TEMPOROMANDIBULAR JOINT    - bruxism, and
Learning Outcomes:
1. To describe in detail the anatomy of the TMJ
2. Enumerate and classify the TMJ as a whole.
3. Apply knowledge and principle in the clinical
practice.
 
Discussion:
Anatomy of the TMJ
- is the articulation between
- the squamous portion of the temporal bone and
- the condyle of the mandible
TMJ is what type of joint:
- Structurally: Synovial
- Functionally: Diarthrosis (freely movable)
What type of synovial joint?
- It is a combination of a hinge joint and sliding
joint
TMJ consists of the following:
- Squamous portion of the temporal bone
- Articular disc (contained within the TMJ)
- Condyle of the mandible
- Ligaments (serve as boundaries)
TMJ Dysfunction
- Affects approximately 25% of the population
and may be severe in a small subgroup
- More common in females
   Causes:
   - arthritis,
   - trauma,
   - infection,
   - disc displacement
Anatomic Features of the TMJ
- Squamous portion of the Temporal Bone
- Anterior—articular eminence becoming the
articular tubercle
- Intermediate—glenoid fossa
- Posterior—tympanic plate tapering to the
postglenoid tubercle
Squamous portion of the Temporal Bone:
1. Articular Eminence
-The strong bony prominence on the base of the
zygomatic process
2. Articular Tubercle
- Located on the lateral part of the articular
eminence
- Provides attachment for the capsule and lateral
temporomandibular ligament
3. Glenoid Fossa
- The depression into which the condyle is
located
- Superior to this thin plate of bone is the middle
cranial fossa
4. Tympanic Plate
- The vertical plate located anterior to the
external auditory meatus
5. Postglenoid Tubercle
- An inferior extension of the squamous portion
of the temporal bone
- Makes the posterior aspect of the glenoid fossa
- Provides attachment for the capsule and
retrodiscal pad
Anatomic Features of the TMJ
Mandibular condyles
- Articulate with the articular disc
- Shaped like footballs:
     Mediolateral—20mm
     Anteroposterior—10mm
- Articular surface is avascular fibrous
connective tissue instead of hyaline cartilage
Articular disc
- Composed of dense fibrous connective tissue
- Located between the squamous portion of the
temporal bone and the condyle
- Is avascular and aneural in its central part but
is vascular
- innervated in the peripheral areas, where load-
bearing is minimal
- Divided into 3 bands:
      Anterior—this thick band lies just anterior to
the condyle with the mouth closed
      Intermediate—this band, the thinnest part, is
located along the articular eminence with the 
                                         mouth closed
      Posterior—this thick band is located superior
to the disc with the mouth closed
- Additional attachments:
     Medial/lateral—strong medial and lateral
collateral ligaments anchor the disc to the
condyle
     Anterior—the disc is attached to the capsule
and the superior head of the lateral pterygoid,
but not the condyle, allowing the disc to rotate
over the condyle in an anteroposterior direction
     Posterior—the disc is contiguous with the
bilaminar zone that blends with the capsule
Bilaminar zone (posterior attachment complex)
- A bilaminar structure located posterior to the
articular disc
- Highly distortable, especially on opening the
mouth
- Composed of:
     Superior lamina—contains elastic fibers and
anchors the superior aspect of the posterior
portion of the disc to the capsule and bone at the
postglenoid tubercle and tympanic plate
     Retrodiscal pad—the highly vascular and
neural portion of the TMJ, made of collagen,
elastic fibers, fat, nerves, and blood vessels (a
large venous plexus fills with blood when the
condyle moves anteriorly)
     Inferior lamina—contains mainly collagen
fibers and anchors the inferior aspect of the
posterior portion of the disc to the condyle
TMJ compartments
- The articular disc divides the TMJ into superior
and inferior compartments
- The internal surface of both compartments
contains specialized endothelial cells that form a
synovial lining that produces synovial fluid,
making the TMJ a synovial joint
Synovial fluid acts as:
- A lubricant
- An instrument for providing the metabolic
requirements to the articular surfaces of the TMJ
Superior Compartment
- Between the squamous portion of the temporal
bone and the articular disc
- Volume = 1.2mL
- Provides for the translational movement of the
TMJ
Inferior Compartment
- Between the articular disc and the condyle
- Volume = 0.9mL
- Provides for the rotational movement of the
TMJ
Capsule
- Completely encloses the articular surface of the
temporal bone and the condyle
- Composed of fibrous connective tissue
- Toughened along the medial and lateral aspects
by ligaments
- Lined by a highly vascular synovial membrane  to the articular tubercle; travels
- Has various sensory receptors including
nociceptors
Attachments:
- Superior—along the rim of the temporal
articular surfaces
- Inferior—along the condylar neck
- Medial—blends along the medial collateral lig.
- Lateral—blends along the lateral collateral lig.
- Anterior—blends with the superior head of the
lateral pterygoid m.
- Posterior—along the retrodiscal pad
Ligaments
- Collateral Ligaments
- Temporomandibular (Lateral) Ligament
- Stylomandibular Ligament
- Sphenomandibular Ligament
Collateral Ligaments
- Composed of 2 ligaments:
     Medial collateral ligament—connects the
medial aspect of the articular disc to the medial
pole of the condyle
     Lateral collateral ligament—connects the
lateral aspect of the articular disc to the lateral
pole of the condyle
     - Frequently called the discal ligaments
     - Composed of collagenous connective tissue;
thus, they do not stretch
Temporomandibular (Lateral) Ligament
- The thickened ligament on the lateral aspect of
the capsule
- Prevents lateral and posterior displacement of
the condyle
- Composed of 2 separate bands:
    Outer oblique part—largest portion; attached
posteroinferiorly to attach immediately inferior
to the condyle; this limits the opening of the
mandible
    Inner horizontal part—smaller band attached
to the articular tubercle running horizontally to
attach to the lateral part of the condyle and disc;
this limits posterior movement of the articular
disc and the condyle
Stylomandibular Ligament
- Composed of a thickening of deep cervical
fascia
- Extends from the styloid process to the
posterior margin of the angle and the ramus of
the mandible
- Helps limit anterior protrusion of the mandible
Sphenomandibular Ligament
- Remnant of Meckel’s cartilage
- Extends from the spine of the sphenoid to the
lingula of the mandible
- May help act as a pivot on the mandible by
maintaining the same amount of tension during
both opening and closing of the mouth
Arterial Supply of the TMJ
- External carotid artery (terminal branch)
                 - Superficial temporal
- Maxillary artery
                  - Deep auricular
                  - Anterior Tympanic
Venous drainage of the TMJ
- Superficial temporal vein
- Maxillary vein
Sensory Innervation of the TMJ
- Trigeminal Nerve
    Mandibular Division
               Posterior
                       - Auriculotemporal Nerve
               Anterior
                       - Masseteric Nerve
                       - Posterior deep temporal Nerve
OPENING THE MANDIBLE
Rotational – initial movement
    - occurs in the lower TMJ compartment
    - Lateral pterygoid (inferior head) initiates the
opening of the jaw (the superior head of the
lateral pterygoid is described as being active
during elevation of the mandible in a “power
stroke”)
     - As the mandible is depressed, the medial and
collateral ligaments tightly attach the condyle to
the articular disc, thereby allowing only for
rotational movement
     - Once the TMJ becomes taut, no further
rotation of the condyle can occur
     - Normally, rotational movement continues
until the upper and the lower teeth are about 20
mm away from each other
uTranslational
uoccurs in the upper TMJ compartment and
provides for most of the mandible’s ability to
open
uthe articular disc and the condyle complex slide
inferiorly on the articular eminences, allowing
for maximum depression of the mandible
Translational
- occurs in the upper TMJ compartment and
provides for most of the mandible’s ability to
open
- the articular disc and the condyle complex slide
inferiorly on the articular eminences, allowing
for maximum depression of the mandible
Mandibular dislocation
- Mandibular dislocation (or subluxation of the
TMJ) occurs when the condyle moves anterior to
the articular eminence
- With dislocation, the mouth appears “wide
open”
- Because the condyle is displaced anterior to the
articular eminence, a depression can be palpated
posterior to the condyle
- Spontaneous dislocations can occur from a
variety of actions ranging from an extended
dental treatment to a simple yawn
- Because the mandible is dislocated, the patient
has a great deal of difficulty verbalizing his or
her predicament
- Relocation involves repositioning the condyle
posterior to the articular eminence
Arthritis
- Arthritis is the most common cause of
pathologic changes in the TMJ
- When rheumatoid arthritis occurs, usually both
TMJs are affected, and other joints tend to be
affected before the TMJ
- Radiologic images in the initial disease stages
show decreased joint space without osseous
changes
- Radiologic images in the late disease stages
show decreased joint space with osseous
changes, possibly including ankylosis
- In osteoarthritis, causes include normal wear,
trauma, and bruxism, and clinical manifestations
may range from mild to severe
Ankylosis
- Ankylosis is an obliteration of the TMJ space
with abnormal osseous morphologic features,
which often occurs as a result of trauma or
infection
- Classified as either true (intracapsular) or false
ankylosis (extracapsular condition usually
associated with an abnormally large coronoid
process or zygomatic arch)
- Treatment varies in accordance with the cause
but may include a prosthetic replacement or
condylectomy