INTRODUCTION

•Compound

•Synovial

•Ginglimoid

•Diarthodial

•Rigid end point

closure
 EMBRYOLOGY OF TMJ
• In 8-9th wk of IU life, Meckel’s cartilage provides the
skeletal support for the development of the mandible &
extends from the midline backwards and dorsally. The
articulation of malleus and incus functions as the primary
TMJ
 FUNCTIONAL ANATOMY

Bony components Soft tissue

Condylar head Articular disc
Glenoid fossa Joint capsule
Articular eminence Ligaments
Muscles attached to
joint
Muscles
Muscles involved in
mastication.
Facial muscles.
Muscles of the neck
 Functional anatomy of the TMJ:
• Bony components:

CONDYLE:
‘Rugby ball’
Projections called
‘poles‘
Line drawn through
centre…..Magnum
• At 90 degree to the ramus

• Then how do condyles

rotate around a common fixed axis??

• Medial poles serve as axis of rotation.

 Clinical Significance
Increased functional loading

cartilagenous hypertrophy

Continuous non physiological overloading

Cartilage degeneration, bone deformation,

ankylosis
 TEMPORAL BONE
• Squamous part
• Concave Mandibular
fossa
‘Glenoid fossa’
‘Articular fossa’

– Articular eminence….
slopes
– Degree of convexity
varies..
• Posterior roof- very thin

• Shape- triangular with apex related to

medial pole
 Capsular ligament
• Surrounds entire TMJ

• Attached superiorly ..

• Attached inferiorly…

Capsular
ligament
 Clinical significance:
Encompasses the joint.
Retains synovial fluid.
Provides proprioception.
 ARTICULAR DISC
Fibrocartilage, biconcave

occupies space between

condyle and fossa

Devoid of nerves and

vessels

Primary function
provides an interface
3 regions:

• Anterior border

• Intermediate zone

• Posterior border
 •Advantage of fibrous
over hyaline-

• Vascular knee…

• Applied..
Superior & Inferior joint cavity
Anteriorly, attached to..

2 cavities:

Internal surface lined by…

hyaline cartilage
Functions of synovial fluid
 Lubrication mechanisms:

• Boundary lubrication:
Border , recess areas

• Weeping lubrication:
Articular surface absorbs synovial fluid.
 Clinical significance:
• Serves as ‘movable fossa’ for condyle.
• Dampens peaks of force

• 2 types of adaptation:

 Progressive reversible deformation

Regressive permanent deformation,
perforation, ossification.
 Retrodiscal tissue:
• Bilaminar zone, retrodiscal fat
pad, retroarticular plastic pad
etc.

• Consists of :

• Function :
 Clinical significance:
Increased functional loading

Fibrosis.

Chronic non physiologic loading

Perforation, inflammation
 Ligaments:
• Composed of collagenous CT with particular length

• Do not stretch.

• When excessive force- elongated.

• Passive restraining devices.

• 3 Functional , 2 accessory ligaments.

 LIGAMENTS:
• True ligaments:
• 1. Collateral ligaments / Discal ligaments
• 2. Capsular ligament
• 3. Temporomandibular ligament / Lateral ligament
•
• Accessory ligaments:
• 1. Sphenomandibular ligament
• 2. Stylomandibular ligament
•
 Collateral / Discal ligament:
• Attaches articular disc to condyle

• 2 ligaments:
I. Medial discal ligament
II. Lateral discal ligament.

• Divides joint into … 2 cavities

• Function:
– restrict movement of the disc
 Clinical significance:
• Strain on these ligaments produces pain.

• Information about joint position and movement.

• Responsible for hinging movements b/w condyle and

disc.
 Temporomandibular ligament:
• Lateral ligament
• 2 parts:
Outer oblique portion

Inner horizontal portion.

• Functions:
– resists excessive dropping
– limits posterior movement
•

Fig – Effect of the outer oblique part of the TM ligament

 •Sphenomandibular ligament:

• Stylomandibular
ligament:
 Innervation of the TMJ : Branches of
mandibular nerve.
• Auriculotemporal n.

• Deep temporal n.

• Masseteric n.
.
Vascularization of TMJ

• Sup. Temporal artery from

posterior
• Middle meningeal artery frm
anterior
• Internal maxillary artery
• Deep auricular, ant. Tympanic,
ascending pharyngeal
 Venous drainage is through
• Superficial temporal vein

• Maxillary plexus

• Pterygiod plexus
 Lateral pterygoid muscle:
 2 functionally different parts:
Superior head :
Inferior head :
Action of muscles on the
mandibular movements:
 ELEVATION

TEMPORALIS MASSETER
MEDIAL PTERYGOID

RETRACTION PROTRACTION

DIGASTRIC
GENIOHYOID LATERAL PTERYGOID

MYLOHYOID

DEPRESSION
Lateral pterygoid
Temporalis
Medial pterygiod
 Mechanics of mandibular movement
• Complex series of inter-related 3-D rotational and
translational activities
• Types :

 Rotational movement

Translational movement
I. Horizontal axis

II.Frontal axis

III.Sagittal axis
1. INFERIOR JOINT CAVITY
Condyle + disc
ROTATIONAL / HINGE

2. SUPERIOR JOINT CAVITY

Condyle-disc + glenoid fossa
• TRANSLATORY / SLIDING MOVEMENTS
Hinge or rotational movement
Translatory/gliding
 Criteria for optimal functional occlusion
• Optimum orhtopedicallly stable
joint position:
The term ‘Centric relation’ …

• Orthopedic principle: muscles

stabilize joints.

• 3 muscles responsible for joint

position and stability:…
 JAW JERK REFLEX

• The jaw jerk reflex is analogous to the knee jerk reflex. It

is a stretch reflex whereby stretching the jaw-closing
muscles (by applying a downward tap on the chin)
produces a reflex contraction of these muscles. It
demonstrates the existence of a feedback loop from the
jaw-closing muscles to their own motor neurons in the
central nervous system.
• This reflex is thought to relate to the fine control of jaw
movements to take into account different consistencies
of food
 Tmj disorder
• Temporomandibular joint and muscle
disorders, commonly called “TMJ,” are a
group of conditions that cause pain and
dysfunction in the jaw joint and the
muscles that control jaw movement
• 1 Myofascial pain involves discomfort or
pain in the muscles that control jaw
function.
• 2 Internal derangement of the joint
involves a displaced disc, dislocated jaw,
or injury to the condyle.
• 3 Arthritis refers to a group of
degenerative/ inflammatory joint disorders
that can affect the temporomandibular
joint.
,
Diagnostic Classification of Temporomandibular
Disorders by American Academy of Orofacial
Pain (AAOP)

• Cranial bones (including the mandible)

• Congenital and developmental disorders:
– aplasia
– Hypoplasia
– Hyperplasia
– dysplasia
• (eg, 1st and 2nd branchial arch anomalies, hemifacial
microsomia, Pierre Robin syndrome, Treacher Collins
syndrome, condylar hyperplasia, prognathism, fibrous
dysplasia).
– Acquired disorders (neoplasia, fracture)
• Temporomandibular joint disorders
– Deviation in form
– Disk displacement (with reduction; without
– reduction)
– Dislocation
– Inflammatory conditions (synovitis, capsulitis)
– Arthritides (osteoarthritis, osteoarthrosis
– polyarthritides)
– Ankylosis (fibrous, bony)
– Neoplasia
• Masticatory-muscle disorders
– Myofascial pain
– Myositis
– Spasm
– Protective splinting
– Contracture
 Epidemiology and etiology of
temporomandibular disorders:
• Age group: 20 and 40 years • Instability of maxillomandibular
• Females > males relationships
• Hormonal • Laxity of the joint
• Genetic • Comorbidity of other rheumatic or
• Parafunctional habits (eg, musculoskeletal disorders
nocturnal bruxing, tooth • Poor general health and an
clenching, lip or cheek biting) unhealthy lifestyle
• Emotional distress • Trauma from hyperextension (eg,
• Acute trauma from blows or dental procedures, oral intubation
impacts for general anesthesia, yawning,
hyperextension associated with
cervical trauma)
• 65 and 85% of people
• 12% experience prolonged pain or
disability that results in chronic symptoms
 Myofascial pain dysfunction
synd.

Description
(regional dull aching pain History
and presence of localized
tender spots [trigger 1. Pain in the jaw, temple, Examination
points] in muscle, tendon, in the ear, or in front of
or fascia that reproduce 1. Regional pain, usually
ear; and dull
pain when palpated and
may produce a 2. Report of pain or ache 2. Localized tenderness in
characteristic pattern of in jaw, temples, face, firm bands of muscle
regional referred pain preauricular area, or and/or fascia
and/or autonomic inside ear at rest or during
symptoms on provocation) function, and pain on 3. Reduction in pain with
palpation in three or more local muscle anesthetic
muscle sites injection or vapocoolant
spray and stretch of
muscle trigger points
 Aetiopathogenesis of MPDS

Micro or macro traumatic events or continued muscle contractions

Over activity of Muscles

Muscle fatigue and Decrease level of ATP and energy

Anaerobic muscle environment

Noxious metabolic end products such as lactic acid gets accumulated

Muscle nociceptors gets activated resulting into Muscle nociception

Muscle tone becomes spastic and sore

Resulting into muscle tenderness and pain

 Sudden
trauma
to musculoskeletal
tissues Lack of
Excessive
Exercise activity

Chilling of Factors which Muscle strain

areas of activate trigger points due to
the body Over activity

Psychological Nutritional
factors deficiencies
Generalized
fatigue
 Laskin’s diagnostic creteria for MPDS

There are four Characteristic sign of MPDS given

by Laskin :
1. Unilateral / Bilateral pain in preauricular region
that is commonly worse on awaking.
2. Tenderness of one or more muscles of
mastication on palpation.
3. Limitation or deviation of mandible on opening.
4. Clicking and popping noise in TMJ
• Laskin also emphasized that other than the
above positive signs, the following signs
must be absent:
– There should be absence of clinical,
radiographic or biochemical evidence of
organic changes in TMJ
– There should be no tenderness on palpation
via external auditory meatus
 Disc Displacement With Reduction

Description History Exam

• An intra-capsular biomechanical
disorder involving the condyle–
disc complex. In the closed
mouth position, the disc is in an
anterior position relative to the
condylar head, and the disc
reduces upon opening of the
mouth. Medial and lateral
displacement of the disc may also
be present. Clicking, popping, or
snapping noises may occur with
disc reduction. A history of prior
locking in the closed position
coupled with interference in
mastication precludes this
diagnosis.
• In the last 30 days,a any • Clinical findings that may
TMJ noise(s) present
with jaw movement or
function
• Reproducible joint
noise, usually at variable
positions during opening
and closing mandibular
support the diagnosis: pain
(when present)
precipitated by joint
movement; deviation
during movement
coinciding with a click; no
restriction in
mandibularmovement
(episodic and momentary
catching of smooth jaw
movements during mouth
opening [< 35 mm] that
self-reduces with
voluntary mandibular
repositioning)
 Disc Displacement Without
Reduction With Limited
Opening
Description

An intracapsular biomechanical History

disorder involving the condyle–
disc complex. In the closed
mouth position, the disc is in
an anterior position relative to
the condylar head, and the disc
does not reduce with opening
of the mouth. Medial and
lateral displacement of the disc
may also be present. This
disorder is associated with
persistent limited mandibular
opening that does not resolve
with the clinician or patient
performing a specific
manipulative maneuver. This is
also referred to as “closed
lock.”
1. Jaw lock or catch so that the
mouth would not open all the
way; and
2. Limitation in jaw opening
severe enough to limit jaw
opening and interfere with
ability to eat.
Examination
Soft-tissue imaging reveals
displaced disk without
reduction.
Clinical findings that may
support the diagnosis: pain
precipitated by forced mouth
opening; history of clicking that
ceases with the locking; pain
with palpation of the affected
joint; ipsilateral hyperocclusion
 Diagnosis Of Temporomandibular
Disorders:
• History
• Examination
• palpation of TMJ
• Auscultation of TMJ
• Normal inter-incisal
opening

• Deviation

• Deflection
Muscles
 DENTAL EXAMINATION
• When teeth are added to stomatognathic system……
i)skeletal open bite
ii) overjet greater than 4 mm
iii)5 or more missing and unreplaced teeth
iv) Occlusal conditions affect by:
a)Introduction of acute changes in occlusion
b) orthopedic instability
v) Attrition
vi) Vertical height reduction
vii)Faulty restoration
• Wear facets
• Mobility
• Missing , supraerupted teeth
• Occlusal interferences
• Arch integrity- drifting,
tipping
various tech. to locate high
points:
 Additional diagnostic aids:
• Radiography

- Panoramic view

- Lateral transcranial view

- Transpharyngeal projection

- Transcranial projection
-Tomography

-Arthrography
-MRI

-Bone scanning
• Analgesic blocking

• Mounted casts

• Electromyography

• Sonography

• Vibration analysis

• Thermography
 Treatment Modalities
EDUCATION & SELF-CARE &
INFORMATION HABIT REVERSAL

PHARMACOTHERAPY INTRA-ORAL
APPLIANCES

TMD
TRIGGER POINT PHYSIOTHERAPY
THERAPY

PSYCHOLOGIC TREATMENT:
COGNITIVE BEHAVIORAL THERAPY
& RELAXATION TECHNIQUES
 Conservative treatment
modalities
• Moist heat
• Ice application
• Soft diet
• Jaw exercise
• Relaxation techniques
• Sleep on one side
 Physical therapy

• Education regarding biomechanics of jaw, neck,

and head posture and integrated movement
patterns
• Passive modalities (heat and cold therapy,
ultrasound, laser, and TENS) for pain
• Passive stretching and range of motion exercises
• Posture therapy sufficient to regain a neutral
zone
• General exercise and conditioning program
 Self-care

• Eliminate oral habits (eg, tooth

clenching, chewing gum)
• Provide information on jaw care
associated with daily activities
 Pharmacologic Agents
• The nonsteroidal anti-inflammatory drugs (NSAID) are the mainstays
in the pharmacological treatment of musculoskeletal disorders
where pain and inflammation are prominent features
– Ex: ibuprofen and naproxen
• Muscle relaxants
– Ex: cyclobenzaprine and metaxalone
• Anxiolytics
– Ex: diazepam
• Antidepressants
– Ex: amitriptyline
• Topical agents
– Ex: lidocaine patches
 Intraoral appliance
therapy
• Cover all the teeth on the arch the
appliance is seated on
• Adjust to achieve simultaneous contact
against opposing teeth
• Adjust to a stable comfortable mandibular
posture
• Does not alter mandibular position
• Use during sleep and rely on behavioral
methods for waking hours
 Behavioral/relaxation
techniques
• Relaxation therapy
• Hypnosis
• Biofeedback
• Cognitive-behavioral therapy
Managing Temporomandibular Disorder
Patients
Requiring Dental Procedures
• Prior to the procedure
– Use hot compresses to masseter and temporalis areas
10 to 20 minutes two to three times daily for 2 days
– Use a minor tranquilizer or skeletal-muscle relaxant
(eg, lorazepam, 1 mg; cyclobenzaprine, 10 mg) on the
night and day of the procedure.
– Start a nonsteroidal anti-inflammatory analgesic the
day of the procedure, before the procedure.
• During the procedure
– Use a child-sized surgical rubber mouth prop to support the
patient’s comfortable
– opening; remove periodically to reduce joint stiffness.
– Consider intravenous sedation and/or inhalation analgesia.
– Provide frequent rest periods to avoid prolonged opening.
– Apply moist heat to masticatory muscles during rest breaks.
– Gentlly massage masticatory muscles during rest breaks.
– Perform the procedure in the morning, when reserve is likely to
be greatest.
• After the procedure
– Extend the use of muscle relaxant and NSAID medication as
necessary.
– Apply cold compresses to the TMJ and muscle areas during the
24 hours after the procedure.
 References:
1. Management of Temporomandibular Disorders & Occlusion – Jeffrey
Okeson III ed.

2. Anatomical Atlas of the Temporomandibular joint – Ide & Nakazawa

3. Oral Histology – A.R. Ten Cate, V ed.

4. Temporomandibular Joint & Masticatory Muscle Disorder – Zarb,

Carlsson, Sessle, Mohl, II ed.

5. Orban’s Oral Histology & Embryology - S.N. Bhaskar, XI ed.

6. The world wide web.

7. Textbook of oral medicine – Burkitt XI edition.

8. Functional occlusion from TMJ to smile design- Peter E. Dawson

 Conclusion:

“NOTHING IS MORE FUNDAMENTAL TO TREATING

PATIENTS THAN KNOWING THE ANATOMY”
THANK YO