The document provides information about the temporomandibular joint (TMJ), including its anatomy, development, movements, epidemiology, and common disorders. It discusses the key anatomical structures of the TMJ, such as the mandibular condyle, articular disc, capsule, and ligaments. It also summarizes the blood supply, nerve innervation, and movements of the joint. Common TMJ disorders mentioned include myofascial pain, disc displacement, and arthritis. Treatment approaches include pain medication, physical therapy, injections, and exercises to improve joint mobility.

1. 1

2. Sk.Parveen
Ist MDS
Public health
dentistry
2

3. Contents:
Introduction
Anatomy
Development of joint
Muscle attachments
Blood supply,Venous drainage &
Nerve supply
3

4. Muscle movement
Epidemiology
Tmj disorders
Treatment
Conclusion
References
4

5. Introduction
 The TMJ is a ‘ginglymo-arthrodial joint’
 It is also described as a complex,multi
axial,synovial,bicondylar and craniomadibular joint.
5

6.  Articulating surface of the TMJ is not formed of
Hyaline cartilage but of a sturdy avascular fibrous
layer.
 Only synovial joint in the human body with an
articulating disc which is present between the
joint surfaces of cranium and mandible which
makes the TMJ a double joint.
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Normal boneTMJ

7. ANATOMY
7

8. Anatomical parts concerned with
mandibular articulation:
 Mandibular Condyle
 Mandibular fossa and articular
eminence
 Articular Disc
 Articular capsule
 Synovial tissue
8

9. Capsule
9

10. Mandibular Condyle:
• The mandibular condyle articulates
with the glenoid fossa and articular
eminence of the temporal bone.
• It is convex in all directions but
wider latero-medially than antero-
posteriorly.
• It has lateral and medial poles:
– The medial pole is directed
more posteriorly.
– The long axis of the two poles
deviate posteriorly and meets at
the anterior border of the
foramen magnum.
Posterior viewAnterior view
10

11. Glenoid Fossa:
– Posteriorly limited by the
squamotympanic fissure.
– Anteriorly bounded by the
articular eminence.
– Roof: thin layer of compact
bone separating the
middle cranial fossa.
11

12.  Composed of: Spongy bone covered by thin layer of
compact bone.
 Fibrous layer is covering the articulating surface of
temporal bone.
 Thin on the articular fossa and thickens on the posterior
slope of the eminence
Articular eminence:
12

13. Articular Disc(Meniscus):
• Disk is fibrous, avascular, non inverted plate
• Shape is oval, biconcave in sagittal section.Anteroposterior
:10mm, Mediolateral: 20mm
• It is thin in central part and thick at posterior borders.It
separates the articular surfaces into 2 compartments :
• Upper compartment between the disc and temporal bone.
• Lower compartment between the condyle and the disc
13

14. • Attachment: Medial and
lateral poles of the condyle by
medial and lateral ligaments.
14

15. • Anterior border divides into upper and lower lamellae
that run forward.
• The upper lamella fuses with the anterior slope of the
articular eminence.
• The lower lamella attaches to the front of the neck of the
condyle.
• Fibers of the superior head of the lateral pterygoid muscle is
attached to the anterior border. 15

16. • Posterior border divides into upper and lower lamellae
– The upper lamella is fibrous and elastic and fuses with the
capsule and is inserted in the squamotympanic fissure.
– The lower lamella, non elastic, attaches to the back of the
condyle.
16

17. Articular Capsule , Ligaments And
Synovial membrane
• The joint capsule is attached below to
the head of the condyle, and above to
the margins of the glenoid fossa and
articular eminence. The inner aspect of
the capsule is lined by a synovial
membrane.
• It is attached to:
– Articular tubercle (in front)
– Lips of squamous tympanic fissure
(posteriorly)
– Borders of articulating glenoid fossa
– Neck of the mandible. (below).
• Laterally, the capsule is reinforced by
TMJ ligaments.
17

18. • The lateral temporo-mandibular ligament is attached above
to the zygoma, and below, it is attached to the lateral
surfaces and posterior border of the neck of the mandible.
• There are 2 accessory ligaments associated with the TMJ:
– The stylomandibular ligament attaches to the styloid
process and to the posterior border of the ramus.
– The sphenomandibular ligament extends between the
spine of the sphenoid bone and the lingula of the
mandible.
• These ligaments limit the range of movement of the condyle
preventing it from coming in contact with the tympanic plate
behind and passing beyond the articular eminence in front.
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19. Sphenomandibular
ligament
19

20. Synovial fluid:
• 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.
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21. Development
21

22. • Involves the development of the
following structures
– Mandible
– Glenoid fossa
– Condyle
– Articular disc
– Upper and lower joint cavity
22

23. Mandible:
• Meckel’s Cartilage
• Begins at week 6 to 7
23

24. • At 12th week of gestation:
– temporal/ glenoid blastema
• Ossifies and becomes glenoid fossa
– condylar blastema
• Becomes the condylar cartilage
• Clefts are formed
– lower joint cavity
– upper joint cavity
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25. 1. Primitive articular disc
2. Upper cleft
3. Lower cleft
4. Glenoid blastema
5. Condylar blastema
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3
3
1
2
4
5
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26. Muscle Attachments
26

27. Masseter:
 Thick
 Quadrilateral muscle
 Superficial and deep portion
Masseter: Superior portion:
 Origin: thick, tendinous aponeurosis from the
zygomatic process of the maxilla.
 Insertion: angle and lower half of the lateral
surface of the ramus of the mandible.
 its fibers pass downward and backward.
27

28. Masseter: deep portion:
 Smaller and more muscular in texture
 Downward and forward
 Partly concealed
 Origin: posterior third of the lower border and
from the whole of the medial surface of the
zygomatic arch
 Insertion: the upper half of the ramus and the
lateral surface of the coronoid process of the
mandible
28

29. Masseter
superior portion
Masseter
deep portion
Masseter muscle
*ACTION: elevation and protrusion of
mandible.
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30. Temporalis muscle:
 Broad
 Radiating
 Side of the head
 Origin: Whole of the temporal fossa (except
that portion of it which is formed by the
zygomatic bone)
 Insertion: the medial surface, apex, and
anterior border of the coronoid process, and
the anterior border of the ramus of the
mandible.
30

31. Temporalis muscle
*ACTION: elevates the mandible. 31

32. Lateral Pterygoid muscle:
 Short
 Thick
 Conical
 Upper and lower head.
Lateral pterygoid: Upper head-
 Origin: lower part of the lateral surface of sphenoid bone
and infratemporal crest
 Insertion: On the aticular disc and fibrous capsule of the
temporomandibular joint.
32

33. Lateral pterygoid: Lower head-
 Origin: lateral surface of the lateral pterygoid plate
 Insertion: On the neck of the condylar process of the
mandible.
* ACTION: Only muscle which depresses mandible. Also
produces side to side movements.
33

34. Medial Pterygoid Muscle:
 Thick
 Quadrilateral
 downward, lateral and posterior
 Origin: medial surface of the lateral
pterygoid plate and the pyramidal process of
the palatine bone.
 Insertion: lower and back part of the medial
surface of the ramus and angle of the
mandible, as high as the mandibular foramen
34

35. Medial pterygoid muscle
*ACTION:Helps in elevating mandible, in protrusion and grinding
movements.
35

36. Blood Supply & Nerve
Supply
36

37. Blood supply:
– Lateral aspect-Superficial temporal branch of
external carotid artery
– Deep & posterior aspect-Other branches of
external carotid artery namely:
Deep auricular artery
Anterior tympanic artery
Ascending pharyngeal
• These arteries approach the joint and penetrate
the capsule.
37

38. 38

39. The venous blood drains through the
superficial temporal vein and the maxillary
vein.
39

40. Nerve Supply:
• Branches from the mandibular nerve
– Auriculotemporal nerve
– Masseteric nerve
– Deep temporal nerves
• Supply all surfaces of the head, fossa, capsule and
part of the disk.
40

41. 41

42. Lymphatic drainage
• Drain into the upper deep cervical lymph nodes
around IJV.
42

43. Movements of TMJ
43

44. • The TMJ is a synovial bilateral joint that permits
the mandible to move as a unit with 2 functional
patterns (Rotatory and Translatory movements).
• Translatory movement – in the superior part of
the joint,the disc and the condyle traverse
anteriorly along the inclines of the articular
tubercle to provide an anterior and inferior
movement of the mandible. 44

45. Mouth closed Mouth open
45

46. • Rotational movement
occurs in first 20-25mm
of mouth opening.
• Translational movement
after that when the
mouth is excessively
opened.
• Closing movements are
just the reversal of
opening & helped by its
own Elastic fibers.
Normal movement
46

47. 1. Depression Of Mandible
 Lateral pterygoid
 Digastric
 Geniohyoid
2. Elevation of Mandible
 Temporalis
 Masseter
 Medial Pterygoids
3. Protrusion of Mandible
 Lateral Pterygoids
 Medial Pterygoids
4. Retraction of Mandible
 Posterior fibers of Temporalis.
47

48. Age changes of the TMJ
• Condyle:
– Becomes more flattened
– Fibrous capsule becomes thicker.
– Osteoporosis of underlying bone.
– Thinning or absence of cartilaginous zone.
• Disk:
– Becomes thinner.
– Shows hyalinization and chondroid changes.
• Synovial fold:
– Become fibrotic with thick basement membrane.
• Blood vessels and nerves:
– Walls of blood vessels thickened.
– Nerves decrease in number 48

49. 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
49

50. WHO Oral Health Assesment
Form(1997)
1. General Information
2. Clinical Assessment
a. Extra-Oral Examination
i. Temporomandibular Joint Assessment
b. Intra-Oral Examination
i. Oral Mucosa
ii. Enamel Opacities/Hypoplasia
iii. Dental Fluorosis
iv. Community Periodontal Index
v. Loss of attachment
vi. Dentition Status & Treatment need
vii. Prosthetic Status & Prosthetic Need
c. Dentofacial Anomalies
3. Need for Immediate Care & Referral
50

51. 51

52. Epidemiology
• 60-70% of general population
have one sign.
• Prevalence by self report: 5-15%
(one source estimates 10% of
women, 6% of men)
• 5% or less seek treatment
• Women>men 4:1
• Early adulthood (ages 20-40)
• Many TMD are self-limiting or
fluctuate over time without
progression
• 5% require surgery Agerberg G, Global prevalence
of TMJ, Swed Dent J, 1974 67:81-
86
52

53. TMJ Disorders
53

54. Temporomandibular disorders are a group of maladies
which can affect the TMJ, as well as the associated
muscles of the jaw, face and neck as well as related
neurological and vascular structures.
 Group I: Musclular conditions
a. Myofascial pain
b. Myofascial pain with limitations in aperture
c. Atrophy and hypertrophy
 Group II: Mechanical conditions
a. Internal derrangement.
Disc displacement with reduction
Disc displacement without reduction
b. Ankylosis
54

55. Group III: Inflammatory conditions
a. Arthralgia
b. Osteoarthritis of the TMJ
c. Synovitis
55

56. Differential diagnosis
• Dental pathology
• Tooth abscess
• Wisdom tooth eruption
• Infection or inflammation
• Herpes zoster and postherpetic neuralgia
• Mastoiditis
• Otitis externa
• Otitis media
• Parotitis
• Sialadenitis
• Trigeminal neuralgia
Pertes RA, Bailey DR. General concepts of diagnosis and
treatment. In: Pertes RA, Gross SG. Clinical Management
of Temporomandibular Disorders and Orofacial
Pain. Chicago, Ill.: Quintessence Pub, 1995:59-68.
56

57. Clinical consideration
TMJ Disorders are seen very commonly
Etiology:
 Deep bite-most commonly associated
 Large mandibular forces
 Over closure of mandible
 Traumatic occlusion
 Increased mandibular activity
 Emotional disturbances
 Bruxism
 Aging
 Heredity
Trauma from occulsion
57

58. TMJ Dysfunction
Syndrome (or) Myofacial
pain dysfunction Syndrome
58

59. • MPDS is charecterised by muscle spasm,dysfunction
as well as pain.
• Cause:The MPDS occurs due to several contributing
factors such as :-
1.Muscular hyper function.
2.Bruxism secondary to stress & anxiety with
occlusion.
3.Internal Joint Problems such as Disk Displacement
disorders or Degenerative Joint Disease(DJD).
4.Physical disorders.
5.Injuries to the tissues.
6.Para functional habits.
7.Disuse.
8.Physiological stress.
9.Sleep disturbances.
59

60. Cardinal symptoms of MPDS
CLINICAL FEATURES:
Pain or
discomfort
Limited motion of
the jaw
Joint noises-
Clicking, snapping
Tenderness to palpation of the
muscles of mastication
60

61. Management
Pharmacotherapy:
 Pain control – mainly used analgesics Salicylates
(aspirin 2 tabs 0.3-0.6 gm/4 hourly)
 Tranquilizers – provides calming effect in anxiety
state and relieves tension, fear and produces a
sense of well being (Diazepam 2-5 mg at bedtime)
 Antidepressants – these are mood elevators like
lithium carbonate and caffeine.
61

62. PHYSICAL THERAPY:
Tongue exercise Mouth opening exercise Hot packs
Ultrasound
Electrical stimulation
62

63. Hinge joint exercise
63

64. ANESTHESIA:
• Muscle and fascia (trigger point)
• TMJ (Intracapsular and extracapsular) – 0.5 ml
of 0.5% Xylocaine in conjugation with injection of
hydrocortisone
• Refrigerated spray – vapocoolant spray, such as
ethyl chloride or fluoromethane is used to reduce
muscle spasm
64

65. Other therapies
Hypnotherapy
Acupuncture
Massage and stretching exercises
65

66. Disc displacement with reduction
and with out reduction
66

67. Disk Displacment With
Reduction
 The jaw will “click” or “pop” when the ligaments that
hold the disk in place become stretched thereby
allowing the disk to slip forward (and usually either
medially or laterally).
 As the mouth opens the lower jawbone begins to slide
forward and this causes the disk to “click” or “pop”.
 The jaw will usually curve or deviate to the affected
side during mouth opening. Pain can vary from none to
severe.
 Often the musculature of the jaw and neck will
tighten up leading to headaches, facial pain and neck
pain. As the condition worsens patients will typically
notice a “catching” sensation where they have to shift
their jaw to open or close normally. Patients will also
at times notice a feeling of their bite shifting. If this
is left untreated it will often progress to jaw locking
and degenerative changes.
67

68. 68
Normal Jaw movement Disc displacement with reduction

69. Management
 Treatment will typically consist of medications,
jaw exercises, manual jaw manipulation, oral
appliance therapy, and in a minority of cases
(approximately 5%) minimally invasive TMJ
arthroscopy. Referrals to physical therapy,
massage therapy.
69

70. Disk Displacement Without
Reduction
 Untreated Disc displacement with reduction
further elongates discal ligaments and
retrodiscal tissue and the disk slips too far out
of position so that it can no longer “click” back
into place.
 As the mouth opening is limited it is also
called “locked jaw” even though typically a
person can still open to two-finger widths.
 When the disk is positioned forward there is
increased load onto the painful and
compressible retrodiscal tissues which can lead
to increased TMJ/ear pain, deviated mouth
opening, bite changes and osteoarthritis.
70

71.  Acute jaw locking episodes can usually be unlocked
using manual jaw manipulation and oral splints. If
the locking is left untreated then the disk
displacement becomes chronic as there are more
permanent anatomic changes within the TMJ.
 Treatment usually consists of medications, jaw
exercises, manual jaw manipulation, oral appliance
therapy and minimally invasive arthroscopy.
71

72. Subluxation
 Also called hypermobility
 Clinical description of condyle as it moves anterior
to crest of articular eminence.
Cause: result of anatomic form of fossa; steep
short poterior slope of eminence- longer flat
anterior slope.
 Results when disc is maximally rotated on condyle
before full translation.
History- patient reports a locking sensation when
ever mouth is opened too widely. Sudden jump of
condyle forward with a ‘thud’ sensation.
72

73. Treatment:
Eminectomy- reducing steepness of eminence.
73

74. Ankylosis
74

75. • It is also called as “Stiff joint”.
• True bony ankylosis of the TMJ involves fusion
of the head of the condyle to the temporal
bone.
• Trauma to the chin is the most common cause of
TMJ ankylosis although infection also may be
involved.
Clinical features:
 Limited mandibular movement
 Deviation of the mandible to the affected side
 Facial asymmetry may be observed in TMJ
ankylosis
 Osseous deposition may be seen on radiographs
75

76. Causes of ankylosis:
Trauma
Intracapsular comminuted fracture of the condyle disorganizes
the joint.
Forceps delivery at birth
Infection
Otitis media
Osteomyelitis
Systemic juvenile arthritis
Psoriatic arthropathy
Osteoarthitis
Rheumatoid arthritis
Neoplasms
Chondroma , osteochondroma , osteoma
76

77. Management
• Brisement force- forceful opening of jaws
under general anesthesia.
Surgical modalities:
• Condylectomy- Condyle is excised.
• Interpositional arthroplasty with
costochondral graft (CCG)
• Gap arthroplasty
77

78. Athroplasty of right ankylosed
tmj
Metallic prosthesis
78

79. TMJ fracture
79

80. Fractures of the condylar head
and neck often result from a blow
to the chin
The patient with a condylar
fracture usually presents with
pain and edema over the joint
area
 Limitation and deviation of the
mandible to the injured side on
opening can be seen.
Intra capsular nondisplaced
fractures of the condylar head
are usually not treated surgically.
Early mobilization of the mandible
is emphasized to prevent bony or
fibrous ankylosis
80

81. Bilateral condylar fracture may
result in anterior open bite
X-ray showing left condyle fracture
81

82. Diagnosis
1. Clinical evaluation:
i. History
ii. Physical examination
iii. TMJ clicking
iv. Pain
v. Limitation of mandibular opening
2. Radiographic evaluation:
i. Magnetic Resonance Imaging
ii. CT scan
iii. Arthrography
iv. Arthroscopy
82

83. Treatment
Extra joint therapy:
 Splint therapy
 Therapeutic manipulation
 Physical therapy
 Drug therapy
Intra joint therapy:
 Surgical treatment
 Artroscopy.
 Arthrocentesis.
83

84. Prevention
• Eliminate oral habits such as teeth
grinding and yawing widely.
• Seek effective treatment for diseases
such as osteoarthritis and fibromyalgia.
• Early Diagnosis and therapy.
84

85. CONCLUSION
 From TMJs genesis till its functions, every aspect should
be known in order to differentiate normal from abnormal.
 Especially, its vulnerability to extrinsic, intrinsic influences
& time-dependant changes involving masticatory muscles, &
leading to the major cause of non-dental pain, in oro-facial
region should be understood well, only by knowing its normal
architecture & physiology.
85

86. References
 B.D. Chaurasia, Human Anatomy, Vol. 3, 4th ed.,, Delhi : CBS
Publishers & distributers 2007; Pg 150-52
 Inderbir Singh, Temporal & infratemporal region In : Textbook of
Anatomy with colour atlas, Vol. 3, 2nd ed., 1999Pg No. 821-929,
Delhi : Jaypee Publications 1999 Pg 821-29
 Inderbir Singh, The Skeleton In : Human Embroyology, 7th ed. Delhi
: Macmillion India Inc 2001, Pg130-35.
 WHO, Oral Health Surveys, 4th ed. Geneva : WHO 1997
 Burkit, TMJ Disorder In : Burkit’s Oral Medicine, 10th ed., London
: BC Decker Inc. 2008, Pg 271-306
 Neelima Anil Malik, TMJ Disorders In : Textbook of Oral &
Maxillofacial Surgery, Delhi : Jaypee Publications 2007, Pg 189-219
 Anil govindrao Ghom,Text book of oral medicine,2nd edition:jaypee
publications 2011,pg 602-637.
 You tube :tmj dislocation
 Google search engine.
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