TEMPOROMANDIBULAR JOINT

PRESENTED BY

NILESH TORWANE

CONTENTS
Introduction Development Gross Anatomy Mandibular condyle Cartilage and synovium Capsule Articular disc Ligaments Vascular And Nerve Supply Examination of TMJ Applied aspects Bibliography

           

INTRODUCTION
     

Synonyms- craniomandibular joint / mandibular joint / articulatiotemperomandibularis joint. The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. Technically it is a ginglymoarthrodial joint. The TMJs are one of the only synovial joints in the human body with an articular disc. It is bilateral diarthroidial joint. Also considered as complex joint.


   

Types of joint
according to tissue presentFibrous joint cartilageous joint- primary and secondary synovial joint- plane joint, hinge joint, pivot joint, condyloid joint, saddle joint, ball n socket joint

DEVELOPMENT

Approximately at 10th week, the components of the future joint become evident in mesenchyme between the condylar cartilage of mandibular bone and temporal bone. Two slit like joint cavities and an intervening disc make their appearance by 12 weeks. The mesenchyme around it forms fibrous capsule. The developing superior Head of lateral Pterygoid muscle attaches the anterior Portion of the fetal disc.

 

The disc also continues posteriorly through the petrotympanic fissure and attaches to the malleus of the middle ear. This connection is obliterated by growth of lips during development.

Gross Anatomy
     

Mandibular condyle Cartilage and synovium Capsule Articular disc Ligaments Vascular And Nerve Supply

Mandibular condyle
  

 

15-20 mm in width 8-10 mm in anteroposterior dimension Mandible articulates with the temporal bone by means of the articular surface of its condyles The condyle tends to be rounded mediolaterally and convex anteroposteriorly Structures form an approximately 145 to 160 angle to each other

Cartilage and Synovium

   

The inner aspect of TMJ containsArticular cartilage & Synovium The space bound by these two structures is termed the synovial cavity, which is filled with synovial fluid. The articular surfaces of both the temporal bone and the condyle are covered with dense articular fibrocartilage. Fibrocartilage covering has the capacity to regenerate and to remodel under functional stresses.

A proliferative zone of cells present deep to the fibrocartilage and on the condyle, may develop into either cartilaginous or osseous tissue. Most changes resulting from function are seen in this layer

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Functions of the synovium- Lubrication - Provide nutrition - Phagocytosis - provide immunological response

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Capsule

    

The capsule is a thin sleeve of fibrous tissue investing the joint completely. It attaches to the articular eminence, the articular disc and the neck of the mandibular condyle. Anteriorly- attached in front of the crest of the articular eminence Posteriorly- it extends medially along the anterior lip of the squamotympanic and petrotympanic fissure. Laterally- adheres to the edge of the articular eminence and fossa.

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The articular capsule is strongly reinforced laterally by the temporomandibular (lateral) ligament.

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Articular Disc
     

The unique feature of the TMJs is the articular disc. The disc is biconcave. Superior surface is concavoconvex and inferior surface is convex. The articular disc is a fibrous extension of the capsule in between the two bones of the joint. The disc functions as articular surfaces against both the temporal bone and the condyles. It divides the joint into two sections and attaches to the condyle medially and laterally.

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Anteriorly, disc is attached to articular eminence and capsule of the joint. Posteriorly, disc is attached to the wall of glenoid fossa above and to the distal aspect of the condyle. This area is called as retrodiscal tissue.

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Rees in 1954 described three zones of the disc- posterior band- it is moderately thick (2mm) but narrow anteroposteriorly. - intermediate zone- thickest and widest(3mm) - anterior band- thinest band (1mm)

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Ligaments
 

Composed of collagen and act predominantly as restraints to motion of the condyle and the disc. Types of ligaments

Functional ligament Capsular ligaments, Lateral or Temporomandibular ligaments Accessory ligaments Sphenomandibular and Stylomandibular

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Capsular Ligaments
   

Entire tmj is surrounded by capsular ligament Superiorly it is attached to temporal bone and mandibular fossa. Inferiorly to neck of the condyle They resists the lateral, medial and inferior forces.

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Temporomandibular (lateral) ligaments

   

It is a main stabilizing ligament located on the lateral aspect of each TMJ It runs downward and forward from articular eminence to posterior side of mandibular condyle. It limits the anterior excursion of the jaw and prevents posterior dislocation so it is called as check ligament of tmj

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Sphenomandibular ligament
  

It is a flat band arising from sphenoid bone and petrotympanic fissure. It runs downward and medial to tmj capsule towards lingula of mandible. It is a important landmark because maxillary artery and auriculotemporal nerve lies between it and mandibular neck.

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Stylomandibular ligament
 

It is dense,thick band of deep cervical fascia extends from styloid process to the angle of mandible. Serves as a point of rotation and also limits excessive protrusion of the mandible

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Vascular Supply

 

Arterial blood supply is provided by branches of the external carotid artery, predominately the superficial temporal branch Other branches of the external carotid artery namely: the deep auricular artery, anterior tympanic artery, ascending pharyngeal artery, internal maxillary artery, mesenteric artery

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Nerve supply


Branches of the auriculotemporal nerve with anterior contributions from the masseteric nerve and the posterior deep temporal nerve

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MUSCLE PRODUCING MOVEMENTS

    

Depression- lateral pterygoid mainly Elevation- masster,temporalis,medial petygoid of both sides. Protrusion- lateral and medial pterygoid. Retraction- posterior fibres of temporalis. Lateral or side to side movement- left lateral pterygoid and right medial pterygoid.

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CLINICAL EXAMINATION OF TMJ

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Symmetry of the face should be recorded Look for any deviation of mandible The maximum interincisal opening of mouth should determined Lateral mandibular range of motion is determined by asking the patient to occlude the teeth and then slide the jaw in both directions (normal 10mm) Pretragus palpation- patient is requested to slowly open and close the mouth while doctor bilaterally palpates pretragus depression with index fingers. 30

Intra-auricular palpation is done by inserting small finger into ear canal and pressing anteriorly to detect tenderness, clicking and crepitus.

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The Jaw And Joint Symptoms Should Be Discussed With Patient

   

Does TMJ click or pop on opening or closing? Has the jaw ever locked or dislocated on opening? Has there been limitation in the movement or deviation of the lower jaw on opening? Has the patient experienced pain and dysfunction in other joints of the body?

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Causes for TMJ disordersOpening the mouth too wide Bruxism. Malocclusion Stress- Both physical and psychological stress can produce abnormal pressure on the TMJ disc causing TMJ disorders. Trauma Any injury that results in bleeding into the joints can even cause Ankylosis of the jaw. Arthritis Hypermobility 33

Symptoms associated with TMJ disorders

PRIMARY SYMPTOMS 1. Pain in the joints associated with jaw movements. 2. Intermittent locking episodes. 3. Limited range of vertical mouth opening 4. Facial pain and muscle fatigue 5. Noises in the joints associated with jaw movements (clicking, snapping, crunching, etc.)

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SECONDARY SYMPTOMS 1. Earaches 2. Frequent headaches 3. Neck/shoulder pain 4. Dizziness, disorientation 5. Sensitive teeth 6. Depression

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Classification of temporomandibular disorders

 

Extrinsic disorders Masticatory muscle disorders- Masticatory muscle inflammation - Masticatory muscle spasm Problems resulting from extrinsic trauma- fracture - traumatic arthritis - tendonitis - myositis 36

Intrinsic disorders Trauma- due to - dislocation - intracapsular fracture - extracapsular fracture Internal disc displacement- due to - anterior disc displacement with reduction - anterior disc displacement without reduction Arthritis - rheumatoid arthritis - juvenile rheumatoid arthritis - infectious arthritis


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Ankylosis Developmental defects - condylar agenesis - bifid condyle - condylar hypoplasia - condylar hyperplasia

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Have a look at some temperomandibular disorders


 

Temperomandibular joint Dislocation

It is uncommon and incidence is recorded in 3.1 % cases It can be unilateral or bilateral

Management of the tmj dislocation-

First attention is given to reduce the tension, anxiety and muscle spasm. This is achieved byReassuring the patient Use of sedative drugs Pressure and massage to the area Manipulation without L.A. with L.A. under general anesthesia with muscle relaxants. 40

Myofacial pain

Symptoms Regional pain in area of masseter or temporalis muscles toothache, tension-type headache Fatigue with chewing May have limited mandibular function secondary to pain

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Ankylosis
 

Ankylosis is the stiffening (immobility) or fixation (fusion) of the joint. Classification-true or false ankylosis, - extra articular or intra articular - fibrous or bony - unilateral or bilateral - partial or complete

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False ankylosis may be caused by enlargement of the coronoid process, depressed fracture of the zygomatic arch, scarring from surgery, irradiation, infection, etc. True bilateral congenital ankylosis of the TMJ leads to micrognathia or bird face

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Condylar agenesis

  

Condylar agenesis is the absence of all or portions of the coronoid process,ramus and mandibular body. It associates with congenital syndromes Occurs as a result of trauma, infection or radiation.

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Condylar hypoplasia

 

Condylar hypoplasia may be congenital, but is usually the result of trauma or infection. The most common facial deformity is shortness of the mandible with deviation of the chin towards the affected side.

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Condylar hyperplasia

 

An idiopathic disease characterized by a progressive, unilateral overgrowth of the mandible. The chin is deviated towards the unaffected side.

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NON-SURGICAL TREATMENT
1. Avoid wide opening of the mouth 2. Fabrication and insertion of an intra-oral splint, to relieve the stresses and pressures 3. Physiotherapy. These include exercises, rehabilitation programs, ultra-sound, etc. Friction massage and hot fermentation consists of rubbing or keeping a hot towel Transcutaneous electrical nerve stimulation involves using a device that stimulates the nerve fibers that do not transmit pain. 4. Adjunctive medications anti-inflammatory & muscle relaxants 48

5. Stress Management 6. Correct any discrepancies between the upper and lower jaws. May include adjustment of the dental occlusion, orthodontic treatment, replacement of missing teeth, etc. 7. Injections of local anaesthetic and other medications. 8. Treatment of any underlying systemic disease that could have caused this problem. 9. A person with osteoarthiritis in a temporomandibular joint needs to rest the jaw as much as possible.

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SURGICAL TREATMENT
ARTHROCENTESIS  ARTHOTOMY - gap Arthroplasty - Interpositional arthroplasty - Condylectomy.  ARTHROSCOPY  Artificial replacement of the joint


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REFEERANCENCES
   

B. D. Chaurasia(2005),Human anatomy vol 3, CBS publications, 4th edition. Richard .L. Drake.wayne.wogl(2005),GRAYS ANATOMY,elesvier publications,1st edition. Jeffry .P. Okenson, MANAGEMENT OF TMJ DISORDERS AND OCCLUSION, 5th edition. Anil Govindrao Ghom(2007).Textbook of oral medicine, jaypee publications, 1st edition reprint

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Neelima Anil Malik(2005), Textbook of Oral And Maxillofacial Surgery,jaypee publications,1st edition. I. B. Singh(2005),Textbook Of Human Embryology,jaypee publications,1st edition Richard s. Snell(2008)Clinical Anatomy by Regions,wolters kluwer(india), 8th edition. Diarthrodial - Wikipedia, the free encyclopedia en.wikipedia.org/wiki/Diarthrodial Google images.

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THANK YOU!

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