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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5531_Библиотеки_им_академика_М_И_Перельмана.pdf
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G. A. Kaspo and C. Angelopoulos
surface of the condylar head to severe degenerative changes, which may include subchondral
cysts and osteophytes. The occurrence of degenerative changes in the condyle alone is more
common than that of degenerative changes in
both the eminence and the condyle. Changes in
the eminence alone are less frequently reported
than the previously mentioned incidents.
Clinical signs of degenerative arthritic
changes in the jaw joints include pain upon palpation of the TMJ area. The pain is aggravated
by chewing, eating, and yawning. The severity of
the pain can range from mild to moderate, dull,
achy pain and is often associated with crepitus
sounds. Most patients who visit orofacial pain
clinics complain of pain and sounds. Limited
mouth opening and stiffness in the jaw joints,
particularly in the morning, are commonly
reported. The mandibular range of motion may
be limited, with jaw opening and some mild
deection to the ipsilateral side may be observed.
Lateral movements will be equal bilaterally, with
occasional limited movement. The patient complains of pain, which is usually reported when
chewing on the contralateral side. However, the
pain is less severe or may not exist when chewing on the same side.
The advent of CBCT has revolutionized the
hard tissue assessment of the TMJ by providing
thin sections of the anatomical areas of interest
(the mandibular condyles, fossae, and eminences). Although sectional imaging was available long before the introduction of CBCT with
computed tomography (CT), this was used infrequently due to inherent limitations of CT (such as
slice thickness), lack of TMJ-specic image
reconstructions, and increased radiation to the
patient. Prior to CT and CBCT, clinicians used to
rely on panoramic radiography as well as other
conventional radiologic examinations for the
evaluation of the TMJ. Panoramic radiographs
are a form of tomographic imaging that seem to
be acceptable for an initial assessment (screening) of the TMJs. Conventional TMJ imaging
including variable projectional types of X-rays
(postero-anterior view, reverse Towne’s view,
submentovertex view) and others aimed to provide visualization of the complex TMJ anatomy
from different perspectives. However, the anatomic superimposition of different anatomical
structures in the TMJ neighborhood was the biggest disadvantage of these diagnostic approaches.
Soon after its introduction, CBCT was established as the imaging modality of choice for the
evaluation of the hard tissues of the TMJs and has
become a very important tool in orofacial pain
practices [1, 8–10] (Figs.8.1, 8.2, 8.3, 8.4, 8.5,
8.6, and 8.7).
Fig. 8.1 A series of sagittal sections of the (R) TMJ
showing minor condylar shape and fossa alterations by
means of slight interruptions in the continuity of the corti-
cal outlines. Small erosion in the roof of the glenoid fossa
(red arrow). Small osseous projection and erosion in the
condyle (green arrow)
8 Cone Beam Computed Tomography forTemporomandibular Joint Disorders andDiseases
87
Fig. 8.2 A series of sagittal sections of the (L) TMJ
showing slight irregularities in the anterior/superior aspect
of the left condylar head (green arrows) in a symptomatic
patient. Commonly, such minor osseous changes pose a
diagnostic dilemma because of the “noise” inherently
present in CBCT images. Noise may imitate the presence
of osseous changes in anatomical areas that are not actually present and may lead to erroneous diagnoses, especially for the inexperienced diagnostician
Fig. 8.3 A series of sagittal sections of the (R) TMJ
showing attening in the anterior/superior aspect of the
right condylar head. Flattening of the articulating surfaces
is often the rst sign of osseous changes in the development of degenerative joint disease (osteoarthritis)
88
G. A. Kaspo and C. Angelopoulos
a
c
Fig. 8.4 The ve most prominent manifestations (morphological changes) of degenerative joint disease (DJD)
in four different case series (patients): (a) Flattening of
the superior aspect of the condyle along with localized
sclerosis. Note the coexistence of severe erosive changes
and glenoid fossa shape alteration. (b) Osteophyte forma-
tion and localized sclerosis on the condyle along atten-
b
d
ing and sclerosis on the anterior slope of the fossa. Also,
note the small loose body (fragmented osteophyte)
(arrow). (c) Erosive lesions in the superior aspect of the
condyle and the articular eminence (arrows) along with
attening and sclerosis of the fossa. (d) Subchondral cyst
formation along with an osteophyte and localized sclerosis in the condylar head and fossa sclerosis
a
Fig. 8.5 A series of sagittal sections of the (R) TMJ (a)
and a coronal section (b), showing an erosive lesion in the
superior aspect of the right condyle (red arrows). This is
surrounded by a thick sclerotic border (green arrows).
This is often reactive sclerosis and indicates a reaction to
chronic stimuli (the erosion in this case). The gravity of
b
the various osseous ndings as recognized in the diagnostic examinations (CBCT scans in this case) determines the
degree of the degenerative joint disease: mild, moderate,
or advanced/severe degenerative changes (mild to moderate in this case). Admittedly, this is a rather subjective
classication heavily based on the diagnostician
8 Cone Beam Computed Tomography forTemporomandibular Joint Disorders andDiseases
89
Fig. 8.6 A coronal section (above right) and a series of
sagittal sections of the (L) TMJ in a symptomatic patient
showing the following imaging ndings: a small osteophyte in the anterior aspect of the condyle, a small erosive
lesion (arrow), and marked narrowing of the left joint
space. The above ndings constitute mild degenerative
changes in the (L) TMJ
90
G. A. Kaspo and C. Angelopoulos
Fig. 8.7 Axial section (above left), coronal section
(above right), and a series of sagittal sections of the (L)
TMJ in a symptomatic patient showing the following
imaging ndings: a large osteophyte in the anterior aspect
of the condyle, diffuse sclerosis in the condylar head, erosive lesions in its superior aspect, a subchondral cyst
towards the lateral pole of the condyle (red arrow), a loose
8.3 Juvenile Idiopathic Arthritis
Juvenile idiopathic arthritis (JIA), formerly
known as juvenile rheumatoid arthritis or juvenile chronic arthritis, represents the most preva-
body (fractured osteophyte, green arrow) just inferior to
the articular eminence, extensive attening and sclerosis
in the fossa, and lastly, total loss of the left joint space; in
fact, the two articulating surfaces are in contact with one
another. The above radiologic ndings constitute severe
degenerative changes in the (L) TMJ
lent pediatric rheumatological disorder. It
encompasses various forms of pediatric inammatory arthritis with unknown etiology, presenting diverse clinical and imaging manifestations.
JIA is classied into oligoarticular, polyarticular
8 Cone Beam Computed Tomography forTemporomandibular Joint Disorders andDiseases
91
(both rheumatoid factor negative and positive),
psoriatic arthritis, enthesitis-related arthritis, and
systemic JIA.Understanding the distinct clinical
features, pathogenic mechanisms, and prognostic
implications of each subtype enables a more
sophisticated, imaging-based approach to diagnosis [11].
JIA is a broad term describing a clinically heterogeneous group of arthritides of unknown
cause, the onset of which is prior to16 years of
age, with arthritis persisting for over 6 weeks
being diagnostic criteria for JIA [12, 13]. The
estimated prevalence of TMJ involvement in children and adolescents with JIA varies widely,
ranging from 17% to 92%, with many cases being
clinically asymptomatic [14]. Pain in the temporomandibular region is relatively common,
affecting about 10% of individuals over 18years
old. It predominantly affects young and middleaged adults rather than children or the elderly and
is approximately twice as prevalent in women
compared to men [15]. Although few differences
were observed between children with and without radiographic TMJ deformities, self-reported
previous TMJ symptoms and reduced maximum
unassisted opening with pain could indicate TMJ
involvement. However, radiographic
examinations are necessary to conrm TMJ
involvement, suggesting limitations in various
classication systems for targeting TMJ involvement in JIA [16].
The diagnostic criteria for TMD, which is the
DC/TMD, comprise physical axis I (clinical condition) and psychosocial axis II (psychosocial
distress) in its assessment. The clinical examination aligns well with consensus-based recommendations for orofacial examination in JIA,
except for craniofacial deformations [17].
JIA is a diagnosis of exclusion that, when
suspected, requires a complete clinical evaluation, including family to personal history and
recent pathologic events, and specic attention
to pain and morning stiffness. A detailed physical examination should always be performed to
examine all body joints at both rst evaluation
and follow- up visits [33]. At the conclusion of
the visit, the physician is asked to provide his/
her global rating of the overall level of disease
activity on a visual analog scale (VAS), ranging
from 0 (no activity) to 10 (maximum activity)
[33, 34]. The identication of systemic JIA may
be challenging as arthritis is often not present at
onset.
for the diagnosis and management of JIA, as with
TMJ disorders. The goals of TMJ imaging are to
evaluate cortical integrity and trabecular architecture of the bony structures, to assess the extent
of the osseous involvement, to monitor the progression of osseous changes over time, and to
evaluate the response to treatment. Although conventional radiologic examinations are limited for
a complete and accurate evaluation due to the
anatomical complexity of the articulation and the
structure superimposition observed in projectional images, they may be of some value for an
initial assessment for the detection of asymmetry
and gross pathology.
8.4 Rheumatoid Arthritis
Rheumatoid arthritis (RA) patients have a higher
prevalence of TMD compared to healthy individuals [18–21]. TMJ involvement in RA is characterized by degenerative bone changes, including
condylar resorption, joint space narrowing, and
erosions [22–24]. These changes can be detected
through imaging techniques such as CBCT and
MRI, even in asymptomatic patients [22, 25].
Clinical symptoms of TMD in RA patients
include joint pain, crepitus, and limited mandibular movement [18]. Interestingly, seronegative
RA patients may have a higher prevalence of
TMD pain compared to seropositive patients
[21]. The duration of RA does not necessarily
correlate with the severity of TMJ involvement
[18, 20]. Early diagnosis and treatment are crucial to prevent structural and functional damage
to the TMJ in RA patients [22] (Figs. 8.8 and
8.9).
The radiologic examination is an essential tool
inAdults
92
G. A. Kaspo and C. Angelopoulos
Fig. 8.8 A series of sagittal sections of the (R) TMJ
towards the midcondyle (above) and towards the lateral
pole (below) of 10-year-old female patient who had a conrmed diagnosis of juvenile idiopathic osteoarthritis
affecting several joints. When the patient reported pain in
the TMJ, a CBCT scan was ordered; the CBCT images
depict early erosive changes (red arrows) in the anterior/
superior aspect of the left condyle. Admittedly, in the
absence of symptoms, the above ndings are generally
mild and could have been regarded as possible noise in the
scan
Fig. 8.9 A series of sagittal sections of the (L) TMJ of a
symptomatic patient (a child) depicting erosive changes
(red arrows) in the superior aspect of the left condyle
causing shape alterations in the condylar head. The patient
was diagnosed with JIA and the above ndings regarded
as involvement of the TMJs
8 Cone Beam Computed Tomography forTemporomandibular Joint Disorders andDiseases
93
8.5 Synovial Chondromatosis
oftheTemporomandibular
Joint
Synovial chondromatosis (primary) is a rare,
benign condition that typically affects large
joints, with its occurrence in the TMJ being
uncommon and more prevalent in females [16]. It
is characterized by the abnormal proliferation of
the synovial membrane, leading to the formation
of loose cartilaginous bodies within the joint
space. These nodules can vary in size and location around the condyle, both within and outside
the synovial tissue. Their presence may exert
pressure, potentially causing erosion of the
glenoid fossa and, in severe cases, intracranial
extension.
Occasionally, the degeneration of the articulating surfaces is followed by the development of
multiple variable-sized loose cartilaginous or
osseous bodies which are scattered within and
around the articulating surfaces. This condition is
known as secondary synovial chondromatosis.
In orofacial pain clinics where cone beam CT
scans are utilized, the prevalence of synovial
chondromatosis may be higher than previously
recognized [17]. Radiographic changes indicative of synovial chondromatosis are observed in
only 45% of affected patients. The increased use
of CBCT scans has signicantly enhanced the
detection and awareness of synovial chondromatosis in the TMJ [18].
The diagnosis of synovial chondromatosis is
conrmed through histopathological investigation. Grossly, hyperplastic synovium covers
white multilobulated nodular projections of hyaline cartilage. Histopathological examination
reveals globular masses of cartilage tissue with
areas of calcication. Chondrocytes within lacunae show mild atypia, and the synovial connective tissue between the cartilages appears delicate
and brillar. The peripheries of the globular
masses exhibit cellular areas with numerous
blood vessels [16] (Figs.8.10, 8.11, and 8.12).
94
G. A. Kaspo and C. Angelopoulos
Fig. 8.10 A coronal section (above left) and a series of
sagittal sections of the (R) TMJ in a symptomatic patient
in which apart from the obvious radiologic ndings of
DJD (attening of the condyle and the fossa, subchondral
sclerosis, and narrowing of the joint space), several
osseous- density loose fragments of varying size are recognized scattered around the condyle, most likely inside
and outside of the joint capsule. This appearance is consistent with secondary synovial chondromatosis of the
right TMJ
8 Cone Beam Computed Tomography forTemporomandibular Joint Disorders andDiseases
95
Fig. 8.11 A series of sagittal sections of the (R) TMJ
(above) and the left TMJ (below) of an older symptomatic
patient. The radiologic ndings on both sides include multiple calcications or loose osseous fragments of varying
shapes and sizes within the joint spaces. This appearance
is strongly suggestive of secondary synovial chondromatosis. Bilateral DJD is evident, with osteophyte formation
bilaterally, localized sclerosis, and erosive changes in the
right articular eminence (red arrows)