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temporomandibular joint.pptx
- 1. PRESENTED BY –DR. SUMEDHA THOSAR I-MDS GUIDED BY- DR. SWAPNA MAHALE MA’AM
- 2. Table of contents- Introduction Development Type of joint Articular surfaces Bony surfaces Ligaments Articular disc Relations Attachment Blood supply Nerve supply Functions Movements Examination of tmj Clinical aspect References
- 3. Introduction- The connecting sliding hinge mechanism between the mandible and the temporal bone (GPT-4th edition) Joint between the head (condyle) of the mandible and the undersurface (articular fossa)of the squamous part of the temporal bone.
- 4. The cranium, with which the mandible articulates, is also mechanically a single component, with a mandibular fossa on each side.
- 5. The temporomandibular joints are the bilateral components of a craniomandibular articulation. Movement cannot take place at one temporomandibular joint without a concomitant movement occurring at the joint on the opposite side.
- 6. Development- There are 3 stages that define the normal embryonic development of TMJ- blastemic stage , cavitation stage , maturation stage
- 7. At 3 months of gestation-1st evidence of TMJ - two distinct regions of mesenchymal condensation : 1)temporal and 2)condylar blastema {between developing ramus and developing squamous tympanic bone}. Ossification : first in temporal blastema and ,condylar blastema is condensed mesenchyme. Cleft appears immediately above condylar blastema- becomes the inferior joint cavity. The condylar blastema differentiates into i)condylar cartilage ii)second cleft appears in relation to temporal ossification that becomes superior joint cavity With the appearance of this cleft, the primitive articular disk is formed.
- 8. Appearance of clefts: Above condylar cartilage- inferior joint cavity Below temporal ossification-superior joint cavity
- 9. At 6th week- Articular disc first appears. At 7th week- Meckels cartilage extends from chin to base of skull acts as scaffolding for mandible development. Two ectomesenchymal condensation appears. At 12th week- Condylar growth appears and condyle begins to develop. At 22nd week- Articular capsule becomes recognisable and merges peripherally with condensation. At 26th week- All components of joints appears expect articular eminence. At 31st week- Sphenomandibular ligament appears. At 39th week- Ossification of bony components starts and resembles the future joint.
- 10. Type of joint Type of joint : synovial joint (condylar variety). Capable of providing -hinging (rotation) -gliding (translation) movement. Sustains incredible forces of mastication.
- 11. Fig: Parts of temporomandibular joint
- 12. Articular surfaces The upper articular surface - formed by parts of temporal bone- 1. Articular tubercle
- 13. 2. Anterior part of mandibular fossa Anterior part of
- 14. 3. Posterior non-articular part formed the tympanic plate.
- 15. The inferior articular surface is formed by the head of the mandible
- 16. The articular surfaces are covered by fibrocartilage The joint cavity is divided into upper and lower parts by an intra articular disc- superior joint cavity and inferior joint cavity. Upper joint cavity Lower joint cavity
- 18. CONDYLAR HEAD GLENOID FOSSA ARTICULAR EMINENCE Bony components- Ovoid process located above the mandibular head. Concavity within temporal bone that houses mandibular condyle. Anterior to glenoid fossa there is a convex bony prominence ie articular eminence/articular tubercle.
- 19. Ligaments- ligaments play an important role in protecting the structures. made up of collagenous connective tissues fibres that have particular lengths & do not stretch. Ligaments do not enter actively into joint function but instead act as passive restraining devices to limit and restrict border movements.
- 21. Other ligaments-"oto-mandibular ligaments“ connect the middle ear (malleus) with the temporomandibular joint. • discomallear (or disco-malleolar) ligament, • malleomandibular (or malleolar-mandibular) ligament.
- 22. The fibrous capsule- Attached – 1. Above : to the articular tubercle, 2. Below : to the neck of the mandible, 3. Front : to the circumference of the mandibular fossa, 4. Behind : to the squamotympanic fissure
- 24. The synovial membrane lines the fibrous capsule and the neck of mandible Capsule is loose above the intra articular disc and tight above it. Function- 1.To resist medial, lateral, or inferior forces that tend to separate or dislocate the articular surfaces. 2.To encompass the joint, to retaining the synovial fluid. 3.It is well innervated & provides proprioceptive feedback regarding position and movement of the joint.
- 25. Lateral (temporomandibular) ligament Attached- above to the articular tubercle, and below to the posterolateral aspect of the neck of the mandible. The lateral temporomandibular ligament strengthens the lateral part of the capsular ligament. Fibers are directed downwards and backwards.
- 26. • The outer oblique portion of the TM ligament functions to resist the impingement of vital submandibular and retromandibular structures of the neck. •The inner horizontal portion of the TM ligament limits posterior movement of the condyle and disc. The TM ligament therefore protects the retrodiscal tissues from trauma created by the posterior displacement of the condyle. •The inner horizontal portion also protects the lateral pterygoid muscle from overlengthening or extension. The effectiveness of this ligament is demonstrated during cases of extreme trauma to the mandible. Functions of temporo- mandibular ligament
- 27. Sphenonmandibular ligament It is an accessory ligament, that lies on a deep plane away from the fibrous capsule. Remanent of dorsal part of Meckel's cartilage. Attached superiorly to the spine of sphenoid and inferiorly to the lingula of the mandibular foramen.
- 28. Relations: 1. Laterally- a) lateral pterygoid muscle b) Auriculotemporal nerve c) Maxillary artery Maxillary artery
- 29. 2. Medially- a) Chorda tympani nerve b) Wall of pharynx . Near its lower end , it is pierced by the mylohyoid nerve and vessels. Mylohyoid nerves and vessels
- 30. Stylomandibular ligament Accessory ligament of the joint. Represents a thickened part of deep cervical fascia. Separates parotid and submandibular salivary glands. Attached – above : to styloid process Below: to the angle and adjacent part of posterior border of ramus of mandible.
- 31. It becomes taut when the mandible is protruded, but is most relaxed when the mandible is opened. The stylomandibular ligament therefore limits excessive protrusive movements of the mandible. This ligament becomes tense only in extreme protrusive movements. Functions of stylo- mandibular ligament
- 32. Colateral ligament Attach the medial and lateral borders of the articular disc to the poles of the condyle. The medial discal ligament attaches the medial edge of the disc to the medial pole of the condyle. The lateral discal ligament attaches the lateral edge of the disc to the lateral pole of the condyle .
- 33. Divide the joint mediolaterally into the superior and inferior joint cavities. True ligaments, composed of collagenous connective tissue fibers; therefore they do not stretch.
- 34. • to restrict movement of the disc away from the condyle. •allow the disc to move passively with the condyle as it glides anteriorly and posteriorly. • responsible for the hinging movement of the TMJ, which occurs between the condyle and the articular disc. have a vascular supply and are innervated. & provides information regarding joint position and movement. •Strain on them produces pain Functions of collateral ligament
- 35. Articular disc- A fibrous connective tissue structure separating the joint cavities of the temporomandibular joint; also termed the meniscus. – (glossary of periodontal terms-4th edition) Oval ,fibrous plate. The disc has a concavo-convex superior surface and concave inferior surface. Periphery of disc is attached to fibrous capsule. Articular disc
- 36. Divides the joint into- 1. Upper compartment permits gliding movements 2. Lower compartment provides rotatory as well as gliding movements. Composed of – anterior extension , anterior thick band, intermediate zone, posterior thick band, and bilaminar region containing venous plexus. The disc represents primitive insertion of lateral pterygoid.
- 37. Functions- 1. Friction between the articulating surfaces. 2. Acts as 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 movements of the joint. 5. Helps in distribution of weight across the TMJ by increasing the area of contact.
- 38. Relations of temporomandibular joint- Lateral – 1. Skin and fascia 2. Parotid gland 3. Temporal branches of the facial nerve. Medial – 1. The tympanic plate separates the joint from the internal carotid artery. 2. Spine of sphenoid , with upper end of the spheno-mandibular ligament attached to it. 3. Auriculotemporal and chorda tympani nerves.
- 39. Anterior – 1. Lateral pterygoid 2. Masseteric nerve and artery Posterior – 1. The parotid gland separates the joint from the external auditory meatus 2. Superficial temporal vessels 3. Auriculotemporal nerve
- 40. Superior – 1. Middle cranial fossa 2. Middle meningeal vessels Inferior- 1. Maxillary artery and vein
- 42. Blood supply- Branches from superficial temporal and maxillary artery. Veins follow the arteries.
- 43. Nerve supply- Auriculotemporal nerve (branch of mandibular nerve) and masseteric nerve (motar branch of anterior division of mandibular nerve).
- 44. Function of temporomandibular joint- Chewing Sucking Swallowing Phonation Facial expressions Breathing Protrusion, Retrusion, Lateralization of the jaw Opening the mouth Maintain the correct pressure of the middle ear
- 45. Movements of TMJ- Side to side grinding
- 46. Examination of TMJ- Inspection – 1. Facial symmetry 2. Swelling/ulceration in preauricular region 3. Deviation/deflection of mandible.
- 47. Palpation- Extra-auricular palpation Intra-auricular palpation
- 49. Auscultation
- 50. Disorders of TMJ-Temporomandibular disorders (TMD) is a collective term embracing a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ) and associated structures, or both. Extrinsic disorders MPDS Myositis Protective muscle splinting Intrinsic disorders Traumatic arthritis fracture Internal disc derangement tendonitis Myofibrotic contractures
- 51. Deviation in form Disc displacement 1. Disc displacement with reduction 2. Disc displacement without reduction Dislocation 1. Inflammatory conditions 2. Synovitis Capsulitis Arthritides 1. Osteoarthrosis 2. Osteoarthritis 3. Polyarthritides Ankylosis 1. Fibrous 2. Bony Recommended Diagnostic Classification for Temporomandibular joint disorders
- 52. Trismus- Trismus, or lockjaw, is a painful condition in which the jaws do not open fully. It can lead to problems with eating, speaking, and oral hygiene. The defining symptom of trismus is the jaw not opening fully or opening to 35 mm or less.
- 53. Most cases of trismus are temporary, typically lasting for less than 2 weeks, but some may be permanent. Can occur as a result of trauma to the jaw, oral surgery, infection, cancer, or radiation treatment for cancers of the head and throat
- 54. Treatment- 1. warm compress (loosens the muscles). 2. Using cold packs for pain relief 3. Rectifying your posture to prevent the lockjaw condition from worsening. 4. Practicing jaw exercises 5. Staying hydrated 6. Taking magnesium and calcium rich foods
- 55. MPDS- myofascial pain dysfunction Myofascial pain dysfunction syndrome (MPDS) is a stomatognathic system disturbance, which consists of pain, jaw movement irregularities, and muscle spasm. Hyperexcitation of peripheral sensory neurons causes a reaction of induction in the motor neuron and then spasms of the masticatory muscles follow.
- 56. Clinical features- • Pain or discomfort. • Limited motion of the jaw • Tenderness to palpation of muscles of mastication • Joint noises i.e clicking ,snapping.
- 58. Myositis- Myositis consists of localized transient muscle and facial tissue swelling caused by infection or injury. mandibular movement and localized tenderness have a tendency to increase the pain threshold. Protective splinting
- 59. Traumatic arthritis- A traumatic injury can result in arthritis of the temporomandibular joint causing limited motion, pain, and tenderness. Treatment typically involves anti- inflammatory medications, heat application, restricted jaw movement, and softer diet. Types -
- 60. Fracture of tmj- A blow to the anterior mandibular body is the most common reason for the condylar fracture. (indirect). The force is transmitted from the body of the mandible to the condyle. The condyle is trapped in the glenoid fossa.
- 61. If the impact is in the midline of the mandible ,fracture of the bilateral condylar region is very common. Commonly a blow to the ipsilateral mandible causes contralateral fracture in the condylar region.
- 62. Luxation / dislocation- Dislocation can be defined as long lasting ability to close the mouth due to the complete translation of the condyle anterior to the articular eminence. Unilateral or bilateral.
- 63. The standard treatment for acute TMJ dislocation is reduction of the mandible, a technique by which the dislocated jaw is pushed downward and backward into its normal position. Frequently takes place in emergency rooms under sedation or GA
- 66. Subluxation- Subluxation is defined as a self reducing partial dislocation of tmj during which the condyle passes anterior to the articular eminence.
- 67. Patient is himself able to manipulate it back into normal position. This is recurrent , incomplete, self-reducing, habitual dislocation
- 68. Ankylosis of TMJ Temporomandibular joint (TMJ) ankylosis is a pathologic condition where the mandible is fused to the fossa by bony or fibrotic tissues. This interferes with mastication, speech, oral hygiene, and normal life activities, and can be potentially life threatening when struggling to acquire an airway in an emergency.
- 70. Treatment-surgery: complete ankylotic block removal and subsequent arthroplasty(), possibly with autologous graft between articular surfaces (skin, rib cartilage, temporal muscle) or heterologous graft (Silastic) to fully restore the anatomic structure.
- 71. Developmental anomalies- s Hypoplasia or aplasia hyperplasia Primary condylar hypoplasia Trecher collins syndrome Hemifaciall microsomia Goldenhar syndrome Hallerman-streiff syndrome Secondary condylar hypoplasia bifidity
- 72. Hypoplasia or aplasia of mandibular condyle of the mandibular condyle indicates underdevelopment or nondevelopment associated mainly with various craniofacial abnormalities. These may be either congenital or acquired
- 73. Treacher Collins syndrome, mandibulofacial dysostosis (MFD) -rare syndrome characterized by underdeveloped facial bones and micrognathia. The most obvious facial differences are the underdeveloped cheekbones and the drooping lower eyelids. Treatment is focused on correcting facial structure, and can involve plastic surgery, orthodontics and dental care.
- 74. Hemifacial microsomia is a congenital condition in which the tissues on one side the face are underdeveloped. Surgery for children- involve one or more procedures to correct underdevelopment. Common surgeries for children dealing with HFM include: Lowering the upper jaw to match the opposite side and lengthening the lower jaw. Using a bone graft to lengthen the jaw.
- 75. Goldenhar syndrome is a rare congenital defect characterized by incomplete development of the ear, nose, soft palate, lip and mandible on usually one side of the body. Hallermann-Streiff syndrome (HSS) is a rare disorder characterized by dyscephalia, with facial and dental abnormalities.
- 76. Condylar hyperplasia, also known as mandibular hyperplasia, is the presence of an enlarged mandible bone within the skull. First identified in 1836 by Robert Adams (associated it with the overdevelopment of mandible). Cause unknown but several theories exists. One theory states that an event of a trauma leading to increase in number of repair mechanism and hormones in that area may lead to increase in growth of mandible on that side.
- 77. Bifid condyle is a rare anatomic variation of mandibular condyle. It can be symptomatic or diagnosed incidentally on routine radiographic examination. No definite etiologic factor, could be a developmental anomaly or secondary to trauma.
- 78. Relation between periodontitis and TMJ Study indicates that unilateral mastication due to chronic periodontitis could induce not only pain but also structural TMJ changes if adequate treatment is not administered and supported within a short time from the onset of the condition. Therefore, immediate treatment of chronic periodontitis is recommended to prevent not only the primary progress of periodontal disease, but also secondary TMJ-related problems. Furthermore, subjects who have suffered chronic long-term periodontitis without treatment should be urged to undergo a TMJ examination.
- 79. References- BD charasia -4th edition Carranza 10th edition Carranza 13th south asia edition Neelima malik textbook of oral and maxillofacial studies -4thh edition. Journal of maxillofcaila surgery Natl J Maxillofac Surg. 2015 Jan-Jun; 6(1): 16–20. doi: 10.4103/0975-5950.168212 PMCID: PMC4668726 PMID: 26668447 J Periodontal Implant Sci. 2017 Aug; 47(4): 211–218. Published online 2017 Aug 21. doi: 10.5051/jpis.2017.47.4.211 PMCID: PMC5577439 PMID: 28861285 Pattern analysis of patients with temporomandibular disorders resulting from unilateral mastication due to chronic periodontitis
- 80. Thank you!