Original Article
Contrast-enhanced MRI of the temporomandibular joint: findings in children without juvenile idiopathic arthritis
Acta Radiologica 2015, Vol. 56(9) 1145–1152 ! The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0284185114548506 acr.sagepub.com
Raimund Kottke1, Rotraud K Saurenmann2, Michel M Schneider2, Lukas Mu¨ller3, Michael A Grotzer4 and Christian J Kellenberger1
Abstract Background: Contrast-enhanced magnetic resonance imaging (MRI) is highly sensitive for assessing temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA), but only sparse data exist on normal TMJ appearance in children. Purpose: To determine normal MRI appearance and enhancement pattern of pediatric TMJ as basis for diagnosing early arthritis. Material and Methods: In 27 children (age range, 1.2–16.8 years) without TMJ pathology undergoing head MRI, fatsaturated T2-weighted (T2W) and postcontrast fat-saturated T1-weighted (T1W) images sagittally aligned to the 54 TMJs, besides standard T1W and T2W images, were assessed for bony and soft tissue signal intensity (SI), the amount of perceptible joint fluid, and contrast enhancement (CE). Results: Bone marrow SI and CE of the mandible were consistent with varying degrees of residual red marrow in 96% of joints. The mandibular condyles were mostly isointense to the ramus, but in 9% showed mild edema-like bone marrow SI and CE. Small amounts of intraarticular fluid were detected in 31% on T2W images without fat saturation and in 83% on T2W images with fat saturation as fine lines in the upper or lower joint compartment or as small dots in an articular recess. Seventy-nine percent of all TMJs showed intense joint enhancement on early images restricted to areas of intraarticular fluid. Conclusion: Small amounts of joint fluid with intense CE are a common MRI finding in TMJs of children without JIA and therefore should not be considered diagnostic for early arthritis.
Keywords Pediatrics, inflammation, normal variants, joints, jaw, magnetic resonance imaging (MRI) Date received: 16 August 2013; accepted: 24 July 2014
Introduction In juvenile idiopathic arthritis (JIA) involvement of the temporomandibular joint (TMJ) occurs in well over 50% of pediatric patients and often results in severe craniofacial deformity when left untreated (1–3). Arthritis of the TMJ is often asymptomatic, leading to considerable delay in diagnosis and treatment (2,4). Through early diagnosis of affected joints appropriate treatment could be instigated before the presumed inflammatory chain of events with synovial proliferation, formation of active pannus, bony erosions, and
1 Department of Diagnostic Imaging, University Children’s Hospital Zu¨rich, Switzerland 2 Division of Rheumatology, University Children’s Hospital Zu¨rich, Switzerland 3 Clinic for Orthodontics and Pediatric Dentistry, University of Zu¨rich, Switzerland 4 Department of Pediatric Oncology, University Children’s Hospital Zu¨rich, Switzerland
Corresponding author: Christian J Kellenberger, Department of Diagnostic Imaging University Children’s Hospital, Steinwiesstrasse 72, CH 8032 Zu¨rich, Switzerland. Email: [email protected]
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finally deformation and destruction of joint anatomy can take place. Currently, magnetic resonance imaging (MRI) is considered the most sensitive test for detecting early involvement of the TMJs (1–3,5,6) by demonstrating edema-like bone marrow changes of the mandibular condyle, joint effusion and synovial contrast-enhancement. However, little is known about the bone marrow signal, the physiological amount of joint fluid and contrast enhancement (CE) of TMJs in normal, non-TMJ diseased children. The purpose of our study was to establish the normal MRI appearance and enhancement patterns of pediatric TMJs, in order to improve the accuracy for diagnosis of early TMJ inflammation in children with JIA.
Material and Methods Written informed consent was obtained prior to examination from all children and/or parents. The study was approved by institutional and governmental ethical committees.
Patient population The TMJs (n ¼ 54) of 27 children (19 boys, 8 girls; age range, 1.2–16.8 years; median age, 9.5 years) without a history of arthritis or symptoms of TMJ disease and undergoing head MRI were prospectively studied. Patients scheduled for contrast-enhanced head MRI for the assessment of intracranial pathology currently not involving the temporal bone or infratemporal fossa were eligible for the study. Potential candidates were screened by an experienced pediatric rheumatologist (RKS) using a structured interview (applied to parents and/or children) with questions regarding signs and symptoms of JIA, TMJ pathology, and a history of accidents involving the mandible. Children with a history of previous joint disease or with mandibular asymmetry, retrognathism, reduced maximal mouth-opening (
Contrast-enhanced MRI of the temporomandibular joint: findings in children without juvenile idiopathic arthritis
Acta Radiologica 2015, Vol. 56(9) 1145–1152 ! The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0284185114548506 acr.sagepub.com
Raimund Kottke1, Rotraud K Saurenmann2, Michel M Schneider2, Lukas Mu¨ller3, Michael A Grotzer4 and Christian J Kellenberger1
Abstract Background: Contrast-enhanced magnetic resonance imaging (MRI) is highly sensitive for assessing temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA), but only sparse data exist on normal TMJ appearance in children. Purpose: To determine normal MRI appearance and enhancement pattern of pediatric TMJ as basis for diagnosing early arthritis. Material and Methods: In 27 children (age range, 1.2–16.8 years) without TMJ pathology undergoing head MRI, fatsaturated T2-weighted (T2W) and postcontrast fat-saturated T1-weighted (T1W) images sagittally aligned to the 54 TMJs, besides standard T1W and T2W images, were assessed for bony and soft tissue signal intensity (SI), the amount of perceptible joint fluid, and contrast enhancement (CE). Results: Bone marrow SI and CE of the mandible were consistent with varying degrees of residual red marrow in 96% of joints. The mandibular condyles were mostly isointense to the ramus, but in 9% showed mild edema-like bone marrow SI and CE. Small amounts of intraarticular fluid were detected in 31% on T2W images without fat saturation and in 83% on T2W images with fat saturation as fine lines in the upper or lower joint compartment or as small dots in an articular recess. Seventy-nine percent of all TMJs showed intense joint enhancement on early images restricted to areas of intraarticular fluid. Conclusion: Small amounts of joint fluid with intense CE are a common MRI finding in TMJs of children without JIA and therefore should not be considered diagnostic for early arthritis.
Keywords Pediatrics, inflammation, normal variants, joints, jaw, magnetic resonance imaging (MRI) Date received: 16 August 2013; accepted: 24 July 2014
Introduction In juvenile idiopathic arthritis (JIA) involvement of the temporomandibular joint (TMJ) occurs in well over 50% of pediatric patients and often results in severe craniofacial deformity when left untreated (1–3). Arthritis of the TMJ is often asymptomatic, leading to considerable delay in diagnosis and treatment (2,4). Through early diagnosis of affected joints appropriate treatment could be instigated before the presumed inflammatory chain of events with synovial proliferation, formation of active pannus, bony erosions, and
1 Department of Diagnostic Imaging, University Children’s Hospital Zu¨rich, Switzerland 2 Division of Rheumatology, University Children’s Hospital Zu¨rich, Switzerland 3 Clinic for Orthodontics and Pediatric Dentistry, University of Zu¨rich, Switzerland 4 Department of Pediatric Oncology, University Children’s Hospital Zu¨rich, Switzerland
Corresponding author: Christian J Kellenberger, Department of Diagnostic Imaging University Children’s Hospital, Steinwiesstrasse 72, CH 8032 Zu¨rich, Switzerland. Email: [email protected]
Downloaded from acr.sagepub.com by guest on November 14, 2015
1146
Acta Radiologica 56(9)
finally deformation and destruction of joint anatomy can take place. Currently, magnetic resonance imaging (MRI) is considered the most sensitive test for detecting early involvement of the TMJs (1–3,5,6) by demonstrating edema-like bone marrow changes of the mandibular condyle, joint effusion and synovial contrast-enhancement. However, little is known about the bone marrow signal, the physiological amount of joint fluid and contrast enhancement (CE) of TMJs in normal, non-TMJ diseased children. The purpose of our study was to establish the normal MRI appearance and enhancement patterns of pediatric TMJs, in order to improve the accuracy for diagnosis of early TMJ inflammation in children with JIA.
Material and Methods Written informed consent was obtained prior to examination from all children and/or parents. The study was approved by institutional and governmental ethical committees.
Patient population The TMJs (n ¼ 54) of 27 children (19 boys, 8 girls; age range, 1.2–16.8 years; median age, 9.5 years) without a history of arthritis or symptoms of TMJ disease and undergoing head MRI were prospectively studied. Patients scheduled for contrast-enhanced head MRI for the assessment of intracranial pathology currently not involving the temporal bone or infratemporal fossa were eligible for the study. Potential candidates were screened by an experienced pediatric rheumatologist (RKS) using a structured interview (applied to parents and/or children) with questions regarding signs and symptoms of JIA, TMJ pathology, and a history of accidents involving the mandible. Children with a history of previous joint disease or with mandibular asymmetry, retrognathism, reduced maximal mouth-opening (
