TemporoMandibular

Joint
by tsegaye.s(DMD)

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DEFINTION OF TMJ

 The temporomandibular joint (TMJ) also known as

craniomandibular joint
 Its the articulation between the squamous part of the
temporal bone and the head of the condyle.
 TMJ is a diarthrodial joint.
 The temporomandibular joint is a synovial joint that
connects the mandible to the temporal bone.
 Because these joints are flexible, the jaw can move
smoothly up and down and side to side, enabling us to
talk, chew and yawn.
 Muscles attached to and surrounding the jaw joint
control its position and movement. 2
TMJ ARTICULATION CONSISTS OF
 mandibular or glenoid fossa
 Articular eminance

 Condyle

 Separating disk

 Joint fibrous capsule

 Extra capsular check ligament

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MANDIBULAR FOSSA
 concave structure extending from the posterior slope of
the Articular eminence to the postglenoid process.
 Lined by a dense fibrous avascular fibro-cartilag.

The Articular eminence

Small prominence of zygomatic arch.
major functional component of the TMJ.

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CONDYLE
 The mandibular condyle is approximately 13-25 mm
mediolaterally and 5.5- 16 mm in anteroposterior
dimension.
 Articular part of the condyle is coverd by
fibrocartilagous tissue and not hyaline cartilage.

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SEPARATING DISK
 The articular disk divides the joint into two
compartments.
 lower/inferior compartment:-between condyle and disk.

 Upper/superior compartment:-between disk and glenoid

fossa.
FUNCTION
 Promote lubrication
 Promote energy absorption

 Promote range of motion

 Act as shock absorber

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JOINT CAPSULE
 Funnel shaped
 Attached

above-ant.articular eminance
Posteriorlly- squamotympanic fissure
Below-neck of Condyle
 Lined by synovial membrane which create synovial
fluid.

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SYNOVIAL FLUID
 Ultrafilterate of blood plasma + musin
 Composed of hyaluronic acid

 Function-

• nutrition
• phagocytosis

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 LIGAMENTS
Tempromandibular ligament
 extend from articular eminance to condylar neck.

 It reinforced TMJ capsule

 Limit anterior excrusion and posterior dislocation.

Accessory ligament
 Stylomandibular

 sphenomandibular

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BLOOD SUPPLY
► Arterial supply:
 Superficialtemporal artery,
 post. Auricular a.
 branch of maxillary artery
 Deep auricular a.
 massetric a.

► Venous drainage:
► venous plexus around capsule

NERVE SUPPLY
Mandibular nerve:
 Auriculotemperal branch
 Masseteric branch
 Post. deep temporal branch
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
MOVEMENTS
► Depression:-

Digastric, sternohyoid, geniohyold, lateral pterygoid

muscle
► Elevation:
Masseter, temporalis, medial pterygoid
► Protrusion:
Medial and lateral pterygoid
►Retrusion:

Temporalis, masseter, digastric, geniohyoid

►Lateral Excursion:
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Medial and lateral pterigoid
TEMPOROMANDIBULAR
JOINT DISORDERS

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TMJ DISORDERS
 Tempromandibular disorders (TMD) is a term used to
describe a group of problems involving the TMJs ,
muscles, tendons, ligaments, blood vessels, and other
tissues associated with them.
 It is the most common cause of facial pain after
toothache.
 TMD broadly classified into 2 syndromes:

 (1) muscle-related TMD (myogenousTMD),sometimes

this is called TMD 2ry to myofacial

pain and dysfunction (MPD)
 (2) joint-related (arthrogenous)TMD. 14
 EVALUATION
-History
-Examination

A. Extraorally
1.Symmetry
2.Deviation
3.Muscular hypertrophy
4.Masticatory muscles palpation
5.TMJ examination
Tenderness
Sounds
Range of movement
B-INTRA ORALLY

 Odontogenic source of pain

 Wear facets

 Mobility

 Soreness
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 Dental & skeletal classification (Occlusion)
 PREAURICULER EXAM.

INTRAAURICULER EXAM. PREAURICULER EXAM.

MASSETER EXAM TEMPORALIS EXAM 16

RADIOGRAPHIC EVALUATION

 1.panoramic radiography
 2.tomograms
 3. transcranial
 4.TMJ arthrography
 5.MRI
 6.nuclear imaging

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CLASSIFICATION OF TMJ DISORDERS
 Developmental
 Limitation of movement
 Myofascial pain dysfunction (MPD)
 Internal derangement
 Degenerative Joint Diseases (DJD)
 Systemic arthritis conditions

Effusion
 TMJ dislocation (open lock)
 Neoplasia

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 DEVELOPMENTAL
 A-Condylar hypoplasia or aplasia
 - unilateral:- cause facial asymmetry and devation of mandible
to the affected side during opening.
 - bilateral (treacher Collins' syndrome)
 Treated by rib grafts.

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 B-CONDYLAR HYPERPLASIA

 uncommon
 usually unilateral
 Asymmetry, deviation to the opposite side
 crossbite
 not painful

treatment
 if diagnosed in active phase
 Intracapsular condylectomy.
 if growth ceased
 corrective osteotomy.

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 LIMITATION OF MOVEMENT
Temporal limitation (trismus)
Causes:
 Inflammation in or near the joint
 Pericoronitis
 Cellulitis
 Abscess (submassetric)
 osteomyelitis
 Mandibular block injection ….. irritation , infection or
hematoma.
 Injuries/truma
 Tetanus and tetany

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 PERMANENT LIMITATION (ANKYLOSIS)
 A-Intracapsular Ankylosis:-
 fusion of condyle,disk and fossa complex as a result of fibrous
tissue, bone or both.
1-Fibrous Ankylosis (Adhesion):-
occurs in superior joint cavity between disk and eminence, it
may occur in inferior space.
 Diagnosis: anterior disk displacement without reduction
 R/F : MRI shows fibrosis in disk space
C/F
 no pain
 deviation on opening
 limited mouth opening
 no joint sound

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 2) BONY ANKYLOSIS
 union of bones of TMJ
 complete immobility

C/F
 no pain
 marked deviation to affected sides
 marked limitation of mouth opening
 no joint sounds
 could be uni or bilateral (severe retrognathia )

R/F:
 bone proliferation

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 ETIOLOGY:
 Trauma:-
 intracapsular Communated # of condyle
 penetrating wounds
 forceps delivery
 Infection:
 - otitis media
 - osteomyelitis
 - pyogenic arthritis
 Juvenile arthritis
 Neoplasm --- chondroma
 Paget’s disease

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TREATMENT:
 Mobilizingthe existing joint, may need to section the
coronoid process and reshaping of condylar head.

 Falsejoint lower down in the mandible (condyler neck

or ascending ramus)

 Total
joint replacement by alloplastic or autogenous
implant (costochondral)

 Active physiotherapy following surgery

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B. EXTRACAPSULAR ANKYLOSIS
 coronoid process hyperplasia
 trauma to zygomatic arch
 infection around temporalis muscle
 oral submucous fibrosis
 systemic sclerosis
 fibrosis due to burn or irradiation

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MYOFASCIAL PAIN DYSFUNCTION SYNDROME
 The most common cause of masticatory pain & limited
function.
 Its a pain disorder in which unilateral pain is referred
from trigger points in myofacial structure of head and
neck.
 The source of pain is muscular.

Etiology
 Psycogenic cause

 Oral habit :- pipe smoking,teeth clenching and

grinding,nail biting,pen biting,toung thrusting.
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 Occlusal disharmony
 C/F:

 Females > males (4:1)

 2nd- 3rd decades
 pain or discomfort in head and neck.
 Muscle tenderness
 Absence of tenderness in the joint
 Limited movement and deviation to affected side
 Joint noise :- clicking
 Headache

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MANAGEMENT:
 Reassuranse
 Conservative treatment
 Analgesics
 Muscle relaxants
 Physiotherapy

 Correction of occlusal
disharmony, splints
 Psychological counselling

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 TMJ DISLOCATION (OPEN LOCK)
excursion of condylar head beyond anterior slope of articular
eminence.
Classifiction
 acute dislocation

 chronic recurrent dislocation

 unilateral

 Bilateral

 Subluxation /incomplete dislocation/

History
 Maximum mouth opening
 Trauma
 Previous dislocation 30
ACUTE DISLOCATION
Clinical feature
 unilateral or bilateral

 Unilateral

 difficulty of mastication, swallowing and speech.

 Deviation of the chin toward contralateral side.

 Mouth is partial open

 Depression in front of tragus

 Affected condyle cannot be palpated

 Lateral cross bite

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BILATERAL
 Pain in temporal region
 Inability to close mouth

 Tenderness of masticatory muscle

 Excessive salivation

 Protruding chin

 Anterior open bite

 Muscle spasm

 Drooling saliva

 Mandibular movement restricted.

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 CAUSES
 1.extrnisic cause
 blow on the chin while the mouth is opening
 Injudicious use of mouth gag during GA.
 Excessive pressure on the mouth.
 2.internsic or self induced cause
 Excessive yawning
 Vomiting
 Singing and laughing loudly
 Opening mouth too wide for eating

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R/F:
condyle will be anterior and superior to the articular eminence.

Complications of dislocation

# condyle
Infection :osteomyelitis
Massive edema
Injury to external carotid artery and
facial nerve
Interposition of soft tissue

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MANIPULATION PROCEDURE
• Patient should be given assurance and asked to relax
completely
• LA is injected into glenoid fossa. This will eliminate
pain and spontaneous reduction
 Stand in front of patient and grasp mandible with both
hands. Thumbs are covered with gauze. As sudden
reduction can trap the thumbs. Thumbs are placed on
occlusal surface of lower molars and finger tips are
placed below chin. Exert downward pressure on
posterior teeth to depress jaw and at the same time
upward and backward pressure with fingertips
Complication of reduction
 Iatrogenic condyle #
 Human bite
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CHRONIC RECURRENT DISLOCATION
 Its repeated episode of dislocation where there is
abnormal anterior excursion of the condyle beyond
articular eminence, but patient is able to manipulate back
into normal position.
Predisposing factor
 Ligament and capsular flaccidity.

 erosion and flattening trauma.

 may precipitate by Yawning, vomiting and laughing.

 It also seen in severe epilepsy teacher speakers and

musician.
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MANAGEMENT
 Intermaxilary fixation or limiting oral opening by elastic.
 Total immobilization of jaw for 3-4 weeks

 Surgical procedure

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NEOPLASIA OF THE TMJ
 Usually rare
 Occurs from any structural component of the TMJ (condylar
head, articular fossae, disc, capsule, etc ….
 Benign neoplasms of the TMJ
 Osteochondroma
 Osteotoma
 Chondroma
 Fibromyxoma
 Giant cell lesions
 Chondromatosis
 Malignant neoplasms of the TMJ
 Chondrosarcoma
 Primary intrinsic malignant neoplasms
 Synovial sarcoma
 Fibrosarcoma
 Metastatic lesions 39
Thank you

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