· Advances in Medical Sciences© ·Medical

Vol. 57(1) · 2012 · pp 157-162 · DOI: 10.2478/v10039-012-0007-9

University of Bialystok, Poland

Comparison of reference points in different methods

of temporomandibular joint imaging
Gedrange T1*, Gredes T2, Hietschold V3, Kunert-Keil C2, Dominiak M4, Gerber H4,
Spassov A2, Laniado M3
1 Department of Orthodontics, Carl Gustav Carus Campus, TU Dresden, Dresden, Germany
2 Department of Orthodontics, Ernst Moritz Arndt University Greifswald, Greifswald, Germany
3 Institute and Policlinic for Radiological Diagnostics, University Clinic of TU Dresden, Dresden, Germany
4 Department of Dental Surgery, Silesian Piast Medical University, Wroclaw, Poland

* CORRESPONDING AUTHOR:
Department of Orthodontics Received 28.07.2011
Carl Gustav Carus Campus Accepted 11.01.2012
Fetscherstr. 74 Advances in Medical Sciences
D- 01307 Dresden, Germany Vol. 57(1) · 2012 · pp 157-162
Tel.: +(49) 351 / 458-2718; Fax.: +(49) 351/ 458-5318 DOI: 10.2478/v10039-012-0007-9
Email: [email protected] (Tomas Gedrange) © Medical University of Bialystok, Poland

ABSTRACT
Purpose: Conventional radiography is a well-established method for imaging of the temporomandibular joint (TMJ) structures.
However, the dental computer tomography becomes more important for the visualization of teeth in the jaw-bone. The
applicability of dental computer tomography for the visualization of the TMJ it not yet been proven. The aim of the study was
to identify TMJ structures using reference points with the magnetic resonance imaging (MRI) and the computed tomography
(CT).
Methods: In order to compare the visualization and measurement of the TMJ a total of eight human cadaver heads was
examined with CT and MRI and analysed using reference points.
Results: In both imaging techniques the selected reference points and distances are well definable and allow objective
evaluation of anatomical structures. The CT images display a clearly better contrast to noise ratio than the MR images. The
distance measurement of different width and length showed significant correlation of both images techniques.
Conclusions: In TMJ diagnostics, maximum information could be obtained using both imaging techniques together due to
synergistic effects.

Key words: temporomandibular joint, computed tomography, magnetic resonance imaging

Introduction For MRI which does not imply the use of ionizing radiation,
hydrogen-based images are computed using magnetic
The temporomandibular joint (TMJ) is among the most field gradients by means of Fourier transformation of
complex and intricate structures of the human organism. high-frequency signals after local coding. Technical details of
A disorder of this structure, therefore, requires imaging this technique have been described by Benbelaid et al. [1,2].
of anatomical and pathological forms. Diagnostics is a Meanwhile, both imaging techniques have become standard
challenge due to the small dimensions of these structures and techniques for the examination of the TMJ and complement
the position of the temporomandibular joint as well as the one another. The indication for such an examination and, thus,
wide variety of pathological processes. For a long time the the choice of the imaging technique depends upon the question
magnetic resonance imaging (MRI) was the standard method at stake.
for imaging of the TMJ. However, the dental computer However, the applicability is not completely proven by
tomography (CT) becomes more important for the using CT imaging to this time point. Furthermore, following
visualization of teeth in the jaw-bone. CT as a radiological radiological diagnostics, documentation of the proceeding
procedure was among the first tomographic techniques pathological processes or therapy outcomes poses a problem.
computing images from a number of projections. Until now, reported findings show only limited reproducibility
158 Comparison of reference points in different methods of temporomandibular joint imaging

Figure 1. Anatomical composition of the TMJ. Figure 2. 2D imaging of the TMJ using computed tomography
(CT).

Figure 3. 2D imaging of the TMJ using magnetic resonance

imaging (MRI). conditions. The anatomical situation (Fig. 1), the CT image
(Fig. 2) and the MR image of the respective sagittal sectional
plane (Fig. 3) are demonstrated by an example case.

Topographic relations in the morphological samples

In the TMJ, the mandibular head articulates with the temporal
bone in the mandibular fossa. The roof of the glenoid fossa
slopes forward, toward the articular tubercle which is very thin
and projects to the mid-cranial fossa. Behind the TM joint the
external acoustic porous is located which is delimited by the
tympanic and the squamous part of the temporal bone. Between
TMJ and ear, the superficial temporal artery and vein as well
as the auriculotemporal nerve run to the epicranium. Medially,
the petrotympanic (Glaserian) fissure is located permitting the
passage of the parasympathic tympanic chord.
Behind the ear, the mastoid process is located which is part
of the temporal bone. It is filled with air chambers, so called
due to missing reference points. Moreover, even if disc
mastoid cells. Its growth is not completed until postnatally
replacement was diagnosed, the metrical extent of the changes
by the tractional force of the sternocleidomastoid muscle. At
could not be given.
the medial side of the mastoid process, the mastoide incisure
This paper presents a morphological comparison of
has developed to harbour a tendon. Medially, the sulcus of
TMJs subjected to CT and MRI examination. The analysis
occipital artery is found.
of reference points and lines obtained from the study images
were compared to anatomical findings. Computed tomography (CT), magnetic resonance
imaging (MRI)
Images of each TMJ were obtained with both techniques in
Material and Method maximal intercuspidation [3]. The sagittal tomographs were
taken at right angle to the condylar longitudinal axis. In
Study material coronal view, the sections were orientated in parallel to the
For quantitative analysis of the TMJs, shape and position of condylar longitudinal axis.
the mandibular condyles, articular fossae and mandibular The computer tomographic examinations were performed
rami, the data sets of CT and MRI of 8 human cadaver heads using the Somaton Sensation 16 (Siemens, Erlangen,
were analysed (Ethics No. III UV 46/06). None of the 16 TMJs Germany). Scanning was continued from the upper border of
displayed any pathological alterations. Subsequently, the the hyoid bone to the inferior margin of the orbita. The standard
joints were analysed macroscopically. The CT and MR images program for cranial images was used for examination with the
were obtained at the Institute and Policlinic of Radiological following parameters: voltage 120 kV at 250 mA; scanning
Diagnostics, University Clinic of TU Dresden. The CT and time 1 s, slice thickness 0.6 mm. The technical details have
MRI examinations were performed under standardized been described by [4,5].
Gedrange T et al. 159

Figure 4. Schematic diagram of the TMJ with articular disc, 5. msjs (maximum superior joint space) = distance between
reference points: superior most point of the condylar head and the inferior
A. Measurement of joint space width and condylar width
most point of the glenoid fossa at right angle to the Frankfurt
B. Measurement of fossa length, height, width
C. Measurement of the slope of fossa surfaces Horizontal (FH) projected to the glenoid fossa
D. Measurement of condyle and tubercle curvatures 6. fw = (fossa width) = distance between the inferior most point
E. Measurement of disc length and position of the articular tubercle and the posterior condylar process
7. fd = (fossa depth) = distance between the inferior most point
of the glenoid fossa at right angle projected to the fossa-width
tangent
PM PP 8. eh = (eminence height) = tubercle height = distance from the
TA inferior most point of the articular tubercle projected at right
angle to the tangent of the superior most joint point parallel
to the FH
9. pgph = (postglenoid process height) = condylar process
height = distance from the inferior most point of the condylar
process projected at right angle to the tangent of the superior
most joint point parallel to the FH
10. ec - fd = (eminence crest - fossa depth) = distance between
the articular tubercle to the inferior most point of the glenoid
Similarly, MR tomographs of each TMJ were taken in the fossa
sagittal and coronal plane. MRI examinations were performed 11. dl = (disc length) = maximum disc length at mouth
using a NMR scanner (Siemens Avanto, magnetic field strength opening
1.5 Tesla) with surface coils for the TMJ. The Double Loop 12. esa = (eminence slope angle) = condylar path inclination
Array was used as receiver coil. The images relevant to the angle = angle between the condylar path tangent and the line
subsequent analyses were produced with a DESS sequence at connecting the articular tubercle and the posterior condylar
TR=19 ms and TE=5.6 ms (image matrix 320*320). Moreover, process
T1-FLASH-, T1 spin-echo and TSE double echo sequences 13. pwsa = (posterior wall slope angle) = posterior glenoid
(proton and T2 weighted) were used at 0.8 to 1.5 mm slice fossa angle = angle between the tangent of the posterior glenoid
thickness. fossa slope and the line connecting the articular tubercle and
For a good view of the TMJ, the MR tomographs were the posterior condylar process
taken in two planes – sagitally and coronally. The image was 14. er = (eminence radius) = radius of articular tubercle = radius
taken at maximum intercuspation (IKP). of the circle positioned between 6 and 9 o’clock position of the
From the CT data sets, tomograph orientation identical to articular tubercle
the MR images was obtained using multiplanar reformatting. 15. cr = (condyle radius) = radius of the circle positioned
between 12 and 3 o’clock position of the condylar head
Measurement variables of the TMJ in CT or MR 16. TA = (tuberculum articulare) = inferior most point of the
images articular tubercle
The following measurement points were used both for CT and 17. PM = (processus mastoideus) = inferior most point of the
MR images (Fig. 4). These variables were have been defined mastoid process
by Pullinger and Seligman [6]. They comprise 13 linear, 2 18. PP = (postglenoid process) = inferior most point of the
angular and 8 ratio variables (Fig. 4). They have been routinely condylar process
used for CT and MRT images by many other authors [7].
Ratio variables of the TMJ
1. pjs (posterior joint space) = smallest distance between The morphological points are well definable by local grey-
glenoid fossa and condylar head in the posterior joint area scale variations.
2. ajs (anterior joint space) = smallest distance between glenoid
fossa and condylar head in the anterior joint area 1) cpi = condyle position index
3. cw (condyle width) = distance between intersections of the cpi = 100 x [(pjs – ajs) / (pjs + ajs)] %
anterior and posterior condylar haed borders with the tangent positive sign = condyle anteriorly positioned
to inferior most points of the articular tubercle and the posterior negative sign = condyle posteriorly positioned
condylar process 2) ajs / pjs (anterior joint space / posterior joint space)
4. asjs (absolute superior joint space) = distance between > 1 → anterior condyle position
the superior most point of the condylar head and the inferior < 1 → posterior condyle position
most point of the glenoid fossa at right angle to the Frankfurt 3) log ajs / pjs → higher value indicates an extremely posterior
Horizontal (FH) projected to the condylar head condyle position
160 Comparison of reference points in different methods of temporomandibular joint imaging

Figure 5. The strength of correlation between the CT and MR Figure 6. The strength of correlation between the CT and MR
(measurement of joint space width and condylar width and (measurement of the slope of fossa surfaces and measurement
measurement of fossa length, height, width; Fig. 4 A and B) of condyle and tubercle curvatures; Fig. 4 C and D) based
based measurements was evaluated by Spearman’s correlation measurements was evaluated by Spearman’s correlation coefficient
coefficient and its square - the coefficient of determination. and its square - the coefficient of determination.

4) fw / cw = fossa width / condyle width = relation between (indicates position and shape of anterior disc border), low
condyle size and fossa size (higher values indicate a relatively values = posterior disc position in the joint space; higher
small condyle) values = anterior disc position in the joint space
5) eh / pgph = tubercle height / condylar process height (higher The images can be analyzed using digital image-processing
values indicate a relatively great tubercle height) software such as ImageJ 1.42 for Windows.
6) asjs / ajs = absolute superior joint space / anterior joint space
(indicates shape of anterior joint space, see 7) Statistical analysis
7) msjs / ajs = maximal superior joint space / anterior joint Statistical data analysis was performed using SPSS for
space (indicates shape of anterior joint space) low values = Windows software. Analysis included means and median
open wedge shape of anterior joint space; higher values = values as well as standard deviations, maximum and minimum
parallel anterior disc space values. Methods were compared by means of linear regression
8) fw / fd = fossa width / fossa depth; higher values = shallow analysis. The deviation of estimated regression coefficients
fossa; small values = narrow fossa and axis sections from expected values (1 or 0) was tested by
For assessment of the articular disc, variables and distances Student’s t-test at a significance level of 5 % (P ≤ 0.05).
for disc measurement were added (Fig. 4E). First, the right and left sides of the mandible were tested
for significant differences using Mann-Whitney’s test (alpha =
Lines for articular disc measurement 0.05). Since differences were non-significant, the data sets were
1. fw = (fossa width) = distance between the inferior most point pooled. The strength of correlation between the CT and MR
of the articular tubercle and the posterior condylar process based measurements was evaluated by Spearman’s correlation
2. fwp = Perpendicular to fossa width = reference line for the coefficient and its square - the coefficient of determination.
variables, first contact point in the posterior condylar process
3. pd = posterior disc = distance between the posterior disc
border and the fossa width perpendicular (fwp) Results
4. ad = anterior disc = distance between the anterior disc border
and the fossa width perpendicular (fwp) Altogether, eight heads were analysed with both techniques
5. dl = total length of articular disc computed tomography (CT) and magnetic resonance imaging
6. adl = anterior disc length = distance between anterior disc (MRI). The CT images display a clearly better contrast to noise
border and fossa width (fw) ratio than the MR images. The bony structures are shown signal
free on the MR images. Owing to the better soft tissue contrast
Ratio variables of articular disc in the MR images, however, the position of the articular disc in
1) pd / fw = distance from posterior disc border / fossa width relation to the articular fossa and the condylar process are very
(indicates position and shape of posterior disc border), low well displayed. Soft-tissue structures such as the articular disc
values = posterior disc position in the joint space; higher are unidentifiable on any CT image (Fig. 2-3).
values = anterior disc position in the joint space
2) ad / fw = distance from anterior disk border / fossa width
Gedrange T et al. 161

The magnification factor of the respective images (MR The suitability of the CT technique for imaging of the joint
and CT) was taken into account for linear measurements. cartilage is limited. Cartilage imaging, however, is crucially
Schematic diagrams of the TMJ with articular disc and important for assessment of overload or adaptive processes in
reference points are shown in Fig. 4. Direct comparison of the TMJ area [14-16].
the measurement points (in the sagittal and coronal planes) In contrast, MRI permits valid and reproducible assessment
applied to the CT and MR images failed to reveal statistically of joint cartilage morphology [17, 18]. In comparison
significant differences between the dimensions of the osseous to computed tomography with its superior sensitivity to
structures. mineralized tissue imaging, MRI is applicable particularly for
In contrast, the distance measurement of the joint space early detection of alterations in the cartilage area. Currently,
width and condylar width (Fig. 4A) as well as the measurement therefore, imaging diagnostics of discopathies and disc
of fossa length, height and width (Fig. 4B) showed a displacement largely relies upon MRI findings. Osseous
significant correlation between both techniques (R²=0.987; structures need to exhibit an estimated 40 to 60 % decalcification
n=160); (Fig. 5). Furthermore, the measurement of angle and to permit detection of changes in the MR images. Based on
TMJ diameter (measurement of the slope of fossa surfaces the studies, Gaudy et al. [19] and Taskaya-Yilmaz et al. [20]
and measurement of condyle and tubercle curvatures; Fig. 4C consider intra-disc perforations as diagnosable. In contrast,
and D) on the CT images significantly correlates with those Benbelaid et al. [1] recommended caution in MR topographic
from MRI (R²=0.982; n=64); (Fig. 6). diagnosis of disc perforations. Another disadvantage of MR
tomography is the poor imaging of fractures, e.g., after an
acute condylar fracture [11, 21].
Discussion In various pathological deformations and degenerative
changes, CT imaging of the osseous structures has been shown
Assessment of the TMJ is very well feasible with both methods to be superior to MR tomography [2, 22] due to both the
(CT and MRI). The complexity of the anatomical structure hitherto higher resolution of computed tomography and the
requires a multitude of measuring points. The findings of the lack of bone signal in MR imaging. Moreover, metric analysis
study substantiate the significance of both examination methods is superior in CT procedures.
for diagnosing TMJ alterations. Since the TMJ is subject to In contrast to MRI, the CT technique implies radiation
continuous remodelling processes, numerous reference points exposure, however provides high-quality information on the
need to be used for TMJ measurement [6, 8]. The inferior most osseous structures. Computed tomography yields reliable
points of the mastoid process (PM) and the articular tubercle evidence of morphological TMJ alterations especially in long-
(TA) proved to be the most reliable ones. The inferior most lasting dysfunctions and distinct clinical symptoms.
point of the condylar process (PP) is difficult to determine in
CT and MR images due to its proximity to the acoustic porous.
One reason for the difficulties on the direct transfer of the Conclusion
reference points could be the variably contrasted imaging of
the anatomical structures in the respective examination. Excellent imaging of anatomical structures of the TMJ can
Numerous alterations and the variability of the TMJ may be achieved with MR and CT. Owing to the high-quality
be recorded with these methods which bear significance also topographical imaging of the condylar head and fossa,
for anatomical studies [3, 9]. The diagnosis of the TMJ gains computed tomography is the diagnostic method of choice for
more and more in importance as patient diseases increase. osseous structures. Using selected breakpoints it is possible
International literature has provided frequent reports on the to compare both techniques. Topometric mapping of the joint
diversity and variability of clinical and radiological symptoms structures during motion permits detection of pathological
in the maxillofacial area [10-12]. hard and soft tissue changes even without disc imaging. MRI
Computed tomography should be used as diagnostic method serves as an adjunctive method for special cartilage or soft
if TMJ disorders are associated with altered bone density or tissue issues.
fractures. Assessment of density in different directions has
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