Clinical resource · Free to use

The Piper TMJ MRI
scan protocol

If a joint has never been imaged, the treatment plan built on it is a guess. This is the protocol I developed and taught to dentists over forty years, published in three tiers so that you can start small. Take it to your dentist. Take it to your imaging center.

Download the protocol (PDF, 1 page)

No email required. Free to reproduce and hand to patients.

The tiers are additive

SCREENING MRI EXAM4
BASIC MRI EXAM7
FULL MRI EXAM12

Every sequence in the screening exam appears in the basic exam, and every sequence in the basic exam appears in the full exam. A screening study is never wasted work if the patient needs to escalate.

Tier 1 of 3

SCREENING MRI EXAM

Is there a derangement, yes or no?

Four sequences. This is the entry point. If your imaging center balks at a long protocol, order this one.

ORIENTATIONSEQUENCEOCCLUSIONSTARTING SIDEVIEWSTARTING POINTENDING POINTQTYTRSHFS SP
AXIALT2NONEBILATERALSUP TO INFSUPERIOR ORBITMANDIBULAR RAMUS20180/3.03.0
SAGITTALSTIRBITE 1 FSCPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
CORONALT2BITE 1 FSCPLEFT THEN RIGHTPOST TO ANTEAC ANTERIORANTERIOR TO EMINENCE18140/3.02.8
SAGITTALPROTON DENSITYBITE 2 IEPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8

Tier 2 of 3

BASIC MRI EXAM

Where is this joint on the classification?

Seven sequences. Enough to stage the joint before restorative work, orthodontics, or orthognathic planning.

ORIENTATIONSEQUENCEOCCLUSIONSTARTING SIDEVIEWSTARTING POINTENDING POINTQTYTRSHFS SP
AXIALT2NONEBILATERALSUP TO INFSUPERIOR ORBITMANDIBULAR RAMUS20180/3.03.0
SAGITTALT1BITE 1 FSCPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
SAGITTALSTIRBITE 1 FSCPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
CORONALT2BITE 1 FSCPLEFT THEN RIGHTPOST TO ANTEAC ANTERIORANTERIOR TO EMINENCE18140/3.02.8
SAGITTALPROTON DENSITYBITE 2 IEPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
SAGITTALPROTON DENSITYPROP OPEN TCPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
SAGITTALPROTON DENSITYCLOSED MOUTH MIPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8

Tier 3 of 3

FULL MRI EXAM

Everything needed to operate, or to defend the record.

Twelve sequences, two of which are localizers. This is what I used for surgical planning across a forty-year practice.

ORIENTATIONSEQUENCEOCCLUSIONSTARTING SIDEVIEWSTARTING POINTENDING POINTQTYTRSHFS SP
AXIALT1 LOCALIZERNONEBILATERALINF TO SUPMANDIBULAR RAMUSSUPERIOR ORBIT16240/4.05.0
AXIALT2NONEBILATERALSUP TO INFSUPERIOR ORBITMANDIBULAR RAMUS20180/3.03.0
CORONALT2 LOCALIZERNONEBILATERALPOST TO ANTEAC ANTERIORORBIT POSTERIOR14200/4.04.0
SAGITTALT1BITE 1 FSCPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
CORONALT1BITE 1 FSCPLEFT THEN RIGHTPOST TO ANTEAC ANTERIORANTERIOR TO EMINENCE18140/3.02.8
SAGITTALSTIRBITE 1 FSCPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
CORONALT2BITE 1 FSCPLEFT THEN RIGHTPOST TO ANTEAC ANTERIORANTERIOR TO EMINENCE18140/3.02.8
SAGITTALPROTON DENSITYBITE 2 IEPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
CORONALPROTON DENSITYBITE 2 IEPLEFT THEN RIGHTPOST TO ANTEAC ANTERIORANTERIOR TO EMINENCE18140/3.02.8
SAGITTALPROTON DENSITYPROP OPEN TCPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8
CORONALPROTON DENSITYPROP OPEN TCPLEFT THEN RIGHTPOST TO ANTEAC ANTERIORANTERIOR TO EMINENCE18140/3.02.8
SAGITTALPROTON DENSITYCLOSED MOUTH MIPLEFT THEN RIGHTLAT TO MEDLATERAL TO CONDYLEMEDIAL TO CONDYLE16140/3.02.8

Occlusal positions

FSCP — fully seated condylar position
A manipulated posture of the mandible, seating the condylar heads as high within each respective fossa as possible with reasonable comfort. Requires a bite registration.
IEP — incisal edge position
Recorded with the incisors contacting edge-to-edge and the central incisor midlines aligned. Requires a bite registration.
TCP — translated condylar position
Registered with a ratchet prop during the MR examination. The condyle is first translated comfortably, then rotated open with the ratchet prop titrated to the patient's comfort level.
MIP — maximal intercuspation position
The posture the patient bites into habitually, contacting the posterior teeth. Practice this with the patient and verify it before they go to the scanning center.

Acquisition notes

Bilateral surface coils. Left joint then right joint throughout.

Sequence names, QTY, TRS and HFS SP are reproduced exactly as generated by the scanner in clinical use.

Background

Schellhas KP, Piper MA, Omlie MR. Facial skeleton remodeling due to temporomandibular joint degeneration: an imaging study of 100 patients. AJNR Am J Neuroradiol 1990;11:541–51.

Schellhas KP, Piper MA, Bessette RW, Wilkes CH. Mandibular retrusion, temporomandibular joint derangement, and orthognathic surgery planning. Plast Reconstr Surg 1992;90:218–29.

Your pain is real. It is in your head — just not made up in your brain.