ANATOMY OF STOMATOGNATHIC SYSTEM

Part-1

Presented by- Dr.Neelesh Shah Done Under The Guidance OfProfessor.Ashima.Valiathan B.D.S {Pb}, D.D.S, M.S{U.S.A} Director of P.G studies Department of Orthodontics, Manipal College Of Dental Sciences, Manipal.

Definition

According to Dorlands medical dictionaryStomatognathic - stomato (mouth) + gnathic (jaws) which means mouth & the jaws collectively forms stomatognathic system.

Components

Introduction Osseous anatomy Temporomandibular Joint.

Articular Disc. Condyle/Disc Assembly.

T M Jt Ligaments. Muscles. Mastication. Muscles of mastication. Tongue Regulation of muscle activity. Reflexes.

Introduction

Bones form the basic underlying structure of the stomatognathic system. Three main bones make up the skeletal portion of the stomatognathic system- the maxilla, the mandible, and a portion of the temporal bone of the skull. The maxilla and mandible are the bones that hold the teeth, while the temporal bone is the site of the mandibles articulation with the skull.

Muscles move the mandible Contacting bony surfaces, upholstered with avascular, dense, fibrous connective tissue influence the direction of the mandibles movements Ligaments limit the mandibles range of motion, acting as a leash to restrain it from travelling too far.

Maxilla & mandible are derived from 1st pharyngeal arch.

Muscles of mastication are derived from mesoderm of 1st branchial arch

The Mandible

The mandible forms the lower part of our face. It is suspended from the skull by muscles, ligaments and soft tissues, and doesnt itself attach bone-to-bone to the maxilla, but hangs in space. U-shaped bone, contains mandibular teeth in alveolar process. Suspended from skull by muscles & ligaments. Major structural parts- condyle, coronoid process, ramus, angle, alveolar process, mental protuberance.

The Condyle
Articular portion of the mandibleConsists of a neck- head & the articular surface Head of the condyle
Oblong (football shaped), convex in all directions, but more curvature anteroposteriorly 15-20 mm wide medio-laterally, 8-10mm antero-posteriorly. 2 poles- medial & lateral- medial larger. Posterior part of articular surface larger than anterior.

Mandible- looking down from above. The condyles are aligned at 90 degrees to the top of the ramus, but due to the flaring out of the mandible at the posterior,they are positioned such that the medial pole is more posterior than the lateral pole is- they make an angle to the horizontal that runs posteriorly at the medial aspect. Lines going through the poles of the condyles aim at the anterior edge of the foramen magnum of the skull.

The Maxilla

Composes most of upper part of face & contains maxillary teeth. Fused to skull & hence non-mobile. Major intra-oral parts- alveolar process, palatal process, incisive foramen, mid-palatal suture, maxillary tuberosity.

The body of the maxilla has four surfaces: Anterior or facial surface Posterior or infratemporal surface Superior or orbital surface. Medial or nasal surface. It has four processes: Frontal. Zygomatic. Alveolar. Palatine.

The Temporal Bone

Part of the skull with which the mandible articulates. Condyle articulates with concave mandibular fossa.

The Temporomandibular Joint

Main functional parts are mandibular condyle, mandibular fossa & articular disc. Ginglymoarthrodial joint- allows hinging and gliding motions. Classified as compound joint- articular disc functions as a third, non-ossified bone. Articular surfaces covered with dense, fibrous connective tissue.

Osseous Anatomy Of - T M Jt

The Mandibular Fossa

Also called articular fossa & glenoid fossa. Posterior bordersquamotympanic fissure- thin bone. Medial wall -temporal bone- steep Anterior border - convex articular eminence-thick, dense bone. Slope of articular eminence & medial wall are major Squamotympanic fissure determinants of mandibular movement.

The Articular Disc

Composed of dense, smooth, fibrous connective tissue. Mostly devoid of nerves & blood vessels Biconcave shape. Thickest at posterior border & medial border. Condyle articulates in thin intermediate zone.

Saggital veiw

Condyle/Disc Assembly

Condyle, articular disc & mandibular fossa surrounded by soft tissue attachments. Attachments aid in structure of joint, positioning and function of joint components. It consist of ligamentous attachments, elastic and collagenous connective tissue attachments and muscle attachment .

LIGAMENTS

Bands of non-elastic collagenous tissue. Function to passively limit range of movement & protect joint structures.

5 ligaments associated with TMJt. 3 functional, 2 accessory Functional:

Collateral (discal) ligaments Capsular ligament Temporomandibular ligament Sphenomandibular Stylomandibular

Accessory:

Collateral (Discal) Ligaments

2 collateral ligaments- Medial & lateral. Stiff, collagenous connective tissue. Divide TMJ mediolaterally into superior & inferior joint cavities. Help keep disc positioned on condyle, allow anteriorposterior rotational movement.

Capsular Ligament

Surrounds entire TMJ. Runs from neck of condyle to temporal bone & articular eminence, surrounds mandibular fossa, 360 degrees around.

Capsular Ligament
Functions:
Prevent dislocation of articulating surfaces. Proprioception. Contains synovial lining produces synovial fluid.

Temporomandibular Ligament

Outer Oblique Portion

articular eminence to neck of condyle limits opening of mouth influences nature of opening movement

Inner Horizontal Portion

articular eminence to head of condyle & disc limits posterior movement

Both are closely related physically with capsular ligament

Accessory Ligaments

Sphenomandibular Ligament sphenoid bone to lingula. non-functional

Medial view

Stylomandibular Ligament styloid process to angle of mandible limits protrusive movement

Lateral Veiw

Joint Cavities

TMJ is divided into 2 distinct joint cavities by articular disc and ligaments: Superior joint cavity
Between articular disc & mandibular fossa Responsible for gliding movements

Inferior joint cavity

Space between articular disc & condyle Responsible for hinging movements

Movements Of Mandible

Synovial Fluid

Joint capsule lined by specialized endothelial cells- synovial lining. Produces synovial fluid, fills both joint cavities. Function- lubrication & metabolism. 2 mechanisms- boundary lubrication & weeping lubrication.

Blood supplyBranches from superficial temporal and maxillary arteries. Veins follows arteries.

Nerve supplyAuriculotemporal nerve and massetric nerve.

Muscles

Muscle fibers grouped into motor units. Motor unit consists of a group of muscle fibers all innervated by 1 motor neuron.

Functional unit of muscles Number of muscle fibers per neuron varies according to function of muscle

fewer fibers/neuron= less force, greater precision of movement- e.g. lateral pterygoid more fibers/neuron= greater force of movement, less precision- e.g. masseter

Actions of Muscles

3 types of muscle action: Isotonic- overall muscle length shortens during contraction- primary movement. Isometric- overall muscle length does not shorten during contraction- develops force, but no movement- stabilization & fixation. Controlled relaxation- slow, smooth, relaxation and lengthening of previously contracted muscle- coordination of movements.

The origin can be thought of as generally being the more stable, more fixed end of the muscle, and when the muscle contracts, it pulls the part at the insertion towards it.

MASTICATION

Mastication (chewing) is the first movement of the digestive tract.

Importance of mastication.

The coarse chunks of food are broken down to smaller particles. This breaking down has the following advantages (i) It increases the surface area . (ii) In case of some vegetable foods, where the surface coating of the food is made up of cellulose or hemicellulose, mastication causes exposure of the inner digestible material. The cellulose or hemicellulose is indigestible in human digestive system but the noncellulose inner material is digestible. Thus digestion is facilitated (iii) It helps in the flow of saliva (iv) It helps in subsequent deglutition.

The teeth are designed for chewing, the anterior teeth (incisors) providing a strong cutting action and the posterior teeth (molars), a grinding action. All the jaw muscles working together can close the teeth with a force as great as 55 pounds on the incisors and 200 pounds on the molars. Much of the chewing process is caused by a chewing reflexThe presence of a bolus of food in the mouth at first initiates reflex inhibition of the muscles of mastication, which allows the lower jaw to drop. The drop in turn initiates a stretch reflex of the jaw muscles that leads to rebound contraction. This automatically raises the jaw to cause closure of the teeeth, but it also compresses the bolus again against the linings of the mouth, which inhibits the jaw muscles once again, allowing the jaw to drop and rebound another time; this is repeated again and again.

EQUILIBRIUM THEORY

States that an object subjected to unequal force will be accelerated and thereby will move to different position in space. It follows that if any object is subjected to a set of force but remains in the same position those forces must be in a balance or equilibrium . From this perspective the dentition is obviously in equilibrium since the teeth are subjected to variety of forces but dont move to a new location under usual circumstances The duration of force is more important than its magnitude, due to its biological effect.

MUSCULAR WEAKNESS SYNDROME

Causes mandible to drop down away from the facial skeleton Distortion of facial proportions, increased facial height Excessive eruption of posterior teeth, narrowing of maxillary arch and anterior open bite.

Muscles producing Movements of mandible

Depression- Lateral pterygoid (mainly) Digastric, geniohyoid and mylohoid muscles help when the mouth is open wide or against resistance. Elevation - Masseter - Temporalis - Medial pterygoid (both sides)

Protrusion Lateral & medial pterygoids. Retraction Temporalis (post fibers). Lateral or side to side movement - Medial & lateral pterygoids together.

Muscles of mastication

There are several different groups of muscles associated with the masticatory system- some are directly involved with mandibular function, others are accessory in nature and just help out. The muscles of mastication are the primary functional muscles that perform the majority of mandibular movements. The suprahyoid group contains the muscles responsible for mouth opening, along with others , the infrahyoids, help to co-ordinate mandibular function. The posterior neck musculature is active in stabilizing and balancing the head, allowing the other muscles to work together to perform the many complicated movements that are possible.

Muscles of mastication

Masseter . Temporalis. Medial pterygoid. Lateral pterygoid. Hyoid muscles. Auxillary oral muscles.

Masseter
Superficial portion

Origin-anterior 2/3rd of zygomatic arch. Insertion-coronoid process,ramus and angle of mandible. Function-powerful elevator
Origin-medial surface of zygomatic arch Insertion-coronoid process,ramus & angle of mandible. Function- elevation & retrusion.

Deep portion

A study was done by( Gedrange T etal J Appl Gnet 46 ,2005) to determine the myosine heavy chain proteins (MyHC) and MyHC mRNA in masseter muscles of patients with different mandibular positions. 10 patients were selected with distal and mesial malocclusion, and amount of MyHC and its different isoforms was determined by western blot essay and PCR. The anterior part of masseter muscle showed more type i and 2x myhc in distal occlusion than in the mesial occlusion.

Medial pterygoid
Origin :

Medial surface of lateral pterygoid plate.

Insertion :

Medial surface of the angle of the mandible.

Function :

Elevation & protrusion. Medial pterygoid

Temporalis muscle
Anterior portion

Origin : anterior temporal fossa Insertion : coronoid process Function : elevation

Middle portion

Temporalis muscle

Origin : Mid temporal fossa Insertion : coronoid process Function : elevation & retraction

Posterior portion

Origin : posterior temporal fossa Insertion : coronoid process Function : retrusion

Temporalis muscle function

Lateral pterygoid
Inferior head of lateral pterygoid Origin:lateral surface of lateral pterygoid plate. Insertion:neck of condyle. Function : protrusion

Superior head of lateral pterygoid Origin : infratemporal surface of greater sphenoid wing. Insertion : articular capsule,disc & neck of condyle. Function : protractor of disc in conjuntion with elevator muscles

Lateral pterygoid muscle function

Nerve supply
Motor nerve supply of masticatory muscles Mandibular division of trigeminal nerve

Blood supply to masticatory muscles

Blood supply to muscles of masticationMaxillary Artery

 A study [Gedrange T etal Rofo. 2005 Feb;177(2):204-9 ] was done to determine the relationship between the morphological parameters of the masticatory muscles and the jaw bone by computer tomography, lateral cephalogram and denture models. It showed higher densities of medial pterygoid, masseter and genioglossus in deep bite individuals than in the open bite cases. Significant difference in the muscle cross section of the masseter muscle was found in individuals with retroclined maxillary incisors and the individuals with open bite.

Orbicularis oris & buccinator muscles

Orbicularis oris
Intrinsic part

Origin - superior incicivus from maxilla;inferior incicivus,from mandible Insertion angle of mouth

Extrinsic part

Origin - thickest middle stratum,derived from buccinator & thick superficial stratum Insertion - lips & the angle of the mouth.

Buccinator Orbicularis oris

Action

Closes & purses the mouth

Buccinator muscleOrigin : Upper fibers from maxilla opposite

to molar teeth.

Insertion :
straight to the upper lip

Lower fibers

from mandible opposite to molar teeth

straight to the lower lip

Middle fibers

from ptergomandibular
raphe

decussates before
passing to the lips

Action flattens cheek against gums & teeth. It is also called as whistling muscle.

 A study done by Jung MH et al (Am J Orthod Dentofacial 2003 Jan) to evaluate the influence of force of orbicularis muscle on the incisor position and craniofacial morphology where average and maximum upper lip force was determined by a device y meter. The skeletal structure and the incisal angulation were recorded by lateral cephalogram. The result showed that the upper incisor proclination was significantly related to the magnitude of the orbicularis oris force. So the disuse atrophy of orbicularis might be an significant factor in the development of malocclusion.

BUCCINATOR MECHANISM
It is a continuous muscle band that encircles the dentition and is anchored at the pharyngeal tubercle. Components Orbicularis oris Buccinator Pterygomandibular raphae Superior constrictor of pharynx Opposing the buccinator mechanism there is a very powerful muscle tongue; which begins its activity even before birth.

BUCCINATOR MECHANISM

Suprahyoid muscles

Geniohyoid . Mylohoid . Digastric . Stylohyoid.

Function :

Elevate hyoid bone & depress mandible when the mouth is wide open or against resistance ; it is secondary to lateral pterygoid .

Suprahyoid muscle function

Infrahyoid muscles

Thyrohyoid . Sternohyoid . Omohyoid .

Function : Lowers hyoid bone allowing suprahyoids to depress mandible.

Tongue

Development of tongue

Papillae of the Tongue

These are projections of mucous membrane or corium which give the anterior two-thirds of the tongue its characteristic roughness. These are of the following three types.

Vallate or circumvallate papillae - They are large in size

1-2 mm in diameter and are 8-12 in number. They are situated immediately in front of the sulcus terminalis. Each papilla is a cylindrical surrounded by a circular sulcus. The walls of the papilla are raised above the surface.

Fungiform papillae are

numerous near the tip and margins of the tongue but some of them are also scattered over the dorsum. These are smaller than the vallate papillae but larger than the filiform papilla consists of a narrow & a large rounded head.they are distinguished by their bright red colour.

Filiform papillae cover the

presulcal area of the dorsumof the tongue & give it a characteristic velvety appearance, they are the smallest & most numerous of the lingual papilla.

Muscles of tongue

Each half contains four intrinsic and four extrinsic muscles. Intrinsic muscles 1. Superior longitudinal 2. Inferior longitudinal 3. Transverse 4. Vertical Extrinsic muscles 1. Genioglossus 2. Hyoglossus 3. Styloglossus 4. Palatoglossus

Nerve supply of tongue

Sensory supply

Motor supply
Hypoglossal nerve except palatoglossus which is supplied by cranial part of the accessory nerve.

Ant 2/3-lingual Post 1/3 nerve for Both general and general taste sensation are sensation. carried by Chorda glossopharyngeal tympani for nerve special taste sensation.

Root Vagus nerve

Blood supply of tongue

Arterial supplyLingual artery branch of ECA Root of tongue is supplied by tonsillar & ascending pharyngeal arteries. Venous drainage2 venae comitantes accompany lingual artery. Deep lingual vein is the principal vein of tongue.

Lymphatic drainage of tongue

Tip of tongue bilaterally drains to submental nodes. Right & left of the remaining part of the anterior 2/3rd of the tongue drain unilaterally to the submandibular nodes. Posterior 1/3rd drains to Jugulo-digastric nodes.

FUNCTION OF THE TONGUE

TASTE SPEECH MASTICATION DEGLUTITION

TASTE

Different type of taste buds are perceived by different papillae which contain taste buds Circumvallate bitter Foliate sour Fungiform - at the tip of the tongue - sweet, and at periphery - salty Tastes are transmitted to the CNS by different nerve roots.

Speech

Bi labialsounds -[m], [b] and [p] are bilabial stops (plosives) Labial-alveolar - [t], [d], or [n] sound. Labiodental [f] &[v]. Dento alveolar [t], [d]. Interdental consonants [n],[l]. Coronal [s],[z]. Velar [g] ,[k] ,[q]. Uvular fricative - [].

According to Proffit, the speech problems related to malocclusions are

Speech sounds S,Z (sibilants) problem lisp Related malocclusion Anterior open bite Lingual position of max. incisors Skeletal class III

T,D (linguoDifficulty in alveolar) production F,V (labio-dental) distortion Th, sh, ch (linguo-dental) distortion

Anterior open bite

ANATOMY OF STOMATOGNATHIC SYSTEM

..continued part - 2

Presented by- Dr.Neelesh Shah Done Under The Guidance OfProfessor.Ashima.Valiathan B.D.S {Pb}, D.D.S, M.S{U.S.A} Director of P.G studies Department of Orthodontics, Manipal College Of Dental Sciences, Manipal.

Swallowing (Deglutition)
Swallowing is a complicated mechanism, principally because the pharynx subserves respiration as well as swallowing. The pharynx is converted for only a few seconds at a time into a tract for propulsion of food. It is especially important that respiration not be compromised because of swallowing. In general, swallowing can be divided into(1) Voluntary stage. (2) Pharyngeal stage. (3) Esophageal stage.

Effect of the Pharyngeal Stage of Swallowing on RespirationThe entire pharyngeal stage of swallowing usually occurs in less than 6 seconds, thereby interrupting respiration for only a fraction of a usual respiratory cycle. The swallowing center specifically inhibits the respiratory center of the medulla during this time, halting respiration at any point in its cycle to allow swallowing to proceed. Yet even while a person is talking, swallowing interrupts respiration for such a short time that it is hardly noticeable.

 Voluntary Stage of SwallowingWhen the food is ready for swallowing, it is "voluntarily" squeezed or rolled posteriorly into the pharynx by pressure of the tongue upward and backward against the palate. From here on swallowing becomes entirely or almost entirely automatic and cannot be stopped.

 Pharyngeal Stage of SwallowingAs the bolus of food enters the posterior mouth and pharynx stimulates epithelial swallowing receptor areas all around the opening of the pharynx, especially on the tonsillar pillars, and sends impulses from the trigeminal and glossopharyngeal nerves into the medulla oblongata cither into or closely associated with the tractus solitarius which receives essentially all sensory impulses from the mouth which initiate a series of automatic pharyngeal muscle contractions. The trachea is closed, the esophagus is opened, and a fast peristaltic wave initiated by the nervous system of the pharynx forces the bolus to pass into the upper esophagus, the entire process occurring in less than 2 seconds.

 Esophageal Stage of Swallowing

The esophagus functions primarily to conduct food rapidly from the pharynx to the stomach, and its movements are organized specifically for this function. The esophagus normally exhibits two types of peristaltic movements: primary peristalsis and secondary peristalsis. Primary peristalsis is simply continuation of the peristaltic wave that begins in the pharynx and spreads into the esophagus during the pharyngeal stage of swallowing. This wave passes all the way from the pharynx to the stomach in about 5 to 10 seconds. Food swallowed by a person who is in the upright position is usually transmitted to the lower end of the esophagus even more rapidly than the peristaltic wave itself, in about 5 to 8 seconds, because of the additional effect of gravity pulling the food downward.

 If the primary peristaltic wave fails to move into the stomach all the food that has entered the esophagus secondary peristaltic waves result from distention of the esophagus itself by the retained food; these waves continue until all the food has emptied into the stomach. The secondary peristaltic waves are initiated partly by intrinsic neural circuits in the myenteric nervous system and partly by reflexes that begin in the pharynx and are then transmitted upward through vagal afferent fibers to the medulla and back again to the esophagus through glossopharvngeal and vaga! efferent nerve fibers.

Deglutition

Tongue thrust

A case report by Dr.Valiathan A. AND Sameer H Shaikh. (J

Ind Ortho Soc 1998;31:53-57) showed the effect of an abnormally large tongue in producing the spaces similar in appearance to primate spaces. A 28 year male patient of south Indian origin was presented with a chief complain of proclination of upper anterior teeth along with spacing between the same. His face was fairly symmetrical with convex facial profile, prominent nose, acute nasolabial angle and incompetence of lip. An additional lateral ceph was taken following the administration of radio- opaque contrast medium to highlight the dorsum of tongue and related soft tissue. Based on detailed examination of the tongue dimension, tongue volume, electromyographic activity and force exerted by the tongue, it was concluded that excessively large volume tongue and dimension produce excessive force which possibly causes the malocclusion.

A study by Dr.Ashima Valiathan & Padmapriya C V was done on tongue volume & tongue force exerted during swallowing to evaluate their effect on the dentition. cephalometric findings of the study group were compared with normal cases as well as togue volume & pressure were measured. The results showed an increase in tongue pressure of 33 cN compared to 20.5 cN in control group & also an increase in the occurance of mouth breathing & tongue & lip habits in the study group.Thus in the complex etiology of bimaxillary protrusion,environmental factors in the form of various habits & excessive tongue force play an important role.

 A study by Jeryl D.English and Kamrin D.G.Olfert (Semin Orthod 11:164-169 2005 ) The article distinguishes between dental open bite and skeletal open bite malocclusions and reviews the etiologic factor and possible treatment options. The addition of light masticatory muscle exercise on two mixed detention cases is illustrated. The patients were treated with a bonded rapid palatal expander followed by a transpalatal arch and a mandibular lingual arch, high-pull headgear therapy and light masticatory muscle exercises for 1 minute five times per day. A third case illustrates an increase in the clenching exercises of at least 5 minutes per hour for 6 hours. This patient had changed her mind on orthognathic surgical treatment plans. Treatment results suggest that clenching exercises helped to control the vertical dimension and assist in closure of open bite malocclusions.

Tooth

Actions of Muscles

Action of different muscles is coordinated, each performing a specific action to work together to accomplish a given movement eg. some contract isotonically to move a part, some isometrically to stabilize, while others undergo controlled relaxation. Movements controlled by CNS.

Neurologic Control of the Masticatory System

Nerve impulses, picked up by sensory receptors, travel through afferent neurons to the CNS Return impulses travel back from the CNS through efferent neurons to muscle to produce an action Most sensory + motor innervation for masticatory system provided by trigeminal nerve

Neurologic Control of the Masticatory System

Areas of the brain involved are:

Brain stem (trigeminal nuclei). Regulatory and modifying areas (e.g thalamus, reticular formation). Cortex.

Sensory Receptors

Detect stimuli and provide information to CNS Types:

Muscle spindles- proprioception Golgi tendon organs- proprioception Pacinian corpuscles- movement & firm pressure Nociceptors- pain

Neural Control of Mandibular Function

Movements can be:

Voluntary- conscious act Involuntary- reflex Automatic- acquired patterns of movement - e.g. chewing

Reflexes

Movement takes place without conscious control Occurs without cortex involvement Protective in nature Results from stimulation of a receptor Masticatory reflexes
Myotatic reflex Nociceptive reflex

Reflexes

Myotatic reflex (stretch reflex)

occurs when a muscle is quickly stretched results in contraction of stretched muscle involved in determining rest position of jaw occurs when a hard object is encountered when chewing results in jaw dropping open

Nociceptive reflex (flexor reflex)

Regulation of Muscle Activity

Automatic movements are controlled by the brainstem- central pattern generator. Coordinates timing of antagonistic muscle function. Somewhere between voluntary & involuntary lies rhythmic, subconscious functions- e.g. chewing, swallowing, etc. Can be altered by cortical input- conscious act or influenced by stress, emotion, etc.

Temporo Mandibular disorder

Temporomandibular joint disorder (TMJD or TMD), or TMJ syndrome, is an acute or chronic inflammation of the temporomandibular joint, which connects the lower jaw to the skull. The disorder and resultant dysfunction can result in significant pain and impairment.

Concepts of orthopedic stability

Musculoskeletal stable position It is that position when the condyles are in their most superoanterior position in the articular fossae, resting against the poosterior slopes of articular eminences, with the articular disc properly interposed. The most stable occlusal position It is the maximal intercuspation of teeth. This type of occlusal relationship furnishes maximum stability for the mandible while minimizing the amount of force placed on each tooth during function.

 Optimal orthopedic stability in the masticatory system is to have even & simultaneous contact of all possible teeth when the mandibular condyles are in their most superoanterior position, resting against the posterior slopes of the articular eminences, with the disc properly interposed. ie- the musculoskeletal stable position of the condyles coincides with the maximal intercuspation position.

Determinants of orthopedic stable position

Closed and opened positions

jaw closed

jaw opened

Types of TMD

Three most common temporomandibular disorders areMyofascial pain and dysfunction, Internal derangement, and Osteoarthrosis.
Myofascial pain and dysfunction is by far the most prevalent. It is primarily a muscle disorder resulting from oral parafunctional habits such as clenching or bruxism. These habits are sometimes related to psychogenic disorders such as headache, chronic back pain, and irritable bowel syndrome. Stress, anxiety, and depression are key features of myofascial pain and dysfunction.

The term internal derangement describes a temporomandibular disorder in which the articular disc is in an abnormal position, resulting in mechanical interference and restriction of the normal range of mandibular activity. Osteoarthrosis is a localised degenerative disorder that affects mainly the articular cartilage of the temporomandibular joint and is often seen in older people.

Precipitating factors

Over-opening the jaw beyond its range or unusually aggressive or repetitive sliding of the jaw sideways or forward (protrusive). These movements may also be due to abnormal habits or a malalignment of the jaw or dentition. This may be due to:

Modification of the occlusal surfaces of the teeth thorugh dentistry or accidental trauma. Speech habits resulting in jaw thrusting. Excessive gum chewing or nail biting. Excessive jaw movements associated with exercise. Repetitive unconscious jaw movements associated with bruxing. Size of foods eaten.

Clinical features
There are three cardinal features of temporomandibular disorders Orofacial pain, Joint noise, and Restricted jaw function.

 Patients describe either a generalised tight feeling, which is probably a muscular disorder, or the sensation that the jaw suddenly "catches" or "gets stuck," which is usually related to internal derangement. Headaches, ear aches, tinnitus, and neck and shoulder pains are just a few of a number of non-specific symptoms that are often reported by patients with temporomandibular disorders.

Differential diagnosis

Dental pain. Disorders of the ears, nose, and sinuses. Diseases of the major salivary glands. Neuralgias. Headaches.

Myofascial pain dysfunction syndrome

There are four cardinal signs and symptoms of the syndrome: (1) Pain, (2) Muscle tenderness; (3) A clicking or popping noise in the temporomandibular joint, (4) Limitation of jaw motion, unilaterally or bilaterally in approximately an equal ratio, sometimes with deviation on opening. Two typical negative disease characteristics: (1) An absence of clinical, radiographic or biochemical evidence of organic changes in the joint itself, (2) Lack of tenderness in the joint when it is palpated through the external auditory meatus.

Functionally dislocated discs

Types of disc displacements

Reciprocal clicking and disc displacement with reduction (DDR)

The Road to Perdition

Adhesions

Temporomandibular disorder screen examination.

Muscle palpation. TMJt palpation.

Click Crepitus.

Range of mandibular motion. Occlusal evaluation

Muscle palpation.

TMJt palpation

.
Range of mandibular motion Occlusal evaluation

How can i locate the musculoskeletally stable position of the condyles in fossa ??

Manual method to achieve MSSP

Use of leaf gauge to achieve MSSP

Treatment
Non-surgical treatment of temporomandibular disorders continues to be the most effective way of managing over 80% of patients. Explanation and reassurance Patient education and self care Drug treatment (non-steroidal anti-inflammatorydrugs,opiates,tranquillisers,
tricyclic antidepressants)

Occlusal therapy (70% of patients) Physiotherapy Behavioural therapy Surgical treatment (5% of patients)

Factors that reduce symptoms with occlusal appliance

Alteration in occlusal condition Alteration in condylar position Increase in vertical dimension Cognitive awareness Placebo effect Increase in peripheral input to the CNS. Regression to mean.

 Study-by Magnusson T (Cranio 4(4):338-344 1986) A 5years longitudinal study - observed untreated subjects at age 15 years, & then again 20 years found that clicking is common in this age group & that clicking can come & go, unrelated to any major clinical symptoms. Therefore if patient reports the onset of a joint sound unrelated to pain and occlusal condition is being developed in harmony with the stable joint position, patient education regarding the problem may be all that is needed.

Conclusion

Anatomy of stomatognathic system is the basic pillar for any dental clinician whose sound knowledge is very important; it helps us in diagnosis & treatment of many oral disorders. It also helps us in various treatment modalities like implant placement, diagnosing TMJt disorders, myofunctional pain dysfunction syndrome,etc. Its knowedge helps an orthodontic treatment in such a manner that the finished result reflects a balance between the structural changes obtained and functional forces acting on the teeth and investing tissue at that time.

The orthodontist is challenged constantly with the task of providing each patient with acceptable esthetics and masticatory function. Although esthetics is often the patients immediate and primary goal, functional outcomes are far more important over the lifetime of the patient. Developing a sound functional masticatory system needs to be the primary goal of all orthodontic therapy. No other dental specialist routinely alters the patient's occlusal condition as a part of the therapy.

The orthodontist is in a unique position to improve or worsen the occlusal condition while carrying out the esthetic goals of the therapy. It therefore behooves the orthodontists to be knowledgeable of normal masticatory function and the goals that need to be achieved to maintain normal function. These goals should be met in all patients, those with and without masticatory dysfunction.

References
1. 2.

3. 4.

5.

6.

Atlas of anatomy- Grant`s 11th edition Lippincot Williams & Wilkins - 2005. Atlas of human anatomy- Neter`s 3rd edition Elsevier - 2006. Grays anatomy- 36th edition Elsevier - 2005. Human anatomy volume -3 B.D.Chaurasia 4th edition C B S Publication-2005. Human embryology Inderbersingh 5th editionMac Millan India -1993. William f Ganong- Medical physiology 19th editionLange medical publication 2005.

8. Sujit Chaudhari- Concise medical physiology. 5th edition New central book agency - 2004 . 9. Guyton- Human physiology & mechanism of disease 11th edition W.B.Saunders 2006. 10. Langman`s Medical embryology 10th edition Lippincot Williams & Wilkins - 2006. 11. Jung MH,Yang WS etal- Effect of upper lip closing force on craniofacial structures.Am.J. Orthod .Dentofacial.Orthop Jan 2003 123,58-63,

12. Ashima Valiathan,Sameer H Shaikh-Malocclusion and the tongue :J Ind Orthod Soc,1988,31:53-57 13. T.M.Graber - The three Ms: Muscles, malformation, and malocclusion .Am. J. Orthodontics vol-49 number- 6 June 1963 14.Thomas P George, Valiathan Ashima, Arji I George & Denny J Payyappilly: Oral habits (Part II) Tongue thrusting. Kerala Dental Association. 1992; 15(3 & 4): 721-724

15. Ashima Valiathan ,Padmapriya C V- Comparison of tongue pressure, tongue volume and cephalometric values in kerela population with and without bimaxillary protrusion-a clinical study- J Ind Orthod Soc ,2003, 36;Page-158-163 16. Gedrange T ,Buttner- Myosine heavy chain protein and gene expression in the masseter muscle of adult patients with distal or mesial malocclusion. C,J.Apply.Genet,46,227-36.2005 17. Gedrange T etal- Computed tomographic examination of muscle volume ,cross section and density in patients with dysgnathia. [, 177(2),204-9,Rofo Feb 2005

18. Robert.E.Moyers-Handbook Of Orthodontics 4th Edition Year book medical publisher 1998. 19. William.R. Proffit- Contemporary Orthodontics,3rd Edition.Henry W.Fields.JR 3rd Edition Mosby - 2000. 20. T.M.Graber - Orthodontics Principles and Practice 4th Edition Elsevier - 2005. 21. Thomas M.Graber, Thomas Rakosi, Alexandre G.Petrovic-Dentofacial Orthopedics with Functional Appliance 2nd Edition Mosby year book - 1997.

22. Jeryl D.English and Kamrin D.G.OlfertMasticatory muscle exercise as an Adjunctive treatment for open bite malocclusions .Semin Orthod 11:164-169 2005. 23. Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion"4th edition. Mosby, Inc. 2003 24. D. M. Laskin, C. S. Greene, W. L. Hylander.TMDs: An Evidence Based-Approach to Diagnosis and Treatment. (2006) Eds: Quintessence Books, Chicago.

25. Clark GT.-A critical evaluation of orthopedic interocclusal appliance therapy. Design theory and overall effectiveness. J Am Dent Assoc 1984; 108: 359-364. 26. Clark GT, Adler RC- A critical evaluation of occlusal therapy. Occlusal adjustment procedures. J Am Dent Assoc 1885; 110: 743-750. 27. Stuart.C.White & Micheal.J.Paroah - Oral Radiology Principles & Interpretation 4th Edition Mosby - 2000. 28. Shafer William.G- A Text Book Of Oral Pathology 4th Edition W.B.Saunders ompany 1983.