The temporomandibular joint (TMJ) connects the mandible to the temporal bone. It is a compound joint composed of bone and soft tissue structures. The TMJ develops from condylar and temporal blastemas and its structures allow for both hinging and gliding movements. Clinically, the TMJ is examined through inspection, palpation, auscultation and assessment of range of motion. Abnormal findings may include swelling, crepitus, limited movement or clicking sounds.

1. TEMPOROMANDIBULAR JOINT
(ANATOMY)
GUIDED BY –
DR. S.R. GODBOLE
DR. ANJALI BHOYAR BORLE
DR. TRUPTI M. DAHANE
DR. SEEMA SATHE
PRESENTED BY –
PRIYANKA N. KHUNGAR

2. SPECIFIC LEARNING OBJECTIVES
5. Prosthodontic
Considerations
Cognitive Must know

3. CONTENTS
• INTRODUCTION
• DEFINITION
• TYPE OF THE JOINT
• DEVELOPMENT OF THE JOINT
• BASIC ANATOMY OF THE JOINT
• MANDIBULAR MOVEMENTS
• CLINICAL EXAMINATION OF THE JOINT
• INVESTIGATIONS
• PROSTHODONTIC CONSIDERATIONS

4. TERMINOLOGIES:
• STOMATOGNATHIC SYSTEM: The combination of structures involved
in the speech, receiving food, mastication and deglutition as well as
the parafunctional actions.
-GPT 9

5. • Gnathology is a branch of dental care that
studies the work and interaction of
temporo-mandibular joint (jaw joint),
masticatory muscles and teeth, which
ensure proper performance of lower jaw.
GNATHOLOGY (TERM
COINED BY DR.HARVEY
STALLARD
Gnathos (GREEK) –
referring to JAW
Ology- meaning to
study
THE GNATHOLOGICAL APPROACH versus THE NEUROMUSCULAR APPROACH to Dental Diagnosis and Treatment
by Clayton A. Chan, D.D.S.

6. TEMPOROMANDIBULAR JOINT

7. • DEFINITION:
“The articulation of the condylar process of the mandible and intra-
articular disc with the mandibular fossa of squamous portion of the
temporal bone; a diarthrodial, sliding hinge joint. Movement in the
upper joint compartment is mostly transitional, whereas that in the
lower joint compartment is mostly rotational. The joint connects the
mandibular condyle to the articular fossa of the temporal bone with the
temporomandibular disc interposed.”
-GPT 9

8. • TEMPOROMANDIBULAR JOINT IS ALSO
TERMED AS
1) Cranio-Mandibular Joint
2) Ginglymo-arthrodial joint
3) Modified ball and socket joint
4) Compound Joint
Okeson, JP: Management of temporomandibular disorders and occlusion. 6th edition

9. • The area where the mandible articulates with the cranium, the TMJ, is
one of the most complex joints in the body.
Provides for HINGING MOVEMENT in one plane
– GINGLYMOID JOINT
Also provides for GLIDING MOVEMENT –
ARTHRODIAL JOINT
Thus, considered as a GINGLYMOARTHRODIAL
JOINT

10. • TMJ is classified as a COMPOUND JOINT
COMPOUND
JOINT
MANDIBULAR
CONDYLE
ARTICULAR
DISC
MANDIBULAR
FOSSA
2 sets of Bone

11. TEMPOROMANDIBULAR
JOINT
OSSEOUS
COMPONENTS
1. Mandibular condyle
2. Mandibular Fossa
3. Articular Eminence
SOFT TISSUE
COMPONENTS
1. Articular disc
2. Synovial fluid
3. Joint capsule
4. Ligaments
5.Muscles
5.Vascular supply
6. Nerve supply
Shivlal Rawlani : manual of Temporomandibular Joint, 1st edition

12. DEVELOPMENT OF TEMPOROMANDIBULAR JOINT
TMJ structures originates
from 2 blastemas
CONDYLAR BLASTEMA
-Arises from the secondary
condylar cartilage of
mandible.
-Evolves to contribute to
the formation of: condylar
cartilage, aponeurosis of
lateral pterygoid muscle,
articular disc and the
capsular elements of the
joint.
TEMPORAL BLASTEMA
-arises from the otic
capsule.
-it develops into the
articular structures of the
upper level.
Shivlal Rawlani : manual of Temporomandibular Joint, 1st edition

13. INTRAUTERINE DEVELOPMENT OF TMJ
• 8th week – condylar blastema as a condensation of mesenchymal
cells.
-Temporal blastema is present posterior and lateral to the condyle.
• 10 – 12 weeks – growth in size of the condylar cartilage in
posterior and lateral direction to developing condyle.
Between the condylar and temporal blastema , third layer
of condensation of cells – develops into the articular disc.
• 12th week – when the two structures meet, cavitation
occurs to form : upper and lower joint spaces.
• 14 weeks – basic morphology of joint is achieved.
David A. -DEVELOPMENT OF THE HUMAN TEMPOROMANDIBULAR JOINT, British Journal of Oral Surgery, 1982.

14. BIRTH:
- Joint displays structural components
of adult joint, but it lies parallel to
occlusal plane instead of several mm
superior to it.
- Articular eminence – inferiorly
positioned, fossa - relatively flat and
joint functions as a pure hinge system
with no translation.
CHILDHOOD
- As primary dentition achieves
occlusion at about age of 3 years –
pressure placed on the joint,
results in change to non vascularity
of the articular surfaces.

15. OSSEOUS COMPONENTS

16. MANDIBULAR CONDYLE
• Forms the inferior articular surface of
the joint.
• The condyle is the portion of mandible
that articulates with the cranium, around
which the movement occurs.
• Consists of medial & lateral projections
called as poles.
• Mediolateral Length- 18 to 23mm
Anteroposterior width- 8 to 10mm.
• Articulating surface – anterior and
posterior surface of most superior aspect
of condyle.
A – MANDIBULAR CONDYLE
B – MEDIAL AND LATERAL POLE OF THE CONDYLE
C – ANTERIOR ARTICULAR SURFACE OF CONDYLE
D - POSTERIOR ARTICULAR SURFACE OF CONDYLE
Okeson, JP: Management of temporomandibular disorders and occlusion. 6th edition

17. GLENOID FOSSA
• Forms the Superior articulating surface of the joint.
• Part of squamous part of temporal bone that houses
the mandibular condyle.
• Shape- concave
• Limited by :
Anteriorly – articular eminence
Posteriorly – squamotympanic fissure
Roof – covered by thin layer of compact bone (thus
cannot sustain heavy forces.)

18. ARTICULAR EMINENCE OR
ARTICULAR TUBERCLE
• Convex bony prominence present immediately
anterior to the mandibular fossa.
• Degree of convexity of articular eminence is highly
variable.
• Consists of – thick dense bone subjected to
loading during function.
• Steepness of the surface of articular eminence
dictates the pathway of the condyle when the
mandible is positioned anteriorly.

19. SOFT TISSUE COMPONENTS

20. ARTICULAR DISC
• Composed of DENSE FIBROUS CONNECTIVE TISSUE and is positioned between
the two articulating bones i.e., the glenoid fossa and the mandibular condyle.
• Non vascularized and non innervated except
in the peripheral non - pressure bearing areas.
• Disc divides the joint space into 2 compartments
SUPERIOR JOINT
CAVITY
-Bordered by the glenoid
fossa and superior surface of
the disc.
-Allows translational
movement
INFERIOR JOINT
CAVITY
-Bordered by the mandibular
condyle and the inferior
surface of the disc.
-Allows rotational
movement.

21. ARTICULAR DISC DIVISION IN
SAGITTAL PLANE : ACCORDING
TO THICKNESS OF THE REGION
ANTERIOR
BORDER
Thicker than the
intermediate
zone.
INTERMEDIATE
ZONE
-Thinnest portion of
the disc.
-In normal joint,
articular surface of
the mandibular
condyle is located in
this zone.
POSTERIOR
BORDER
Even thicker
than the
anterior border.

22. ARTICULAR DISC IS ATTACHED POSTERIORLY TO-
Retrodiscal tissue OR Posterior
Attachment
-Region of loose connective tissue that is highly
vascularized and innervated.
bordered by superior retrodiscal lamina
-Lamina of loose connective tissue containing
ELASTIC FIBRES.
-Lamina attaches the articular disc to the tympanic
plate.
bordered by inferior retrodiscal lamina
-lamina chiefly composed of COLLAGENOUS FIBRES.
-Lamina attaches inferior border of posterior edge of the
disc to posterior margin of articular surface of condyle
RT – retrodiscal tissue
SRL – superior retrodiscal lamina
IRL – inferior retrodiscal lamina

23. FUNCTIONS OF ARTICULAR DISC
1. Shock absorption.
2. Prevents undue forward gliding.
3. A ball bearing action.
4. Allows a combination of different movement by dividing the joint
into compartments and allows bony elements to move
independently on the disc.
5. Assists in lubrication of the joint.

24. SYNOVIAL FLUID
-Clear, straw colored, viscous fluid, composed of dialy-sate of blood
plasma in combination with mucopolysaccharide – hyaluronic acid.
-Produced by the specialized endothelial cell lining that form
synovial lining in the joint cavities along with the specialized
synovial fringe.
It fills both the joint cavities that is superior (1.2ml) and inferior
(0.9ml) cavities. Hence, TMJ is referred to as a SYNOVIAL JOINT.
Serves 2 purposes:
1. Acts as a medium for providing metabolic requirements to the
articular tissues.
2. Serves as a lubricant between the articular surfaces during
function.

25. Synovial fluid lubricates articular surfaces by 2
mechanisms:
BOUNDARY LUBRICATION
• Primary mechanism of joint lubrication.
• Lubricates the articular tissues by surface contact.
• When synovial fluid becomes too viscid , its lubricating qualities are impaired –
i.e., clinically termed as GELATION.
WEEPING LUBRICATION
• Refers to ability of the articular surfaces to absorb small amount of synovial
fluid.
• Under compressive forces – small amount synovial fluid released that acts as a
lubricant between articular tissues.
• Helps eliminate friction in compressed but not moving joint.
Bell, W.E: Temporomandibular disorders, classification, diagnosis & management. 3rd edition

26. LIGAMENTS OF TMJ
FUNCTIONAL LIGAMENTS:
COLLATERAL (DISCAL)
LIGAMENT – MEDIAL
AND LATERAL
CAPSULAR LIGAMENT
TEMPOROMANDIBULAR
LIGAMENT
ACCESORY LIGAMENTS:
• SPHENOMANDIBUL
AR LIGAMENT
• STYLOMANDIBULA
R LIGAMENT
as

27. COLLATERAL (DISCAL) LIGAMENTS
• Attach the MEDIAL and LATERAL borders of the
articular disc to the poles of the mandibular condyle.
• Two discal ligaments- medial and lateral.
• MEDIAL discal ligament- attaches medial edge of disc to
medial pole of condyle.
• LATERAL discal ligament- attaches lateral edge of disc to
lateral pole of condyle.
• Function: Restrict movement of the disc away from the
condyle.
• They are responsible for the HINGING MOVEMENT. MDL – MEDIAL DISCAL LIGAMENT
LDL – LATERAL DISCAL LIGAMENT
Okeson, JP: Management of temporomandibular disorders and occlusion. 6th edition.

28. CAPSULAR LIGAMENT
• Capsular Ligament surrounds and
encompasses the entire TMJ.
• Acts to resist any medial, lateral or
inferior forces that tends to separate or
dislocate the articular surfaces.
• Encompass the joint, thus retaining the
synovial fluid.

29. TEMPOROMANDIBULAR LIGAMENT
CONSISTS OF 2 PARTS:
OUTER OBLIQUE PORTION:
• Resists excessive dropping of the condyle, therefore
limiting the extent of mouth opening.
• During initial phase of opening, the condyle can
rotate around a fixed point until the TM ligament
becomes tight.
• When ligament is taut, neck of condyle cannot
rotate further. If the mouth is to be opened wider,
the condyle would need to move downward and
forward across the articular eminence.
OUTER OBLIQUE
TM LIGAMENT

30. EFFECT OF OUTER
OBLIQUE PORTION
OF TM LIGAMENT
• This can be demonstrated by closing the mouth and applying mild posterior force to the
chin.
• The jaw will easily rotate to open until the teeth are 20 to 25 mm apart. When opened
wider than this, resistance is felt. At this point resistance will be felt when jaw is opened
wider.
• If jaw opened wider than this, rotation of the condyle at a fixed point to a movement
forward and down the articular eminence is seen.

31. INNER HORIZONTAL PORTION
• Limits posterior movement of the condyle and
disc.
• when force applied to the mandible, displaces
the condyle posteriorly.
• Therefore the ligament protects the retrodiscal
tissues from trauma created by the posterior
displacement of the condyle.
• It also protects lateral pterygoid muscle from
overlengthening and extension.
INNER HORIZONTAL
TM LIGAMENT

32. ACCESSORY
LIGAMENTS
SPHENOMANDIBULAR
LIGAMENT
• Arises from spine of
sphenoid bone and
extends downward and
inserts over LINGULA.
STYLOMANDIBULAR
LIGAMENT
• Arises from the styloid
process and extends
downward and forward to
the angle and posterior
border of mandibular
ramus.
• Limits excessive protrusion
of mandible.

33. PINTO LIGAMENT:
• The mandibular-malleolar ligament
found connecting the neck and
anterior process of the malleus to
the medio-postero-superior part of
the capsule, interarticular disc and
sphenomandibular ligament.
• Starching of the Pinto Ligament
causes ringing in the ears
(TINNITUS).
DML, Discomalleolar ligament
fibers; PML, fibers from sphenomandibular
ligament; PMAL, fibers from the discomalleolar
and sphenomandibular ligament.
T. Rowicki1 , A study of the discomalleolar ligament in the adult human, Folia Morphol., 2006

34. MUSCLES OF MASTICATION
TEMPORALIS
LATERAL
PTERYGOID
MEDIAL
PTERYGOID
MASSETER

35. • TWO JOINT SYSTEMS IN ONE JOINT:
1. CONDYLE DISC COMPLEX – ROTATIONAL / HINGING MOVEMENT
2. CONDYLE DISC COMPLEX functioning against the mandibular fossa –
TRANSLATORY MOVEMENTS
3. ROTATIONAL / HINGING MOVEMENT –
initial mouth opening from 20 to 25mm
4. TRANSLATORY MOVEMENTS –
After 20 to 25 mm when the mouth is opened further.
Okeson, JP: Management of temporomandibular disorders and occlusion. 6th edition.

37. VASCULAR SUPPLY OF TMJ
1. POSTERIOR – Superficial Temporal Artery
2. ANTERIOR – Middle Meningeal Artery
3. INFERIOR- Internal Maxillary Artery

38. NERVE SUPPLY OF TMJ
• Innervation provided by:
1. Auriculo-temporal nerve
2. Deep temporal nerve
3. Masseteric nerve

39. MANDIBULAR MOVEMENTS

43. CLINICAL EXAMINATION
TEMPOROMANDIBULAR JOINT
1. Inspection
2. Palpation
3. Auscultation
4. Range of Motion
5. Palpation of Muscles of Mastication

44. 1. INSPECTION
• Presence of any local swelling or erythema in preauricular region.
• Any gross asymmetry or hypertrophy of muscles.
• Any deformation, deviation of chin and tooth wear.

45. 2. PALPATION
• On palpation – if severe
effusion present, bulge is
palpated.
• Note the abnormal sound and
crepitus and the
anteroposterior gliding
movements of the condyle.

46. 3. AUSCULTATION
• Examined using stethoscope.
1. Joint sounds of single event for a
short duration – as CLICK,
• If loud – generally referred as POP.
• Clicking most commonly associated
with Internal Disc Derangement.
2. Crepitus- rough gravel like sound.
• The character of the sound and
timing of its occurrence should be
noted – as this may explain
presence of various conditions like
osteoarthritis, condyle- disk
incoordination, etc.

47. 4. RANGE OF MOTION
• ROM assessment is a simple and objective method to evaluate the
function of masticatory system.
• Degree of mandibular opening measured using – distance between
the incisal edges of upper and lower anterior teeth.
• Normal jaw opening – 40 to 60mm (directly related to the height)
• Opening if < 35mm in an adult – considered abnormal.

48. 5. PALPATION OF MUSCLES OF MASTICATION
MASSETER
MUSCLE
Only superficial
part can be
examined
extraorally.
Patient is asked to
clench his teeth.
MEDIAL
PTERYGOID
MUSCLE
Only inferior part
of the muscle can
be palpated by this
method.
TEMPORALIS
MUSCLE
Palpation is done
while clenching of
teeth.

49. INVESTIGATIONS – TMJ IMAGING
1. Panoromic Radiography
2. Transcranial Radiography
3. Computed Tomography
4. Cone Beam Computed Tomography
5. Magnetic Reasonance Imaging

50. PANORAMIC RADIOGRAPHY
-Method for observing acute bone deformation
and presence of cysts or tumours.
-The superimposition of the base of the skull and
zygomatic arch restricted the evaluation of the
condyle and glenoid fossa in the panoramic film.
TRANSCRANIAL RADIOGRAPHY
-provides relationship between head of
the condyle and glenoid fossa
-Used to examine the joint for fracture
with marked dislocation, gross arthritic
changes.
Pramod Kumar : Recent advances in Temporomandibular joint imaging – an update . Journal of Dental Sciences and Oral Rehabiltation- dec2013

51. COMPUTED TOMOGRAPHY
• For diagnosis of disc
displacement, condylar fracture,
degenerative bone changes,
ankylosis.
• Less convenient than MRI.
CONE BEAM COMPUTED
TOMOGRAPHY (CBCT)
• It is also known as volumetric CT.
• For examination of osseous
components of the TMJ.
• Has high diagnostic quality, less
radiation exposure than CT.

52. MAGNETIC REASONANCE IMAGING
• Non invasive technique, imaging of soft
tissue better than CT, less invasive than
arthrography.
• Used for imaging articular disc
displacement helpful to indicate any
fibrosis, joint effusion, neoplasm etc.
• Contraindicated in pregnant women,
patients with cardiac pacemakers,
claustrophobic patients.

53. PROSTHODONTIC IMPLICATIONS OF
TEMPOROMANDIBULAR JOINT

54. A] CONGENITAL AND DEVELOPMENTAL TMJ ANOMALIES
Condylar aplasia or hypoplasia
• Failure of the condyle to develop
• May occur unilaterally or bilaterally
• Shift of the mandible towards affected side
• Alters occlusion and mastication
• In bilateral cases, the shift is not evident
Condylar hyperplasia
• Gradual enlargement of the mandibular condyle,
• progressive unilateral enlargement of the mandible,
• facial asymmetry and shifting of the midline of the chin to the
unaffected side, with resulting cross-bite malocclusion.
Keiseki Kaneyama: Congenital deformities and developmental abnormalities of the mandibular condyle in the temporomandibular joint , Congenital Anomalies

55. B] JOINT DISORDERS
a) Disc displacement with reduction:
Treatment : 1. if recent and painless, sometimes possible to
reduce the dislocated by manipulation.
2. If painful, a modified occlusal bite plane can be used to
reduce displacement.
b) Disc Displacement without reduction:
Treatment: 1. Patient education and self care
2. Pharmacotherapy
3. Occlusal therapy
William 6. Farrar, Differentiation of temporomandibular joint dysfunction to simplify treatment, J. Prosthet. Dent. December, 1972

56. C] TRAUMA
UNILATERAL DISLOCATED CONDYLAR
FRACTURE:
TREATMENT : mandibular repositioning
splint using acrylic resin guiding ramp.

57. REFERENCES:
• THE GNATHOLOGICAL APPROACH versus THE NEUROMUSCULAR APPROACH to Dental Diagnosis and
Treatment by Clayton A. Chan, D.D.S.
• Okeson, JP: Management of temporomandibular disorders and occlusion. 6th edition
• Shivlal Rawlani : manual of Temporomandibular Joint, 1st edition
• David A. -DEVELOPMENT OF THE HUMAN TEMPOROMANDIBULAR JOINT, British Journal of Oral
Surgery, 1982.
• Bell, W.E: Temporomandibular disorders, classification, diagnosis & management. 3rd edition
• T. Rowicki1 , A study of the discomalleolar ligament in the adult human, Folia Morphol., 2006
• Pramod Kumar : Recent advances in Temporomandibular joint imaging – an update . Journal of
Dental Sciences and Oral Rehabiltation- dec2013
• Keiseki Kaneyama: Congenital deformities and developmental abnormalities of the mandibular condyle in
the temporomandibular joint , Congenital Anomalies 2008
• William 6. Farrar, Differentiation of temporomandibular joint dysfunction to simplify treatment, J. Prosthet.
Dent. December, 1972

58. NOTHING IS MORE FUNDAMENTAL TO TREATING
PATIENTS THAN KNOWING THE ANATOMY.
-Jeffrey P. Okeson
THANK YOU