Tmj imaging

Imaging modalities of TMJ

1. TMJ Imaging Dr.Manisha Saxena 2 nd year PG Oral medicine and Radiology 19-03-2021

2. Contents Introduction to TMJ Imaging Modalities of TMJ 1. Imaging of osseous structures 2. Imaging of soft tissues 3. Abnormal Findings in TMJ 4. References 19-03-2021

3. Structure of TMJ 19-03-2021

4. Anatomy of TMJ TMJ is a ginglymo-diarthroidal joint that is freely mobile with superior and inferior joint spaces separated by articular disc. “Ginglymus” meaning a hinge joint, allowing motion only backward and forward in one plane, “ Arthrodia ” meaning a joint of which permits a gliding motion of the surfaces 19-03-2021

5. Components of TMJ 1. Glenoid Fossa & Articular Eminence/Protuberance 2. Mandibular Condyle 3. Articular Disk & Capsule 4. Synovial Fluid 5. Discal Ligaments 6. Posterior Attachment or Retrodiscal Tissue or Bilaminar Zone 7. Ligaments associated with TMJ 8. Muscles of Mastication 19-03-2021

6. TMJ imaging technique 1. Plain radiography 2. Panormic radiography 3.CBCT 4. Ultrasonography 5. MRI 19-03-2021

7. TMJ Imaging Osseous structure Soft tissue Plain radiography Panormic radiography CT CBCT Arthrography MRI USG 19-03-2021

8. Imaging of osseous structure 19-03-2021

9. Plain radiography( Transcranial) Most common and most well-established plain film technique for TMJ This disadvantage is partly compensated for by the fact that most of the early osseous changes occur laterally in the joint. It visualize the sagittal view of the lateral aspects of condyle and temporal component. It is taken in open and close mouth positions. TMJ Imaging: A Review . Irfan Ashraf Baba. . International Journal of Contemporary Medical Research , Volume 3 | Issue 8 | August 2016 An intensifying screen of 7 to 15 impulses with a fast film and exposure time at 65 kVp and 10 mA is used. 19-03-2021

10. Film position: • flat against patients ear • Centered over TM joint of interest • Against facial skin parallel to sagittal plane Position of patient: Head adjusted so sagittal plane is vertical & ala tragus line parallel to floor Central Ray 1. The central ray is direct at an angle of 250 (+ ve angulation) from the opposite side, through the cranium and above the petrous ridge of the temporal bone. 2. The horizontal angulation can be individually corrected for the condylar long axis, or an average 200 anterior angle may be used. 19-03-2021

11. Transcranial view in closed and open mouth position 19-03-2021

12. Transpharyngeal view Central ray- D irected from opp side cranially at angle(-5 to -10 degrees) Beneath the zygomatic arch, through sigmoid notch posteriorly across pharynx at the condyle Comparison of both condylar heads Film placement - Patient holds the cassette flat against patients Ear Centered over TM joint of interest. Against facial skin parallel to sagittal plane ½ inch anterior to EAM. It give a sagittal view of the medial pole of condyle. The patient's mouth is open and a bite block is insert for stability. 19-03-2021

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14. Transorbital projection A anterior view of the TMJ, perpendicular to transcranial and transpharyngeal projections. It is done in open mouth position and depicts entire medial-lateral aspect of condyle. The cassette is placed behind the patient's head, perpendicular to the x- ray beam. The patient open the mouth maximally . This view is useful for visualize the condyle fractures. X- ray beam is directed from the front of the patient through the ipsilateral orbit from medial canthus of eye and TMJ of interest. TMJ Radiography ( Imaging) 19-03-2021

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16. Film position – Behind the head Patient position – Cathomeatal line should be 10 degree to the horizontal with the head tipped downwards. Central ray – Tube head in front of patient near the medial canthus of ipsilateral eye. Directed at an angle of +20 degree to strike at right angle to cassette. 19-03-2021

17. Submentovertex projection Useful for viewing condyles, zygomatic arches, base of skull and sphenoid sinuses. It demonstrate osseous changes from skull base tumors , fractures of zygomatic arches and integrity and aeration of the sphenoid sinuses. Image receptor –Positioned parallel to the patients transverse plane. Patient neck is extended as backwards as possible with cathomeatal line parallel to the image receptor. Central beam is directed perpendicular to the image receptor, from below the mandible towards the vertex of the skull. White and Pharoah’s Oral radiology 19-03-2021

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20. Panormic radiography Panoramic radiography does not appear in the list of imaging techniques provided by RDC/TMD. Only the lateral part of the condyle can be assessed with this technique, being limited due to the superimposition of the zygomatic arch and the base of the skull . Panoramic radiography can help evaluate the following: IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 Degenerative bone changes (only in late stages; it is inadequate for the early detection of osseous modifications); • asymmetries of the condyles, • hyperplasia, hypoplasia; • trauma and tumors • Thick image layers 19-03-2021

21. The panoramic radiography does not reveal the functional status of the joint and has a relatively low specificity and sensitivity when compared with CT . Panoramic radiography: important asymmetry between right and left mandibular condyle IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 19-03-2021

22. Computed Tomography First used for TMJ evaluation in 1980 . CT is considered to be the best method for assessing osseous pathologic conditions of TMJ. It allows a multi planar reconstruction , obtaining 3D images in closed and opened-mouth positions . Signs of degenerative changes in the joint, like surface erosions, osteophytes, remodeling, subcortical sclerosis, can be evaluated . Basically focus on : intactness of the cortex, normal size and shape of the condyles and their centered position in the fossa, the adequate joint spaces, centric relation loading zone. IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 19-03-2021

23. CBCT The main disadvantage of CT, compared to other radiological methods, is the high cost and the radiation exposure. After being introduced in1990, CBCT is now most widely used IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 19-03-2021

24. Studies developed by Hintze et al. found no significant differences between conventional tomography and cone beam CT in the detection of morphological TMJ changes. A review published by Silvia Caruso et al pointed out the main contributions of cone beam CT in the field of TMJ: IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 19-03-2021

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26. Cone beam CT of the right TMJ: flattening and erosions of the mandibular condyle. Sagittal plane (a), coronal plane (b). IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 19-03-2021

27. Cone beam CT of TMJ: left condyle hyperplasia (arrow). Coronal plane (a), axial plane (b). IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 19-03-2021

28. Limitation of CBCT 19-03-2021

29. MRI MRI is currently considered the reference method for imaging the soft tissue structures of the TMJ (articular disc, synovial membrane, lateral pterygoid muscle) . The best imaging modality in diagnosing disc displacements . MRI could also detect the early signs of TMJ dysfunction, like thickening of anterior or posterior band, rupture of retrodiscal tissue, changes in shape of the disc, joint effusion . 19-03-2021

30. Images can be obtained in all planes (sagittal, axial, coronal). T1 weighted images – osseous tissue T2 – Inflammation and joint effusion. PD (proton density) – Visualize disc condyle relationship. 19-03-2021

31. The slice thickness is important for image quality. The most frequent used section thickness is 3 mm. Reducing the slice thickness improves the quality of the images, but requires longer scanning time . Sagittal, proton density, MRI of a normal TMJ: mouth-closed (a), mouth-opened (b). The disc (arrow) is in a correct position 19-03-2021

32. Sagittal, proton density, MRI of an anterior disc displacement with reduction: mouth-closed (a), mouth-opened (b). The displaced disc (arrow) returns to its normal position at maximal mouth opening. 19-03-2021

33. Drawings (sagittal oblique views) illustrate disk displacement in the closed-mouth position. (a) A pathologic condition is considered to be present if the angle between the posterior band and the vertical orientation of the condyle (twelve o’clock position) exceeds 10°. (b) Rammelsberg et al recommended that anterior disk displacement of up to 30° be considered normal to better correlate disk displacement with clinical symptoms of TMJ dysfunction. MR Imaging of Temporomandibular Joint Dysfunction: A Pictorial Review. Xavier Tomas. RadioGraphics 2006; 26:765–781 19-03-2021

34. Limitation of MRI The disadvantages of the MRI investigation - 1. It is costly and time consuming; 2. Restricted use in patients with claustrophobia; 3. There is a possibility of missing the portion of condyle having a pseudo cyst . 19-03-2021

35. Ultrasonography It was first used for TMJ exploration in 1991, by Nabeih et al, using a 3.5 MHz transducer . Scanning transducer of 7.5–12 MHz frequency is presently used. Patient sits in semi reclining position. The transducer is placed over the joint parallel to the long axis of the mandible. The disc is situated between two hyperechoic lines represented by the mandibular condyle and the articular eminence . TMJ Imaging: A Review . Irfan Ashraf Baba. International Journal of Contemporary Medical Research. Volume 3 | Issue 8 | August 2016 19-03-2021

36. During the examination it is possible to directly observe the joint disk move when the mouth is opening and closing. If the disc is displaced in the closed-mouth position, the diagnosis is disc displacement. If the disc returns to its normal position during opening, the diagnosis is disc displacement with reduction A 70–85 % agreement was seen in studies comparing the results of MRI and USG. 19-03-2021

37. High-resolution US of an anterior disc displacement without reduction: mouth-closed (a), mouth-opened (b). 1 - articular eminence; 2 – articular disc; 3 - mandibular condyle IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 19-03-2021

38. Arthrography Nørgaard in the 1940s. Arthrography is indicated for an evaluation of the soft-tissue components of the TMJ, especially disk position, function, and morphology in those patients presenting with a suspected internal derangement . TMJ Imaging: A Review . Irfan Ashraf Baba. International Journal of Contemporary Medical Research. Volume 3 | Issue 8 | August 2016 19-03-2021

39. Radionuclide imaging It is based on radiotracer method, which assumes that radioactive atoms or molecules in an organism behave in a manner identical to that their stable counterparts because they are chemically indistinguishable . The TMJ is ideal for SPECT (single proton emission computed tomography), as TMJ is a small joint situated close to the skull base. In normal individual, the perfusion is symmetrical . Sensitivity is high, its specificity is low. Inflammation , trauma or tumors increase the local isotope concentration. Use as a screening method. TMJ Imaging: A Review . Irfan Ashraf Baba. International Journal of Contemporary Medical Research. Volume 3 | Issue 8 | August 2016 19-03-2021

40. Applied aspect Bifid condyle /double headed condyle Coronal reformatted computed tomography image through the temporomandibular joint (TMJ) demonstrates bifid left mandibular condyle. It can be noted that one of the condyles (arrow) is smaller than the other. Advanced degenerative changes are noted in bilateral TMJ. Imaging of temporomandibular joint.Bag A K et al. WJR.August 28, 2014 | Volume 6 | Issue 8 | 19-03-2021

41. Foramen of Huschke Foramen of Huschke. Sagittal reformatted CT image through the temporomandibular joint demonstrates a focal defect (arrow) in the tympanic plate. Persistence of developmental defect in tympanic plate. With growth , this defect changes in position from inferior to anterior and usually closes by the 5th year of life. Rarely, a 3-4 mm defect p ersists . It act as a path of communication between the EAC and TMJ or infratemporal fossa allowing the spread of infection, inflammation or tumor 19-03-2021

42. Condylar hypoplasia 19-03-2021

43. OPG shows condylar aplasia on the right side, condylar hypoplasia on the left side, prominent antigonial notch, and hypoplasia of mandible. Condylar aplasia and hypoplasia –A rare case. Peeyush Shivhare . Case Report | Open Access Volume 2013 |Article ID 745602 19-03-2021

44. Condylar hyperplasia Increase in volume of condyle Unilateral 2/3 decade of life. Causes- Hormonal influence on osteogenesis, trauma Facial asymmetry Rotating chin towards affected side. Resection of the hyperplastic condyle causes the abnormal growth to cease and restores facial symmetry 19-03-2021

45. Condylar hyperplasia. Panoramic reformation of the source CT data including both the temporomandibular joints of a young patient demonstrates hyperplasia of the left condyle (arrowhead) in comparison to the right side. 19-03-2021

46. Coronoid hyperplasia An elongation of the coronoid process of the mandible. Acquired or developmental Most often diagnosed in young men who have a long history of progressive limitation of mouth opening. Jacob disease- Prejoint develops between hyperplastic coronoid process and posterior surface of zygoma. 19-03-2021

47. First case of bilateral coronoid hyperplasia in monozygotic twin sisters—a new aetiological perspective? Sunil Dixit Khandavilli 16 Sept.2016 pages441–443(2016) 19-03-2021

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49. Idiopathic condylar resorption Condylosis /“cheerleader syndrome. Teenage girls Rapidly progressing condylar erosion resulting in increased joint space. 19-03-2021

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51. Morphologic changes in idiopathic condylar resorption with different degrees of bone loss Author links open overlay panel YifanHeBS Vol.123 issue 3 September 2019, Pages 332-340 19-03-2021

52. Pneumatization Extensive pneumatization of the mastoid bone can involve the glenoid fossa and articular eminence. Important to know before any TMJ surgery Complications can occur during TMJ surgery due to forceful flap retraction, dissection or with placement of screws in cases where fossa-eminence prostheses are required. 19-03-2021

53. Internal derangements of TMJ Internal derangement (ID) is defined as a mechanical fault of the joint that interferes with smooth joint function. Disc displacement is the most common cause of ID. Up to 34% of asymptomatic volunteers can have anterior disc displacement and 23% of patients with derangement can have normal disc positon . The displacement can be anterior, anterolateral , anteromedial, lateral, medial and posterior. Anterior disc displacement can be – with reduction (ADR) without reduction.(ADNR) White and Pharoh’s Principles of Radiology 19-03-2021

54. On MRI, the normal disc has a low signal intensity relative to the signal from the joint space immediately surrounding it. In other words, the disc signal is lower (i.e., darker). In contrast, the signal intensity of the posterior attachment is usually higher (i.e., brighter). the normal biconcave disc has a “bow tie” shape In the closed mouth position, the normal disc is positioned with the thick posterior band located either directly superior to or slightly anterior to the condylar head.(12 ‘o clock) The thin intermediate zone of the disc is located anterior to the condyle. In all positions of mouth opening, the thin intermediate zone should remain the articulating surface of the disc between the condyle and the articular eminence. 19-03-2021

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58. Sagittal proton density weighted magnetic resonance imaging (MRI) in the closed mouth position demonstrates anterior displacement of the disk (arrow) in front of the mandibular condyle (the letter, c); B: Sagittal proton density weighted MRI in the open mouth position demonstrates reduction of the disk (arrow) between the articular eminence (the letter, a) and the mandibular condyle (the letter, c). 19-03-2021

59. Posterior disc displacement is a rare entity and accounts for only 0.01% to 0.001% of all disc displacement. 19-03-2021

60. Sagittal T2-weighted magnetic resonance image shows fluid effusion in superior joint cavity (arrow) and anterior displacement and folded deformity of articular disc (arrowhead 19-03-2021

61. Osteochondritis dissecans and avascular necrosis Common clinical features of OCD/AVN of the mandibular condyle include pain and joint disability. Pain is commonly over the joint and along the third division of the trigeminal nerve. Radiologic changes of OCD and AVN of the mandibular condyle are frequently associated with joint effusion and internal derangement of the disc. 19-03-2021

62. Loose bodies/Joint mice Common clinical symptoms associated with loose bodies include pain, periauricular swelling, decreased range of jaw motion, crepitation and unilateral deviation of the jaw during mouth opening. Primary /secondary synovial chondromatosis . 19-03-2021

63. Ankylosis Fusion of mandibular condyle with glenoid fossa. Unable to open the mouth. Bony/Fibrous. 19-03-2021

64. 19-03-2021 Use of indomethacin as an adjuvant to surgery for recurrent temporomandibular joint ankylosis in adults.NJOMS 2014 vol 5 issue 2 Krushna Bhat

65. Association between the clinical features of and types of temporomandibular joint ankylosis based on a modified classification system Long Xia Scientific reports.19 July 2019 19-03-2021

66. TMJ osteoarthritis(DJD) Breakdown of the articulating fibrocartilage covering the bony components of the joint leading to eventual deterioration of the osseous structures. DJD is thought to occur when the ability of the joint to adapt to excessive joint loading forces. White and Pharoh Principles of Radiology 2 SA edition 19-03-2021

67. Imaging feature of TJD Osseous changes in DJD are more accurately depicted on CT images. manifest as small to large “bites” or “scoops” out of the articulating surfaces of the joint, resulting in loss of the continuity of the cortices and eventual loss of bone volume. White and Pharoh Principles of Radiology 2 SA edition 19-03-2021

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69. Imaging Sci Dent. 2018 Mar;48(1):1-9. Ely cyst 19-03-2021

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74. Rheumatoid arthritis heterogeneous group of systemic disorders that manifests as synovial membrane inflammation in several joints. The TMJ becomes involved in approximately 1/2 of affected patients. The characteristic imaging findings are a result of villous synovitis, which leads to formation of synovial granulomatous tissue (pannus ) that grows into fibrocartilage and bone, releasing enzymes that destroy the articular surfaces and underlying bone. White and Pharoh Principles of Radiology 2 SA edition 19-03-2021

75. Patients with TMJ involvement complain of swelling, pain, tenderness, stiffness on opening, limited range of motion, and crepitus. The chin appears receded, and an anterior open bite is a common finding because the condyles settle in an anterosuperior position as the articulating components are progressively destroyed. White and Pharoh’s Principles of radiology 19-03-2021

76. CT imaging - assessment of the osseous . MRI - demonstrate the pannus, joint effusions, marrow edema, and disc abnormalities Bilateral TMJ Involvement in Rheumatoid Arthritis. Pritesh B. Ruparelia . Case Report | Open Access Volume 2014 |Article ID 262430 Scooped out area of erosion in posterosuperior aspect of head of condyle giving appearance of mouthpiece of flute. 19-03-2021

77. Chondrocalcinosis/Pseudogout Acute /Chronic synovitis and ppt. of calcium pyrophosphate dihydrate crystal in joint space. Classical gout –Monosodium urate monohydrate crystals. Massive Calcium Pyrophosphate Dihydrate Crystal Deposition Disease: A Cause of Pain of the Temporomandibular Joint . Kathlyn Marsot-Dupuch . American Journal of Neuroradiology May 2004, 25 (5) 876-879; 19-03-2021

78. Tumors of TMJ Benign Tumors of Temporomandibular Joint.By Mehmet Emre Yurttutan .  December 20th 2017 DOI: 10.5772/intechopen.72302 19-03-2021

79. Tumor like condition Synovial chondromatosis Synovial chondromatosis (SC) is a benign condition with chondrometaplasia of the synovial membrane and formation of cartilaginous nodules. These nodules can become detached and form loose bodies which later calcify. Synovial chondromatosis typically involves large joints, such as the knee, hip, and elbow. It is rare in TMJ. superior compartment of TMJ The radiologic findings of SC include calcified loose bodies, soft tissue swelling, widening of the joint space, irregularities of the joint surface, and sclerosis of the glenoid fossa and/or mandibular condyle. 19-03-2021

80.  Axial CT image shows multifocal calcified loose bodies (arrow) within a low-attenuated soft tissue mass anterior to the right mandibular condyle. (b) Coronal CT image also shows loose bodies (arrow). It shows bony erosion of glenoid fossa (arrowhead) and widening of joint space but does not show extra-articular extension. (c) Follow-up CT obtained after 10 months confirms complete removal of intra-articular mass and calcifications and the absence of recurrence Synovial chondromatosis in the temporomandibular joint: a case with typical imaging features and pathological findings S W Lim .BJR .  2011 Nov; 84(1007): e215–e218. 19-03-2021

81. (a)  T 1  weighted (W) sagittal image shows multiple loose bodies, most of which have small and low signal intensity (SI) within a soft tissue mass (arrows). The soft tissue mass shows high SI because of fluid collection in it which represents expanded articular cavity. (b) Post-contrast  T 1 W coronal MR image shows a soft tissue mass (arrows) expanding into the right temporomandibular joint space.  19-03-2021

82. Malignant neoplasm Primary /Metastatic Primary rare include Chondrosarcoma, Osteosarcoma, Synovial sarcoma and fibrosarcoma of joint capsule. Extrinsic malignant neoplasm may include Salivary gland malignancy, rhabdomyosarcoma. Metastatic lesions originating from breast, kidney, , prostrate, lung and thyroid . 19-03-2021

83. Dislocation Condyle outside the mandibular fossa but inside the capsule. Bilateral Condyle is displaced anteriorly and superiorly Inability to close the mouth Muscle spasm Reduction done by applying pressure in downward and backward direction. 19-03-2021

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85. Fractures AOFoundationclassificationofhigh-neckandlow-neck mandibular condylar fractures.  19-03-2021

86. Imaging of mandibular fractures: a pictorial review Cosimo Nardi . Insights into Imaging   volume 11 , Article number: 30 (2020) 19-03-2021

87. Coronoid process Fracture Imaging of mandibular fractures: a pictorial review Cosimo Nardi . Insights into Imaging   volume 11 , Article number: 30 (2020) 19-03-2021

88. Diagnostic task Panormic Transcranial Skull views Tomography Arthrography CBCT MRI Ankylosis bony ++ +++ + Ankylosis fibrous ++ +++ Arthritis + + ++ ++ +++ Anomaly + + + ++ +++ ++ Disc positions ++ + +++ Fractures ++ + ++ ++ +++ ++ Inflammatory condition + ++ + +++ Radiographic appearances of TMJ anomalies in relation to various imaging techniques TMJ Imaging: A Review Irfan Ashraf Baba International Journal of Contemporary Medical Research . Volume 3 | Issue 8 | August 2016 19-03-2021

89. Conclusion The reliability of a complex joint such as that of the jaw is the result of a stable interaction of soft tissue and bony structures. In spite of its daily exposure to wear and tear, simple changes in the TMJ are rare. Imaging of TMJ should be performed on a case by case basis depending upon clinical signs and symptoms. Understanding of the TMJ anatomy, biomechanics, and the imaging manifestations of diseases is important to accurately recognize and manage these various pathologies. 19-03-2021

90. References TMJ Imaging: A Review . Irfan Ashraf Baba. . International Journal of Contemporary Medical Research , Volume 3 | Issue 8 | August 2016 IMAGING MODALITIES FOR TEMPOROMANDIBULAR JOINT DISORDERS: AN UPDATE . DANIEL TALMACEANU et. Clujul Medical Vol. 91, No. 3, 2018: 280-287 Imaging of temporomandibular joint.Bag A K et al. WJR.August 28, 2014 | Volume 6 | Issue 8 | Condylar aplasia and hypoplasia –A rare case. Peeyush Shivhare . Case Report | Open Access Volume 2013 |Article ID 745602 Imaging of mandibular fractures: a pictorial review Cosimo Nardi . Insights into Imaging   volume 11 , Article number: 30 (2020) Imaging of mandibular fractures: a pictorial review Cosimo Nardi . Insights into Imaging   volume 11 , Article number: 30 (2020) 19-03-2021

91. First case of bilateral coronoid hyperplasia in monozygotic twin sisters—a new aetiological perspective? Sunil Dixit Khandavilli 16 Sept.2016 pages441–443(2016) Morphologic changes in idiopathic condylar resorption with different degrees of bone loss Author links open overlay panel YifanHeBS Vol.123 issue 3 September 2019, Pages 332-340 Association between the clinical features of and types of temporomandibular joint ankylosis based on a modified classification system Long Xia Scientific reports.19 July 2019 Imaging Sci Dent. 2018 Mar;48(1):1-9. Bilateral TMJ Involvement in Rheumatoid Arthritis. Pritesh B. Ruparelia . Case Report | Open AccessVolume  2014 |Article ID 262430 Massive Calcium Pyrophosphate Dihydrate Crystal Deposition Disease: A Cause of Pain of the Temporomandibular Joint . Kathlyn Marsot-Dupuch . American Journal of Neuroradiology May 2004, 25 (5) 876-879 Benign Tumors of Temporomandibular Joint.By Mehmet Emre Yurttutan .  December 20th 2017 DOI: 10.5772/intechopen.72302 Synovial chondromatosis in the temporomandibular joint: a case with typical imaging features and pathological findings S W Lim .BJR .  2011 Nov; 84(1007): e215–e218. 19-03-2021

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