1

Pre-natal and post-natal

development of mandible and TMJ

Presented By: Dr. Shraddha Patil

1st Year PG
Guided by: Dr. Rashmi Jayanna
Dr. Priyanka Razdan
Dr. Swapnil Mhatre
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Contents:
• Introduction
• Anatomy of Mandible
• Pre Natal Growth of the mandible
• Post Natal Growth of the mandible
• Age Changes in Mandible
• Clinical significance
• Developmental Anomalies of mandible
• Anatomy of TMJ
• Pre Natal Growth of TMJ
• Post-Natal Growth of TMJ
• Developmental Anomalies of TMJ
• Review of literature
• Conclusion
• References
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Introduction:

Growth:

 An increase in size -Todd

 Quantitative aspect of biological development per unit of
time -Moyers
 Change in any morphological parameter which is
measurable -Moss

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Development:

 Progress towards maturity -Todd

 Development refers to all the naturally occurring

unidirectional changes in the life of an individual from its
existence as a single cell to its elaboration as a
multifunctional unit terminating in death. - Myores

5
 Growth and development of an individual can be divided
into pre-natal and post-natal periods.

 Prenatal period is a dynamic phase where, growth occurs

at a higher rate when compared to post natal growth.

 Among facial bones, mandible undergoes largest amount

of growth post natally and exhibits large variability in
morphology.

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 7

Periods of growth:

1)Period of ovum- 2) Period of embryo- 3) Period of fetus-

 Also called as pre-
 14-56th day of intra-  56th day of IUL-
embryonic period.
uterine life. birth
 Fertilization to 2  Major development  Accelerated growth
weeks. of facial and cranial of craniofacial
 Attachment of region. structures.
ovum to intra
uterine wall.
ANATOMY OF MANDIBLE

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 Mandible
 Body

Surfaces:

External/ Outer-symphysis menti,

mental protuberance, mental
foramen, oblique line, incisive
fossa
Internal/ Inner- mylohoid line,
submandibular fossa, sublingual
fossa, superior and inferior genial
tubercles, mylohoid groove
Borders:

Superior/Alveolar

Inferior/ Base 9
 Two Rami
Surfaces

Lateral/ External- flat and

bears a number of oblique
ridges
Medial / Internal- mandibular
foramen, lingula, mylohyoid
groove
Processes

Condyloid

Coronoid

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Borders

Anterior-thin

Posterior-thick

Superior-thinand forming
mandibular notch
Inferior-backward
continuation of base of
mandible

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 Attachments and relations of mandible

• Oblique line – Buccinator muscle

• Oblique line below mental foramen – Depressor
labii inferioris , Depressor anguli oris
• Lateral side of ramus – Masseter muscle
• Lower border – Platysma
• Midsurface of coronoid – Temporalis
• Incisive fossa – Mentalis

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• Posterior superior part of lateral surface-
Parotid gland
• Lingula – Sphenomandibular ligament
• Pterygoid fossa – Lateral pterygoid muscle
• Mylohyoid line – Mylohyoid muscle
• Posterior end of the mylohyoid line –
Superior constrictor muscle
• Digastric fossa – Anterior belly of digastric
• Genial tubercle – Genioglossus & Geniohyoid

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Pre-natal growth of mandible

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 Start about the 4th week of intra-uterine life.

 Developing brain & the pericardium form 2

prominent bulges on the ventral aspect of the
embryo separated by stomodeum.

 The floor of the stomodeum is formed by the

buccopharyngeal membrane, which separates it
from the foregut.

 Mesoderm of foregut arranged in form of six bars

that run dorsoventrally in the sidewall of the
foregut. These are called Pharyngeal arches. 15
 Each of these 5 arches contain:

1. Central cartilage rod that

forms the skeleton of the
arch.

2. Muscular components
termed as branchiomere.

3. Vascular component.

4. Neural element

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 First pharyngeal arch called Mandibular
Arch.

 At this stage Mandibular arch forms the

lateral wall of the stomodeum

 Mandibular arch gives off a bud from its

dorsal end - maxillary process

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 Maxillary process grows ventromedial
cranial to the main part of the arch -
mandibular process

 Mandibular processes of both sides fuse in

the midline.

 Forms lower border of the stomodeum i.e.

lower lip & lower jaw.

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Meckel’s cartilage:

 Derived from the first branchial arch on

41th- 45th day of I.U.L

 Provides a template for subsequent

development of the mandible.

 Extends from cartilaginous Otic capsule to

Symphysis.

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 Most cartilaginous substance disappears during growth and
remaining part develops into –

1. The mental ossicles

2. Incus and malleus

3. Spine of sphenoid bone

4. Anterior ligament of malleus

5. Spheno-mandibular ligament

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Ossification of Meckel’s cartilage
Mandibular div. of trigeminal nerve precedes ectomesenchymal
condensation, inducing osteogenesis by production of neurotropic factors

Ossification center for each half of the mandible arises in the 6th week of
IUL in the region of the bifurcation of the inferior alveolar nerve into
mental & incisive branches.

Ossifying membrane is located lateral to the Meckel’s cartilage.

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Ossification spreads below & around the inferior alveolar nerve & upwards
to form trough for accommodating the developing tooth buds.

Spread of the intramembranous ossification dorsally & ventrally forms the

body & ramus of the mandible.

Ossification stops dorsally at the site that will become future mandibular
lingula from where meckel cartilage continue into the middle ear.
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Endochondral bone formation:

 Seen in 3 areas of the mandible –

1. The condylar process

2. The coronoid process
3. The mental region

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Condylar process:

• About 5th week of I.U.L. seen as mesenchymal

condensation above the ventral part of developing
mandible.
• About 10th week develops into cone-shaped cartilage
• Ossification starts at 14th week of IUL & the first
evidence of endochondral bone appears in the
condyle region.

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• By 4 months migrates inferiorly and fuses with ramus.
• 4th month onwards replaced by bone but proximal end
persists into adulthood acting as:
i. Growth cartilage
ii. Articular cartilage
• Condylar head separated from temporal bone by thin
disc of connective tissue – future articular disc

Brings changes in the mandibular position and form

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26
Coronoid process:

 Appear in the region of the coronoid process by about 10-

14 week of IUL.

 Develop within temporalis muscle.

 Incorporated into intramembranous bone of ramus.

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Mental region:

 1 or 2 small cartilages appear & ossify in the 7th month of

I.U.L to form mental ossicles on either side of symphysis.

 It gets incorporated into intramembranous bone when

symphysis ossifies completely during the first year of post-
natal life.

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Post-natal growth of mandible

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 Postnatal period starts from
birth to 20 years of age.

 Mandible undergoes the largest

amount of growth and variability
in morphology post-natally.

 Developmentally and
functionally divisible into several
skeletal subunits- body, condyle,
coronoid, and chin.

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Neonatal Mandible

 Ascending Ramus low and wide

 Large Coronoid process and poorly developed

condyles

 Body – open-shell containing tooth buds and

partially formed deciduous teeth

 Mandibular canal that runs low in the body

 The angle of the mandible is about 175⁰ with

condyle nearly in line with the body.
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Mandibular Growth During First Year

Appositional growth especially active at:

 Alveolar border
 Distal and superior surface of ramus
 Condyle
 Lower border of the mandible
 Lateral surface of the mandible

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 After first-year growth becomes more selective, condyle shows
considerable activities, mandible moves and grows forward
and downward.

 By the end of the first-year mandible appears as a single bone.

 It configures symmetrically as a U-shaped structure as it

accommodates the mandibular dentition and completes the
dental arch.

The mandible does not simply grow, It “remodels”.

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 Growth Progression After First
Year – Mechanism & Site

Ramus:

 Moves progressively posterior by a

combination of deposition and resorption .
 Resorption – anterior part of ramus
 Deposition – posterior region
 Results in drift of ramus in a posterior
direction.

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 Function of remodelling of ramus are:
1.to accommodate increasing mass of
masticatory muscles inserted into it.
2.to accommodate enlarged breadth
of pharyngeal space.
3.to facilitate lengthening of mandibular
body, which in turns accommodates
erupting molars.

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Corpus or body of mandible:

 Post. Displacement of ramus converts -

former ramal bone into post. part of body
of mandible.
 So body of the mandible lengthens.
 Additional space made available to
accommodate erupting permanent
premolars.

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Angle of mandible :

 Lingual side-
resorption: posterior-inferior aspect
deposition: antero-superior aspect

 Buccal side:
resorption: antero-superior aspect
deposition: posterior-inferior aspect

 Results in flaring of the angle of

mandible as age advances.
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The lingual tuberosity:
 Border between ramus and body.
 Grows Important structure as it is direct
anatomic equivalent of the maxillary
tuberosity.
 Site of growth for lower body arch.
 Moves posteriorly by deposition on its
posteriorly facing surface.
 The prominence of tuberosity is increased by
presence of large resorptive fields just below
it called lingual fossa.
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The alveolar process:

 It develops in response to the

presence of tooth bud.
 As teeth erupt alveolar process
develops and increases in height
by bone deposition at the
margins.
 In case of absence of teeth,
alveolar bone fails to develop and
it resorbs in the event of tooth
extraction.
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AGE CHANGES IN MANDIBLE

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 AT BIRTH:

• Mental foramen- Opens below the sockets of the two

deciduous molar teeth near the lower border.
• Mandibular canal- Runs near the lower border.
• Angle- between ramus and body of the mandible is
obtuse i.e. 175 degree
• Coronoid and Condylar process- Coronoid is larger and
above the condyle
• Symphysis menti- Present; two halves united by fibrous
tissue 41
AT CHILDHOOD:

 Mandibular foramen- slightly below the occlusal plane

 Angle- becomes less obtuse around 140 degree
 The body becomes elongated in its whole length, especially behind the
mental foramen, to provide space for the three additional teeth developed
in this part.
 The two halves of the mandible fuse during the first year of life.

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 IN ADULT:
Mental foramen- opens midway between the upper and lower borders
Mandibular canal- runs parallel with the mylohyoid line.
Angle- reduces about 110 or 120 degree
Coronoid and Condylar process- Condyle is above the coronoid
Symphysis menti- Represented by a faint ridge only in the upper part

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IN OLD AGE:
 Mental foramen and Mandibular canal- are close to the alveolar
border.
 Angle- Again becomes obtuse at about 140 degrees
 Coronoid and Condylar process- Condyle is above the coronoid but
in extreme old age bent backward
 Symphysis menti- Not recognizable or Absent

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 Review of Literature

Mandibular Development and Its Age Change

 Sanjay Madhavan
 Pharmaceutical Sciences and Research, in 2014
 Concluded that the mandible is the only movable bone in
the face its development is useful in forensic studies. The
identified features of the mandible such as the weight of
the mandible, and the positions of the mandibular
foramen help in identifying the age and sex of the person.
 Deposition of calcium in the development of the mandible
changes the positions of the foramen in the bone
according to age.
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Clinical significance:

 The changing direction of the mental foramen has clinical

implications in the administration of local anesthetic to the
mental nerve:
 In infants and children, the syringe needle may be applied at
right angles to the body of the mandible to enter the mental
foramen whereas the needle must be applied obliquely from
behind to achieve entry in the adult.

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Myofunctional appliances:
 Treatment can be initiated at early age, often started in
the mixed dentition period so the psychological
disturbances associated with malocclusion can be avoided.
 Optimum time for myofunctional therapy is in between 10
years of age and pubertal growth phase.
 Capable of accelerating the growth in the condylar region.
 Can bring about remodelling of glenoid fossa.
 Bring dento-alveolar changes in the sagittal, transverse,
and vertical direction.
 Moderate to severe skeletal class II malocclusion idealy
suited for functional appliance therapy.
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Orthodontic treatment:
 Ideal time to start growth modification treatment is late mixed
dentition period before the shedding of the 2nd deciduous
molars.
 Routine orthodontic treatment are best initiated in the early
permanent dentition period.
 Benefits –
1. Reduces risk of trauma associated with proclined anteriors.
2. Possible to utilize growth.
3. May reduces need for extraction in the future by expansion
procedures and growth modification.
4. Reduces need for long term future treatment.
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DEVELOPMENTAL ANOMALIES

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Agnathia (Otocephaly, holoprosencephaly
agnathia):

 Autosomal recessive
 Characterized by hypoplasia or absence of the mandible with
abnormally positioned ears
 Partial absence of the mandible is even more common
 The complete mandible on one side may be absent, or only the
condyle or the entire ramus, while bilateral agenesis of the
condyles and rami has also been observed.

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 Eitiology- It is probably due to failure of migration of
neural crest mesenchyme into the maxillary prominence
at the 4th to 5th week of gestation.
 The prognosis of this condition is very poor and it is
considered to be lethal.

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Micrognathia:
 small jaw
 micrognathia is not due to an abnormally small jaw in
terms of absolute size, but rather to an abnormal
positioning or an abnormal relation of one jaw to the
other or to the skull
 True micrognathia may be classified as either congenital
or acquired.
 The clinical appearance of mandibular micrognathia is
characterized by severe retrusion of the chin, a steep
mandibular angle, and a deficient chin button

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Etiology:
1) Congenital: In the congenital type,
etiology is usually unknown. In many
instances, it is associated with other
congenital abnormalities, particularly
congenital heart disease and Pierre
robin syndrome
2) Acquired: Acquired type is a postnatal
type and results from disturbances in
the area of TM joint (ankylosis).

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Syndromes associated with micrognathia:
• Pierre Robin syndrome
• Trisomy 13
• Trisomy18
• Turner’s syndrome
• Treacher-Collins syndrome
• Marfan’s syndrome

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 Macrognathia:
• Refers to the condition of abnormally large
jaws.
• It is caused by Pituitary gigantism, Paget’s
disease of bone, acromegaly, and in some form
of fibrous dysplasia.
• Patients tend to have long rami which forms a
less steep angle with the body of the
mandible.
• General factors which conceivably would
influence and tend to favor mandibular
prognathism are as follows:
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• Increased height of the ramus
• Increased mandibular body length
• Increased gonial angle
• Anterior positioning of the glenoid fossa
• Decreased maxillary length
• Posterior positioning of the maxilla in relation to the
cranium
• Prominent chin button
• Varying soft-tissue contours

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 Treatment-
Surgical correction - resection of a portion of the
mandible to decrease its length.

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Pierre Robin’s syndrome:

 Named after the French physician ‘Pierre Robin’

who reported a case of nonspecific anomaly
consisting of glossoptosis with cleft palate.
 Congenital defect with the classic triad of
micrognathia/ retrognathia, glossoptosis, and
cleft palate.
 It occurs as an isolated defect, as a part of other
syndromes, or as part of a complex of multiple
congenital anomalies.

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 Clinical features-
• Presence of a small mandible with an obtuse
gonial angle and posteriorly located
condyle(micrognathia). or
• Jaw size is normal but the mandible is retro-
positioned with respect to the maxilla
(retrognathia).
• ‘Bird face’ appearance.
• Because of this, the tongue tends to fall back
and obstruct the airway, resulting in serious
complications such as breathing and feeding
difficulties.

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Cleft palate which involves both soft and hard palates and usually palatine
vault takes a U or V shape.
Obstructive sleep apnoea
Airway obstruction
Hearing loss
• Nasal deformities
• A complication of airway obstruction may include infection leading to
bronchitis and pneumonia.

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 Treatment and Prognosis-

Primarily aimed at preventing airway obstruction.

Obturators for the cleft may be useful in facilitating feeding
in milder cases.
• Children with severe micrognathia may suffer severe
respiratory distress and fail to survive, requiring surgical
intervention to correct the respiratory obstruction.

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 Review of Literature
Case report of Pierre Robin sequence with severe upper airway
obstruction who was rescued by fiberoptic nasotracheal
intubation

 Takeshita et al.
 BMC Anesthesiology (2017)
 Concluded that extreme type of glossoptosis in PRS concludes
tongue invaginated into the nasal cavity which has not been
reported before and that such cases require resuscitation by
fiberoptic intubation immediately after birth. As such,
neonatologists should obtain the skill of fiberoptic intubation.

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Mandibulofacial Dysostosis (Treacher
Collins Syndrome):
 Genetic disease inherited as an autosomal
dominant trait.
 Earliest report of it was by Berry in 1889
 Detail observation was done by Treacher Collins in
1900
 Occurs due to mutation of TCOF1 gene.

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 Clinical Features-
• Antimongoloid palpebral fissures
with coloboma of the outer portion
of the lower lids, and deficiency of
the eyelashes.
• Hypoplasia of the facial bones,
especially of the malar bones and
mandible
• Malformation of the external ear,
and occasionally of the middle and
internal ears.
• Microstomia, high palate, and
abnormal position & malocclusion of
the teeth 64
• Facial clefts
• Skeletal deformities
• Salivary gland pathologies lead to dryness of the oral cavity and
high caries activity
• Faces of patients are often described as being bird-like or fish-
like in nature.
• In severely affected patients, because of hypoplasia of the
mandible and TMJ, airway obstruction may lead to sleep apnoea
syndrome and sudden death.

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Radiographic features-
Bodies of both malar bones are grossly and symmetrically
underdeveloped.
Agenesis of malar bones with no fusion of the zygomatic arches as
well as the absence of the palatine bones.
A cleft palate may be visible on the radiograph.
• Hypogenesis and sometimes agenesis of the mandible.
• Paranasal sinuses are grossly underdeveloped.
• Auditory ossicles are often absent and the cochlea and vestibular
apparatus may be deficient.

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Treatment and prognosis-
A multidisciplinary approach involving craniofacial surgeons,
orthodontists, ophthalmologists, otolaryngologists, and
speech pathologists.
Tracheostomy at birth to guard the airway and facilitate
feeding.
Later multiple surgeries are carried out to correct eyelid
coloboma, orbital reconstruction, and osteotomies.
• Prognosis is good and most of the patients live a normal
life

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Anatomy of TMJ

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 Synovial joint type.

 Articular surfaces-
• The upper articular surface is formed
by the following parts of the
temporal bone:
1. Articular tubercle
2. Anterior part of mandibular fossa
3. The posterior nonarticular part
formed by the tympanic plate
• The inferior articular surface is
formed by the head of the mandible.
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 Articular surfaces are covered with fibrocartilage.
 Joint cavity is divided into upper and lower parts by an intra-
articular disc

70
Ligaments:
1. Fibrous capsule :
• Attached above the articular
tubercle
• Circumference of the mandibular
fossa in front
• Squamotympanic fissure is behind
• Neck of the mandible is below

2. Temporomandible ligament:
• Attached above to the articular
tubercle
• Below to the posterolateral aspect
of the neck of the mandible.
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3. Sphenomandibular ligament:
• Attached superiorly to the spine of
the sphenoid
• Inferiorly to the lingula of the
mandibular foramen
• Remanent of the dorsal part of
Meckel’s cartilage

4. Stylomandibular ligament:
• Attached above to the lateral surface
of the styloid process
• Below the angle and adjacent part of
the posterior border of the ramus of
the mandible 72
Articular disc:
• Oval fibrous plate divides the joint into an
upper and a lower compartment
• Upper compartment – gliding movement
• Lower compartment – rotary and gliding
movements
• Disc has a concavo-convex superior
surface
• Periphery of the disc is attached to the
fibrous capsule
• Parts – anterior extension, anterior thick
band, intermediate zone, posterior thick
band, and bilaminar region
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Function –
• Acts as a cushion and helps in shock absorption.
• Proprioceptive fibers present in the disc help to regulate
movements of the joint.
• Helps in the distribution of weight across the TMJ by increasing
the area of contact.

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Pre-natal growth of TMJ

75
 The critical period in the early prenatal morphogenesis of
the human temporomandibular joint is approximately
during the time of early 7 to 11 weeks of fertilization age.

 There appears to be a definite pattern or sequence in the

early shaping of each component of the
temporomandibular joint relative to structure and
chronology.

 The chronological events leading to development of the

temporomandibular joint is-

76
 Chronology of TMJ development
Timing Structures developed
Approximately 7-7.5 weeks First appearance of the temporal
bone articular fossa.
Beginning signs of mesenchymal
condensation and shaping of the
mandibular condyle.
7-7.5 weeks First appearance of the articular
disk.
9-11 weeks Articular capsule development
initiated.
77
 Chronology of TMJ development
Timing Structures developed
10 weeks Initiation of lower joint cavity.

11.5 weeks Initiation of upper joint cavity.

17 weeks Articular disc fully formed.

17.5 weeks Fully formed joint cavities.

78
 Primary Joint:
• At about the 7th week of intrauterine life, Meckel's cartilage
extends from the midline backward and dorsally, acting as a
scaffold to the developing mandible.
• It terminates at the malleus and articulates with the incal
cartilage forming the primary joint and any movement of the
early jaws occurs between them.
• This primary joint exists for about four months until the
cartilages ossify and become incorporated in the middle ear.

79
 Secondary Joint:

Two distinct regions of mesenchymal condensation

(blastemata) appear at three months of gestation-

1. Temporal blastemata

2. Condylar blastemata.

80
1. Temporal Blastema:
• Gives rise to articular eminence and glenoid
fossa. The first appearance of the temporal bone
articular fossa occurs at approximately 7 to 7.5
weeks.
• Spicules of primary cancellous bone appear most
prominently at 10 to 11 weeks.
• The shape of the articular fossa is initially convex
during the first weeks of its development up to 9
weeks.
• After that time, the fossa progressively takes on
its definitive concave shape, which matches the
shape of the condylar head.
81
2. Condylar Blastema:
• The condensation and shaping of the mandibular
condyle occur at about the same time as for the
articular fossa.
• This mass is superiorly convex.
• Condylar cartilage cells first appear between 9 and
10 weeks.
• Till the 10th week, the ossification of the condyle
and articular fossa are synchronous.
• After the 10th week, the continuing ossification of
the articular fossa appears more advanced in terms
of increased cortical thickness and density of bony
trabeculae.
82
• Up to about 10 weeks, the ossifying masses of the
articular fossa and mandibular condyle are separated by a
continuous and unseparated block of dense staining
mesenchyme.

 The upper and lower joint cavities:

• They progressively appear as a group of small spaces or
clefts within the mesenchymal tissue block that had
earlier given rise to the articular fossa, disk, and condyle.
• Initiation of both joint cavities is not synchronous.

83
• Small, coalescing clefts for the lower joint cavity appear
at about 10 weeks, whereas those for the upper cavity are
first seen at about 11.5 weeks.
• These small spaces or clefts between the mesenchymal
cells in the area gradually enlarge and coalesce into larger
spaces or cavities superior and inferior to the disk.

84
 Stages of temporomandibular development

• Blastematic stage (7-8 weeks of development) :

Corresponds with the onset of the organization of the condyle, the
articular disc, and the capsule. During the 8th week, intramembranous
ossification of the temporal squamous bone begins.

85
• Cavitation stage (9-11 weeks of development) :
Corresponding to the initial formation of the inferior joint
cavity (9th week) and the start of condylar chondrogenesis.
11th Week marks the initiation of the organization of the
superior joint cavity.
• Maturation stage:
After 12 weeks of development.

86
• By the 12th week of IUL, two joint cavities are delineated
by intervening fibrous articular disk.
• After cavitation, the synovial membrane invades and lines
the joint cavities, it secretes the synovial fluid.

87
 Progressive development of the joint occurs and the
articular disk by its compression in the center leads to a
biconcave shape.
 At birth, the mandibular fossa is flat and articular
eminence is not developed.
 This configuration helps in anteroposterior movement of
the mandible during suckling.
 Articular eminence starts development with the eruption
of deciduous teeth.

88
Post-natal growth of TMJ

89
 Temporomandibular joint is the reason the mandible is the
only movable bone in the skull.

 Ginglymodiarthroidal joint.

 Starts developing at the 10th week of intrauterine life.

 The joint cavity is divided into two: upper and lower by

the intervening biconcave fibrous, articular disk.

90
 As the TMJ is a secondary joint
(embryologically), cartilage is
also secondary.
 It is formed of the articular
surfaces of the condyle and
temporal bones.
 Condylar cartilage is merely a
growth site, in other words, it
is extremely adaptive in its
growth.

91
 The condylar surface has four zones:
1. Articular zone
2. Proliferative zone
3. Fibrocartilagenous zone
4. Calcified cartilage

92
 Articular zone:
• It is the most superficial layer, found just adjacent to the
joint cavity, forming the outermost functional surface.
• It consists of tightly packed collagen bundles oriented
parallel to the articular surfaces, allowing them to
withstand the forces of movement.

93
 Proliferative zone- formed of two layers,
• The outer layer - is formed of small cells, numerous rapidly
mitotic and with little intercellular substance.
• The inner layer - is less wide than the outer layer, formed
of large round cells.
• It is mainly cellular, consisting of undifferentiated mesenchymal
tissues.
• which are responsible for the proliferation of articular cartilage in
response to the functional demands placed on the articular surfaces.

94
 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
compressive and lateral forces.

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 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.

96
 TMJ has a multidirectional growth tendency.
 Adaptive remodeling can contribute to the growth of the
mandible even after adolescence.
 In infants, the condylar cartilage (all the zones) is highly
vascular and cellular.
 Decrease in vascularity occurs with increasing age
 By 5 to 6 years of age, the articular layer becomes less cellular,
and more fibrous (coarse and dense).

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 Till 13 to 15 years of life - Active proliferation of cells is evident,
after which there is a decrease in the number of cells and mitotic
index.

 At 20 years of age – Cartilage islands are seen in the superior and

anterior part of the condyle and posterior part of the articular
eminence.

 After 20 years - superior and anterior part of the condyle and the
posteroinferior part of the eminence retain the condylar cartilage.

98
 Condylar cartilage is not an active growth center; instead,
it is a growth site with rapid growth during the initial
years.

 In the later part of life, TMJ takes the job of resisting

stress and pressure.

99
 Clinical significance:
 Dislocation of the mandible:
• During the excessive opening of the mouth, the head of the
mandible of one or both sides may slip anteriorly into the
infratemporal fossa, as a result of which there is the inability to
close the mouth.
• Reduction is done by depressing the jaw with the thumbs placed on
the last molar teeth, and at the same time elevating the chin.

100
 The TMJ provides the essential functional connection
between the cranium and the maxillary and mandibular
jaw.
 The first primary role of the mandibular condyle is
directed toward growth, which is most evident and
important prenatally and early postnatally, and diminishes
in expression as development proceeds postnatally
through adolescence.
 The second role of the mandibular condyle is directed
towards mandibular articulation and its load-bearing
capabilities.

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 The condylar head inclination and superior joint space
proved to be the most significantly correlated condylar
characteristics to facial morphology.
 Patients with vertical facial morphology displayed
decreased superior joint spaces and posteriorly angled
condyles.
 Patients with horizontal facial morphology demonstrated
increased superior joint spaces and anteriorly angled
condyles.

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DEVELOPMENTAL ANOMALIES

103
Condylar Hypoplasia or Aplasia:
 Aplasia is a failure of development of the mandibular
condyle.
 Hypoplasia is an underdevelopment of the condyle.
 May be congenital or acquired.
 May occur unilaterally or bilaterally.

104
 Congenital or Primary hypoplasia or aplasia-
Unilateral or bilateral underdevelopment of the condyle, due
to disturbances in the first or second branchial arches.

 Acquired or Secondary hypoplasia-

Trauma, infection of the mandible or middle ear, and
therapeutic dose of irradiation interfere with the normal
development of the condyle.

105
Clinical features-
• Frequently associated with another anatomical defect
such as defective or absence of external ear,
underdeveloped mandibular ramus, or macrostomia.
• Unilateral, resulting in an obvious facial asymmetry.
• The mandible shifts to the affected side while the patient
opens the mouth and a noticeable midline shift is often
present.
• result of retardation of the downward and forward growth
of the mandible on the affected side, as the growth is
normal in the unaffected side.

106
 Bilateral condylar hypoplasia or
aplasia results in micrognathia,
often in association with
crowding of the teeth and
anterior open bite.

 persistent airway obstruction

may occur due to posterior
positioning of the tongue which
interferes with the feeding and
speech process.

107
Treatment-

• Early diagnosis and intervention are important in

managing occlusion, speech, and other functions.

• Cartilage or bone transplants have been used to build up

the underdeveloped portion.

• Infants with condylar aplasia who exhibit respiratory

difficulty may require tracheotomy.

108
Condylar hyperplasia:

 rare, unilateral enlargement of the

condyle
 The cause is unclear but a mild,
chronic inflammatory process
resulting in a condition analogous
to proliferative osteomyelitis has
been suggested.

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 According to Obewegeser and Makek,

Type A –
• Hemimandibular hyperplasia, causing asymmetry in the
vertical plane.
• In this type, the growth is unilateral in the vertical plane,
with minimal deviation of the chin.
• Typically, the maxilla shows compensatory growth.

110
Type B –
• Hemimandibular hyperplasia, causing asymmetry in the
transverse plane.
• In this type, the chin deviates toward the contralateral
side with no vertical asymmetry.
• The patient may exhibit crossbite.

Type C -
• A combination of both type A and type B,
• Exhibits hyperplastic features unilaterally or bilaterally.

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 Clinical features-
• More frequently in females.
• Most common occurrence is in the third decade of
life.
• Usually exhibit a unilateral.
• Slowly progressive elongation of the face with a
deviation of the chin away from the affected side.
• The enlarged condyle may be clinically evident or
often palpated and presents a striking radiographic
appearance in both coronal and sagittal views.
• The affected joint may or may not be painful.
• Malocclusion is a usual sequel of the condition.

112
 Treatment-

• The treatment of condylar hyperplasia is usually surgical.

• Depending on the severity of the hyperplasia,
condylectomy, orthognathic surgery, or a combination of
both may be carried out.

113
Case Report: unilateral condylar
hyperplasia
 Shishir Shetty and
Shrihari
Guddadararangiah
 F1000Research 2021

114
 Concluded that Prompt diagnosis is very important for the
successful management of CH. Apart from a patient’s
history and clinical findings, serial photographs of the
patient from the past 10 to 15 years also provide vital
information about the approximate time of occurrence
and progression of the CH. Hence it is advisable to study
serial photographs of patients with CH during the
diagnostic stage.

115
Bifid condyle:
 A rare condition
 characterized by the presence of a groove or depression of
varying depth around the midline of the condylar head.

116
 Etiology-
• The reason for the bifidity is controversial and two
theories have been proposed.
• Accordingly, one theory speculates that bifidity may
originate in the embryo where the blood supply to the
condylar head is limited.
• The other theory suggests trauma due to either birth
injury or fracture of the condylar head as the cause of
bifidity.
• Usually patients with bifid condyles are asymptomatic and
do not require any treatment.

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Traumatic disturbances

118
Ankylosis of TMJ (hypomobility):

 Adhesion of joint components takes place

by fibrous or bony union.
 Causes - Traumatic injuries and local or
systemic infections.
 Classified into two types- intra-articular
and extra-articular.

119
 Clinical features-
• Age- occurs at any age, but most cases occur before the
age of 10 years.
• Distribution is approximately equal among the genders.
• Mouth opening may be normal or restricted to varying
degrees depending on the type of ankylosis.
• In complete ankylosis, bony fusion limits the TMJ
movements. However, there is usually some degree of
movement in fibrous ankylosis when compared to bony
ankylosis.
• The type and extent of deformity are partially dependent
on whether the ankylosis is unilateral or bilateral.
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• Unilateral ankylosis – The chin is displaced
laterally and backward on the affected side
because of the failure of development of the
mandible on the affected side. Attempt to
open the mouth leads to deviation of the
chin toward the affected side.
• Bilateral ankylosis - results in the
underdevelopment of the lower face,
receding chin, and micrognathia.

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 Radiographic features:
• In fibrous ankylosis, the joint space is often limited.
• The articulating surfaces of the condyle and the fossa may
be irregular and appear to interdigitate in a locking fashion.
• In bony ankylosis, a bony bridge exists from the condylar
head to the articular fossa.

122
 Treatment:
• Early surgical intervention in childhood can reduce the
adverse effect on facial development.
• Different surgical procedures, including condylectomy,
gap arthroplasty, interpositional arthroplasty, and joint
reconstruction, have been attempted.

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Internal derangement of articular disk:
 An abnormality of the internal components of the joint, in
which the articular disk is displaced from its normal functional
relationship with the condylar head and the articular fossa of
the temporal bone.
 Etiology:
• not known
• Injury to the condylar region
• Variation of normal function
• Muscle hyperactivity
• Excessive opening of the mouth.
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• Bruxism
 Four clinical stages:

• Stage I: The articular disk is displaced in

the closed mouth position and reduces
to normal contact in the open mouth
position.

• Stage II: The disk is displaced in the

closed mouth position, and
intermittently locks in the open mouth
position.

125
• Stage III: The disk is displaced in the closed mouth
position, and does not reduce to normal contact in the
open mouth position (closed lock).
• Stage IV: The disk is displaced without reduction and with
perforation of the disk or posterior attachment tissues.

126
 Clinical features:
• More common in females than in males, the ratio is 8:1.
• Young adults are more frequently affected than children or persons
older than 40 years.
• Patients with internal derangement are usually asymptomatic.
• Patients with disk displacement with reduction may have limitation of
movement, primarily due to pain.
• Clinical examination may reveal clicking or joint sound during opening
and closing of the mouth.
• Patients who have disk displacement without reduction have limited
mouth opening.
• During opening, the mouth may deviate toward the involved joint.
• The patient often experiences pain during closed mouth position as
the condyle rests on the retrodiscal tissues.
127
 Showing disk displacement with
Showing normal disk relationship with the
reduction
condylar head and articular fossa/eminence

Showing disk displacement without 128

reduction.
 Treatment:
The treatment of disk displacement can be surgical or non-
surgical.
Current understanding of the function of TMJs and the roles
of articular disks suggest that it may not be necessary to re-
establish the position of the disk.
An anterior positioning appliance may be helpful in patients
who have disk displacement with reduction.

129
CONCLUSION:

 Bone growth in the mandible is a remodeling process

represented by apposition and resorption.

 Knowledge of general facial growth provides a background

to the understanding of the etiology and development of
malocclusion, which is an important part of diagnosis and
treatment planning.

130
REFERENCES:

 Textbook of craniofacial growth – Sridhar Premkumar

 Orthodontics art and science- Bhalajhi,3rd edition
 Human embryology- Inderbir Singh,7th edition
 Textbook Oral pathology – Shafer, 8th edition
 Human Anatomy –BD Chaurasia, 3rd edition
 Mandibular development and its Age changes, Journal of
Pharmaceutical Sciences and Research, Vol. 6
(11),2014,360-362

131
 Prenatal Development of the Human Mandible, The
Anatomical Record 263:314-325 (2001).
 Takeshita et al, A Case report of Pierre Robin sequence
with severe upper airway obstruction who was rescued by
fiberoptic nasotracheal intubation. BMC Anesthesiol. 2017
Mar 14;17(1):43
 Kolsi N et. al.Treacher Collins syndrome: A case report
and review of the literature. Clin Case Report 2022
 Shetty S and Guddadararangiah S. Case Report: unilateral
condylar hyperplasia [version 1; peer review: 2
approved]. F1000Research 2021, 10:46 

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