I.T.

S Dental College, Greater Noida

Subject :Dental Histology

Lecture Topic: Maxillary Sinus
Lecture Number: L83

Program, Year: BDS, First Year

Faculty : Dr. Moulshree Kohli,Sr. Lecturer.
 Lecture Objectives & Learning Outcomes

• General Objective : To describe

temporomandibular joint in detail.
Temporomandibular Joint
 CONTENTS
Introduction
Classification
Development
Bones of the joint
Cartilage associated with the joint.
Capsule, Ligaments and Disk of the joint.
Synovial Membrane
Muscles of Mastication
Clinical Consideration
 INTRODUCTION
TMJ- SYNOVIAL SLIDING –GINGLYMOID JOINT
Why Synovial joint ?
Because lined on its inner aspect
by a synovial membrane, which
secretes synovial fluid.
Compound joint, ?? --- composed of four articulating
surfaces:
the articular facets of the temporal bone
articular facets of the mandibular condyle
the superior and inferior surfaces of the articular
disk.
Why Ginglymoid joint ?
Hinge movement takes place between the
mandible and the articular disc.
Classification of Joints:
Fibrous joints
Suture joint
Gomphosis
Syndesmosis
Cartilaginous joints
Primary cartilaginous joint
Secondary cartilaginous joint
Synovial joints
Fibrous joint : 2 bones connected by
fibrous tissue
Suture joint: Little / no movt.
Function is to permit growth
ex:Sutural joints between skull bones
Gomphosis: Intrusion & recovery in
response to biting forces
ex: Socketed attachment of tooth to bone
by fibrous PDL
Syndesmosis: Bony components apart
here, but joined by
interosseus ligament which
permits limited movement.
ex:joints between radius & ulna
between tibia & fibula
Cartilaginous joints :
Primary cartilaginous joint: bone &
cartilage in direct apposition
ex: Costochondral junction
Secondary cartilaginous joint: Bone-
cartilage- fibrous tissue- cartilage- bone
ex: Pubic symphysis
Synovial Joints:
Provide significant movement.
2 bones united & surrounded by a capsule
creating a joint cavity.
Cavity is filled with synovial fluid formed by
synovial membrane that lines non-articular
surfaces
Cavity may be divided by an articular disk
Synovial joints classified as
Based on number of axes in which bone
can move
• Uniaxial , Biaxial & Multiaxial

Based on shapes of articulating surfaces

• Planar, Hinged, Ginglymoid [Pivot], Condyloid,
Saddle, Ball & Socket.
Development of the Joint
Meckel’s cartilage provides the skeletal support
for the development of lower jaw and extends
from midline backward and dorsally, where it
terminates as the malleus.
Secondary jaw joint, TMJ starts to develop
around 3 months of gestation.
First evidence – appearance of 2 distinct regions
of mesenchymal condensations, the Temporal &
Condylar blastemata
Temporal blastema appears
before the condylar & initially lie
at some distance from each
other.
Condylar blastema grows rapidly
to close this gap
Ossification begins first in
temporal blastema.
While the condylar blastema
is still condensed
mesenchyme, a cleft appears
immediately above it-
becomes the inferior joint
cavity
The condylar blastema
differentiates into cartilage
(condylar cartilage)
Second cleft appears in
relation to temporal
ossification- upper joint cavity
Primitive articular disk is
formed
Bones of the Joint

Glenoid fossa (on the undersurface of

the squamous part of temporalbone)

Condyle (supported by the condylar

process of the mandible)

Glenoid fossa:
Posteriorly – squamotympanic &
petrotympanic fissure
Medially – spine of the sphenoid
Laterally – root of the zygomatic process of
temporal bone
Anteriorly – articular eminence
Superiorly – thin plate of bone separating it from
Middle Cranial Fossa
Condyle :
articulating surface of the mandible
• Antero posteriorly – strongly convex
• Medio laterally – slightly convex
Medial & lateral ends termed poles
Variations in condyle shape occur, often condyle
surface divided by sagittal crest into medial & lateral
slopes
 Condyle covered by fibrous
layer consisting of
fibroblasts scattered through
dense, largely avascular
layer of type I collagen
(lamina splendens)

Fibrous layer sits on a

proliferative zone of cells,

associated with formation

of condylar cartilage.
Cartilage associated with the Joint
Earlier- that surface coverings consist of fibro
cartilage rather than fibrous tissue.
Evidence points that fibro cartilage is present deep
to the fibrous layer, in the condyle & on the
articular eminence
Condylar cartilage similar to epiphyseal cartilage –
I.e., it contains proliferating layer of cells which
become chondroblasts & elaborate an extra cellular
matrix of proteoglycans & type II collagen
Production of cartilage 
endochondral
ossificationmineralization of
cartilage, vascular invasion,
loss of chondrocytes,
differentiation of osteoblasts to
produce bone.
Fibrous articular covering

Proliferative layer

Hypertrophic zone

Calcified cartilage

Bone
Capsule, Ligament & Disk of Joint
Capsule:
Consist of dense collagenous membrane that
seals joint space, provides passive stability
Active stability from proprioceptive nerve endings
in the capsule
Extends into joint cavity to form disk, dividing
cavity into 2 compartments
Capsular attachments:
Posteriorly – squamo-
tympanic fissure
Laterally – glenoid fossa
Anteriorly – articular
eminence
Inferiorly – neck of
condyle
 LIGAMENTS:
Temporomandibular ligament:

Fan shaped, seen as lateral thickening of capsule.

Runs obliquely backward & downward from
lateral aspect of the articular eminence to
posterior aspect of condylar neck
• 2 parts : Outer oblique portion
Inner horizontal portion
Restricts displacement of mandible in 3 planes:
prevents lateral dislocation, limits inferior
displacement & limits posterior displacement
Outer oblique portion - extends from the outer surface of
the articular tubercle and zygomatic process
posteroinferiorly to the outer surface of condylar neck
Inner horizontal portion - extends from outer surface of the
articular tubercle and zygomatic process posteriorly and
horizontally to the lateral pole of the condyle and the posterior
part of the articular disc.
Sphenomandibular ligament:
Accessory ligament
Attached superiorly to the
spine of sphenoid and
inferiorly to the lingula of
mandibular foramen.
Remnant of the dorsal
part of Meckel’s cartilage.
Stylomandibular ligament:
Accessory ligament.
Represents thickened part
of the deep cervical fascia.
Attached above- lateral
part of styloid process
Below-angle and posterior
border of ramus of the
mandible.
Disk:
Consists of dense fibrous tissue, shape
conforms to apposed articular surfaces
Divides joint into upper & lower compartments
Provides articular surface for head of condyle
Anterior & posterior components are thickened,
central portion is thin (devoid of blood vessels,
nerves)
Anterior band = 2mm
Intermediate zone = 1mm
Posterior band = 3mm
At rest:
Central portion separates anterior slope of
condyle from the slope of the articular eminence.
Thickened posterior portion occupies gap
between condyle & floor of glenoid fossa,
anterior portion lies slightly anterior to condyle
Anterior portion of disk fuses with the anterior
wall of capsule.
• Above point of fusion, capsule blends with periosteum
of anterior slope of articular eminence.
• Below, it merges with periosteum of front of neck of
condyle.
Posteriorly, disk appears to divide into
2 lamellae representing the posterior
wall of capsule Disc
attachments Mandibular
• Upper part of lamellae – fibrous & elastic fossa

tissue & inserts into squamotympanic Articular

eminence

fissure
• Lower part blends with the periosteum of
the condylar neck
Gap between 2 lamellae filled with
loose, highly vascular connective tissue
Disk has good vascular & neural supply
at periphery, but is avascular and not Mandibular
condyle
innervated at the centre
Synovial Membrane
Lining of inner surface of capsule
Lines entire capsule, with folds/villi of membrane
protruding into joint cavity
Folds increase with age & in pathologic processes.
Does not cover the articular surfaces of joint or
disk
 Histology of Synovial Membrane
2 layers: cellular intima &
vascular subintima
Intima: varies in structure,
having 1-4 layers of synovial
cells embedded in an
amorphous, fiber free
intercellular matrix.

Sub-intima: loose connective

tissue containing vascular
elements with scattered
fibroblasts, macrophages, mast
cells, fat cells, elastic fibres.
Histological section through the temporomandibular joint showing the
synovial membrane,articular disc and articular surface of the condyle.
Often, sub-intimal layer borders the joint
cavity. These cells are not connected by
junctional complexes & does not rest on a
basement membrane
Cells forming this discontinuous layer:
Type A (macrophage like): have many plasma
membrane invaginations & many pinocytotic
vesicles. Cytoplasm has numerous
mitochondria,lysosomal elements & prominent
golgi complex.rough endoplasmic reticulum is less
found. Function-phagocytic properties.
Type B (fibroblast like):more RER, synthesize
Hyaluronate found in synovial fluid.
Synovial membrane:
Produces synovial fluid
• Physical Properties: viscosity, elasticity &
plasticity
• Contains small amounts of monocytes,
lymphocytes, free synovial cells & PMN
leukocytes
• Chemical composition: it is a dialysate of
plasma with some added protein & mucin
Function of synovial fluid:to provide
• Liquid environment for joint surfaces
• Lubrication to increase efficiency & reduce
erosion
 Histological Structure of TMJ
1- articular
eminence
2-fibrous
covering
3- articular
disc
5- fibrous
covering
6- hyaline
cartilage
4- lower
joint
7- cancellous
cavity
bone
Muscles of Mastication

Masseter
Medial pterygoid
Lateral pterygoid
Temporalis
 MASSETER:
Superficial layer
• Tendinous portion-zygomatic process
of maxilla
• Fleshy portion- inferior border of ant.
two thirds of zygomatic arch
• Run infero posteriorly
• Insert into angle & lower border of
mandibular ramus
Deep layer
• Inferior aspect & border of posterior
third of Zygomatic arch
• Run vertically down
• Insert into upper border & lateral
aspect of ramus.
MEDIAL PTERYGOID:
Superficial head: tuberosity of maxilla and
adjoining bone.
Deep head: medial surface of lateral pterygoid
plate and adjoining process of palatine bone.
Insertion-Roughened area on the medial surface of
angle and adjoining ramus of mandible,below and
behind the mandibular foramen.
 LATERAL PTERYGOID:
Upper head: Infratemporal surface and crest of
greater wing of sphenoid bone.
Lower head: Lateral surface of lateral pterygoid plate.
Insertion- Pterygoid fovea on the anterior surface of
neck of mandible.
Anterior margin of articular disc and capsule of
temporomandibular joint.
TEMPORALIS
Fan Shaped muscle.
Originates- Temporal
fossa excluding
zygomatic bone and
temporal fascia.
Insertion- Margins and
deep surface of coronoid
process, anterior border
of ramus of mandible.
 MOVEMENTS
Elevation: Masseter, temporalis (Middle
& anterior fibres), Medial Pterygoid
Depression: lat.ptertygoid, mainly by
geniohyoid and digastric muscles

Elevation

Depression
 Retraction: posterior
Retraction fibres of temporalis
Side to side movement:
It is brought out bycontraction
Of lat & Med pterygoid muscle
On one side, acting alternatly
With the other side

Protraction Protraction: Both pterygoids (Med & Lat)

 Vascular supply

Anterior region– Massetric artery

Posterior part -- branch of superficial

temporal artery and branch of maxillary
artery.

Posterior aspect of the joint has a rich

plexus of veins.
 Nerve Supply
Primarily from AURICULOTEMPORAL nerve
Massetric nerve (accessory)
Deep temporal nerve (accessory)

TMJ also has mechanoreceptors

Ruffini’s corpuscle
Pacinian corpuscle
Golgi tendon organs
Free nerve endings
Anatomic & Functional Designations
for Nerve endings
Anatomic Designations Functional Designations
Ruffini’s corpuscle Posture(Proprioception)-dynamic
& static balance.
Pacinian corpuscle Dynamic Mechanoreception-
movement accelerator.
Golgi tendon organs Static Mechanoreception-
protection(ligament)
Free nerve endings Pain(nociception)-protection(joint)
 CLINICAL CONSIDERATIONS
Mandibular dislocation
Definition:
Displacement of condyle from the glenoid fossa
which cannot be reduced by the patient.
I -Unilateral
-Bilateral
II -Acute
-Chronic
1. Long standing
2. Recurrent
3. Habitual
Clinical features
Bilateral dislocation
 Pain in temporal region
 Inability to close the mouth & speach
 Tense masticatory muscle
 Excessive salivation
 Protruding chin
 Open bite
 Distinct hollow in front of tragus
Unilateral dislocation
 Contralateral cross and
open bite
 Mandible swung away
 Protrusive occlusion
 Hollow in front of tragus
on the same side
D/D – Unilat. subcondylar #
Subluxation
Recurrent self reducible dislocation of tmj.
Capsule becomes so lax that patient by
virtue of habituation moves the mandible
forward and backward.
Seen in professional singers , musicians,
speakers and aged people.
 Myofacial Pain Dysfunction Syndrome
(MPDS)
It is a pain disorder ,in which unilateral pain is
referred from the trigger points in myofacial
structures ,to the muscles of head and neck.

Pain is constant, dull in nature ,

in contrast to the sudden sharp, shooting,
intermittent pain of neuralgias (chronic pain).
The pain may range from mild to intolerable.
Clinical features :
Laskins 4 cardinal signs:
• Unilateral pain
• Muscle tenderness
• Clicking or popping noise in TMJ
• Limitation of jaw function or deviation
of the mandible.
• Associated symptoms.
Symptoms :
Masticatory pain may be due to
myalgia,arthralgia or from both.
Difficulty in chewing & restriction of
mandibular excursion.
Interference with mandibular
movement
clicking & popping snapping sounds
 Management :
Education
Self care(elimination of oral habits) Intraoral appliance therapy
splints,bite guards,night guards)
Physical therapy
 Heat application
 Ultrasound Pharmacotherapy
 Cryotherapy NSAIDs, acetaaminophen,muscle
 Massage with counterirritants & vibrators relaxants,antianxiety agents,tricyclic
 Use of vapocoolent spray depressants,clonezepam
 Tetanizing & sinusoidal currents
 Electrogalvanic stimulation
 Transcutaneous electronic nerve Behvioral/or relaxation technique
stimulator(tens)  Relaxation therapy
 Active stretch exercises.
 Hypnosis
 Biofeedback
TMJ ANKYLOSIS

• Greek terminology meaning ‘stiff joint’ .

• It may be defined as the immobility or

consolidation of a joint due to disease,
injury or surgical procedure.
Clinical features :
Facial features:
Deviation of chin and the mandible toward the side of the
defect.
Unilateral vertical deficiency of the side of the defect.
Retrognathic mandible with a short ramus and small body
Often a retruded maxilla

Convex facial profile

Relatively short hyo-mental distance with tight suprahyoid
musculature
Absent or deficient cervico-mental angle
Bird face deformity
Prominent ante-gonial notch
Oral feature :
Deviation of maxillary and mandibular midlines
towards the affected side
Generally a Class II malocclusion
Posterior crossbite
Deviation to affected side an opening
Trismus
In bilateral ankylosis, trismus may also be
associated with an open bite
Severe oral hygiene maintainance problems
leading to caries and periodontal problems
Markedly elongated coronoid process
 Radiographic finding :
FIBROUS ANKYLOSIS : Reduced joint space and hazy
appearance is seen.
Still the normal anatomy of the head and glenoid fossa
can be appreciated.

BONY ANKYLOSIS : complete obliteration of joint space.

Normal TMJ anatomy is disabled. Deformed Condylar
head or complete bony consideration replacing the joint
space can be seen
Elongation of coronoid process on the side of
hypomobility will be seen.
 OPG findings :
Ankylotic mass (osteoid mass)
Decreased joint space
Elongation of coronoid process
Complete flattening in
condyle
Decreased ramus
height
Midline shift
Impacted teeth
Displaced teeth and crowding
Maxillary arch canting
Carious teeth
Surgical techniques
Condylectomy
Gap arthroplasty
Interpositional arthroplasty
 Commonly Asked Questions

Histology of Temporomandibular
joint.
REFERENCES
Nanci A: Ten Cate’s Oral Histology
development, structure, and function; 7th edition.

Orban’s Oral Histology & Embryology;12th edition

 Berkovitz BKB, Holland GR, Moxham BJ: A

Colour Atlas & Text of Oral Anatomy, Histology
& Embryology ; 3rd edition
THANKYOU

70