Temporomandibular Joint

Presented by-
Vishakha Vatsa
JR-1
 Contents
Anatomy of Temporomandibular joint
Development of joint
Mechanism of TMJ Movements
Types of movements
Examination of TMJ
TMJ syndrome
Classification of Temporomandibular disorders
Dislocation, subluxation and ankylosis of TMJ
Sydromes associated with TMJ
Temporomandibular joint
 Funtionally- Structurally synovial Anatomically-
diarthrodial joint joint condyloid joint
Articular Surface

• The upper articular surface is formed by the

• (a) glenoid/articular fossa,
• (b) articular eminence of the temporal bone.
• This surface is concavo-convex .
• The lower articular surface is formed by the
head (condyle) of the mandible.
Why TMJ is atypical joint?

• The articular surfaces are covered by

fibrocartilage and not by hyaline cartilage,
hence temporomandibular joint is an atypical
synovial joint
 JOINT CAVITY

• The cavity of temporomandibular joint is

divided into upper menisco-temporal and
lower menisco-mandibular compartments by
an intra-articular disc of fibrocartilage.
• The upper compartment permits gliding
movements, whereas lower compartment
permits gliding as well as rotational
movements.
• The articular disc is an avascular oval plate of
fibrocartilage.
• The concavo-convex superior surface fits against
the articular eminence and the concavity of the
articular fossa.
• The lower concave surface fits with convex head
of the mandible.
• The periphery of the disc is attached firmly to the
fibrous capsule.
Parts of articular disc

(a) anterior extension

(b) anterior thick band

(c) intermediate zone

(d) posterior thick band

(e) posterior bilaminar zone

 fibrous capsule,

Lateral ligamnet

Sphenomandibular

stylomandibular ligaments.
 Fibrous capsule

• It is a fibrous sac to enclose the joint cavity.

• It is attached above to the articular tubercle, the
circumference of articular fossa, and the
squamotympanic fissure; and below to the neck
of mandible.
• The capsule is loose above the intra-articular disc
and tight below it.
• The synovial membrane lines the inner aspect of
the fibrous capsule and the neck of the mandible
Lateral (temporomandibular) ligament

• It is a true ligament and formed as a result of

thickening on the lateral aspect of the capsular
ligament.
• Its fibres are directed downwards and backwards.
• It is attached above to the articular tubercle and below
to the posterolateral aspect of the neck of the
mandible.
• Known as the “check ligament”
• The lateral ligament strengthens the lateral aspect of
the capsule.
Sphenomandibular ligament

• It is attached above to the spine of the

sphenoid and below to the lingula and lower
margin of the mandibular foramen of the
mandible.
• The sphenomandibular ligament represents
the unossified remenant of the Meckel’s
cartilage of the first pharyngeal arch.
• It is pierced by mylohyoid nerve and vessels.
 Stylomandibular ligament

• It is attached above to the lateral surface of

the styloid process and below to the angle and
adjoining posterior border of the ramus of the
mandible.
• The stylomandibular ligament is formed due
to thickening of the investing layer of deep
cervical fascia,which separates the parotid and
submandibular glands.
 RELATIONS

• Lateral:
(a) Skin and fasciae.
(b) Parotid gland.
(c) Temporal branches of the facial nerve.
• Medial:
(a) Tympanic plate separating it from internal carotid
artery.
(b) Spine of sphenoid.
(c) Auriculotemporal nerve.
(d) Middle meningeal artery.
(e) Sphenomandibular ligamet
(f) Chorda tympani nerve.
• Anterior
(a) Tendon of lateral pterygoid.
(b) Masseteric nerve and vessels.
• Posterior:
(a) Postglenoid part of parotid gland
separating it from external auditory meatus.
(b) Superficial temporal vessels.
(c) Auriculotemporal nerve.
 NERVE SUPPLY

The mandibular nerve, the third division of the

fifth cranial nerve innervates the jaw joint.
1. The largest is the auriculotemporal nerve
which supplies the posterior, medial and lateral
parts of the joint.
2. Masseteric nerve, and
3. A branch from the posterior deep temporal
nerve, supply the anterior parts of the joint.
 Massetric nerve Deep temporal
Auriculotemporal nerve
 BLOOD SUPPLY

• Lateral aspect superficial temporal branch of

the external carotid artery.
• Deep retrodiscal capsular deep auricular, and
masseteric branches of the internal maxillary artery.
• Vascular supply to the lateral pterygoid muscle
provides penetration of numerous nutrient vessels.
• The venous pattern is diffuse, forming plentiful
plexus all around the capsule .
Deep auricular and
messetric branch
 LYMPHATIC DRAINAGE

• The lymph from temporomandibular joint is

drained into:
• 1. Superficial parotid (preauricular) nodes.
• 2. Deep parotid nodes.
• 3. Upper deep cervical nodes.
 Development of Human Temporomandibular Joint
Merida-Velasco JR, et al. Anat Rec 1999

●
Organisation of condyle and articular disc
Blastematic phase- ●
Intramembranous ossification of temporal
7-8 weeks IUL bone begins

Cavitation phase- ●
Beginning of condylar chondogenesis
9-11 weeks IUL ●
Organisation of superior joint cavity

Maturation stage – ●
Vascualr invagination
after 12 weeks of ●
Articular disc inserted into external surface
IUL of condyle
 Mechanism of TMJ Movements

• When the TMJ of two sides are in position of

rest a small free space exists between the
upper and lower teeth but lips are in contact.
• All movements of lower jaw involve two basic
movements, which occur at TMJ with the help
of muscles:
1. Gliding movement.
2. Rotational movement.
• With these two types of movements, gliding
and rotation, and with right and left TMJs
working together, most of the movements of
the lower jaw can be accomplished. The
movements performed by the joints are:
• 1. Depression
• 2. Elevation
• 3. Protraction
• 4. Retraction
• 5. Side to side (Chewing) movements
Depression (lowering of jaw to open mouth):

• During depression, the head of mandible along

with an articular disc glide forward in the upper
meniscotemporal compartment on both the sides
by the contraction of lateral pterygoid muscle.
• on forced opening, head rotates forward
underneath the articular disc by the contraction
of suprahyoid muscles, viz. digastric , geniohyoid,
and mylohyoid. The gravity also helps in opening
the mouth.
Elevation (elevating of jaw to close the mouth):

• During elevation ,the head of mandible along

with an articular disc glide backward in the
upper meniscotemporal compartment by
temporalis, masseter, and medial pterygoid,
and then head rotates backward on the lower
surface of the disc by posterior fibres of
temporalis.
Protrusion/Protraction:

• In this act, head of mandible along with

articular disc glide forwards in the upper
meniscotemporal compartment on both sides
by simultaneous action of medial and lateral
pterygoids of both sides.
Retraction:

• The head of mandible glide backwards in the

upper compartment by the contraction of the
posterior fibres of temporalis muscle and bring
the joint in the resting position.
• The forceful retraction is assisted by deep fibres
of masseter, digastric, and geniohyoid muscles.
• At the end of this movement the head of the
mandible comes to lie underneath the articular
tubercle.
Side-to-side (Chewing) movements:

• During this, the head of the mandible on one side

glides forwards along with the disc (as in
protraction), but the head of the mandible on the
opposite side merely rotates on the vertical axis.
• As a result, the chin moves forwards on which no
gliding has taken place.
• During this movement, the medial and lateral
pterygoids of one side contract alternatively with
those of opposite sides.
Palpation of the temporomandibular joint and
associated muscles

• The bilateral palpation is must to assess the entire

joint and its associated muscles.
• First, the patient is asked to open and close the mouth
several times.
• Then he is asked to move the opened jaw to left, and
to right, and finally he is asked to move the jaw
forward.
• For digital palpation of condyle of moving mandible
place a finger into the outer portion of the external
auditory meatus.
Examination of TMJ

• Check the degree of mandibular opening.

• Check for pattern of deviation. Mandible often
deviates towards affected side during opening
because of muscle spasm or mechanical
locking due to displaced meniscus.
Temporomandibular joint syndrome

• This syndrome consists of group of symptoms

arising from temporomandibular joints and their
associated masticatory muscles.
• The typical presenting symptoms are:
• – Diffuse facial pain, due to spasm of masseter
muscle.
• – Headache, due to spasm of temporalis muscle.
• – Jaw pain, due to spasm of lateral pterygoid.
General classification of TMJ disorder

Traumatic ●

●
Dislocation
Fracture
disease ●
ankylosis

Inflammatory ●
Synovitis
●
Rheumatoid arthritis
arthropathies

Growth ●
developmental (hyperplasia, hypoplasia,
dysplasia)
Disturbances
Neopla ●
Pseudotumors (synovial
chondromatosis)

sms Benign (chondroma, osteotoma)

●

●
Muscle spasm
Muscular ●

●
Myofascial pain and dysfunction
Fibromyalgia
Disorders ●

●
Myotonic dystrophies
Myositis ossificans progressiva
Disorders of TMJ

1 Arthritis refers to a group of degenerative/

inflammatory joint disorders that can affect the
temporomandibular joint
2 Internal derangement of the joint involves a
displaced disc, dislocated jaw, or injury to the
condyle.
3 Myofascial pain involves discomfort or pain in the
muscles that control jaw function.
.
National Institute of Dental and Craniofacial Research
 Arthritis

●
Non inflammatory degenerative joint changes
Osteoarthrosis ●
Funtional capacity of joint decreases due to increase in
stress which causes degenrative changes.

●
Auto-immune disease with progressive joint involvement
Rheumatoid arthritis ●
Inflammatory changes causes joint destruction and
deformity

●
Direct infection to open wound of joint
Infective arthritis ●

●
Spread from osteomyelitis or mastoiditis
Blood borne infection
 Osteoarthrosis

Clinical Manageme
features nt
●
Pain in joint ●
If diagnosed at early
●
Pain in muscles of stage then it may be
mastication controlled
●
Joint crepitations ●
Removal of cause helps
●
Decreased movements in repair of fibrous
and stiffness layer over synovium
 Rheumatoid Arthritis

Clinical Manageme
features nt
●
Pain in joint ●
Anti- inflammatory
●
Swelling
analgesics
●
Decreased movements
●
Involvement of other
●
Intra articular
joints as well steroid injections
 Osteoarthrosis

Clinical Manageme
features nt
●
Pain and swelling in joint
●
Pus discharge from external
●
Antibiotics and
●
auditory meatus
Decreased movements
analgesics
●
Constitutional symptoms ●
Incision and
like fever, malaise,
lymphadenopathy drainage of pus.
Internal Derangement of Joint

• It is defined as a disruption within the internal

aspects of the TMJ in which there is a
displacement of the disc from its normal
functional relationship with the mandibular
condyle and the articular portion of the
temporal bone.
• Internal derangement results in clicking or
popping sounds.
Wilkes classification of internal derangement of TMJ
The etiological factors

• systemic diseases rheumatoid arthritis,

ankylosing spondylitis
• secondary inflammatory component from the
neighbouring regions (otitis, maxillary sinusitis,
tonsillitis),
• trauma from bruxism
• malocclusion,
• endocrinological disturbances,
• odontogenic infections .
Clinical features of internal derangement

1. Disc Displacement With Reduction

• Early stage of disc displacement
• Disc is deranged and placed more anteromedially
• Condyle translates for a short distance with
retrodiscal tissue and then assumes a normal
position in intermediate zone.
• As mouth closes, disc slips back to its displaced
anteromedial position.
• It produces a clicking sound while opening of mouth.
2. Disc Diplacement Without Reduction
• A condition where disc is anteromedially
dislocated and doesn’t return to its normal
position with condylar movement.
• Limited jaw (<30mm) opening is seen because
the disc mechanically prevents the forward
movement of condyle.
• Closed lock- it results from unreduced,
persistant anterior displacement of the disc.
 Etiology
uxism

tress

mastication

lubrication

pe alteration

f lateral pterygoid

axity/ sprain
Dislocation of the mandible

• During normal or unstrained opening of the mouth,

the condylar heads translate forward to a position
under the apices of the articular eminences.
• If oral opening proceeds to its maximum capacity,
the condylar heads move to the anterior slope of
the articular eminences in many normal individuals.
• Excursion of the condylar heads beyond these limits
may be viewed as abnormal and termed as
dislocation.
 Subluxation of joint
• The term subluxation is also used for acute
dislocation.
• The patient is unable to close his mouth and is
referred as open lock.
• Management – the most popular method is to
put the operator’s thumb on the molar teeth
of the patient and push the dislocated jaw
downward, backward and upward direction.
Predisposing factors

Laxity of
ligament
capsule

Previous
injuries,

abnormali
occlusal
ty of
skeletal
disharm
form. ony

Ehlers-
shallow
Danlos
fossa, syndrome

Parkinso
Flattened
n epilepsy,
eminence
disease,
 Unilateral acute dislocation

Difficulty A Deviation
The A Definite
Deviation Depression
In Of The Chin Produces A
Speaking Profuse Will Be
Masticati Toward Lateral Cross
May Be Drooling Contralater And Open
Seen And
on And Felt In
Difficult Of Saliva. al Side Is Bite On The
Swallowi Contralateral Front Of
Seen.
ng. Side The Tragus.
Unilateral acute dislocation of TMJ.
(1)Note the preauricular area depression
(2) Laterognathia of the mandible
 Bilateral acute dislocation
It is associated with pain, inability to close the mouth,
Tense masticatory muscles,
Difficulty in speech,
Excessive salivation,
Protruding chin.
The mandible is postured forward and movements are restricted.
Drooling of saliva is seen.
Patient will complain of pain in the temporal region
The distinct hollowness can be felt in both the preauricular regions.
Associated muscle spasm
 Acute bilateral dislocation of TMJ
(1) Elongated face
(2) Depression in preauricular area. Prominence of
dislocated head seen
 Management
• The major problem in reduction of dislocation
is overcoming the resistance of the severe
muscle spasm.
• (i) reassuring the patient,
• (ii) tranquilizer or sedative drugs,
• (iii) pressure and massage to the area,
• (iv) capsulorraphy
Myofascial Pain Dysfunction Syndrome.
• Laskin (1969) put forward the myofascial pain
dysfunction syndrome.
• Definition :- MPDS is a pain disorder in which
unilateral pain is referred from the trigger point
in myofascial structures, to the muscles of the
head and neck. Pain is constant dull ache in
contrast to the sudden sharp, shooting
intermittent pain of neuralgias (chronic pain)
but the pain may range from mild to intolerable.
 Etiology

Muscular Injuries to Parafunctio

hyperfunction. the tissues. nal habits.

Nutritional Physiologic Sleep

problems. al stress. disturbances

Physical Occlusal
trauma disharmony
Cardinal symptoms of MPDS
Pain or discomfort
anywhere about the
head or neck.

Tenderne
ss to Limitatio
palpation n of
of the
muscles
motion
of of the
masticati jaw.
on.

Joint noises
Patho-physiology of MPDS
 Management
• NSAIDS— Ibuprofen : 200 to 600 mg/3 times a day to
reduce inflammation and to provide pain relief, both in the
muscles as well as in the joints (for 14 to 21 days.)
• Muscle relaxants— Diazepam 2 to 5 mg or cyclobenzapine
10 mg at bedtime can be given for 10 days.
• Ethyl chloride spray or intramuscular local anaesthetic
injections in the affected muscles can also give relief.
• Patient counselling
• Soft diet and behaviour management
• TMJ arthrocentesis for recurrent cases.
 Occlusal Splints
• Twelve to eighteen hours use is advocated upto 4 to 6
months.
• These are fabricated covering the occlusal and incisal surface.
• A flat platform is added perpendicular to the mandibular
incisors, so that the splint will disengage the teeth and relax
the muscles
Tmj ankylosis

• Ankylosis is a Greek terminology meaning ‘stiff

joint’.
• Here because of immobility of the joint, the
jaw function gets affected.
 Classification of Ankylosis

• False ankylosis or true ankylosis.

• Extra-articular or intra-articular.
• Fibrous or bony.
• Unilateral or bilateral.
• Partial or complete.
 Trauma

ETIOLOGY • Congenital

• At birth, forceps delivery

• Condylar fractures

• Infections like Otitis media , Parotitis

• Abscess around the joint

• Osteomyelitis of the jaw

• Inflammation

• Rheumatoid arthritis

• Osteoarthritis

• Systemic diseases like Smallpox, Measles

 Features Of Unilateral Ankylosis
• Obvious facial asymmetry.
• Deviation of the mandible and chin on
the affected side.
• Hypoplastic mandible
• Flatness and elongation on the
unaffected side.
• Interincisal opening will vary
depending on whether it is fibrous or
bony ankylosis.
• Unilateral posterior cross bite on the
same side.
 Features of Bilateral Ankylosis
• Inability to open the mouth
• The mandible is symmetrical but micrognathic.
• The patient develops typical ‘bird face’
deformity with receding chin.
• The neck chin angle may be reduced or almost
completely absent.
• Class II malocclusion
• Upper incisors are often protrusive with
anterior open bite.
• Multiple carious teeth with bad periodontal
health
• Severe malocclusion, crowding can be seen
and many impacted teeth
 Management
• Surgical Technique
• The three basic methods are
• Condylectomy
• Gap arthroplasty
• Interpositional arthroplasty
 Syndromes
• Ehlers-Danlos syndrome
• This is a rare inherited disorder of the connective
tissue, in which recurrent dislocation of the TMJ is
seen.
• Four cardinal symptoms are as follows:
• 1. Hyperelasticity of the skin.
• 2. Fragility of the skin.
• 3. Hypermobility of the joints.
• 4. Fragility of the blood vessels.
• Costen syndrome-Mandibular joint neuralgia
• first reported by Costen in 1934
• The pathology is either malocclusion from any cause
or destructive changes of one or both mandibular
joints.
• The resultant abnormal pressure in the mandibular
fossa causes partial or complete closure of the internal
auditory canal, accounting for the "stuffy deaf"
sensation so common to the syndrome.
• The neuralgic pains are due to either direct nerve
compression within the abnormal joint or reflex
irritation of the nerves lying in close association with
the joint.
• Frey’s Syndrome
• Frey’s syndrome was described by Frey.
• He reported the incidence of localized gustatory sweating and
flushing following a gun shot wound and suppurative parotitis.
• This auriculotemporal nerve syndrome may follow the surgery
of the parotid gland and TM joint, a facial wound or parotid
abscess.
• It is characterized by pain in the auriculotemporal nerve
distribution.
• Associated gustatory sweating and occasionally erythema is
seen
• There is flushing on the affected side of the face accompanied
by sweating in the periauricular region and beneath the pinna.
 Question Asked in EXamination
• Describe temporomandibular joint and its
clinical implications in child patients. (Basic sciences
BBDCODS, june 2019)

• A short note on anatomy of

Temporomandibular joint
 References
• Temporomandibular Joint. In:chitra Chakravarthy, Editor.
Textbook Of Oral And Maxillofacial Surgery, 2nd Edition.
Paras
• Temporomandibular Joint: Afflictions and Management, In
Neelima Anil Malik editor. Textbook Of Oral And
Maxillofacial Surgery, 2nd Edition, Jaypee, 2008.
• Merida-Velasco JR, et al.development of human
temporomandibular Joint. Anatomy records. 1999 May
1;255(1):20-33