This document discusses the temporomandibular joint (TMJ), including its classification, development, anatomy, disorders, and examination. It begins by classifying joints in the body and describing the development of the TMJ from mesenchymal condensation in the embryo. It then details the bony and soft tissue anatomy of the TMJ, including the articular disc, ligaments, muscles, and vascular supply. Common TMJ disorders like disc displacement, subluxation, dislocation, and ankylosis are outlined. The document concludes with descriptions of examining the TMJ through inspection, palpation, range of motion testing, and imaging modalities.

2. PRESENTED
by:
Dr Rajat Singla

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

4. 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

6. 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.  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.  Craniomandibular joint /
articulation
 Bicondylar joint
 Mandibular joint
 Modified Ball & Socket
 ‘Compound ‘ joint

9.  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. BONY COMPONENTS
• Condylar Head
• Glenoid Fossa
• Articular Eminence
SOFT TISSUE COMPONENTS
•Articular Disc
•Synovial fluid
•Ligaments

13. •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. 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. • 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.

17.  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 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 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. 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. 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.  It re-enforces the Capsular
ligament on the lateral side.
The unique feature of
Temporomandibular
ligament is to limits the
rotational movement .

24.  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. Attached:
 Above- styloid process
 Below- posterior border of
the ramus
FUNCTION-
 It limits excessive
protrusive movements of
the mandible.

26.  Branches from the
superficial temporal
artery
 Deep auricular artery
VENOUS DRAINAGE
•Superficial temporal vein

27. 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. Suprahyoid
muscle
Infrahyoid
muscle
Sternocleido-
mastoid muscle

35. 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

36. 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

38. ROTATIONAL MOVEMENTS
 Rotation – “the process of turning around an axis:
movement of a body about its axis”.
 Occurs when the mouth opens & closes around a fixed
point or axis i.e teeth can be separated & occluded with
no positional change of the condyle.
 Within inferior joint cavity
 Hinge movements.
 Hinge axis
 When condyles are in their most superior position in the
glenoid fossae & the mouth is purely rotated open, the
axis around which the movement occurs is – Terminal
Hinge axis

39. Translational movements
 Translation – movement in which every point of the moving
object has simultaneously the same velocity & direction
 Seen when mandible moves forwards as in protrusion – teeth,
condyle & rami all move in the same direction & to the same
degree
 Occurs in the superior joint cavity
 During most normal movements both rotation & translation
occur simultaneously – while mandible is rotating around one or
more axis, each of the axis is translating.

40. FACIAL ASSYMETRY
DEFLECTION
DEVIATION

41. 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)

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

43.  Trans-cranial
 Trans-pharyngeal
 Computed tomography
 MRI
 T-Scan

45. ESTABLISHING ALTERATIONS IN ARTICULAR DISK POSITION
IN OPEN AND CLOSED MOUTH POSITION, INFLAMMED JOINT
EXAMINATION

48. 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.

49. 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

50. 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

51. 1. Pulpitis
2. Pericoronitis
3. Parotitis
4. Otitis
5. Maxillary sinusitis
6. Trigeminal
neuralgia

52. 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

53. Anterior bite
plane
Soft or resilient
appliance

54. 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

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

56. 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

57.  Disk displaced to an anterior and medial/lateral position;
reduces on full opening with a ‘click’ sound.

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

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

60. 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.

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

63. 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

64. DISLOCATION

65. 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)

66. Occurs mostly when the mouth is wide
opened and the Masticatory muscles
contract suddenly.

67.  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.

68. Fusion of the Bony components of the
joint.
Etiology:
• Trauma
• Infections ( Otitis Media)
• Osteomyelitis of the condyle

69. 1. False or True ankylosis
2. Extra- articular or Intra- articular
3. Fibrous or Bony
4. Unilateral or Bilateral

70. • Inability to open mouth
• Facial asymmetry in long
standing cases
• Deranged occlusion
• Retarded growth may also be
present

71. 71
FIBROUS ANKYLOSIS

72. Condylotomy/Condylectomy
Gap Arthroplasty
Interpositional Arthroplasty
Surgical treatment

73.  Hypoplasia of the Joint
 Hyperplasia of the Joint
 Dysmorphia

74. 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

75. 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.

76. Collectively termed as Lateral facial
Dysplasia that includes:
• Differences in size
• Differences in function
 only one joint is affected.

78. Etiology :
• Overloading producing
Degenerative changes in
the joint.
• Bruxism
• Absence of posterior
occlusal contact

79. 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

80. 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

81. 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

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

83. 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

85. 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.

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

87. The procedure was to
designed to induce a
displaced fracture
through the condylar
neck so that the condyle
would be repositioned
inferiorly and anteriorly.

88. Temporomandibular joint problems and periodontal condition in
rheumatoid arthritis patients in relation to their rheumatologic status
J Oral Maxillofac Surg. 2011 Dec;69(12):2971-8. doi:
10.1016/j.joms.2011.02.131. Epub 2011 Jul 20.

89.  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