seminar on temporomandibular joint and disorders.pptx

CONTENTS
INTRODUCTION
DEVELOPMENT
ANATOMY OF TMJ AND ITS
COMPONENTS
RELATIONS OF TMJ
LIGAMENTS
BLOOD SUPPLY
 NERVE SUPPLY
TMJ MOVEMENT
TMJ IMAGING
TMJ DISORDERS
DEVELOPMENTAL ANOMALIES
OF TMJ
CONDYLAR HYPERPLASIA &
HYPOPLASIA
SOFT TISSUE ABNORMALITIES
IN TMJ
DISC DISPLACEMENT
OSTEOARTHRITIS &
RHEUMATOID ARTHRITIS
ANKYLOSIS
CONCLUSION
REFERENCES

INTRODUCTION
o The TMJ is also known as
craniomandibular joint as it involves
temporal bone and mandible.
o It is an example of
ginglymodiarthrodial articulation,
derived from ginglymus, meaning a
hinge joint allowing motion only
backward and forward in one plane
and arthrodia, meaning a joint which
permits a gliding motion of the
surfaces.
Wheeler’s Dental Anatomy, Physiology, and Occlusion, First South Asia Edition,

DEVELOPMENT
o TMJ is the last joint to start develop in about 7th week in
utero.
o There are three stages that define the normal embryologic
development of TMJ-
1)BLASTEMIC STAGE
2)CAVITATION STAGE
3) MATURATION STAGE
oTMJ is distinct from other synovial joints as it is formed by 2
separate mesenchymal tissue condensation
Article-Development of the pediatric temporomandibular joint; ORAL AND
MAXILLOFACIALSURGERY CLINICS OF NORTH AMERICA;february 2018

MAXILLOFACIALSURGERY CLINICS OF NORTH AMERICA;february 2018

MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA;february 2018
DEVELOPMENTAL CHANGES OF TMJ
WITH AGE
oAt birth, the mandible is small and the arch is more obtuse
where as in adult it is more angular.
oTMJ is loose at birth with flat mandibular fossa.
oThe fibrous connective tissue changes into fibrocartilage over
time.
oAt birth, condylar cartilage is replaced by bone via endochondral
ossification and remaining portion persists till adulthood.

oBoth thickness and vascularity of condylar cartilage decreases
with age.
oAt birth, ramus is small but coronoid process is relatively
large.
oArticular eminence has mild slope at birth.
oBy 3 yrs of age, due to forces created by muscles of
mastication & teeth, articular eminence to half of its adult form
and it is achieved entirely by 12 years of age.

ANATOMY OF TMJ
o TMJ has 2 parts:-
1. Bony part
This includes-
 Glenoid fossa
 Condyle
 Articular eminence
2. Soft tissue part
This includes-
 Articular disc
 fibrous capsule
 Ligaments
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume 3, Eight Edition

Atlas of temporomandibular joint surgery: 2nd edition; Peter D. Quinn, Eric J. Granquist

GLENOID FOSSA
o The glenoid or mandibular fossa is an oval or oblong
depression in the temporal bone just anterior to the
auditory canal and the bone is very thin at the depth
of the fossa.
o It is bounded anteriorly by the eminentia articularis
(articular eminence).
o The fossa is lined by a dense avascular
fibrocartilage.
o In cross section the fossa and the eminence form a
‘lazy S’ posteroanteriorly.
Textbook of oral and maxillofacial surgery, neelima anil malik, 4th edition

CONDYLE
o it is the articular part of the
mandible with narrow neck.
oBroad laterally and narrow
medially.
oAccording to recent article, its
mediolateral dimension is 15- 20 mm
and 8-10mm wide in anteroposterior
direction.
oMajority of human condyles are
convex superiorly(58%).
oThe articular part of the condyle is
covered by fibrocartilaginous tissue.

ARTICULAR EMINENCE
oIt is a small prominence on the
Temporal bone.
o It is strongly convex
anteroposteriorly and somewhat
concave mediolaterally.
Postglenoid tubercle :
It separates the articular surface
of the fossa laterally from the
tympanic plate.

ARTICULAR DISK
o The articular disk is oval fibrous plate that divides the joint into
an upper and a lower compartments.
o The upper compartment permits gliding movements and the
lower permits rotatory as well as gliding movements.
o The disk has concavo-convex superior surface and a concave
inferior surface and is composed of fibrocartilage.
o The disk is composed of anterior thick band, intermediate zone,
posterior thick band and bilaminar region containing venous
plexus.
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume 3, Eight
Edition

FUNCTIONS OF ARTICULAR
DISK:
1) Prevents friction between the
articulating surfaces.
2) Acts as a cushion and helps in
shock absorption.
3) Stabilises the condyle by filling
up the space between
articulating surfaces.
4) Proprioceptive fibres present in
the disc help to regulate the
movements of the joint.
5) Helps in distribution of weight
across the TMJ by increasing the
area of contact.
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume 3, Eight Edition

FIBROUS CAPSULE
o The TMJ is enclosed in the fibrous/ joint capsule.
o It is attached above to the articular tubercle, the
circumference of the mandibular fossa in front and the
squamotympanic fissure behind and below to the neck
of the mandible.
o The capsule is loose above the intra-articular disk and
tight below it.
Wheeler’s Dental Anatomy, Physiology, and Occlusion, First South Asia Edition, Pg-
253;
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume 3, Eight
Edition

Atlas of temporomandibular joint surgery: 2nd edition; Peter D. Quinn, Eric J.
Granquist

o The synovial
membrane lines the
fibrous capsule.
o The innervation of
the capsule arises from
the auriculotemporal
nerve and vascular
supply arises from the
maxillary, temporal and
masseteric arteries.
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume 3, Eight Edition

LIGAMENTS
o Ligaments act as passive restraining devices to limit
and restrict border movements.
oThree functional ligaments support the TMJ:
1) The collateral ligaments
2) The capsular ligament
3) The temporomandibular/lateral ligament
o There are also two accessory ligaments:
1) The sphenomandibular ligament
2) The stylomandibular ligament
Management of temporomandibular disorders and occlusion: 5th edition & 8th edition;
Jeffrey P. Okeson

Capsular ligament-
oThe entire TMJ is surrounded and
encompassed by this ligament.
oIts fibres are superiorly attached
to the temporal bone along the
borders of the articular surfaces of
the mandibular fossa and articular
eminence and inferiorly attached to
the neck of the condyle.
oThese ligaments act to resist any
medial, lateral, inferior forces that
tend to separate or dislocate the
articular surfaces.
Jeffrey P. Okeson

These attach the medial and lateral borders of the disk.
o They are commonly called as discal ligaments and there are two
i) The medial discal ligament attaches the medial edge of the disk
to the medial pole of the condyle.
ii) The lateral discal ligament attaches the lateral edge of the disk
to the lateral pole of the condyle.
o These are composed of collagenous connective tissue fibres
therefore they do not stretch.
o They are responsible for hinging movement of the TMJ.
COLLATERAL DISCAL LIGAMENT
Jeffrey P. Okeson

o This is main stabilizing ligament and is composed of
collagenous fibres that have poor ability to stretch.
o It extends downward and backward from the
articular eminence and its posterior fibres are united
with the capsular fibres.
o It mainly limits the anterior excursion of the jaw as
well as prevents posterior dislocation hence, it is called
as “check ligament” of TMJ.
TEMPOROMANDIBULAR / LATERAL
LIGAMENT

Management of temporomandibular disorders and occlusion: 5th edition &
8th edition; Jeffrey P. Okeson

1. The Sphenomandibular Ligament-
o It lies on a deep plane away from the fibrous capsule.
o It is attached superiorly to the spine of the sphenoid and
inferiorly to the lingula of the mandibular foramen.
o It is remnant of the dorsal part of Meckel’s cartilage.
ACCESSORY LIGAMENTS
BD Chaurasia’s Human Anatomy regional and applied Head and Neck
volume 3, Eight Edition

2. The Stylomandibular
Ligament-
o It represents a thickened part of
the deep cervical fascia which
separates the parotid and
submandibular salivary glands.
o It is attached above to the lateral
surface of the styloid process
and below to the angle and
adjacent part of the posterior
border of the ramus of the
mandible.
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume
3, Eight Edition

RETRODISCAL TISSUE
o The retrodiscal tissue consists of superior and inferior
lamellae enclosing a region of loose vascular tissue,
and this is often referred to as the bilaminar zone.
o The retrodiscal tissues are well innervated, highly
vascular and may be the source of pain when the
posterior attachment becomes trapped between the
condyle and the articular eminence in cases of anterior
disk displacement.

RELATIONS OF TMJ
o LATERAL –
1. Skin and fasciae
2. Parotid gland
3. Temporal branches of facial nerve
o MEDIAL –
1. The tympanic plate separates the joint from the internal
carotid artery.
2. Spine of the sphenoid ,with upper end of the
sphenomandibular ligament attached to it.
3. Auriculotemporal & chorda tympani nerves
4. Middle meningeal artery
o ANTERIOR –
1. Lateral pterygoid
2. Masseteric nerve & artery

o POSTERIOR –
1. The parotid gland separates the joint from the
external auditory meatus.
2. Superficial temporal vessels.
3. Auriculotemporal nerve.
o SUPERIOR –
1. Middle cranial fossa
2. Middle meningeal vessels.
o INFERIOR –
Maxillary artery and vein
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume 3, Eight Edition

BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume
3, Eight Edition

BLOOD SUPPLY OF TMJ
o Arterial supply of TMJ is from superficial
temporal artery and maxillary arteries (deep
auricular, posterior auricular & masseteric
branches).
o Both the arteries are the branches of external
carotid artery.
oVeins follows the arteries.

NERVE SUPPLY
o Nerves that supplies to TMJ are -
Auriculotemporal nerve
Masseteric nerve
o Auriculotemporal nerve is the branch from the posterior
trunk of mandibular nerve.
o Its auricular part supplies to the skin of the tragus, upper
parts of the pinna, the external acoustic meatus & the
tympanic membrane.
oThe temporal part supplies to the skin of the temple.

TMJ movement
oMandible can be depressed, elevated, protruded or
retruded.
oLateral excursions can also be carried out.
oBennett movement-
It is the lateral bodily shift of the mandible resulting from
movements of the condyles along the lateral inclines of
the mandibular fossa in lateral jaw movement.

oBennett angle-
The angle formed between the sagittal plane and
the average path of the advancing condyle (at the
balancing side).
Formula-
L=H/8+12,
where L is bennett angle and H is sagittal condylar
inclination.
Average BA was 15 degrees.

TMJ IMAGING
FOR HARD TISSUES –
i. Lateral transcranial view-
Helps in the visualization of the superior surface of the condyle
& the articular eminence.
ii. Transpharyngeal view-
Demonstrate the condylar process from the midmandibular
ramus to the condyle .This helps in diagnosis of fractures of
condyle and condylar neck.
ii. TMJ Tomography-
Helps in the visualization of condyle, the articular eminence &
glenoid fossa.
White and pharoah’s Oral Radiology principles and interpretation; second south asia
edition

Fig. Diferent TMJ imaging modality

FOR SOFT TISSUES-
•ARTHROGRAPHY
•CT scan
•MRI
White and pharoah’s Oral Radiology principles and interpretation; second south
asia edition

o Disorders of the TMJ include all abnormalities that
interfere with the normal form or function of the TMJ.
Classification-
1. Intra-articular origin or intrinsic disorders.
2. Extra-articular origin or extrinsic disorders.
 Disorders due to Extrinsic Factors
Masticatory Muscle Disorders
 Protective muscle splinting
 Masticatory muscle spasm (MPD syndrome)
 Masticatory muscle inflammation (myositis).

Problems that Result from Extrinsic Trauma
 Traumatic arthritis
 Fracture
 Internal disk derangement
 Myositis, myospasm
Disorders due to intrinsic factors-
Trauma
■ Dislocation, subluxation
■ Hemarthrosis
■ Intracapsular fracture, extracapsular fracture.
Internal disk displacement
■ Anterior disk displacement with reduction
■ Anterior disk displacement without reduction.

Arthritis
■ Osteoarthrosis (degenerative arthritis,
osteoarthritis)
■ Rheumatoid arthritis
■ Juvenile rheumatoid arthritis
■ Infectious arthritis.
 Developmental defects
■ Condylar agenesis or aplasia—unilateral/bilateral
■ Bifid condyle
■ Condylar hypoplasia
■ Condylar hyperplasia
 Ankylosis

CLINICAL FEATURES OF TMJ
DISORDER
o TMJ disorders manifest with extensive asssortment
of clinical features like:
i. Pain in the TMJ or ear
ii. Headache
iii.Muscle tenderness
iv.Joint stiffness
v. Clicking or joint noises
vi.Reduced range of motion
vii.Locking of jaw
White and pharoah’s Oral Radiology principles and interpretation; second
south asia edition

o Careful examination can help identify the joint
dysfunction . For example-
 Pain to palpation of the muscles of mastication &
headache suggest a myofascial pain disorder.
 Crepitus & pain over the joint indicate arthritic
involvement.
 Redness & heat over the joint may indicate an
inflammatory condition.
edition

DEVELOPMENTAL ABNORMALITIES
oThese are the result of disturbances in the normal growth and
development of TMJ.
oThese may affect the form or size of the joint components,
mostly the mandibular condyle.
oAs the condylar articular cartilage is considered as the growth
centre for the mandible, disturbances involving this result in
altered growth of condyle, ramus, body and alveolar process on
affected side.
oDevelopmental abnormalities are mostly unilateral and manifest
with facial asymmetry.
edition

CONDYLAR HYPERPLASIA
oIt is a developmental abnormality that results in enlargement and
deformity of condylar head and is usually unilateral.
oEtiological factors include hormonal influences, trauma, infection,
heredity and hypervascularity.
Clinical features-
oMore common in females and is self-limiting, tends to arrest with
the termination of skeletal growth.
oThere is mandibular asymmetry and chin may be deviated to the
unaffected side.
oPatient may complain of limited or deviated mandibular opening.
edition

Imaging feature-
oThe hyperplastic condyle is normal in shape but enlarged and
appears more radiopaque in plain image.
oGlenoid fossa may be enlarged to compensate the enlarged
condyle. Forward bending of the condylar head and neck.
oA characteristic downward bowing of the inferior mandibular
border on the affected side.
Management-
oIt consists of combination of condylectomy, orthognathic
surgery ad orthodontics.
oManagement also may be delayed until growth is completed to
avoid relapse.
edition

edition

CONDYLAR HYPOPLASIA
oIt involves an undersized mandibular condyle which may be
the result of the congenital, developmental or acquired
diseases that affect condylar growth.
oSevere congenital malformations result in complete lack of
formation of condyle (aplasia).
edition

Clinical features-
oMore commonly unilateral unless is a feature of syndrome
(treacher collin syndrome, pierre robin syndrome).
oFacial asymmetry, deviation of mandibular midline to the
affected side and malocclusion may develop.
Treatment-
oOrthognathic surgery
oBone grafts
oOrthodontic therapy
south asia edition

TMJ DISLOCATION
o If oral opening proceeds to its maximum capacity, the
condylar head move to the anterior slope of the articular
eminences in many normal individuals.
o Excursion of the condylar head beyond these limits may be
viewed as abnormal and termed as dislocation.
o Anterior mandibular dislocation, which occurs more
commonly, can be classified as:
 Acute dislocation (complete luxation)
 Chronic recurrent (habitual) subluxation

Unilateral acute dislocation:
It is characterized by-
oDifficulty in mastication and swallowing.
oSpeaking may be difficult and profuse drooling of
saliva can be present in the early stages.
o A deviation of the chin toward contralateral side is
seen.
Causes of Acute Dislocation-
 Extrinsic forces or iatrogenic causes.
 Intrinsic or self-induced forces.
Textbook of oral and maxillofacial surgery, neelima anil malik, 4th
edition

Bilateral acute dislocation:
It is associated with-
o pain, inability to close the mouth, tense masticatory muscles,
difficulty in speech, excessive salivation, protruding chin.
o The mandible is postured forward and movements are
restricted.
o There is a gagging of the molar teeth with the presence of
anterior open bite.
o Difficulty in swallowing and drooling of saliva is seen.

Treatment for TMJ dislocation-
oIt ranges from bimanual relocation of the condylar head to
invasive surgical procedures.
o The major problem in reduction of dislocation is overcoming
the resistance of the severe muscle spasm.
oTherefore, initially attention is given to reduce tension,
anxiety and muscle spasm.
oThis can be achieved by
(1)reassuring the patient
(2) tranquilizer or sedative drugs
(3) pressure and massage to the area, and
(4) manipulation.

DISK DISPLACEMENT WITHOUT
REDUCTION
oThere is closed lock form when the disk interferes with the
condylar translation.
oPatient will not be able to open mouth fully.
oIf the patient attempts to open mouth, pain in the affected joint
and deviation of the mandible towards the painful side will be
noticed.
oIf this chronic condition continues, it progresses towards
perforation of the disk.

There are 5 clinical findings seen in disk
displacement without reduction:
1. Limited mandibular opening
2. Unilateral condition, one side condyle cannot translate fully
3. Unrestricted ipsilateral eccentric movement( 10-12 mm
normal range)
4. Restricted contralateral eccentric movement (less than
8mm)
5. Loss of joint sounds- earlier history of clicking.

DISK DISPLACEMENT WITH
REDUCTION
o Disk is dislocated anterior to condylar head resulting in pain
during translation.
o Patient demonstrate a click on opening and closing as the disk
slips on and off the condyle during functional movements.
During opening-
o Due to disk reduction a clicking or popping sound is heard as the
posterior part of the disk interferes with the condylar translation.
During closing-
o Reciprocal click occurs again, as the condyle returns to the
original position, gliding over the posterior part of the disk.

o It is also known as false ankylosis.
o Trismus is defined as a condition in which muscle spasm
or contracture prevents opening of the mouth .
TRISMUS
Causes of Trismus
o Due to infection
oTrauma
oInflammation
oMyositis ossificans
oTetany or Psychosomatic trismus: It is also known as trismus
hystericus.
o Drug induced trismus: due to Strychnine poisoning
o Mechanical blockage
oExtra-articular fibrosis

oAlso known as Chronic Recurrent or Habitual Dislocation
oThe repeated episodes of dislocation, where there is
abnormal anterior excursion of the condyles beyond the
articular eminence, but the patient is able to manipulate it back
into normal position.
SUBLUXATION
oThis recurrent, incomplete, self-reducing, habitual dislocation is
termed as hypermobility or chronic subluxation of the TMJ.
oThe triad of ligamentous and capsular flaccidity, eminential
erosion and flattening and trauma, are well recognized in the
genesis of chronic recurrent subluxation.

The management procedures are as follows:
Intermaxillary fixation or limiting the oral opening by giving
elastics: Total immobilization of the jaw for the period of 3–4
weeks gives rest to the joint. But patient has to be kept on liquid
diet.
Use of sclerosing solution injections into the joint space:
Sodium psylliate, Sodium morrhuate has been used as a
sclerosing agent, but has failed to produce good results.

OSTEOARTHRITIS/DEGENERATIVE
JOINT DISEASE
oIt is the breakdown of the articulating fibrocartilage covering the
bony components of the joint.
oIt occurs when the ability of joint to adapt to excessive loading
forces is exceeded.
Etiology-
oAcute trauma, hypermobility, abnormal loading of joint in
parafunction.
oIt is a non inflammatory disorder characterized by joint
deterioration (erosion) and bony proliferation (new bone called
osteophyte).
edition

Clinical features-
oHas female preponderance
oSymptoms like pain on palpation and movement, joint
noises (crepitus), limited range of motion and muscle
hyperactivity.
Imaging features-
oEly cyst are visible. These are small radiolucent areas
with irregular margins surrounded by area of sclerosis.
oJoint mice are fragments that break off from
osteophyte and lie free in the joint space. These causes
joint space radiopacities.
south asia edition

Treatment-
oChanges to the joint cannot be reversed.
oTreatment is directed towards -
unloading the forces on the abnormally loaded joint
relieving secondary inflammation with anti-
inflammatory drugs and
 increasing joint mobility (physiotherapy).
south asia edition

RHEUMATOID ARTHRITIS
oIt manifests mainly as synovial membrane inflammation
in several joints.
oThe TMJ becomes involved in half of the affected
patients.
oThe characteristic imaging findings are a result of villous
synovitis, which leads to formation of synovial
granulomatous tissue (pannus) that grows into
fibrocartilage and bone releasing enzymes that destroy
the articular surfaces.
edition

oMost common in females.
oWhen the TMJ is affected, involvement is bilateral.
oPatient complains of pain, swelling, tenderness,
stiffness on opening, crepitus. Chin appears receded and
an anterior open bite is common finding.
oManagement-
Directed towards pain relief (analgesics), suppresssion
of inflammation(NSAIDs), antirheumatic drugs and
preservation of muscle & joint function(physiotherapy).
White and pharoah’s Oral Radiology principles and interpretation; second south
asia edition

ANKYLOSIS
Early joint involvement—less than 15 years:
Severe facial deformity and loss of function.
Late joint involvement - after the age of 15 years:
Facial deformity marginal or nil. But, functional loss severe.
oAnkylosis meaning “stiff joint or the joint which cannot
move”.
o In temporomandibular joint (TMJ) ankylosis, it is stiffening
(immobility) or pathological intracapsular fusion/union (either
of fibrous tissue adhesion or bony deposition) between the
head of the condyle and glenoid fossa articular area.

oFibrous Ankylosis
oIn fibrous ankylosis, reduced joint space and hazy appearance
can be seen on radiograph.
o But, the normal anatomy of the head and glenoid fossa can be
appreciated.
oBony Ankylosis
oComplete obliteration of joint space.
oNormal TMJ anatomy is distorted.
o Deformed condylar head or complete bony consolidation
replacing the joint space can be seen.
Surgical Treatment of ankylosis done by three methods -
1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty

Atlas of temporomandibular joint surgery: 2nd edition; Peter D. Quinn, Eric J. Granquist

CONCLUSION
oThe understanding of the normal anatomy, morphology and
functions of TMJ is important to make a decision of what is wrong
and when it’s functioning comfortably.
oThis understanding of TMJ is foundational.
oThe classification of TMJ disorders are useful for identifying the
functional disturbances of the soft tissues of TMJ and also to
indentify the developmental abnormalities that occurred in
osseous structures of TMJ.
oThere are multiple functional & structural contributions of the
TMJ to patients who need to be addressed when determining
proper care & management of TMJ malformations.

REFERENCES
Wheeler’s Dental Anatomy, Physiology, and Occlusion, First South Asia Edition, Pg-253;S
BD Chaurasia’s Human Anatomy regional and applied Head and Neck volume 3, Eight
Edition
Jeffrey P. Okeson
Article-Development of the pediatric temporomandibular joint; ORAL AND
edition
Gray’s anatomy: anatomical basis of clinical practice: 39th edition.
Oral histology: development, structure and function: tencate; 5th edition
Atlas of temporomandibular joint surgery: 2nd edition; Peter D. Quinn, Eric J. Granquist

seminar on temporomandibular joint and disorders.pptx

Recommended

Recommended

More Related Content

Similar to seminar on temporomandibular joint and disorders.pptx

Similar to seminar on temporomandibular joint and disorders.pptx (20)

Recently uploaded

Recently uploaded (20)

seminar on temporomandibular joint and disorders.pptx