The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. The TMJ is a bilateral synovial articulation between the mandible and temporal bone. The name of the joint is derived from the two bones which form the joint: the upper temporal bone which is part of the cranium (skull), and the lower jawbone or mandible. There are six main components of the TMJ. Mandibular condyles Articular surface of the temporal bone Capsule Articular disc Ligaments Lateral pterygoid

2. P R E S E N T E D B Y : -
D R . S I D D H A R T H
TEMPOROMANDIBULAR
JOINT

3. CONTENTS
 Joint & its Classification
 Development of TMJ
 Gross anatomy of TMJ
 Vascular supply
 Muscle of mastication
 TMJ Disorders
 References

4. JOINT & its CLASSIFICATION
When two bony structures come in contact/articulate
with each other, they form a variety of structural
arrangements termed as a joint or Arthroses.
Arthroses
Synarthroses
(solid/non-synovial)
Diarthroses
(synovial)
Fibrous
Cartilaginous
Simple
Compound
Complex

5. FIBROUS JOINTS:-
 Suture
 Gomphosis
 Syndesmosis
CARTILAGINOUS JOINTS:-
 Primary cartilaginous Joint/Synchondrosis
 Secondary cartilaginous joint /Symphysis
GOMPHOSES

6. TYPES OF SYNOVIAL JOINTS
1. Based on complexity- 3. Based on shape of the
articulating surfaces-
 Planer joint
 Ginglymoid (hinge) joint
 Condyloid (bicondylar)
joint
 Sellar(saddle) joint
 Spheroidal(ball & socket)
joint2. Based on degrees of
freedom-
•Uniaxial
•Biaxial
•Multiaxial

7. TEMPOROMANDIBULAR JOINT
 The Temporomandibular joint is also known as the
Craniomandibular joint or Bilateral diarthroidial
joint.
 It is the articulation between the squamous part of
the temporal bone and the head of the condyle.
 It is also considered as a complex joint because it
involves two separate synovial joint ,in which there is
a presence of intra-capsular disc or meniscus.

8. Synonyms of TMJ
 Craniomandibular joint /
articulation
 Bicondylar joint
 Mandibular joint
 Modified Ball & Socket
 ‘Compound ‘ joint

9. Development of TMJ
 In 8-9th wk of IU life, Meckel’s cartilage provides the
skeletal support for the development of the mandible &
extends from the midline backwards and dorsally.
 The articulation of malleus and incus functions as the
primary TMJ.

10. ~10th week-Two distinct regions of mesenchymal condensation between
the condylar cartiage of mandible & the developing temporal bone
temporal blastema & condylar blastema
At the same time lateral pterygoid muscle attaches to condyle.
~12th weeks- Two slit like joint cavities & an intervening disc appear
1st cleft appears immediately above condylar blastema becomes inferior
joint cavity. The condylar blastema then differentiates into condylar
cartilage
2nd cleft appears in relation to the temporal ossification that becomes
the superior joint cavity.
With the appearance of this cleft, the primitive articular disk is formed
~16th wk-Malleus & Incus begin Transformation into middle ear bones &
dissappearance of primary joint starts
18th-20th wk-Secondary joint becomes functional & Meckel’s Cartilage
loses its function & dissapears

11. Gross Anatomy of TMJ
BONY COMPONENTS
• Condylar Head
• Glenoid Fossa
• Articular Eminence
SOFT TISSUE COMPONENTS
•Articular Disc
•Synovial fluid
•Ligaments

12. BONY
Components

13. CONDYLE
•Broad & slightly convex
Mediolaterally(15-20mm).
•Narrow & strongly convex
Anteroposteriorly(8-10mm)
•Articular surface covered by
fibro cartilage to adapt excess
loading.
• Medial & lateral projections
termed poles.

14. GLENOID /ARTICULAR FOSSA
Also k/a MANDIBULAR FOSSA.
BOUNDARIES:
Anteriorly – Articular
eminence.
Posteriorly – Squamotympanic
& petrotympanic fissure.
Medially – Spine of the
sphenoid.
Laterally – Root of the
zygomatic process of temporal
bone.
Superiorly – Thin plate of
temporal bone.

15. ARTICULAR EMINENCE
• Forms posterior root of
zygomatic arch and
anterior wall of Articular
fossa, present on the
inferior aspect of the
zygomatic process of the
temporal bone.

16. SOFT TISSUE COMPONENTS

17. ARTICULAR DISC
 Articular disc composed of
dense fibrous connective
tissue devoid of blood vessels
and nerve fibers.
 Consists of type I and 2
collagen & few Elastic fibers.
 The articular disc is an oval
fibrous plate that divides the
joint into an Upper &
Lower Compartments

18. PARTS Of the disc
1. Anterior Thickening
(2mm)
2. Intermediate zone or
central segment
(1mm)
3. Posterior Thick Band
(3mm)
SIGNIFICANCE
The addition of articular
disc decreases the
intra-articular pressure
while simultaneously
facilitating the loaded
sliding movements.

19. SYNOVIAL FLUID
Synovial Membrane
Cellular intima
Vascular Subintima
Synovial cells
Type A (macrophage like)
Type B (fibroblast like)
Synovial Fluid
Lubrication (minimizes
friction), Nutrition,
Cleansing action.

20. LIGAMENTS
Ligaments act as passive restraining devices to limit and
restrict border movements thus protect the structure of the
joint.
Made up of collagenous connective tissues.
APPLIED: Have a particular length – do not stretch.
However if sudden or prolonged forces are applied, they gets
elongated & thus can cause compromised joint function.
Functional Ligaments
1. Collateral
2. Capsular
3. Temporomandibular
Accessory Ligaments
1. Sphenomandibular
2. Stylomandibular

21. COLLATERAL LIGAMENTS
FUNCTIONS:
 Responsible for dividing the
joint medio-laterally.
 Restrict the movement of the
disc away from the condyle
as the Disc glides Anteriorly
& Posteriorly.
 Also aids in Hinging
movement of condyle.

22. CAPSULAR LIGAMENT
Function:-
 It acts to resist any medial,
lateral or inferior forces
that tend to separate or
dislocate the articular
surfaces.
 Well innervated – provides
proprioceptive feedback
regarding position &
movement of the joint.

23. TEMPOROMANDIBULAR / LATERAL
LIGAMENT
 It re-enforces the Capsular
ligament on the lateral side.
The unique feature of
Temporomandibular
ligament is to limits the
rotational movement .

24. SPHENOMANDIBULAR LIGAMENT
 It is an accessory
ligament, lies on
a deep plane
away from the
fibrous capsule.
 It does not have
any significant
limiting effects on
mandibular
movement.

25. STYLOMANDIBULAR LIGAMENT
Attached:
 Above- styloid process
 Below- posterior border of
the ramus
FUNCTION-
 It limits excessive
protrusive movements of
the mandible.

26. BLOOD SUPPLY
 Branches from the
superficial temporal
artery
 Deep auricular artery
VENOUS DRAINAGE
•Superficial temporal vein

27. NERVE SUPPLY
Nerve supply to the TMJ
arises from the
mandibular division of the
trigeminal nerve
specifically the:-
 The auriculotemporal
nerve which runs below &
behind the joint
 The nerve to masseter also
sends a twig to the joint

28.  It is to the pre-
auricular nodes
 The intraparotid
nodes
 The upper deep
cervical nodes
LYMPH DRAINAGE

30. ACCESARY MUSCLES OF
MASTICATION
 Suprahyoid muscle
 Infrahyoid muscle
 Sternocleido-
mastoid muscle

32. AGE CHANGES OF TMJ
Flattened condyle
Thinning of the disc
Fibrotic synovial folds
Thickening of the blood vessel walls
Decrease the number of nerves
Osteoporosis of the condyle bone
Thickening of the fibrous covering of the condyle
Thinning of the cartilaginous zone of condyle

33. BIOMECHANICS OF MASTICATORY
SYSTEM
 Understanding mandibular movement
begins from an initial reference point for
each condyle, usually referred to as
’centric relation’.
FUNCTIONAL
MOVEMENTS
TRANSATIONAL
MOVEMENTS
ROTATIONAL
MOVEMENTS
BORDER
MOVEMENTS

34.  Rotational movement it is only the physiologic
movement that occur between the surface. The
condyle is not sliding out of the fossa so, only one
joint system is involved.
 Translational movement it is free sliding movement
of the disk b/w the surface in the superior cavity ,
referred to as translation.
 When mandible moves through the outer range of
motion, reproducible discernable limits result
which are called Border movements.

35. ENVELOPE OF MOTION
 When we combine the
border movements of all
the 3 planes (i.e sagittal,
horizontal & frontal) a
three- dimensional envelop
of motion can be produced
that represents the
maximum range of
movements of the
mandible.
 It was 1st described by
Posselt in 1952.

37. TMJ EXAMINATION
FACIAL ASSYMETRY
DEFLECTION
DEVIATION

38. TMJ EXAMINATION
Examination
component
Observations
Inspection Facial asymmetry/Swelling masseter and temporal
muscle hypertrophy. opening pattern( corrected and
uncorrected deviations, uncoordinated movements ,
limitations)
Assessment of range of
movements
Maximum opening with comfort, with pain and with
clinician assisstance
Palpation Masticatory muscles
TMJ
Neck muscles and accessory muscles
Parotid and submandibular area
Lymph nodes
Provocation Test Pain in joint or muscle with tooth clenching
Reproduction of symptoms with chewing
Intraoral Examination Signs of parafunction(cheek lip biting, occlusal wear,
scalloped tongue borders, tooth mobility,sensitivity to
percussion, fractures of enamel , restorations)

39. PALPATION OF TMJ
PALPATION OF THE
TEMPOROMANDIBULAR
JOINT
A-With mouth closed
B-During opening & closing
C-Palpation of posterior
aspect of joint with mouth
fully open

40. DIAGNOSTIC IMAGING TECHNIQUES
 Trans-cranial
 Trans-pharyngeal
 Computed tomography
 MRI
 T-Scan

41. COMPUTED TOMOGRAPHY

42. MRI
Establishing alterations in articular disk position in open
and closed mouth position, Inflammed joint examination

43. TEMPOROMANDIBULAR JOINT
DISORDERS
(TMD’s)

45. Definition
 It is a pain referred from a localized tender area or
trigger point in a taut band of skeletal muscle.
Etiology
 Trauma
 Muscular overextension
 Muscular overcontraction
 Muscle fatigue.
MYOFASCIAL PAIN DYSFUNCTION SYNDROME

46. Muscular overextension
 Over contoured dental
restoration
 Highly contoured FPD
& RPD
Muscular over contraction
• Bilateral loss of
posterior teeth
• Bone resorption by
denture
Muscle fatigue
 Caused by Muscle
Hyperactivity
1. Chronic Para
functional habits
2. Localized
periodontitis
3. Prolonged opening of
mouth
4. Chewing hard food

47. Clinical features
 At the 3rd & 4th decade of life
 More common in female
 Pain is constant and unilateral
 More severe in morning
 Patient is unable to identify exact site involved
 Deviation to unaffected site
 Aggravated by chewing and excessive eating
 Inability to open mouth

49. Differential diagnosis
1. Pulpitis
2. Pericoronitis
3. Parotitis
4. Otitis
5. Maxillary sinusitis
6. Trigeminal neuralgia

50. Treatment
1. Removal of the cause
2. Diet modification
3. Injection of trigger point
4. Splint therapy
5. Pharmacotherapy
6. Psychotherapy
7. TENS
8. Moist heat application

51. Stabilization or muscle relaxation appliance
Anterior bite
plane
Soft or resilient
appliance

52. PHARMACOTHERAPY
Local anesthetics:
 Lignocaine – 1-2%
 Procaine – 0.5%
 Without vasoconstrictor
NSAIDS
 Ibuprofen-200-600mg TDS
 Aspirin-2 Tabs 0.3-0.6gm
4hourly
Muscle relaxants:
 Cyclobenzapine-10mg at
bedtime for 10 days
 Meprobamate – 400mg TDS
Combination preferable
Anti anxiety drugs -
 Alprazolam – 0.5 mg at bed
time
 Diazepam – 2-10 mg at bed
time
 Clonazepam – 0.5-1 mg at bed
time
Tricyclic antidepressants
 Amitryptalline – 10-25 mgTDS
or at bed time
Opoids

53. TENS
 Trans-Cutaneous electric nerve stimulation
 TENS use of electric current produced by a device
to stimulate the nerves for therapeutic purposes

54. INTERNAL DERANGEMENT
Anatomical disturbances of disk-condyle relationship and
consequent changes in the mechanics of the joint, such as
clicking, locking and the presence or absence of associated
pain and muscular disorders.
- Clark & Solbey

55. Disk Displacement with reduction
 Disk displaced to an anterior and medial/lateral position;
reduces on full opening with a ‘click’ sound.

57. Disc displacement without Reduction
 Disk displaced anteriorly and medially/laterally, with
limited mouth opening
Disc displacement without Reduction and without opening
LOCKED JAW / CLOSED JAW

58. MANAGEMENT
AIM: to bring the joint back to healthy normal
position
Conservative treatment:
1. soft diet
2. avoidance of habits like Bruxism etc.

59. 3. Medications ( NSAIDS)
4. Muscle relaxants ( Diazepam)
5. Intra-articular injection of Triamcinolone,
Placentral extract, Hydrocortisone,
Hyaluronidase provides quick relief
6. New drug trials : Glucosamine &
Chondroitin sulfate as a synovial fluid
component replacement.

60. 7. Supportive therapy :
1. Appliances:
1. Stabilization splint
2. Repositioning splint

61. Hypermobility

62. Subluxation and dislocation
Subluxation:
Self reducing derangement between the articulating
components of a joint that is associated with symptoms of
pain, clicking, or momentary locking.
Dislocation or Luxation:
Derangement between the articulating components of a
joint that is not self- reducing

63. DISLOCATION

64. ETIOLOGY
1. Birth injuries ( forceps delivery)
2. Iatrogenic
Prolonged dental procedures
i. Traumatic mandibular extractions
ii. Injudicious use of Mouth props or Gags
3. Trauma to the Mandible or the TMJ
4. Physiologic (Extreme opening)
5. Positional pressure ( sleeping with head resting on the
arm)

65. Pathophysiology of Dislocation
 Occurs mostly when the mouth is wide opened and
the Masticatory muscles contract suddenly.

66. Treatment of Dislocation
 Manual Reduction
Is done by downward pressure on the molars
with padded thumbs, together with an upwards and
backwards force applied to the underside of the chin.

67. ANKYLOSIS
Fusion of the Bony components of the joint.
 Etiology:
 Trauma
 Infections ( Otitis Media)
 Osteomyelitis of the condyle

68. CLASSIFICATION OF ANKYLOSIS
1. False or True ankylosis
2. Extra- articular or Intra- articular
3. Fibrous or Bony
4. Unilateral or Bilateral

69. CLINICAL PRESENTATION
 Inability to open mouth
 Facial asymmetry in long
standing cases
 Deranged occlusion
 Retarded growth may also be present

70. 70
BONY ANKYLOSIS
FIBROUS
ANKYLOSIS

71.  Condylotomy/Condylectomy
 Gap Arthroplasty
 Interpositional Arthroplasty
Surgical treatment

72. GROWTH DISORDERS
 Hypoplasia of the Joint
 Hyperplasia of the Joint
 Dysmorphia

73. Hypoplasia of the Joint
Can occur as a part of unilateral or bilateral
Hypoplasia of the Mandible
 Size of the joint is small
 Size of the Zygoma is normal
Conditions with hypoplastic joint
 Pierre- Robin Syndrome
 Teacher-Collins Syndrome

74. Hyperplasia of the Joint
 Occurs most commonly with Facial
Hemiatrophy.
 Condyle head may or may not be greatly
enlarged .
 Normal movements of the joint might be
absent or present, depending upon the
condylar head size.

75. Dysmorphias
 Collectively termed as Lateral facial Dysplasia
that includes:
 Differences in size
 Differences in function
 only one joint is affected.

76. INFLAMMATORY ARTHROPATHIES

77. OSTEOARTHRITIS
 Etiology :
 Overloading producing
Degenerative changes in the
joint.
 Bruxism
 Absence of posterior occlusal
contact

78. Clinically
 Joint tenderness to manual
palpation
 Joint pain, increases with function
 Crepitation
 Dislocation and ankylosis may be
present
 Signs of disk displacement and
perforations
Radiographically:
 Flattened anterior slope of the
condyle
 Flattened posterior slope of the
articular eminence

79. Management
 Conservative
treatment
 Establishment of
functional occlusion
 Use of TMJ diathermy
 Relief of associated
myospasm
 Supplement analgesics
Surgical treatment
 High condylectomy
 If meniscus perforated –
dermal graft or silicon
blocks – glenoid fossa

80. RHEUMATOID ARTHRITIS
 unknown etiology but may be due to hypersensitivity
reaction to bacterial toxin specially Streptococci.
 2 phase process:-
 phase 1 systemic infection – inflammatory response within
joint
 phase 2 autoimmune reaction

81. Sign and symptoms:
 affects multiple joints
 pain & crepitus of TMJ
 limitation of movements
 Deformity
 Diagnostic by if rheumatoid factor is positive

82. Treatment
Conservative
 anti-rheumatoid therapy
 rest
 Moist heat application
 analgesics
 anti-inflammatory
 steroids
Surgical
 excision of the pathologically
involved portion of the
Condylar head & interposing a
carved silicon block
 total joint replacement

84. Meniscectomy [Lanz (1905)]
Meniscectomy is the
removal of central
avascular portion of the
disk and the area of
perforation through the
posterior ligament, where
the tissues may be
irreparably damaged.

85. CONDYLECTOMY
It is necessary surgical
maneuver to treat
ankylosis and to prepare
the joint for a total
alloplastic prosthesis or
a costochondral graft

86. CONDYLOTOMY [Ward(1952)]
The procedure was to
designed to induce a
displaced fracture
through the condylar
neck so that the condyle
would be repositioned
inferiorly and anteriorly.

87. REFRENCES
 BD Chaurasia’s, Human anatomy 2nd edition.
 Gray’s Anatomy-39th Edition
 Neelima Anil Malik: Textbook of Oral & Maxillofacial
Surgery-2nd Edition
 Greenberg,Glick,Ship: BURKET’S Oral Medicine-11th
Edition
 Jeffrey P.OKESON:BELL’S Orofacial Pain-6th Edition
 Color Atlas of Dental Medicine: Klaus H. Rateitschak and
Herbert F. Wolf Axel Bumann and Ulrich Lotzmann:TMJ
Disorders and Orofacial Pain-The Role of Dentistry in a
Multidisciplinary Diagnostic Approach
 Snell’s Anatomy