Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2012; 57:(1 Suppl): 109–118

doi: 10.1111/j.1834-7819.2011.01663.x

Application of cone beam computed tomography

for assessment of the temporomandibular joints
S Barghan,* S Tetradis,* SM Mallya*
*Section of Oral and Maxillofacial Radiology, School of Dentistry, The University of California, Los Angeles, USA.

ABSTRACT
Radiographic examination is essential for the diagnosis and management of temporomandibular joint (TMJ) disorders. The
goals of TMJ radiography are to evaluate cortical and trabecular architecture of the bony structures and confirm their
integrity, to assess the extent and monitor progression of osseous changes, and to evaluate the response to treatment.
Accurate evaluation of the TMJ by conventional radiography is limited by structure superimposition. Cone beam computed
tomography (CBCT) provides high-resolution multiplanar images and delivers substantially lower radiation dose, compared
with multislice CT. CBCT allows examination of TMJ anatomy without superimposition and distortion to facilitate
analysis of bone morphology, joint space and dynamic function in all three dimensions. This article will describe the role of
CBCT imaging for the assessment of the TMJ osseous structures and present typical appearances of common pathological
conditions of the TMJ.
Keywords: Cone beam, temporomandibular joints.
Abbreviations and acronyms: CBCT = cone beam computed tomography; CH = coronoid hyperplasia; CT = computed tomography; FOV
= field of view; MRI = magnetic resonance imaging; OA = osteoarthritis; RA = rheumatoid arthritis; SC = synovial chondromatosis; TMD
= temporomandibular disorders; TMJ = temporomandibular joints.

tissue components of the TMJ2 and thus, imaging is

INTRODUCTION
used to augment the diagnostic process. Over the last
Temporomandibular disorders (TMD) are a heteroge- three decades, advances in imaging have made impor-
neous group of complex disorders of varied and often tant contributions to improving diagnosis of TMD.3
multifactorial aetiologies. These disorders can affect the Importantly, in addition to its diagnostic benefits,
masticatory musculature, the osseous components of imaging findings also play a valuable role in influencing
the temporomandibular joint (TMJ) and the soft tissue the clinician’s treatment of patients with TMD.4
components of the TMJ, including the articular disc A variety of imaging modalities have been used to
and its ligamentous attachments. TMD is the most evaluate the TMJ. Panoramic radiography, conven-
common cause of non-dental pain in the orofacial tional linear or complex motion tomography and
region – patients with this disorder frequently present computed tomography (CT) are used to assess the
with pain in the masticatory musculature and the TMJ osseous components of the joints, whereas magnetic
or preauricular area. Additional symptoms may include resonance imaging (MRI) is used to assess the soft-
TMJ sounds, limited or asymmetric mandibular move- tissue components. Traditionally used two-dimensional
ment, headache and earache. TMJ projections, such as the transcranial view, are of
The American Academy of Orofacial Pain classifies limited use nowadays. These projections suffer from
TMD as masticatory muscle disorders and articular significant superimposition of the overlying structures,
disorders.1 The latter group includes developmental which compromises their ability to detect pathological
and acquired disorders, articular disc disorders, inflam- TMJ changes. Panoramic radiography is useful in
matory disorders, osteoarthritis, condylar dislocation, evaluating gross TMJ osseous pathology.5–7 Although
ankylosis and fracture. These diagnostic classifications this technique is simple and relatively inexpensive, it
are initially based on the presenting symptoms and the has several limitations that minimize its value for TMJ
clinical examination. However, clinical examination assessment. First, these radiographs do not show the
alone is insufficient to fully assess the osseous and soft entire articular surface of the TMJ. Structures are
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distorted and often there is superimposition from the view (FOV), the detector type and the size of the
zygomatic process.8 Panoramic radiographs have a reconstructed voxels. These parameters vary between
poor reliability and low sensitivity for detecting TMJ CBCT units and can be adjusted in most CBCT
osseous changes9,10 and thus, are of limited value in machines. Thus, when performing CBCT imaging, it
radiographic evaluation of the TMJ. is important that the clinician adjusts these parameters
To overcome the issues with superimposition and to produce optimal images for the specific diagnostic
image distortion, linear or complex motion tomogra- task. For example, when using a limited CBCT unit, the
phy was used for several years as the modality of choice image FOV can be collimated to 4 cm x 4 cm x 4 cm,
for bony TMJ examination.11,12 With tomography, the and images acquired at a voxel size of as low as 78 lm.
reported sensitivity for detecting osseous changes These limited FOV scans provide sufficient anatomic
ranges from 53% to 90% and the specificity ranges coverage to encompass the condylar head, glenoid fossa
from 73% to 95%.11,13 However, tomography under- and articular eminence of one TMJ. In our experience,
estimates small bone abnormalities and thus, the these high-resolution scans provide excellent visualiza-
diagnostic accuracy is limited.13 tion of osseous changes within the TMJ (Fig. 1). Full
CT has been a valuable aid in the evaluation of the FOV CBCT machines can also be used to image the
TMJ. This technique was found to be superior to TMJ. Typically with these units, the collimated image
hypocycloidal tomography.14 CT provides excellent size can vary from approximately 10 cm to 20 cm and
visualization of a broad spectrum of osseous patholog- the voxel sizes range from 200 lm to 400 lm. Depend-
ical changes, such as osteophytes, condylar erosion, ing on the selected FOV, the image volume may
fractures, ankylosis, dislocation, and growth abnormal- encompass both TMJs. However, it is important to
ities such as condylar hyperplasia. Studies on autopsy consider that with larger FOV and higher voxel sizes,
specimens found CT to have a sensitivity of 75% and a the image resolution is decreased and this could
specificity of 100% for detecting bony changes with a potentially compromise the ability to detect early
positive predictive value of 100% and a negative osseous changes. A recent study showed that CBCT
predictive value of 78%.15 However, the high cost, scans with smaller FOV and voxel sizes had a higher
access to equipment and the relatively high radiation diagnostic accuracy for detection of TMJ erosions.20
dose have limited the widespread use of CT for TMJ Depending on the diagnostic task, it may be necessary
evaluation. With the advent of cone beam CT (CBCT), to image the entire maxillofacial skeleton, where an
these barriers have been overcome. Today CBCT units assessment of craniofacial asymmetry is required. In
are located in dental schools, dental radiographic our clinic, we find that a combination of limited and
laboratories and private practices, and have provided full FOV scans might be appropriate for select patients.
increased access to CT technology. Furthermore, the CBCT imaging provides multiplanar images in the
cost of imaging patients with CBCT units is generally anatomic axial, sagittal and coronal planes. For easier
lower than medical CT. In addition to the lower cost TMJ visualization, the image volume can be recon-
and better access to equipment, CBCT offers several structed in planes parallel and perpendicular to the long
advantages over medical CT. First, the radiation dose axis of the condyle instead of the true anatomic coronal
from CBCT examinations is typically much lower than and sagittal planes. These reconstructed sections also
that from medical CT units.16,17 Second, the spatial allow for better assessment of the condyle position
resolution of CBCT images is typically higher than that within the glenoid fossa (Fig. 1).
of medical CT imaging protocols. The diagnostic
efficacy of CBCT is as good as conventional CT18 and
CBCT imaging appearances of common TMD
is superior to that of panoramic radiography and linear
tomography.19 Recent guidelines recommend CT as the The goals of TMJ imaging by CBCT are to evaluate the
modality of choice for evaluation of TMJ osseous integrity of the bony structures when disorders are
changes.9 Given the lower radiation dose and the suspected, to confirm the extent and stage of progres-
growing availability of CBCT, this modality is becoming sion of disorders, and to evaluate the effects of
the modality of choice for evaluation of TMJ osseous treatment. Below we describe common conditions of
components. In this review, we discuss the applications the TMJ where CBCT imaging plays an important role
of CBCT imaging for evaluation of the TMJ. in diagnosis and treatment planning.

Considerations for CBCT protocols for TMJ imaging Remodelling

It is important to recognize that the term CBCT does Remodelling is a physiologic process that aims to adapt
not refer to a single imaging protocol. There are several the structure of the TMJ to the mechanical forces
parameters that influence the quality of CBCT images, applied to the joint. It is an essential biological response
including X-ray beam factors, the size of the field of to normal functional demands, ensuring homeostasis of
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(a) (b) (c)

Fig 1. Normal TMJ in the closed position. Images were acquired using limited FOV CBCT (3D Accuitomo 80, J. Morita Manufacturing
Corporation). (a) Axial, (b) corrected sagittal and (c) corrected frontal sections.

(a) (b)

Fig 2. (a) Corrected frontal and (b) corrected sagittal CBCT sections. Note flattening of the antero-superior surface of the condylar head with
cortical thickening and subchondral sclerosis.

joint form, and function and occlusal relationships.21 joint,31,32 as well as microtrauma caused by bruxism
Excessive forces can alter the shape of the condyle and and unilateral chewing.
articular eminence resulting in flattening of curved joint CBCT provides essential information needed to
surfaces, thickening of articular cortical surfaces and diagnose OA.18,33,34 The diagnostic efficacy of CBCT
subchondral sclerosis (Fig. 2). These changes may affect for detecting these osseous changes is superior to that of
the condyle, temporal components, or both.21,22 TMJ panoramic radiography, linear tomography and
remodelling is often detected even in the absence of MRI.19,35 Bony changes associated with OA include
symptoms and is considered abnormal only when irregular and possibly thickened cortical outlines,
accompanied by signs and symptoms of pain or erosions, osteophyte formation, and subchondral ‘cyst’
dysfunction or when the degree of remodelling seen formation.9,36,37 Other changes include narrowing of
radiographically is judged to be severe.23 the joint space and other signs of osseous remodelling
such as flattening of the articular surfaces and sub-
chondral sclerosis. These changes are most commonly
Osteoarthritis
seen on the condyle but may also involve the mandib-
Osteoarthritis (OA) of the TMJ is an age-related ular fossa or articular eminence (Fig. 3). In addition to
degenerative disease and is more frequent in females depicting these changes, the imaging findings also
than in males.24–26 This process is characterized by contribute to staging of the disease29 and to monitor
degeneration of the joint cartilage with subsequent progression of changes over time or in response to
release of degraded proteoglycans and proteolytic treatment.
enzymes into the synovial fluid. This provokes a
secondary inflammatory response with further degra-
Inflammatory arthritis
dation of the joint components.27–29 Aetiological fac-
tors include biomechanical overloading, loss of molar This group of high-inflammatory arthritis includes
support and attrition,30 internal derangement of the systemic disorders that manifest as synovial membrane
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(a) (b)

(c) (d)

Fig 3. Osseous changes characteristic of osteoarthritis. (a and c) Corrected sagittal and (b and d) corrected frontal sections using limited FOV
CBCT. (a and b) Mild erosion of the condylar head and normal glenoid fossa. (c and d) Severe erosion, bone sclerosis, osteophyte formation,
subcondral cysts and reduced joint space.

inflammation in several joints.38 These diseases supported by clinical symptoms of OA or age-related

include rheumatoid arthritis (RA), juvenile idiopathic changes, the possibility of inflammatory arthritis should
arthritis, psoriatic arthritis, gout, ankylosing spondy- be considered. Correlation with patient symptomatol-
litis, lupus erythematosus and Reiter syndrome.29 Of ogy in other joints, as well as clinical laboratory tests
these inflammatory arthritidies, RA is the most might be necessary to further evaluate the patient.
common. It primarily affects the periarticular struc-
tures, such as the synovial membrane capsule, tendon
Synovial chondromatosis
sheaths, and ligaments.39 In a recent study of RA
patients, almost 94% of the patients had symptoms or Synovial chondromatosis (SC) is due to chondrometa-
positive CT findings in the TMJ,40 underscoring the plasia of the synovial joint tissues.41,42 Cartilaginous
need for thorough TMJ examination in this patient nodules form within the synovium and often detach
population. from the synovial membrane, becoming loose bodies
When an inflammatory disorder of the TMJ is within the joint space. It usually affects large joints and
suspected, CBCT is recommended for evaluation of is relatively uncommon in the TMJ. SC is thought to be
subtle osseous abnormalities. Both joints should be secondary to factors such as trauma, microtrauma or
imaged for comparison. Cortical erosions most often degenerative arthritis. Clinical symptoms include joint
involve the articular eminence and the anterior aspect swelling, pain, limitation of mouth opening, crepitation
of the condylar head. CBCT images also show sub- and deviation on opening. CBCT findings of synovial
chondral sclerosis, flattening of articulating surfaces, chondromatosis include the presence of multiple,
subchondral cysts and osteophyte formation. The calcified, loose bodies in the joint space, widening of
radiographic manifestations of inflammatory arthritis the joint space, irregular or sclerotic glenoid fossa.
are not specific and are similar to osteoarthritis. Scans in the open mouth position often demonstrate a
However, the degree of joint destruction is typically change in the positions of these calcified bodies. Co-
more advanced. When CBCT findings demonstrate existing osseous changes of osteoarthritis are frequently
severe arthritic changes of the TMJ that cannot be noted (Fig. 4).
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 CBCT of the TMJ

(a) (b)

Fig 4. Synovial chondromatosis. Corrected sagittal limited FOV CBCT sections in (a) closed and (b) open positions. Note multiple calcifications
within the joint space. The position of the calcifications relative to the fossa changes upon opening.

(a) (b)

Fig 5. Limited FOV CBCT scans showing (a) Retruded condylar position in the closed-mouth position. (b) Limited translational movement of the
condyle upon opening.

displacement without reduction, there may be limited

Internal derangement of the articular disc
translational motion of the condyle.4,45 Both these
Internal derangements are the most common disorders changes are manifested on CBCT scans. When accom-
associated with TMJ dysfunction.43,44 Internal derange- panied by a high clinical suspicion for internal derange-
ment of the TMJ is defined as an abnormal positional ments, MRI can be used to provide definitive diagnosis.
relationship of the articular disc relative to the man-
dibular condyle and articular eminence. This disorder is
Trauma
often characterized by an anterior articular disc dis-
placement, with or without reduction.44 Clinically, Fractures of the TMJ usually occur at the condylar
these disorders manifest as clicking in the affected joint neck and often are accompanied by condylar head
or by a restricted opening. Importantly, chronic internal dislocation. Clinical signs include difficulty in opening
derangements frequently result in OA. Thus, CBCT the mouth, malocclusion (particularly open bite of the
imaging is often used to detect the presence of any co- contralateral side), and oedema in the peripheral
existing OA in patients with clinically suspected region of the auricle.46 CBCT imaging demonstrates
internal derangements. the fracture location (intracapsular, extracapsular or
It is important to note that the articular disc is not subcondylar), its direction and the presence and
visualized on CBCT examinations – for a conclusive degree of displacement (Fig. 6). Although limited
evaluation of disc position, MRI is the modality of CBCT scans may be sufficient to image localized
choice. Nevertheless, there are CBCT findings that condylar fractures, a full FOV scan may be necessary
although not confirmatory, raise the suspicion of especially when trauma to the entire maxillofacial
internal derangements. For example, disc displacements skeleton needs to be assessed. However, when TMJ
often result in alteration of condylar position, leading capsular tears and haemarthrosis are suspected or
to a posterior positioning of the condylar head within when detailed soft tissue evaluation is needed, MRI is
the glenoid fossa (Fig. 5). Frequently, in the case of disc recommended.
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(a) (b)

(c) (d) (e)

Fig 6. Condylar neck fracture. (a) Sagittal and coronal CBCT sections and (c and d) three-dimensional volume renderings show a fracture of the
condylar neck with dislocation of the condylar head in a medial direction. (b and e) The contralateral condyle is shown for comparison.

(a) (b)

Fig 7. Osseous ankylosis. (a) Coronal and (b) sagittal CBCT sections showing an irregular articular surface, narrow joint space and continuity of the
condylar head with the glenoid fossa at the central region of the condyle.

piece of bone or a large amorphous bone mass often

Ankylosis
involving the condyle of the mandible, temporal bone
Ankylosis of the TMJ is characterized by restriction or and zygomatic process.47 There is partial to complete
limitation of mandibular movement. TMJ ankylosis is obliteration of the joint space and secondary degener-
classified according to type of tissue involved (bony ative changes are commonly observed (Fig. 7). In
versus fibrous versus fibro-osseous), or according to its fibrous ankylosis, the osseous components of the TMJ
location (intra- versus extracapsular). Trauma is the often present a normal image, or may manifest areas of
leading cause of TMJ ankylosis. Other causes of TMJ erosion or other degenerative changes. However, the
ankylosis include condylar fractures, infections, RA and joint space is reduced and open mouth views demon-
post-surgical complication. The classic clinical mani- strate limited, if any, condylar movement. Additionally,
festation of ankylosis is limitation of mouth opening. other signs of remodelling may be observed, as the TMJ
CBCT examination in this condition has important osseous components attempt to adapt to this disorder.48
diagnostic and therapeutic implications. First, it pro-
vides a conclusive diagnosis of bony ankylosis and
Developmental abnormalities of the TMJ
allows evaluation of the extent of the bony union. The
characteristic radiographic features of this condition Developmental disorders of the TMJ such as condylar
demonstrate a bony bridging between the condyle and aplasia, hypoplasia, or hyperplasia frequently present
the temporal bone. This union could be via a small as a progressive facial asymmetry. Although gross
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asymmetries resulting from these disorders are visible

Coronoid hyperplasia
on panoramic radiographs, these radiographs cannot
accurately detect vertical asymmetries of condyle and Coronoid hyperplasia (CH) resulting in elongation of
ramus.49 Furthermore, slight variations in the patient the coronoid process is often an unrecognized cause of
positioning can result in unequal magnification of the restricted mouth opening. The symptoms of limited
two sides and compromise an accurate evaluation of opening are typically chronic and insidious in onset.
facial symmetry. CBCT provides information in three The limitation of jaw movement results from impinge-
dimensions and allows assessment of the presence and ment of the coronoid process on the zygomatic arch or
severity of asymmetry in the maxilla and mandible. the zygomatic process of the maxilla during mouth
Given that CBCT images are not distorted, it also opening. In these clinical situations, a full FOV CBCT
allows precise measurements, provides a quantitative scan is used to evaluate the size of the coronoid process.
measure of the degree of asymmetry and allows When acquired in the open mouth position, it can
radiographic follow-up to determine any progression. demonstrate the exact contact point of the coronoid
Depending on the diagnostic task, a limited FOV CBCT process with the zygomatic arch or posterior aspect of
scan may suffice (Fig. 8). Alternatively, full FOV scans the maxilla (Fig. 9).
may be needed to allow evaluation of mandibular
development and bilateral asymmetry.
Neoplasms
Neoplastic lesions involving the TMJ are relatively
(a) uncommon. Benign lesions include osteomas, osteo-
chondromas and osteoblastomas.23 Of these, osteo-
chondroma is the most common benign tumour of the
TMJ. Although common in the axial skeleton, it is
relatively uncommon in the TMJ. These are slow-
growing lesions that often present clinically as a
progressive asymmetry or a recent alteration in the
bite. This clinical presentation is similar to that of
unilateral condylar hyperplasia and thus, it is important
to distinguish between these two entities. The findings
of CBCT imaging contributes to this differentiation. In
contrast to condylar hyperplasia that manifests as a
(b) (c) uniform enlargement of the condylar head, osteochon-
droma appears as an irregular condylar mass, often
pedunculated and with an altered trabecular pattern.
The outlines of the condyle are usually discernible,
although occasionally the tumour erodes adjacent
osseous structures (Fig. 10).
Primary bone malignancies such as osteosarcoma and
Fig 8. Left condylar hypoplasia. (a) Panoramic and (c) corrected
chondrosarcoma, or metastatic lesions occur very rarely
sagittal CBCT sections. (b) Corrected sagittal section of the normal in the TMJ. These lesions manifest as pain, limited
right condyle is shown for comparison. opening, unilateral swelling and external auditory canal

(a) (b) (c)

Fig 9. Bilateral coronoid hyperplasia. (a) Axial section demonstrating the proximity of the coronoid process to the medial aspect of the zygomatic
process of the maxilla. (b and c) Sagittal sections of the right and left rami show elongation and hyperplasia of the coronoid processes.

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(a) (b) (c)

Fig 10. Osteochondroma of the condyle. (a) Axial, (b) coronal and (c) sagittal CBCT sections show an exophytic osseous mass on the antero-
superior surface of the condylar head. Note the continuity of the normal condylar trabeculation with the tumour and a thin discernible cortical
outline of the condylar head.

(a) (b) (c)

Fig 11. Multiple myeloma involving the condylar head. (a) Sagittal section, (b) coronal section and (c) 3-dimensional volume rendering showing an
ill-defined, radiolucent, destructive lesion of the condylar head.

obstruction. This non-specific clinical presentation is

Future directions for use of CBCT imaging
often mistaken for osteoarthritis. Lack of response to
appropriate therapy should alert the clinician to this CBCT images are rich in information about the
mistaken diagnosis. On CBCT examination, these osseous structures. As described above, current evalu-
malignancies show variable degrees of bone destruction ation of the changes in the osseous morphology are
with minimal expansion and erosive, ill-defined, irreg- based on qualitative assessments. To further tap into
ular margins (Fig. 11). Importantly, when malignancy this information, recent studies have used image
is suspected on CBCT, additional advanced imaging analysis algorithms to examine whether these radio-
using MRI or CT with contrast is recommended to graphic changes can be quantified and correlated to
determine extension of the lesion into the soft tissues, patients’ symptoms. In these studies, shape correspon-
and to evaluate regional lymph node involvement. In dence, a 3-D surface mapping technique, was used to
case of metastatic disease, a whole body CT and PET map the condylar morphology and its alteration in
scanning might be appropriate. osteoarthritis.51 Indeed, this technique showed marked
differences between OA and asymptomatic condyles.
Importantly, the extent of these morphological changes
Comprehensive radiographic evaluation
paralleled pain severity and duration.51 Such technol-
In addition to evaluating the structures of the TMJ, it is ogies hold promise to evaluate temporal changes in the
also imperative that the clinician evaluates the entire joints and to identify morphological variations that
CBCT volume.50 A detailed assessment is necessary to may have implications for clinical management or
detect pathological changes that may contribute to the prognosis.
patient’s TMJ symptoms, as well as to detect any
incidental findings that may be of importance in the
CONCLUSIONS
management of the patient in general. For example,
pathological changes in structures adjacent to the TMJ CBCT is rapidly growing as the imaging modality of
including mastoiditis and external or middle ear choice to evaluate the osseous components of the TMJ.
abnormalities may accompany TMJ dysfunction. Fre- This modality provides high-resolution multiplanar
quently, pathological conditions such as impacted images of the TMJ, and importantly, at a lower
teeth, dental disease and paranasal sinusitis result in radiation dose compared with CT. CBCT provides
referred facial pain. All of these conditions are likely to essential information to aid in the diagnosis of a variety
manifest on CBCT scans, and their identification is of TMD, including osteoarthritis, inflammatory arthri-
important to overall evaluation of the patient. tis, trauma and development disorders.
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