THE TEMPOROMANDIBULAR JOINT IS ALSO
KNOWN AS THE CRANIOMANDIBULAR JOINT or
IT IS THE ARTICULATION BETWEEN THE
SQUAMOUS PART OF THE TEMPORAL BONE AND
THE HEAD OF THE MANDIBULAR CONDYLE.
IT IS ALSO CONSIDERED AS COMPLEX JOINT
BECAUSE IT INVOLVES TWO SEPARTE SYNOVIAL
JOINT, IN WHICH THERE IS A PRESENCE OF
INTRACAPSULAR DISC OR MENISCUS.
Masticatory and accessory
Occlusion of teeth
The function is governed
by sensory and motor
branches of the third
division of trigeminal
IT HAS AN ANTERIOR ARTICULAR AREA BY THE INFERIOR
ASPECT OF TEMPORAL SQUAMA.
THE FOSSA IS LINED BY A DENSE AVASCULAR
IT SEPARATES THE ARTICULAR SURFACE OF THE FOSSA
LATERALLY FROM THE TYMPANIC PLATE.
THE EMINENCE IS COVERED BY DENSE, COMPCT, FIBROUS
TISSUE THAT CONSISTS PRIMARILY OF COLLEGEN WITH
AFEW FINE ELASTIC FIBERS
IT IS A THIN SLEEVE OF FIBROUS TISSUE INVESTING THE
IT IS A FUNNEL SHAPED CAPSULE,WHICH BLENDS WITH THE
PERIOSTEUM OF THE MANDIBULAR NECK AND ENVELOPS
IT REINFORCE THE TMJ CAPSULE
IT EXTENDS DOWNWARD & BACKWARD FROM THE
ARTICULAR EMINENCE TO THE EXTERNAL AND
POSTERIOR SIDE OF THE CONDYLAR NECK
ITS POSTERIOR FIBER ARE UNITED WITH THE
THIS LIGAMENT IS COMPOSED OF COLLAGENOUS
FIBERS THAT HAVE SEPIFIC LENGTH AND POOR
ABILITY TO STRETCH, HENCE IT MAINTAINS THE
INTEGRITY AND LIMITS THE MOVEMENT OF TMJ
IT MAINLY LIMITS THE ANTERIOR EXCURSION OF THE
JAW AS WELLAS PREVENTS POSTERIOR DISLOCATON ,
ALSO CALLED CHECK LIGAMENT.
A FLAT BAND ARISING
FROM THE APHENOID
MEDIAL TO THE TMJ
NERVE LIES B/W IT
IT IS DENCE THICK BAND OF THE DEEP CERVICIVAL FASIA
EXTENDING FROM THE STYLOID PROCESS TO THE
THE MENISCUS DIVIDES THE TWO ARTICULAR SPACE
INTO TWO COMPARTMENT
LOWER OR INFERIOR COMPARTMENT- condylodiscal complex
b/w the condyle and the disc
UPPER OR SUPERIOR COMPARTMENT – b/w disc and the glenoid
The disc is biconcave in the sagital section.
The superior surface is concavoconvex to match the anatomy of
the glenoid fossa.
The inferior surface is concave to fit over condylar head
The disc blends medially and laterally with the capsule, which is
attached to the medial and lateral poles of the condyle.
Anteriorly the disc is attached to the articular eminence above &
to the articular margin of the condyle below.
Posteriorly disc is attached to the posterior wall of glenoid fossa
The disc is a meshwork of firmly woven avascular fibrous
connective tissue & it is also noninnervated with possible
exceptions around its periphery.
These collagen fibers impart flexibility to the disc.
The disc is designed to transmit the forces generated
through the condyle to the articular eminence.
It promotes lubrication energy absorption and joint
range of motion. It acts as a main shock absorber
enabling the articulating bones to move against each
other with minimum friction and heat production.
Disc has Avery little potential for repair after inult.
Lateral aspect is supplied by
superfical temporal branch
of the external caroid artery.
Rich vascular supply to the
deep and posterior aspect of
retrodiscal capsular part by
deep auricular, posterior
auricular & masseteric
branches of the internal
Vascular supply to the lateral
pterygoid muscle also
supplies to the head of the
condyle by penetration of
numerous nutrient foramina
THE MANDIBULAR NERVE,
THE THIRD DIVISION OF
THE FIFTH CRANIAL NERVE
INNERVATES THE JAW
The largest is the
auriculotemporal nerve which
supplies the posterior, medial
and lateral part of the joint
A branch from the posterior
deep temporal nerve, supply
the anterior parts of the joint
The movements of tmj are manifold. It is ginglimus
diarthroidai type of joint, as it sis capable of rotating
around more than one axis and is capable of
MUSCLE FUNCTION- The functions of the muscles of
mastication in jaw movement are coordinated and
balanced by normal muscle tone.
The muscle of mastication (medial and lateral
pterigoid,masseter, buccinator, mylohyoid, temporalis
& anterior belly of the digastric) are assisted by the
suprahyoid and digastric muscle.
JAW OPENING It is dominated by daigastric muscle
contraction, which depress the body of the mandible.
This action is assisted by the suprahyoid, sternohyoid
and geniohyoid muscles.
JAW CLOSURE It is accomplished by the simultaneous
contraction of the masseter, medial pterigoid muscles.
PROTRUSIVE MOVEMENT It requires equal
simultaneous contracture of lateral and medial
RETRUSION It is brought about by posterior fibers of
temporalis muscles, assisted by middle and deep parts
of the masseter, digastric and geniohyoid muscles.
LATERAL MOVEMENT These are carried out by
unilateral contracture of medial and lateral pterygoid
of each side acting alternatively.
Intra –articular origin or intrinsic disorder
Extra –articular origin or extrinsic disorder
MASTICATORY MUSCLE DISORDER
Protective muscle splinting
Masticatory muscle inflamation
Masticatory muscle spasm
PROBLEMS DAT RESULT FROM EXTRINSIC TRAUMA
Internal disc derangement
Contracture of elevator muscle
Surgical access to the tmj is an exacting procedure.
Tmj has got close proximity to the main trunk of the facial
nerve with its branches in the temporal and facial areas
It has also got close proximity to the auriculotemporal nerve
and the abundant vascular supply
Uniform predictability of anatomic exposure &
avoidance of a salivary fistula.
No distortion of anatomic landmarks
Infection involving the external auditory canal
Paresthesis of the external pinna
Small surgical exposure with poor access and visibility
Excellent lateral and posterior exposure with
intermediate anterior exposure
Possibility of meatal stenosis
Excellent visibility and accessibility
Close proximity of the posterior facial vein and trunk of
the facial nerve
Proximity of the posterior border of the parotid gland
Ideal approach to the condyle neck and ramus
Inconspicuous location of the incision
Standard approach to the TMJ
The dissection follows a route through an area which is
rice in nerve and vascular supply.
BLAIR AND IVY INCISION
THOMA;S ANGULATED INCISION
AL- KAYAT AND BRAMLEY
ADVANTAGES OF POPWICH’S
REDUCTION IN INCIDENCE OF FACIAL
GOOD COSMETIC RESULTS
REDUCTION IN TOTAL OPERATION
AVOIDANCE OF AURICULOTEMPORAL
REDUCTION IN POSTOPERATIVE
OEDEMA AND DISCOMFORT
It is a greek terminology meaning “STIFF JOINT”
The jaw function gets affected because of immobility
of the joint.
Hypomobility to immobility of the joint can lead to
inability to open the mouth from partial to complete.
Onset is usually seen before the age of 10 years.
FALSE ANKYLOSIS OR TRUE ANKYLOSIS
EXTRA –ARTICULAR OR INTRA –ARTICULAR
FIBROUS OR BONY
UNILATERAL OR BILATERAL
PARTIAL OR COMPLETE
- At birth (with forceps)
- Blow to the chin (causing haemarthrosis)
- Condylar fracture
Infections and Inflammatory
- Rheumatoid Arthritis
- Septic arthritis
- Otitis media
- Small pox
- Ankylosing spondylitis
- Typhoid fever
- Scarlet fever
- Post radiology
- Post surgery
- Prolonged trismus
Extravasation of blood into the joint space
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis
It depends more upon clinical examination, rather
than the diagnostic test.
Restricted or nil oral opening is seen.
Patient will complain of difficulty in mastication.
Protrusive movements are not possible on the involved
Partial mobility or complete immobility of the condyle
is readily noticed.
Pain is totally absent
In young patient a nature of facial deformity will help
to differentiate b/w unilateral and bilateral
IT VARY ACCORDING TO:
Severity of ankylosis
Time of onset of ankylosis
EARLY JOINT INVOLVEMENT- less than 15 years:
severe facial deformity and loss of function
LATER JOINT INVOLVEMENT- after the age of
15years: facial deformity marginal or nil but functional
loss is severe.
Those patient in whom ankylosis develops after full
growth completion have no facial deformity.
Obvious facial asymmetry
Deviation of the mandible and chin on the affected side
The chin is receded with hypoplastic mandible on the
The appearance of the flatness and elongaltion on the
The lower border of the mandible onthe affected side hass
a concavity that ends in a well- defined antegonial notch
In unilateral ankylosis some amount of oral opening may
be possible. Interincial opening will vary depending on
whether it is fibrous or bony ankylosis
Cross bite may be seen
Classic angles malocclusion on the affected side plus
unilateral posterior cross bite on the ipsilateral side seen
Condylar movements are absent on the affected side
Inability to open the mouth progresses by gradual decrease in
interincisal opening. The mandible is symmetrical but
micrognathic.The patient develops typical 'bird face' deformity
with receding chin.
The neck chin angle may be reduced or almost completely absent
Antegonial notch is well defined bilaterally
Classii malocclusion can be noticed
Upper incisors are often protrusive with anterior open
bite.Maxilla may be narrow
Oral opening will be less than 5mm or many times there is nil
Multiple carious teeth with bad periodontal health can be seen
Severe malocclusion, crowding can be seen and many impacted
teeth may be found on the x-rays.
History of trauma, infection, etc
Radiographic finding- are important in arriving at a final daignosis
Orthopantomograph- will show both the joints picture which can
be compared in unilateral cases.
Lateral oblique view- will give anteroposterior dimension of the
condylar mass. Elongation of coronoid process can be seen.
Cephalometric radiograph- is taken to evaluate the associated
Posteroanterior radiograph- will reveal the medio lateral extent
of the bony mass. It will also highlight the asymmetry in unilateral
CT scan- very helpful guide for surgery. Relation to the medial
cranial fossa, the anteroposterior width, mediolateral depth can be
assessed. Any presence of fractured condylar head on the medial
aspect of ramus can be located
Reduced JOINT SPACE AND HAZY APPEARANCE CAN
But, still the normal anatomy of the head and glenoid
fossa can be appreciated.
Complete OBLITERATION OF JOINT SPACE NORMAL
TMJ ANATOMY IS DISTORTED.
Deformed condylar head or complete bony
consolidation replacing the joint space can be seen.
Elongation of the coronoid process onthe side of
hypomobility will be seen.
Normal facial growth and development affected.
Respiratory distress, especially in bilateral involvement
with severe micrognathia.
Poor oral hygiene.
Multiple carious and impacted teeth.
Release of ankylosed mass and creation of a gap to
mobilize the joint
Creation of a functional joint
To improve patient's nutrition
To improve patient's oral hygiene
To carry out necessary dental treatment
To reconstruct the joint and restore the vertical height
of the ramus.
To prevent recurrence.
To restore normal facial growth pattern.
To improve esthetics and rehabilitate the patient.
Early surgical intervention
Aggressive resection: a gap of atleast 1- 1.5cm should be
created. Special attention should be given to fusion on the
medial of the ramus.
Ipsilateral coronoidectomy and tempralis myotomy:
in most of these cases there is always association of
elongated coronoid process. After carrying out gap
arthoplasty. The coronoidectomy on the same side should
be carried out either separately or in combination with
the gap arthroplasy cut from the same etraoral incision.
Lining of the glenoid fossa region with temporalis
Reconstruction of the ramus with a costochondral
Early mobilization and aggressive physiotherapy for
the period of at least six months postoperatively
Regular long-term follow-up
To carry to cosmetic Surgery at the later date when the
growth of the patient is completed
Release of the jaw movements is quite dramatic, upon
competion of coronoid rather than release it and allow
it to be pulled up superior process is removed, there is
potential for reankylosis after reattachment.
Most surgical procedures can be done through a
preauricular incision alone.
The popwich's incision is chosen for its obvious
Whenever required additional submandibular incision
can be used for fixation of the graft.
I : condylectomy
II : gap arthroplasty
III : interpositional arthroplasty
It is advocated in cases of fibrous ankylosis, where
joint space is obliterted with deposition of fibrous
bands , but there is not much deformity of the
Radiologically and clinically after surgical exposure
one can see the demarcation between the roof of the
glenoid fossa and the head of the condyle.
The procedure can be done via preauricular incision
The unilateral condylectomy tends to cause devation
of the mandibule towards the operated side on oral
opening and if bilateral, anterior open bite will be
caused as a result of the loss of the height in the
Therefore. When the site of the fused joint is
mobilized via condylectomy. Then after recontouring
by arthroplasty, an alloplastic material can be used to
maintain the joint space, satisfactory occlusion and
In the extensive bony ankylosis, a broad,thick area of
bone deposition obliterates the entire joint, sigmoid
notch and coronoid process
Identification of the previous joint structure is
impossible and mobilization at level of joint become
In this operation the level of section is below that
previous joint space
The section consist of two horizontal osteotomy cuts
and removal of a bony wedge for creation of a gap
between the roof of the glenoid fossa and ramus.
Minimum gap of 1cm is recommended to pervent
It involves the creation of gap , but in addition a
barrier is inserted between the cut bony surfaces to
minimize the risk of recurrence and to maintain the
vertical height of the ramus
Tamporalis fascia along with a varying thickness of
temporalis muscle may be harvested as an axial flap
based on the middle and deep temporal arteries and
The dependable blood supply, the proximity to the tmj
and the ability to alter the arc of rotation by basing the
flap inferiorly or posteriorly, makes this a versitile flap
for lining the glenoid fossa.
It is used as an interpositional material after release of
ankylosis of tmj.
Basic 3 goals
1. To replicate structurally normal joint anatomy
2. To provide functional articulation
3. To establish an area , where adaptive growth can
Costochondral graft is harvested through the infra-
Either 5th, 6th, or 7th rib is harvested.
Costochondral junction of rib is chosen along with
some amount of length of the rib.
The length of the total graft will depend on the height
of ramus to be restored
Minimum of 1.5cm of costochondral junction should
be included in the graft
The graft should be fixed on the lateral aspect of the
rammus with the screws.
A minimum gap of 0.5 - 1 cm should be kept between
the graft and the glenoid fossa side, so that free
movement is possible without any friction
Increased operating time
Additional surgical site
Donor site morbidity
Graft over growth
Possible potential for reankylosis
As the patient cannot open the mouth, awake blind
intubation has to be done, where patients cooperation is
required, which is very difficult to obtain from younger
group of patients
Because of small mandible and altered position of the
larynx .intubation poses a problem
Aspiration of blood clot tooth or foreign body during
extubation as throat cannot be packed prior to surgery
Danger of falling back of tongue and obstructing airway
is always there after extubation
Haemorrage due to damage to any of the superficial
temporal vessels, transverse facial artery, inferior
alveolar vessel and internal maxillary vessels, pterygoid
plexus of veins
Damage to external auditory meatus
Damage to zygomatic and temporal branch of facial
Damage to glenoid fossa and thus leading entry into
middle cranial fossa
Damage to auriculotemporal nerve
Damage to parotid gland
Damage to the teeth during opening of the jaws with jaw
DURING POSTOPERATIVE FOLLOW-UP
Recurrence of ankylosis
An inadequate gap created between the fragments
Missing on the medial condylar stump and leaving it
Fracture of the costochondral graft
Loosening of the costochondral graft due to
inadequate fixation to the ramus
Inadequate coverage of the glenoid fossa surface
Inadequate postoperative physiotherapy
Higher osteogenic potential and periosteal osteogenic
power may be responsible for high rate of recurrence