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  • Since so many TMJ problems involve the muscles, it is extremely helpful to know their names and how they work.
  • Nitzan et al.,9 then described a technique whereby twoneedles instead of one were introduced into the upper jointspace. This adaptation permitted massive lavage of the joint aswell as aspiration and injection.9 In this technique the pointsfor the needle’s insertion are marked on the skin according tothe method suggested by McCain et al. for arthroscopy (posterolateralapproach to the upper joint space).17,18 A line isdrawn from the lateral canthus to the most posterior and centralpoint on the tragus (Holmlund–Hellsing Line, Fig. 1).22The posterior point of entry is located along the canthotragalline 10mm from the middle of the tragus and 2mm belowthe canthotragal line (point A in Fig. 1).5 This is the approximatearea of the maximum concavity of the glenoidfossa.The distance is about 25mm from skin to the centre of thejoint space.5 The anterior point of entry is placed 10mm furtheralong the canthotragal line and 10mm below it (point Bin Fig. 1). This marking indicates the site of the eminence ofthe TMJ.Laskin et al.7 suggested that because access to the anteriorrecess is not necessary, as it is when the entire joint mustbe visualised during arthroscopy, it is easier merely to insertthe anterior needle 2–3mm in front of the posterior needle(point D in Fig. 1). Alkan and Etöz15 proposed another technique,in which the posterior point of entry was the same asdescribed earlier for point A. However, the second needlewas inserted 7mm anterior from the middle of the tragus and2mm inferior along the canthotragal line (point C in Fig. 1).This second needle was adjusted parallel and almost 3mmposterior to the first until bony contact was made. Outflowwas easier to achieve when the second needle was insertedbehind the first one in the wider part of the upper joint compartment.They suggested that the use of this landmark asthe default technique may be reasonable, as repeated insertionsof a needle are uncomfortable both for physicians andpatients and adversely affect the success of the treatment.15
  • Tmj.ppt

    3. 3. Introduction• The most important functions of the temporomandibularjoint (TMJ) are mastication and speech and are of greatinterest to dentists, orthodontists, clinicians, andradiologists.• The TMJ is a ginglymoarthrodial joint, a term that isderived from ginglymus, meaning a hinge joint, allowingmotion only backward and forward in one plane, andarthrodia, meaning a joint of which permits a glidingmotion of the surfaces.Dorland WA: Medical Dictionary. Philadelphia and London, SaundersCo., 1957
    4. 4. • The right and left TMJ form a bicondylararticulation and ellipsoid variety of the synovialjoints similar to knee articulation.• The common features of the synovial jointsexhibited by this joint include a disk, bone, fibrouscapsule, fluid, synovial membrane, and ligaments.However, the features that differentiate and makethis joint unique are its articular surface coveredby fibrocartilage instead of hyaline cartilage.Williams PL: Gray’s anatomy, in Skeletal System (ed 38).Churchill. Livingstone, London, 1999, pp 578-582
    5. 5. Peculiarity of TMJ1. Bilateral diarthrosis – right & left function together2. Articular surface covered by fibrocartilageinstead of hyaline cartilage3. Only joint in human body to have a rigid endpointof closure that of the teeth making occlusal contact.
    6. 6. 4. In contrast to other diarthrodial joints TMJ is lastjoint to start develop, in about 7th week inutero.5. Develops from two distinct blastema.Peculiarity of TMJ…….
    7. 7. Components
    8. 8. • Mandibular condyle• Articular surfaces of Temporal bone• Capsule• Articular disc• Ligaments• Muscular component
    9. 9. THE MANDIBULARCONDYLE• An ovoid process seated atop anarrow mandibular neck. It’s thearticulating surface of themandible.• It is convex in all directions butwider latero-medially (15 to 20mm) than antero-posteriorly (8 to10mm).
    10. 10. It has lateral and medialpoles:• The medial pole is directedmore posteriorly.• Thus, if the long axes of twocondyles are extendedmedially, they meet atapproximately the basion onthe anterior limit of theforamen magnum, formingan angle that opens towardthe front ranging from 145to 160
    11. 11. • The lateral pole of thecondyle is rough, bluntlypointed, and projects onlymoderately from the planeof ramus, while the medialpole extends sharply inwardfrom this plane.• The articular surface lies onits anterosuperioraspect, thus facing theposterior slope of thearticular eminence of thetemporal bone.
    12. 12. • It further continuesmedially down andaround the medial pole ofthe condyle to face theentoglenoid process ofthe temporal bone wherethe jaw is held in anoccluded position.
    13. 13. Cranial ComponentorArticular surfaces of Temporal bone• The articular surface of thetemporal bone is situated onthe inferior aspect oftemporal squama anterior totympanic plate.• Various anatomical terms ofthe joint are elaborated
    14. 14. • (a) Articular eminence:This is the entiretransverse bony bar thatforms the anterior root ofzygoma. This articularsurface is most heavilytraveled by the condyleand disk as they rideforward and backward innormal jaw function.
    15. 15. (b) Articular tubercle: This is asmall, raised, rough, bony knobon the outer end of the articulareminence.It projects below the level of thearticular surface and serves toattach the lateral collateralligament of the joint.(c) Preglenoid plane: This is theslightly hollowed, almosthorizontal, articular surfacecontinuing anteriorly from theheight of the articular eminence.
    16. 16. (d) Posterior articular ridge and thepostglenoid process:The posterior part of the mandibularfossa is an anterior margin of thepetrosquamous suture and iselevated to form a ridge knownas the posterior articular ridge orlip.This ridge increases in heightlaterally to form a thickenedcone-shaped prominence calledthe post glenoid processimmediately anterior to theexternal acoustic meatus.E: Articular eminence; enp: entogolenoidprocess; t:articular tubercle; Co: condyle;pop: postglenoid process; lb: lateral borderof the mandibular fossa; pep: preglenoidplane; Gf: glenoid fossa; Cp: condylarprocess
    17. 17. (e) Lateral border of themandibular fossa: This structuris usually raised to form a slightcrest joining the articulartubercle, in front, with thepostglenoid process behind.(f) Medially the fossa narrowsconsiderably and is bounded bya bony wall that is theentoglenoid process, whichpasses slightly medially as themedial glenoid plane.
    18. 18. • The roof of the mandibularfossa, which separates itfrom the middle cranialfossa, is always thin andtranslucent, even in theheavy skull.• This demonstrates that,although the articular fossacontains the posterior rimof the disk and the condyle,it is not a functionallystress-bearing part of thecraniomandibulararticulationPatnaik VVG, Bala S,Singla Rajan K: Anatomy of temporomandibular joint? Areview. J Anat Soc India 49(2):191-197, 2000
    19. 19. Articular Disc• The articular disc is the most importantanatomic structure of the TMJ.• It is a biconcave fibrocartilaginousstructure located between themandibular condyle and the temporalbone component of the joint.• Its functions to accommodate ahinging action as well as the glidingactions between the temporal andmandibular articular bone.
    20. 20. • The articular disc is a roughlyoval, firm, fibrous plate.1. anterior band = 2 mm inthickness,2. posterior band = 3 mm thick,3. thin in the centre intermediateband of 1 mm thickness.More posteriorly there is abilaminar or retrodiscalregion.• It is shaped like a peaked cap that divides the joint into alarger upper compartment and a smaller lowercompartment.
    21. 21. • Hinging movements take placein the lower compartment andgliding movements take placein the upper compartment.• The superior surface of the disc - saddle-shapedto fit into the cranial contour,• The inferior surface - concaveto fit against the mandibular condyle.
    22. 22. • The disc is attached all around thejoint capsule except for the strongstraps that fix the disc directly tothe medial and lateral condylarpoles, which ensure that the discand condyle move together inprotraction and retraction.Williams PL: Gray’s anatomy, in Skeletal System (ed 38).ChurchillLivingstone, London, 1999, pp 578-582
    23. 23. • The anterior extension of thedisc is attached to a fibrouscapsule superiorly andinferiorly.• In between it gives insertionto the lateral pterygoidmuscle where the fibrouscapsule is lacking and thesynovial membrane issupported only by looseareolar tissue.Williams PL: Gray’s anatomy, in Skeletal System (ed 38).ChurchillLivingstone, London, 1999, pp 578-582
    24. 24. • The anterior and posteriorbands have predominantlytransversal runningfibers, while the thinintermediate zone hasanteroposteriorly orientedfibers.• Posteriorly, the bilaminarregion consists of two layersof fibers separated by looseconnective tissue.
    25. 25. • The upper layer ortemporal lamina iscomposed of elastin andis attached to thepostglenoidprocess, mediallyextended ridge, which isthe true posteriorboundary of the joint. Itprevents slipping of thedisc while yawning.Harms SE, Wilk RM: Magnetic resonance imaging of the temporomandibular joint.Radiographics 7(3):521-542, 1987• The inferior layer of the fibers or inferior lamina curve downbehind the condyle to fuse with the capsule and back of thecondylar neck at the lowest limit of the joint space. It preventsexcessive rotation of the disc over the condyle.
    26. 26. • In between the two layers, anexpansile, soft pad of bloodvessels and nerves aresandwiched and wrapped inelastic fibers that aid incontracting vessels andretracting disc in recoil ofclosing movements.Harms SE, Wilk RM: Magnetic resonance imaging of the temporomandibular joint.Radiographics 7(3):521-542, 1987• The volume of retrodiscal tissue must increaseinstantaneously when the condyle translatesanteriorly.
    27. 27. • On sagittal MR imaging, thedisk - biconcave structure withhomogeneous low signalintensity that is attachedposteriorly to the bilaminarzone, which demonstratesintermediate signal intensity.• The anterior band liesimmediately in front of thecondyle and the junction of thebilaminar zone, and the disk liesat the superior part of thecondyle.Harms SE, Wilk RM: Magnetic resonance imaging of the temporomandibular joint.Radiographics 7(3):521-542, 1987• The posterior bandand retrodiskal tissueare best depicted inthe open-mouthposition.
    28. 28. FibrousCapsule• Thin sleeve of tissue completely surroundingthe joint.• Extends from the circumference of thecranial articular surface to the neck of themandible.• The outline – anterolaterally to the articular tubercle, laterally to the lateral rim of the mandibularfossa, posterolaterally to the postglenoid process, posteriorly to the posterior articular ridge, medially to the medial margin of thetemporal, anteriorly it is attached to the preglenoidplanePatnaik VVG, Bala S,Singla RajanK: Anatomy oftemporomandibular joint? Areview. J Anat Soc India49(2):191-197, 2000
    29. 29. The outline of attachment on themandibular neck -• Laterally- the lateral condylar pole but• Medially - dips below the medial pole.• On the lateral part of the joint, the capsuleis a well-defined structure thatfunctionally limits the forward translationof the condyle.
    30. 30. • Medially and laterally-blends with thecondylodiscal ligaments.• This capsule is reinforced more laterally by anexternal TMJ ligament, which also limits thedistraction and the posterior movement of thecondyle.
    31. 31. • Anteriorly, the capsule has anorifice through which the lateralpterygoid tendon passes. This areaof relative weakness in thecapsular lining becomes a sourceof possible herniation of intra-articular tissues, and this, in part,may allow forward displacementof the disk.Kreutziger KL, Mahan PE: Temporomandibular degenerative jointdisease. Part II. Diagnostic procedure and comprehensive management.Oral Surg Oral Med Oral Pathol 40(3):297-319, 1975
    32. 32. • The synovial membrane lining thecapsule covers all the intra-articularsurfaces except the pressure-bearingfibrocartilage.Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg11(3):207-212, 1974• There are four capsular or synovial sulci situated at the posteriorand anterior ends of the upper and lower compartments.• These sulci change shape during translatory movements, whichrequires the synovial membrane to be flexible.
    33. 33. TemporomandibularLigaments Complex
    34. 34. CollateralLigaments• The ligament on each side of thejaw is designed in two distinctlayers.• The wide outer or superficiallayer is usually fan-shaped andarises from the outer surface of thearticular tubercle and most of theposterior part of the zygomaticarch.• There is often a roughened, raisedbony ridge of attachment on thisarea.
    35. 35. • The ligamentous fascicles run obliquelydownward and backward to be inserted onthe back, behind, and below the mandibularneck.• Immediately medial to this layer, a narrowligamentous band arises from the crest of thearticular tubercle continuously, withattachment of the outer portion at this site.• This narrow inner or deep band runshorizontally back as a flap strap to the lateralpole of the condyle.• An upper part of this band continues on toattach to the back of the disk, lateral to thecondylar pole.
    36. 36. • Medial slippage of the condyleis prevented medially by theentoglenoid process andlaterally by thetemporomandibular ligament.McMinn, RMH: Last’s anatomy regional and applied, in Head and Neckand Spine. Churchill Livingstone, Edinburgh, London, 1994, p. 523• The outer oblique band becomes taut in the protraction ofthe condyle, which accompanies the opening of thejaw, thereby limiting the inferior distraction of the condylein forward gliding and rotational movements, while theinner horizontal band tightens in retraction of the head ofthe mandible, thereby limiting posterior movement of thecondyle .
    37. 37. Sphenomandibular Ligament• Arises from the angular spineof the sphenoid andpetrotympanic fissure.• Runs downward and outward.• Insert on the lingula of themandible.
    38. 38. • The ligament is related –1. Laterally - lateral pterygoidmuscle.2. posteriorly - auriculotemporal nerve.3. anteriorly - maxillary artery.4. Inferiorly - the inferior alveolar nerveand vessels a lobule of the parotidgland.5. Medially - medial pterygoid with thechorda tympani nerve and the wall ofthe pharynx with fat and thepharyngeal veins intervening.
    39. 39. • The ligament is pierced bythe myelohyoid nerve andvessels.• This ligament is passiveduring jawmovements, maintainingrelatively the same degreeof tension during bothopening and closing of themouth.
    40. 40. Stylomandibular Ligament• This is a specializeddense, local concentration ofdeep cervical fascia extendingfrom the apex and beingadjacent to the anterior aspectof the styloid process and thestylohyoid ligament to themandible’s angle andposterior border.
    41. 41. • This ligament then extendsforward as a broad fasciallayer covering the innersurface of the medialpterygoid muscle.• The anterior edge of theligament is thickened andsharply defined.
    42. 42. • It is lax when the jaws are closed and slackensnoticeably when the mouth is opened because theangle of the mandible swings up and back whilethe condyle slides downward and forward.• This ligament becomes tense only in extremeprotrusive movements. Thus, it can be consideredonly as an accessory ligament of uncertainfunction.
    43. 43. Lubrication of the Joint• The synovial fluid comes from two sources: first, fromplasma by dialysis, and second, by secretion from type Aand B synoviocytes with a volume of no more than 0.05ml.• However, contrast radiography studies have estimated thatthe upper compartment could hold approximately 1.2 ml offluid without undue pressure being created, while the lowerhas a capacity of approximately 0.5 ml.Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg11(3):207-212, 1974
    44. 44. Synovial fluid……• It is clear, straw-colored viscous fluid.• It diffuses out from the rich cappillary network of thesynovial membrane.Contains:• Hyaluronic acid which is highly viscous• May also contain some free cells mostly macrophages.Functions:• Lubricant for articulating surfaces.• Carry nutrients to the avascular tissue of the joint.• Clear the tissue debris caused by normal wear and tear ofthe articulating surfaces.
    45. 45. Muscular Component• The masticatory muscles surrounding the joint are groupsof muscles that contract and relax in harmony so that thejaws function properly.• When the muscles are relaxed and flexible and are notunder stress, they work in harmony with the other parts ofthe TMJ complex.• The muscles of mastication produce all the movements ofthe jaw.• These muscles begin and are fixed on the craniumextending between the cranium and the mandible on eachside of the head to insert on the mandible.
    46. 46. Teeth and Occlusion• The way the teeth fit together may affect the TMJcomplex.• A stable occlusion with good tooth contact andinterdigitation provides maximum support to the musclesand joint, while poor occlusion (bite relationship) maycause the muscles to malfunction and ultimately causedamage to the joint itself.• Instability of the occlusion can increase the pressure on thejoint, causing damage and degeneration.
    47. 47. VASCULARISATION• Branches of External Carotid Artery– Superficial temporal artery– Deep auricular artery– Anterior tympanic artery– Ascending pharyngeal artery– Maxillary artery
    48. 48. VASCULARISATION• The Blood supply to TMJ is only Superficial,i.e. there is no blood supply inside the capsule• TMJ takes its nourishment from Synovial fluid
    49. 49. InnervationsMovements of synovial joint initiated & effected by muscle coordination.Achieved in part through sensory innervation.Hilton’s Law:The principle that the nerve supplying a joint also supplies both the musclesthat move the joint and the skin covering the articular insertion of thosemuscles.Therefore:Branches of the mandibular division of the fifth cranial nerve supplythe TMJ (auriculotemporal, deep temporal, and masseteric)
    50. 50. Innervations4 Types of nerve endings:1. Ruffini’s corpuscles (limited to capsule)2. Pacini’s corpuscles (limited to capsule)3. Golgi tendon organs (confined to ligament)4. Free nerve endings (most abundant)
    51. 51. PROPIOCEPTION• Ruffini Endings Position the mandible• Pacinion Receptors Accelerate movement during Reflexes• Golgi tendon Organs Protection of ligaments Around TMJ• Free Nerve Endings Pain receptors
    52. 52. Pacinian Corpuscle“Onion-likeencapusulated pressurereceptorsSurrounding concentriclamellae respond todistortion, generateaction potential inunmyelinated fiber incoreBar = 100 microns
    53. 53. Ruffini’s & Golgi CorpuscleFunction:Ruffini’s = Posture (proprioception), dynamic and static balanceGolgi tendon organ = Static mechanoreception, protection (ligament)Free nerve endings = Pain (nociception) protection (joint) MicroscopicAnatomy/Section06/Section06.shtml
    55. 55. 1. The articular zone• Dense fibrousconnective tissue• Poor blood supply• Better ability torepair• Good adaption to sliding movement• Shock absorber• Less susceptible to the effect of agingtime & breakdown over time.
    56. 56. 2. The proliferativezone• Mainly cellularzone• Undifferentiatedmesenchymal cells• Proliferation &regenerationthroughout life
    57. 57. 3. The cartilagenouszone• Collagen fibersarranged in criss -cross pattern ofbundles• Offers considerable resistance againstcompressive & lateral forces• But becomes thinner with age.
    58. 58. 4. The calcified zone• Deepest zone• Chondrocytes, chondroblasts &osteoblasts• Active site for remodeling activity as bonegrowth proceeds.
    59. 59. RELATIONSAnteriorly - Mandibular notchLateral pterygoidMasseteric nerve andartery
    60. 60. • A careful dissection of 16intact human cadaverichead specimens revealedThe location of themasseteric artery wasthen determined inrelation to 3 pointsprocess:1) the anterior-superioraspect of the condylarneck = 10.3 mm;2) the most inferior aspect ofthe articular tubercle =11.4 mm;3) the inferior aspect of thesigmoid notch = 3 mm.Bashar M. Rajab, Ammar A.Sarraf, A. Omar Abubaker,Daniel M. Laskin MassetericArtery: Anatomic Location andRelationship to theTemporomandibular Joint AreaJournal of Oral andMaxillofacial Surgery. 2009;67(2) : 369–371
    61. 61. RELATIONSPosteriorly - parotid glandSuperficial temporal vesselsAuriculotemporal nerve
    62. 62. RELATIONSLaterally –Skin and fasciaParotid glandTemporal branches of facial nerve
    63. 63. Medially - Tympanic plate (separates from ICA)spine of sphenoidAuriculotemporal & chorda tympani nervemiddle meningeal arterymaxillary artery
    64. 64. Superiorly –middle cranial fossamiddle meningeal vessels
    65. 65. Inferiorly –maxillaryartery&vein
    66. 66. Inferiorly –maxillaryartery&vein
    67. 67. Inferiorly –maxillaryartery&vein
    68. 68. Movements• Rotational / hinge movement in first 20-25mm of mouth opening• Translational movement after that when themouth is excessively opened.
    69. 69. • Translatory movement – in the superior part of the joint as thedisc and the condyle traverse anteriorly along the inclines ofthe anterior tubercle to provide an anterior and inferiormovement of the mandible.
    70. 70. Mouth closed Mouth open Hinge movement – the inferior portion of the joint between thehead of the condyle and the lower surface of the disc to permitopening of the mandible.
    71. 71. 1. Depression Of Mandible– Lateral pterygoid– Digrastric– Geniohyoid– Mylohyoid
    72. 72. 2. Elevation of Mandible Temporalis Masseter MedialPterygoids
    73. 73. 3. Protrusion of Mandible– Lateral Pterygoids– Medial Pterygoids
    74. 74. 4. Retraction of Mandible Posterior fibres of Temporalis
    75. 75. Age changes of the TMJ:• Condyle:– Becomes more flattened– Fibrous capsule becomes thicker.– Osteoporosis of underlying bone.– Thinning or absence of cartilaginous zone.• Disk:– Becomes thinner.– Shows hyalinization and chondroid changes.• Synovial fold:– Become fibrotic with thick basement membrane.• Blood vessels and nerves:– Walls of blood vessels thickened.– Nerves decrease in number
    76. 76. These age changes lead to: -Decrease in the synovial fluid formation -Impairment of motion due to decrease in the discand capsule extensibility -Decrease the resilience during mastication due tochondroid changes into collagenous elements -Dysfunction in older people
    77. 77. Development
    78. 78. • At week 12 of gestation:– temporal/ glenoid blastema• Ossifies and becomes glenoid fossa– condylar blastema• Becomes the condylar cartilage• Clefts are formed– lower joint cavity– upper joint cavity
    79. 79. 1. Primitivearticular disc2. Upper cleft3. Lower cleft4. Temporalblastema5. Condylarblastema433
    80. 80. 1. Glenoid fossa2. Upper joint cavity3. Articular disc4. Lower joint cavity5. Condyle
    84. 84. ENDAURAL
    88. 88. PREAURICULARDINGMAN’S INCISIONDingman and Grabb (1962)
    92. 92. • For a wider exposure.• A question mark shaped skin incision whichavoids main vessels and nerves.• About 2 cm above the malar arch, the temporalisfascia splits into 2 parts, which can be easilyidentified by fat globules between 2 layers whichform an important landmark.• In this, temporal facia and superficial temporalartery are reflected with skin flap. Later helps inbetter healing of the flap.• Under no circumstances should the inferior endof the skin incision be extended below the lobeof the ear as it increases the risk of damage tomain trunk of facial nerve. It is particularlyimportant in children where it may be quitesuperficial.AL-KAYAT & BRAMLEY 1979
    93. 93. • The length of the facial nerve which is visibleto the surgeon is about 1.3 cm.
    94. 94. • In 30 patients study ofprecise location of thetemporal branch of thefacial nerve in relation tothe most anterior aspect ofthe bony external acousticcanal was done byMiloro et alMichael Miloro, Scott Redlinger, Diane M. Pennington, Tommy Kolodge, In Situ Location of theTemporal Branch of the Facial Nerve. Journal of Oral and Maxillofacial Surgery. 2007; 65(12):2466–2469• mean distance from most posterior ramus of the temporalbranch of the facial nerve to the most anterior aspect of theexternal acoustic canal was 2.12 cm ± 0.21 cm (range, 1.68 to2.49 cm).
    95. 95. • Intraoral approach: It was described by Sear(1972) for removal of hyperplastic condyles. Theincision commences at the level of upper occlusalplane and passes downwards and forwardsbetween the internal and external oblique ridges ofmandible and then forwards as necessary alongmandibular body. Upper end should not beextended beyond the level of upper molar teeth,otherwise buccal pad of fat is encountered andprolapses in the wound decreasing the visibility
    96. 96. ArthroscopyArthroscopy of the TMJ was first introduced byOhnishi in 1975.
    97. 97. 1. Superior posterolateral2. Superior anterolateral3. Inferior posterolateral4. Inferior anterolateral5. Endaural approachApproaches for the arthroscopiclysis and lavage of the TMJ
    98. 98. 1 = Superior anterolateral approach;2 = endoaural approach;3 = superior posterolateral approach;C= condyle;G= glenoid fossa.The superior posterolateralapproach is the most common.In this technique, the mandibleis distracted downward andforward, producing a triangulardepression in front of the tragus.The trocar is inserted into the roof of this depression tooutline the inferior aspect of the glenoid fossa. This providesvisualisation of the superior joint space.
    99. 99. 1 = Superior anterolateral approach;2 = endoaural approach;3 = superior posterolateral approach;C= condyle;G= glenoid fossa.In the superior anterolateralapproach the trocar is directedsuperiorly, posteriorly, andmedially, along the inferiorslope of the articulareminence. This approachallows visualisationof the anterosuperior jointcompartment.
    100. 100. 1 = Superior anterolateral approach;2 = endoaural approach;3 = superior posterolateral approach;C= condyle;G= glenoid fossa.In the inferior posterolateralapproach, the trocar isdirected against the lateralposterior surface of themandibular head. Thisprovides visualisation of theposterior condylar surface andthe inferoposterior synovialpouch.
    101. 101. 1 = Superior anterolateral approach;2 = endoaural approach;3 = superior posterolateral approach;C= condyle;G= glenoid fossa.In the inferior anterolateralapproach the trocar is insertedat a point anterior to the lateralpole of the condylar headand immediately below thearticular tubercle. Thistechniqueallows observation of thelower anterior synovial pouch.
    102. 102. 1 = Superior anterolateral approach;2 = endoaural approach;3 = superior posterolateral approach;C= condyle;G= glenoid fossa.The endaural approach is initiatedby entering the posterosuperiorjoint space with a trocar from apoint 1 to 1.5 cmmedial to the lateral edge of thetragus through the anteriorwall of the external auditorymeatus. The trocar is directedin an anterosuperior and slightlymedial direction towardthe posterior slope of the eminence.The posterior superiorjoint space and medial and lateralparadiscal troughs can beexamined with this technique
    103. 103. LC = lateral canthus; T = tragus; A = 10mm from the middle ofthe tragus and 2mm below the canthotragal line. B = 10mmfurther along the canthotragal line and 10mm below it; C= 7mmanterior from the middle of the tragus and 2mm inferior alongthe canthotragal line; and D= 2–3mm in front of point A.
    104. 104. Ankylosis & Kaban’s protocol
    105. 105. • The 7-step protocol consists of1) Aggressive excision of the fibrous and/or bony ankyloticmass,2) Coronoidectomy on the affected side,3) Coronoidectomy on the contralateral side, if steps 1 and 2do not result in a maximal incisal opening greater than 35mm or to the point of dislocation of the unaffected TMJ,4) Lining of the TMJ with a temporalis myofascial flap orthe native disc, if it can be salvaged,5) Reconstruction of the ramus condyle unit with eitherdistraction osteogenesis or costochondral graft6) Rigid fixation,7) Early mobilization of the jaw.A Protocol for Management of Temporomandibular JointAnkylosis in Children. Leonard B. Kaban, CarlBouchard, Maria J. Troulis . Journal of Oral and MaxillofacialSurgery 2009; 67(9):1966–1978
    106. 106. • If distraction osteogenesis is used toreconstruct the ramus condyleunit, mobilization begins the day of theoperation. In patients who undergocostochondral grafteconstruction, mobilization begins after 10days of maxillomandibular fixation. Finally(step 7), all patients receive aggressivephysiotherapy
    107. 107. Dislocation
    108. 108. Conclusion• The temporomandibular joint (TMJ), also knownas the mandibular joint, is an ellipsoid variety ofthe right and left synovial joints forming abicondylar articulation.• The common features of the synovial jointsexhibited by this joint include a fibrous capsule, adisk, synovial membrane, fluid, and toughadjacent ligaments.
    109. 109. • Not only is the mandible a single bone but the cranium isalso mechanically a single stable component; therefore, thecorrect terminology for the joint is the craniomandibulararticulation.• The term temporomandibular joint is misleading and seemsto only refer to one side when referring to joint function.• Magnetic resonance imaging has been shown to accuratelydelineate the structures of the TMJ and is the besttechnique to correlate and compare the TMJ componentssuch as bone, disk, fluid, capsule, and ligaments withautopsy specimens.
    110. 110. REFERENCES - TEXTBOOK1. Sicher and Dubruls Oral Anatomy by E. Lloyd Dubrul2. The Tmj Book by Andrew S. Kaplan, Jr. Williams Gray3. B.D. Chaurassia’s human anatomy 4th edition vol. 3 TheHead & Neck.4. Williams PL: Gray’s anatomy, in Skeletal System (ed38). Churchill Livingstone, London, 1999, pp 578-5825. Fonseca volume 2 by Robert D. Marciani6. Temporomandibular Disorder, A Problem BasedApproach by Dr Robin J. M. Gray & Dr M. Diad Al –Ani7. Surgical Approaches To Facial Skeleton By – EdwardEllis III & Nmichael F. Zide8. Surgery Of TMJ 2nd ed. by David A. Keith
    111. 111. REFERENCES - ARTICLES1. Dorland WA: Medical Dictionary. Philadelphia and London, Saunders Co., 19572. Williams PL: Gray’s anatomy, in Skeletal System (ed 38). ChurchillLivingstone, London, 1999, pp 578-5823. Yale SH: Radiographic evaluation of the temporomandibular joint. J Am DentAssoc 79(1):102-107, 19694. Patnaik VVG, Bala S,Singla Rajan K: Anatomy of temporomandibular joint? Areview. J Anat Soc India 49(2):191-197, 20005. Harms SE, Wilk RM: Magnetic resonance imaging of the temporomandibularjoint. Radiographics 7(3):521-542, 19876. Tallents RH, Katzberg RW, Murphy W, et al: Magnetic resonance imagingfindings in asymptomatic volunteers and symptomatic patients withtemporomandibular disorders. J Prosthet Dent 75(5):529-533, 19967. Helms CA, Kaplan P: Diagnostic imaging of the temporomandibular joint:recommendations for use of the various techniques. AJR Am J Roentgenol154(2):319-322, 19908. Helms CA, Kaban LB, McNeill C, et al: Temporomandibular joint: morphologyand signal intensity characteristics of the disk at MR imaging. Radiology172(3):817-820, 1989
    112. 112. REFERENCES - ARTICLES9. Kreutziger KL, Mahan PE: Temporomandibular degenerative joint disease. PartII. Diagnostic procedure and comprehensive management. Oral Surg Oral MedOral Pathol 40(3):297-319, 197510. Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg11(3):207-212, 197411. McMinn, RMH: Last’s anatomy regional and applied, in Head and Neck andSpine. Churchill Livingstone, Edinburgh, London, 1994, p. 52312. Roberts D, Schenck J, Joseph P, et al: Temporomandibular joint: magneticresonance imaging. Radiology 154(3):829-830, 198513. Harms SE, Wilk RM, Wolford LM, et al: The temporomandibular joint: magneticresonance imaging using surface coils. Radiology 157(1):133- 136, 198514. Edelstein WA, Bottomley PA, Hart HR, et al: Signal, noise, and contrast innuclear magnetic resonance (NMR) imaging. J Comput Assist Tomogr 7(3):391-401, 198315. Westesson PL, Katzberg RW, Tallents RH, et al: Temporomandibular joint:comparison of MR images with cryosectional anatomy. Radiology 164(1):59-64, 1987
    113. 113. T H A N KYOU