJ arthritis, but they involve radiation exposure, which can be a concern in young patients. MRI and ultrasound have gained popularity in assessing TMJ involvement in JIA due to their superior soft tissue resolution and the absence of ionizing radiation. These techniques allow for earlier diagnosis of TMJ arthritis without compromising patient safety. Acute TMJ arthritis typically presents with joint effusion and synovial thickening, which are visible on T2-weighted MRI images, without apparent bony changes. However, it is important to note that joint or periarticular tissue enhancement is not a specic sign of acute TMJ arthritis, as abnormal enhancement can also be observed in healthy individuals. Evaluation of condylar resorption, which suggests a more chronic TMJ arthritis, is better achieved using nonfat-suppressed T1-weighted sequences [52–55].

6.2.2 Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inammatory condition primarily affecting periarticular tissues such as the synovial membrane, joint cap-

sules, tendons, tendon sheaths, and ligaments. Involvement of the internal joint structures occurs as a secondary effect. The prevalence of RA in the general population is approximately 2–2.5%, with a higher incidence among females. The typical age of onset is between 40 and 60years, and TMJ involvement is observed in approximately 50–75% of patients with RA [54, 56, 57].

RA is a slowly progressive disease with an insidious onset, leading to the gradual destruction of articular and periarticular soft tissues and adjacent bones, ultimately resulting in joint deformity. TMJ involvement typically occurs at a later stage of the disease (Fig.23). Symptoms of TMJ involvement in RA include deep, dull aching pain in the preauricular area particularly during chewing, as well as limited range of motion and morning stiffness. As the disease progresses, there is gradual resorption of the mandibular condyle [27, 58, 59].

Radiographically, RA is characterized by specic features such as loss of joint space, destruction of the condyle, attening with anterior positioning of the condyle, attening of the articular eminence, and erosion of the glenoid fossa. One distinguishing factor of RA is the presence of synovial proliferation, which is an early pathological process and can be visualized on MRI.Synovial proliferation is a consistent nding in all patients with RA and helps differentiate it from other types of arthritis. Additionally, joint effusion is relatively common in RA cases and can be detected through imaging examinations [24, 56–59].

6.3 Metabolic Arthritis/Crystalline

Arthropathies

Calcium pyrophosphate dihydrate deposition disease (CPPD) is a metabolic arthropathy characterized by the accumulation of calcium pyrophosphate dihydrate crystals in and around joints, particularly in the articular and brocartilage. TMJ involvement in CPPD can range from asymptomatic calcication of the disc to signicant joint destruction with erosive changes in the mandibular condyle and adjacent skull base. Common symptoms include pain, swelling in the

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Fig. 23 Coronal proton density-weighted (a), sagittal proton density-weighted (b), and sagittal T1-weighted (c) magnetic resonance imaging (MRI) and sagittal reformation (d) of multislice computed tomography (CT) of the same patient demonstrate erosions (arrowheads) of the

preauricular area, and occasional hearing loss. Pain can be aggravated by chewing. Less common symptoms may include TMJ clicking, tinnitus, and malocclusion [60].

The radiographic appearance of CPPD can vary. Computed tomography (CT) reveals calcium deposits in the disc or periarticular tissues. On MRI, CPP deposits typically appear as areas of decreased signal intensity on both T1- and

glenoid fossa (g) and of the mandibular condyle (c). There is also synovial proliferation (arrow in a and b) in the joint space, associated with bone marrow edema in the mandibular condyle (c)

T2-weighted sequences (Fig. 24). CT and MRI also show erosions near the condyle and fossa, accompanied by adjacent CPPD deposits. These erosions can extend into the skull base and middle cranial fossa. Involvement of other joints with chondrocalcinosis can provide clues for the diagnosis. Differential diagnoses to consider include synovial chondromatosis, synovial osteochondroma, and osteosarcoma [46, 54].

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Fig. 24 Coronal proton density-weighted (a), sagittal proton density-weighted (b), sagittal T1-weighted (c), and sagittal T1-weighted FAT SAT post-endovenous gadolinium injection magnetic resonance imaging (MRI) of the same patient demonstrates joint distension with uid and

6.4 Infectious Arthritis

multiple small foci with low signal intensity in all sequences, compatible with calcications (arrowheads). There is also exuberant synovitis (arrows in d), depicted in the post-contrast image. Mandibular condyle (c)

systems and concurrent systemic conditions

such as diabetes mellitus, rheumatoid arthriInfections of the TMJ typically occur as a result of the direct spread of infection from nearby tissues into the joint space. Another important mechanism is direct contamination of the articular space, after joint injections. While relatively rare, systemic infections like tuberculosis and syphilis can also affect the TMJ [25].

TMJ infection is more commonly observed

in individuals with compromised immune

tis, or a history of intravenous drug use. These

factors increase the susceptibility to TMJ

infection and can contribute to the severity

and complications associated with the

condition.

Therefore, it is crucial to consider these underlying factors when evaluating and managing TMJ infections to ensure appropriate treatment and prevent further complications [54].

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6.5 Idiopathic Condylar Resorption

Idiopathic condylar resorption (ICR), also known as progressive condylar resorption or condylar atrophy, is a rare and perplexing condition that primarily affects the TMJ.ICR is characterized by the progressive resorption of the condylar head, leading to signicant mandibular deformities and functional disturbances. The etiology of ICR remains unclear, as the condition occurs spontaneously without any apparent triggering factors or underlying systemic diseases. This idiopathic nature makes the diagnosis and treatment of ICR particularly challenging for clinicians [61–63].

ICR typically affects females in their late teens or early adulthood and often presents unilaterally, although bilateral involvement can occur. Patients with ICR may initially complain of mild symptoms such as clicking or popping in the TMJ, joint pain, or limited jaw movement. However, as the condition progresses, patients may experience facial asymmetry, malocclusion, and severe TMJ dysfunction [61, 64].

The radiographic ndings typically demonstrate progressive condylar resorption, with the condylar head gradually diminishing in size and shape, leading to a loss of condylar height and structural integrity (Fig.25) [62–64].

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Fig. 25 Coronal proton density-weighted (a, c) and sag- ittal proton density-weighted (b, d) magnetic resonance imaging (MRI) of the same patient demonstrates normal-

sized mandibular condyle (c) in (a) and (b) and typical ndings of idiopathic condylar resorption in (c) and (d)

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7 Summary

TMJ disorders are a heterogeneous group of conditions that can affect the articular, muscular, and/or ligamentous components of the joint. The most common symptoms include pain, restricted movement, joint noises, and muscle tenderness, which can signicantly impact the quality of life of affected individuals. Although the etiology of TMJ disorders is not fully understood, several factors have been implicated in their pathogenesis, including trauma, malocclusion, parafunc-

tional habits, and systemic diseases such as rheumatoid arthritis. MRI is an imaging modality that is commonly used for TMJ evaluation, especially for assessing the soft tissue components of the joint. MRI is highly sensitive for detecting disc displacement and other soft tissue abnormalities such as joint effusion, synovitis, and muscle edema. Moreover, MRI can provide information about the blood ow and perfusion of the joint, which can be useful for differentiating between inammatory and noninammatory conditions.