TEMPOROMANDIBULAR JOINT

PRESENTED BY

NILESH TORWANE

CONTENTS
Introduction Development Gross Anatomy Mandibular condyle Cartilage and synovium Capsule Articular disc Ligaments Vascular And Nerve Supply Examination of TMJ Applied aspects Bibliography 

          

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INTRODUCTION 
    

Synonyms- craniomandibular joint / mandibular joint / articulatiotemperomandibularis joint. The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. Technically it is a ginglymoarthrodial joint. The TMJs are one of the only synovial joints in the human body with an articular disc. It is bilateral diarthroidial joint. Also considered as complex joint.

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Types of joint ±
according to tissue presentFibrous joint cartilageous joint- primary and secondary synovial joint- plane joint, hinge joint, pivot joint, condyloid joint, saddle joint, ball n socket joint

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DEVELOPMENT 

Approximately at 10th week, the components of the future joint become evident in mesenchyme between the condylar cartilage of mandibular bone and temporal bone. Two slit like joint cavities and an intervening disc make their appearance by 12 weeks. The mesenchyme around it forms fibrous capsule. The developing superior Head of lateral Pterygoid muscle attaches the anterior Portion of the fetal disc.  



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This connection is obliterated by growth of lips during development. The disc also continues posteriorly through the petrotympanic fissure and attaches to the malleus of the middle ear.  5 .

Gross Anatomy       Mandibular condyle Cartilage and synovium Capsule Articular disc Ligaments Vascular And Nerve Supply 6 .

Mandibular condyle      15-20 mm in width 8-10 mm in anteroposterior dimension Mandible articulates with the temporal bone by means of the articular surface of its condyles The condyle tends to be rounded mediolaterally and convex anteroposteriorly Structures form an approximately 145° to 160° angle to each other 7 .

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9 . which is filled with synovial fluid.Cartilage and Synovium     The inner aspect of TMJ containsArticular cartilage & Synovium The space bound by these two structures is termed the synovial cavity. The articular surfaces of both the temporal bone and the condyle are covered with dense articular fibrocartilage. Fibrocartilage covering has the capacity to regenerate and to remodel under functional stresses.

  A proliferative zone of cells present deep to the fibrocartilage and on the condyle. may develop into either cartilaginous or osseous tissue. Most changes resulting from function are seen in this layer 10 .

 Functions of the synovium.Phagocytosis .Lubrication .provide immunological response 11 .Provide nutrition .

It attaches to the articular eminence.attached in front of the crest of the articular eminence Posteriorly. the articular disc and the neck of the mandibular condyle. Anteriorly.Capsule      The capsule is a thin sleeve of fibrous tissue investing the joint completely.it extends medially along the anterior lip of the squamotympanic and petrotympanic fissure. Laterally. 12 .adheres to the edge of the articular eminence and fossa.

13 .- The articular capsule is strongly reinforced laterally by the temporomandibular (lateral) ligament.

The articular disc is a fibrous extension of the capsule in between the two bones of the joint. 14 . Superior surface is concavoconvex and inferior surface is convex. It divides the joint into two sections and attaches to the condyle medially and laterally. The disc is biconcave.Articular Disc       The unique feature of the TMJs is the articular disc. The disc functions as articular surfaces against both the temporal bone and the condyles.

  Anteriorly. disc is attached to the wall of glenoid fossa above and to the distal aspect of the condyle. disc is attached to articular eminence and capsule of the joint. This area is called as retrodiscal tissue. 15 . Posteriorly.

posterior band. .thickest and widest(3mm) .thinest band (1mm) 16 .intermediate zone.it is moderately thick (2mm) but narrow anteroposteriorly.anterior band. Rees in 1954 described three zones of the disc.

Ligaments   Composed of collagen and act predominantly as restraints to motion of the condyle and the disc. Lateral or Temporomandibular ligaments Accessory ligaments ²Sphenomandibular and Stylomandibular 17 . Types of ligaments Functional ligament ²Capsular ligaments.

Capsular Ligaments     Entire tmj is surrounded by capsular ligament Superiorly it is attached to temporal bone and mandibular fossa. 18 . Inferiorly to neck of the condyle They resists the lateral. medial and inferior forces.

It limits the anterior excursion of the jaw and prevents posterior dislocation so it is called as check ligament of tmj 19 .Temporomandibular (lateral) ligaments     It is a main stabilizing ligament located on the lateral aspect of each TMJ It runs downward and forward from articular eminence to posterior side of mandibular condyle.

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Sphenomandibular ligament    It is a flat band arising from sphenoid bone and petrotympanic fissure. It is a important landmark because maxillary artery and auriculotemporal nerve lies between it and mandibular neck. It runs downward and medial to tmj capsule towards lingula of mandible. 21 .

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Serves as a point of rotation and also limits excessive protrusion of the mandible 23 .thick band of deep cervical fascia extends from styloid process to the angle of mandible.Stylomandibular ligament   It is dense.

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anterior tympanic artery. ascending pharyngeal artery. mesenteric artery 25 . predominately the superficial temporal branch Other branches of the external carotid artery namely: the deep auricular artery. internal maxillary artery.Vascular Supply   Arterial blood supply is provided by branches of the external carotid artery.

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Nerve supply  Branches of the auriculotemporal nerve with anterior contributions from the masseteric nerve and the posterior deep temporal nerve 27 .

lateral pterygoid mainly Elevation.temporalis.posterior fibres of temporalis.medial petygoid of both sides.lateral and medial pterygoid. Retraction. Lateral or side to side movement.MUSCLE PRODUCING MOVEMENTS      Depression.masster. Protrusion.left lateral pterygoid and right medial pterygoid. 28 .

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30 - - - .patient is requested to slowly open and close the mouth while doctor bilaterally palpates pretragus depression with index fingers.CLINICAL EXAMINATION OF TMJ - Symmetry of the face should be recorded Look for any deviation of mandible The maximum interincisal opening of mouth should determined Lateral mandibular range of motion is determined by asking the patient to occlude the teeth and then slide the jaw in both directions (normal 10mm) Pretragus palpation.

31 . clicking and crepitus. Intra-auricular palpation is done by inserting small finger into ear canal and pressing anteriorly to detect tenderness.

The Jaw And Joint Symptoms Should Be Discussed With Patient     Does TMJ click or pop on opening or closing? Has the jaw ever locked or dislocated on opening? Has there been limitation in the movement or deviation of the lower jaw on opening? Has the patient experienced pain and dysfunction in other joints of the body? 32 .

Both physical and psychological stress can produce abnormal pressure on the TMJ disc causing TMJ disorders. Malocclusion Stress.        Causes for TMJ disordersOpening the mouth too wide Bruxism. Trauma Any injury that results in bleeding into the joints can even cause Ankylosis of the jaw. Arthritis Hypermobility 33 .

3. snapping. crunching.) 34 . 2. Noises in the joints associated with jaw movements (clicking. Intermittent ³locking´ episodes. Pain in the joints associated with jaw movements. Limited range of vertical mouth opening 4. etc.Symptoms associated with TMJ disorders PRIMARY SYMPTOMS 1. Facial pain and muscle fatigue 5.

disorientation 5. Earaches 2. Frequent headaches 3. Neck/shoulder pain 4. Depression 35 . Sensitive teeth 6.SECONDARY SYMPTOMS 1. Dizziness.

myositis 36 .Masticatory muscle spasm Problems resulting from extrinsic trauma.Classification of temporomandibular disorders    Extrinsic disorders Masticatory muscle disorders.tendonitis .traumatic arthritis .Masticatory muscle inflammation .fracture .

anterior disc displacement with reduction .infectious arthritis  37 .Intrinsic disorders Trauma.intracapsular fracture .rheumatoid arthritis .extracapsular fracture Internal disc displacement.due to .due to .dislocation .anterior disc displacement without reduction Arthritis .juvenile rheumatoid arthritis .

condylar hypoplasia .condylar hyperplasia  38 . Ankylosis Developmental defects .condylar agenesis .bifid condyle .

1 % cases It can be unilateral or bilateral .Have a look at some temperomandibular disorders    Temperomandibular joint Dislocation It is uncommon and incidence is recorded in 3.

A.Management of the tmj dislocation- - First attention is given to reduce the tension. This is achieved byReassuring the patient Use of sedative drugs Pressure and massage to the area Manipulation without L. 40 . under general anesthesia with muscle relaxants. with L. anxiety and muscle spasm.A.

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Myofacial pain ‡ Symptoms ± Regional pain in area of masseter or temporalis muscles ± toothache. tension-type headache ± Fatigue with chewing ± May have limited mandibular function secondary to pain 42 .

partial or complete 43 .extra articular or intra articular .Ankylosis    Ankylosis is the stiffening (immobility) or fixation (fusion) of the joint. . Classification-true or false ankylosis.fibrous or bony .unilateral or bilateral .

etc. infection. depressed fracture of the zygomatic arch. True bilateral congenital ankylosis of the TMJ leads to micrognathia or ³bird face´ 44 . scarring from surgery. irradiation.  False ankylosis may be caused by enlargement of the coronoid process.

It associates with congenital syndromes Occurs as a result of trauma. 45 .Condylar agenesis    Condylar agenesis is the absence of all or portions of the coronoid process. infection or radiation.ramus and mandibular body.

Condylar hypoplasia   Condylar hypoplasia may be congenital. 46 . The most common facial deformity is shortness of the mandible with deviation of the chin towards the affected side. but is usually the result of trauma or infection.

The chin is deviated towards the unaffected side. unilateral overgrowth of the mandible.Condylar hyperplasia   An idiopathic disease characterized by a progressive. 47 .

Friction massage and hot fermentation consists of rubbing or keeping a hot towel Transcutaneous electrical nerve stimulation involves using a device that stimulates the nerve fibers that do not transmit pain. 4. Physiotherapy. to relieve the stresses and pressures 3. etc. Fabrication and insertion of an intra-oral splint. Avoid wide opening of the mouth 2. ultra-sound.NON-SURGICAL TREATMENT 1. Adjunctive medications anti-inflammatory & muscle relaxants 48 . These include exercises. rehabilitation programs.

etc. Stress Management 6. orthodontic treatment. 8. Injections of local anaesthetic and other medications. 7. replacement of missing teeth. Treatment of any underlying systemic disease that could have caused this problem. May include adjustment of the dental occlusion. Correct any discrepancies between the upper and lower jaws. 9. 49 .5. A person with osteoarthiritis in a temporomandibular joint needs to rest the jaw as much as possible.

gap Arthroplasty .Interpositional arthroplasty .Condylectomy.  ARTHROSCOPY  Artificial replacement of the joint  50 .SURGICAL TREATMENT ARTHROCENTESIS  ARTHOTOMY .

CBS publications.Human anatomy vol 3.elesvier publications. Richard .REFEERANCENCES     B.wogl(2005). D.Textbook of oral medicine. 5th edition.GRAYS ANATOMY. jaypee publications. 4th edition. Jeffry .wayne. Anil Govindrao Ghom(2007).1st edition. Okenson.L. 1st edition reprint 51 . MANAGEMENT OF TMJ DISORDERS AND OCCLUSION. Chaurasia(2005). Drake.P.

Textbook Of Human Embryology. the free encyclopedia en. Singh(2005). I.wolters kluwer(india). 8th edition. 52 .wikipedia. Diarthrodial .org/wiki/Diarthrodial Google images.1st edition. Snell(2008)Clinical Anatomy by Regions. Textbook of Oral And Maxillofacial Surgery.     Neelima Anil Malik(2005). B.1st edition Richard s.jaypee publications.jaypee publications.Wikipedia.

THANK YOU! 53 .