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TMJ & ITS PROSTHODONTICS IMPLICATION
- 5. The articulation of the condylar process of the mandible and the intra-articular disc with the mandibular fossa of the squamous portion of the temporal bone; a diarthrodial, sliding hinge (ginglymus) joint; movement in the upper joint compartment is mostly translational, 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 JOINT ARTICULAR DISC interposed According to GPT :-9
- 8. Presence of dense avascular fibrocartilaginous instead of hyline cartilage. Temporomandibular joint is in fact a double joint consisting of 2 synovial joint cavities separated by an articular- disc, each performing different functions. 2 Temporomandibular joint does not function independently, one joint is dependent on the other. Functional movement of the joint are guided by the nature of the occlusal surface of the teeth Walia MS, Arora S, Arora N, Rathee M. Temporomandibular Joint (TMJ): A Weight Bearing Joint?. Indian Journal of Stomatology. 2014 Jan 1;5(1).
- 9. Weeks Gestation TMJ Development 7-8 weeks Blastemic stage: formation glenoid fossa and condylar blastemas 9 weeks Cavitation stage: formation inferior joint space 11 weeks Cavitation stage: formation superior joint space 17 weeks Joint capsule develops 19-20 weeks Cartilage develops within the joint 26 weeks until birth Further maturarion of joint structure Bender et al. Oral Maxillofacial Surg Clin N Am 30 (2018) 1-9
- 11. Chaurasia BD. Human Anatomy (Head, Neck and Brain part) volume-3 osteology of head and neck.
- 12. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 13. Squamous tympanic fissure extend mediolaterally from posterior part of the glenoid fossa. The roof is mostly thin and translucent, which shows that the articular fossa is not a stress bearing part of functional TMJ. Anterior portion of mandibular fossa , which extend from the roof to anterior eminence is the true articulating surface / articulating surface. Steepness of the articular eminence surface indicates the pathway of the condyle( condylar guidance ). Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 14. • Bony apophysis of mandibular ramus. • Slim neck & ellipsoid shaped head • Mediolateral width > anterioposterior width (15-20 mm) ( 8-10 mm) • Condyle is covered by a thin layer of fibrocartilage that is thickest superiorly and anteriorly, which are the areas loaded under function and parafunction. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 15. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 16. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 17. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 19. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 20. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 21. Shock absorption thus protecting the articular surfaces. Prevents undue forward gliding. Allowing a combination of different movements in the joint by dividing the joint into compartments and allowing the bony elements to move independently on the disc. Distribution of weight across the joint, by increasing the area of contact which may prevent wear. Aid lubrication of the joint by storing fluid squeezed out from loaded area
- 22. Chaurasia BD. Human Anatomy (Head, Neck and Brain part) volume-3 osteology of head and neck.
- 23. To resist any lateral or downward forces that tends to separate or dislocate the articular surface . To retain the synovial fluid Chaurasia BD. Human Anatomy (Head, Neck and Brain part) volume-3 osteology of head and neck.
- 24. Resists excessive dropping of the condyle so limits the extent of mouth opening Chaurasia BD. Human Anatomy (Head, Neck and Brain part) volume-3 osteology of head and neck.
- 25. Superiorly:- spine of the sphenoid Inferiorly :- lingula of the mandibular foramen Laterally : a. Lateral pterygoid muscle b. Auriculotemporal nerve c. Maxillary artery Medially : a. Chorda tympani nerve b. Wall of the pharynx Chaurasia BD. Human Anatomy (Head, Neck and Brain part) volume-3 osteology of head and neck.
- 26. It is also an accessory ligament of the joint. Represents a thickened part of the deep cervical fascia which separates the parotid and submandibular salivary glands. It is attached above to the lateral surface of the styloid process, and below to the angle and adjacent part of posterior border of the ramus of the mandible It limits excessive protrusive movements of the mandible Chaurasia BD. Human Anatomy (Head, Neck and Brain part) volume-3 osteology of head and neck.
- 27. Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 28. Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 29. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 30. SYNOVIAL FLUID Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 31. Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 32. Alomar X, Medrano J, Cabratosa J, Clavero JA, Lorente M, Serra I, Monill JM, Salvador A. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR. 2007 Jun;28(3):170-83
- 34. Horizontal axis Vertical axis Sagittal axis Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 35. Rotational Movement of the Mandible With the Condyles in the Terminal Hinge Position. This pure rotational opening can occur until the anterior teeth are some 20 to 25 mm apart. Second Stage of Rotational Movement During Opening. Note that the condyle is translated down the articular eminence as the mouth rotates open to its maximum limit.
- 36. Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 37. Lateral pterygoid Digastric, Geniohyoid Mylohyoid muscles 1. Masseter, 2. Anterior vertical, middle oblique fibres of temporalis 3. Medial pterygoid muscles Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 38. • Lateral and medial pterygoid • superficial oblique fibres of masseter • Posterior horizontal fibres of the temporalis • Deep vertical fibres of masseter. Okeson JP. Management of temporomandibular disorders and occlusion. Elsevier Health Sciences; 2019 Feb 1.
- 41. Panoramic radiography Transcranial radiography Tomography Arthrotomography Arthrography Magnetic resonance imaging (MRI) Computed tomography (CT) Karjodkar FR. Textbook of Dental and Maxillofacial Radiology by Karjodkar. Jaypee Brothers Publishers; 2006.
- 42. Karjodkar FR. Textbook of Dental and Maxillofacial Radiology by Karjodkar. Jaypee Brothers Publishers; 2006. INDICATIONS: TMJ pain dysfunction syndrome- pain , clicking and limitation in opening. Fractures of the condylar heads or necks Condylar hypo/hyperplasia
- 43. Transmaxillary view Submentovertex view A. Open position B. Close position Karjodkar FR. Textbook of Dental and Maxillofacial Radiology by Karjodkar. Jaypee Brothers Publishers; 2006.
- 44. Arthrography Karjodkar FR. Textbook of Dental and Maxillofacial Radiology by Karjodkar. Jaypee Brothers Publishers; 2006.
- 45. A. Normal B. Flattening C. Erosion D. Osteophyte Karjodkar FR. Textbook of Dental and Maxillofacial Radiology by Karjodkar. Jaypee Brothers Publishers; 2006.
- 46. Karjodkar FR. Textbook of Dental and Maxillofacial Radiology by Karjodkar. Jaypee Brothers Publishers; 2006.
- 48. GLOSSARY OF PROSTHODONTIC TERMS:-9
- 50. I. MASTICATORY MUSCLE DISORDERS A. Muscle splinting B. Myospasm C. Myositis D. Myofascial trigger point pain Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 51. A. Derangements of the condyle-disc COMPLEX 1. Disc displacement i) single clicks ii) reciprocal clicks 2. Disc displacement with reduction ( Loud pop or catching ) 3. Disc displacement without reduction (closed lock) B. Structural incompatibility of the articular surface 1. Alteration in form: a. Disc b. Condyle c. Fossa 2. Adhesions a. Disc to condyle b. Disc to fossa 3. Subluxation (hypermobility) 4 spontaneous dislocation ( open lock) II. DISC- INTERFERENCE DISORDERS Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 52. 1. Synovitis/capsulitis a. Traumatic b. Secondary inflammatory 2. Retrodiscitis a. From extrinsic trauma b. From intrinsic trauma 3. Degenerative joint disease III INFLAMMATORY DISORDERS OF THE TEMPOROMANDIBULAR JOINT 4. Inflammatory arthritis a. Traumatic b. Infectious c. Rheumatoid d. Hyperuricemia 5. Inflammatory disorders of associated structures: a. Temporal tendonitis b. Stylomandibular ligament inflammation Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 53. IV. CHRONIC MANDIBULAR HYPOMOBILITY 1. Contracture of elevator muscles 2. Capsular fibrosis 3. Coronoid impedance 4. Ankylosis a. Fibrous b. Osseous V. GROWTH DISORDER OF THE JOINT 1. Hypoplasia 2. Hyperplasia 3. Neoplasia Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 54. ETIOLOGY 1)Occlusal factors 2) Trauma 3) Emotional stress 4)Deep pain input 5) Parafunctional activities. Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 56. TMD Treatment divided into • Conservative Therapy • TMJ Surgery
- 57. Phase 1: Include Education, anxiety Control, behavioral modifications, physiotherapy, medication therapy and splint therapy. Phase 2: Dental rehabilitation, occlusion correction, fixed prosthesis, restorative treatments, orthodontic treatments and orthognathic surgery.
- 58. Arthrocentosis Arthroscopy. Disc-Repositioning Surgery. Condylotomy. Arthroplasty. Total Joint Displacement
- 59. TMJ pain relieving exercises
- 60. Relaxed Jaw Exercise Gold fish exercise (partial opening)
- 61. Chin tuck Exercise Gold Fish Exercise (Full Opening)
- 62. Resisted Opening of the mouth Resisted Closing of the mouth
- 63. Tongue Up Exercise Side to Side Movement
- 71. • Until the positions of TMJ’s are precisely determined an accurate maxillomandibular relationship cannot be verified and correct occlusal analysis is not possible. • Bilateral relaxation of external pterygoid muscle is essential to obtain true centric. 1 ) Chin point guidance Guichet (1970): Thumb and forefinger— positions the condyle in RUM position
- 72. 2) Bimanual method Peter Dawson (1974): Guides the mandible in most superoanterior position. 3. Three finger method—Peter Thomas (1980): Thumb, forefinger, middle finger— positions condyle in anterior superior position
- 73. Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 74. TMJ works as class III lever Walia MS, Arora S, Arora N, Rathee M. Temporomandibular Joint (TMJ): A Weight Bearing Joint?. Indian Journal of Stomatology. 2014 Jan 1;5(1).
- 75. • The way the teeth fit together may affect the TMJ complex. • A stable occlusion with good tooth contact and interdigirior belly is responsible for proper disk movement in coordination with movement of the lower jaw, especially when closing the mouth, just the opposite of the inferior belly. • It then exerts forward pressure on both the condyle and the disk, stabilizing their relationship to each other and assuring the most effective position possible when the strong forces of chewing move the condyle backward and forward
- 76. VERTICAL DIMENSION • In normal or structurally intact TM joints, the soft tissue and hard tissue maintain a vertical dimension at the TM joint level. • If there any joint alteration, initial tissue deformation typically occur at soft tissue level, resulting in a loss of ligament attachment between the disk and the condyle. • Loss of attachment result in anteriorly displacement of disk resulting in decrease in vertical dimension . • Vertical dimension can increase in a situation where the condyle functions against the thickened posterior band of the disk Silverman, M. Vertical dimension must not be increased. J Pros Dent; 1952;2,2:188-97
- 77. • As the mandible is protruded, the condyle descends along the articular eminence. • Horizontal reference plane is determined by the steepness of the eminence. • The steeper the eminence the more the condyle is forced to move inferiorly as it shifts anteriorly. • Results in greater vertical movement of the condyle, mandible, and mandibular teeth. • Steeper angle of the eminence (condylar guidance) steeper posterior cusps. Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health Sciences; 2019 Feb 1.
- 78. Occlusal dysharmony High points/defective tooth inclines Muscle hyperactivity Pain
- 79. El-Zawahry MM, El-Ragi AA, El-Anwar MI, Ibraheem EM. The Biomechanical Effect of Different Denture Base Materials on the Articular Disc in Complete Denture Wearers: A Finite Element Analysis. Open Access Maced J Med Sci. 2015 Sep 15;3(3):455-61
Editor's Notes
- A joint is the place of union of two or more bones The masticatory system is the functional unit of the body primarily responsible for chewing, speaking, and swallowing. Components also play a major role in tasting and breathing. The system is made up of bones, joints, ligaments, teeth, and muscles. In addition, an intricate neurologic controlling system regulates and coordinates all these structural components
- Developmental disturbances of tmjoint????????????????????????????????????? Between the 10th and 12th weeks post conception, the accessory mandibular condylar cartilage develops as first blastema, growing toward lateral developing temporal blastema. The temporal blastema arises from otic capsule(a component of basicranium that forms petrous temporal bone) The condylar blastema arises from secondary condylar cartilage of mandible Blastema is mass of cells capable of growth and regeneration into organs or body parts. During 10th week two clefts develop in interposed vascular fibrous connective tissue Cavitation occurs by degradation. Synovial membrane invades for cavitation A condensation of mesenchyme forms joint capsule The joint capsule recognizable by 11th week forms lateral ligaments The development of articular tubercle accelerates until 12th year of life
- Lateral pole of condyle is usually pointed. • Medial pole: Medial pole is mostly rounded and more prominent than lateral pole.
- E: Articular eminence; enp: entogolenoid process; t: articular tubercle; Co: condyle; pop: postglenoid process; lb: lateral border of the mandibular fossa; pep: preglenoid plane; Gf: glenoid fossa; Cp: condylar process
- SUPERIOR FREE SLIDING INFERIOR ROTATION
- Anterior band Relatively thick part leading into tendinous bundles of the external pterygoid muscles. 2mm thick Intermediate Slim avascular portion providing protection as the condyle glides during opening movements. 1mm thick Posterior band Thick band acting as a cushion between the condyle & mandibular fossa roof when jaws are closed. 3mm thick
- Mandibular movement around the horizontal axis is an opening and closing motion. It is referred to as a hinge movement. It is probably the only example of “pure”’ rotational movement. Axis around which rotation occurs is hinge axis When the condyles are in their most superior position in the articular fossae and the mouth is purely rotated open, the axis around which movement occurs is called the terminal hinge axis. Mandibular movement around the frontal axis occurs when one condyle moves anteriorly out of the terminal hinge position with the vertical axis of the opposite condyle remaining in the terminal hinge position. Mandibular movement around the sagittal axis occurs when one condyle moves inferiorly while the other remains in the terminal hinge position. Sagittal and vertical type of isolated movement does not occur naturally
- mandible can be rotated around the horizontal axis to a distance of only 20 to 25 mm as measured between the incisal edges of the maxillary and mandibular incisors. At this point of opening the TM ligaments tighten, after which continued opening results in an anterior and inferior translation of the condyles. Maximum opening is reached when the capsular ligaments prevent further movement at the condyles. Maximum opening is in the range of 40 to 60 mm when measured between the incisal edges of the maxillary and mandibular teeth
- Translation can be defined as a movement in which every point of the moving object has simultaneously the same velocity and direction. In the masticatory system, it occurs when the mandible moves forward, as in protrusion. The teeth, condyles, and rami all move in the same direction and to the same degree
- On opening, the TMJ is palpated with the finger below the zygomatic bone just anterior to the condyle or, as for closing, with the tip of the finger placed either just anterior to the tragus behind the condyle or in the external auditory meatus, exerting some anterior directed pressure against the posterior aspect of the joint. The coronoid process can be palpated on opening and closing the mouth when the fingers are placed just below the zygomatic arch. The process is felt through the masseter muscle. Palpation of the temporal muscle is performed on clenching the teeth. Joint sounds may be single event for a short duration such as click, or if it is loud then loud is generally referred to as pop. Crepitation is rough gravel like sound and is usually associated with inflammation.
- White arrow indicates degenerative changes of right condyle It is a useful screening technique for condylar abnormalities such as erosions, sclerosis, osteophyte formation, resorption, and fractures and help with the overall diagnosis by ruling out odontogenic sources or other pathology of the jaws Arthrography is ideal for small disk perforations and for visualizing the movement of the joints
- The transcranial view shows mainly the lateral part of the joint and can be used to determine condylar position and size, depth of the fossa, slope of the eminence, and width of the joint space Transmaxillary view :This view, along with the transcranial view, provides a three-dimensional evaluation of the condyle for fractures, severe degenerative joint disease, and neoplasms. Submentovertex view : enable to visualize condyles along mediolateral axis. This view is a useful supplement to examine condylar displacement and rotation in the horizontal plane associated with trauma or facial asymmetry. contraindicated in trauma patients who are suspected of neck injury Reverse townes view offers an excellent view of the condylar neck and is usefulin the trauma setting when a condylar fracture is suspected
- information on soft tissue state of the TM joint, especially the integrity and position of the disk and its posterior attachment. It also provides evidence of internal disk derangement or disk perforation Arthrographs in which both upper and lower joint spaces have been injected with contrast media (spaces appear white) that highlights the disk (black). In both images anterior aspect of the patient is on the left side of the image. In A. The posterior band (white arrow) and the anterior band (black arrow) are evident. B. Reveals a disk with an enlarged posterior band
- Pathologic changes, such as osteophytes, condylar erosion, fractures, ankylosis,dislocation, and growth abnormalities such as condylar hyperplasia, are optimally viewed. Multidetector row CT can be used to show disk displacement and synovitis, effusions, and erosions
- Magnetic resonance imaging showing the disk centered over the condyle (A). Note the image is reversed from typical radiographs. The cortical bone and the disk appear dark. B, The disk is clearly visible in front of the condyle. Depending on the depth of the slice, the medial pole can be distinguished from the disk position at the lateral pole
- GPT definition
- otic complaints such as tinnitus, sensation of blockage, and sensations of exaggerated or diminished hearing; – ocular disturbance such as peri or retro-orbital discomfort, and problems of accommodation; – cephalic discomfort derived from tension of the frontal, temporal, and sub-occipital musculature; – neurovegetative manifestations of edema, rhinorrhea, and excessive lacrimation.
- Rest your tongue gently on the top of your mouth behind your upper front teeth. Allow your teeth to come apart while relaxing your jaw muscles Place your tongue on the roof of your mouth and one finger in front of your ear where your TMJ is located. Put your middle or pointer finger on your chin. Drop your lower jaw halfway and then close. There should be mild resistance but not pain.
- 3) Keeping your tongue on the roof of your mouth, place one finger on your TMJ and another finger on your chin. Drop your lower jaw completely and back. 4) With your shoulders back and chest up, pull your chin straight back, creating a “double chin.”
- 5) Place your thumb under your chin. Open your mouth slowly, pushing gently against your chin for resistance 6) Squeeze your chin with your index and thumb with one hand. Close your mouth as you place gently pressure on your chin. This will help strengthen your muscles that help you chew
- 7) With your tongue touching the roof of your mouth, slowly open and close your mouth. 8) Put a ¼ inch object, such as stacked tongue depressors, between your front teeth, and slowly move your jaw from side to side. As the exercise becomes easier, increase the thickness of the object between your teeth by stacking them one on top of each other.
- Put a ¼ inch object between your front teeth. Move your bottom jaw forward so your bottom teeth are in front of your top teeth. As the exercise becomes easier, increase the thickness of the object between your teeth.
- CHLORZOXAZONE , CYCLOBENAPRINE METAXOLON, TIZANIDINE
- Class 3 lever, just like a nutcracker. where maximum mechanical advantage resides. Well the same principles of physics apply to teeth, thats why our molars that are designed for the greatest crunching (molars) are located in the posterior aspect. Anterior teeth receive less stress because they are the furthest from tmj which is the fulcrum. Range of mandibular movements: Maximum opening: 40-60mm Maximum lateral movement: 10-12mm Maximum protrusive movement: 8-11mm Maximum retrusive movement: 1mm-2mm……………………. CLASS 1 lever =F at centre and L & F on either side (DISTAL EXTENSION ) CLASS 2 LEVER =L centre(INDIRECT RETAINER IN DISTAL EXTENSION
- This can occur at the posterior ligament attachment, the lateral ligament attachment, the medial ligament attachment or a combination of the ligament attachments. 5
- In Fig. 6.5 condylar guidance and anterior guidance are presented as being 60 degrees to the horizontal reference planes. With these steeper vertical determinants, premolar A will move away from premolar B at a 60-degree angle, resulting in longer cusps. It can therefore be stated that a steeper angle of the eminence (condylar guidance) allows for steeper posterior cusps.
- occlusal interferences can play an important role in the development of TMDs……………….. WHICH Causes- alteration of muscular tonus which can lead to pain in chewing and in the head and neck muscles . It seems to b evident that occlusal interferences can lead to development of or an increase in severity of tmds
- Lost vertical dimension is not a cause of temporomandibular 201disorders (TMDs).