ANNALS OF ANATOMY

The human temporomandibular joint region in

different positions of the mandible*

Cordula Schmolke 1 and Alfons Hugger z

1Department of Anatomy, University of Bonn, Nussallee 10, D-53115 Bonn, Germany,

and 2Westdeutsche Kieferklinik, University of Dtisseldorf, Moorenstrage 5,
D-40225 Dfisseldorf, Germany

Summary. The anatomy of the human temporomandibular
joint region has been investigated mainly under the condi-
tions of dental occlusion. The aim of the present study was
to elucidate the topographical situations in other func-
tional positions such as wide-open mouth, protrusion and
lateral displacement. The respective mouth positions were
adjusted before fixation and controlled by magnetic reso-
nance tomography. The temporomandibular joint regions
were embedded in epoxy resin, and cut serially in the sagit-
tal or the frontal plane. Wide-open mouth: The articular
disc lies with its intermediate zone between the articular
tubercle and the dorsal convexity of the condylar process,
and thus adapts the articulating surfaces of the bones per-
fectly to each other. Massive enlargement of the retroarti-
cular cushion is seen, whereas the loose connective tissue
on the anterior side of the joint appears completely com-
pressed. Protrusion: The disc lies with its intermediate
zone between the convexities of the condylar process and
the articular eminence. On the lateral side it appears to be
compressed between mandible and temporal bone. The ret-
roarticular cushion is moderately enlarged. The anterior
compartment of loose connective tissue is smaller than in
occlusion. Lateral displacement: On the working side the
articular disc is in a stabilized position between the bony
joint elements. The balancing condyle is in a protruded po-
sition with the retroarticular cushion reaching into the
dorso-lateral half of the mandibular fossa. Conclusion:
Protrusion appears as the position with the highest me-
chanical stress upon the articular disc.
* This study has been supported by the Deutsche Forschungsge-
meinschaft (Schm 1117/1-2)
Correspondence to: C. Schmolke
Key words: Wide-open mouth - Protrusion - Lateral dis-
placement - Retroarticular cushion - Bruxism - Magnetic
resonance tomography
Introduction
Most topographical studies of the human temporomandi-
bular joint region have been done in closed mouth posi-
tion or in dental occlusion (Zenker 1956; Marguelles-
Bonnet et al. 1989; Schmolke 1994). However, the possibi-
lity of drawing functional conclusions from these data that
might provide a better understanding of the mechanisms
of normal joint movements or of joint disorders is limited.
Among the various functional possibilities of the man-
dible, only the opening and closing cycle of the mouth has
been investigated carefully with respect to anatomical
changes (Rees 1954). Little is known about the anatomical
differences in a protruded position of the condyle (Car-
pentier et al. 1988; Pinkert 1992). The anatomical situation
under the condition of lateral displacement of the man-
dible has up to now not been investigated. Therefore, in
the present study, the human temporomandibular joint
region has been examined in sagittal and frontal series of
sections under the conditions of closed mouth, wide-open
mouth, protrusion and lateral displacement of the mand-
ible. The sections provide information about the 3-dimen-
sional arrangement of the articulating bones, the interposed
disc, and also of connective tissue compartments which are
close to the joint, such as the retroarticular cushion de-
scribed by Zenker (1956). Moreover, the serial sections pos-
sibly reveal anatomical details which might help to interpret
equivalent planes of magnetic resonance tomograms
(MRT) of patients with temporomandibular joint disor-
ders. Therefore, in some cases, MRTs were done for com-
parison before starting anatomical studies.

Ann Anat (1999) 181:61-64 0940-9602/99/181/1-61 $12.00/0

© Urban & FischerVerlag
 Materials and methods
In 14 fresh cadavers between 25 and 91 years, the desired posi-
tions of the mouths, i.e. closed mouth or dental occlusion
(8 cases), wide-open mouth (2 cases), protrusion (2 cases) and
lateral displacement (2 cases), were adjusted before starting the
fixation. About 4 weeks after injecting a solution of 4% formal-
dehyde, 0.5% glutaraldehyde and 60% alcohol, blocks with
edges of about 8 cm containing the temporomandibular joint re-
gion were sawn out from both sides of the heads. In 4 cases of
closed mouth or dental occlusion, in 1 case of wide-open mouth
and in the 2 cases of protrusion, magnetic resonance tomography
was done in order to find out whether or not the functional posi-
tions induced passively in cadavers resemble the normal situa-
tions in living persons. The blocks were then dehydrated in 100%
acetone at -25°C and impregnated with a solution of 2 parts
epoxy resin Biodur El2, 4 parts of Biodur E6 hardener and
0.15% of Biodur E600 accelerator under vacuum (v. Hagens
1979). After polymerization, series of sections were cut with a dia-
mond wire saw (Well W. Ebner, Mannheim, Germany) at a thick-
ness of about 1 mm, either in the sagittal or in the frontal plane.
These sections were brought onto glass slides, treated with a
grinding and polishing machine (Phoenix 4000, Jean Wirtz, Dtis-
seldorf, Germany) up to transparency and stained either with
methylene blue/azur II and basic fuchsin according to Laszk6 and
L~vai (1975) or with carbol methylene blue/carbol gentian violet
and pararosanilin (Tolivia et aI. 1994).
Results
The magnetic resonance tomograms were in all cases
comparable to those in living persons with similar posi-
tions of the mandible.
The topographical situation in the closed mouth posi-
tion as it appears in sagittal (Fig. 1 a) and frontal (Fig. I b)
plasticized sections has already been described earlier
(Schmolke 1994) and will now be mentioned only for
comparison. The present paper will concentrate on the
other functional positions of the mandible.
In the cases with wide-open mouth, the incisial dis-
tances were 32 and 42 ram, which means they were within
physiological ranges. In contrast to the closed mouth
position the mandibular condyle appears anteriorly ro-
tated and is with its dorsal convexity opposite to the
deepest point of the articular tubercle (Fig. I c). The ar-
ticular disc at its thinnest part, the intermediate zone, lies
between the convex surfaces of the 2 bones. The position
of the anterior band of the disc is in front of, that of the
posterior band behind the deepest and highest points of
the convexities of the apposing bones. Thus, the articulat-
ing surfaces are more precisely adapted to each other by
the disc in the wide-open mouth than in the closed mouth
position. On the anterior side of the joint, in the wide-
open mouth position, the collagen fibres of the upper and
lower lamellae of the disc have condensed so as to form
strong ligaments. The mandibular condyle has rotated
into the anterior recess of the lower joint compartment
and thus causes tension of the lower lamella. Both man-
dibular condyle and articular disc have glided forward
62
into an extreme anterior position. The upper lamella of
the disc is thereby reflexed and elongates the anterior
part of the upper joint compartment for a few mm. The
prearticular compartment, which in the closed mouth po-
sition is filled with loose connective tissue and a venous
plexus, appears in a wide-open mouth position almost
completely compressed. The temporal muscle, and more
laterally also the masseteric muscle thus come into close
contact with the anterior part of the articular disc. On the
dorsal side, the upper posterior lamella of the bilaminar
region is elongated and the retroarticular cushion is al-
most 5 times as large as in dental occlusion. The lumina
of the blood vessels belonging to the venous plexus of the
retroarticular cushion are wide.
In sections cut in the frontal plane, the shape of the ar-
ticular disc in the wide-open mouth position with its
upper and lower side is exactly complementary to that of
the articular surfaces of the temporal bone and the man-
dibular condyle (Fig. l d ) . The disc does not extend be-
yond the medial margin of the mandibular condyle as it
does in the closed mouth position (Fig. i b). In the wide-
open mouth situation the lumina of the blood vessels in
venous plexuses on the lateral side of the condylar neck
are wide.
Under the condition of protrusion the mandibular con-
dyle is in a more anterior position than in the situation of
dendal occlusion (Fig. 1 e). The condylar process has left
the mandibular fossa and its summit now apposes the
mandibular tubercle. Unlike the situation in the wide-
open mouth position, the protruded condyle shows no
anterior rotation. It has glided from the posterior band to
the intermediate zone of the disc. Thereby, the lower la-
mella of the bilaminar region in some planes of section-
ing has formed a fold. The position of the articular disc in
relationship to the temporal bone is almost unchanged
compared to dental occlusion (cf. Fig. i a). The retroarti-
cular cushion behind the protruded condyle is slightly en-
larged compared with that in the closed mouth position.
The loose connective tissue compartment in front of the
joint is smaller, and the anterior side of the protruded
mandible as well as the anterior part of the disc are very
close to the masseteric muscle.
In frontal sections the protruded condyle is seen
throughout its entire mediolateral width to be separated
from the articular tubercle by the thin intermediate zone
of the disc (Fig. 1 f). The lateral part of the disc appears
compressed between the 2 articulating bones. On the
medial side, however, comparable to the situation of den-
tal occlusion (cf. Fig. l b ) , p a r t of the lower side of the
disc is not in contact with the mandibular condyle but is
hanging free above the dorsal side of the lateral ptery-
goid muscle.
In the case of lateral displacement one has to take into
account that the condyles on both sides of the mandible
are in different positions. A loaded side has to be distin-
guished from a balancing side. In the cases which we have
investigated we have found the loaded condyle in a some-
what retracted position compared to the normal closed
Fig. 1. 1 mm plasticized sections through the human temporomandibular joint (a) and (b) closed mouth position. (e) and (d) wide-
open mouth (incisidal distance: 42 mm). (e) and (f) protrusion. Sagittal sections on the left, frontal sections on the right side. The
planes of frontal sections are indicated in the respective sagittal section. LPM = lateral pterygoid muscle. TM = temporal muscle.
MM = masseteric muscle. Staining in (a), (b), (e), (d) according to Laszk6 and Ldvai (1975)0 in (e) and (f) according to Tolivia et al.
(1994). Bar = 0.5 cm

63
mouth situation. Due to a slight rotation around a verti-
cal axis, the articulating surfaces of the bones are well
adapted to each other by the interposed articular disc.
The balancing condyle was seen in a protruded position.
However, due to a complementary rotation of the con-
dyle on this side, part of the loose connective tissue of
the retroarticular cushion was found to be distorted and
to fill the dorsolateral half of the mandibular fossa. In the
situation of laterotrusion the venous plexus around the
lateral pterygoid muscle appears more prominent than in
the other positions investigated.
Discussion
In each of the functional positions of the mandibles inves-
tigated the position of the articular disc in relation to the
mandibular condyle as well as to the temporal bone was
found to be different. In all cases the disc showed its
characteristic biconcave shape. There is no evidence that
movements of the condyle in a physiologically configu-
rated temporomandibular joint should be accompanied
by extensive deformations of the disc as postulated by
Osborn (1985).
Especially in the wide-open mouth position, but also
on the working side during lateral displacement, the bi-
concave structure of the articular disc serves in an opti-
mal way to bring into apposition the 2 convex surfaces of
the articulating bones. Hence, in these positions the disc
obviously stabilizes the joint.
The shape of the articular disc and those of the bony ele-
ments of the joint are most badly adapted to each other
when the mandible is in a protruded position and on the
balancing side of the mandible during lateral displace-
ment. The gliding movements which during opening of the
mouth mainly take place in the upper cavity of the joint
are, during protrusion, performed in the lower joint cavity
so that the bony elements of the joint come very close to
each other. They appear to compress the disc, especially in
the lateral part of the intermediate zone. This part of the
disc does not contain any cartilage which would provide
some special resistance to pressure. Therefore, protrusion,
if it is performed extremely often as in patients who suffer
from bruxism, would involve high risk of articular disc
damage on the lateral side of the joint.
Finally, it has to be pointed out that all functional posi-
tions of the mandible are accompanied by a different
three-dimensional architecture of the adjacent compart-
64
ments filled with loose connective tissue and venous
plexuses. These compartments are not only localized be-
hind the joint and on the medial side of the lateral ptery-
goid muscle, but were also shown to exist in front of the
joint and lateral to the mandibular neck. The vascular
meshes of these compartments, followed throughout the
series of sections, were found to be continuous with each
other. These periarticular venous plexuses are thought to
be identical with the plexus articularis already described
in 1867 by Luschka. One gains the impression that joint
movements are supported by respective changes in the dis-
tribution of blood within these plexuses. Therefore, we
propose to replace the term retroarticular cushion by the
term periarticular cushion. The retroarticular cushion
described in 1956 by Zenker is part of the periarticular
cushion.
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