SEMINAR

TEMPEROMANDIBULAR JOINT DISORDERS

Content
1. Introduction

2. Anatomy

3. Functions

4. Examinations
5. Classification of maxillary sinus disorders

6. Intrinsic disease involving maxillary sinus

7. Extrinsic disease involving maxillary sinus

8. Structures displaced in maxillary sinus

9. References

TEMPEROMANDIBULAR JOINT DISORDERS

Temporomandibular joint (TMJ) is a unique joint in which translatory as well as

rotational movements are possible and where both the ends of bone articulate, in the same
plane, with that of other bone. It is also called as ginglymodiarthrodial type of joint,
 meaning that it has a relatively sliding type of movement between bony surfaces, in
addition to hinge movement, common to diarthodial joint.

ANATOMY OF TMJ --

The TMJ is located between the mandibular fossa (glenoid fossa), the inferior surface of
temporal bone and condylar process of the mandible. It is a synovial type of joint and it is
distinguished from most of the joints by following points.

• Fibrocartilage—articulating surface of the bones is covered by avascular, fibrous connective

tissue, which may contain variable number of cartilage cells. Thus called as fibrocartilage.

• Point of closure—the two articulating surface complex of bone carry teeth, whose shape and
position influence the movement of joint. It is the only joint with rigid end point of closure.

• Articulation—it has bilateral articulation with cranium, so both the joint must function
together.

• TMJ is a complex joint as it has an articular disc interposed between the condyle and the
temporal bone.

NT PROPER Glenoid fossa

• The mandibular condyle articulates at the base of the cranium with the squamous portion of
the temporal bone. This is called as the glenoid fossa.

• This is a continuous surface consisting of three regions:

• The posterior slope to the height of convexity of the articular eminence just anterior to the
glenoid fossa.

• The flattened preglenoid plane continuing anteriorly from the height of eminence.

• Entaglenoid process is continuous with the narrow glenoid plane.

• Posterior to the glenoid fossa, there is a squamous

tympanic fissure, which extends mediolaterally.

• Postglenoid process—the posterior part of the fossa is elevated to form a ridge, the posterior
articular ridge. This ridge increases in height laterally to form the thickened cone shaped
prominence called the postglenoid process, immediately anterior to the external acoustic
meatus.

• Entaglenoid process—the lateral border of the fossa is usually raised to form a narrow crest
joining the articular tubercle in front, with the postglenoid process behind. Medially, the
articular fossa narrows and is bounded by a bony wall, the entaglenoid process.
• Roof—the roof of the glenoid fossa is always thin and even translucent in many skulls. There
is clear evidence that the articular fossa is not a stress bearing functional part of TMJ
articulation.

• Articular eminence—the articular eminence is strongly convex in an antero-posterior direction

and somewhat concave in a transverse direction. The degree of convexity varies, with the
radius of the curvature varying from 5 to 15 mm.

Mandibular Condyle

The articular surface of the mandible is seated on its ovoid condylar process. From the
anterior view, it has medial and lateral projections called poles

• Lateral pole—the lateral pole of condyle is roughened and often bluntly pointed.

• Medial pole—the medial pole is usually rounded and is more prominent than the lateral pole.

• Lateral view—in lateral view, the condyle appears tilted forward at the mandibular neck, with
its articular surface on its anterio-superior aspect. The articular surface thus faces the posterior
slope of the articular eminence, when the jaw is held with teeth in complete occlusion.

• Articular surface—the articular surface continues medially down and around the rounded
medial pole of the condyle. Medial articular surface faces the entaglenoid process of the
temporal bone, when the jaw is held in an occluded position.

• Condyle

• The condyle is about 15 to 20 mm long and 810 mm thick.

• Its long axis lies at right angle with the plane of the ramus.

• The condyle is usually quite convex anteroposteriorly and only slightly convex
mediolaterally.

• The mediolateral convexity is often irregular, with medial and lateral slopes divided by a
more or less prominent anteroposterior ridge.

Articular Disc

• It is composed of dense fibrous connective tissue devoid of any blood vessels or nerve fibers.

• In the sagittal plane, it can be divided into three regions according to thickness. The central
area is the thinnest and is called as intermediate zone. Both anterior and posterior to the
intermediate zone, the disc becomes considerably thicker. The posterior border is generally
slightly thicker than the anterior border.
• From the anterior view, the disc is generally thicker medially than laterally. The precise shape
of the disc is determined by the morphology of the condyle and mandibular fossa. During
movement the disc is somewhat flexible and can adapt to the functional demands of the
articular surface.

• The articular disc is attached posteriorly to an area of loose connective tissue that is highly
vascularized and innervated it is called as retrodiscal tissue. Superiorly, it is bordered by the
lamina of connective tissue, which contains many elastic fibers, the superior retrodiscal
lamina. This gives the disc the necessary freedom of anterior movement. Since this

region consists of two areas, it is called as bilaminar zone.

• The articular disc is attached to the capsular ligament anteriorly, posteriorly as well as
medially and laterally. This divides the joint into two distinct cavities; the upper or superior
cavity which is bordered by the mandibular fossa, superior surface of the disc and the lower or
inferior cavity are, which is by the mandibular condyle and inferior surface of the disc.

• The internal surface of the cavity is surrounded by specialized endothelial cells that form the
synovial lining. This lining along with a specialized synovial lining located at the anterior
border of the retrodiscal tissue produce the synovial fluid, which fills both the joint cavities.
Thus, TMJ is referred to as a synovial joint.

LIGAMENTOUS STRUCTURES

Functional Ligament

• Collateral ligaments

• The collateral ligament attaches the medial and lateral borders of the articular disc to the poles
of the condyle. It is commonly called as distal ligament and is two in number.

• The medial one attaches the medial edge of the disc to the medial pole of the condyle and the
lateral one attaches to the lateral edge of the disc to the lateral pole of the condyle.

• These ligaments are responsible for dividing the joint mediolaterally into the superior and
inferior joint cavities.

• Their function is to restrict the movement of the disc away from the condyle, as it glides
anteriorly and posteriorly. The reason for it is that they contain collagenous connective tissue
fibers which cannot be stretched. They have a vascular supply and are innervated. The
innervations provide information regarding the joint position and movement.

• Capsular ligament

• The entire TMJ is surrounded and encompassed by the capsular ligament.

 The fibers of the capsular ligament are attached superiorly to the temporal–bone, along
the border of the articular surface of the mandibular fossa and articular eminence.
Inferiorly, the fibers are attached to the neck of the condyle.

• It acts to resist any medial, lateral or inferior forces that tend to separate or dislocate the
articular surface. Another function is to encompass the joint, thus retaining the synovial
fluid.

• It is well innervated and provides proprioceptive feedback regarding the position and the
movement of joint.

• Temporomandibular ligament

• It is also called as lateral ligament as it is located laterally to the joint.

• It is composed of two parts, an outer oblique portion and an inner horizontal portion. The
outer portion extends from the outer surface of the articular tubercle and zygomatic process,
postern-inferiorly to the outer surface of the condylar neck.

• The inner horizontal portion extends from the outer surface of the articular tubercle and
zygomatic process posteriorly and horizontally to the lateral pole of the condyle and
posterior part of the articular disc.

• The oblique portion of the ligament resists excessive dropping of the condyle and therefore
acts to limit the extent of mouth opening.

Accessory Ligaments

• Sphenomandibular ligament

• It is attached to the spine of the sphenoid bone and extends downwards and laterally to the
small bony prominence on the medial surface of the ramus of the mandible, called the
lingula.

• It does not have any significant effect on mandibular movement.

• Stylomandibular ligament

• It arises from the styloid process and extends downward and forward to the angle and
posterior border of the ramus of the mandible.

• It becomes taut when mandible is protruded but is most relaxed when the mandible is
opened.

• Its function is to limit the excessive protrusive movements of mandible.

• Mandibular malleolar ligament

• Actually the mandibular malleolar ligament consists of fibroelastic tissue with some liga-
mentous qualities.

• It originates from the neck and anterior process of malleus and is inserted on the medio-
posterior superior part of the capsule, interarticular disc and sphenomandibular ligament.

SYNOVIAL FLUID

• The passive volume of upper and lower joint cavity is 1.2 and 0.8 ml respectively.

• A small amount of a clear, straw colored viscous fluid is found in the articular spaces, which is
known as synovial fluid.

• It is secreted by synovial membrane lining the articular disc, the capsule and also by
retrodiscal tissue lining.

• Synovial fluid is characterized by well defined physical properties of viscosity, elasticity and
plasticity.

• It contains small population of varying cell type such as monocytes, lymphocytes, free
synovial cells and occasionally polymorphonuclear leukocytes.

• The chemical composition of synovial fluid indicates that it is dialysate of plasma, with some
added protein and mucin.

• When the TMJ movements are reduced or restricted due to some reasons, the synovial fluid
becomes viscid; its lubricating qualities are seriously impaired, a condition clinically referred
to as gelation.

• Functions of synovial fluid

• It is a lubricant and reduces the mechanical friction between the condyle and the articular
disc and the mandibular fossa and articular disc.

• It is also a nutritional fluid for the vascular tissues covering the condyle and the articular
tubercle and also for the disc. It is elaborated by diffusion from the rich capillary network
of the synovial membrane, augmented by mucin secreted by the synovial cells.

• It provides liquid environment for the joint surface.

• Synovial fluid is also considered to be responsible for the removal of entraneosis material
shed into the joint cavity. The intimate cells have been demonstrated to possess marked
phagocytic properties.
 JOINT INNERVATIONS

Vascular supply—it comes from the branches of the superficial temporal arteries, deep
auricular arteries, anterior tympanic arteries and ascending pharyngeal arteries.

Nerve supply—it is innervated by the branches of auriculotemporal nerve, masseteric

nerve and the posterior deep temporal nerve, which are branches of the mandibular
portion of the trigeminal nerve.

FUNCTIONAL MOVEMENT OF TMJ

Elevation (Jaw Closing)

• The mandibular elevators include the coordinated functions of masseter, temporal and medial
pterygoid muscle of both the sides.

• Temporalis maintains the physiological rest position of the mandible.

• The posterior fibers of temporalis retract the head of mandible while closing the mouth.

Depression

• The depression of mandible includes the activity of the lateral pterygoid and the suprahyoid
muscles.

• The inferior head of the lateral pterygoid is the main muscle used for depressing the mandible.

• The superior head of the lateral pterygoid pulls the articular disc forward, creating the glenoid
joint activity.

• The suprahyoid group of muscles also act in mandibular movement; by initiating and assisting
opening of the jaw.

• The lateral pterygoid muscle has a major role, particularly when the mouth is opened wide or
against resistance by the diagrastic, geniohyoid and mylohyoid muscle.

• The infrahyoid group of muscles participates in the activity by fixing the hyoid group to exert
a downward pull on the mandible.

Protrusion

• It is performed by the medial and lateral pterygoid muscle of both the sides.

Retrusion

• It is performed by the posterior fibers of temporalis and digastric muscle.

Lateral Excursive Movements

• In this type of movement, the medial pterygoid and lateral pterygoid of each side, act alter-
nately.

If the mandible is moved to the right side the medial pterygoid of right side and the
lateral pterygoid of left side act simultaneously.

Disorders of the TMJ are abnormalities that interfere with the normal form and function of the
joint.

These disorders include dysfunction of the articular disk and associated ligaments, muscles, joint
arthritides, inflammatory lesions, neoplasms and growth or developmental abnormalities.

 ETIOLOGY

• Malocclusion,

• Systemic diseases,

• Predisposition

• Cervical dysfunction,

• Postural factors,

• Trauma,

• Faulty habits,

• Developmental abnormalities

• Psychologic factors

 Malocclusion
• A faulty occlusion is probably the most common cause of TMJ disorders

• A faulty tooth position or cuspal interferences in closing or lateral movements can create
muscle imbalances by changing the resting length and function of the masticatory muscles

• Loss of vertical dimension (overclosure) often causes muscle dysfunction by permitting

overcontraction of the closing masticatory muscles

• Unreplaced lost posterior teeth or faulty dental restorations

 • Clicking and locking disorders caused by disc derangements show a very definite relation to
malocclusion

 Systemic diseases
• Immune system disorders such as rheumatoid arthritis, juvenile rheumatoid arthritis
(JRA),psoriatic arthritis, ankylosing spondylitis, and lupus erythematosus, - TMJ
inflammations

• Osteoarthritis

• Various viruses can also cause TMJ inflammation

• infection in the bloodstream easily gains access to the joint

• . Scleroderma can cause limited jaw opening.

 Predisposition
• Genetic predisposition

 Cervical dysfunction
• A change in head position caused by the cervical muscles changes mandibular position

 Postural factors
• Normal- the bottom of the ear lobe is in line with the center of the lateral portion of the
shoulder and with the hip joint

• This abnormal position affects the TMJ and surrounding areas

 Trauma
• Trauma has greater impact on intracapsular disorder than muscular disorder

• Macrotrauma – any sudden force that produce strctural alterations eg direct blow to the face

• Microtrauma- any small force that is repeatedly applied to the structure over a long period of
time. Eg bruxism, clenching

• TMJ synovitis, masticatory muscle dysfunction, and disc dysfunction

• Prolonged or excessive jaw openings, such as occur during some dental procedures,
commonly cause TMJ inflammation or disc dislocation
 Faulty habits
• Parafunctional activity- diurnal, nocturnal

• Diurnal – (day time)clenching grinding, cheek or tnge biting thumb sucking, biting pencils
holding object under chin, singing or gum chewing

• Nocturnal- buxism

 Developmental abnormalities
• Abnormal tooth development or a growth variation of the condyle, coronoid process, or other
part of the mandible affects the TMJ.

• Psychologic factors and tension

 EPIDEMOLOGY
• 65- 80%- TMDs

• 12%- chronic symptoms

• 5-7%-sever – require t/t

• Common in 20-40yrs & more frequently affect female.

 Summary of Symptoms:
• History of trauma, blow to jaw, MVA, dental malocclusions

• Pain and tenderness of the TMJ

• Head and/or ear pain

• Sore and stiff jaw muscles

• Locking of the jaw in a shut or open position

• Frequent headaches and/or neck aches

• Pain that worsens when teeth are clenched

• Grinding teeth at night

• Pain that worsens with stress

• Pain with opening of your mouth

 • Teeth that meet differently from time to time

• Pain while chewing

CLASSIFICATION

 First Classification by Weldon Bell

A Masticatory muscle disorders

Protective muscle splinting
Masticatory muscle spasm (MPD) Masticatory muscle inflammation (Myositis)
B. Derangement of TMJ Incoordination
Anterior disk displacement with reduction (clicking)
• Anterior disk displacement without reduction (mechanical restriction, closed lock)
C. Extrinsic trauma
• Traumatic arthritis
• Dislocation
• Fracture
• Internal disk derangement
• Myositis
• Myospasm
• Tendonitis
D.Degenerative Joint Disease
• Non-inflammatory phase (Arthrosis)
• Inflammatory phase (Osteoarthritis)
E. Inflammatory Joint Disease
• Rheumatoid arthritis
• Infective arth ritis Metabolic arthritis
F. Chronic Mandibular Hypomobility
• Ankylosis (Fibrous and Osseous) Fibrosis of articular capsule Contracture of
elevator muscles - Myostatic contracture
- Myofibrotic contracture
• Internal disk derangement (Closed lock)
G.Growth Disorders of the Joint
• Developmental disorders
• Acquired disorders
• Neoplastic disorders

 (adapted from Clark GT et al) 1989

Diagnostic Category Diagnosis

  Muscles & facial disorders- Myalgia, muscle contracture,

splinting, hypertrophy, spasm,

dyskinesia, forceful jaw closure habit, myositis (bruxism)

 TMJ disorders - Disk condyle incoordination, osteoarthritis, disk condyle

restriction, inflammatory polyarthritis, open dislocation, traumatic articular disease, arthralgia

 Disorders of mandibular mobility - Ankylosis, adhesions(intracapsular), fibrosis of muscle

tissue, coronoid elongation-hypermobility of TMJ

 Disorders of maxillomandibular growth -

Masticatory muscle hypertrophy/atrophy, neoplasia (muscle, maxillomandibular or

condylar), maxillomandibular or condylar

hypo p I asia/hype rp I as i a

 (adapted from McNeill) AAOP

Diagnostic Category Diagnosis

• Cranial bones (including Congenital and developmental the mandible) disorders: aplasia,
hypoplasia, hyperplasia, dysplasia

 (e.g. 1st and 2nd branchial arch anomalies, hemifacial microsomia, Pierre Robin
syndrome, Treacher Collins syndrome, condylar hyperplasia, prognathism,
fibrous dysplasia)

• Temperomadibular Joint Disorders Deviation in form Disk displacement (with

reduction; without reduction) Dislocation Inflammatory conditions (synovitis, capsulitis)

o Arthritides (osteoarthrosis polyarth ritides) Ankylosis (fibrous, bony) Neoplasia

Masticatory-Muscle Disorders Myofacial pain Myositis, Spasm , Protective splinting Contracture