TEMPORO MANDIBULAR JOINT

INTRODUCTION
• The stomatognathic system includes various anatomical structures
which allow the mouth to open,swallow,breathe,phonate,suck and
perform different facial expressions.the structures are
TMJ,jaw,mandible,muscles tissues and tendons,dental arches,salivary
glands as well as hyoid bone and muscles.
• TMJ through its complex movements on different orthogonal planes &
multiple rotation axis,works in synergy with all the structure just listed
above.TMJ also works in cordination with the contralateral TMJ to
cordinate dynamic function.
• TMJ also known as MANDIBULAR JOINT
• GINGLYMO DIARTHROIDAL JOINT
 GROWTH & DEVELOPMENT OF TMJ

PRENATAL DEVELOPMENT:
• Meckels cartilage-
• provides skeletal support for development of lower jaw.
• It extends from midline backwards and dorsally terminates into
malleus(articulare).
• It articulates with incal cartilage.
• Thus early jaw movements occurs between these two cartilages-
primary joint.
• Exits till 4th month of intrautairine life,later secondary joint develops.
• 2 distint mesenchymal condensations are formed
• .1.temporal blastema
• 2.condylar blastema
POSTNATAL DEVLOPMENT:
• Condyle –mesiolateral width:from birth to adults it increases
-anterioposterior:faster than mediolateral growth
• Cartilage slowly changes to fibrocartilage as age progresses
• Articular disc is highly vascularised rich in fibroblast at lateral side
and central part becomes avascular.
TMJ IN NEONATE:
• Flat glenoid fossa
• Develops on eruption of permanent dentition.
• Articular eminence is absent
• Condyle is immature small in size and essentially rounded
• Articular disc is prominent uniform thickness
• AGE CHANGES:
Stop growing at 20 yrs of age
1.Condylar head:decrease in convexity.
decrease in condylar head.
resorption more on lateral aspect than medial
2.Glenoid fossa & articular eminence:
flatening of articular fossa
decrease in articular eminence
decrease vertical dimension of glenoid fossa
• Anatomy of TMJ:
TMJ is basically synovial joint composed of two articulating
surfaces.so it called diarthoidal joint where articulation of two bones
permitting freedom of movement that is dictated by associated muscles
and limited by ligaments.

CRANIAL SURFACES OF TMJ CONSIST OF SQUAMOUS AREA OF

TEMPORAL BONE,IT TAKES NAME OF GLENOID FOSSA AND
WELCOMES THE CONDYLE OF THE JAW.
 TMJ

1.GLENOID FOSSA 1.JOINT CAPSULE

2.CONDYLAR HEAD 2.ARTICULAR DISC
3.ARTICULAR EMINENCE 3.LIGAMENTS
Functionally four articulating surfaces are present:
1.Articulating facet of temporal bone.
2.Articulating facets of condyle.
3.Superior surface of the disc.
4.Inferior surface of disc.
GLENOID FOSSA:
-It is also known as mandibular fossa.
-It is concave depression on inferior surface of petrous part of
temporal bone.
-It is bounded posteriorly by pertrotymphanic fissure
anteriorly by articular eminence.
-fossa is wider in it mediolateral portion compared to
anterioposterior area.
ARTICULAR EMINENCE:sigmoid shape
• Present anterior to glenoid fossa.
• consistsof decending slope,ascending slope and a transverse
bony ridge that is medial extension of zygoma.
• Articular eminence is covered by dense compact fibrous tissue that
consists primarily of collagen with few elastic fibers.
• Fibrous covering is thickest in desending slope.
• Underlying fibrous tissue covering is chondroid bone and then
compact bone.
• This is subjected to loading during function.most heavily trav-
elled by condyle and disk as they ride forward and backward
in normal jaw function.
ARTICULAR TUBERCLE:
• It is small,raised,rough,bony knob on outer end of articlar eminence.
CONDYLE:
• Adult condyle is elliptical in shape.
• Long axis of each condyle is approximatley at right angles to the
body of mandible and if projected medially would meet that of
opposite side at an angle somewhere near that anterior edge of
foramen magnum.
• Mediolaterally greater than anteriopoaterior width.
• Condyle has lateral and medial tubercles
• These tubercles provide attachments to the lateral and medial
collateral ligaments.
SOFT TISSUE COMPONENTS:
JOINT CAPSULE:The joint is enclosed with funnel shaped,fibro
elastic,highly vascular and innervated by den-
se connective tissue.
• Above -- It is circumferentially attached to rim of the glenoid
fossa and articular eminence of temporal bone,below to neck
of condyle.
• The entire lateral aspect of capsule is thickened to form main
stabilizing ligament of the joint.
LIGAMENTS:
• Extracapsular ligaments provide stability to joint are spheno-
mandibular joint and lateral ligament.
Sphenomandibular ligament:
• Medial to capsule weak ligament originates superiorly from spine of
sphenoid and inferiorly inserts into lingula of mandibular foramen.
• It is remenant of meckels cartilage
• Relations :laterally –auriculotemporal nerve
- maxillary artery
- lateral pterygoid
medially –chorda tymphani
-mylohyoid nerve and vessels
STYLOMANDIBULAR LIGAMENT:
• These ligament is associated with TMJ and considerd as accesory
ligaments to provide stability of joint
• It is band of cervical fascia that attaches above to styloid process and
below to angle and posterior border of ramus.
PTERYGOMANDIBULAR RAPHE:
• It also provides stability of joint.
• It attaches to pterygoid hamulus above and to posterior end of
mylohyoid ridge of mandible below.
LATERAL LIGAMENT:
• Reinforces and strengthens the lateral part of capsular ligament.
• Fibers are directed downwards and bckwards.
• Attaches above to articular tubercle&below to posterolateral aspect of
neck of condyle.
ARTICULAR DISC:
• Disc or meniscus that fills the space between the condyle and
temporal bone is semilunar,avascular and is a fibro cartilagious
structure.
• It acts as shock absorber and acts as protector of body components
of joint.
• Sagital section of the disc reavels an Anterior extension
Anterior fibrous band
Intermidiate zone
Posterior fibrous band
Bilaminar extension
MUSCLES CLOSLEY RELATED TO TMJ:
MUSCLES ORIGIN INSERTION ACTION
Masseter zygomatic arch angle of mandible elevates,protudes
inferior and lateral mandible
surface

Temporalis temporal line coronoid process elevates,retrudes

Lateral infra temporal pterygoid fovea protudes,depre-

Pterygoid crest sses

Medial maxillary medial surface elevates,protrude

Pterygoid tuberosity of ramus
SYNOVIAL MEMBRANE:
• Inside of TMJ capsule and non articulating surfaces of the disc
ligaments are lined by synovial membrane.
• Synovial villous projections can be seen grossly as hyperemic tissue
in the anterior,posterior,medial and lateral recess of joint cavities.
• SYNOVIAL FLUID:comes from two sources
• 1st from plasma and 2nd by secreation from synoviocytes type A &B.
• Toller assessed its volume to be not more than 0.05ml.
• Fluid exit under negative intra articular pressure.
• Fluid contains glycoprotien known as lubricin,which serves to
lubricate and minimizes fiction between articular surfaces and
synovial joints.
• VASCULAR SUPPLY AND NERVE SUPPLY:
• BIOMECHANICS OF TMJ:
SUPERIOR JOINT CAVITY
-condyle+glenoid fossa
-disc not tighly attahes to fossa
-Translatory/sliding movements.
AT REST:
-12’0 clock position
-disc space is wide
-no elastic traction on disc
JAW OPENING
-condyle rotates on disc
-disc glides on fossa
-pulls forward,downward the
Articular eminenece.
INFERIOR JOINT CAVITY
-condyle +disc
-tighly attaches to discal ligaments.
-rotational/hinge movements.
JAW CLOSING
-disc glides posteriorly
-condyle comes back to position
-ligaments do not strech
-relaxed lateral pterygoid.
RELATIONS :
SUPERIOR:middle cranial fossa
middle meningeal artery
INFERIOR:maxillary artery
ANTERIOR:masseteric nerve and artery
lateral pterygoid nerve and artery
POSTERIOR:auriculotemporal nerve
parotid gland
superficial temporal vessels
MEDIAL:medial end of capsule
spine of sphenoid
chorda tymphani
middle meningeal artery
upper end end sphenomandibular ligament
LATERAL:lateral TMJ ligament
joint capsule
styloid process
stylomandibular ligament
SUPERFICIAL:skin capsule
parotid gland
branches of facial nerve
DIAGNOSIS OF TMJ DISORDERS:
HISTORY:-h/o of onset,duration,frequency,and dental treatment
-factors like pain,click are to be considerd while taking history.
-history of trauma.
CLINICAL EXAMINATION:includes inspection
palpation for better diagnosis
auscultation
• INSPECTION:interincisal distance on mouth opening
-facial asymmetry
-deviation of mouth opening/closing
-swelling
-open bite
-abrasion of occlusal surfaces of teeth
-fillings,dentures
-overlying skin changes/colour changes.
Dental examination
Range of motion
Mandibular movements
PALPATION:muscles tenderness
ear pain
neurological tests
AUSCULTATION:tmj noises
SPECIAL INVESTIGATIONS:
• RADIOGRAPHIC EXAMINATION:
1.Possible malformation of condyle:OPG
TOWNE’S PROJECTION
2.MPDS:left and right transcranial views of joints
MRI
3.Degenerative lesions/suspected inflamation;left and right transcranial

projections
ELECTROMYOGRAPHIC INVESTIGATIONS:used for monitaring the
activity of disodered TMJ
Eg:electromyography,thermography,sonography,mandibular
kinesography,electrovibrography
DRUGS:drugs like NSAIDS,muscle relaxants,anti depressents can be
used as diagnostic aid in MPDS.
OCCLUSAL SPLINTS:
APPLIED ASPECTS:
TAXONOMIC CLASSIFICATION FOR TEMPOROMANDIBULAR
DISORDERS:
• TEMPOROMANDIBULAR JOINT DISORDERS:
1.JOINT PAIN:Arthralgia
Arthritis
2.JOINT DISORDERS:
A.Disc disoders:
1)Disc displacement with reduction
2)Disc displacement with reductiom with intermittent locking
3)Disc displacement without reduction with limited opening
4)Disc displacement without reduction without limited opening
B.Hypomobility disorders:
1)Adhesion/Adherence
2)Ankylosis
 C.Hypermobility disorders:
1)Dislocations:subluxations,luxations
3)JOINT DISEASES:
A)Degenerative joint diseases
1)osteoarthritis
2)osteoarthrosis
B)Systemic arthritides
C)Condylosis
D)Osteochondritis
E)Osteonecrosis
F)Neoplasm
G)Synovial chrondramatosis
4)FRACTURES
5)CONGENITAL/DEVELOPMENTAL DISORDERS:
A)Aplasia
B)Hypoplasia
C)Hyperplasia
MASTICATORY MUSCLES DISORDERS:
1.Muscle pain:
A)Myalgia:local myalgia
myofacial pain
myofacialpain with refferal
B)Tendonitis
C)Myositis
D)Spasm
2.Contractures
3. Hypertrophy
4. Neoplasm
5. Movement disorders:orofacial dyskinesia
oromandibular dykinesia
6.Masticatory pain attributed to systemic/central pain disorders:
-fibromyalgia
• HEADACHE:headache attributed to TMJ

ASSOCIATED STRUCTURES:coronoid hyperplasia.

Description:
ARTHRALGIA:
Pain of joint that is affected by jaw movement,function
DISC DISODERS:
1)DISC DISPLACEMENT WITH REDUCTION:
• In closed mouth position,the disc is in anterior position relative to
condylar head.
• The disc reduces upon opening of the mouth
• Medial and lateral displacement of the disc may also present.
• Clicking noises may occur.
2)DISC DISPLACEMENT WITH REDUCTION WITH INTERMITTENT
LOCKING:
• In closed mouth position,the disc is in anterior position relative to
condylar head,
• the disc intermittently reduces with mouth opening.
• When the disc doesnot reduce with opening of mouth,intermittent
limited opening occurs
• When limited opening occurs a maneuver may be neededto unlock
the tmj
Treatment:
• No pain- no theraphy …if pain is present then
• Flat-plane stabilization splints that do not change mandibular position
and anterior repositioning splints have both been used to treat
painful clicking.
• Anterior repositioning splints maintain the mandible in an anterior
position, preventing the condyle from closing posterior to the disc.
• repositioning splints weremore effective than stabilization splints in
eliminating both clicking and pain in patients with Articular disc
disoredrs.
3)DISC DISPLACEMENT WITH OUT REDUCTION WITH LIMITED
MOUTH OPENING:
• In closed mouth position,the disc is in anterior position relative to
condylar head
• The disc doesnot reduce with opening mouth
• This disorder is persistent limited mouth opening which does not
resolve with out a clinician performing special maneuver.
• Also called as closed lock
• Treatment:
-No or mild pain ---no theraphy
-Management of a locked TMJ may be nonsurgical or surgical.
-The goals of successful therapy are to eliminate pain, restore
function, and increase the range of mandibular motion.
-Patients who present with restricted movement but minimal
pain frequently benefit from manual manipulation and an
exercise program designed to increase mandibular motion.
-A flat-plane occlusal stabilization appliance to decrease the
adverse effects of bruxism on the affected joint is appropriate.
-flat-plane stabilization splint and anti-inflammatory drugs was
successful in reducing pain and increasing the range of motion in
over 75% of patients.
• ANKYLOSIS:
• True bony ankylosis of the TMJ involves fusion of the head of the
condyle to the temporal bone.
• Trauma to the chin is the most common cause of TMJ ankylosis,
although infections also may be involved.
• 338 Children are more prone to ankylosis because of greater
osteogenic potential and an incompletely formed disc.
• Ankylosis frequently results from prolonged immobilization following
condylar fracture.
• Limited mandibular movement, deviation of the mandible to
• the affected side on opening, and facial asymmetry may be observed
in TMJ ankylosis.
• Osseous deposition may be seen on radiographs.
• Ankylosis has been treated by several surgical procedures.
• Gap arthroplasty .
DISLOCATION:
• In dislocation of the mandible, the condyle is positioned anterior to
the articular eminence and cannot return to its normal position
without assistance.
• This disorder contrasts with subluxation, in which the condyle moves
anterior to the eminence during wide opening but is able to return to
the resting position without manipulation.
• Dislocations of the mandible usually result from muscular
incoordination in wide opening during eating or yawning and less
commonly from trauma; they may be unilateral or bilateral.
• The typical complaints of the patient with dislocation are an inability
to close the jaws and pain related to muscle spasm resting position
without manipulation
• The condyle can usually be repositioned without the use of muscle
relaxants or general anesthetics.
• If muscle spasms are severe and reduction is difficult, the use of
intravenous diazepam (approximately 10 mg) can be beneifited.
• chronic reccurent dislocation can be treated with both surgical or non
surgical approaches.
OSTEOARTHRITIS:
it is disoder of articular cartilage and subcondral bone,
secondary inflamation of synovial membrane.
it is localized joint disease with out systemic manifestations
• Treatment:
• supportive local theraphy consisting of jaw self
care,physiotheraphy,oral appliance
theraphy,topical NSAIDS,
• when non surgucal management is not
effective then intra articular corticosteriods
injection.
• Arthocentisis is done if injection is ineffective.
• Arthroplasty or condylectomy with place ment
of costochondral grafts has been performed.
• SYNOVIAL CHONDRAMATOSIS:
• uncommon benign disorder characterized by presence of multiple
cartilagenous nodules of synovial membrane that break off resulting
in clusters free floating loose calcified bodies in the joint.
• Treatment:
• conservative and consists of removal of mass of loose bodies.
• MYALGIA:
• Pain of muscle origin that is affected by jaw movement,function
• sub types of myalgia are local myalgia,myofacial pain,myofacial pain
wth refferal
• loxal myalgia reffers to pain that remains local to the proveked
muscle
• in contrast myofaciap pain taht can be associated with either
spreading or radiating of pain with in muscke or refferal to different
structures
• Treatment:
• priority should be givrn to treatments that have following
characteristics:relatively accessible,not prohibitive due to
expense,safe,reversible
• treatments includes education,self
care,phisical theraphy,intra oral appliance
theraphy,short term
pharmacotheraphy,behavioral theraphy,
relaxation techniques