Temporomandibular joint

TMJ ANATOMY AND FUNCTION
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P0ur HARDWORK into cup of CONSISTENCY and top it with
PRESERVANCE .Serve it hot and leave the rest to GOD
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Dr Sekiba k
Dept of cons and endo

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 INTRODUCTION
 DEFINITION
 SYNONYMS
 JOINTS
CLASSIFICATION
BASED ON STRUCTURE
BASED ON FUNCTION
 PECULIARITY OF TMJ
 EMBRYOLOGY OF TMJ
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 DEVELOPMENT OF TMJ
 TOPOGRAPHIC RELATION OF TMJ
 COMPONENTS OF TMJ
 MANDIBULAR CONDYLE
 ARTICULAR SURFACE OF TEMPORAL BONE
 CAPSULE OF TMJ
 ARTICULAR DISC
PARS ANTERIOR
PARS POSTERIOR
PARS INTERMEDIA
RETRODISCAL TISSUE
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 INNERVATION OF TMJ
 PROPRIOCEPTION OF TMJ
 VASCULAR SUPPLY OF TMJ
 LYMPHATIC DRAINAGE OF TMJ
 HISTOLOGY
 SYNOVIAL MEMBRANE
 SYNOVIAL FLUID
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 INNERVATION OF TMJ
 PROPRIOCEPTION OF TMJ
 VASCULAR SUPPLY OF TMJ
 LYMPHATIC DRAINAGE OF TMJ
 HISTOLOGY
 SYNOVIAL MEMBRANE
 SYNOVIAL FLUID
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 LIGAMENTS OF TMJ
 PRIMARY LIGAMENTS
COLLATERAL OR DISCAL LIGAMENT
FIBROUS OR CAPSULAR LIGAMENT
LATERAL OR TMJ LIGAMENT
 ACCESSORY LIGAMENTS
STYLOMANDIBULAR LIGAMENT
SPHENOMANDIBULAR LIGAMENT
DISCOMALLEOLAR LIGAMENT
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 MUSCLES OF MASTICATION
 MASSETER
TEMPORALIS
LATERAL PTERYGOID
MEDIAL PTERYGOID
 RELATIONS OF TMJ
 AGE CHANGES OF TMJ
 APPLIED ASPECT
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INTRODUCTION
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 Tmj influences the function ,aesthetics & structural
harmony of the teeth,dentition,face and thus a
person in total
 .Therefore understanding of anatomy,physiology
biomechanics is very much necessary
 Tmj is the one of the most intricate and complicate
joint in the body
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DEFINITION
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 “Tmj is a ginglylomoarthroidal joint,a term that is
derrived from ginglymus ,meaning hinge joint allowing
motion only backward and forward plane and arthrodia
meaning a joint of which permits a gliding motion of the
surfaces”
 - DORLAND WA MEDICAL DICTIONARY
 PHILIDELPHIA &LONDON .CO 1957
 “The articulation between temporal bone and the
mandible.It is a bilateral diarthroidal and bilateral
ginglymoid joint”
 -GPT 8
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DEFINITION
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“Temporomandibular joint is formed by the
articulation between articular eminence and anterior
part of glenoid fossa of the squamous part of
temporal bone above and condylar head of the
mandible”
-ORBAN’S
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TEMPORO MANDIBULAR JOINT
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 SYNONYMS
 ARTICULATIO TEMPOROMANDIBULARIS
 ARTICULATIO MANDIBULARIS
 JAW JOINT
 MANDIBULAR JOINT
 CRANIO MANDIBULAR JOINT
 GINGLYMOARTHROIDAL JOINT
 MODIFIED BALL AND SOCKET JOINT
 Ref Williams pl grays anatomy in skeletal system 38th ed
 Ref Falex partner medical dictionary 3/20/2021

JOINT
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 A structure that separates two or more adjacent
elements of skeletal system
 CLASSIFICATION OF JOINT
 BASED ON STRUCTURE
 BASED ON FUNCTION
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BASED ON STRUCTURE
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JOINTS BASED ON STRUCTURE
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JOINTS BASED ON STRUCTURE
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TMJ IS UNIQUE!!!!!
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 ARTICULAR surface is covered by fibrocartilage
rather than hyaline cartilage
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;co ordinated movement of
right and left
 Only joint in human body to have
closure
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 Develops from
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EMBRYOLOGYOF TMJ
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 TMJ develops during 7th week of IU life
 Develops from two distinct blastema
 TMJ develops from two widely separated blastema that
grow towards each other
 Condylar blastema
 Temporal blastema

Intervening mesenchymal connective tissue between two
blastema defferentiate into fibrous connective tissue
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EMBRYOLOGYOF TMJ
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10th week of IU life:
Clefting of the
fibrous connective
tissue forming two
joint cavities and
thereby defining the
intra articular disc.
INFERIOR
COMPARTMENT
forms first at about
10th week of IU life
SUPERIOR
COMPARTMENT
starts to appear at
about eleven and
half week
CAVITATIO OCCUR
BY DEGRADATION
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EMBRYOLOGYOF TMJ
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EMBRYOLOGYOF TMJ
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 Early functional activity of produces biomechanical
stresses that facilitates chondrogenesis in the
condyle and articular fossa
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 AT birth mandibular fossa is almost flat bears no
articular surface
 After eruption of DECIDOUS dentition articular
tubercle becomes prominent
 Its development accelerates until 12 years of life
 Articular surface of the fossa and tubercle becomes
more fibrous and less vascular with age
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Difference
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COMPONENTS OF TMJ
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MANDIBULAR
CONDYLE
ARTICULAR SURFACES
OF TEMPORAL BONE
CAPSULE
ARTICULAR DISC
LIGAMENTS
MUSCULAR
COMPONENT
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MANDIBULAR CONDYLE
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MANDIBULAR CONDYLE
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 ARTICULATING SURFACE OF THE MANDIBLE
 AN OVOID PROCESS SEATED AT THE TOP OF
THE MANDIBULAR NECK
 CONVEX
 WIDER LATEROMEDIALY THAN
ANTEROPOSTEIORLY
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MANDIBULAR CONDYLE
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1. TWO POLES
 MEDIAL POLE AND LATERAL POLE
Lateral pole of the condyle is rough blunty pointed and
project only modarately from the plane of ramus while
medial pole sharply from this plane
 Long axis of the two condyle extended medialy ,they
meet at foramen magnum at an angle of 145 to 160
degree
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 ARTICULAR SURFACE
Lies on the
anterosuperior surface
thus facing the posterior
slope of the articular
eminence
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 Inferior aspect of
temporal squama anterior
to tympanic plate
 ARTICULAR
EMINENCE:
 Transverse bony bar
forms the anterior root of
zygoma.
 Most heavily travelled by
the condyle and the disc
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 ARTICULAR TUBERCLE
 Small raised rough bony
knob on the outer end of
aricular eminennce.
 Attachment to lateral
collateral ligament .
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 PREGLENOID PLANE
 Slightly hollowed almost
horizontal continuing
anteriorly from the
height of the articular
eminence
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 POSTERIOR ARTICULAR
RIDGE AND
POSTGLENOID PROCESS
 Anterior margin of the
Petrosquamous suture is
elevated to form a ridge or
lip
 The ridge increases in height
laterally to form thickened
cone shaped prominence
called post glenoid process.
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ARTICULAR DISC
/MENISCUS
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ARTICULAR DISC /MENISCUS
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 Liter ally m eans
c r es c ent
 Bic onc av e
f ib r oc ar tilagenous
tis s ue loc ated
b etween
m and ib ular
c ond yle and
tem p or al b one
c om p onent of th e
joint
 Rough ly ov al,f irm ,
f ib r ous , v is c o
elas tic p late
 Dis c repres ent
p r im itiv e ins er tion
of later al
p ter y gioid
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 Devides the joint into
meniscotempotal cavity
and menisco mandibular
cavity
 GLIDING - upper
compartment
 ROTARY AS WELL AS
GLIDING movement -
lower compartment
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 Superior surface
:saddle shaped to fit
intocranial contour
 Inferior surace is
concave to fit against
mandibular condyle
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 On sagital plane it is
devided into three region
 Pars anterior- 2mm in
thickness
 Pars intermedia-1mm in
thickness
 Pars posterior-3mm in
thickness
 More posteriorly there is
bilaminar or retrodiscal
region/retroarticular
pad/trilaminar pad
 More anteriorly anterior
extension
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 Anterior extension of the
disc attached to fibrous
capsule superiorly and
inferiorly
 In between it gives
insertion to lateral
pterygoid where the
fibrous capsule is lacking
.
 Synovial membrane here
is supported by loose
areolar tissue
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ARTICULAR DISC /MENISCUS…
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 The anterior and
posterior parts -
transverse running fibres
 intermediate zone -
anterio posteriorly
oriented fibres
 Anatomical arrangement
allows greater degree of
movement during active
mandibular movement
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BILAMINAR REGION
/RETRODISCAL PAD
 Three parts
 Superior portion elastic
 Inferior portion inelasic
 Intermediate zone richly
innervated and has rich
blood supply
 Elastic fibres of
retrodical tissue pulls the
disc during jaw closure
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ARTICULAR DISC /MENISCUS..
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;Significance
Upper
lamina;prevents the
displacement of the
disc while yawning
lower lamina;prevents
excessive rotation of
disc over the condyle
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The disc is attached to the
capsule all around
except at for the strong
straps that fix the disc
directly to the medial and
lateral condylar pole
Significance;Ensures the disc
and condyle move together
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ARTICULAR DISC /MENISCUS..
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 ANATOMICAL DISC
POSITION
 Pars posterior on the
superor portion of the
condylar head
 Pars intermedia anterio
superior convexity of the
condyle and articular
protuberance
 Parsanterior in front of
the condyle
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CAPSULE OF TMJ
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 Thin sleeve of fibrous
tissue surrounding
entire tmj
 Extends from the
circumference of cranial
articular surface to the
neck of the condyle
 Capsule is loose above
intra articular disc tight
below the disc
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CAPSULE OF TMJ
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ANTERIORLY-PRE
GLENOID PLANE
POTERIORLY-POSTERIOR
ARTICULAR RIDGE
MEDIALLY;MEDIAL PART
OF TEMPORAL BONE
Laterally-lateral
condylar pole
Medially-dips below
the medial pole
LATERALLY;LATERAL
RIM OF MANDIBULAR
FOSSA
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CAPSULE OF TMJ
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 TMJCAPSULE - LIMITS TRANSLATION OF THE
CONDYLE
 Reinforced more laterally by an external tmj
ligament,
 Laterally and medially blend with the
condylodiscoidalligament
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CAPSULE OF TMJ
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 Anteriorly the capsule has an orifice through which
lateral pterygoid tendon passes
 Area of relative weakness in the capsular lining
 Source of possible herniation of intra articular disc
and this place may allow forward displacement of
disc
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LIGAME NTS
OF TMJ…LLIGA
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 Passive restraining structure limits and restricts the
border movement thus protects the joint
 Made of collagenous tissue
 Particular length
 If sudden or prolonged forces are applied they get
elongated thus compromise the function.
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Primary
ligaments
• Collateral or discal
ligament
• Fibrousorcapsular
ligament
• Lateral or temporo
mandibular ligament
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ACCESSORY
LIGAMENT
• Stylomandibular
ligament
• Sphenomandibular
ligament
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 True ligaments
 Attaches medial and lateral
border of articular disc to
the poles of the condyle
 Medial discal ligament-
medial pole of the condyle
 Lateral discal ligament-
lateral pole of the condyle
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 COLLATERAL LIGAMENT
 FUNCTIONS ;
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 Reinforces the lateral aspect of capsular ligament
 TWO LAYERS
 Outer oblique portion
 Inner horizontal portion
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 Functions
 Thehorizontal portion
limits retrusion and
laterotrusion and protect
sensitive bilaminar zone
from injury
 Oblique part limits the
jaw opening
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 Applied anatomy
 Superior portion of temporomandibular ligament
contains golgi tendon organs.
 These nerve endings very important in
neuromuscular monitoring of mandibular
movements
 For this reason anaesthetizing the lateral portion of
the joint permits15-20% increase in jaw movements
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SPHENOMANDIBULAR
LIGAMENT (5th muscle)
ACCESSORY LIGAMENT
ORIGIN;FROM THE SPINE
OF THE SPHENOID
INSERTION ;LINGULA OF
THE MANDIBLE
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 SPHENOMANDIBULAR
LIGAMENT/INTERNAL
LATERAL LIGAMENT
 Represents the
remanants of meckels
cartilage
 Fibers directed
outwards and
downwards
 FUNCTION ;limits the
distension of
mandible in inferior
direction
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 STYLOMANDIBULAR
LIGAMENT
 Thickened posterior
portion of the
investing cervical fascia .
 Styloid process of
the temporal bone to the
angle and posterior border
of the mandible between
the masseter and medial
pterygoid
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 STYLOMANDIBUL
AR LIGAMENT
 Separates parotid and
submandibular gland
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 DISCOMALLEOLAR
LIGAMENT (PINTOS
LIGAMENT)
 Described by pinto 1962
as a connection between
malleus and medial wall
of the joint capsule
 Demonstrated only in
29% of tmj
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 DISCOMALLEOLAR
LIGAMENT (PINTOS
LIGAMENT)
 Define the border movement
or farthest extent of the of
the mandiblar movement
 The disco-malleolar
ligament: A possible cause of
subjective hearing loss in
patients with
temporomandibular joint
dysfunction
 Article in Journal of Maxillofacial Surgery 11(5):227-
31 · November 1983 with 93 Reads
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 HILTONS LAW
 The principle is THAT NERVE SUPPLYING A
JOINT ALSO SUPPLIES BOTH MUSCLES
THAT MOVES THE JOINT AND THE SKIN
COVERING THE ARTICULAR INSERTION OF
THOSE MUSCLE
 Mandibular division of fifth cranial nerve
supply the tmj
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 Most innervation by
auriculotemporal
 Additional by massetric
and deep temporal
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Involves four receptors (retrodiscal tissue)
Ruffini endings ;static mechanoceptors which position the mandible
Pancian corpuscle;dynamic mechanoceptors
Golgi tendon organs;static mechanoceptors for the protection of
ligament around tmj
Free nerve endings;pain receptors for the protection of tmj itself
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 free nerve ending ofC&A fibres that conduct pain
impulses from the joint
 This is part of feedback mechanism that limits
execessive mandibular movements
 Inorder to work properly there is neither innervation
nor vascularisation in the central portion of the disc
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Blood supplyto tmj is circumferential every vessle
within radius of 3 cm contributes branches to the
joint capsule and contribute one or two branches of
it
 superficial temporal branch of ECA
 Rich vasular supply to the retrodiscal lamina by
internal maxillary artery, posterior auricular and
deep auricular
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 SUPERFICIAL TEMPORAL VEIN
 MAXILLARY VEIN
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DRAINAGE
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MUSCLES OF MASTICATION
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 DEVELOPS FROM FIRST BRACHIAL ARCH
 SUPPLIED BY MANDIBULAR NERVE
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MASSETER
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 ACTION
 Elevation of the
mandible
 Protrusion
 NERVE SUPPLY
 Massetric nerve
APPLIED ANATOMY
Hypertrophy in bruxism
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MASSETER MUSCLE
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TEMPORALIS
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 It is a broad, fan-shaped
muscle on each side of
the head that fills the
temporal fossa, superior
to the zygomatic arch so
it covers much of
the temporal bone

TEMPORALIS
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ORIGIN- Temporal fossa
and temporal fascia
INSERTION-Coronoid
process and anterior
border of ramus
NERVE SUPPLY-DEEP
TEMPORAL NERVE
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Applied anatomy
 A myotendinous rupture of the temporalis can occur
during a seizure due to extreme clenching of the jaw.
 Habitual grinding of teeth can lead to overwork of
the temporalis and results in pain
affa, Lena; Yasmeen, Tandon; Rubin, Michael (2014). "Myotendinous rupture of
temporalis muscle: A rare injury following seizure". World Journal of
Radiology. 6 (6)

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TEMPORALIS MUSCLE
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LATERAL PTERYGOID
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 EXTERNAL PTERYGOID
MUSCLE

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 Depress the mandible
 Protrusion of the
mandible
 Applied anatomy
 Peripheral heart of
head and neck

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DEPRESSION;
LATERAL
PTERYGOID
ELEVATION;
MASSETER,TEMPO
RALIS,&MEDIAL
PTERYGOID

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PROTRUSION;
LATERAL&MEDIAL
PTERYGOID
RETRACTION;
POSTERIOR
FIBRESOF
TEMPORALIS

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MOVEMENTS OF TMJ
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FIRST 25mm-
rotation of the
condyle-inferior
joint space
UNTILL 35mm-
gliding motion-
upper joint
space
Opening greater
35mm-further
translation with
over rotation

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NORMAL TMJ FUNCTION
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Video of normal tmj
movement

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RELATIONS OF TMJ
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ANTERIORLY
 Massetric nerve and artery
 Laterral pterygoid
 Mandibular notch
POSTERIORLY
 Parotid gland
 Superficial temporal vessles
 Auriculotemporal nerve
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SUPERIORLY
 MIDDLE CRANIAL
FOSSA
 MIDDLE MENINGEAL
VESSLE
INFERIORLY
 MAXILLARY ARTERY
AND VEIN
LATERALY
 SKIN AND FASCIA
 PAROTID GLAND
 TEMPORAL BRANCH OF
FACIAL NERVE

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 Histological appearance varies with age due the
presence of secondary cartilage
 The cartilage appears at about 10 th month of iu life
and remains as proliferating zone until about later
half of second decade of life
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 ARTICULAR SURFACE
consist of four distinct
layer
1. ARTICULAR ZONE
2. PROLIFERATIVE
ZONE
3. FIBRO
CARTILAGENOUS
ZONE
4. CALCIFIED
CARTILAGENOUS
ZONE

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 ARTICULAR ZONE
 Outermost functional
surface
 Made of dense
connective tissue rather
than hyaline cartilage
 Has much better ability
to repair

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PROLIFERATIVE ZONE
Undefferentiated
mesenchymal tissue
responsible for proliferation
of articular
FIBRO CARTILAGENOUS
ZONE
 Collagen fibrils are arranged
in bundles in acrossing
pattern
 Random orientation provide a
3d network that offer
resistance against
compressive and lateral forces

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 CALCIFIED
CARTILAGENOUS
ZONE
 Deepest zone made of
chondrocyte and
chondroblast distibuted
throughout the articular
cartilage
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SYNOVIAL MEMBRANE
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SYNOVIAL MEMBRANE…
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TWO LAYERS
 CELLULALAR INTIMA
 VASCULAR SUB
INTIMA
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SYNOVIAL MEMBRANE…
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FUNCTIONS
 PRODUCTION OF THE SYNOVIAL FLUID
 PRODUCTION OF VARIOUS DEFENCE CELLS
 REMOVAL OF FOREIGN MATERIAL
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SYNOVIAL FLUID
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 Produced by synovial
membrane intimal cell
 Formed by viscious fluid
containig varying types
of CELLS
(monocyte,lymphocyte,le
ukocyte, macrophage)

SYNOVIAL FLUID
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FUNCTIONS
 Provides lubrication to joint surface
 BOUNDARY LUBIRICATION AND WEEPING
LUBRICATION
 Shock absorption
 Reduce the wear during joint function
 Provides nutrition to disc, articular surfaces
 Removal of foreign material(phagocytosis)
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AGE CHANGES OF TMJ
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Physical examination of the joint
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 Inspection
Maximum mouth
opening
Lateral range of
movements

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 Palpation

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 AUSCULTATION
Clicking sound
Crepitus

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 Sensitivity develops to
hot and cold
 Tenderness on biting
•Spastic masticatory
muscle

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 Muscle tension headache Condyledisc derrangement
Degenerative disc changes

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Supporting Cusp/Stamp
Cusp or
Centric Holding Cusp
 A centric holding cusp is
that which ideally occludes
along the line of the central
grooves of opposing teeth
These are the palatal
cusps on the maxillary
and buccal
on the mandibular
teeth.

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 Non centric cusp
 These cusps overlap the
opposing tooth without
contacting the tooth.
 They are present on
buccal cusps of maxillary
teeth and lingual cusps of
mandibular teeth

CENTRIC RELATION
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"The maxillo-mandibular
relationship in which the
condyles articulate with
the thinnest avascular
portion of their
respective discs with the
complex in the anterior-
superior position against
the slopes of the
articular eminences”
-GPT8.

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Concept of 138 points of occlusal contact
 Proposed by Hellman
 138 posible contact for 32 teeth

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 The list of occlusal contacts (total, 138) follows:
 1. Lingual surfaces of maxillary incisors and canines, 6
 2. Labial surface of mandibular incisors and canines, 6
 3. Triangular ridges of maxillary buccal cusps of
premolars and molars, 16
 4. Triangular ridges of lingual cusps of mandibular
premolars and molars, 16
 5. Buccal embrasure of mandibular premolars and
molars, 8

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139
 6 Lingual embrasures of maxillary premolars and
molars
 7. Lingual cusp points of maxillary premolars and
molars, 16
 8. Buccal cusp points of mandibular premolars and
molars, 16
 9. Distal fossae of premolars, 8

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 10. Central fossae of the molars, 12
 11. Mesial fossae of the mandibular molars, 6
 12. Distal fossae of the maxillary molars, 6
 13. Lingual grooves of the maxillary molars, 6
 14. Buccal grooves of the mandibular molars, 6*

CURVES OF OCCLUSION
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CURVES OF SPEE
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 Anatomic curvature of
the occlusal alignment of
the teeth, beginning at
the tip of the lower
incisor, following the
buccal cusps of the
natural premolars and
molars and continuing to
the anterior border of the
ramus.

CURVE OF WILSON
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 Contacts the buccal and
lingual cusps of the
molars, being lower in
the middle due to the
lingual inclination of the
long axes of the
mandibular molars

CURVE OF MONSOON
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An ideal curve of occlusion
in which each cusp and
incisal edge touches the
surface of an imaginary
sphere 8 inches in
diameter.

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The occlusal treatment goals for selective grinding
are as follows:
1.CENTRIC RELATION-centric cusp and opposing
fossa
2. LATEROTRUSIVE -contacts on the anterior teeth
disocclude the posterior teeth.
Okeson J.P., Management of Temporomandibular Disorders and Occlusion. 7th edition Elsevier, Mosby 2013

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3.PROTRUSION- contacts on the
anterior teeth disocclude the posterior teeth.
4. Upright head position-the posterior teeth contact
more heavily than the anterior teeth.

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 video

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BRUXISM
150
DEFINITION
Bruxism is defined as “diurnal or nocturnal parafunctional activity including
clenching, bracing, gnashing, and grinding of the teeth.”
-American academy of orofacial pain
Clenching - centric bruxism
Grinding - eccentric bruxism
 "A movement disorder of the MASTICATORY SYSTEM characterized by
teeth-grinding and clenching during sleep as well as wakefulness."
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BRUXISM
151
BASED ON TEMPORAL PATTERN
 NOCTURNAL
 DIURNAL
BASEDON CAUSE
 PRIMARY
 SECONDARY
BASED ON SEVERITY
 MILD
 MODERATE
 SEVERE
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BRUXISM
152
 PSYCHOSOCIAL FACTORS
 GENETIC FACTORS
 MEDICATION
 OCCLUSAL FACTORS
 MISCELLENIOUS
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153
 CLINICAL FEATURES
Bruxism is usually detected
because of the effects of
the process rather than
the process itself
 Excessive tooth wear
 Tooth fractures, and repeated
failure of dental restorations
 Hypersensitive teeth
 Inflammation of
the periodontal ligament of
teeth
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154
 A grinding or tapping
noise during sleep,
 Hypertrophy of
the muscles of
mastication
 Tenderness, pain or
fatigue of the muscles of
mastication,.
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155
 Trismus
 Pain or tenderness of
the temporomandibular
joints which may
manifest as preauricular
pain (in front of the ear),
or pain referred to the
ear otalgia.
 Clicking of the
temporomandibular
joints.
 Headaches

management
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156
 Occlisal splints and
dental guard
• Pyschosocial
intervention
• Medications
• Biofeedback

157
 Tmj dislocation is the separation from the articular
surface and fixation in an abnormal position.
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158
 Akinbami classified TMJ dislocation into the
following three types:
 Type I - the head of the condyle is directly below the
tip of the eminence
 Type II - the head of the condyle is in front of the tip
of the eminence
 Type III - the head of the condyle is high-up in front
of the base of the eminence.
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160
Neuromuscular –laxity of the articular disc and the
capsular ligament,
long-standing internal derangement, and spasm of the
lateral pterygoid muscles.
Structural deficit-flattening or narrowing
decrease in the height of the articular eminence
morphological changes of the glenoid fossa,
zygomatic arch, and squamotympanic fissure
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TMJ ANATOMY AND FUN
CTION
161
FUNCTIONAL
 Forceful wide opening of the mouth while
yawning Laughing, vomiting, or
seizures, dental treatments like third
molar extractions or ROOT CANAL
TREATMENTS
 Antipsychotic medications

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162

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163

Clinical features
164
 Inability to close the oral cavity,
 Difficulty in speech
 Drooling of saliva
 Lip incompetency
 Pain in the pre auricular region is present.
 Deviation of the chin to the contralateral side.
 Palpation over the preauricular region may suggest
emptiness in the joint space.
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DIAGNOSIS
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165
 Clinical history and
examination
 Plain and panoramic
radiographies, showing
the location of the
condylar head anterior to
the articular eminence.
 Three-dimensional
computed tomography

MANAGEMENT
166
 Conservative methods of
management symptomatic
pain relief with analgesics
and manual reduction.
 The manual reduction
method
 Described by Hippo crates
 First pressing the
mandible downward, then
backward, and finally
upward
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MANAGEMENT
167
 LEWIS MODIFICATION(1981)
 PATIENT -sitting position
 CLINICIAN - stand in front of him/her or at 11o’
clock position.
 THUMB- pressed down on the occlusal surface of
the lower molar teeth.
 CHIN- elevated with the fingers and the entire
mandible should be pushed posteriorly.
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MANAGEMENT
168
FURTHER MODIFICATION
 Position of the thumb from the occlusal surface of
the teeth to the anterior border of the ramus
 Under local anesthesia by giving auriculotemporal
nerve block or local infiltration in the joint space.
 Muscle relaxants
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MANAGEMENT
169
 AWANGS
MODIFICATION
 Simple, safe, and rapid
method
 Induction of the gag
reflex by probing the soft
palate creates a reflex
neuromuscular action
that resulted in the
reduction.
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170
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171
Nature has blessed us with marvelously dynamic
masticatory system
A sound knowledge of tmj anatomy and function is
very essential as a part of masticatory system.

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172

References
173
 Williams pl grays anatomy in skeletal system 38th
edition
 Falex partner medical dictionary
 Berkovitz, Holland, Moxham. Oral Anatomy,
Histology and Embryology.
 Tencate’s oral histology 8th edition
 BD chaurasias human anatomy fifth edition
 Peterson principle of oral and maxillofacial surgery
 1. Okeson JP. Management of Temporomandibular
Disorders and Occlusion. 5th ed. Louis: Mosby; 2003
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References
174
 lustrated Dental Embryology, Histology, and Anatomy,
Bath-Balogh and Fehrenbach, 2011, page 266.
 Illustrated Anatomy of the Head and Neck, Fehrenbach and
Herring, Elsevier, 2012, page 118.
 Jump up^Rodríguez-Vázquez, J.F.; Mérida-Velasco,
J.R.; Mérida-Velasco, J.A.; Jiménez-Collado, J.
(1998). "Anatomical considerations on the discomalleolar
ligament" J. Anat. 192.
 Article in Journal of Maxillofacial
Surgery11(5):227-31 · November 1983 with 93
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