Temporomandibular joint is the most complex and unique joint of the body and to understand its surgical anatomy is very important in the surgical management of its disorders .
Temparo mandibular joint disorders /certified fixed orthodontic courses by In...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
This seminar explains about the development, relations, ligaments, various attachments, vascular and nervous supply and various surgical approaches and its modifications to TMJ
this presentation describes the detail anatomy of Temporo-mandibular joint with respect to its articulating surfaces, ligaments, muscles and blood and nerve supply.
Temparo mandibular joint disorders /certified fixed orthodontic courses by In...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
This seminar explains about the development, relations, ligaments, various attachments, vascular and nervous supply and various surgical approaches and its modifications to TMJ
this presentation describes the detail anatomy of Temporo-mandibular joint with respect to its articulating surfaces, ligaments, muscles and blood and nerve supply.
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Basics about TMJ ( development fuction movement etc ) with classification of tmj disorders and stress on tmj examination.
Also covers muscles of masstication
Tmj surgical anatomy and approaches (nx power lite) /certified fixed orthodon...Indian dental academy
The Indian Dental Academy is the Leader in
continuing dental education , training dentists
in all aspects of dentistry and offering a wide
range of dental certified courses in different
formats.
Indian dental academy provides dental crown &
Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit
www.indiandentalacademy.com ,or call
0091-9248678078
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Basics about TMJ ( development fuction movement etc ) with classification of tmj disorders and stress on tmj examination.
Also covers muscles of masstication
Tmj surgical anatomy and approaches (nx power lite) /certified fixed orthodon...Indian dental academy
The Indian Dental Academy is the Leader in
continuing dental education , training dentists
in all aspects of dentistry and offering a wide
range of dental certified courses in different
formats.
Indian dental academy provides dental crown &
Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit
www.indiandentalacademy.com ,or call
0091-9248678078
TMJ is formed by the mandibular condyle and the mandibular fossa of the temporal bone. The articular disc separates these two bones from direct articulation .
The main components of TMJ
Mandibular condyles
Articular surface of temporal bone
Articular disc
LigamentsSPHENOMANDIBULAR LIGAMENT
morphologically, it is remnant of cephalic end of meckel’s cartilage is attached
superiorly to: spine of sphenoid bone
inferiorly to: lingula of mandibular foramen
laterally related to: lateral pterygoid muscle, auriculotemporal nerve, maxillary artery.
medially related to: chorda tympani nerve.
near its lower end it is pierced by: mylohyoid nerves and vessels
STYLOMANDIBULAR LIGAMENT:
It is thickened part of deep cervical fascia.
Above: lateral surface of styloid process.
Below: angle and adjacent part of posterior part of ramus.
AGE CHANGES
CONDYLE:
Becomes more flattened
Fibrous capsule becomes thicker.
Osteoporosis of underlying bone.
Thinning or absence of cartilaginous zone.
ARTICULAR DISK:
Becomes thinner.
Shows hyalinization and chondroid changes.
BLOOD VESSELS AND NERVES:
Walls of blood vessels thickened.
These age changes lead to:
-Decrease in the synovial fluid formation
-Impairment of motion due to decrease in the disc and capsule extensibility
-Decrease the resilience during mastication due to chondroid changes into collagenous elements
-Dysfunction in older people
TMJ EXAMINATION
Examined both clinically and radiographically.
PALPATION OF TMJ is determined by digital palpation..
CREPITATION This is a grating or scalping noise that occurs on jaw movements. may be an early sign of degenerative joint disease. AUSCULTATION OF THE TMJ can be examined with a stethoscope. Also the timing of clicking during opening and closure can be noted.
CLICKING It occurs due to the uncoordinated movement of condylar head and TMJ disc. Joint clicking is differentiated as:
Initial clicking: it is a sign of retruded condyle.
Intermediate clicking: it is a sign of uneven condyle surfaces and articular disc.
Terminal clicking: it is an effect of the condyle being moved too far anteriorly in relation to the disc on maximum jaw opening. TMJ ARTHROGRAPHY
Norgaard (1940)
Indications:
Position and function of disk -pain and dysfunction-long standing
History of locking-persistent
Perforations of the disk and retrodiskal tissue.
Therapeutic :
To delineate loose bodies in the joint spaces
Diagnostic aspiration of joint fluid.
Intraarticular injections of steroids
Contraindications:
Infections in the preauricular region.
Patients allergic to contrast media.
Patients with bleeding disorders and on anticoagulant therapy
TMJ ARTHROGRAPHY
Norgaard (1940)
Indications:
Position and function of disk -pain and dysfunction-long standing
History of locking-persistent
Perforations of the disk and retrodiskal tissue.
Therapeutic :
To delineate loose bodies in the joint sp
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
2. PRESENTATION BY:
Dr. Minal Sonare
Junior resident 1 st year
Department of Oral and maxillofacial surgery
1
3. Introduction
Basic Anatomy
Relations of Tmj
Movements of Normal Tmj
Associated surgical anatomy
Various surgical approaches and their modifications
Complications
References
2
4. INTRODUCTION:
• The tmj is a ginglymoarthrodial joint, a term that is derived
from ginglymus, meaning a hinge joint, allowing motion only
backward and forward in one plane, and arthrodia, meaning
a joint of which permits a gliding motion of the surfaces.
• The most important functions of the temporomandibular
joint are mastication and speech .
5. • Craniomandibular joint -Articulation between the
condylar head of mandible and the anterior part of the
glenoid fossa of two temporal bones.
• Frequently termed as tmj
• Acts like class III lever
• Embryology - In contrast to other diarthrodial joints
TMJ is last joint to start develop, in about 7th week in
utero. It develops from condensation of temporal and
condylar blastemata each has its own joint cavity hence
there are two spaces in joint .
6. • Bilateral diarthrosis – right & left function together
• Only joint in human body to have a rigid endpoint of
closure that of the teeth making occlusal contact.
• Compound joint
• Complex joint
• only ellipsoid type of synovial joints with an articular
disc and articular surfaces are covered by
fibrocartilage instead of hyaline cartilage- can handle
better shear forces due to occlusal load.
Peculiarity of TMJ :
8. The Mandibular Condyle
• An ovoid process
• It is convex in all directions but wider L-M (15 to 20 mm)
than A-P (8 to 10mm).
• The medial pole extends sharply inward and is directed
more posteriorly. lateral pole is rough, bluntly pointed
• Elliptical in shape, long axis angled backward between 15
– 33 to frontal plane
• Thus, if the long axes of two condyles are extended
medially, they meet at approximately at the basion
forming an angle that opens toward the front ranging
from 145 to 160
• articular surface lies on its anterosuperior aspect
9. Articular surfaces of Temporal bone
• situated on the inferior aspect of temporal squama anterior
to tympanic plate.
• Articular eminence: transverse bony bar that forms the
anterior root of zygoma.
• Articular tubercle: this is a small, raised, rough, bony knob
on the outer end of the articular eminence.
• Preglenoid plane: slightly hollowed, almost horizontal,
articular surface
10. Articular disc
• Biconcave fibrocartilaginous structure located between
• Divides the joint into a larger upper compartment and a
smaller lower compartment
• Its function is to accommodate a hinging action (lower
compartment )as well as the gliding actions(upper
compartment)
• Shape -Roughly oval, firm, fibrous plate.
• Anterior band = 2 mm in thickness, Posterior band = 3 mm
thick,Thin in the centre intermediate band of 1 mm thickness.
• More posteriorly there is a bilaminar or retrodiscal region.
• Superior surface - saddle-shaped ; inferior surface - concave
11. Articular disc
• The disc is attached all around the joint capsule except for the strong
straps
• Anteriorly - attached to a fibrous capsule superiorly and inferiorly.
• Posteriorly -the bilaminar region consists of two layers of fibers
separated by loose connective tissue.
• Upper layer or temporal lamina -composed of elastin and is attached to
the postglenoid process. It prevents slipping of the disc while yawning.
• Inferior layer - curve down behind the condyle to fuse with the capsule
and back of the condylar neck. It prevents excessive rotation of the disc
over the condyle.
12. Fibrous Capsule
• Thin sleeve of tissue completely surrounding joint.
• Extension- the circumference of the cranial
articular surface to the neck of the mandible.
• The outline – anterolaterally to the articular tubercle, laterally to the lateral rim of the
mandibular fossa, posterolaterally to the postglenoid process, posteriorly to the posterior
articular ridge, medially to the medial margin of the temporal, anteriorly it is attached to
the preglenoid plane
• Medially and laterally- blends with the condylodiscal ligaments
13. Fibrous Capsule
• Area of relative weakness in the anterior capsular lining becomes a
source of possible herniation of intraarticular tissues, and this, in
part ,may allow forward displacement of the disk.
• Synovial membrane lining the capsule covers all the intra-articular
surfaces except the pressure-bearing fibrocartilage.
• Four capsular or synovial sulci -the posterior and anterior ends of
the upper and lower compartments which changes shape during
translatory movements.
15. Collateral ligaments
• The ligament on each side of the jaw in two distinct layers.
• The wide outer or superficial layer is usually fan-shaped and
arises from the outer surface of the articular tubercle and
most of the posterior part of the zygomatic arch.
• The ligamentous fascicles run obliquely downward and
backward to be inserted on the back, behind, and below the
mandibular neck.
16. Lateral/Temporomandibular ligament
• Main stabilizing ligament - thickened capsule - collagen
fibers
• Course: Down & back attached above to articular eminence
, below to outer & post side of neck of condyle, Posterior
fibers unite with capsule
• Function: limits protraction , inferior distraction ,posterior
movement of condyle
• Specific length & poor ability to stretch- maintains integrity
& limits movement of TMJ (mainly anterior excursion &
prevents posterior dislocation – CHECK LIGAMENT
• Slippage of condyle:medially prevented by glenoid process ,
laterally by TM ligament
17. Sphenomandibular ligament
• Arises from the angular spine of the sphenoid and
petrotympanic fissure. Runs downward and
outward.Insert on the lingula of the mandible.
• The ligament is related – Laterally - lateral
pterygoidmuscle. Posteriorly - auriculotemporal nerve.
Anteriorly - maxillary artery. Inferiorly - the inferior
alveolar nerve and vessels a lobule of the parotid gland.
Medially - medial pterygoid with the chorda tympani
nerve and the wall of the pharynx with fat and the
pharyngeal veins intervening.
• The ligament is pierced by the mylohyoid nerve and
vessels.
• This ligament is passive during jaw movements
18. Stylomandibular ligament
• a specialized dense, local concentration of deep cervical
fascia extending from the apex and being adjacent to the
anterior aspect of the styloid process and the stylohyoid
ligament to the mandible’s angle and posterior border.
• This ligament then extends forward as a broad fascial layer
covering the inner surface of the medial pterygoid muscle.
• The anterior edge - thickened and sharply defined.
• Relaxes when the jaws are closed and slackens noticeably
when the mouth is opened
• This ligament becomes tense only in extreme protrusive
movements.
19. Muscular component
• The masticatory muscles surrounding the
joint are groups of muscles that contract
and relax in harmony so that the jaws
function properly.
• When the muscles are relaxed and flexible
and are not under stress, they work in
harmony with the other parts of the tmj
complex.
• The muscles of mastication produce all the
movements of the jaw.
20.
21. Vascularisation : Arterial Supply
• Branches of external carotid artery
• Superficial temporal artery
• Deep auricular artery
• Anterior tympanic artery
• Ascending pharyngeal artery
• Maxillary artery
• 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
24. Relations of Tmj : Anteriorly
• Mandibular notch, lateral pterygoid muscle, masseteric nerve
and artery
• A careful dissection of 16 intact human cadaveric head
specimens revealed the location of the masseteric artery was
then determined in relation to 3 points process:
1 ) the anterior-superior aspect of the condylar neck = 10.3 mm
2 ) the most inferior aspect of the articular tubercle = 11.4 mm;
3 ) the inferior aspect of the sigmoid notch = 3 mm.
28. TMJ Movement :
• Rotational / hinge movement in first 20-25mm of mouth
opening and Translational movement after that when
the mouth is excessively opened.
• Translatory movement – in the superior part of the joint
as the disc and the condyle traverse anteriorly along the
inclines of the anterior tubercle to provide an anterior
and inferior movement of the mandible.
• Hinge movement – the inferior portion of the joint
between the head of the condyle and the lower surface of
the disc to permit opening of the mandible.
29. TMJ Movement :
• Depression Of Mandible- Lateral pterygoid
Digrastric Geniohyoid Mylohyoid
• Elevation of Mandible - Temporalis Masseter
Medial Pterygoids
• Protrusion of Mandible - Lateral Pterygoids
Medial Pterygoids
• Retraction of Mandible- Posterior fibres of
Temporalis
30. Lubrication Of The Joint
• The synovial fluid comes from two sources: first, from plasma by dialysis, and second, by secretion
from type A and B synoviocytes with a volume of no more than 0.05 ml.
• • However, contrast radiography studie - the upper compartment could hold approximately 1.2 ml
of fluid without undue pressure being created, while the lower has a capacity of approximately 0.5
ml.
• It is clear, straw-colored viscous fluid.It diffuses out from the rich capillary network of the
synovial 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 of the articulating surfaces.
35. Liebman et al in 1982, described histologically that the layer in
which it travels.
They reported that it was locked in the fascial layer between temporalis
fascia and subdermal fat superficially.
Stuzin et al in 1988, examined the temporal region by cadaver
dissection and reported that it lay within the temporoparietal fascia
and travels along undersurface of this fascial layer.
35
Temporoal Branch :
36. A straight trajectory A curved trajectory.
TEMPORAL BRANCHES OF
FACIAL NERVE
Ishikawa Y:An anatomical study on the distribution of the temporal branch of the facial
nerve.
36
37. Pitanguy, L, A. S. Ramos: The
frontal branch of the facial
nerve: The importance of its
variation in face lifting.
Plast. Reconstr. Surg. 38 (1966)
352
MIDDELTON’S
LINE
37
38. The new guideline for preservation of
the entire temporal branch is drawn
with a dashed line.
38
J.CRANIO-MAX-FAC.SURG.18(1990),287-292.
41. 41
Auriculotemporal
nerve
Auriculotemporal
nerve
ARISES FROM POSTERIOR PART OF
MANDIBULAR DIVISION OF CN V
41
Atlas of human anatomy – Frank H Netter 6th ed
Runs beneath lateral pterygoid muscle.
Passes from medial surface of condyle &
emerges on to the face behind the TMJ
within the superior surface of the parotid
gland.
Ascends posterior to the superficial
temporal vessels, passes over the posterior
root of the zygoma, and divides into
superficial temporal branches
42. Superficial temporal vein
Maxillary vein
Retromandibular vein
Anterior division
Posterior division
42
GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed
43. largest ascending branch of the cervical plexus
arises from the second and third cervical rami,
encircles the posterior border of
sternocleidomastoid,
perforates the deep fascia and ascends on the
muscle beneath platysma
On reaching the parotid gland, it divides into
anterior and posterior branches
43Greater auricular nerve
46. Concept given by Teisser & defined by
Mitz and Peyronie in 1976.
Continuous fibromuscular layer.
Synonyms:
In scalp – galea aponeurotica
In temporal region – temporoparietal
fascia, superficial temporal fascia or
suprazygomatic SMAS
Below zygomatic arch –
parotideomasseteric fascia
46
Superficial Musculoaponeurotic System
47. Accessibility to the joint
Avoiding damage to vital neurovascular structures
Aesthetic concerns on visibility of post op scars
Technique sensitivity and surgeon’s experience
In case of ankylosis, choice of interpositioning
material.
47
50. • SUPRAFASCIAL PROCEDURE
-ROWE NL: SURGERY OF THE TEMPORO-MANDIBULAR JOINT.
PROC R SOC MED 65:383, 1972
•SUBFASCIAL PROCEDURE
-AL-KAYAT A, BRAMLEY P:AMODIFIED PRE-AURICULAR
APPROACH TO THE TEMPOROMANDIBULAR JOINT AND MALAR
ARCH. BR J ORAL SURG 17:91, 19
•DEEP SUBFASCIALAPPROACH
- MASSIMO POLITI : J ORAL MAXILLOFAC SURG 62:1097-1102, 2004
51. • Incising temporalis fascia
• Make an oblique incision (450)parallel to the frontal branch of the facial nerve(2 cm below
the malar arch), through the superficial layer of the temporalis fascia above the zygomatic
arch.
• Begins at the root of zygomatic arch and extends anterosuperiorly towards upper corner of
reflected flap
51
52. Coronal view of dissection to the lateral
portion of the zygomatic arch and
mandibular condyle region.
Insert the periosteal elevator beneath the
superficial layer of the temporalis fascia
and strip the periosteum off the lateral
zygomatic arch.
52
54. 54
First incision is through the upper joint space followed by the lower joint incision
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
56. Blair’s Inverted Hockey
Stick – angulated
superiorly
Dingman’s Incision-
preauricular crease
Endaural Incision-
lies in ear cartilage
Popowich and Crane
Incision-question mark
shaped incision line goes into
the hairline
Thoma’s Angulated Incision-
angulated at 450
56
Modification
of
preauricular
approach
57. Skin incision is question mark shaped
Begins antero-superiorly within the
hairline & curves backwards and
downwards well posterior until it meets
upper ear attachment
Incision then follows ear attachment
endauraly
57
59. Advantage:
less bleeding
fascial planes can be
easily identified
excellent
visibility
good cosmetic
result
59
60. Incision is started in the fold at
the junction of anterior margin
of helix
Carried downwards to upper
portion of tragus where it is
contained inside the margin of
tragus to anterior fold of lobule
It again becomes visible at this
point and is carried downwards
to lower attachment of ear
60
61. Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
61
FIRST DESCRIBED BY
LEMPART AS AN APPROACH
TO MASTOID PROCESS FOR
SURGICAL IMPROVEMENT
OF OTOSCLEROSIS FOR
APPROACHING TMJ
62. Incision begins well within the EAM at superior meatal
wall
The incision is carried carefully through the skin over the
tragal cartilage at a 90- degree angle to the most convex
part of the tragus itself.
The incision is carried superiorly to the uppermost
portion of the auricle and then extends in approximately
a 45 degree angle into the temporal hairline for about 3
to 4 cm.
62
64. Comparison of standard preauricular
and endaural surgical approaches
Advantages:
• Most of the vital structures are in a superficial
plane.
• Very good access to the joint and also the
coronoid process.
• Excellent esthetic result with minimal post
operative scar
Disadvantage:
• Esthetic compromise if tragal projection is lost
• Risk of possible perichondritis
64
65. ADVANTAGES:
• Broad based flap with excellent
blood supply
• Possibility of residual cartilaginous
deformity is less
• Damage to CN VII is unlikely
65
67. Descibed by Alexander & James
Incision is placed in the grove between the helix
and post auricular skin
Pre-op considerations described by Walter and
Geist:
1. History of normal scar formation
2. Healthy auditory system with no infection
3. No TMJ infection
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
67
68. 68
3-5cm incision is made parallel & posterior
to postauricular flexure
Begins at superior aspect of external pinna
and extended till the tip of mastoid process
Dissection is done through posterior
auricular muscle to the level of mastoid
fascia
70. ADVANTAGES
Predictability of anatomic
exposure
Excellent surgical exposure of
the bilaminar zone and the
mandibular condyle
posteriorly
Cosmetic superiority
Less risk of CN VII injury
Dissection is more rapid
70
DISADVANTAGES
Not advised in patients
susceptible to keloid
Infection
Meatal stenosis can occur
Anterior exposure is
limited
71. versatile surgical approach to the upper and middle regions of the
facial skeleton, including the zygomatic arch and TMJ.
major advantage of this approach is that most of the surgical scar
is hidden within the hairline.
71
74. 74
Incision placement for patients with male pattern
hair recession. The incision is stepped posteriorly
just above the attachment of the helix of the ear
Incision placement for most female patients.
The incision is kept approximately 4 cm
behind the hairline
76. THE INCISION IS THROUGH THE SKIN,
SUBCUTANEOUS TISSUE, AND GALEA REVEALING
THE SUBGALEAL PLANE OF LOOSE AREOLAR
CONNECTIVE TISSUE OVERLYING THE
PERICRANIUM
76
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
78. The skin incision below the superior
temporal line should extend to the
depth of the glistening superficial
layer of the temporalis fascia,
into the subgaleal plane, continuous
with the dissection above the
superior temporal line.
78Surgical approaches to facial skeleton – Edward Ellis 2nd ed
79. 79
Along the lateral aspect of the skull, the
glistening white temporalis fascia
becomes visible where it blends with the
pericranium at the superior temporal
line.
The plane of dissection is just
superficial to this thick fascial sheet
80. Near the ear, the flap is dissected
inferiorly to the root of the
zygomatic arch by incising
superficial layer of temporalis
fascia
The lateral portion of the
flap is dissected inferiorly
atop the temporalis fascia
81. EXPOSURE OF THE
TEMPOROMANDIBULAR JOINT:
81
Access to the TMJ region is gained by
dissecting below the zygomatic arch anterior
to tragal cartilage.
Masseter is detached from the zygomatic arch
exposing the sigmoid notch and TMJ
capsule.
Capsule is then incised exposing the TMJ.
82. CLOSURE: DONE IN LAYERS
82
Closure of TMJ capsule is done followed by closure of
temporalis fascia .
Superficial layer of the temporalis fascia, which is
incised during the approach, is sutured approximately 1
cm superior to the superior edge of the incised fascia.
Galea is closed as a distinct layer.
Scalp incision is closed.
83. The coronal incision has been modified.
The principal difference involves the position of the skin incision –
• placed behind the ear.
• use of a zigzag incision instead of a straight incision within the hairline.
84. The initial incision is carried through the skin and subcutaneous tissues to
the level of the platysma muscle.
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Incision usually starts 1.5-2cm inferior to the lower border of mandible.
Submandibular
Or Risdon
Approach
88. Dissection is performed
through the fascia at the level
of the initial skin incision,
followed by dissection
superiorly to the level of the
periosteum of the mandible
88
89. With retraction of the dissected
tissues, the inferior border of
the mandible is seen.
89Surgical approaches to facial skeleton – Edward Ellis 2nd ed
The pterygomasseteric sling is
sharply incised with a scalpel
along the inferior border
91. THE MASSETER AND MEDIAL
PTERYGOID MUSCLES ARE
SUTURED TOGETHER
subcutaneous tissues and skin
closure is done
91
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
93. exposes the entire ramus from behind the
posterior border.
therefore may be useful for procedures
involving the area on or near the
Condylar neck/head or the ramus itself
93
94. ADVANTAGES: close proximity to the condylar area
DISADVANTAGES: passing through the parotid gland tissue,
thus increasing the risk of facial nerve
injury and salivary fistulae.
94
101. 1. Smaller scar as access was limited to 2cm only.
2. Plane of dissection was superficial to SMAS.
3. Risk of Frey’s syndrome, sialocoele and salivary fistula
can be eliminated.
4. Surgical site is always perpendicular to fracture site.
5. Integrity of joint is always maintained.
101
102. Also called as facelift
approach.
Variant of retromandibular,
transmasseteric -
anteroparotid approach
102
103. When using the rhytidectomy approach, the structures
that should be visible in the field include –
1. the corner of the eye,
2. the corner of the mouth, and the lower lip anteriorly,
3. the entire ear and descending hairline, and 2 to 3 cm of
hair superior to the posterior hairline, posteriorly
4. the temporal area must also be completely exposed
superiorly
103
104. The incision begins approximately
1.5 to 2 cm superior to the zygomatic arch just
posterior to the anterior extent of the hairline.
The incision then curves posteriorly and
inferiorly, blending into a preauricular incision
in the natural crease anterior to the pinna.
The incision continues under the earlobe and
approximately 3 mm onto the posterior surface
of the auricle instead of continuing in the
mastoid–ear skin crease.
It curves posteriorly toward the hairline and
then runs along the hairline, or just inside it,
for a few centimeters.
104Surgical approaches to facial skeleton – Edward Ellis 2nd ed
111. Once the capsule has been identified, access to the
articular surfaces (superior and inferior joint spaces)
can be obtained by a great variety of incisions.
111-
112. ;
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
112
The lateral ligament, capsule, and
periosteum are reflected inferiorly
en masse.
Discal or posterior attachment are
dissected sharply with scissors to
the level of the condylar neck.
113. 113
The posterior attachment and disc attachments are then severed sharply at the
lateral pole of the condyle from within the developed flap.
These tissues are then reflected superiorly from the head of condyle to expose
inferior joint space
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
114. The superior joint space is
punctured at the level of
discocapsular sulcus.
A dissection is then carried inferiorly
removing the attachment of the
capsule to the disc and exposing the
inferior joint space.
114
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
120. SYMPTOMS: pain over auricle and deep in ear canal, edema, erythema, induration
121. MANAGEMENT:
1. Conservative: mildest form is treated by using oral and topical
antibiotics.
2. Hematoma of the auricle should be drained properly
3. If there is any sign of pus drainage – C/S followed by broad
spectrum IV antibiotics.
4. In resistant cases, continuous drainage and irrigation with
antibiotics and steroids solution.
5. In severe cases, aggressive excision of the necrosed cartilage
involving overlying subcutaneous tissues and skin should be
done.
121
122. Sialocoeles result in the
accumulation of saliva in
glandular/periglandular or
subcutaneous tissues.
When the accumulated
saliva drain through the
skin it is termed as
salivary fistula.
122
123. MANAGEMENT
1. Small sialocoeles have said to resolve spontaneously by scar
formation which seals the salivary flow.
1. Non surgical management:
repeated aspirations and compression dressings
administration of anticholinergics
antisialogogues
123
124. Surgical management:
These procedures direct the salivary flow into
the mouth or
Depresses the salivary secretion
1. Creating a tract intraorally
2. Duct ligation
3. Sectioning of auriculotemporal nerve
4. Surgical excision of fistulous tract
124
125. 125
J Oral Maxillolac Surg49:680-682. 1991
NAMED AFTER DR. LUCIA
FREY
Frey’s syndrome or gustatory sweating and flushing is characterized
by sweating and flushing of the facial skin during meals.
The area involved is on the lateral aspect of the face and upper neck,
usually around the parotid region.
126. Techniques to evaluate - Blotting paper method
Iodine sublimated paper histogram
Treatment:
1. external radiotherapy
2. local or systemic application of anticholinergic drugs
Laage-Hellman was the first to apply scopolamine (3%
cream) for the treatment of gustatory sweating.
1. interposition of a subcutaneous barrier
2. injection of botulinum toxin in the involved skin
126
127. Surgical Interposition
the use of a barrier between the facial skin and
the parotid bed.
127
Botulinum Toxin
The injection of botulinum A toxin in the skin involved
by gustatory sweating was recently proposed by Drobik and
Laskawi. It acts by blocking the exocytosis mechanism of
the presynaptic terminal, thereby inhibiting release of
acetylcholine.
128. Know your anatomy properly.
- Emphasis on Facial .N relation to fascial layers.
Importance of maintaining proper dissection
plane.
Chose the appropriate approach based on the
problem.
Be aware of the possible complications from each of
the approach.
129. 1. GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed
2. Atlas of human anatomy – Frank H Netter 6th ed
3. Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
4. Oral and maxillofacial trauma – Fonseca 4th ed
5. Surgical approaches to facial skeleton – Edward Ellis 2nd ed
6. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
7. Salivary gland disorders - Myers
8. An Anatomical Study on the Distribution of the Temporal Branch ofthe
Facial Nerve - J. Cranio-Max.-Fac. Surg. 18 (1990) 287-292.
9. A modified pre-auricular approach to the temporomandibular jointand
malar arch - British Journal of Oral Surgery 17 (1979-80), 91-103.
10. The surgical anatomy of the mandibular distribution of the facial nerve
British Journal of Oral Surgery (1981) 19, 159-l 70. 129
130. AModified EndauralApproach to the Temporomandibular JointOral Maxillofac
Surge 51:33-37,1993.
A new modified endaural approach for access to the temporomandibularjoint
British Journal of Oral and Maxillofacial Surgery (2001) 39, 371–373.
The Deep Subfascial Approach to the Temporomandibular Joint - J Oral
Maxillofac Surg 62:1097-1102, 2004.
Ankylosis of temporomandibular joint - Dingman
A truly endaural approach to the temporo-mandibular joint - British Journal of
Plastic Surgery (1984) 37,65-68.
Transmasseter Approach to Condylar Fractures by Mini-RetromandibularAccess
- J Oral Maxillofac Surg 67:2418-2424, 2009
Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular
Condyle Fracture of the Mandible - J Oral Maxillofac Surg 68:1578-1584, 2010.
The post-auricular approach for gap arthroplasty e A clinical investigation-
Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500-505.
130