The Temporomandibular Joint & Jaw Bones

as you now the tempromandibular joint is the only visible or the gross movable joint in the skull in addition to the ear osseckels, So as any other joint we studied we have five questions to answer: what is the type of that joint? what is are the articular surfaces of that joint? the supporting ligaments? specially if it's synovial cuz as u know its "bonespace-bone" so the joint is attaching by ligaments mainly. what kind of movements are available in that joint? is there any special characteristic for this joint? like cartilaginous disk for example, there are two joints in the body that have a complete round articular disk those are the sernoclavicular joint and the TMJ. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- -So let's take the TMJ and answer the what's the type of the TMJ? ginglymoarthrodial synovial joint ,in other words u can say modified hinge synovial joint, Synovial: we have free range of movement. ginglymus: hinge joint like the elbow joint has rotational movement which is the first movement of the TMJ. arthrodial: a plane joint has two flat surfaces opposite to each other the movement is sliding or gliding which is the second movement of the TMJ in dentistry we call it translational cuz it translocate from one place to another. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- - what are the articulations? the are three artecular parts the head of the mandiblular condyle AND the anterior half of the mandibular fossa of the temporal bone & the articular tubercle, anterior to the mandibular fossa there is an elevation which is short and wide we call it tubercle and since this tubercle is contributing to the articulation of the TMJ we call it articular tubercle cuz its part of the articular parts of the TMJ, it's part also of the temporal bone. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- -1

let's jump to the last Q : is there any special characteristic for this joint? in addition to the articular disk we mentioned, the articular cartilage here is fibro cartilage, on the surface of the articular bones "when the bones come to form the articular joint bone space bone" to smoothen the surface of the of the articular part of the bone it is usually covered with hyaline cartilage we refer to it as the articular cartilage of the joint, u could see that also on the surfaces of the knee joint tibia and femur also in the shoulder humerus and the glenoid cavity of scapula. always the surface of the bone which is part of the articulation has to be smoothened by adding hyaline cartilage, in the case of TMJ the kind of this articular cartilage is changed from hyaline to more stronger one which is fibrocartilage, so the kind of the articular cartilage at the surface of the condyle, the mandibular fossa and articular tubercle is fibrocartilage not hyaline, this because of the continuous movement speaking, eating and whatever u do u move the TMJ it's one of the most frequently move in the body, to avoid any kind of friction. so there is two special characteristics : 1- complete articular disk, between the head of the condyl and the mandibular fossa. 2- the articular cartilage is fibrocartilage. 3- having extrinsic ligaments. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- -- What are the supporting ligaments?

Main (Intrinsic)
like any synovial joint the first supporting ligament is 1- the articular fibrous capsule which is fibrous tissue extend from one end to the other end of the bone all the way around 360, capsulating the articular surfaces of that joint, it important in the synovials cuz of the space between the bones. it attaches superiorly to the margins of the mandibular fossa and inferiorly to the neck of the mandible covering all the articular parts. thickening in the capsule we refer to it as ligament, when u look laterally to the capsule it becomes thickened to be specialized in more supporting to form ligaments which are part from it we call it 2-lateral tempromandibular ligament cuz it located laterally, it extends downward backward between the articular tubercle anteriorly all the way into the lateral surface of the neck of the mandible, it prevents the posterior dislocation of the joint protecting
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structures behind the mandible " the external auditory meatus", and that's why most of the dislocations of the joint are anteriorly because there is no ligament to prevent this but posteriorly dislocations is very very rare to occur cuz of the TM ligament. the main supporting ligaments of the TMJ are the articular fibrous capsule itself & the lateral tempromandibular ligament.

Accessory (Extrinsic)
the are not related to the joint put they help in determining the extensions of movement of the TMJ the defined the borders of the mandible or how much the mandible could go as far as possible , because once the ligament become taut it prevent the farther movement. 1- Stylomandibular lig.: extends between the styloid process all the way to the angle of the mandible it has no relation to the TMJ, it determine how much u can protrude the mandible or prevent farther protrusion. it is a thickened part of investing layer of deep cervical facia. this lig ia posterior to the TMJ. 2- Sphenomandibular lig.: lies on medial side of the TMJ, it extends between the spine of sphenoid bone from the base of the skull all the way medially to the margin of the mandibular foramen the lingula "Now that's why we have a lingula cuz of this lig"

it has two important fxns: - protecting the inferior alveolar nerve which is located btw the ramous and the Sphenomandibular lig, so laterally it's protected by the ramous and medially by this lig. - limiting the lateral movement of the mandible, the left one limited the extension of the left lateral movement and the right for the right lateral. 3.pterigomandibular lig.: there is an additional ligament not mentioned in our textbook it's the pterigomandibular lig arising from the hamulus of medial pterigoid plate all the way down to the posterior end of the mylohyoid line on the medial aspect of the mandible,it determines the local anesthesia when you put the needle it should be lateral to this ligament and be default lateral to the Sphenomandibular lig so between the ligaments and the ramous, there are two muscles attach to this ligament those are the buccinator and the superior constrictor muscle of the pharynx. one example for the exam Qs: which of the following nerves are contributing to the pterigomandibular lig? the buccal branch of facial nerve for buccinator and the vagus nerve of the pharyngeal plexus for the superior constrictor, the answer is facial & vagus. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- - what kind of movements are available in that joint? Movements of Mouth Opening we have two kind of movements a rotational hinge movement then we have translational or sliding or gliding movement. 1. Rotation: the first movement starts with rotation at the first 20 when you open ur mouth the condyle rotate. 2. Translation: after the condyle rotate it & disc slide from the mandibular fossa until the articular tubercle when the full mouth open the condyle is inferior to the articular tubercle Movements in more specific of the mandible : there are five different movement u can apply it from the TMJ: 1. Depression of mand. or mouth opening we have 3 different muscle groups the first one pulls the
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neck of the mandible forward which is the main one the lateral pterigoid the second is the supra hayoid group "mylohayoid, digastric, stylohayoid and geniohayoid" and the third group is the infra hayoid , put the main thing that allows u to open ur mouth is the action of gravity, we need those three groups just when there is resistant, so to open ur mouth u just have to relax all muscles. 2. Elevation: or mouth closing we need 3 muscles the masseter from outside of the ramous, the medial pterigoid and the anterior half (vertical fibers) of temporalis muscle. 3. Protrusion: or forwards moving we need 3 muscles main one is the lateral pterigoid in addition anterior part of masseter and medial pterigoid muscles. 4. Retrusion, Retraction: or backwards moving by the posterior half (horizontal fibers) of temporalis. 5. Lat. Movement to the sides: by the medial and lateral pterigoid of the opposite side when we have unilateral contraction of the right ones they push the mandible to the left and when the left ones contract they push the mandible to the right.

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The Articular Disc

Oval plate of fibrocartilage that is located between articular surfaces of TMJ between the condyle and the mandibular fossa. it's Attaches at periphery all the way around to the fibrous capsule and anteriorly to the lateral pterigoid muscle and the head of the mandible cuz the head of the mandible is within the fibrous capsule, so because of its attachment to the lateral pterigoid when it contracts it pull the mandible and also the disk so the disk is moving with the mandible, and posteriorly it attches to post glenoid tubercle of temporal bone and to the neck of the mandible.

By this the disk is dividing the TMJ cavity into two spaces: - the superior space(superur compartment of TMJ) "between the disk and the amndibular fossa"

- theinferior space (inferior compartment of TMJ) "between the disk and the condyle" why this happening? to specialized the joint into two different movements now we have two cavities so we can have two different movements the first one is the rotational movement it happens between the head of the ramous and the lower surface of the disk itself in the inferior compartment in the first 20, the second one is the transitional movement between the upper surfaceof the disk and the mandibular fossa and the articular condyle, so the head and the disk move together that's why the disk attaches to the medial pterigoid, the mandible along with the articular disk will slide from the mandibular fossa over the articular tubercle this happen in the superior compartment of the TMJ. this movement continuo until the head of the mandible is below the articular tubercle.

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Relations of TMJ
this topic is important in what we call surgeries involves with TMJ : Ant.: there are the masseteric artery from the 2nd part of maxillary a. & masseteric nerve from the anterior division of mandibular n. they are coming outside through the masseteric notch to the masseter muscle. Post.: we have the glenoid process of the parotid gland, the tympanic plate of EAM, the superficial temporal artery and vein & the auriculotemporal nerve from posterior division of mandibular. Lat.: part of the parotid gland
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Med.: maxillary artery and vein in the infra temporal fossa & auriculotemporal nerve. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- --

Dislocation of TMJ
commonly happen anteriorly cuz there is a lig. prevent the posterior dislocation, so The head of the mandible moves ant. To the articular tubercle this usually happens because of the exessive opening of the mouth mandible is depressed & the patient cannot close his mouth, this most commonly happens with an inexperienced dentist when he is working on the lower teeth and resting on the dentition but the patient will not realised cuz he is
anaesthetized then after he finish working he said OK! to the patient BUT unfortunately he can't close his mouth :))

Cause: - excessive contraction of lat. Pterygoid m. as in: taking a large bite - over opening for the dentist Rx.: pressure the mandible inferior Then posterior by grasping the mandible with your thumbs over lower dentition (mandibular teeth) and ur hand outside holding the inferior border of the ramous then go down then backward, when u get it down it will get back immediately by the action of the stylomandibular ligament itself. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- --

Clicking of TMJ
Ant. Displacement with reduction
it happens When the poststerior Band of articular disc is anteriorly displaced cuz its very thin in the middle and very thick at the peripheries when you look to it from a saggital view its thick anteriorly which is the anterior band then thin in the middle then thick posteriorly which is the posterior band, in the end if the rotational movement what is happening there is the disk itself is displaced anteriorly to its normal position by the contraction of the lateral pterygoid pulling the disk with it to be trapped between the head of the condyle and the articular tubercle keeping the same position until the translational movement starts it moves posteriorly suddenly to its normal position making the click sound.
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Ant. Displacement without reduction

The disc remains anteriorly displaced as the mouth is opening you don't hear clicking you hear Grinding sounds cuz you grind the disk between the tubercle and the head of condyle, the pt. cannot fully open his mouth because the disk will prevent the anterior movement of the condyle inferior to the articular tubercle, and in more sever condition because of the continuous grinding perforation of the disc may happened usually in the middle part of the disk. at the normal opening the disk is located between the head of condyle and the mandibular fossa, but in the case of ant.displacement with reduction the disk in a certain point it clicks back and in the case of no reduction we hear the grinding sound cuz it's grinded between the head and the articular tubercle you can see the videos of those three movements on the doc specified to head and neck anatomy scripts --> -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --- -- -- -- -- -- -- -- -- -- --

The Jaw Bones Maxilla

we have a Body & 4 Processes of the maxilla: Body is pyramidal hollow inside (max. sinus), the Upper surface of it is in infra orbital or the floor of the orbit, the Anterolateral surface in the face, the Posterolateral surface is in the infra temporal fossa and the Medial surface the lateral surface of nasal cavity. Maxillary Processes are 4 which are: 1- Zygomatic: projects laterally and forms the anterior zygomatic Arch 2- Frontal: projects superiorly, it is lateral to nasal bones 3- Alveolar: projects inferiorly, it contains upper teeth 4- Palatine: projects posteriorly, forms the anterior 2/3 of hard palate it has 2 foramina: 1- Infraorbital F.: opens in the ant. wall, presides infraorbital n. & a. 2-Incisive Foramen: located between palatine processes, opens posterior to central incisors, presides the incisive n. (nasopalatine n.)
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Mandible
it is the Largest & strongest facial bone and it's the Only movable skull bone beside The ear ossicles, it divides into three parts : the Horizontal part is the Body, Vertical Parts is the Rami (ramus)and the Junction between them is the Angle.

the structures within the Body: mental foramen below the 2nd premolar, it has one alveolar process forming the lower dental arch, the mental protuberance anteriorly, the sup. & inf. Mental spines forming attachment for genioglossus to the superior one and geniohayoid to the inferior one, then you have the mylohyoid line which is demarcating the floor of the mouth with the mylohyoid muscle the structures within the Ramus: we have the mandibular notch coronoid process condylar process: head & neck lingula attaching to it the sphenomandibular ligament & the mand. foramen located there Mention 8 muscles attached to the mandible ? 4 muscles of mastication : temporalis , masseter, lateral and medial pterygoid and another four are genioglossus, geniohyoid, mylohyoid and anterior belly of digastric.

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