TemporoMandibular Joint SEMINAR Nivi

TEMPOROMANDIBULAR JOINT
CONTENTS
 Introduction
 Classification of Joints
 Peculiarity of TMJ
 Development of TMJ
 General Anatomy of TMJ
 Functional anatomy of TMJ
 Mandibular movements and muscle activity
 Examination & Diagnosis of TMJ Disorders
 TMJ disorders
 Treatment modalities
 TMJ and Orthodontics
 Conclusion
 References
JOINT
• Joint is a junction between two or more bones & is responsible for movement, growth or
transmission of forces.
• They are constructed to allow movement and provide mechanical support, and are classified
structurally and functionally.
• Structural classification is determined by the way the bones connect to each other, while
functional classification is determined by the degree of movement.
Structural classification/Type:
1. Fibrous or fixed joints (Immovable)
2. Cartilaginous or Slightly moveable joints
3. Synovial or Freely moveable joints

The anatomical basis of clinical practice . Gray's anatomy . Standring, S., & Gray, H. (2008). 41 st Edition
FUNCTIONAL CLASSIFICATION
A. Synarthroses permit little or no mobility. Most synarthrosis joints are fibrous. They can be
categorized by the way the two bones are joined together:
i. Synchondroses are joints where the two bones are connected by a piece of cartilage.
ii. Synostoses is a condition where two bones that are initially separated eventually fuse together,
essentially becoming one bone. In humans the plates of the cranium fuse together as a child
approaches adulthood.
B. Amphiarthroses permit slight mobility. The two bone surfaces at the joint are both covered in hyaline
cartilage and joined by strands of fibrocartilage. Most amphiarthrosis joints are cartilaginous.
C. Diarthroses Permit a variety of movements (e.g. flexion, adduction, pronation). Only synovial joints
are diarthrodial.
The anatomical basis of clinical practice . Gray's anatomy . Standring, S., & Gray, H. (2008). 41st Edition
TEMPOROMANDIBULAR JOINT
 The Temporomandibular Joint is formed by articulation between the Articular Eminence and
the anterior part of the Glenoid Fossa of the squamous part of temporal bone above and the
condylar head of the mandible below.
 It’s a Synovial Joint of condylar variety.
 The TMJ is a ginglymoarthrodial joint, meaning a hinge joint, allowing motion only backward
and forward in one plane, and a joint which permits a gliding motion of the surfaces.
Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

Superior compartment Inferior compartment
Hinging
Gliding movements
movements
GINGLYMOID ARTHROIDAL
JOINT JOINT
GINGLYMOARTHROI
DAL JOINT
DEVELOPMENT OF TMJ
 Early TMJ develops from first branchial arch mesenchyme.
 TMJ develops from two blastema :-
1. Temporal blastema arise from otic capsule.

2. Condylar blastema arises from secondary cartilage of mandible.
• During 7th week - Articulation between malleus and incus at the dorsal end of Meckel’s
cartilage results in PRIMARY JOINT .
• 8th week- Membranous Bone laid down in a plate like form lateral to Meckels cartilage.
• 10 weeks- evidence of future joint as mesenchyme between the condylar cartilage &
developing temporal bone.
Craniofacial embryogenetic and development. Sperber H G . 3rd edition. Br Dent J 227, 773 (2019).
 During 12 weeks of intrauterine life the following changes occur:
• Two mesenchymal condensations occurs
• Condylar grows dorsolaterally
• Ossification of temporal blastema takes place
• Inferior joint cavity formation
• Differentiation of condylar into cartilage & Superior joint cavity
• Formation of disc
• During 13th week : Condyle and articular disk have moved up into contact with temporal bone.
• Remnant of meckels cartilage - sphenomandibular ligament
• Full differentiation of all articular surfaces occurs by 4th fetal month
Differences:
Neonatal TMJ Adult TMJ
Mandibular fossa Flat Concave
Articular eminence Absent Present

ANATOMY OF TMJ
A compound joint:
 The TMJ is formed by the mandibular condyle fitting into the mandibular fossa of the temporal
bone.
 By definition, a compound joint requires the presence of at least three bones, yet TMJ is made
of only two bones.
 Functionally, the articular disk serves as a non-ossified bone that permits the complex
movements of the joint.
 As the articular disk functions as a third bone, the craniomandibular articulation is considered
to be a compound joint.
PARTS OF TMJ
 Mandibular fossa
 Condylar process
 Joint capsule
 Articular disc
 Synovial fluid
 Muscles and ligaments

MANDIBULAR FOSSA
• Oval or oblong depression in the temporal bone just anterior to auditory canal.
BOUNDARIES:
Anteriorly Posteriorly Externally
Tympanic plate Middle root of

Articular of petrous portion zygoma and
eminence of temporal bone auditory process

CONDYLAR PROCESS
 Convex on all bearing surfaces although somewhat flattened posteriorly.
 Its knob like form is wider latero-medially (20mm) than antero-posteriorly(8-10mm).
 Its long axis is in a lateral plane.
 Condyle is perpendicular to the ascending ramus of the mandible.

JOINT CAPSULE
• TMJ is enclosed in a capsule that is attached at the borders of articulating surfaces of the
mandibular fossa and eminence of the temporal bone and the neck of mandible.
• Capsule contains:
1.Internal Synovial layer
2.External fibrous layer containing veins, nerves and collagen fibers.

Mandibular
fossa
Upper
compartment
Superior
surface of disc
Articular disc
Inferior surface
of disk
Lower
compartment
Mandibular
condyle
ARTICULAR DISK
 Its composed of dense fibrous connective tissue, for the most part devoid of any blood vessels
or nerve fibers.
 In sagittal plane, the disk is divided into three regions:
i. Thicker anterior and posterior zones

ii. Thinner intermediate zone
 Posterior border is slightly thicker than anterior border.
 In normal TMJ, the condyle articulates in the intermediate zone.
 From anterior view, the disk is usually thicker medially than laterally which corresponds to the
increased space between the condyle and articular fossa towards the medial portion of the joint.

SYNOVIAL FLUID
The internal surface of the cavities are surrounded by specialized endothelial cells which forms a
synovial lining.
This lining along with synovial fringe produces synovial fluid which fills the joint cavities.
Synovial fluid features:
• Ultra filtrate of blood plasma.

• Clear or pale yellow, viscous, slightly alkaline fluid.
• It also contains mucin( hyaluronic acid) lymphocytes, monocytes, and macrophages.
Functions:
a. Nutrition of articular cartilage

b. Lubrication of the joint cavity
c. Prevents wear & tear
 BOUNDARY LUBRICATION:
 It’s the primary mechanism of joint lubrication and prevents friction.
 It occurs when the joint is moved and the synovial fluid is forced from one area of the
cavity into another.
 Synovial fluid is located in the border or recess areas and its forced on the articular surface,
thus providing lubrication.
 WEEPING LUBRICATION:
 It’s a secondary lubricating system and provides metabolic exchange.
 Refers to the ability of the articular surfaces to absorb small amounts of synovial fluid.
 During function, forces are created between articular surfaces which drive a small amount
of synovial fluid in and out of the articular surfaces. Thus metabolic exchange occurs.

MUSCLES AND LIGAMENTS
MUSCLES OF MASTICATION:
• Temporalis
• Medial pterygoid
• Lateral pterygoid
• Masseter
• Digastric
All the muscles dev from the mesenchyme of the 1st brachial arch.
MASSETER
 This is a quadrilateral muscles which cover the lateral surface of the ramus of the mandible. Its fiber
are arranged in three layers.
SUPERFICIAL LAYER
 Originates from the Anterior 2/3 of the lower border of the zygomatic arch. Pass downward and
backward at the angle of 45 degree. Inserted into the lower part of the lateral surface of the ramus of the
mandible.
MIDDLE AND DEEP FIBERS
 originates from medial aspect of zygomatic arch and pass vertically and downwards and inserts in
lateral part of ramus of the mandible.
 NERVE SUPPLY- Masseteric nerve( branch of anterior division of the mandibular nerve).
 BLOOD SUPPLY: Masseteric artery .
 ACTION- Muscles elevates the mandible to close the mouth and clenches the teeth
Palpation:
• The patient is asked to clench their teeth and, using both hands, the practitioner palpates the
masseter muscles on both sides extra orally, making sure that the patient continues to clench
during the procedure.
• Palpate the origin of the masseter bilaterally along the zygomatic arch and continue to palpate
down the body of the mandible where the masseter is attached
Applied anatomy:
a) The motor part of mandibular nerve is tested by asking the patient to clench his teeth and then
feeling for the contracting masseter and temporalis muscles.
b) b) If one masseter is paralyzed the jaw deviates to paralyzed side on opening the mouth by
action of normal lateral pterygoid of opposite side.
TEMPORALIS
 Large fan shaped.
 Origin and Insertion: From the Parietal bone of the skull and is inserted on the coronoid
process of the mandible.
 AP- anterior portion
 MP- middle portion &
 PP- posterior portion. Largest muscle of mastication.
FUNCTIONS:
 Elevation of the mandible
 Retraction of the mandible.
 Crushing of food between the molars.
 Posterior fibers draw the mandible backwards after it has been protruded.
 It is also contributes side to side grinding movement. Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition
• Arterial supply:
The Deep Temporal Artery
• Nerve Supply:
Deep temporal Nerve
Palpation:
 To locate the muscle the patient have to clench.

 Apply two pounds of pressure
 The anterior region is palpated above the zygomatic arch and anterior to the TMJ
 The middle region is palpated directly above the TMJ and superior to the zygomatic arch
 The posterior region is palpated above and behind the ear.
Applied anatomy :
• Temporal tendonitis: - sharp headaches at temple joint.

• Sudden contraction of temporalis muscle will result in coronoid fracture, which is rare.
LATERAL PTERYGOID
Lateral Pterygoid Muscle is divided into 2 heads
• Origin:
i. Upper head – infratemporal surface & crest of greater wing of sphenoid bone
ii. Lower head – lateral pterygoid plate
• Insertion :
iii. Pterygoid fovea on the neck of mandible
iv. Anterior margin of articular disc & capsule of TMJ
Nerve Supply:
Pterygoid branch of Trigeminal nerve
Arterial supply:
Pterygoid branch of Maxillary artery Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition
Action-
Depression, protrusion & side to side movements
i. When medial and lateral pterygoids of two sides act together they protrude the mandible so
that lower incisors project in front of upper.
ii. Upper head - Chewing
iii. Lower head - Protrusion
PALPATION OF THE LATERAL PTERYGOID
• Placing the forefinger, or the little finger, over the buccal area of the maxillary third molar
region and exerting pressure in a posterior, superior, and medial direction behind the maxillary
tuberosity
Clinical Importance of Lateral Pterygoid Muscle:
• Most commonly involved muscle in MPDS
• Unilateral failure of lateral pterygoid muscle to contract results in deviation of the mandible
toward the affected side on opening
MEDIAL PTERYGOID MUSCLE
Medial Pterygoid muscle is a thick muscle of mastication.
Origin and Insertion :
It Arises lateral pterygoid plate, and from the maxillary tuberosity. Insertion is seen on the Medial
angle of the Mandible.
Arterial supply: Pterygoid branch of Maxillary artery.
Nerve Supply: Mandibular nerve through the medial pterygoid.
Functions:
• Elevates the mandible,
• Closes the jaw,
• Helps in side to side movement.
Palpation of medial pterigoid
• Gently palpate them on the medial aspect of the jaw, simultaneously from both inside and
outside the mouth.
Clinical Importance of Medial Pterygoid Muscle:
• Medial Pterygoid muscle can be palpated only intraorally
• Most commonly involved in MPDS
• Trismus following inferior alveolar nerve block is mostly due to involvement of medial
pterygoid muscle

Collateral (discal)
Functional
Capsular
ligaments
Temporomandibular
ARTICULAR
LIGAMENTS
Sphenomandibular
Accessory ligaments
Stylomandibular
• Attaches the medial
Medial discal edge of the disc to
ligament medial pole of
condyle.
• Attaches the lateral

Lateral discal edge of disc to lateral
ligament pole of condyle.

 These ligaments divide the joint mediolaterally into superior and inferior joint cavity.
 These have vascular supply and are innervated.
ACTIONS:
 Passive movement with the condyle

 Hinging movement

CAPSULAR LIGAMENT
• Superiorly- Temporal bone.
• Inferiorly- Neck of the condyle.
• Actions: Resists medial, lateral or inferior forces that tends to dislocate the articular surface.
• Functions- to encompass the joint and retains the fluid.
• They are well innervated and provides proprioceptive feedback.

Temporo-
mandibular
ligament
Outer Oblique Inner Horizontal
From-outer surface From-outer surface Horizontally to-

of articular tubercle To-outer surface of of articular tubercle lateral pole of
& zygomatic process condylar neck & zygomatic process condyle &posterior
postero-inferiorly posteriorly part of articular disc

Action of outer oblique-limits the rotational opening of mandible and thus resists the
impingement on vital structures.
Action of inner horizontal -limits the posterior movement of condyle and disc.
FUNCTION :
Protects the retrodiscal tissues from trauma created by posterior displacement of condyle.
Protects the lateral pterygoid muscle from extension.
CLINICAL IMPORTANCE:
During trauma to the mandible ,effectiveness of this ligament demonstrated.

Neck of condyle will be seen to fracture before retro discal tissues are severed or condyle enters
the middle cranial fossa.
SPHENOMANDIBULAR LIGAMENT
• Arises from spine of sphenoid bone and extends downwards to a bony prominence on medial
surface of ramus called lingula.
• Actions: no significant effect on limiting movements.
• Remnant of Meckel’cartilage.
STYLOMANDIBULAR LIGAMENT
• Formed by thickening of deep fascia.
• Separates parotid gland from submandibular gland.

RELATIONS OF TMJ
LATERAL MEDIAL
• Skin & fascia • Spine of sphenoid

• Parotid gland • Auriculo-temporal and
• Temporal branches of Chorda tympani nerves
facial nerve. • Middle meningeal artery.
• Tympanic plate

43

 Blood supply:
Predominant vessels for TMJ are:
i. Superficial Temporal artery from the posterior aspect

ii. Middle Meningeal Artery from anterior aspect
iii. Internal Maxillary from Inferior aspect
 Other important arteries are:

 Deep auricular, Anterior Tympanic and Ascending Pharyngeal arteries.
 Condyle receives its vascular supply through its marrow spaces by way of Inferior
Alveolar Artery

Nerve Supply:
i. Auriculotemporal nerve
ii. Masseteric nerve
iii. Deep temporal nerve
Lymphatic drainage:
1. Anterior surface of TMJ -parotid lymph nodes.

2. Posterior & medial surface of TMJ - submandibular lymph node.
3. Lateral surface of TMJ - pre auricular and parotid lymph nodes
AGE CHANGES OF TMJ:
Condyle:
• Becomes more flattened
• Fibrous capsule becomes thicker.
• Osteoporosis of underlying bone.
• Thinning or absence of cartilaginous zone.
Disk:
• Becomes thinner.
• Shows hyalinization and chondroid changes.
Synovial fold:
• Become fibrotic with thick basement membrane.
Blood vessels and nerves:

• Walls of blood vessels thickened.
• Nerves decrease in number.
HISTOLOGY
Condyle of the Mandible:
 This is composed of cancellous bone covered by a thin layer of compact bone.
 The trabeculae radiate from the neck of the mandible and reach the cortex at right angles,
giving maximal strength to the condyle.
 Red marrow in the condyle is of myeloid or cellular type which is replaced by fatty marrow in
older individuals.
Roof of Glenoid Fossa:

 It consists of a thin compact layer of bone. The articular eminence is composed of spongy bone
covered with a thin layer of compact bone.
 Areas of chondroid bone are commonly seen in the articular eminence, and in rare cases,
islands of hyaline cartilage.
Essentials of Oral Histology and Embryology: A Clinical Approach . Avery, J. K., & Chiego, D. J. (2006).
Articular Surfaces of the Mandibular Condyle and Fossa:
 They are lined by dense fibrous connective tissues which contain some elastic fibers.
 The articular layers are thicker over the convexity on the anterior part of the condyle and over
the articular eminence of the temporal bone.
 It is composed of four distinct layers or zones.
1. Articular
2. 2. Proliferative
3. 3. Fibrocartilaginous
4. 4. Calcified cartilage
Articular zone:
 It is the most superficial layer, found just adjacent to the joint cavity, forming the outermost
functional surface.
 Unlike most other synovial joints, where the articular surfaces are covered by hyaline cartilage,
the TMJ articulation is covered by a layer of fibrous tissue.
 It is less susceptible to the effects of aging, and therefore, less likely to breakdown and it has
much better ability to repair than the hyaline cartilage.
Proliferative zone:
 It is mainly cellular, consisting of undifferentiated mesenchymal tissues
 They are responsible for the proliferation of articular cartilage in response to the functional
demands placed on the articular surfaces.
Fibrocartilagenous zone:
• This zone consists of the collagen fibrils arranged in bundles in a crossing pattern.
• The fibrocartilage appears in a random orientation, providing a three-dimensional network that
offers resistance to the compressive and lateral forces.
Calcified cartilage:
 It is the fourth and the deepest zone.
 This zone is made up of chondroblasts and chondrocytes distributed throughout the articular
cartilage.
 In this zone, chondrocytes become hypertrophic and die, causing their cytoplasm to be
evacuated, forming bone cells from within the medullary cavity.
Articular Disk:
 The disk is a dense, collagenous, fibrous pad between the condylar heads and the articular surfaces.
 Elastic fibers are found only in relatively small numbers.
 The fibroblasts in the disk are elongated and send flat cytoplasmic processes into the interstices
between the adjacent bundles.
 The disk is thinnest centrally and thickens in the periphery.
 It is devoid of any blood vessels and nerves for the most part, except for the extreme periphery of
the disk which is slightly innervated.
 The fibers in the disk comprise about 80 percent of type I collagen and 5 percent
glycosaminoglycans of its dry weight.
 Of the 5 percent of glycosaminoglycans, 80 percent is chondroitin sulphate and about 15
percent is dermatan sulphate.
MANDIBULAR MOVEMENTS
• Occurs as a complex series of inter-related 3D rotational and translational activities.

• It is determined by combined and simultaneous activities of both TMJs.
Types of movements:
 Rotational movement
 Translational movement
Management of Temporomandibular Disorders and Occlusion. Okeson J. 7th Edition. (2012)

 The lower joint compartment formed by the mandible and the articular disk is involved in
rotational movement (opening and closing movements).
 The upper joint compartment formed by the articular disk and the temporal bone is involved in
translational movements (sliding the lower jaw forward or side to side).
 The inferior compartment allows for the pure rotation of the condylar head, which corresponds
to the first 20 mm or so of the opening of the mouth.
 Beyond 20 mm of opening, the mouth can no longer open without the superior compartment
of the TMJ becoming active.
 At this point, if the mouth continues to open, not only is the condylar head rotating within the
lower compartment of the TMJ; but the entire apparatus (condylar head and articular disk)
translates, or slides forward in the glenoid fossa and down the articular eminence of the
temporal bone.
 This incorporates an anterior movement into the further opening of the mouth and can be
demonstrated by placing a resistance fist against the chin and trying to open the mouth more
than 20 mm.
 Rotation occurs as movement within the inferior cavity of the joint i.e. between superior
surface of condyle and inferior surface of articular disc.
 Movement can occur in all 3 planes.

i. Horizontal axis of rotation
ii. Frontal/vertical axis of rotation
iii. Sagittal axis of rotation
HORIZONTAL AXIS OF MOVEMENT
 Only example of mandibular activity where pure rotation
occurs.
 In all other movements rotation occurs with translation
movement.
 It is an opening and closing motion of the mandible around the
horizontal axis with the condyles in the most superior position
in the articular fossa.
 Axis is called as TERMINAL HINGE AXIS.
 The movement is called as HINGE MOVEMENT.

FRONTAL AXIS OF MOVEMENT
 Occurs when one condyle moves anteriorly out of the TERMINAL Hinge position with
vertical axis of opposite condyle remaining in Terminal Hinge Position.
 It occurs because of inclination of the articular eminence which prompts the frontal axis to tilt
as the moving condyle travels anteriorly.
 This type does not occur naturally.

SAGITTAL AXIS OF ROTATION
 Occurs when one condyle moves inferiorly out of the TERMINAL Hinge position with sagittal
axis of opposite condyle remaining in Terminal Hinge Position.
 Because of attached muscles and ligaments, it does not occur naturally.

TRANSLATIONAL MOVEMENTS
 In TMJ, translational movements occurs when the mandible moves forward as in protrusion.
i.e. teeth, condyle and rami moves in one direction.
 Occurs within superior cavity of the joint between superior surface of articular disk and inf.
Surface of articular fossa.
 During most normal movements, both rotation and translation occurs simultaneously.
 That is, while mandible is rotating around one or more axes, each of the axes is translating at
the same time.(Changing its orientation in space).
EXAMINATION AND DIAGNOSIS OF TMJ DISORDERS
 HISTORY :-
 History of onset, duration, frequency of the disease and dental treatment are important to
asses the acute or chronic nature of the disease.
 Factors like pain, click or dysfunction are to be considered while taking history.
 History of trauma and history of dental treatment can usually pinpoint the etiology of the
disease.
 CLINICAL EXAMINATION :-
 Inspection :-
• Interincisal distance on mouth opening, facial asymmetry and deviation of mouth on
opening and closing , preauricular swelling, occlusal cant, malocclusion, occlusal
derangements, improper prosthesis, attrition of teeth decreasing vertical dimension
should be noted.

 Dental examination :-
 Any pre mature contacts.
 Evaluationfor evidence of bruxism such as attrition of teeth, check or lip ridges caused
by trapping of mucosa during clenching.
Occlusal evaluation :-
 Molar and canine relationship.
 Freeway space, overjet, overbite, prosthesis.
 Other oral habits and their possible effects on dentition, periodontium or other oral
structures.
 Number of missing teeth specially the posterior relationship which may predispose the
TMJ to degenerative joint diseases.

Palpation :-
 Tenderness on palpation suggests the presence of fracture, synovitis, or capsulitis of the

joint.
 Jaw is palpated for evidence of muscle enlargement and any unusual features such as
movement of disc (hypermobility) during activity.
 Overlying skin is checked for temperature and consistency in case of any inflammatory
condition.
Muscle tenderness :-
o Masseter With finger and thumb.
o Temporalis while the patient is clenching the teeth at the same time, attempting to move
jaws sideways.
o Lateral pterygoid with a finger pushed into retromolar area of maxilla.
METHODS OF PALPATION
Anterior to tragus In the external auditory meatus

Neurological tests :-
Trigeminal nerve supplies sensation to the superficial and deep structures of the head
and face and motor function to the muscles of mastication.
Sensory nerve activity is assessed by applying pressure , cotton wool and pin-pricks to
the areas of distribution of trigeminal nerve.
This test helps in clinical diagnosis of myofascial pain.
Auscultation :-
Noise is assessed by stethoscope and classified either click (open or close click) or
crepitus.
SPECIAL INVESTIGATIONS :-
Laboratory investigation :-
• Indicated when primary diseases are diagnosed by biochemical and serological tests.
e.g. gout, infectious arthritis/ suppurative arthritis, rheumatoid arthritis.
Electromyographic investigations :-
• Helps in monitoring the activity of disordered TMJ.
Drugs :-
• Anti-inflammatory , muscle relaxants and antidepressants can be used to rule out the
cause in myofascial dysfunction syndrome (MPDS).

Occlusal splints :-
To diagnose MPDS.
Intermaxillary fixation :-
• When there is pain of uncertain origin, IMF may be applied.

• It is diagnostic as it relieves the pain if the source is the TMJ (condylar fracture) or
masticatory muscles (prevents overstretching of muscles).
Local anesthesia :-
• To confirm the muscular pain.

• E.g. Injection in the masseter muscle.
RADIOGRAPHIC EXAMINATION
Panoramic radiography:
 It can reveal advanced bone alterations in the condyle, such as asymmetries, erosions, osteophytes,
fractures, changes in size and shape, degenerative and inflammatory processes, growth alterations,
maxillary tumors, metastases, and ankylosis.
 It is indicated when the patient has reduced mouth opening and the differential diagnosis of fracture
is considered.
 However, it does not provide functional information on condylar excursion. Also, only gross
alterations in the articular tubercle morphology can be seen because of the superimposition of
images of the skull base and the zygomatic arch.
Temporomandibular Disorders .A Problem-Based Approach. Gray . Wiley J. (2011) .
DISLOCATION OF LEFT TMJ

PLANIGRAPHY (OR PANORAMIC RADIOGRAPHY WITH
PROGRAMS FOR TMJ)
 This method provides considerable accuracy and produces images without much overlap.
 It visualizes the articular boney detail and reveals any anatomical abnormalities in structures
adjacent to the TMJ, such as the styloid process, mastoid process, and zygomatic arch.
 It can be obtained in the sagittal and coronal planes, documenting the relationship of the
condyle with the articular fossa in maximum habitual intercuspation (MHI) and the excursion
extension during maximal mouth opening (MMO).
 It provides a direct comparison of both sides regarding the hypo-, normo-, or hyperexcursion
of the condyle, which is useful in confirming a clinical suspicion of hypermobility.

 In spite of the relative identification of the TMJ boney structures, it does exhibit some
magnification that is inherent to the technique.
 However, it is useful for functional assessment of mouth opening, evaluation of morphological

alteration and the joint spaces, analysis of dimension, fractures, and ankylosis.
TRANSCRANIAL RADIOGRAPHY
 Similarly to the planigraphy, this evaluation provides good anatomical assessment of the
condyle, fossa, and articular tubercle.
 In this technique, an X-ray beam is obliquely directed through the skull to the contralateral
TMJ, producing a sagittal view.
 The central and medial portions of the condyle are projected inferiorly and only the lateral joint
contour is displayed.
 It is useful to identify bone alterations and displaced fractures of the head and neck of the
mandibular condyle, as well as to assess excursion and to determine radiographic joint spaces.
 This type of projection is limited by the fact that it produces an image with a large overlap of
the skull bones; it also requires the use of a specific cephalostat for standardization, usually
requiring complex positioning.
ARTHROGRAPHY
 Arthrography is a variant of the radiographic technique for TMJ, which aims to assess the TMJ
soft tissues.
 In the 1970s and 1980s, arthrography was the method of choice for the identification of disc
displacement.
 Disc morphology, positioning, and function were indirectly identified by contrast injection into
the superior and/or inferior joint spaces.
 After the injection, dynamic images were obtained, recording mandibular movements.
 Even though it is useful for disc position identification, arthrography is not currently
recommended as it is an invasive procedure and carries a risk of iatrogenic disc perforation and
facial nerve damage.

 There are also the risks of radiation to radiosensitive structures (crystalline and thyroid), pain
and limitation of movement after the injections, infections, allergies to the injected dye, and it
is an examination that is considered difficult to perform.

Other combined radiographic techniques:
 Due to the two-dimensional radiographic visualization of the TMJ, the combined use of different
techniques is necessary to provide an accurate diagnosis and location of the alterations.
 The evaluation of the structures in different planes illuminates fracture extension, degenerative
joint disease, postoperative status, ankylosis, and neoplasms.
 Additionally, the anatomic relations of areas adjacent to the lesion can be studied with greater
diagnostic accuracy, providing more efficient surgical and therapeutic planning.
 The main combined views are submental (or submento-vertex), transpharyngeal, transmaxillary,
reverse Towne, posterior-anterior, and lateral teleradiography.
 Despite their lower cost, technical simplicity, and lower levels of radiation, the use of combined
radiographic images has become less common due to increasing use and availability of accurate
images such as cone-beam computed tomography.
COMPUTED TOMOGRAPHY (CT)
 CT comprises a set of images obtained through a sophisticated and highly accurate technique,
compared to plane radiographs.
 Recently, cone-beam computed tomography (CBCT) technology has been used for dental
diagnosis due to its specific use for the maxillofacial region.
 Its main advantage is the observation of boney joint structures in the sagittal, coronal, and axial
planes, in addition to the possible image manipulation at different depths and three-dimensional
reconstruction through specific software.
 The examination time varies between 10 and 70 s, and the radiation dose is much lower
compared to the combined radiographic technique.
 The main indications of CBCT include structural assessment of bone components of the TMJ,
which precisely determines the location and extent of boney alterations:
fractures, neoplasms, and ankylosis; erosive degenerative, pseudocystic, osteophytic alterations;
 osteophytic alterations; presence of asymptomatic bone remodeling; evaluation of post-surgical
conditions; hyperplasia of condylar, coronoid, and styloid processes;; as well as intraarticular
calcification derived from synovial chondromatosis or metabolic arthritis.
 Hard tissues, teeth, and bones are well demonstrated and measured in their real morphological
condition, with minimal noise and artifacts.
 Drawbacks include few details are provided on soft tissue and it is not possible to evaluate the joint
disc.
 Significant disadvantages are the cost of the examination and exposure to significant levels of
radiation compared to conventional radiographic techniques.
MAGNETIC RESONANCE IMAGING (MRI)
 MRI has been the method of choice to study disease processes involving the TMJ soft tissues, such
as the articular disc, ligaments, retrodiscal tissues, intracapsular synovial content, adjacent
masticatory muscles, as well as cortical and medullary integrity of bone components.
 The technique allows three-dimensional analysis in the axial, coronal, and sagittal planes. It is
considered the gold standard for assessing disc position and is highly sensitive for intraarticular
degenerative alterations.
 The clinical conditions that suggest its use include persistent symptoms of joint or pre-auricular
pain, presence of clicking and crepitation noises,
 functional alterations such as lateral projections of the condyle during mouth opening,
 frequent subluxations and dislocations,
 limited mouth opening movement with terminal stiffness,
 suspected neoplastic processes.
 This diagnostic test protocols usually include the recording in the Maximum Mandibular Opening
position, using proton density (PD), in the sagittal and coronal planes.
 The main advantages include detecting soft tissue alterations, necrosis, edema, presence or absence
of invasion, and lack of exposure to ionizing radiation.
 MRI is also indicated for the assessment of the integrity and anatomical relation of neural
structures, which, when compressed by tumor or vascular processes, can produce orofacial pain by
demyelination and deafferentation.
 Its disadvantages are related to the high cost and the need for sophisticated facilities.
 It is contraindicated in claustrophobic patients, those with pacemakers and metallic heart valves,
ferromagnetic foreign bodies, and pregnant women.
NUCLEAR MEDICINE EVALUATION
 Nuclear medicine facilitates establishing a diagnosis by detecting minute concentrations of
radioactive pharmacological substances that determine osteometabolic alterations expressed in
imaging exams.
 Bone scintigraphy is indicated to define neoplastic activity, metabolic disorders, and bone
growth, as well as to evaluate synovitis and osteoarthritis.
 It is an examination with considerable sensitivity, low invasiveness, and high organ specificity,
with low levels of radiation.
 It has some advantages over radiographies, conventional CT, and MRI because it provides an
estimate of metabolic and inflammatory activity.
 It can facilitate an early diagnosis and is less costly than CT and MRI. However, it does not
differentiate among bone scar disorders, infections, osteoarthritic manifestations, or tumors.
 Positron-emission tomography (PET) is usually indicated for the assessment and staging of
metastatic tumors.
 It is able to provide accurate functional, morphological, and metabolic information.
 Three-dimensional images facilitate anatomical visualization and can significantly reduce the
time required for diagnosis, in addition to properly direct treatments by ensuring that the
therapies are appropriate.
 Currently, single photon emission computed tomography with technetium-99m methylene

diphosphate (SPECT/CT with 99m Tc-MDP) is largely employed.
 This technology allows for multiplane image acquisition and 3-D display. The radiotracer 99m
Tc is able to reflect the local osteometabolic rate, while the anatomic mapping is obtained by
tomographic technique.
 Its main advantage is its sensitivity and specificity.

DISORDERS OF TMJ
 The dental profession was first drawn into the area of Temporo-Mandibular Disorders by Dr.
James Costen (1934) who described a group of symptoms that centered around the ear &
TMJ.
 Refers to the group of disorders of the TMJ as a result of primary or secondary degenerative
changes within the joint or muscle hyperfunction or parafunction.
Petersons Principles Of Oral And Maxillofacial Surgery. 3rd Volume. (2012)

CLASSIFICATION OF TMJ DISORDERS:
A. STRUCTURAL (DISORDERS ARISING WITHIN JOINT)
1.DEVELOPMENTAL
I. Condylar hyperplasia
II. Hemi mandibular elongation
III.Hemi mandibular hyperplasia
IV. Condylar hypoplasia and aplasia
2. ACQUIRED
I. Traumatic arthritis
II. Suppurative arthritis
III.Osteoarthritis
IV. Rheumatoid arthritis (RA)
V. Psoriatic arthritis
VI.Infection from contagious disease that spreads from other tissue like TB , Syphilis
vii. Metabolic disorders like gout
viii. Condylar fracture
ix. Dislocation : acute , chronic, recurrent (habitual)
x. Posttraumatic – ankylosis
xi. Internal derangement
xii. Tumors
• Benign: Para/juxta-articular chondroma
• Malignant: osteosarcoma, metastatic condylar tumors
xiii. Synovial fistula and synovial cyst of TMJ
xiv. Ankylosing spondylitis
B. FUNCTIONAL
1. Disorders arising from structures outside the joint

2. Myofascial pain dysfunction syndrome (MPDS)
CONDYLAR HYPERPLASIA
 Condition of mandibular condyles creating overgrowth of the
mandible, first described by Robert Adams.
Bilateral Unilateral
Facial asymmetry and

Progressive prognathism
articular disc dislocations.

Obwegeser and Makek (1996) differentiated it into three categories:
I. Hemi mandibular hyperplasia :-

Enlargement of the condyle, condylar neck, ramus, body with tilting of the occlusal plane.
II. Hemi mandibular enlargement :-
Condylar neck enlargement, variable displacement of the ramus without tilting of the
occlusal plane.
III.Condylar hyperplasia :-
Only hyperplastic condyle with no associated mandibular changes.
Treatment :-
• Condylectomy to ensure removal of the growing cartilage.

• More conservative condylar shave (condyloplasty) can also be performed in certain cases.
• Correction of facial asymmetry by orthognathic procedures or orthomorphic surgery.
HEMI MANDIBULAR ELONGATION
Clinical features :-
1. Horizontal displacement of the mandible and chin towards the unaffected side.
2. Mild mandibular protrusion.
3. Lip line slopes towards the affected side.
4. Lateral crossbite on the unaffected side.
5. In severe cases lateral open bite is observed on the affected side & in mild cases it is
compensated by supraeruption of the teeth.
6. The displacement of the midline is greater at the anatomical mid-chin than at the incisor
midline, so that there appears to be an apical drift of the incisors towards the unaffected
side.
Age group :- Generally during adolescence.
Nature of the deformity :- Generally worsens throughout the growth and ceases when the
growth stops (second decade).
Treatment :-
 Condylar surgery is not necessary.
 It is advisable to wait till the cessation of mandibular growth before jumping on surgical
approach.
 In fully developed cases, following any presurgical orthodontics, spatial correction is
required.
 In cases where there is no cant of occlusal plane , a bilateral mandibular ramus osteotomy
is usually sufficient to achieve a reasonable result.
 In addition genioplasty is sometimes necessary to achieve symmetry.
HEMI MANDIBULAR HYPERPLASIA
 Always presents with the same general appearance as hemi mandibular elongation.
 This varies in the degree of development, depending on the age at which abnormal growth commences,
the degree of abnormal growth and its duration.
 Age group :- 5-8 years of age, it generally ceases after cessation of general growth but occasionally it
continues for a few years.
1.3D enlargement of one side of mandible.
2.Enlargement of condyle ,condylar neck and ascending ramus and the body.
3.No chin displacement but lip line slopes downwards to the affected side.
4.No midline shift with lateral open bite seen in some cases.
5.Downward cant of maxillary plane due to overeruption of teeth on the affected side.
6.Pain in the TMJ of the affected side.
Radiographically :-
Mandible on the affected side is enlarged and inferior dental canal is displaced towards the lower
border.
Management :-
During growth period , some form of condylar surgery (condylotomy, condyloplasty) will arrest
and retard growth, thus limiting the secondary distortion.
Treatment protocols are :
1. High condylectomy to arrest the growth.
2. Articular disc repositioning.
3. Concomitant orthognathic surgery.
Maxillary Le fort 1 osteotomy. (If maxilla is affected.)
Care must be taken to determine the exact position of the mandibular canal prior to operation.
CONDYLAR HYPOPLASIA AND APLASIA
Presence of facial deformity expressed on the affected side by a short mandibular ramus.
Can be Unilateral or Bilateral.
UNILATERAL CONDYLAR HYPOPLASIA :-
 Shortening of mandibular vertical height occurs on the affected side.
 A midline shift towards the same side.
 Occlusal cant.
 Shifting of the chin towards the shorter side of the face.
 Deviation of the mandible on mouth opening.
Etiology :- Can be congenital due to pharyngeal first and second arch malformation or it may
result due to trauma ,infection or irradiation during growth period.
Common syndromes with hemi mandibular hypoplasia as a component are:
 Goldenhar-gorlin syndrome.
 First and second branchial arch syndrome
 Craniofacial microsomia.
 Femoral facial syndrome.
Bilateral condylar hypoplasia :-
 Bilateral condition results in micrognathia or small mandible.
 Bird like face, retruded chin with a small mandibular arch.
 In congenital cases , it causes respiratory distress
due to obstruction of pharyngeal airway by falling back of tongue.

Syndromes :
 Pierre Robin Syndrome
 Treacher Collins syndrome
 Nager’s Syndrome
 Townes brocks Syndrome
Treatment :-
Severe mandibular dysostosis should be treated in growing age itself to produce to avoid
secondary deformities because mandibular ramus is lengthened as the secondary dentition is
erupting.
Can be achieved by :-
I. Growth centre transplantation
II. Graft
III.Distraction osteogenesis
IV. Orthognathic surgery and orthodontics

I. Growth centre transplantation :-
Insertion of cartilaginous graft, typically an autograft, in the osteotomy site is most common
method.
Costochondral rib grafts are most suitable for this purpose since they can be transplanted as
growth centre replacements to achieve mandibular growth.
II. Distraction osteogenesis :-

Powerful technique for creating new bone for lengthening of mandible without the need
of bone grafting.
The occlusal outcomes are aided by concomitant orthodontic therapy.
III. Orthognathic surgery and orthodontics :-
 A combination of maxillary and mandibular osteotomies can be performed to correct the

skeletal deformity caused by condylar hypoplasia after cessation of growth.
 BSSO for the correction of micrognathia by doing mandibular advancement.
 Advancement greater than 10mm require a long sagittal split, which is difficult to achieve.
 Unilateral facial asymmetry can be corrected by using combination of maxillary and
mandibular osteotomies and camouflage procedures.
 Le Fort I osteotomy to correct the occlusal cant; followed by vertical sub sigmoid
osteotomy and mandibular contouring often yields good symmetry and aesthetic results.

TRAUMATIC ARTHRITIS
 Any traumatic incident involving the TMJ may lead to acute arthritis.
 Site of inflammation is capsule.
 Chronic trauma to the joint due to trauma from occlusion is also responsible for osteoarthrosis.
 Characterized by, tenderness of the affected joint and restriction of the movement which cause
mandible to swing on the affected side on opening.
 Oedema around the joint can be seen.
 Pain in movement leads to classic trismus.
Treatment :-
 Treating the cause followed by physiotherapy.
 Long term trismus may require surgical removal of coronoid processes and temporalis muscle
attachment followed by physiotherapy.
OSTEOARTHRITIS
 Chronic noninflammatory and degerative disease affecting the articular cartilage of joints.
 Most common skeletal disease of human body affecting the TMJ.
Pathology :-
 Earliest degenerative changes are seen in articular cartilage as proteoglycans are lost at the
surface.
 Chondrocytes are stimulated and DNA synthesis increases.
 Growth of surrounding bone is stimulated, resulting in osteocyte formation.
 Subchondral pseudocysts become evident as synovial fluid passes through the cartilage and
cortical bone to fill the marrow cavities.

TMJ Disorders and Orofacial Pain: The Role of Dentistry in
a Multidisciplinary Diagnostic Approach (Color atlas dent
med)
Clinical Features :-
 Usually 5th decade- -slow onset of disease with mild symptoms.
 Usually one TMJ is involved (but may be bilateral),symptoms are usually unilateral.
 Women are more likely to be afflicted with TMJ involvement.
 Pain in the joint and muscles of mastication, causing limitation of mandibular motion.
 Joint noises, especially crepitus.
 Osteophyte formation and marginal bone thickening leads to palpable masses over
preauricular region.
Investigations :-
Plain films and CT scans can reveal flattening of the condylar head, Cyst formation of
subchondral bone, joint narrowing, osteophyte formation and subchondral sclerosis.
MRI, arthrography can reveal disc perforations and dislocations.
Treatment :-
 Initial intervention should limit excessive and recurrent trauma.
 Moderate exercise and physical therapy should be started to strengthen the musculature
supporting the joints.
 NSAIDs to reduce pain.
 In severe case, thermal therapy can be obtained with ultrasonography and infrared heat.
 Orthopedic procedures with osteotomy and prosthetic replacement may be required.
RHEUMATOID ARTHRITIS(RA)
 Autoimmune disease predominantly affecting diarthrodial joints.
 It can affect the joint at any age.
 Juvenile rheumatoid arthritis (Still's disease) may be of varying severity.
Etiology :-
 Genetic susceptibility.
 Autoimmune response.
 Increased HLA DR4 antigen, correlated with increased levels of rheumatoid factor.
Pathophysiology :-
 Synovial membrane proliferation and outgrowth causes erosion of articular cartilage and
subchondral bone.
 After microvascular injury, synovial cells proliferate, swell and are infiltrated by mononuclear
cells and T lymphocytes.
 The production of inflammatory mediators, which is stimulated by the RA cells, result in the
production of proteinases and prostaglandin. Collagenases are responsible for typical erosions
seen over the joint surface.

 Intermittent pain, swelling and progressive limitation of joint motion.
 Characteristically, the joints of the hands and feet are first affected.
 Preauricular joint pain on chewing and moving.
 Advanced disease leads to decreased range of motion and stiffness.
 Decreased bite force, muscle tenderness.
 Clicking, crepitus and tenderness of the joint on palpation.
 Limitation of motion occurs as the bone is destroyed and joint space is filled with scar
tissue leading to fibrous ankylosis.
 Progressive class II occlusion develops resulting in retrognathia,bird-face deformity and
apertognathia may result in young children.
Radiograph:-
 Early pathology is not revealed as RA starts in soft tissues.

 Erosions, marginal proliferation and abnormal flattening of the condyle head, loss of joint
space, osteophyte formation are seen as the process continues.
 MRI reveals TMJ disc destruction, displacement and joint effusions.
 Advanced RA reveals shortening of the posterior ramus, premature posterior occlusal contacts
and ante-gonial notching.
Treatment :-
1. Conservative methods
 Drug therapy
 Anti inflammatory drugs (salicylates, NSAIDs, corticosteroids), soft diet, avoiding extreme jaw
movements.
 If NSAIDs are ineffective, disease modifying anti-rheumatic drugs like hydroxychloroquine,
penicillamine or the cytotoxic agents like methotrexate or cyclophosphamide are considered.
 Drug of choice for juvenile rheumatoid arthritis patients is methotrexate.
.
2. Surgical methods:-
 High condylectomy is the procedure of choice for intractable pain.
 Arthroplasty for total joint reconstruction usingalloplasts.
 Synovectomy
TUMOURS
 Any tumour in the area of TMJ and/or muscles of mastication can significantly cause
jaw hypomobility.
 Both benign and malignant lesions affect the condyles and synovial components of the
joint.
ANKYLOSING SPONDYLITIS(MARIE- STRUMPELL DISEASE)
• Chronic inflammatory disease involving the articulators of spine adjacent soft tissues.
• High sex ratio of male:female sufferers (8:1)
 Symptoms are due to imperfect head posture caused by the vertebral lesions.
 The most common complaints are of pain, stiffness, decreased range of motion and eventually
ankylosis.
 Extra-articular manifestations such as iritis, uveitis and cardiac symptoms are common in patients
with TMJ involvement.
Radiographic findings :-
 Inerosion of the condyle and fossa, osteophyte formation and subchondral sclerosis.
 As disease progresses, severe narrowing of the joint clude space becomes evident.
Treatment :-
 The load must be reduced across the joint by the use of acrylic splints.
 The drug with proven efficacy sulphasalazine.
 Surgical intervention should be limited to those patients with severe crippling disease .
DISORDERS ASOCIATED WITH TMJ DISC
A. Derangement of condyle -disc complex:
1. Disc displacements
2. Disc dislocation with reduction
3. Disc dislocation without reduction
B. Structural incompatibility of the articular surfaces:
4. Deviation in form: a. Disc b. Condyle c. Fossa
5. Adhesions :
a. Disc to condyle
b. Disc to fossa
c. Subluxation
d. Spontaneous dislocation
DISC DISPLACEMENT:
Causes:
 TMJ dislocation may occur with trauma, extreme opening of the mouth during yawning,
laughing, singing, vomiting, or dental treatment .
 Symmetric mandibular dislocation is most common, but unilateral dislocation with the jaw
deviating to the opposite side also can occur.
 TMJ dislocation is painful and frightening for the patient.
Clinical examination:
• Difficulty in normal range of movements
• Joint sounds are noticeable.
A. Disc displacement with reduction :
The articular disc displaces anteriorly to the condylar head, when the mouth is opened the disc relocates on
the condylar head.
1. Hearing and palpating joint noises during opening and closing
2. Protrusive opening and closings stops the reciprocal click
3. There is unlikely to be any restriction in range of movement due to the disc relocating when the mouth
opens.
B. Disc displacement with reduction with intermittent locking:
Identical to DDWR with the additional symptom of intermittent limited jaw opening. This occurs when the disc
does not reduce.
C. Disc displacement without reduction with limited opening:
The articular disc displaces but does not reduce.

1. TMJ pain
2. Limited jaw range of movement <40mm
3. Clicking and popping.
MANAGEMENT:
• The Management Goals include:

• Reduction of Pain and Anxiety .
• Reduction of Functional or Parafunctional Activities Leading to Adverse Loading .
• Restoration of Acceptable Function .
• Resumption of Normal Daily Activities .
• Emergency Therapy include:
• Patient Education & Reassurance .
• Medication to relieve pain (Analgesics – Anti - inflammatory)
• Injecting active trigger points with local anesthetic agents .
• Short – term of soft vinyl splint to relieve pressure on joint structures .
Conservative Treatment of TMDs include:
1.Patient Education.
2.Home - care Instructions.
3.Intra - oral Appliance Therapy (occlusal splints).
4.Physiotherapy that includes jaw exercises.
5.Pharmacotherapy for management of pain and discomfort.
6.Behavioural therapy includes management of noxious habits accompanying the musculoskeletal
disorder, Hypnosis , Acupuncture , Biofeedback , Relaxation exercises.
OCCLUSAL SPLINT THERAPY
 Occlusal Splint Therapy is defined as a Non – invasive and Reversible Biomechanical Method
of Managing Pain and Dysfunction of the TMJ and its Associated Musculatures .
 Splint is defined as a removable appliance used to break neuromuscular engrams to create

neuromuscular harmony in masticatory system.
Purpose of Occlusal Splint Therapy:
 Stabilize or improve the function of the TMJs .
 Improve the function of the Masticatory Muscles & Reduce abnormal muscle activity.
 Protect Teeth from attrition and adverse traumatic loading .

Interocclusal Appliances or Occlusal Splint Therapy:
Classification:
A. Based on mode of action:
I. Joint-stabilization splint
II. Anterior Repositioning splint
a. Anterior Bite Plates
b. Posterior Bite Plates
c. Soft ( Resilient ) splint

B. Based on movement of mandible:
a) Permissive splint :
 It allows the teeth to move on the splint unimpeded, which in turn allows the condylar head
and disk to function anatomically.
 Examples of permissive splints include bite planes (anterior jigs, Lucia jig, Anterior
Deprogrammer).
 stabilization splints (flat plane, Tanner, superior repositioning, and centric relation [CR])
b) Nonpermissive :
 A nonpermissive splint has a ramp or “indentations” that position the mandible inferiorly and
anteriorly and secure it there.
 An example of a nonpermissive splint is A repositioning splint (anterior repositioning
appliance [ARA])
The characteristics of a successful splint should :
1.Stability;
2.Balance in CR;
3.Immediate posterior disocclusion;
4.Equal intensity stops on all teeth;
5.Smooth transitions in lateral, protrusive movements.
6.Comfort during wear; reasonable esthetics.
7.Patient compliance
THE JOINT- STABILIZATION SPLINT
Synonyms :
 Muscle Relaxation Splint, Centric Relation Splint, Michigan Splint, Bruxism Appliance.
 The most commonly used appliance , which is a hard acrylic splint that provides a temporary
& ideal occlusion .
 Main purposes : To stabilize the TMJs by decreasing pressure on joint structures and reducing
parafunctional activity such as bruxism .
 The Stabilization Splint Covers the entire dental arch , Occludes with all opposing teeth . The
Occlusal surface is flat , with slight indentations for opposing cusp tips.
 Placement in the Maxilla or Mandible : Most often in the Maxilla for reasons of comfort .
Mandibular placement is recommended for esthetic reasons and in patients with Angle’s Class III
malocclusion .
 Area to Cover : All the teeth as well as areas without teeth if these areas are opposed by teeth in
the opposite arch , to achieve optimum stability.
 Retention : By having the acrylic pass the prominence line of the teeth by about 1 mm. - In most
cases retention by clasps is unnecessary .
 Thickness : The bite rise in the frontal region should be 3 – 4 mm in most cases , but in patients
with severe bruxism it can be made another 1 to 2 mm thicker .
 Occlusal Relationships : The teeth in the opposite arch should have point contact against the
appliance, and its occlusal surface should be as flat as possible.

 A suggested protocol would include adjustments at 24 hours, 54 hours, 7 days, 2 weeks, and 1
month after seating.
 After 3 months with no changes on the splint, a comfortable musculature, and no pain on
loading, the patient is advised to withdraw the wearing of the splint.

 Occlusal Adjustments :
• It is Very Important to recheck the occlusion at follow-ups since the occlusal relationships may
change as a consequence of jaw-muscle relaxation , forcing the mandible in a more backward
position .
 Use of the Stabilization Splint:

• Primarily at night.
• Static Pain ( Muscular involvement) : Nocturnal use only.
• Dynamic Pain ( Joint involvement) : Full-time use .
• Acute Cases : Full-time use initially ,then decreased
gradually.
• Nocturnal Bruxism : Continued Night-time use.
THE MICHIGAN SPLINT BY RAMFJORD AND ASH
 The Michigan splint by Ramfjord and Ash is an occlusal bite plane stabilization splint with
cusped rise and freedom in centric in a space of 0.5-1.0 mm on the splint plane .
 Indications for Michigan splint are as follows:
 TMDs of arthrogenic and/or myogenic origin,

 Management of nocturnal bruxism and uncontrolled parafunction during the day,
 Maintaining of centric relations as a precondition to extensive prosthodontic restoration in patients
with painful and stiff masticatory muscles or limited mandibular movements, and
 as a means of differential diagnostics of TMDs with respect to other ailments with similar
symptoms (orofacial and craniocervical pain, tension headache, secondary tinnitus, etc.)
McNamara Jr JA, Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and temporomandibular disorders: a review.
Journal of orofacial pain. 1995 Jan 1;9(1).
 In Michigan splint, centric relation serves as a therapeutic position which stabilizes the
mandible in occlusal relations, wherein the habitual mandibular position is often identical to
the centric position in the TMJ.
 Michigan splint is most often indicated for the maxilla, but esthetic and phonetic reasons can
also indicate its placement on the mandibular teeth.
KAOHSIUNG MEDICAL UNIVERSITY(KMU) SPLINT
 The KMU splint is a mandibular splint. It is a full-coverage occlusal splint with indentation
made from heat-cured resin.
 Stabilization of the disc cannot be achieved in a short time.
 To ensure the disc stay in the normal position, we recommend that patients gradually reduce
the amount of time wearing the splint.
 We recommend wearing the splint 24 hours a day for the first 4 weeks, then wearing it while
sleeping and eating for the next 2 weeks, and wearing it only while sleeping for another 2
weeks for a total of 8 weeks of treatment.
 Because the splint had needed to wear all the day, we suggest that a splint should be designed
to be worn on the
Wu, J.-H., Kao, Y.-H., Chen, C.-M., Shu, C.-W., Chen, C.-M., & Huang, I.-Y. (2013). Modified mandibular splint therapy for disc
displacement with reduction of the temporomandibular joint. Journal of Dental Sciences, 8(1), 91–93.
FABRICATION:
 To minimize the bite opening and thus eliminate joint noise while opening the mouth, a patient
with joint sounds is instructed to open his or her mouth and produce the sound, after which a
wooden tongue depressor is placed between the upper and lower teeth.
 The patient is then instructed to bite down on the depressor and open the mouth again; if the sound
disappears, a KMU splint is appropriate for this patient.
 Ideally, the wooden tongue depressor should be approximately 1.5 mm in thickness, since our
clinical experience shows that if a patient’s bite opening is approximately 1.5 mm, joint noises
disappear, and prognosis improves.
 We then take the patient's dental casts and bite record. The patient is instructed to open and close
the mouth several times to ensure a stable path of mouth opening and closing without midline
deviation or protruding jaw.
 Two pieces of putty are then placed on the bilateral posterior tooth areas, and the patient is asked to
bite the tongue depressor naturally in order to obtain an occlusal record.
 The key points for fabrication of the KMU splint and its associated treatment regimen include the
following:
 The splint is worn on the lingual side of the mandible.
 The occlusal surface of the splint must be indented.
 The patient should not protrude or deviate the mandible when making an impression of the bite for
the splint fabrication.
 The average bite elevation should be 1.5 mm.
 Total treatment time is 8 weeks. The patient should wear it 24 hours a day for the first 4 weeks,
then wear it while eating and sleeping for the next 2 weeks and wear it only while sleeping
for the last 2 weeks.
 Patients must understand the success of treatment depends on their compliance with the regimen.
ANTERIOR REPOSITIONING SPLINT
 The appliance has a well-defined fossae on the occlusal surface to actively guide the mandible into
a more protrusive position to improve the disc-condyle relationship.
 The Goal is to advance the mandible forward into a “ therapeutic position” to maintain the disc in
proper alignment and thus eliminate pain and joint noise.
 The Therapeutic Position of the mandible : 2-3 mm forward of the intercuspation position.
Represents the smallest anterior change from the patient’s habitual intercuspation position that will
maintain the disc between the condyle and eminence .

 Indication :
• Anterior Disc Displacement With Reduction when the disc displacement is thought to be the
source of pain.
• The disc can be reduced by moving the mandible only 2-3 mm forward of the IC position
• The use of stabilization splint has not reduced pain symptoms .
• For patients with Retro-discitis .
 Drawbacks :
• Creation of a posterior or lateral open bite .
ANTERIOR BITE PLATES
• A hard acrylic – resin appliance placed in the maxillary arch and has a bite platform that
provides contact only with the mandibular anterior teeth .
Aim :
• To disengage the posterior teeth in order to eliminate their role in masticatory function .
• To alleviate Masticatory Muscle Pain .

POSTERIOR BITE PLATES
 Posterior Bite Plates - Decompression splint.

 Used to decompress the TM joint and reduce
overloading .
 Indicated in cases of Articular pain & symptoms
related to an inflammation localized in the TMJ area.
 Very effective in Acute ADD Without Reduction .
Drawbacks:
 Long-term use of this partial coverage splints may encourage the development of posterior
open bite .
SOFT RESILIENT SPLINTS
 For temporary relief for patients in acute distress due to injury or severe muscle spasm .
 To protect dental and TMJ structures against traumatic injury during contact sports .
Disadvantages:
 Difficulty in adjusting and polishing the appliance .
 Can be easily perforated .
 Ineffective in treating bruxism because the resiliency of the material stimulated the patient to
clench on the appliance. Example - Aqua Splint
The Weaning Process:
 When Symptoms Have Been Significantly Reduced or Patient is Asymptomatic for a Minimum of
3 Months ,Discontinue the splint use in a gradual Manner i.e., Stop Daytime Use , Then Stop
Nighttime Use .
PIVOT APPLIANCES
 The pivoting appliance is constructed with hard acrylic resin that covers either the maxillary or
mandibular arch and incorporates a single posterior occlusal contact in each quadrant.
 This contact is placed as far posteriorly as possible. The purpose of this design is to reduce
intra-articular pressure by condylar distraction as the mandible “fulcrums” around the pivot,
resulting in an “unloading” of the articular surfaces of the joint.
 This appliance was recommended for patients with internal derangements and/or osteoarthritis.
 Due to the design and force vectors created by this appliance, a potential adverse effect with its
use may be occlusal changes manifesting as a posterior open bite where the pivot was placed.
Srivastava R, Jyoti B, Devi P. Oral splint for temporomandibular joint disorders with revolutionary fluid system. Dent Res J
(Isfahan). 2013;10(3):307-313.
(Isfahan). 2013;10(3):307-313.
HYDROSTATIC APPLIANCE
 This unique appliance was designed by Lerman.
 In its original form, it consisted of bilateral water-filled plastic chambers attached to an acrylic
palatal appliance, and the patient's posterior teeth would occlude with these chambers.
 Later this was modified to become a device that could be retained under the upper lip, while
the fluid chambers could be positioned between maxillary and mandibular posterior teeth.
AQUALIZER
 Use of Aqualizer is indicated in TMJ pain, headache, neck and shoulder pain and stiffness,
orthodontic-triggered muscle pain during treatment, pre-surgical differential diagnoses, post-
surgical pain and inflammation.
 Aqualizer has flexible fluid layer that equalizes all bite forces by preventing tooth to tooth
contact.
 The Aqualizer has unique water system that immediately optimizes biomechanics, supports the
jaw in a comfortable position, removes the teeth from dominance, placing bite and body in
harmony.
 It straightens the bite to maximize other structures, enables systemic function and balance,
allows the body to naturally balance itself, finds perfect occlusal balance after starting the
treatment immediately.
(Isfahan). 2013;10(3):307-313.
 Aqualizers are available in three different vertical dimensions: Low, medium, and high .
 The amount of fluid in the Aqualizer controls the vertical dimension (thickness).
 Medium volume aqualizers are used in most of the cases. Low volume aqualizers are indicated
in the patients with inadequate freeway space or those sensitive to anything in their mouths.
 High volume aqualizers are used when a patient has excessive freeway space or needs a greater
vertical dimension to fill the space between the upper and lower occlusal surfaces.
 Aqualizer is available in two basic models that are ultra and Mini. The ultra is a new improved
version designed for increased gum comfort and improved retention.
 It is used for average size mouths. The Mini is the new improved ultra shape with smaller pads
and arch size. It is used for kids and small adult mouths.
(Isfahan). 2013;10(3):307-313.
METHOD OF USE:
a) Instruct the patient to keep the fluid pads between the posterior teeth .
b) The patient should relax and rest their teeth against the fluid pads while swallowing.
c) It is not desirable to clench. Ask the patient to be aware of any change in sensation anywhere
in the head, neck, shoulders, and upper back.
d) Monitor the patient's symptoms in every 5-10 min for 30-40 min.
e) Pain relief confirms the diagnosis. Relief of pain usually occurs within 5-10 min after insertion
of the Aqualizer, particularly in the episodic sufferer.
(Isfahan). 2013;10(3):307-313.
f) Instruct the patient to wear the Aqualizer continuously for the next 48 h, except when eating
or brushing teeth.
g) At the end of this period, re-examine the patient. If the patient's bruxism improves after
wearing the bite splint, occlusal treatment is indicated.
h) If the patient's symptoms do not improve significantly, they are most likely not occlusal in
origin and occlusal treatment alone is unlikely to be successful.
i) Patients should not exceed 8 h of Aqualizer wear per 24-h period.
(Isfahan). 2013;10(3):307-313.
RA.DI.CA. SPLINT AND ITS COMPONENTS.
 A heat-cured acrylic resin upper plate (1),
 A heat-cured acrylic resin lower plate (2),
 An anterior hinge (3),
 Two vestibular springs made with orthodontic wire (4),
 Two or more Adams clasps and/or two ball clasps (5),
 A vestibular steel arch .
 The upper plate has two surfaces. The inner one also called “occlusal/palatal” adapts to the
masticatory surfaces of the upper teeth and with the anterior 2/3 of the palatal vault.
 The outer one is smooth and faces the lower plate. Two Adams clasps are placed on teeth 16 and
26 and the ball ones are placed in the interdental space of 14–15 and 24–25.
Di Paolo C, Falisi G, Panti F, Di Giacomo P, Rampello A. "RA.DI.CA." Splint for the Management of the Mandibular Functional
Limitation: A Retrospective Study on Patients with Anterior Disc Displacement without Reduction. Int J Environ Res Public
Health. 2020 Dec 4;17(23):
 The upper plate plays a stabilizing role, having a double mucous and dental anchorage.
 The lower plate, also shaped like a horseshoe, has two smooth surfaces. One is in contact with
the outer surface of the upper plate and the other one with the masticatory surfaces of the lower
teeth.
 The two plates are connected to each other by a front hinge placed at the incisor level and by
two (left and right) vestibular springs, connected in the canine-premolar site, in order to give
an elastic resistance to the lower plate during the functional movements of mouth closure.
 The springs can be hard or soft according to the characteristics of the patient. The functional
action is carried out through a “pushing” mechanism at the level of the posterior area of the
lower dental arch, which induces a downward and forward movement of the mandibular
condyle.
Health. 2020 Dec 4;17(23):
Application Protocol of RA.DI.CA Splint:
 The management protocol included progressive phases which modified the duration of daily
application of the occlusal splint, up to a minimum use.
 It lasted not less than 6 weeks and no more than 24 months.
 In general, at the end of therapy with the RA.DI.CA. splint, the patient is evaluated again, in
order to establish the need to replace this kind of splint with other ones, such as DI.TRA
(Direct Tridimensional Repositioning Appliance) or Michigan splint .
 In this phase, the rationale was to guide the stabilization of the functional outcome.
Health. 2020 Dec 4;17(23):
UNIVERSAL NEUROMUSCULAR IMMEDIATE RELAXING APPLIANCE
(UNIRA BY RAMPELLO)
 The design of the UNIRA is the result of a combination of clinical considerations associated with
the following technical prerequisites: small dimensions and reduced trauma, good comfort, easily
managed, and low economic and biological cost.
 The UNIRA is made of some parts that are considered active and others that have a prevailing
“stabilizing” action. The so-called active parts are:
1) Two lateral genal shields that are vertical and symmetric, and have a right- and left-of-oval form
2) Two interocclusive levels with a roughly triangular form, but with round angles; also right and left
symmetric
3) Palatal arch linking the two horizontal, triangular, occlusive levels passing near the palatal vault
The stabilizing parts are:
1.An arched string connecting the two lateral shields placed in the vestibular fornix inferior and front.
2.Two small vertical and semilunar wings that are detachable at the lower part in a right angle from
the two occlusive horizontal levels, encircling the mouth on the molar and premolar teeth
The therapeutic protocol for our study of the UNIRA splint was as follows:
1.The splint was applied for a minimum of 1 night, followed by rest to a maximum of 12 h/day
(including night and rest) for patients with intense pain.
2.For all patients, the UNIRA splint was only used as therapeutic aid .
3.The maximum period of treatment was fixed at 4 months.

ANTERIOR REPOSITIONING APPLIANCE (ORTHOPEDIC
REPOSITIONING APPLIANCE BY FARRAR)
 The intent of this appliance, is to alter the maxillomandibular relationship so that a more
anterior position assumed by the mandible.
 Acrylic guiding ramp added to the anterior third of the maxillary appliance that direct the
mandible into a more forward position, upon closing.
 This type of appliance designed to be used in treating patients with anterior disk displacement
with reduction.
 It was supposed that by altering the mandibular position in this manner, the anteriorly
displaced disks could return back to its normal position (recaptured), to stabilized condyle-disk
relationship a new comprehensive dental or surgical occlusal procedures .
(Isfahan). 2013;10(3):307-313.
 With long term use of this appliance, there are permanent and irreversible occlusal changes.
 Therefore, the anterior bite plane appliance should be used with caution only for short periods
of time as a temporary therapeutic measure to relieve internal derangements pain.
TMJ AND ORTHODONTICS
Functional
appliance Increased
Supplementary
contractile
lengthening of
activity of the
mandible
LPM
Additional OPERATION OF
Intensification of
subperiosteal FUNCTONAL
repetitive activity
ossification of APPLIANCES of the retrodiscal
posterior border
pad
of mandible
Additional Increase in
growth of growth
condylar Change in stimulating
cartilage trabecular factor
orientation
Dentofacial orthopedics with functional appliances. Graber, T. M., Rakosi, T., & Petrovic, A. G. (1997).
GROWTH RELATIVITY HYPOTHESIS:
 John C Voudouris gave the concept of Growth
relativity.
 It refers to growth that is relative to its displaced condyles
from actively relocating fossae.
 John C Voudouris introduced this concept to explain the
possible effect of functional appliances on condyle and the
resulting growth.
 The main foundations of growth relativity hypothesis are:
 Displacement of condyle
 Nonmuscular viscoelastic tissue stretch
 Force transduction beneath the fibrocartilage of the glenoid
Displacement of Condyle:
 The displacement that takes place initially following mandibular advancement affects the
fibrocartilagenous lining in the glenoid fossa to induce bone formation locally.
Viscoelastic Stretch:
 Once the condyle is displaced, it is followed by the stretch of nonmuscular viscoelastic tissues.
 Viscoelasticity addresses the viscosity and flow of the synovial fluids, the elasticity of the
retrodiscal tissues, the fibrous capsule and other nonmuscular tissues including LPM, perimysium,
TMJ tendons and ligaments, other soft tissues and bodily fluids.
 Due to viscoelastic stretch there is influx of nutrients and other biodynamic factors into the region,
through engorged blood vessels of the stretched retrodiscal tissue that feed into the fibrocartilage of
the condyle..
Voudouris JC, Kuftinec MM. Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and
fossa in treatment and long-term retention: growth relativity. Am J Orthod Dentofacial Orthop. 2000 Mar;117(3):247-66.
Force Transduction and New Bone Formation:
 The glenoid fossa and the displaced condyle are both influenced by the articular disk, fibrous
capsule and synovium which are contiguous.
 Thus condylar growth is affected by viscoelastic tissue forces through attachment of the
fibrocartilage that covers the head of the condyle.
 Effect of three growth stimuli (Displacement + viscoelasticity + transduction of force).
 Voudoris and Kuftinec compares this process to the light bulb analogy .
 The resultant increase in new bone formation appears to radiate as multidirectional finger like
processes beneath the condylar fibrocartilage and significant appositional bone formation is
seen in the fossa.
Voudouris JC, Kuftinec MM. Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the
condyle and fossa in treatment and long-term retention: growth relativity. Am J Orthod Dentofacial Orthop. 2000 Mar;117(3):247-66.
LIGHT BULB ANALOGY OF CONDYLAR GROWTH AND RETENTION .
 When the growing condyle is continuously advanced, it lights up
like a light bulb on a dimmer switch. When the condyle is released
from the anterior displacement, the reactivated muscle activity
dims the light bulb and returns it close to normal growth activity.
 In the boxed area, the upper open coil shows the potential of the
anterior digastric muscle and other peri mandibular connective
tissues to reactivate and return the condyle back into the fossa
once the advancement is released.
 The lower coil in the box represents the shortened inferior LPM.
 The open coil above the yellow condylar light bulb represents the
effects of the stretched retrodiscal tissues.
HISTOLOGICAL CHANGES
 Rabie et al reported that mechanical strain caused by forward mandibular positioning
stimulated the cells of the chondroid layer in the glenoid fossa to secrete vascular endothelial
growth factor (VEGF), which was 220% more than its levels during natural growth.
 VEGF enhances the invasion of new blood vessels and the perivascular connective tissues
surrounding these new blood vessels are repository sites of mesenchymal cells.
 These cells could in turn replenish the population size of osteoprogenitor mesenchymal cells.
VEGF also stimulates the vascular endothelial cells to secrete growth factors and cytokines
that influence the differentiation of mesenchymal cells to enter the osteogenic pathway and
engage in bone synthesis.
D.G. Woodside, A. Metaxas, G. Altuna, The influence of functional appliance therapy on glenoid fossa remodeling, American Journal of
Orthodontics and Dentofacial Orthopedics ,Volume 92, Issue 3,1987
 On the other hand, the amount of VEGF expressed in the condyle in response to mandibular
advancement was only 48% more than natural growth.
 Therefore, it is conceivable that the significant difference in the response between the glenoid
fossa and the condyle is because of the ability of both tissues to vascularize to a different
degree in response to advancement .
 The ideal period for therapy with respect to the maximum mandibular growth stimulation and
long term stability of the treatment, is in the permanent dentition at or just after the pubertal
peak of growth corresponding to the skeletal maturity stages FG to H of the MP3 (implying to
the pre capping and pre union stages of the epiphysis and metaphysis).
D.G. Woodside, A. Metaxas, G. Altuna, The influence of functional appliance therapy on glenoid fossa remodeling ,American
Journal of Orthodontics and Dentofacial Orthopedics, Volume 92, Issue 3,1987
ONE STEP VERSUS STEPWISE ADVANCEMENT USING FIXED
FUNCTIONAL APPLIANCES
 Rabie et al’s work on experimental rats showed that during the first advancement ,bone
formation in the condyle and the glenoid fossa was less than that of the one step advancement .
 In response to the second advancement ,new bone formation in the condyle and the glenoid
fossa was significantly greater when compared with single advancement with a maximum
increase of 50% and 100% respectively.
 The amount of increase in bone formation in the glenoid fossa in response to stepwise
advancement when compared with single advancement was two times more than that
expressed in the condyle.
 Woodside and coworkers they showed that in older primates there was a more pronounced
response in the glenoid fossa than the condyle in mandibular advancement, whereas in the
younger primates there was a more pronounced response in the condyle.
 Additional explanation of the enhanced response of the glenoid fossa was found to be caused
by the amount of the blood vessels recruited in the glenoid fossa in response to advancement.
FIXED VS FUNCTIONAL APPLIANCE THERAPY
 A study was conducted by Christos Serbesis et.al to evaluate the effective temporomandibular
joint (TMJ) changes (the sum of condylar modeling, glenoid fossa modeling, and condylar
position changes within the fossa), and their influence on chin position in patients with a Class
II division 1 malocclusion treated orthodontically with a multibracket appliance and Class II
elastics (Tip-Edge) and orthopedically with a fixed functional appliance (Herbst).
 Materials and Methods: Two groups of successfully treated subjects were evaluated: Tip-
Edge (n = 24) and Herbst (n = 40). The Bolton Standards served as a control group. Lateral
head films obtained before treatment and after an observation period of 2.6 years (Herbst also
after 0.6-year period) were analyzed.
Serbesis-Tsarudis, C., & Pancherz, H. (2008). “Effective” TMJ and Chin Position Changes in Class II Treatment. The Angle
Orthodontist, 78(5), 813–818.
 Results: In comparison with the Herbst and control groups, the Tip-Edge group exhibited less
favorable sagittal “effective” TMJ growth and chin position changes necessary for skeletal
Class II correction.
 Conclusions: Orthodontic therapy with a multibracket appliance and Class II elastics seems

not to have any favorable sagittal orthopedic effect on the mandible, while bite jumping with
the Herbst appliance has a favorable sagittal orthopedic effect on a short-time basis.
Serbesis-Tsarudis, C., & Pancherz, H. (2008). “Effective” TMJ and Chin Position Changes in Class II Treatment. The Angle
Orthodontist, 78(5), 813–818.
REMOVABLE VS FIXED FUNCTIONAL THERAPY
 A cephalometric roentgenographic was conducted by Sandra Baltromejus et.al to evaluate
Effective temporomandibular joint growth and chin position changes: Activator versus Herbst
treatment.
 In 138 successfully treated Class II division 1 patients (40 Activator and 98 Herbst). Lateral
head films in habitual occlusion from before and after an average treatment period of 2.6 years
for the Activator patients and 0.6 years for the Herbst patients were evaluated.
 Two different treatment changes were assessed: (1) overall growth changes and (2) treatment
effects (overall growth changes minus age‐related normal growth values: Bolton Standards).
 The comparison between the Activator and the Herbst group revealed larger effective TMJ and
chin changes during Activator therapy due to the longer observation period (2.6 years versus
0.6 years).
Baltromejus, S. (2002). Effective temporomandibular joint growth and chin position changes: Activator versus Herbst treatment. A
cephalometric roentgenographic study. The European Journal of Orthodontics, 24(6), 627–637.
 The treatment effects showed marked group differences for both the amount and direction of
effective TMJ changes. The changes were vertical and slightly anterior in the Activator group,
and predominantly posterior in the Herbst group.
 Concerning the chin changes, the treatment effects for the Herbst group exceeded those for the
Activator group in both directions, caudally and anteriorly.
 The Activator group showed an anterior rotation and the Herbst group a slight posterior
rotation of the mandible.
 The investigation revealed that the effective TMJ and chin changes were increased by both
Activator and Herbst treatment. However, the Herbst appliance renders more favorable
sagitally orientated treatment effects in a much shorter period of time compared with the
Activator.
Baltromejus, S. (2002). Effective temporomandibular joint growth and chin position changes: Activator versus Herbst treatment. A
cephalometric roentgenographic study. The European Journal of Orthodontics, 24(6), 627–637.
EXTRACTION VS NON EXTRACTION ON TMJ
A study was conducted by Paul Major et.al to determine Condyle displacement associated with
premolar extraction and non-extraction orthodontic treatment of Class I malocclusion .
This study assessed condyle position change with premolar extraction and non-extraction
orthodontic treatment in Class I malocclusions.
Axially corrected pretreatment and posttreatment tomograms were obtained in 22 extraction and
13 non-extraction cases.
Tomographic images were randomized and blinded for joint space measurement.
A total of 27 linear anterior, superior, and posterior joint spaces were obtained from each
tomogram and averaged. Comparisons of pretreatment and posttreatment joint spaces between
groups were done.
Major, P., Kamelchuk, L., Nebbe, B., Petrikowski, G., & Glover, K. (1997). Condyle displacement associated with premolar
extraction and nonextraction orthodontic treatment of Class I malocclusion. American Journal of Orthodontics and Dentofacial
Orthopedics, 112(4), 435–440.
 Left and right anterior joint spaces were significantly increased during orthodontic treatment of
the non-extraction group.
 No other significant changes in condyle position were determined in either group. There were
no significant correlations between mean joint space changes with length of Class II elastic
wear.
 There was no significant difference in condyle position change with extraction space closure
using closing arch wires compared with elastic chain.
Major, P., Kamelchuk, L., Nebbe, B., Petrikowski, G., & Glover, K. (1997). Condyle displacement associated with premolar
extraction and nonextraction orthodontic treatment of Class I malocclusion. American Journal of Orthodontics and Dentofacial
Orthopedics, 112(4), 435–440.
ORTHODONTICS AND TMD
 The relationship between orthodontic treatment and temporomandibular disorders (TMDs) has
long been of interest to the practicing orthodontist.
 This interest in orthodontics and TMD in part was prompted in the late 1980s after litigation
that alleged that orthodontic treatment was the main cause of TMD in orthodontic patients.
 A research investigation was conducted by McNamara et.al to figure out the relationship
between orthodontic treatment and temporomandibular disorders. This resulted in an increased
understanding of the need for risk management as well as for methodologically sound clinical
studies.
 The findings of this research investigating the relation of orthodontic treatment and TMD can
be summarized as follows:
(1) Signs and symptoms of TMD may occur in healthy persons;

McNamara, J. A. (1997). Orthodontic treatment and temporomandibular disorders. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology, and Endodontology, 83(1), 107–117.
(2) Signs and symptoms of TMD increase with age, particularly during adolescence, until menopause,
and therefore TMDs that originate during orthodontic treatment may not be related to the treatment;
(3) In general, orthodontic treatment performed during adolescence does not increase or decrease the
chances of development of TMD later in life;
(4) The extraction of teeth as part of an orthodontic treatment plan does not increase the risk of TMD;
(5) There is no increased risk of TMD associated with any particular type of orthodontic mechanics;
(6) Although a stable occlusion is a reasonable orthodontic treatment goal, not achieving a specific
gnathologic ideal occlusion does not result in signs and symptoms of TMD; and
(7)Thus far, there is little evidence that orthodontic treatment prevents TMD.
McNamara, J. A. (1997). Orthodontic treatment and temporomandibular disorders. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology, and Endodontology, 83(1), 107–117.
CONCLUSION
 Temporomandibular joint & Masticatory muscles form the vital part of orofacial system
both structurally and functionally.
 As dental practitioners, we seldom examine the TMJ during routine examination.
 Though treating the cause is important, it’s also duty of a dentist to thoroughly examine the
patient, identify any underlying asymptomatic disorders.
 Educate and motivate the patient to take up preventive measures & early treatment to avoid
further symptoms that serve as precursors to TMJ disorders.
REFERENCES
 The anatomical basis of clinical practice . Gray's anatomy . Standring, S., & Gray, H. (2008).
41st Edition.
 Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition .
 Essentials of Oral Histology and Embryology: A Clinical Approach . Avery, J. K., & Chiego,
D. J. (2006).
 Management of Temporomandibular Disorders and Occlusion. Okeson J. 7th Edition. (2012).
 Oral Radiology: Principles and Interpretation. White, Stuart C, Pharoah M J. 7th Edition.
 Petersons Principles Of Oral And Maxillofacial Surgery. 3rd Volume. (2012).
 Dentofacial orthopedics with functional appliances. Graber, T. M., Rakosi, T., & Petrovic, A.
G. (1997).
 Voudouris JC, Kuftinec MM. Improved clinical use of Twin-block and Herbst as a result of
radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term
retention: growth relativity. Am J Orthod Dentofacial Orthop. 2000 Mar;117(3):247-66.
 D.G. Woodside, A. Metaxas, G. Altuna, The influence of functional appliance therapy on

glenoid fossa remodeling, American Journal of Orthodontics and Dentofacial
Orthopedics ,Volume 92, Issue 3,1987.
 Serbesis-Tsarudis, C., & Pancherz, H. (2008). “Effective” TMJ and Chin Position Changes in
Class II Treatment. The Angle Orthodontist, 78(5), 813–818.
 Baltromejus, S. (2002). Effective temporomandibular joint growth and chin position changes:

Activator versus Herbst treatment. A cephalometric roentgenographic study. The European
Journal of Orthodontics, 24(6), 627–637.
 McNamara, J. A. (1997). Orthodontic treatment and temporomandibular disorders. Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 83(1), 107–117.
 Major, P., Kamelchuk, L., Nebbe, B., Petrikowski, G., & Glover, K. (1997). Condyle
displacement associated with premolar extraction and nonextraction orthodontic treatment of
Class I malocclusion. American Journal of Orthodontics and Dentofacial Orthopedics, 112(4),
435–440.
 Temporomandibular Disorders .A Problem-Based Approach. Gray . Wiley J. (2011) .
 Wu, J.-H., Kao, Y.-H., Chen, C.-M., Shu, C.-W., Chen, C.-M., & Huang, I.-Y. (2013). Modified
mandibular splint therapy for disc displacement with reduction of the temporomandibular joint.
Journal of Dental Sciences, 8(1), 91–93.
 McNamara Jr JA, Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and
temporomandibular disorders: a review. Journal of orofacial pain. 1995 Jan 1;9(1).
 Srivastava R, Jyoti B, Devi P. Oral splint for temporomandibular joint disorders with
revolutionary fluid system. Dent Res J 2013;10(3):307-313.
 Di Paolo C, Falisi G, Panti F, Di Giacomo P, Rampello A. "RA.DI.CA." Splint for the

Management of the Mandibular Functional Limitation: A Retrospective Study on Patients with
Anterior Disc Displacement without Reduction. Int J Environ Res Public Health. 2020 Dec
4;17(23):
 Brooks SL, Brand JW, Gibbs SJ, Hollender L, Lurie AG, Omnell KA, et al. Imaging of the
temporomandibular joint: a position paper of the American Academy of Oral and Maxillofacial
Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(5):609–618.

TemporoMandibular Joint SEMINAR Nivi

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TEMPOROMANDIBULAR JOINT

1. Fibrous or fixed joints (Immovable)

2. Cartilaginous or Slightly moveable joints

3. Synovial or Freely moveable joints

 It’s a Synovial Joint of condylar variety.

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

 TMJ develops from two blastema :-

1. Temporal blastema arise from otic capsule.

• Two mesenchymal condensations occurs

• Condylar grows dorsolaterally

• Ossification of temporal blastema takes place

• Inferior joint cavity formation

• Differentiation of condylar into cartilage & Superior joint cavity

• Remnant of meckels cartilage - sphenomandibular ligament

• Full differentiation of all articular surfaces occurs by 4th fetal month

Neonatal TMJ Adult TMJ

Mandibular fossa Flat Concave

Articular eminence Absent Present

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

Anteriorly Posteriorly Externally

Tympanic plate Middle root of

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

 Its knob like form is wider latero-medially (20mm) than antero-posteriorly(8-10mm).

 Its long axis is in a lateral plane.

 Condyle is perpendicular to the ascending ramus of the mandible.

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

 In sagittal plane, the disk is divided into three regions:

i. Thicker anterior and posterior zones

 Posterior border is slightly thicker than anterior border.

 In normal TMJ, the condyle articulates in the intermediate zone.

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

Synovial fluid features:

• Ultra filtrate of blood plasma.

a. Nutrition of articular cartilage

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

MIDDLE AND DEEP FIBERS

 BLOOD SUPPLY: Masseteric artery .

 PP- posterior portion. Largest muscle of mastication.

 To locate the muscle the patient have to clench.

• Temporal tendonitis: - sharp headaches at temple joint.

Origin and Insertion :

Arterial supply: Pterygoid branch of Maxillary artery.

Nerve Supply: Mandibular nerve through the medial pterygoid.

Clinical Importance of Medial Pterygoid Muscle:

• Medial Pterygoid muscle can be palpated only intraorally

• Most commonly involved in MPDS

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

• Attaches the lateral

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

 These have vascular supply and are innervated.

 Passive movement with the condyle

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

• Inferiorly- Neck of the condyle.

• Functions- to encompass the joint and retains the fluid.

• They are well innervated and provides proprioceptive feedback.

Outer Oblique Inner Horizontal

From-outer surface From-outer surface Horizontally to-

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition

During trauma to the mandible ,effectiveness of this ligament demonstrated.

• Actions: no significant effect on limiting movements.

• Formed by thickening of deep fascia.

• Separates parotid gland from submandibular gland.

Human anatomy . B.D Chaurasia . Vol 3 . 5th Edition