1) Hypermobility of the temporomandibular joint (TMJ) refers to excessive translation of the condyle beyond the articular eminence on opening. Subluxation involves reduction of the condyle whereas dislocation prevents reduction. 2) Causes of hypermobility include trauma, connective tissue disorders, internal derangements and occlusal discrepancies. Chronic dislocation can be long-standing, recurrent or habitual. 3) Treatment depends on the severity and chronicity of the condition. More severe or chronic cases may require surgery like eminectomy while milder cases can be managed with exercises, injections or occlusal splints.

1. HYPERMOBILITY OF
TMJ
DR. SWATI SAHU
MDS FELLOW
ORAL & MAXILLOFACIAL SURGERY

2. INTRODUCTION
 The temporomandibular joint is a synovial joint
between the mandibular fossa of squamous part
of the temporal bone above and the mandibular
condyle below.

3. SYNONYMS
1. DIARTHROIDIAL JOINT –
 Discontinuous articulation of two bones permitting freedom of movement that is dictated by
associated muscles and limited by ligaments.
 Its fibrous connective tissue capsule is well innervated and well vascularized and tightly
attached to the bones at the edges of their articulating surfaces.

4. 2. SYNOVIAL JOINT –
 Lined on its inner aspect by a synovial
membrane, which secretes synovial
fluid, which fills both joint cavities.
 The fluid acts as a joint lubricant and supplies
the metabolic and nutritional needs of the
nonvascularized internal joint structures.

5. 3. COMPOUND JOINT –
 A compound joint requires the presence of at least three
bones, yet the TMJ is made up of only two bones.
 Functionally, the articular disc serves as a nonossified bone
that permits the complex movements of the joint.
 Because the articular disc functions as a third bone, the
craniomandibular articulation is considered a compound
joint.

6. 4. GINGLYMOARTHRODIAL JOINT -
• The lower compartment permits hinge motion or rotation and hence is termed
ginglymoid.
• The superior compartment permits sliding (or translatory) movements and is
therefore called arthrodial.
• Hence the temporomandibular joint as a whole can be termed ginglymoarthrodial.

7. ARTICULAR DISC
 Oval "dumbbell-shaped" plate
 Disc superior surface: Concavoconvex to fit articular eminence &
mandibular fossa
 Disc inferior surface: Concave to conform to condylar head
 Intermediate zone of disc found between anterior & posterior
bands
 Anterior band
 Anteriorly attaches to joint capsule
 Portion is integrated into superior aspect of lateral pterygoid muscle
 Posterior band: Posterior disc margin is bilaminar = bilaminar
zone
 Superior portion composed of loose fibroelastic tissue; attached to
posterior mandibular fossa
 Inferior portion composed of taut fibrous material; attached to
posterior margin of mandibular condyle
 Medially & laterally disc attaches to joint capsule as well as
medial & lateral mandibular condyle

8. COMPARTMENTS OF TMJ
• Disc creates superior & inferior compartments
• Superior joint compartment
• Between disc & mandibular fossa of T-bone
• Inferior joint compartment
• Between disc & condyle; two distinct recesses
• Anterior recess: Anterior to condylar head
• Posterior recess: Posterior to condylar head,
deep to posterior insertion of articular disc onto
posterior condylar neck

10. A, Lateral view. B, Diagram showing the anatomic
components. ACL, Anterior capsular
ligament (collagenous); AS, articular surface; IC,
inferior joint cavity; ILP, inferior lateral
pterygoid muscles; IRL, inferior retrodiscal lamina
(collagenous); RT, retrodiscal tissues; SC,
superior joint cavity; SLP, superior lateral pterygoid
muscles; SRL, superior retrodiscal
lamina (elastic). The discal (collateral) ligament has
not been drawn.

11. EXTRACAPSUAR LIGAMENTS
 Three functional ligaments support the TMJ:
(1) the collateral ligaments
(2) the capsular ligament, and
(3) the temporomandibular (TM) ligament.
 Two accessory ligaments also exist:
(4) the sphenomandibular and
(5) the stylomandibular

12. To restrict movement
Of disc away from
condyle

13. CAPSULAR LIGAMENT
Encompasses the joint thus
Retaining the synovial fluid
TEMPOROMANDIBULAR JOINT LIGAMENT

14. ACCESSORY LIGAMENTS

15. MUSCLES OF TMJ

17. INNERVATION OF TMJ
 Branches of the mandibular nerve provide
the afferent innervation.
 Most innervation is provided by the
auriculotemporal nerve
 Additional innervation is provided by the
deep temporal and masseteric nerves.

18. VASCULARIZATION OF TMJ
 Superficial temporal artery from the posterior
 Middle meningeal artery from the anterior
 Internal maxillary artery from the inferior
 Deep auricular A.
 Anterior tympanic A.
 Ascending pharyngeal arteries

19. BIOMECHANICS
OF TMJ

22. HYPERMOBILITY OF TMJ
1. Introduction
2. Definitions
3. Classification
4. Cause of Hypermobility
5. Pathogenesis of hypermobility
6. Clinical presentation
7. Diagnosis
8. Treatment options
1. Nonsurgical
2. Surgical
9. conclusion
10. References
CONTENTS –

23. DEFINATIONS
 Subluxation (hypermobility)- An overextension of the disc–condyle complex on
opening beyond the eminence & is able to return to the fossa after either self
manipulation or spontaneous voluntary retention.
Joint dislocation- A dislocation of the entire disc–condyle complex beyond the
eminence combined with the inability to return passively into the fossa

24. SUBLUXATION OF TMJ

25.  An incomplete dislocation of the condyle with maximum opening
the condyle translates anterior to the articular eminence and is
able to return to the fossa after either self manipulation or
spontaneous voluntary retention.
 It usually report a momentarily / short duration of open
dislocation with the jaw ‘sticking’ / temporarily inability to close
the jaw completely.

26. ETIOLOGY
1. Intrinsic trauma.
 Yawning, vomiting.
 Wide biting, seizure disorder
2. Extrinsic trauma:
I. Trauma
 Flexion, extension injury to the mandible.
 Intubation with general anesthesic.
 Endoscopy.
 Dental extractions.
 Forceful hyperextensions.

27. II. Connective tissue disorders
 Hypermobility syndrome.
 Ehler’c Danlos syndrome.
 Marfan syndrome.
III. Miscellaneous causes
 Internal derangement.
 Contralateral intraarticular obstruction.
 Host vertical dimensions.
 Occlusal discrepancies.
IV. Psychogenic
 Tardive orofacial dyskinesia.
V. Drug induced
 Phenothiezines

28. PREDISPOSING FACTORS
 Previous capsule and ligament injury.
 Laxity of ligaments (TMJ)
 Degenerative joint disease.
 Morphologic conditions of the condyle and eminence.
 Joint over extension may be caused by yawning ,wide jaw opening / vomiting.

29. CLINICAL FEATURES
 Subluxation is noted by the mandible sticking / catching open for a short period
before it reduces itself into the fossae.
 When internal derangement is associated with hypermobility multiple clicks can
be detected which represents the condyle snapping over the posterior and
anterior edges of the disk.
 “Click” occurs only on wide opening and not on protrusive or lateral movement /
excursions.

30. TREATMENT
 Limit mouth opening.
 Exercise to strengthen the elevator muscle.
 Inj of sclerosing solution to reduce the laxity of the capsule.
 Eminectomy.

31. DISLOCATION OF TMJ

32.  “Occurs when the condyle moves into a
position anterior to the articular eminence
(open lock) from which it cannot be
voluntarily reduced or repositioned into
the glenoid fossa”.
 Dislocation is also called luxation of the
TMJ.

33. CLASSIFICATION
 UNILATERAL
 BILATERAL

34. A. Acute
B. Chronic
1. Long standing
2. Recurrent
3. Habitual

35. Based on the position of the head of the condyle to the
articular eminence seen on clinico-radiological evaluation
 Type I - the head of condyle is directly below the tip of the eminence
 Type II - the head of condyle is in front of the tip of the eminence
 Type III -the head of condyle is high up in front of the base of the eminence.

36. PATHOGENESIS
 Normal joint stability depends on:
i. Integrity of joint ligaments
 Laxity of ligaments
 Capsular abnormality
ii. Bony architecture of joint surfaces
iii. Activity of muscles acting on the joint

37. ACUTE DISLOCATION
 Acute dislocation is common.
 Can be brought about by a blow on the chin while mouth is open.
 Injudicious use of mouth gag during G.A., excessive pressure during dental
extractions , excessive yawning, vomiting, laughing loudly, opening mouth too
wide .

38. CHRONIC DISLOCATION
3 TYPES -
 Long standing.
 Recurrent
 Habitual.

39. RECURRENT DISLOCATION
 Dislocation which takes place repeatedly and which last for short/long intervals.

40. LONG STANDING
 A dislocation that remains locked anteriorly for several days to years

41. HABITUAL DISLOCATION
 This term chronic dislocation is appropriately used in those cases where the patient is able to
dislocate and reduce at will ,this condition is often referred as habitual.
 Habitual dislocation is usually associated with psychological factor.
 Chronic dislocation may be an expression of a centrally mediated motor disturbance.

42. CLINICAL PRESENTATION
Bilateral dislocation
1. Pain
2. Inability to close mouth
3. Tense masticatory muscles
4. Difficulty with speech
5. Excessive salivation
6. A protruding chin
7. Open bite
8. A distinct hollow in front of the tragus
9. The lateral pole of the condyle produces a characteristic protuberance anterior to and below
the articular eminence
10. Coronoid process may create a prominence below the zygoma.
11. Pain is usually experienced in the temporal fossa rather than in the joint.

43. Unilateral dislocation
1. The mandible swung away from the side of dislocation.
2. The deviation produces a open bite on the contralateral side.
3. Occlusion is protrusive
4. The hollow just in front of the tragus is present on the ipsilateral side.

44. DIAGNOSIS
 History
 Determine cause & onset.
 A prior h/o local joint laxity, ID, & other TMJD
 use of antipsychotic drugs
 physical examination
 Neurological and musculoskeletal disorders
 Radiological examination

45. RADIOGRAPHIC EXAMINATION

46. GOALS OF TREATMENT
The goals of treatment are-
 To restrict mandibular translation
 Remove obstacles
 Thus preventing mandibular dislocation and locking anterior to the articular
eminence.

47. MANAGEMENT
SURGICAL NON-SURGICAL

49. ACUTE DISLOCATION
 Requires immediate treatment
 Manual reduction can be done with or without the use of LA immediately or
within 72 hours.
 Beyond that duration, reduction may be done under sedation/LA or GA

50. 1. DINGNAN & NATWIG
 Recommended use of LA based on theory that dislocation is maintained by
muscle spasm secondary to painful stimuli arising from the capsule
 On injection of lignocaine into the glenoid fossa or muscle of mastication
Sensory muscle spasm is blocked
Muscle spasm overcomed

51. 2. REDUCTION
• Manipulation under G.A. with the muscle relaxants.
• Manipulation under either oral / IV sedation..
Bimanual mandibular manipulation
Dingman & Natwig

52. YURINO’ S METHOD –
 Yurino’s method places the patient is a supine position without a pillow.
 The patient is encouraged to relax completely while the operator stands near
the patient’s head and holds the body of the mandible from the opposite
 The patient is asked to open and close the mouth and the operator moves
mandible up and down in phase with the patients opening and closing
movements.
 The operator then locates the dislocated condyle with his thumb and
simultaneously with the patients closing motion pushes it completely
downward while moving the body of the mandible upward by this procedure
the condyle moves over the articular eminence and ships into the fossa. In
of bilateral dislocation one side is reduced first.

53. 3. INTERMAXILLARY FIXATION
• Limiting the oral opening by giving elastics total
immobilization of the jaw for the period of 3 to 4
weeks gives rest to the joint.
• Keep the patient on soft diet.

54. CHRONIC / LONG-STANDING DISLOCATION
 Develops fibrous adhesion between the disc, condyle & articular eminence
 Jaw muscles & ligaments also undergo fibrous change, preventing non-surgical
reduction

55.  Manual reduction – under GA & muscle relaxant
 IF fails – Open reduction
 Wire is passed through inferior border of ramus or a hook placed in the
notch to aid in distracting the condyle inferiorly & repositioning the condyle into
fossa.
 Condylectomy
 Bilateral ramus osteotomy – to restore occlusion

56. RECURRENT DISLOCATION
A. IMF for prolonged period of 4-6 weeks
B. CHEMICAL CAPSULORRAPHY -
 The injection of sclerosing agents into the supporting ligaments into the joint.
 Objective: is to produce fibrosis and tightening of the capsular ligaments thus limiting motion of
the mandible and preventing subluxation and dislocations.
Ex:
 Sodium psylliate emulsion in oil.
 Sodium morrhurate
 Sodium tetraderyl sulfate
 Alcohol, homogenous blood.

58. SURGICAL PROCEDURE
ALTERATION OF LIGAMENTS ALTERATION OF MUSCULATURE
ALTERATION OF BONY
STRUCTURES
• Use of sclerosing
agents
• Strengthing of
ligaments
• Capsular plication
• Ligamentorraphy
• Active physiotherapy
• Injection of Botulinum
Toxin
• Lateral pterygoid
myotomy
• Closed Condylotomy
• Ligation of coronoid
process to the
zygomatic arch
• Scarification of
temporalis tendon
• Condylectomy
• Eminectomy
• Creation of
mechanical obstacle

59. ALTERATION OF LIGAMENTS

60. USE OF SCLEROSING AGENTS
 Injection of sclerosing agents into capsular space of the TMJ
 AIM – Cause fibrosis with resultant tightening of the capsule, prevents / limits exaggerated
condylar movement
 Sclerosing Agents –
- Alcohol
- 5% sodium psylliate
- Sodium morruhate
- 3% sodium tetradecyl sulphate
- Autologous blood

61. STRENGTHING OF LIGAMENTS
 Surgical exposing the temporalis fascia & suturing a flap of fascia onto the
capsular ligaments

62. CAPSULAR PLICATION
 Exposure of the capsule, followed by an incision vertically through the body of
ligaments
 Incision margins are then overlapped and sutured

63. LIGAMENTORRAPHY
 Involves anchoring the lateral ligaments of the capsule to the periosteum of the
zygomatic arch, followed by IMF for a week

64. ALTERATION OF MUSCULATURE

65. ACTIVE PHYSIOTHERAPY
 To strengthen the suprahyoid muscles thereby counterbalancing the action of
lateral pterygoid muscle

66. INJECTION OF TYPE A BOTULINUM TOXIN
 1 cm anterior to condyle in a slight mouth
opening position
 So as to inject into the lateral pterygoid
 AIM – to weaken the lateral perygoid
muscle sufficiently to prevent dislocation
 Contraindication – patient with impaired
neuromuscular function

67. LATERAL PTERYGOID MYOTOMY
 Attachment of the muscle to condylar neck & anterior aspect of disc is exposed &
divided
 Followed by IMF for 7-10 days
 DISADVANTAGE – loss of translatory movement in the condyle

68. CLOSED CONDYLOTOMY
 To affect the lateral pterygoid muscle indirectly
 Gigli saw is used to bisect the condylar neck thus eliminating the effect of
spasticity of lateral pterygoid
 Disadvantage – potential bleeding from internal maxillary artery

69. LIGATION OF CORONOID PROCESS TO
ZYGOMATIC ARCH
 2 holes are drilled, one into the condylar neck & other into zygomatic arch
 A dacron mesh is passed through the 2 holes & tightened, thereby restraing the
condyle

70. SCARIFICATION OF TEMPORALIS
TENDON AT ITS AREA OF INSERTION
 An intraoral incision is made in the posterior regions along the external oblique
ridge
 Tendinous fibres are dissected off from the ascending ramus& sutured to the
reflected periosteum & oral mucosa
 Incision is then sutured
 This creates a horizontal scar which may tighten the tendon & limit the range of
motion

71. ALTERATION OF BONY STRUCTURES

72. CONDYLECTOMY
 Intracapsular procedure
 Involves removal of entire articular surface of the condyle, above the attachment
of lateral pterygoid
 Resulting pseudoarthrosis may limit the range of mandibular motion
 Occlusion returns to normal after 4 weeks of surgery

73. EMINECTOMY
 Reduction of height of eminence to allow free forward & backward movements of the
condyle
 Success rate – 100%
 COMPLICATIONS –
- Pneumatisation of eminence
- Dural tear
- Recurrent subluxation
- Formation of postoperative osteophytes
- Crepitus & pain

75. CREATION OF MECHANICAL OBSTACLE
 LINDEMANN – performed an osteotomy on the
eminence and turned it down in front of condylar head
to prevent its forward movement.
 MAYOR – advocated a placement of a graft over the
eminence to increase size & height
 Placement of silastic block or vitallium mesh implants to
add the height of eminence
MAYORS PROCEDURE

76.  DAUTRY advocated osteotomy on the zygomatic arch
& depressing it in front of the condylar head to serve
as an obstacle to abnormal forward translation
 FINDLAY – used L-shaped pins anchored in the
zygomatic process of the temporal bone& projecting
it anterior to the condyle
DAUTRY PROCEDURE

77. THANK YOU