TEMPOROMANDIBULAR

JOINT

Presented by : Dr. Shefali

Mangrolia
Guided by : Dr. Rajashri Kolte
 • INTRODUCTION
• PECULIARITY OF TMJ
• DEVELOPMENT OF TMJ
• COMPONENTS OF TMJ
• BLOOD AND NERVE SUPPLY
Contents •
TO TMJ
BIOMECHANICS/
MOVEMENTS OF TMJ
• AGE CHANGES IN TMJ
• TMJ DISORDERS
• CONCLUSION
 Introduction
Temporomandibular joint is the articulation between
the condyle of mandible and squamous portion of
temporal bone.

Other names:

• Ginglymoarthroidal joint (ginglymus -hinge or

rotation, arthrodial -sliding or translation)

• Diarthroidal
• Craniomandibular joint
• Modified ball and socket joint
Peculiarity of TMJ

• Bilateral diarthrosis- right and left function

together.

• Articular surface covered by white fibrous cartilage-

instead of hyaline cartilage.

• Only joint in human body that have a rigid end point,

due to closure of teeth making occlusal contact.

• In contrast to other diarthroidal joints, TMJ is last to

develop ( i.e., in about 7th week of uterine life).
Development

There are 3 stages that

define the normal
embryonic development of
TMJ-
• blastemic stage
• cavitation stage
• maturation stage
• Early TMJ develops from the first branchial
arch and is therefore innervated by fifth
cranial nerve. This is the early embryonic
joint.

• This early embryonic joint is the joint

between malleus and incus which develops
from first branchial arch and serves as the
primary TMJ joint up to 11 weeks of prenatal
life.
• By the end of 11 weeks of gestation, the
secondary TMJ begins to develop i.e. at
about 9th week – a condensation of
mesenchyme appears surrounding the
upper posterior surface of rudimentary
ramus (joint capsule develops from the
condensed mesenchyme).
• At about 12th week of IUL, 2 clefts appear
in that mesenchyme - producing the
upper and lower joint cavities.

• The remaining intervening mesenchyme –

becomes the intra articular disc which
becomes well defined by 16th week of IUL

• At birth – mandibular fossa( in temporal

bone) is flat, with out any articular
eminence, this becomes prominent only
after the eruption of deciduous dentition.
Relations
Laterally
• skin and fascia
• Parotid gland
• Temporal branches of 7th cranial nerve

Medially
• Tympanic plate
• Spine of sphenoid
• Auriculotemporal and chorda tympani nerve
• Middle meningeal artery
Anteriorly

• Lateral pterygoid muscle.

• Masseteric nerves and artery.

Posteriorly

• Parotid gland seperates it from external

acoustic meatus.
• Auriculotemporal nerve.
Superiorly
Middle cranial fossa
Middle meningeal vessels

Inferiorly
Maxillary artery and vein
Components of TMJ

• Articular surfaces of Temporal bone

• Mandibular condyle

• Articular disc

• Ligaments

• Muscular components
Articular surfaces
• The articular surfaces of the joint
includes the
-temporal components and
-mandibular component.

• The temporal bone surface consists of

articular eminence(convex) and glenoid
fossa(concave).

• The articular surface of the mandibular

component is the mandibular condyle.
 Glenoid fossa(mandibular fossa)
• It is the concave depression on the
petrous part of the temporal bone
at its inferior surface.
• It is bounded posteriorly by
petrotympanic fissure and anteriorly
by articular eminence.

Articular eminence
• The articular eminence is present
anterior to the glenoid fossa.
• Unlike the glenoid fossa, the
articular eminence is subjected to
loading during function.
Condyle
• The adult condyle is elliptical in shape.

• The long axis of each condyle is

approximately at right angles to the
body of mandible.

• It has a medial tubercle and a lateral

tubercle, the tubercles provide
attachments to the medial and lateral
collateral ligaments
Fibrous capsule
The joint is enclosed by a fibroelastic
highly vascular connective tissue
capsule that encircles the joint creating
a closed joint cavity.

Superiorly
• Articular tubercle
Anteriorly
• Circumference of mandibular fossa
Posteriorly
• Squamotympanic fissure
Inferiorly
• Neck of the mandible
 Articular disc
• It is an oval plate of fibrocartilage which caps the head of mandible and divides the
joint into two compartment.
• Menisco-temporal
• Menisco-mandibular
Functions of articular disc

• The upper surface is concavo-

convex which provides a friction-
free gliding surface for the condyle
of mandible.
• Presence of articular disc may also
reduce wear because the friction is
nearly halved.
• It acts as a shock absorber and
provides protection to the bony
components of the joint.
Ligaments
 Collateral ligament

• Attach the medial and lateral borders of the

articular disc to the poles of the condyle.

• Divide the joint mediolaterally into the

superior and inferior joint cavities.

• True ligaments, composed of collagenous

connective tissue fibers; therefore they do
Functions of collateral
ligament
• 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.
Capsular ligament

• Entire TMJ is surrounded and encompassed

by the capsular ligament.
• Provide proprioceptive feedback regarding
position and movement of joint.
 Sphenonmandibular
ligament
• Attached superiorly to the spine of
sphenoid and inferiorly to the lingula of
the mandibular foramen.

• It is an accessory ligament, that lies on

a deep plane away from the fibrous
capsule.

• Remanent of dorsal part of Meckel's

cartilage.
 Stylomandibular ligament

• Accessory ligament of the joint.

• Represents a thickened part of deep
cervical fascia.
• Separates parotid and
submandibular salivary glands.

Functions of stylo-mandibular
ligament
• The stylomandibular ligament limits excessive protrusive
movements of the mandible
Blood supply of TMJ
• The joint derives its arterial
supply from the superficial
temporal artery laterally and
the maxillary artery medially.

• The venous drainage of the

joint is through superficial
temporal vein, maxillary
plexus and posterior venous
plexus.
Nerve supply of TMJ
• Branches from the mandibular
division of the trigeminal nerve,
mostly through the
auriculotemporal branch, along with
branches from the masseteric and
deep temporal nerves.

• Joint capsule, lateral ligament and

retroarticular tissue contain
mechanoreceptors which provides a
source of proprioceptive sensation
that helps control mandibular
posture and movement
Movements of TMJ
• Depression Of Mandible
Lateral pterygoid
Digrastric
Geniohyoid
• Elevation of Mandible
Temporal
Masseter
Medial Pterygoids
• Protrusion of Mandible
Lateral Pterygoids
Medial Pterygoids
• Retraction of Mandible
Posterior fibres of Temporalis
 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
 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.

Clinical Examination of TMJ
• History taking
• Measuring maximum interincisal opening
• Palpation of pre-tragus area
• Intra – auricular palpation
• Palpation of masseter muscle
• Palpation of lateral pterygoid muscle
• Palpation of medial pterygoid
• Palpation of temporalis
• Palpation of sternocliedomastoid
• Palpation of digastric
Screening history and
examination
• Because the prevalence of TMD is very high, every patient
who comes to dental office should be screened for these
problems.

• The purpose of screening history is to identify patients with

subclinical signs and symptoms that the patients may not
relate but are commonly associated with functional
disturbances of masticatory system.

• The screening history consists of several questions that will

help orient the clinician to any TMD.
Questions to be
asked
• H/o limited or painful jaw opening.

• Discomfort of the joint during closure.

• Locked or restricted movement of the jaw.

• Sounds like clicking or popping during

movements.

• Soreness of facial and neck muscles.

• H/o trauma to the head and neck region.

• Pain around the ear, temples or cheeks.

• A deviation is any shift of • A deflection is any shift of the
the jaw midline during midline to one side that
opening that disappears becomes greater with opening
with continued opening (a and does not disappear at
return to
• Occurs midline).
due to a disc maximum opening (does not
displacement with reduction • return toto
It is due midline)
restricted
in one or both joints. movement in one joint
Palpation of T.M.J.
• Pain or tenderness of the TMJ is determined by digital palpation
of the joints when the mandible is both stationary and during
dynamic movements.
• The fingertips are placed over the lateral aspects of both joint
areas simultaneously.
TMJ Imaging
2 D Imaging
• Panoromic radiographs
• Transcranial, Transorbital, Transpharyngeal view
• Reverse Towne’s view
• Submento-vertex (SMV) view
• Conventional tomography
• Arthrography

3 D Imaging
• Computed tomography (CT)
ABSTRAC This study aimed to examine the anatomic structures of the
T: temporomandibular joints (TMJs) using cone-beam computed
tomography (CBCT) in patients with chronic periodontitis.
Conclusion:

• In patients with chronic periodontitis, TMJ space vertical

to the condyles and the distances between the outer and
inner poles of the condyle may change over time.

• These two indices can potentially be used as indicators

for diagnosis and further comparative analyses
TMJ DISORDERS
• Temporomandibular joint disorders are a
group of medical problems related to the
jaw joint.

• TMJ disorders can cause headaches, ear

pain, bite problems, clicking sounds,
locked jaws, and other symptoms that
can affect quality of life for the patient.
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.

Extracapsular disorders Intracapsular disorders

• MPDS • Traumatic arthritis

• Myositis • Fracture
• Myospasm • Internal disc derangement
• Tendonitis
• Myofibrotic contractures
Myofascial Pain Dysfunction Syndrome
Myofascial pain is a myogenous (muscle) pain
condition characterized by local areas of firm,
hypersensitive bands of muscle tissue known
as trigger points.

It arises from hypersensitive areas in muscles

called trigger points.

Aetiology
• Trauma.
• Parafunctional habit.
• Occlusal disharmony-deep overbite /overjet.
• Emotional stress and sleep disturbances.
 Clinical
features

• Pain is usually continuous, diffuse, dull and deep

quality which is increased during muscle activity,
chewing etc

• The pain radiates to the surrounding areas i.e.

head and neck, ear, based on muscle
involvement.

• Positive jump sign-Sudden withdrawal when

palpating trigger points.

• Laskin criteria:
-Pain
-Muscle tenderness
-Clicking or popping in TMJ
Treatment

• Education and instructions to patients for self

care.

• Pharmcotherapy : analgesics/nonsteroidal
anti inflammatory analgesic drugs(NSAIDS),
muscle relaxants.

• Alternative heat and cold therapy.

• Physiotherapy: Transcutaneous electrical

nerve stimulation, passive exercises,
electrogalvanic stimulation.
Ankylosis
Inability to open the mouth due to either a
fibrous or a bony union between head of
condyle and the glenoid fossa.

Aetiology
• Trauma (congenital, hemarthrosis, condylar
fractures)

• Infections(otitis media, parotitis, abscesses

around joint, osteomyelitis of jaw)

• Inflammation of joint(rheumatoid
arthritis, septic arthritis)

• Syndromes associated with TMJ

ankylosis(Treacher Collins syndrome, Pierre
Robin’s syndrome)
 CLINICAL FEATURES

Unilateral ankylosis Bilateral

ankylosis
• Facial asymmetry • Typical ‘bird face’
• Receeded chin deformity
• Fullness of face on affected side • Reduced mouth opening
• Deviation of mandible on affected • Antegonial notch well
side defined bilaterally.
• Condylar movements absent on
affected side
Treatment
• Early surgical intervention - condylectomy, arthroplasty

• Elaborate resection

• Early mobilization

• Aggressive physiotherapy for at least 6 months

Subluxation and Dislocation
• Dislocation of TMJ occur when the head
of the condyle moves anteriorly over
the articular eminence into such a
position that it cannot be returned
voluntarily to its normal position.

• Luxation of the joint refers to complete

dislocation, while subluxation is a
partial or incomplete dislocation
Aetiological factors
• Alteration in the neuromuscular function: laxity of articular disc and
capsular ligament, muscle hyperactivity or spasm.

• Structural deficit (arthritic changes in condyle i.e.flattening or narrowing,

decrease in height of articular eminence, morphological changes of the
glenoid fossa, Zygomatic arch and squamotympanic fissure.

• Collagen metabolism: ligamentous hyperlaxity, Ehlers Danlos syndrome,

Marfan syndrome.

• Precipitating factors: forceful wide opening of mouth while yawning,

dental treatments like third molar extractions or root canal treatments,
endotracheal intubation and laryngoscopy.
Clinical features
Subluxation

o Normal mouth opening, easily able to close mouth but may have clicking
sound.

o Deviation is present.

Dislocation

o Inability to close mouth, difficulty in speech, drooling of saliva and lip

incompetency.

o Usually bilateral in nature

o Unilateral dislocation may lead to deviation of chin to the contralateral side.

 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.
• 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
Treatment-

• warm compress (loosens the muscles).

• Using cold packs for pain relief

• Rectifying your posture to prevent the lockjaw condition

from worsening.

• Practicing jaw exercises

 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
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
 Purpose: The purpose of the present study was to perform a pattern
analysis in patients with
TMD resulting from unilateral mastication due to chronic periodontitis.
Conclusions:
• The results of the present study indicate that unilateral mastication due to
chronic periodontitis could induce not only pain but also structural TMJ
changes if adequate
•treatment is not administered.
Hence, immediate treatment of chronic periodontitis is recommended
to prevent not only the primary progress of periodontal disease, but
also secondary TMJ-related problems.
Abstract:
Fluctuating levels of estrogen during childbearing age potentiates
facial pain, high estrogen levels during pregnancy promote
gingivitis, and low levels of estrogen during menopause
predisposes the TMJ to degeneration and increases alveolar bone
Conclusions:
Estrogen signaling is complex and the varying levels of
loss.
estrogen during woman’s lifetime may play a unique role on
oral diseases.
Increased estrogen levels during pregnancy may cause changes in
the oral microbiome leading to gingivitis and low levels of
estrogen post-menopause may potentiate temporomandibular
joint degeneration and alveolar bone loss.
CONCLUSION
• Chronic periodontitis is associated with alterations of TMJ
structures.

• TMJs examination of patients with chronic periodontitis has

clinical significance
.
• TMJs, the masticatory muscles, and periodontium are closely
interconnected
References

• BD chaurasia -4th edition

• Carranza 10th edition

• Carranza 13th south asia edition

• Neelima malik textbook of oral and maxillofacial studies -4thh edition.