Review Article

Efficacy of plain radiographs, CT

scan, MRI and ultra sonography
in temporomandibular joint
disorders
Department of Oral and Maxillofacial Vijai P. Sinha, Harsha Pradhan1, Hemant Gupta,
Surgery, Babu Banarsi Das College of
Dental Sciences, 1Department of Oral Shadab Mohammad2, R. K. Singh2, Divya Mehrotra2,
and Maxillofacial Surgeon, Career Post M. C. Pant3, R. Pradhan
Graduate Institute of Dental Sciences
and Hospital, 2Department of Oral
and Maxillofacial Surgery, Chattrapati
Shahuji Maharaj Medical University, ABSTRACT
3
Dr. Ram Manohar Lohia Institute of
Medical Sciences, Lucknow, India The complexity of structure and functions of the Temporomandibular Joint (TMJ) make the
diagnosis of its diseases/disorders difficult. Remarkable progress made in the field of imaging
of this joint led us to compare four imaging modalities viz. plain radiographs, CT scan, MRI and
Address for correspondence: ultrasound. We found that MRI was most specific and sensitive for interpretation of soft tissue
Prof. Vijai P. Sinha, and inflammatory conditions in the joint, whereas CT examination produced excellent image
Department of Oral and for osseous morphology and pathology. Plain X-rays are useful for destructive bony changes
Maxillofacial Surgery, Babu and sonography is a good in aid in diagnosing disc derangement and is very economical.
Banarsi Das College of Dental
Science, Lucknow, India.
E-mail: [email protected]
Key words: CAT scan, MRI, plain radiography, TMJ, ultrasonography

lay down interpretation of these that this study was

INTRODUCTION undertaken.
The remarkable progress and increasing sophistication Review of literature
in the imaging of the Temporomandibular Joint TMJ disorders are a heterogeneous collection of signs
(TMJ) seems to have added to the confusion among and symptoms that can be generally characterized
practitioners as to when and what imaging should be by the presence of pain, TMJ noise and limitation of
used, if at all. Further all imaging techniques are not jaw motion. They have largely been classified into
equally effective for many conditions in which the TMJ structural/organic (ankylosis, trauma, infection,
is involved. neoplasia or arthritis) and functional (pain, joint noise or
limitation of joint movement) and various diseases that
Obtaining an image by itself means little unless affect the TMJ including congenital and developmental
effective, standardized interpretation is available. It malformations of the mandible and / or cranial bones
is with the intention to compare the transpharyngeal and acquired disorders.[2]
view X-ray, CT scans, MRI and ultrasound with the
Clinical Diagnostic Criteria (CDC)[1] and to possibly The National Center for Devices and Radiological
Health of the Food and Drug Administration
Access this article online (USA), in 1979, recommended that the imaging
Quick Response Code:
Website:
examination must be capable of providing the desired
www.njms.in information regarding patient’s internal anatomy
or physiology, and the radiographic information
DOI:
sought, even if negative or normal, is expected to be
10.4103/0975-5950.102138 significantly useful in the medical management of the
patient.

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 Sinha, et al.: TMJ imaging : 4 Modalities compared

The efficacy of any imaging examination rests not just and joint effusions.[12] In patients with inflammatory
with its technical adequacy but also with its diagnostic arthritides, MRI has been shown to demonstrate
accuracy, as a complex interaction exists between the disc destruction. Gadolinium used as a contrast
image and the person interpreting it.[3] Additionally, agent, pannus formation can be detected with active
increasing sophistication of imaging technique does not rheumatoid or other inflammatory arthritis.
guarantee better management of the patient.[4]
On comparing CAT and MRI images of 15 fresh TMJ
Rudisch et al,[5] evaluated the CDC for TMJ disorders autopsy specimens with cryosection in a blinded fashion,
against the MRI diagnosis of TMJ internal derangement no statistically significant difference between these
and osteoarthritis in a patient group, and it was observed procedures in detecting bony abnormalities or disc position
that the classification system of the CDC for TMJ was found.[13] However, a side by side image analysis
disorders are not sufficiently reliable for determining demonstrated that MRI depicted the soft tissue anatomy
TMJ internal derangement and osteoarthritis; further, of the joint with greater detail. Further, CAT images could
that a clinical diagnosis of internal derangement not assess the configuration of the disc and the borderlines
type 3 may need to be supplemented by evidence between the disc and its attachment, which MRIs did.
from an MRI to determine functional disc condyle Single Photon Emission Computed Tomography (SPECT)
relationship. However, in a long-term study of patients is particularly sensitive for inflammatory disorders and
(55 TMJs), with history of osteoarthrosis and internal arthritides but is not specific for these conditions. It is not
derangement, it was observed that 30 years after initial useful for determining deviation in the form of joint disc
diagnosis there were few clinical signs of osteoarthritis displacement, dislocation or ankylosis.[8]
and internal derangement although MRI findings were
extensive.[6] Accuracy for diagnosis of internal derangement, disc
displacement with reduction and disc displacement
In a comparison of MR images of 28 patients with without reduction based on prospective interpretation
those of respective arthrograms, it was found that the of high-resolution sonograms was 95%, 92% and 90%,
anatomic configuration of the meniscus as seen with respectively. High-resolution sonography allowed
MR correlated directly with normal variations of the greatly improved diagnostic efficacy because of a more
anterior recess seen with arthography.[7] defined tissue differentiation and enhanced near-field
clarity.[14] Furthermore, the advantage of dynamic high-
The description of the use of CAT in the evaluation of the resolution sonography in investigating the disc condyle
meniscus of the TMJ was made in 1983. Computerized relationship during repeated motion at the respective
reconstruction was used extensively and compared with open-mouth positions probably made these structures
other radio modalities.[8] more clearly distinguishable.[10]

High-contrast sensitivity of MRI to tissue differences

and the absence of ionizing radiation are the reasons MATERIALS AND METHODS
why MRI has replaced CT for imaging soft tissue. Since
high-resolution anatomical detail is a feature for TMJ This study comprised 10 patients of TMJ disorders
imaging, surface coil imaging is essential for adequate who visited the outpatient department of Oral and
investigation.[9] Maxillofacial Surgery of Gandhi Memorial and
Associated Hospitals, CSM Medical University
Since each TMJ is significantly affected by (Erstwhile KGMC), Lucknow. Diagnosis was made
the contralateral joint, it has been advocated to on the basis of history, clinical examination and
simultaneously image TMJ bilaterally, which allows investigations (Routine and Specific).
the assessment of side to side differences in a range of
motions and joint structure at the identical points of Routine TMJ X-rays (Transpharyngeal view), CT scan
mouth opening for either side.[10] MRI may assist the of TMJ in saggital plane in soft tissue mode, MRI (1.5
clinician in determining whether primary or delayed Tesla) and high-resolution ultrasonography (using 10
treatment is indicated in cases of trauma to the TMJ. MHZ probe) were obtained.
The saggital and coronal MRI of TMJ articulation are
complimentary, and this might be important for a Ultrasound was included later in the study because it has
full assessment of joint dysfunction.[11] Using high- shown encouraging results in other studies;[14] moreover
field strength surface coil MRI to illustrate specific it is much cheaper than MRI, hence more feasible.
changes associated with disc derangement, trauma
and previous surgery, other information obtained The transpharyngeal view radiograph provides a
includes the presence of soft tissue ingrowths, fibrosis saggital view of the medial pole of the condyle. In

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 Sinha, et al.: TMJ imaging : 4 Modalities compared

our study, these radiographs were taken at standard by internal derangement type III 30%. Internal
angulations employing standard technique. derangement type I, Degenerative Joint Disease (DJD)
type I and DJD type II was 10%.
Saggital section CT scans were obtained as per
Manzione’s et al. (1984) technique. [15] These were Pseudocyst was found in one patient, osteophytes
obtained by a GE 8800 CT/T machine with scout view were interpreted in two patients and flattening of
and saggital reconstruction capabilities. The blink condylar head was seen in one radiograph. The disc
mode, a computer function that highlights a particular position was seen in 6 CT scans. In other scans it could
tissue density, was also used. Selection of desired not be determined. Osteophytes were present in 20%
density at random enabled the differentiation between patients. Flattening of condylar head were present in
subtle shades of grey that might not be appreciated 10% patients. By MRJ, disc position was determined in
visually. Scans were obtained in mouth open and mouth 90% patients. Fluid effusion was seen in 10% patients.
closed positions and each section was 2 mm apart. The Normal findings were seen in 30% patients. Adhesions
upper and lower levels of the scan were determined on and degenerated disc were not detected.
the lateral scout view, making certain that each condylar
head was scanned. About 12–15 sections were obtained Pseudocyst was not appreciated in any patient by
for each patient. MRI. Osteophytes and flattening were present in 20%
patients in MRI. Disk position was determined in MRI
MRIs of the TMJ were performed on a 1.5 Tesla MR system in 90% patients followed by CT in 60% patients then
of the GE company. Fast scan were used to obtain scout in ultrasound 10% and could not be appreciated in
images to determine the image location v/s anatomic part transpharyngeal view. Fluid effusions were seen in
having a scan time of 52 sec. Following detection of the MRI, in one patient. Degenerated disc and adhesion
optimal image plane, slow scan were obtained at a higher was not interpreted in any patient. Pseudocyst was
resolution of the specific anatomic part. Slow scan had observed in transpharyngeal view in 10% patients,
a scan time of 256 sec. The initial images were obtained while it was not detected CT/MRI in the same patient.
with a saggital plane of focus approximately 1.5 cm deep Osteophytes were detected transpharyngeal view,
to the skin surface anterior to the tragus of the ear. CT and MRI in 20% patients. In ultrasonography,
osteophytes could not be assessed. Flattening of
Ultrasonography was performed using a 10-MHz condylar head was observed in transpharyngeal view,
linear array transducer on an HDI 5000 scanner CT and MRI in 10% patients while was absent in
using standardized protocol to obtain cross sections ultrasound findings.
intersecting the anterior–superior joint compartment in
a saggital to frontal plane. Optimal visualization was CT scan was most sensitive diagnostic technique after
obtained by tilting the transducer. On the sonograms, MRI. Its sensitivity was 83.33% followed by ultrasound
the disc is visualized as a homogenized hypo to 33.33% and transpharyngeal view’s sensitivity 0% for
isoechoic band lying adjacent to the inferior relation soft tissues interpretation. The difference in sensitivity
(overlying the mandible condyle). and specificity differed significantly in different
techniques (P = 0).
Clinical diagnosis was made using CDC.[1] The signs and
symptoms noted were as follows: Pain in pre-auricular Transpharyngeal view and CT scan were the most
region (Unilateral/Bilateral), Clicking/Crepitus/Grating sensitive techniques in interpretation of hard tissue
Sounds, Deviated/Deflected Jaw Movement, Maximal against MRI. Their sensitivity was 100% followed by
Mouth Opening (in mm) besides any other symptom. ultrasound (0% for hard tissue interpretation).

Imaging assessment was done on the basis of bony The difference in diagnostic interpretation in different
changes (Pseudocyst, Osteophyte and Flattening of techniques was not statistically significant. In soft
condylar head), soft tissue changes (Disc Position, tissue assessment, sensitivity of transpharyngeal
Adhesions, Fluid or Inflammatory Changes and view against MRI was found to be 0% and specificity
Degenerated Disc). The above were clinically co-related was 100%. In hard tissue interpretation, sensitivity
and the radiation dose noted. of transpharyngeal view was found to be 100% and
specificity 87.5% against MRI. Interpreting the hard
tissue, sensitivity of CT scan against MRI was found
RESULTS to be 100% while specificity was 87.5%. In soft tissue
interpretation of three cases, sensitivity of ultrasound
Internal derangement (ID) type II was most common against MRI was found to be 33.33% whereas specificity
as per CDC classification of patients at 40% followed of ultrasonography was 100%. Ultrasonography could

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 Sinha, et al.: TMJ imaging : 4 Modalities compared

Correlation of Imaging Techniques with CDC Classification Table l: Demographic, clinical and radiological findings (n
for Temporomandibular Disorder = 10)
Transpharyngeal CT Scan MRI Ultrasound Characteristic Statistic
view Male/Female 4/6
No. % No. % No. % No. % CDC Class
Matched 2 20 4 40 4 40 1 10 Internal derangement type I 1 (10%)
Not matched 8 80 6 60 6 60 9 90 Internal derangement type II 4 (40%)
X = 3.10 (P = 0.37) NS
Internal derangement type III 3 (30%)
Degenerative Joint Disease type I 1 (10%)
Degenerative Joint Disease type II 1 (10%)
Diagnostic interpretation of soft tissue by
Radiation dose transpharyngeal view
Imaging technique Radiation dose (Milli sievert, mSv) Diagnostic interpretation of hard tissue by
Transpharyngeal view 0.05 mSv transpharyngeal view
CT Scan 0.69 mSv Pseudocyst 1 (10%)
MRI - Osteophytes 2 (20%)
Ultrasound - Flattening of condylar head 1 (10%)
CT scan finding of soft tissue s/o disc position 6 (60%)
MRI was most expensive, followed by CT scan, and transpharyngeal view was
CT scan finding of hard tissue
least expensive
Osteophytes 2 (20%)
Flattening of condylar head 1 (10%)
Diagnostic interpretation of soft tissue by MRI
not detect any hard tissue, thus its sensitivity to hard Disc position 9 (90%)
tissue was 0% and specificity was 100%. Fluid effusion inflammatory change 1 (30%)
Diagnostic interpretation of hard tissue by MRI
Osteophytes 2 (20%)
Correlation matched maximum in CT scan and MRI Flattening of condylar head 1 (10%)
(40%), followed by transpharyngeal view (30%) and
minimum in ultrasound (10%) but was statistically
non-significant [Tables 1-3]. Table 2: Comparison of different diagnostic techniques
Diagnostic findings Trans- CT MRI Ultra-
phar- scan sonog-
DISCUSSION yngeal
view
raphy

N % N % N % N %
Our understanding and interest in the diagnosis and Soft tissue
management of patients with various types of TMJ Disc position – – 6 60 9 90 1 10
Adhesion – – – – – – – –
disorders has increased as research has identified Fluid effusion/inflammatory change – – – – 1 10 – –
structural abnormalities and disease mechanisms Degenerated disc – – – – – – – –
associated with some of these disorders. Along with Normal finding – – – – 3 30 – –
Hard tissue
these discoveries, there has also been remarkable Pseudocyst 1 10 – – – – – –
progress in the imaging of the TMJ. Osteophytes 2 20 2 20 2 20 – –
Flattening of condylar head 1 10 1 10 1 10 – –
The aim of present study was to evaluate the efficacy
of transpharyngeal view, X-ray, CT scan and MRI patients (80%) having internal derangement, based
in diagnosing the multitude of TMJ disorders. on the CDC.[1] Transpharyngeal view X-ray was of no
Ultrasound was not included at the start of our study, value in interpreting soft tissue as plain radiographs
but it was included later on as it has shown attractive are unable to depict soft tissue images. In hard tissue
results. interpretation, pseudocyst was diagnosed in one patient
in the glenoid fossa, in the same patient flattening of
In our study group of 10 patients, 2 patients were condylar head and osteophytes were found anteriorly.
diagnosed as having DJD and rest of the patients CT scan and MRI interpreted the same findings in
were diagnosed as having internal derangement (disc the patient. On the other hand, pseudocyst detected
displacement with reduction or without reduction). in transpharyngeal view of one patient could not be
The patients with DJD were of older age group (above detected by other imaging techniques. This may be
35 years of age). DJD is the most common disease explained due to the fact that CT or MRI sections
affecting the TMJ. Radiographic evidence of DJD were made 2 mm apart; the portion of condyle having
occurs in 20%. pseudocyst may not be visualized by CT or MRI.

Internal derangements of the TMJ have been noted In our study there was no statistically significant
in 40–50% of the general population. However, only difference in efficacy of transpharyngeal view, CT scan
a fraction of these individuals require interventional or MRI in interpreting hard tissue. Ultrasound was of
treatment. In our study of 10 cases, we diagnosed 8 no value in interpreting hard tissue. MRI was found

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 Sinha, et al.: TMJ imaging : 4 Modalities compared

Table 3: Diagnostic efficacy of different techniques against MRI

Technique MRI finding Diagnostic efficacy
Positive (n = 9) Negative (n = l)
Positive Negative Positive Negative Sens Spec PPV* NPV**
Soft tissue
Transpharyngeal view 0 9 0 1 0 100 0 10
CT 5 4 1 0 55.6 0.0 83.3 0.0
USG 1 8 0 1 11.1 100.0 100.0 11.1
Hard tissue
Transpharyngeal view 3 0 1 6 100.0 85.7 75.0 100.0
CT 3 0 0 7 100.0 100.0 100.0 100.0
USG 0 0 0 10 0.0 100.0 _ 70.0
Agreement with CDC Classification for TMJ disorders
Transpharyngeal view CT scan MRI Ultrasound
No. % No. % No. % No. %
Matched 2 20 4 40 4 40 1 10
Comparison of Cost of Diagnostic Techniques in Govt. Set-up
Cost in Rs 200/- 2000/- 4000/- 250/-
*
Positive predictive value, **Negative predictive value

to be superior to CT scan or transpharyngeal view, in could detect internal derangement in only one patient
diagnosing DJD.[3] This difference may be due to the fact (33.33%) while MRI detected internal derangement
that our study group was very small. Moreover, MRI in all the three patients (100%). This finding is in
shows early subchondral erosion or disc degeneration, contradiction to that of study of Emshoff et al.,[14] who
more clearly than by other techniques, which are found internal derangement in 92.3% cases by using
indicative of early osteoarthritis or DJD. ultrasonography. This may be due to the fact that we
used 10 MHz probe, whereas Emshoff et al.[14] used 12
Our patients who were initially diagnosed as having MHz probe in sonography. Using ultrasound we could
DJD, by CDC, were divided into DJD type I i.e. arthrosis not assess any bony structure clearly.
with arthralgia and type II i.e. arthrosis without
arthralgia. There was not much difference in their Transpharyngeal view X-ray correlated in only two
imaging presentation (either by transpharyngeal view, cases, which were diagnosed as having DJD as per
CT scan or MRI), in other words either clinical findings CDC[1] and were predictable as this view depicted bony
or imaging alone are not sufficient in diagnosing DJD, structures quite accurately.
rather it should be supplemented by laboratory tests
(such as for rheumatic factor, etc.), for arriving on Diagnosis made by CT scan and MRI could match
definitive diagnosis. In a study of 259 patients, it was only with our four patients’ clinical diagnosis. In the
found that CT scan was superior than arthrograms in remaining 6 patients, it could not be matched and we
depicting osseous changes.[16] Arthrograms were not had to change our clinical diagnosis. There was no
within the scope of this study hence not carried out. difference in radiographic features of type I or type II
internal derangement.
Out of 10 patients, disc position could be determined
in 6 patients only by CT scan, whereas MRI depicted Diagnosis made by transpharyngeal view correlated
position of disc in 9 cases. Moreover fluid effusion or with clinical diagnosis in 20% cases, by CT scan and
inflammatory changes were appreciable in MRI of MRI, it was 40% whereas diagnosis made by ultrasound
one patient clinically, who was diagnosed as having correlated with clinical diagnosis only in 10% cases; but
internal derangement type III. Adhesion or degenerated this was statistically non-significant (P = 0.37).
disc could not be appreciated in any patient probably
because of our small sample size. Rudisch et al.[5] in their study of 69 patients, who had
a clinical diagnosis of unilateral internal derangement
In our study, for soft tissue interpretation, MRI was type III, compared clinical diagnosis with MRI findings
found to be more specific and sensitive than CT. On and found that overall diagnostic agreement for
the other hand, a study has found MRI more specific internal derangement type III was 78.3%. Most of the
and equally sensitive to CT scan (15 TMJs) i.e. MRI disagreement was due to false-positive interpretations
has shown the configuration of the disc more clearly, of an absence of internal derangement. They concluded
thereby causing less false-positive results.[13] that a clinical TMJ-related diagnosis of internal
derangement may need to be supplemented by
In our study, high-resolution ultrasonography was evidence from an MRI to determine the functional
performed on three patients using 10 MHz probe, but disc–condyle relationship [Figures 1-14].

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 Sinha, et al.: TMJ imaging : 4 Modalities compared

Figure 1: Closed Mouth Plain Transpharyngeal View X Ray (Left) Figure 2: Open Mouth Plain Transpharyngeal View X Ray (Left)

Figure 3: Closed Mouth Plain Transpharyngeal View X Ray (Right) Figure 4: Open Mouth Plain Transpharyngeal View X Ray (Right)

Figure 5: Closed Mouth Saggital Section CT Scan (Right)

Figure 6: Open Mouth Saggital Section CT Scan (Right)

CONCLUSIONS
tissues of the joint. MRI provides the most accurate
It was observed that no single imaging modality studied information about the soft tissues of the joint, whereas
can accurately show all changes in the hard and soft CAT provides the most accurate information about hard

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 Sinha, et al.: TMJ imaging : 4 Modalities compared

Figure 7: Closed Mouth Saggital Section CT Scan (Left) Figure 8: Open Mouth Saggital Section CT Scan (Left)

Figure 9: 1.5 Tesla Closed Mouth Saggital Section MRI (Right) Figure 10: 1.5 Tesla Open Mouth Saggital Section MRI (Right)

Figure 11: 1.5 Tesla Closed Mouth Saggital Section MRI (Left) Figure 12: 1.5 Tesla Open Mouth Saggital Section MRI (Left)

tissues changes. The plain transpharyngeal radiograph encouraging from the economic point of view. Although
provides reasonably accurate information regarding the aims of the study included comparing the imaging
hard tissue changes in the joint. Ultrasonography results with CDC, it was not possible to correlate with
provides information only about soft tissue and is any single imaging modality.

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 Sinha, et al.: TMJ imaging : 4 Modalities compared

Figure 13: Closed Mouth High Resolution Ultra Sonograph (10 MHz Probe) Figure 14: Open Mouth High ResoluƟon Ultra Sonograph (10 MHz Probe)
(Right) (Right)

imaging in confirming internal derangement of the temporomandibular

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