ANATOMY OF TMJ,MUSCLES OF

MASTICATION,TONGUE,PHARYNGEAL AIRWAYS

By:-
Dr.N.Shivaram
 Contents
• Anatomy of TMJ
• Anatomy of muscles of mastication
• Anatomy of Tongue
• Anatomy of pharyngeal airway
• Conclusion
TMJ
 TERMINOLOGIES OF TMJ
• Bicondylar – Bilateral, unison functioning
• Ginglymoarthroidal – Hinge type movement
• Compound – More than one articular surface
• Complex – Presence of intracapsular disc
• Secondary
– Ontogenetically – Evolution
– Phylogenetically –embryological
– Developmentally – Growth
• Synovial
 Components
• Bony components
1. Glenoid fossa
2. Condylar head
3. Articular eminence
• Soft tissue attachments
1. Articular disc
2. Joint capsule
3. Ligaments
Muscle attachments
1. Muscles of mastication
2. Muscles attached to the joint
3. Muscles of facial expression
4. Muscles of the neck
Evolution
AGNATHA
GNATHOSTOMATA
OSTIECTHYES
AMPHIBIANS
REPTILES
MAMMAL LIKE REPTILE
MAMMALS
Embryology
 GLENOID FOSSA

7-8 weeks - Develops earlier than the condyle

10th week- ossification

22 weeks- medial and lateral walls

Shape of the fossa

 ARTICULAR CAPSULE
9-11 Weeks- first appearance

17th Week- differentiation

26th Week- completion

 ARTICULAR EMINENCE
7TH month- Formation of the trabeculae

8-9 months- Completion

• The mandible develops from the Meckel’s
cartilage, which provides the basic skeletal
support for the lower jaw, and terminates
dorsally into MALLEUS
• It articulates with the incal cartilage
(Quadrate in nonmammals) and any
movement of the early jaw, if any, occurs
between these two cartilages
• At 3 months of gestation the secondary
joint begins to form with the appearance of
two distinct mesenchymal condensations,
which are initially positioned some
distance from each other.
• Temporal blastema – appears first, begins to
ossify first and the second cleft which appears in
relation to the temporal ossification becomes the
superior joint cavity.

• Condylar blastema – appears after temporal

blastema, begins ossifying second and the first
cleft appears immediately above it to form the
inferior joint cavity while it is still in condensed
mesenchyme
• The condylar blastema grows rapidly to
decrease the intervening gap between the
two blastemas.
• The appearance of clefts and formation of
inferior and superior joint cavities gives
rise to the primitive articular disk in the
centre.
Anatomy
GLENOID FOSSA/ MANDIBULAR
FOSSA
• The mandibular fossa is limited in front by
the articular eminence of the zygomatic
process. It presents an anterior articular
area, formed by the squamous part, and a
posterior non-articular area, formed by the
tympanic element
CONDYLAR HEAD
• The mandibular condyle varies considerably both in
size and shape. When viewed from above, the
condyle is roughly ovoid in outline, the
anteroposterior dimension of the condyle (c.1 cm)
being approximately half the mediolateral dimension.
 ARTICULAR CARTILAGE

• The articular surface of both temporal bone and

condyle are covered by fibrocartilage- a dense fibrous
connective tissue.
• The fibro cartilage has the capacity to regenerate and
to remodel under functional stress
• Deep to the fibro cartilage in condyle is the
proliferative zone of cells-cartilage and osseous
• The articular cartilage is composed of chondrocytes
an inter cellular matrix of collagen fibres Water and
non fibrous filler material(the ground substance)
ARTICULAR EMINENCE
• Immediately anterior to the glenoid fossa
is a convex bony prominence at the base
of the zygomatic process of the temporal
bone called the articular eminence. The
eminence appears saddle-shaped with a
central shallow depression that is the path
of the condyle, when viewed from below
CAPSULAR LIGAMENT
• Thin structure – reinforced by ligaments
• Inner surface lined by synovial membrane
 ARTICULAR DISC
• The transversely oval
articular disc is composed
predominantly of dense fibrous
connective tissue. It has a thick
margin which forms a
peripheral annulus and a central
depression in its lower surface
that accommodates the articular
surface of the mandibular
condyle.
Attachments of articular disk
1. Posteriorly disc attached -
Retrodiscal tissue
2. Medial and lateral parts
attached to condyle through -
“DISCAL / COLLATERAL
LIGAMENTS” or Joint
capsule,
3. Anteriorly – Joint capsule,
Lateral pterygoid muscle
fibres – ‘Sphenomeniscus’
fibres
- stabilize disk during
mastication & deglutition
 RETRODISCAL TISSUE

• ‘POSTERIOR ATTACHMENT’
• Between bilaminar zone of disc
• SRL – Menisco-temporal frenum
• IRL – Menisco-mandibular frenum
• Loose connective tissue,Compressible
• Rich blood supply & nerve supply
SUPERIOR

INFERIOR
SYNOVIAL MEMBRANE
Lines inner surface of capsule
– villi
Functions:
1. Medium for metabolic
exchange to avascular
articulating surfaces
2. Lubricant – minimizes
friction
LIGAMENTS
 True ligaments:
– 1. COLLATERAL / DISCAL LIGAMENTS
– 2. CAPSULAR LIGAMENT
– 3.TEMPOROMANDIBULAR / LATERAL
LIGAMENT
Accessory ligaments:
– 1. SPHENOMANDIBULAR LIGAMENT
– 2. STYLOMANDIBULAR LIGAMENT
 COLLATERAL / DISCAL LIGAMENT

2 – Medial & distal

Attach edges of disc to
condylar poles
Joint – 2 compartments
Functions:
1. Restricts movement of disc
away from condyle
2. Disc moves passively with
condyle
3. Hinge movement between
condyle & disc
TEMPOROMANDIBULAR
(LATERAL) LIGAMENT
• This broad ligament is attached above to the articular
tubercle on the root of the zygomatic process of the
temporal bone.
• It extends downwards and backwards at an angle of c.45°
to the horizontal, to attach to the lateral surface and
posterior border of the neck of the condyle, deep to the
parotid gland. It appears to be poorly developed in the
edentulous.
• A short, almost horizontal, band of collagen connects the
articular tubercle in front to the lateral pole of the condyle
behind. It may function to prevent posterior displacement
of the resting condyle.
 SPHENOMANDIBULAR
LIGAMENT
• The sphenomandibular ligament is medial to,
and normally separate from, the capsule.
• It is a flat, thin band that descends from the
spine of the sphenoid and widens as it reaches
the lingula of the mandibular foramen.
• Some fibres traverse the medial end of the
petrotympanic fissure and attach to the anterior
malleolar process. This part is a vestige of the
dorsal end of Meckel's cartilage.
 STYLOMANDIBULAR LIGAMENT
• The stylomandibular ligament is a thickened
band of deep cervical fascia that stretches from
the apex and adjacent anterior aspect of the
styloid process to the angle and posterior
border of the mandible.
• Its position and orientation indicate that it
cannot mechanically constrain any normal
movements of the mandible and does not seem
to warrant the status of a ligament of the joint
MUSCLES OF MASTICATION
 DIRECT MUSCLES OF MASTICATION

• MASSETER
• TEMPORALIS
• LATERAL PTERYGOID
• MEDIAL PTERYGOID
 ACCESSORY MUSCLES OF
MASTICATION

• MYLOHYOID
• ANTERIOR BELLY OF DIGASTRIC
• TENSOR VELI PALITINI
• TENSOR TYMPANI
Masseter
• Masseter consists of three layers which
blend anteriorly
• The superficial layer arises by a thick
aponeurosis from the maxillary process of
the zygomatic bone and from the anterior
two-thirds of the inferior border of the
zygomatic arch insert into the angle and
lower posterior half of the lateral surface of
the mandibular ramus.
• The middle layer of masseter arises from the
medial aspect of the anterior two-thirds of the
zygomatic arch and from the lower border of
the posterior third of this arch. It inserts into
the central part of the ramus of the mandible.
• The deep layer arises from the deep surface
of the zygomatic arch and inserts into the
upper part of the mandibular ramus and into
its coronoid process.
• Vascular supply :Masseter is supplied by
the masseteric branch of the maxillary
artery, the facial artery and the transverse
facial branch of the superficial temporal
artery.
• Innervation : Masseter is supplied by the
masseteric branch of the anterior trunk of
the mandibular nerve.
Temporalis
• Temporalis arises from the whole of the
temporal fossa up to the inferior temporal
line - except the part formed by the
zygomatic bone - and from the deep
surface of the temporal fascia.
• Its fibres converge and descend into a
tendon which passes through the gap
between the zygomatic arch and the side of
the skull
• Vascular supply:deep temporal branches-
the second part of the maxillary artery-
anterior deep temporal artery supplies
c.20%- posterior deep temporal supplies
c.40%-posterior regionm-middle temporal
artery supplies c.40%-mid-region.
• Innervation:deep temporal branches of
the anterior trunk of the mandibular nerve.
Lateral pteygoid
• Lateral pterygoid consists of upper head
arises from the infratemporal surface and
infratemporal crest of the greater wing of
the sphenoid bone.
• The lower head arises from the lateral
surface of the lateral pterygoid platefovea).
• From the two origins, the fibres converge,
and pass backwards and laterally, to be
inserted into a depression on the front of
the neck of the mandible (the pterygoid
• Vascular supply:pterygoid branches-
maxillary artery-given off -artery crosses
the muscle-ascending palatine branch of
the facial artery.
• Innervation:The nerves to lateral
pterygoid-anterior trunk of the mandibular
nerve, deep to the muscle.
• Upper head and the lateral part of the
lower head receive their innervation from-
the buccal nerve.
• Medial part of the lower head has a branch
arising directly from the anterior trunk of
the mandibular nerve.
Medial pterygoid
• Medial pterygoid is a thick, quadrilateral
muscle with two heads of origin.
• The major component is the deep head
which arises from the medial surface of
the lateral pterygoid plate of the sphenoid
bone and is therefore deep to the lower
head of lateral pterygoid.
• The small, superficial head arises from the
maxillary tuberosity and the pyramidal
process of the palatine bone, and
therefore lies on the lower head of lateral
pterygoid
• Vascular supply:Medial pterygoid derives
its main arterial supply from the pterygoid
branches of the maxillary artery
• Innervation:the medial pterygoid branch
of the mandibular nerve
Mylohyoid
• Mylohyoid lies superior to the anterior belly
of digastric and, with its contralateral
fellow, forms a muscular floor for the oral
cavity.
• It is a flat, triangular sheet attached to the
whole length of the mylohyoid line of the
mandible.
• The posterior fibres pass medially and
slightly downwards to the front of the body
of the hyoid bone near its lower border.
• The middle and anterior fibres from each
side decussate in a median fibrous raphe
that stretches from the symphysis menti to
the hyoid bone
• Vascular supply:sublingual branch of the
lingual artery, the maxillary artery, via the
mylohyoid branch of the inferior alveolar
artery, and the submental branch of the
facial artery.
• Innervation:mylohyoid branch of the
inferior alveolar nerve.
Tensor veli palatini
• Tensor veli palatini arises from the
scaphoid fossa of the pterygoid process
and posteriorly from the medial aspect of
the spine of the sphenoid bone.
• Vascular supply:The blood supply of
tensor veli palatini-ascending palatine
branch of the facial artery-greater palatine
branch of the maxillary artery.
• Innervation:The motor innervation of
tensor veli palatini is derived from the
mandibular nerve via the nerve to medial
pterygoid
Tensor tympani
• Tensor tympani is a long slender muscle
which occupies the bony canal above the
osseous part of the pharyngotympanic
tube, from which it is separated by a thin
bony septum.
• It arises from the cartilaginous part of the
pharyngotympanic tube and the adjoining
region of the greater wing of the sphenoid,
as well as from its own canal.
• It passes back within its canal, and ends in
a slim tendon which bends laterally round
the pulley-like processus trochleariformis
and finally attaches to the handle of the
malleus, near its root
• Vascular supply:Tensor tympani receives
its arterial blood supply from the superior
tympanic branch of the middle meningeal
artery.
• Innervation:nerve to medial pterygoid-a
ramus of the mandibular nerve-which
traverses the otic ganglion without
interruption to reach the muscle.
Tongue
Embryology
 Anatomy
• It is partly oral and partly pharyngeal in
position, and is attached by its muscles to
the hyoid bone, mandible, styloid
processes, soft palate and the pharyngeal
wall.
• It has a root, an apex, a curved dorsum
and an inferior surface.
 MUSCLES OF THE TONGUE

• Extrinsic muscles
• Intrinsic muscles
 Genioglossus
• Genioglossus is triangular in sagittal
section, lying near and parallel to the
midline. It arises from a short tendon
attached to the superior genial tubercle
behind the mandibular symphysis, above
the origin of geniohyoid..
• Vascular supply
• Genioglossus is supplied by the sublingual
branch of the lingual artery and the
submental branch of the facial artery.
• Innervation
• Genioglossus is innervated by the
hypoglossal nerve
 Hyoglossus
• Hyoglossus is thin and quadrilateral, and
arises from the whole length of the greater
cornu and the front of the body of the
hyoid bone. It passes vertically up to enter
the side of the tongue between
styloglossus laterally and the inferior
longitudinal muscle medially
• Vascular supply:Hyoglossus is supplied
by the sublingual branch of the lingual
artery and the submental branch of the
facial artery.
• Innervation :Hyoglossus is innervated by
the hypoglossal nerve
 Styloglossus
• Styloglossus is the shortest and smallest
of the three styloid muscles. It arises from
the anterolateral aspect of the styloid
process near its apex, and from the styloid
end of the stylomandibular ligament.
• Vascular supply:Styloglossus is supplied
by the sublingual branch of the lingual
artery.
• Innervation:Styloglossus is innervated by
the hypoglossal nerve.
 Palatoglossus
• Palatoglossus is narrower at its middle
than at its ends. Together with its overlying
mucosa it forms the palatoglossal arch or
fold.
• It arises from the oral surface of the
palatine aponeurosis where it is
continuous with its fellow
• Vascular supply:ascending palatine
branch of the facial artery-from ascending
pharyngeal artery
• Innervation :cranial part of the accessory
nerve via the pharyngeal plexus
Intrinsic muscles
 Intrinsic muscles
• The superior longitudina muscle:constitutes
a thin stratum of oblique and longitudinal
fibres lying beneath the mucosa of the
dorsum of the tongue.
• It extends forwards from the submucous
fibrous tissue near the epiglottis and from
the median lingual septum to the lingual
margins
• The inferior longitudinal muscle:narrow
band of muscle close to the inferior lingual
surface between genioglossus and
hyoglossus.
• It extends from the root of the tongue to
the apex. Some of its posterior fibres are
connected to the body of the hyoid bone.
Anteriorly it blends with styloglossus.
• The transverse muscles: pass laterally
from the median fibrous septum to the
submucous fibrous tissue at the lingual
margin, blending with palatopharyngeus.
• The vertical muscles extend from the
dorsal to the ventral aspects of the tongue
in the anterior borders.
• Vascular supply:The intrinsic muscles
are supplied by the lingual artery. 
• Innervation:All intrinsic lingual muscles
are innervated by the hypoglossal nerve
Vascular supply and innervation
• Lingual artery : dorsal lingual artery
sublingual artery
deep lingual artery
 Veins
• Lingual veins: lymphatic drainage
marginal vessels
central vessels
dorsal vessels
 Innervation
• The muscles of the tongue, with the
exception of palatoglossus, are supplied
by the hypoglossal nerve.
• It distributes fibres to styloglossus,
hyoglossus and genioglossus and to the
intrinsic muscles of the tongue
• Palatoglossus is supplied via the
pharyngeal plexus
• The lingual nerve is sensory to the
mucosa of the floor of the mouth,
mandibular lingual gingivae and mucosa of
the presulcal part of the tongue (excluding
the circumvallate papillae).
• The glossopharyngeal nerve is distributed
to the postsulcal part of the tongue and the
circumvallate papillae. It communicates
with the lingual nerve.
PHARYNGEAL AIRWAY
 PHARYNGEAL AIRWAY
• The pharyngeal airway is kept patent in the patient
who is awake by the combined dilating action of
genioglossus, tensor veli palatini, geniohyoid and
stylohyoid, which act to counter the negative pressure
generated in the lumen of the pharynx during
inspiration.
• The tone in the muscles is reduced during sleep, but
is also affected by alcohol and other sedatives,
hypothyroidism and a variety of neurological
disorders.
• If the dilator muscle tone is insufficient, the walls of
the pharynx may become apposed.
• Intermittent pharyngeal obstruction may cause
snoring, and complete obstruction may cause apnoea,
hypoxia and hypercarbia which lead to arousal and
sleep disturbance
Airway-compromising conditions
Congenital
• Pierre-Robin syndrome
Micrognathia, macroglossia, cleft soft
palate
• Treacher-Collins syndrome
Auricular and ocular defects, malar and
mandibular hypoplasia
• Goldenhar’s syndrome
Auricular and ocular defects, malar and
mandibular hypolasia
• Down’s syndrome
Poorly developed or absent bridge of the
nose, macroglossia
• Kippel-Feil syndrome
Congenital fusion of a variable number of
cervical vertebrae, restriction of neck
movement
• Goiter
Compression of trachea, deviation of
larynx/trachea
Acquired
• Infections
Supraglottis Laryngeal oedema
• Croup
Laryngeal oedema
• Abscess (intraoral, retropharygeal)
Distortion of the airway and trismus
• Ludwig’s angina
Distortion of the airway and trismus
 Specific tests for assessment
Mallampatti test
The Mallampati classification
correlates tongue size to pharyngeal size. This test is
performed with the patient in the sitting position, head in
a neutral position, the mouth wide open and the tongue
protruding to its maximum. Patient should not be actively
encouraged to phonate as it can result in contraction and
elevation of the soft palate leading to a spurious picture.
Classification is assigned according to the extent the base
of tongue is able to mask the visibility of pharyngeal
structures into three classes
 Obstructive Sleep Apnea
• Broadbent (1877), described Obstructive Sleep Apnea
as “ there will be perfect silence through two, three,
or four respiratory periods, in which there are
ineffectual chest movements; finally air enters with a
loud snort, after which there are several
compensatory deep inspirations”
 Predisposing factors
• Obesity – airway is compromised because of more fat
deposits in soft palate, tongue and surrounding
pharynx
• Alcohol ingestion – decrease in hypoglossal nerve
output while phrenic nerve output is spared
• REM sleep – muscles of airway are most hypotonic
in this stage of sleep
• Pharyngeal length was found to be longer in apnea
patients in supine position compared with upright
position
 Anatomic alterations reducing airway

• Posteriorly positioned maxilla and mandible

• Steep occlusal plane
• Overerupted anterior teeth
• Large gonial angle
• Anterior openbite associated with large tongue
• Posteriorly placed pharyngeal walls
• Retrognathic mandibles
• Large tongue and soft palate
• Large anteroposterior discrepancies between maxilla
and mandible
• Micrognathia
• Acromegaly
• Downs’ syndrome
 Hereditary variables
• Adenoid and tonsillar hypertrophy
• Glottic webs
• Vocal cord paralysis
• Lymphoma or Hodgkin’s disease
• Ectopic thyroid
• Systemic disease involving mandible like
Rheumatoid arthritis
• Severe Kypho-Scoliosis
• Cushing syndrome
• Types based on the level of obstruction
Retropalatal
Retroglossal
Retropalatal + Retroglossal
• The features of retrognathia, micrognathia, and
skeletal Class II tendency were most pronounced in
the Rp + Rg group.
• Pronounced to a somewhat lesser extent in the Rp
group
• The tendency for a long face was dominant in the
tonsillar hypertrophy group, and the presence of a
long and large soft palate was very pronounced in the
Rp group
• All of the groups shared the characteristics of having
an inferior position of the hyoid bone.
• Oropharyngeal airway size was positively correlated
to
-the length of the mandible (Go-Me)
-the distance between 3rd cervical vertebra and the
hyoid bone (C3-Hy)
-the cranial base angle (NSBa)
 Clinical features
Nocturnal symptoms Daytime symptoms

1. Snoring 1. Excessive sleepiness

2. Drooling 2. Morning headaches
3. Xerostomia 3. Gastro-esophageal reflux
4. Diaphoresis disease
5. Choking or gasping 4. Impaired concentration
5. Depression
6. Decreased libido
7. Irritability
 Conclusion
Though anatomy of head and neck
or for say human body as a whole have
been described in detail many years back
there are always changes in the
perception of the clinician towards the
subject and a person should be updated in
his knowledge of anatomy , as anatomy is
one of the important subjects which effects
the treatment plan in all specialties' even
in orthodontics
 Bibliography
1. Text book of Greys anatomy
2. Atlas of Human Anatomy by Netters
3. Craniofacial development , SPERBER
4. Applied Anatomy and Physiology of the
Airway and Breathing Dr. Rajagopal M.
R,Dr. Jerry Paul.
5. Relationship Between Cephalometric
Characteristics and Obstructive Sites in
Obstructive Sleep Apnea Syndrome
Un Bong Baik, DDS; Masaaki Suzuki MD, PhD;
Katsuhisa Ikeda, MD, PhD;Junji Sugawara,
DDS, PhD; Hideo Mitani, DDS, PhD
6. Craniofacial profile in Asian and white subjects
with obstructive sleep apnoea B Lam, M S M
Ip, E Tench, C F Ryan
7. Indian J Med Res 131, February 2010, pp
188-195 Consequences of obstructive
sleep apnoea, Indira Gurubhagavatula
8. MAGICALDENTISTRY FORUMS / PG-
Arena / PG-Dental / ORTHODONTIA,
PEDODONTIA / Evolution of
Temporomandibular Joint
 Q &A
• Diaphoresis is excessive sweating
commonly associated with shock and other
medical emergency conditions.
• Physiological causes: physical exertion,
menopause, fever, spicy foods, and high
environmental temperature. Strong
emotions (anger, fear, etc.) and
remembrance of past trauma can also
trigger profuse sweating