Recommendations for Imaging of the Temporomandibular Joint. Position Statement from the American Academy of Oral and Maxillofacial Radiology and the American Academy of Orofacial Pain

This position statement was developed by an ad hoc committee of the American Academy of Oral and Maxillofacial Radiology and the American Academy of Orofacial Pain. The committee reviewed the pertinent literature and drafted recommendations for imaging. This joint statement provides evidence-based recommendations and clinical guidance for applying appropriate diagnostic imaging to evaluate the temporomandibular joint (TMJ). This manuscript guides the design of TMJ imaging examinations, addresses in-office CBCT imaging, and provides timely evidence-based recommendations to evaluate the TMJ bony components, also addressing the use of MRI and other modalities to evaluate TMJ involvement in different pathologic conditions.

1. Brooks SL, Brand JW, Gibbs SJ, et al. Imaging of the temporomandibular joint: A position paper of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:609–618.

2. Schiffman E, Ohrbach R. Executive summary of the Diagnostic Criteria for Temporomandibular Disorders for clinical and research applications. J Am Dent Assoc 2016;147:438–445.

3. Bond EC, Mackay S, English R, Liverman CT, Yost O (eds). Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press, 2020.

4. Slade G, Prevalence Durham J. Impact, and Costs of Treatment for Temporomandibular Disorders. In: Bond EC, Mackay S, English R, Liverman CT, Yost O (eds). Temporomandibular Disorders: Priorities for Research and Care, Washington, DC: The National Academies Press; 2020:361–400.

5. de Leeuw R, Klasser GD (eds). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management, ed 6. Chicago: Quintessence, 2018.

6. Persson RE, Hollender LG, Persson GR. Assessment of alveolar bone levels from intraoral radiographs in subjects between ages 15 and 94 years seeking dental care. J Clin Periodontol 1998;25:647–654.

7. Masood F, Katz JO, Hardman PK, Glaros AG, Spencer P. Comparison of panoramic radiography and panoramic digital subtraction radiography in the detection of simulated osteophytic lesions of the mandibular condyle. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:626–631.

8. Mawani F, Lam EW, Heo G, McKee I, Raboud DW, Major PW. Condylar shape analysis using panoramic radiography units and conventional tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:341–348.

9. Ruf S, Pancherz H. Is orthopantomography reliable for TMJ diagnosis? An experimental study on a dry skull. J Orofac Pain 1995;9:365–374.

10. Ahn SJ, Baek SH, Kim TW, Nahm DS. Discrimination of internal derangement of temporomandibular joint by lateral cephalometric analysis. Am J Orthod Dentofacial Orthop 2006;130:331–339.

11. Barghan S, Tetradis S, Mallya S. Application of cone beam computed tomography for assessment of the temporomandibular joints. Aust Dent J 2012;57(suppl 1):s109–s118.

12. Zain-Alabdeen EH, Alsadhan RI. A comparative study of accuracy of detection of surface osseous changes in the temporo-mandibular joint using multidetector CT and cone beam CT. Dentomaxillofac Radiol 2012;41:185–191.

13. Lukat TD, Perschbacher SE, Pharoah MJ, Lam EW. The effects of voxel size on cone beam computed tomography images of the temporomandibular joints. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:229–237.

14. Al-Ekrish AA, AlKofide EA, Al-Shawaf MD, et al. Impact of rou-tine open-mouth osseous temporomandibular joint tomography on diagnosis and therapeutic options. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;123:508–514.

15. Ahmad M, Hollender L, Anderson Q, et al. Research diagnostic criteria for temporomandibular disorders (RDC/TMD): Development of image analysis criteria and examiner reliability for image analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:844–860.

16. Alkhader M, Ohbayashi N, Tetsumura A, et al. Diagnostic performance of magnetic resonance imaging for detecting osseous abnormalities of the temporomandibular joint and its correlation with cone beam computed tomography. Dentomaxillofac Radiol 2010;39:270–276.

17. Larheim TA, Abrahamsson AK, Kristensen M, Arvidsson LZ. Temporomandibular joint diagnostics using CBCT. Dentomaxillofac Radiol 2015;44:20140235.

18. Whyte A, Matias MATJ. Imaging of orofacial pain. J Oral Pathol Med 2020;49:490–498.

19. Maillet M, Bowles WR, McClanahan SL, John MT, Ahmad M. Cone-beam computed tomography evaluation of maxillary sinusitis. J Endod 2011;37:753–757.

20. Whyte A, Boeddinghaus R. Imaging of odontogenic sinusitis. Clin Radiol 2019;74:503–516.

21. Estrela C, Guedes OA, Silva JA, Leles CR, Estrela CR, Pécora JD. Diagnostic and clinical factors associated with pulpal and periapical pain. Braz Dent J 2011;22:306–311.

22. Salineiro FCS, Kobayashi-Velasco S, Braga MM, Cavalcanti MGP. Radiographic diagnosis of root fractures: A system-atic review, meta-analyses and sources of heterogeneity. Dentomaxillofac Radiol 2017;46:20170400.

23. Vaz de Souza D, Schirru E, Mannocci F, Foschi F, Patel S. External cervical resorption: A comparison of the diagnostic efficacy using 2 different cone-beam computed tomographic units and periapical radiographs. J Endod 2017;43:121–125.

24. Brady E, Mannocci F, Brown J, Wilson R, Patel S. A comparison of cone beam computed tomography and periapical radiography for the detection of vertical root fractures in non-endodontically treated teeth. Int Endod J 2014;47:735–746.

25. Special Committee to Revise the Joint AAE/AAOMR Position Statement on use of CBCT in Endodontics. AAE and AAOMR joint position statement: Use of cone beam computed tomog-raphy in endodontics 2015 update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;120:508–512.

26. Ahmad M, Schiffman EL. Temporomandibular joint disorders and orofacial pain. Dent Clin North Am 2016;60:105–124.

27. Campos DES, de Araújo Ferreira Muniz I, de Souza Villarim NL, et al. Is there an association between rheumatoid arthritis and bone changes in the temporomandibular joint diagnosed by cone-beam computed tomography? A systematic review and meta-analysis. Clin Oral Investig 2021;25:2449–2459.

28. Goupille P, Fouquet B, Cotty P, Goga D, Mateu J, Valat JP. The temporomandibular joint in rheumatoid arthritis. Correlations between clinical and computed tomography features. J Rheumatol 1990;17:1285–1291.

29. Goupille P, Fouquet B, Cotty P, Goga D, Valat JP. Direct coronal computed tomography of the temporomandibular joint in patients with rheumatoid arthritis. Br J Radiol 1992;65:955–960.

30. Mupparapu M, Oak S, Chang YC, Alavi A. Conventional and functional imaging in the evaluation of temporomandibular joint rheumatoid arthritis: A systematic review. Quintessence Int 2019;50:742–753.

31. Rehan OM, Saleh HAK, Raffat HA, Abu-Taleb NS. Osseous changes in the temporomandibular joint in rheumatoid arthritis: A cone-beam computed tomography study. Imaging Sci Dent 2018;48:1–9.

32. Voog U, Alstergren P, Eliasson S, Leibur E, Kallikorm R, Kopp S. Inflammatory mediators and radiographic changes in temporomandibular joints of patients with rheumatoid arthritis. Acta Odontol Scand 2003;61:57–64.

33. Helenius LM, Tervahartiala P, Helenius I, et al. Clinical, radio-graphic and MRI findings of the temporomandibular joint in patients with different rheumatic diseases. Int J Oral Maxillofac Surg 2006;35:983–989.

34. Mercuri LG, Handelman CS. Idiopathic condylar resorption: What should we do? Oral Maxillofac Surg Clin North Am 2020;32:105–116.

35. Sansare K, Raghav M, Mallya SM, Karjodkar F. Management-related outcomes and radiographic findings of idiopathic condylar resorption: A systematic review. Int J Oral Maxillofac Surg 2015;44:209–216.

36. Exposto CR, Stoustrup P, Kristensen KD, Dalstra M, Pedersen TK. Condylar changes in patients with idiopathic condylar resorption: Retrospective 2-year follow-up CBCT-based case-control study. Eur J Orthod 2020:cjz099. Epub ahead of print 9 February.

37. Lee LM, Zhu YM, Zhang DD, Deng YQ, Gu Y. Synovial chondromatosis of the temporomandibular joint: A clinical and arthroscopic study of 16 cases. J Craniomaxillofac Surg 2019;47:607–610.

38. Meng J, Guo C, Yi B, Zhao Y, Luo H, Ma X. Clinical and radiologic findings of synovial chondromatosis affecting the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:441–448.

39. Zhao W, Ruan Y, Zhang W, Yang F. Synovial chondromatosis of the temporomandibular joint with 400 loose bodies: A case report and literature review. J Int Med Res 2021;49:3000605211000526.

40. Liu X, Huang Z, Zhu W, Liang P, Tao Q. Clinical and imaging findings of temporomandibular joint synovial chondromatosis: An analysis of 10 cases and literature review. J Oral Maxillofac Surg 2016;74:2159–2168.

41. Crow HC, Parks E, Campbell JH, Stucki DS, Daggy J. The utility of panoramic radiography in temporomandibular joint assessment. Dentomaxillofac Radiol 2005;34:91–95.

42. Hintze H, Wiese M, Wenzel A. Comparison of three radiograph-ic methods for detection of morphological temporomandibular joint changes: Panoramic, scanographic and tomographic examination. Dentomaxillofac Radiol 2009;38:134–140.

43. Honey OB, Scarfe WC, Hilgers MJ, et al. Accuracy of cone-beam computed tomography imaging of the temporo-mandibular joint: Comparisons with panoramic radiology and linear tomography. Am J Orthod Dentofacial Orthop 2007;132:429–438.

44. Kaimal S, Ahmad M, Kang W, Nixdorf D, Schiffman EL. Diagnostic accuracy of panoramic radiography and MRI for detecting signs of TMJ degenerative joint disease. Gen Dent 2018;66:34–40.

45. Nozawa M, Ogi N, Ariji Y, et al. Reliability of diagnostic imaging for degenerative diseases with osseous changes in the tem-poromandibular joint with special emphasis on subchondral cyst. Oral Radiol 2020;36:156–162.

46. Chouinard AF, Kaban LB, Peacock ZS. Acquired abnormali-ties of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 2018;30:83–96.

47. Sun R, Sun L, Sun Z, et al. A three-dimensional study of hemi-mandibular hyperplasia, hemimandibular elongation, solitary condylar hyperplasia, simple mandibular asymmetry and condylar osteoma or osteochondroma. J Craniomaxillofac Surg 2019;47:1665–1675.

48. Nolte JW, Verhoeven TJ, Schreurs R, et al. 3-dimensional CBCT analysis of mandibular asymmetry in unilateral condylar hyperplasia. J Craniomaxillofac Surg 2016;44:1970–1976.

49. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989;115:469–477.

50. Chantaracherd P, John MT, Hodges JS, Schiffman EL. Temporomandibular joint disorders’ impact on pain, function, and disability. J Dent Res 2015;94(suppl 3):s79–s86.

51. Larheim TA. Role of magnetic resonance imaging in the clinical diagnosis of the temporomandibular joint. Cells Tissues Organs 2005;180:6–21.

52. Sano T, Widmalm SE, Yamamoto M, et al. Usefulness of proton density and T2-weighted vs. T1-weighted MRI in diagnoses of TMJ disk status. Cranio 2003;21:253–258.

53. Matsubara R, Yanagi Y, Oki K, et al. Assessment of MRI findings and clinical symptoms in patients with temporomandibular joint disorders. Dentomaxillofac Radiol 2018;47:20170412.

54. Afrooz PN, Bykowski MR, James IB, Daniali LN, Clavijo-Alvarez JA. The epidemiology of mandibular fractures in the United States, Part 1: A review of 13,142 cases from the US National Trauma Data Bank. J Oral Maxillofac Surg 2015;73:2361–2366.

55. Sawazaki R, Lima Júnior SM, Asprino L, Moreira RW, de Moraes M. Incidence and patterns of mandibular condyle fractures. J Oral Maxillofac Surg 2010;68:1252–1259.

56. Wilson IF, Lokeh A, Benjamin CI, et al. Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures. Plast Reconstr Surg 2001;107:1369–1375.

57. Schimming R, Eckelt U, Kittner T. The value of coronal computer tomograms in fractures of the mandibular condylar process. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:632–639.

58. Dwivedi AN, Tripathi R, Gupta PK, Tripathi S, Garg S. Magnetic resonance imaging evaluation of temporomandibular joint and associated soft tissue changes following acute condylar injury. J Oral Maxillofac Surg 2012;70:2829–2834.

59. Warner BF, Luna MA, Robert Newland T. Temporomandibular joint neoplasms and pseudotumors. Adv Anat Pathol 2000;7:365–381.

60. Koga M, Toyofuku S, Nakamura Y, Yoshiura K, Kusukawa J, Nakamura Y. Osteochondroma in the mandibular condyle that caused facial asymmetry: A case report. Cranio 2006;24:67–70.

61. Yibulayin F, Yu CX, Feng L, et al. Malignant tumours of temporomandibular joint. BMC Cancer 2020;20:967.

62. Kirschnick LB, Schuch LF, Cademartori MG, Vasconcelos ACU. Metastasis to the oral and maxillofacial region: A systematic review. Oral Dis 2022;28:23–32.

63. Oliver-Puigdomènech C, González-Navarro B, Polis-Yanes C, Estrugo-Devesa A, Jané-Salas E, López-López J. Incidence rate of metastases in the oral cavity: A review of all metastatic lesions in the oral cavity. Med Oral Patol Oral Cir Bucal 2021;26:e619–e625.

64. Daley T, Darling MR. Metastases to the mouth and jaws: A contemporary Canadian experience. J Can Dent Assoc 2011;77:b67.

65. Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic tumours to the oral cavity - pathogenesis and analysis of 673 cases. Oral Oncol 2008;44:743–752.

66. Miles BA, Schwartz-Dabney C, Sinn DP, Kessler HP. Bilateral metastatic breast adenocarcinoma within the temporomandibular joint: A case report. J Oral Maxillofac Surg 2006;64:712–718.

67. Nel C, Uys A, Robinson L, Nortjé CJ. Radiological spectrum of metastasis to the oral and maxillofacial region. Oral Radiol 2022;38:37–48.

68. Chen MJ, Yang C, Qiu YT, Zhou Q, Huang D, Shi HM. Osteochondroma of the mandibular condyle: A classification system based on computed tomographic appearances. J Craniofac Surg 2014;25:1703–1706.

69. Honda K, Larheim TA, Maruhashi K, Matsumoto K, Iwai K. Osseous abnormalities of the mandibular condyle: Diagnostic reliability of cone beam computed tomography compared with helical computed tomography based on an autopsy material. Dentomaxillofac Radiol 2006;35:152–157.

70. Li C, Men Y, Yang W, Pan J, Sun J, Li L. Computed tomography for the diagnosis of mandibular invasion caused by head and neck cancer: A systematic review comparing contrast-enhanced and plain computed tomography. J Oral Maxillofac Surg 2014;72:1601–1615.

71. American College of Radiology. ACR-ASNR-SPR Practice parameter for the performance of magnetic resonance imaging (MRI) of the head and neck. 2022. Accessed 8 February 2023. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR-HeadNeck.pdf

72. American College of Radiology. ACR-ASNR-SPR Practice parameter for the performance of computed tomography (CT) of the extracranial head and neck. Revised 2021. Accessed 8 February 2023. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-Head-Neck.pdf

73. Shintaku WH, Venturin JS, Langlais RP, Clark GT. Imaging modalities to access bony tumors and hyperplasic reactions of the temporomandibular joint. J Oral Maxillofac Surg 2010;68:1911–1921.

74. Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:106–114.

75. Kadesjö N, Benchimol D, Falahat B, Näsström K, Shi XQ. Evaluation of the effective dose of cone beam CT and multislice CT for temporomandibular joint examinations at optimized exposure levels. Dentomaxillofac Radiol 2015;44:20150041.

76. Jordan DW, Becker M, Brady S, et al. ACR Appropriateness Criteria Radiation Dose Assessment Introduction. Revised February 2020. Accessed 8 February 2023. https://www. acr.org/-/media/ACR /Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf