temporomandibular joint
TRANSCRIPT
TEMPOROMANDIBULAR JOINT &
MUSCLES OF MASTICATION
CONTENTS
• Introduction
• Temporomandibular Joint
– Evolution
– Embroyology
– Anatomy
– Histology
• Muscles Of Mastication
• Biomechanics
• Temperomandibular Disorders
• Conclusion
• References
JOINT
• Joint is a junction between two or more bones & is
responsible for movement, growth or transmission of
forces.
• Classification
Based on function
Synarthosis Diarthosis
Synarthrosis
Fibrous
Suture
Syndesmosis
Gomphosis
Cartilagenous
Primary
Secondary
Diarthosis - Synovial joint
• Permits significant movement
• Features:
- 2 bones (articular surface covered by hyaline cartilage)
- capsule
- synovial fluid
• Classified based on shape of articular surfaces
TEMPOROMANDIBULAR JOINT
So called a temporomandibular joint as the involving bones are
the mandible & the os temporale.
Synonyms:
Compound system
Synovial joint
Ginglymoarthrodialjoint,
Diarthoidaljoint
Evolution
• Amphibian skull: Confinement of teeth to dentary bone.
• Articulation : between the terminal portion of the meckel’s
cartilage (articulare) & palatoquadrate bar.
• Reptile skull: Joint in the same palatoquadrate & articulare but
dentary joint is increased in size.
• Mammal like reptile fossil:
– Dentary is increased greatly & possess a coronoid process.
– Jaw articulation is still the same.
• Mammals: Dentary articulates with the temporal bone.
Embryology of TMJ
• Ontogenetically & Phylogenitically tmj is a secondary joint.
• Temperomandibular joint
• 7th week - Articulation between malleus and incus at the
dorsal end of Meckel’s cartilage - PRIMARY
JOINT .
• 8th week- Membranous Bone laid down in a plate like form
lateral to Meckels cartilage.
• 10 weeks- evidence of future joint as mesenchyme between the
condylar cartilage & developing temporal bone.
• 12 weeks:
2 mesenchymal condensations
Condylar grows dorsolaterally
Ossification of temporal blastema
Inferior joint cavity
Differentiation of condylar into cartilage & Sup.joint cavity
Formation of disc
• 13th week : Condyle and articular disk have moved up into
contact with temporal bone.
• Remnant of meckels cartilage - sphenomandibular ligament
• Full differentiation of all articular surfaces occurs by 4th fetal
month.
Differences
Neonatal tmj Adult tmj
Mandibular fossa Flat Concave
Articular
eminence
Absent Present
GENES REQUIRED FOR THE
FORMATION OF TMJ
• Key gene noted to be expressed in condylar cartilage is
INDIAN HEDGEHOG (IHH)
Secreted by prehypertrophic chondrocytes that are just
entering the differentiation pathway.
• FGF and FGF receptor (Fgfr) gene families - all stages of bone
development.
• Fgfr1 – periosteum of the condyle and fossa
• Fgfr2 – perichondrium of the condyle and fossa
• Fgfr3 - immature chondrocytes of the condyle .
Pecularities of tmj
A. Bilateral diarthosis
B. Articular surface covered by fibrocartilage
C. Last joint among diarthoidals to begin development
D. Development from 2 blastemas
Synovial joint( 7th week) TMJ
Articular surface of tmj
• Upper – articulae eminence of mandibular fossa of temporal
bone
• Lower – condylar process of mandible
mandibular fossa of temporal bone
condylar process of mandible
Components of TMJ
• Bony components:
1. Mandibular condyle
2. Glenoid fossa
3. Articular eminence
1. CONDYLE:
• Transversely elliptical in shape
• Head is covered with fibro-cartilage-articulates with anterior
part of mandibular fossa of temporal bone
PosteriorAnterior
Soft tissue componets
ARTICULAR DISC:
• Dense fibrous connective tissue
• Avascular except at the extreme periphery of the disc.
• Saggital plane:
• Anterior view:
– Thick medially corresponding to increased space between
condyle & articular fossa
Attachment of articular disc
• Between Attachments to capsular ligament is tendinous fibres
of superior lateral pterygoid
• Disc attaches to capsular ligament not only anteriorly &
posteriorly but also medially & laterally.
• Movements of tmj:
– Superior cavity: Gliding movement.
– Inferior cavity: Rotatory +Gliding movement
• Functions of articular disc
i. Separation
ii. Protection
iii. stabilization
During functional movements of
condyle
Synovial membrane
• Internal surfaces of cavity are surrounded
by specialized endothelial cells forming
synovial lining.
• The lining located at the anterior border
of retrodiscal tissue produces synovial
fluid.
Synovial fluid
• Ultra filtrate of blood plasma
• Clear or pale yellow, viscous, slightly alkaline fluid.
• Dialysate of blood that also contains mucin( hyaluronic acid)
lymphocytes, monocytes, and macrophages.
• Functions
a. Nutrition of articular cartilage
b. Lubrication of the joint cavity
c. Prevents wear & tear.
character Normal plasma Synovial fluid
Chief content water Hyaluronic acid
protein High protein content Low protein content
amount 55% of total blood
volume
2ml
Mechanism of lubrication
• Primary mechanism of lubrication
• Prevents friction in moving joint
Boundary lubrication
• Facilitates Metabolic exchange
• Eliminates small amount of friction in Compressed but not moving joint
Weeping lubrication
Ligaments
• Collagenous & act predominantly as restraints to motion of the
condyle and the disc.
Functional ligaments
Accessory ligaments
FUNCTIONAL LIGAMENTS
Temperomandibular Collateral/Discal Capsular
Temperomandibular ligament
• Broad ligament formed due to thickening of lateral part of
capsular ligament
1. Outer oblique portion:
Resists excessive dropping of condyle during mouth
opening
Oop resists the impingement submandibular &
retromandibular structures..
2. Inner horizontal portion:
Prevents further posterior movement of condyle into the
gleniod fossa
Eg: During extreme trauma to mandible, neck of condyle
fractures before the retrodiscal tissues are injured.
Collateral ligament
• Syn: Discal ligaments
• Possess vascular supply & are innervated.
Function:
• Gliding & hinging movements
Capsular ligament
• Surrounds the joint.
• Attachments:
• Functions:
1. Resists forces that tend to dislocate the articular surfaces.
2. Retains synovial fluid.
3. Provides proprioception
ACCESSORY LIGAMENTS
Sphenomandibularligament
Stylomandibularligament
Sphenomandibular ligament
• Derived from fibrous envelope of Meckel’s cartilage of first
branchial arch
• No significant movement
Stylomandibular ligament
• Formed by thickening of deep fascia
• Separates parotid gland from submandibular gland
HISTOLOGY OF TMJ
• 4 distinct zones in the articular surfaces of condyle &
mandibular fossa
i. Articular zone
ii. Proliferative zone
iii. Fibro Cartilagenous zone
iv. Calcified zone
RELATIONS OF TMJ
Blood Supply Of TMJ:
• Posteriorly - Superficial temporal A.
• Inferiorly - internal MaxillaryA.
• Anteriorly - middle meningeal A.
Others
• Deep auricular artery
• Anterior tympanic artery
Nerve supply:
• Branches of mandibular nerve
• Auriculotemporal nerve
• Deep temporal nerve
• Massetric nerve
Lymphatic drainage:
1. Anterior surface of TMJ -parotid lymph nodes.
2. Posterior & medial surface of TMJ - submandibular
lymph node
3. Lateral surface of TMJ - pre auricular and parotid lymph
nodes
Muscles of mastication
• Four muscles are present
• They are
A. Masseter
B. Temporalis
C. Medial pterygoid
D. Lateral pterygoid
MASSETER
• Nerve supply:
Palpation:
• Applied anatomy
a) The motor part of mandibular nerve is tested by asking the
patient to clench his teeth and then feeling for the contracting
masseter and temporalis muscles.
b) If one masseter is paralysed the jaw deviates to paralyzed side
on opening the mouth by action of normal lateral pterygoid of
opposite side.
TEMPORALIS
Action :-
i. Elevates mandible
ii. Lateral movements.
iii. Retraction: posterior fibres
Applied anatomy :
• Temporal tendonitis:
- sharp headaches at temple joint.
MEDIAL PTERYGOID
• Nerve supply- medial pteygoid nerve.
• Blood supply: Maxillary artery.
• Action:
i. Elevation
ii. protrusion
iii. side to side movements
• Palpation:
• Applied anatomy
Bleeding created by needle puncture in medial pterygoid
muscle produces a hematoma followed by fibrosis and
subsequent trismus.
LATERAL PTERYGOID
• Nerve supply - branch of ant div of madibular nerve
• Blood supply: Maxillary artery.
• Action- Depression, protrusion & side to side movements
• When medial and lateral pterygoids of two sides act together
they protrude the mandible so that lower incisors project in
front of upper.
• Upper head - Chewing
• lower head - Protrusion.
• Palpation –Palpate by pressing in a superior, medial, &
posterior direction.
• Sphenomandibularis-5th muscle
• Discovered by Dunn et al in the mid
1990s at University of Maryland,
Baltimore.
• Considered to be a part of temporalis.
• Origin- Infratemporal surface of greater
wing of sphenoid bone.
Insertion-Temporal crest of mandible.
• Blood supply- From maxillary artery, from vessels of medial
pterygoid.
• Nerve supply- Not yet determined
• Function: Considered as an elevator muscle of mandible
Temporalis
Temporalis,
Geniohyoid,
Digastric
Lateral
pterygoid
Lateral pterygoid
Suprahyoid
Masseter
Medial &
Lateral pterygoid
Movements of
mandible
EXAMINATION OF TMJ
• Interincisally : 53- 58 mm
• Restricted mouth opening:
– Mouth opening : < 40 mm
– Lateral & protrusive movement:< 8mm
PALPATION OF TMJ
• Pain & tenderness of TMJ is determined by digital palpation
when mandible is in both stationary & dynamic movements.
• Lateral palpation
• Posterior palpation
AUSCULTATION :
Click : single sound with short duration. If loud = popping
Crepitus: multiple gravel like sounds.
GERBER RESILIENCE TEST:
Enables to measure the resilience & thickness of the discus
articularis.
useful to plan possible corrections that is necessary through
dental occlusion.
Normal range :0.6 to 0.9mm & even up to 1.2mm
Musculoskeletal stability
Interarticularpressure
Ligaments
Stabilization of joint:
I. Musculoskeletal stability:
Orthopedically Stable joint is when the condyles are in their antero
superior position in the glenoid fossa, resulting against posterior
slopes of articular eminence with discs properly interposed.
II. Ligaments:
Stabilise the joint by limiting the movement
Ligaments elongate but are not streched
Compromising the normal jaw function
III. Interarticular pressure:
• Pressure between the articular surfaces of articular eminence
& the condyle
• Absence of inter articular pressure results in separation of
joints and dislocation
Functional appliance
Increased contractile
activity of the LPM
Intensification of repetitive activity of the retrodiscal pad
Increase in growth stimulating factors
Change in trabecularorientation
Additional growth of condylarcartilage
Additional subperiostealossification of
posterior border of mandible
Supplementary lengthening of
mandible
OPERATION OF FUNCTONAL APPLIANCES
TemporomandibularJoint Disorders
A. Derangement of condyle -disc complex
i) Disc displacements
ii) Disc dislocation with reduction
iii) Disc dislocation without reduction
B. Structural incompatibility of the articular surfaces
1. Deviation in form
a. Disc
b. Condyle
c. Fossa
2. Adhesions
a. Disc to condyle
b. Disc to fossa
3. Subluxation
4. Spontaneous dislocation
C. Inflammatory disorders
1. Synovitis/ capsulitis
2. Arthritidis
3. Osteoarthritis
4. Polyarthritidis
D. Inflammatory disorders of associated structures
a)Temporal tendonitis
b)Stylomandibular ligament inflammation
Disc displacement:
Causes:
• Break down of normal rotation of condyle due to elongation of
discal ligaments& inferior retrodiscal lamina resulted from
trauma.
• Thinning of posterior border of disc predisposes to
derangement
• Displaced condyle
positioned anteriorly by
lateral pterygoid.
• Constant application results in
thinning of posterior disc &
allows the disc to be displaced
more anteriorly.
Clinical examination
normal range of movements
Joint sounds are seen
• Disc dislocation with reduction :
Disc dislocation:
Further elongation of inf.retrodiscal lamina , discal ligament &
sufficient thinning of posterior border.
Results in slippage of joint. Disc & condyle no longer articulate
disc dislocation.
If the patient can manipulate to reposition the condyle onto
posterior border of disc , disc is termed reduced in nature
Management:
• Reduce the intracapsular pain
• Definitive treatment of disc displacement is to reestablish a
normal condyle disc relationship.
• Anterior positioning appliance by Format .
– This appliance is worn 24 hrs a day for3 to 6 months.
– Appliance repositions the condyle back into the disc
Disc displacement with out reduction:
• Further elongation leads to loss in elasticity of superior
retrodiscal lamina & recapturing is difficult.
• Anterior positioning appliance - contraindicated because it will
aggrevate the condition by forcing the disc even more forward.
• Supportive therapy/ surgical therapy is indicated.
Deviation in form:
• Supportive therapy - Patient education
• In case of muscle hyperactivity : stabilization appliance is
used.
Adhesions:
When adhesions are present breaking the fibrous attachment is
only definitive treatment
It is done by using arthroscopic surgery
Subluxation:
• Only definitive treatment by surgical alteration of joint i.e, by
eminectomy.
• Supportive therapy .
Spontaneous dislocation:
• surgical therapy is indicated
Conclusion
Temporomandibular joint & Masticatory muscles form the
vital part of orofacial system both structurally and
functionally.
It is crucial for an orthodontist to recognize the
musculoskeletal stability of the joint and be aware of problems
related to deviation from this point.
References:
• Management of Temporomandibular Disorders & Occlusion –
Jeffrey Okeson III
• Principles of Oral and Maxillofacial Surgery- Peterson's Vol 1
• Dentofacial Orthopedics with Functional Appliances – Graber,
Rakosi, Petrovic, II ed
• Text book of oral histology- Ten cate
• Human anatomy – B.D Chaurasias 5th Ed
• Grey’s anatomy – 38th edition
• Craniofacial development: Sperber
• Graber, Vanarsdal, Vig