ORAL & ORAL MAXILLOFACIAL SURGERY 1

TMJ Disorders

TMJ Two accessory ligaments

 Attached to osseous structure at some distance
DEVELOPMENTAL ANATOMY
from the TMJ, passive restraints on mandibular
 The TMJ begins to develop by the 10th week of
motion
gestation from two separate blastomas –one for the
1. Sphenomandibular ligament
temporal bone component and one for the condyle
2. Stylomandibular ligament
 Superior to the condylar blastema a band of
mesenchymal cell develops that will eventually
Collateral ligaments
differentiate into the disk
 Short, paired (medial and lateral) structures
 The temporal condylar mesenchymal cell
attaching the disk to the lateral and medial
differentiate into osteoblasts which lay down
poles of each condyle
membrane bone, from 12 – 32 weeks of gestation
 Restrict movement of the disk away from
there is a high degree of calcification of the condylar
condyle, allows smooth synchronous motion of
head
the disk condyle complex
 The developing TMJ shows all component of the
 Vascular, innervated, fibroelastic in nature
mature joint by 14th week of gestation
 The most medial portion of the disk is
connected posteriorly to a ligament – pinto’s
CLASSIFICATION
ligament (diskomalleolar – presence of a fibrous
 Freely movable
link between disk and the anterior process of
 Ginglimoid (hinge like movement) (COMEDK-07)
the malleus of middle ear)
 Diarthrodial (two articulating bone components)
(COMEDK-07)
Capsular ligament
 Synovial
Attachments
 Paired joint located between glenoid fossa and
 Superiorly – temporal bone along the border of
condyle
the fossa and the eminence
 Inferiorly – neck of the condyle along the edge
TMJ COMPONENTS
of the articular facet
 Capsule
Function
 Ligaments of TMJ
 Resists medial, lateral and inferior forces
 Glenoid fossa
 Condyle
Temporomandibular (lateral) ligament
 Articular disk (meniscus)
 Outer oblique portion - descends from the outer
 Synovial membrane
aspect of articular tubercle of zygomatic process
 Vascular supply and innervation
posteriorly and inferiorly to outer posterior of
 Musculature
condylar neck
 Limits amount of inferior distraction that the
TMJ CAPSULE
condyle may achieve in translatory & rotational
 Fibroelastic, highly vascular & highly innervated
movements
dense connective tissue
 Inner horizontal portion – originates medial to
 Funnel shaped, blends with periosteum of
the outer oblique portion of the ligament, runs
mandibular neck & envelops meniscus
horizontally backwards to attach to the lateral
 Laterally-zygomatic tubercle, lat. rim of glenoid
pole of the condyle and posterior aspect of the
fossa, post glenoid tubercle
disk
 Medially-medial rim of glenoid fossa
 Limits posterior movements of the condyle
(protects the retrodiskal tissues)
LIGAMENTS
 Also called as “check ligament” of TMJ
 These are composed of collagen and act
predominantly as restraints to motion of the condyle
Sphenomandibular ligament
and the disk
 Arises from spine of sphenoid bone and
descends into a fan like insertion on mandibular
Three functional ligaments
lingula and lower portion of medial side of
1. Collateral/diskal ligaments
condylar neck
2. Capsular ligament
3. Temporomandibular ligament
Function

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 ORAL & ORAL MAXILLOFACIAL SURGERY 2
TMJ Disorders

 Partly contributes to translation of the condyle

SURGICAL APPROACHES
Stylomandibular ligament 1. Pre-auricular approach
 Dense thick band of deep cervical fascia A. Blair’s
extending from styloid process to posterior B. Thoma’s
border of angle of mandible blends with the C. Dingman’s
fascia of medial pterygoid muscle D. Al-Kayat & Bramley’s (KAR-2K; PGI-07)
Function E. Popowitch’s modification of Al-kayat &
 Similar to above, also limits excessive Bramley’s
protrusion of the mandible 2. Endaural approach
3. Post-auricular approach
ARTICULAR DISK 4. Submandibular (Risdon’s) approach (AIPG-02)
 Dense, non vascular, non innervated fibrous 5. Post ramal(Hind’s) approach
connective tissue 6. Hemicoronal / Bicoronal approach
 Biconcave in sagittal section 7. Rhytidectomy(Face-lift) approach
 Anatomically divided into three zones 8. Intraoral approach
1. Anterior band  Al-Kayat & Bramley noted that the facial nerve
2. Central intermediate zone (thinnest) bifurcated into temporofacial & cervicofaial
3. Posterior band (thicker) components within 2.3 cm (range 1.5-2.8cm)
 Articular disk divides the joint into two cavities inferior to the lowest concavity of the bony
Superior compartment (temporodiskal complex) ex.audi.canal & within 3 cm (range 2.4-3.5cm) in
 Permits translation of condyle disc complex an inferoposterior direction from postglenoid
 Larger of the two compartments tubercle. Posterior to the parotid gland, the
 Extends further anteriorly than lower joint nerve is at least 2cm deep into the skin surface.
space The temporal nerve br’s lie closest to the joint &
 Has a synovial fluid volume of 1.2 ml are the most commanly injured br’s during
Inferior compartment (condylodiskal complex) surgery.Their location was measured by Al-
 Permits rotation & slight translatory movements Kayat & Bramley as 2.0cm from the ant. margin
 Smaller, more tightly reinforced by disk of the ex.audi.canal. Protection of this nerve can
attachments be achieved by making an incision thr’o the
 Has a synovial fluid volume of 0.9ml temporal fascia & periosteum down to the arch
not more than 0.8cm in front of the anterior
SYNOVIAL MEMBRANE border of the ex.audi.canal.
 Lines the joint spaces  Popowich & Crane (1982) further modified basic
 Responsible for secreting synovial fluid (nutrition Al-Kayat & Bramley’s incision. A large incision
and lubrication) shaped like a questionmark was made in the
 Extremely thin, smooth connective tissue membrane temporal area & extended in the pre-auricular
 Cells in the synovial membrane have the ability to area.
differentiate into chondrocytes
Intraoral Approach
VASCULAR SUPPLY  Steinhauser(1964)
 Branches of superficial temporal and maxillary  Lachner initially described the technique for the
arteries posteriorly and massetric artery anteriorly treatment of low subcondylar fractures but later
 Retrodiskal region has a rich venous plexus that fills expanded its use to all extracapsular #’s
and empties under the influence of the mandibular  Incision along the anterior border of ascending
movement ramus,extending antr’ly along ex.oblique ridge
& ending in the vestibule adjacent to the 2 nd
NERVE SUPPLY molar
 The mandibular nerve innervates the jaw joint  Full thickness mucoperiosteal flap along with
1. Auriculotemporal nerve (largest) – posterior, messeter is reflected,exposing lateral aspect of
medial and lateral part of the joint mandible till the posterior border
2. A branch from the posterior deep temporal  Subperiosteal dissection superiorly to the level
nerve and of sigmoid notch
3. 3Massetric nerve – anterior part of the joint

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TMJ Disorders

 Retractor can b placed in the sigmoid notch to  Tranquilizer

aid in access.it may b necessary to distract the  Manipulation
mandible inferiorly to locate medially displaced
condyle Chronic Dislocation or subluxation (MAHE-97)
Advantages  Abnormal anterior excursion of condyle beyond
 Condyle segment can b directly visualized the articular eminance, but patient is able to
during application of IMF manipulate back into normal position
 No visible scars  Recurrent, incomplete, self reducing, habitual
Disadvantages dislocation
 Luxation #’s are difficult to treat by this  Predisposed persons get it by acts of yawning,
approach because of limited access vomiting, and laughing
 Control of the result of reduction is difficult  Seen more in teachers, musicians, singers
since the posterior edge of the mandibular  With each episode of subluxation, there is
ramus can hardly b accessed further stretching of capsular ligament
 Associated with Ehlers – Danlos syndrome
Bicoronal Approach  May or may not be associated with pain
 Indication: # dislocated mandibular condyle Management
displaced into middle cranial fossa  Intermaxillary fixation or limiting the mouth
opening by giving elastics
TMJ DISLOCATION  Use of sclerosing solution into the joint space,
 Excursion of condyle beyond articular eminence STD
(AIIMS-03)  Surgical procedures (Dautrey procedure)
 Unilateral/ bilateral Capsule tightening procedures
 Acute/chronic (subluxation)  Capsulorraphy – shortening the capsule by
 Most common dislocation is IN anterior (COMEDK- removing a section & suturing it to make it
04, 08) tight.
 Placement of vertical incision and overlapping
Causes (MAHE-02) them, suturing
Extrinsic  Reinforcement of the joint capsule by turning
 Blow down a piece of temporoparietal fascia
 Use of gag Creation of mechanical obstacle
 Dental extraction Direct restrain of the mandible
Intrinsic  Temporalis fascia turned down & sutured to the
 Yawning lateral surface of articular capsule
 Singing loudly  Piece of fascia lata threaded through a hole in
 Opening mouth widely to eat zygomatic arch & second hole in condyle. Fascia
 Hysterical fits tightened till half of preoperative opening
existed
Unilateral acute dislocation  These are complicated Procedures & have
 Difficulty in mastication/swallowing (AIPG-04) questionable prognosis
 Speaking Creation of new muscle balance
 Profuse drooling of saliva, pain  Incision from tip of coronoid to retromolar area
 Deviation of chin to contra lateral side  This vertical wound is then sutured into tight
 Depression in front of tragus horizontal manner
 Same procedure repeated on opposite side
Bilateral acute dislocation  This procedure brings about scar formation &
 Difficulty in mastication/swallowing/speaking fibrosis
 Pain Removal of mechanical obstacles
 Profuse drooling of saliva  Removal of torn meniscus or menisectomy
 Protruding chin  High condylectomy
 Depression in front of tragus  Eminectomy (MAHE-97)
 Gagging of occlusion, anterior open bite
Management (AIIMS-97) ANKYLOSIS OF TMJ
 Reassurance

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TMJ Disorders

 Ankylois means “ stiff joint ”  Bilateral antegonial notch

 False of true  Oral opening < 5mm
 Fibrous or bony  Severe malocclusion and class ii occlusion
 Extra articular or intra articular Diagnosis
 Partial or complete  H/o of trauma
 Unilateral & bilateral  Clinical examination
 Radiographic findings:-
Etiology o OPG- antegonial notch can be appreciated
Congenital o Lateral oblique- A-P dimension of condylar
Trauma – most At birth, forceps delivery mass
common cause Haemarthrosis o PA view- mediolateral extent of bony mass
(AIIMS-91; MAN-02) Condylar fracture o CT [3d scan]- all aspects of deformity
Glenoid fossa fracture Radiographic findings
Otitis media  Fibrous ankylosis:- reduced joint space,but
Parotitis normal anatomy of head and glenoid fossa
Tonsillitis  Bony ankylosis:- complete obliteration of joint
Infections Furuncle space,deformed condylar head and elongation
Abscess around the joint of coronoid process
Osteomyelitis of the jaw Management
Actinomycosis  Always surgical
Rheumatoid arthritis Aims
Inflammation Osteoarthritis  Create a gap to mobilize the joint
Septic arthritis  Creation of functional joint
Polyarthritis  Restore vertical height
Rare causes
Measles  Restore normal facial growth pattern
Small pox
 Improve esthetics, cosmetic surgery done at 2nd
Scarlet fever
phase
Typhoid
Surgical techniques (AIPG-93, 94; PGI-03,07)
Gonococcal arthritis
Systemic diseases 1. Condylectomy
Scleroderma
2. Gap arthroplasty
Beriberi
3. Inter positional arthroplasty
Marie-Strumpell disease
Incisions: preauricular, popowich
Ankylosing spondylitis
Condylectomy
Bifid condyle
 Done in fibrous ankylosis
Prolonged Trismus
 Exposure of condylar head via pre auricular
Other causes Prolonged immobilization
incision
Unknown
 Sectioning of condylar head, separate from
Burns
superior attachment carefully
 Rest of stump smoothened
Unilateral ankylosis (AIPG-04)
 Wound closed in layers
 Onset since childhood
 Disadv:- unilateral condylectomy causes
 Facial asymmetry
deviation towards operated side
 Deviation of chin on the affected side
 Bilateral causes anterior open bite
 Fullness of face on the affected and flatness on
 Recontouring by arthrolasty and alloplastic
the unaffected side
material to maintain the joint space
 Condylar movement absent on the affected side
 Receded chin
Gap arthroplasty
 Hypoplastic mandible
 Done in bony ankylosis
 Class II occlusion and unilateral posterior cross
 Term gap arthroplasty means no substance is
bite on affected side
interposed betweem the two cut bony surfaces
Bilateral ankylosis
 Two horizontal osteotomy cuts and removal of
 Symmetrical but micrognathic mandible
bone to create a gap between roof of glenoid
 Typical “bird face” with neck chin angle
fossa and ramus
reduced or absent

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 ORAL & ORAL MAXILLOFACIAL SURGERY 5
TMJ Disorders

 Minimum gap of 1cm is created 4. Limitation of jaw motion

 Care to be taken for internal maxillary artery
present on the medial aspect
Interpositional arthroplasty
 Gap arthroplasty can cause recurrence
 Interpositional arthroplasty involves placement
of a barrier between the created gap
 Interpositional materials used
autogenous[ cartilaginous grafts,temporal
muscle,fascia lata]
 Alloplast[ss,titanium,gold,teflon,nylon acrylic]
Kaban, Perrot, Fisher [1990] Protocol
 Early surgical intervention
 Aggressive resection- gap of 1-1.5 cm is created
 Ipsilateral coronoidectomy and temporalis
myotomy- interincisal opening of 35mm or
greater
 Contralateral coronoidectomy and temporalis
myotomy- if incisal opening is < 35 mm
 Lining of glenoid fossa with temporalis fascia
 Reconstruction of ramus with costochondral
graft
 Early mobilization and physiotherapy
 Regular long term follow up
MYOFACIAL PAIN DYSFUNCTION SYNDROME
 Also known as temperomandibular joint pain
dysfunction syndrome
 The term was coined by Schwartz in 1955
 MPDS is also known as Masticatory Myalgia
Syndrome
Etiology
Characteristics of MPDS pain
 Unilateral
 Dull in character
 Pain near the pre auricular region
 Radiation to the angle of the mandible, temporal
area or lateral cervical area
are Treatment
 Patient Education
 Self care
 Physical therapy
 Intraoral appliance therapy
 Pharmacotherapy
 Relaxation techniques
Patient education - Explanation of the diagnosis &
treatment and reassurance about the generally good
prognosis for recover and natural course
Self care - Eliminates oral habits & provides information
on jaw care associated with daily activities
Physical therapy - Heat & cold therapy, ultrasound, range
of motion exercises, posture therapy, passive stretching,
general exercise & conditioning exercises
Intraoral appliance therapy - Cover all the teeth on the arch
the appliance is seated on, adjust to a stable comfortable
mandibular posture & avoid changing mandibular
position
Pharmacotherapy - NSAIDs, acetaminophen, muscle
relaxants, anti anxiety agents, tricyclic antidepressants,
clonazepam
Relaxation techniques - Hypnosis, biofeedback, cognitive-
behavioral therapy
*****

Clinical Features
 80% - 90% of the patients are females and below
the age of 40 years.
 Four cardinal signs & symptoms are
1. Pain
2. Muscle Tenderness
3. A clicking or popping noise in the TMJ

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