Seminar On

TemporoMandibular Joint and Its Movements

Index 1. Introduction 2. Development of TMJ 3. Anatomy of TMJ 4. Blood supply 5. Nerve supply 6. Postures and movements 7. Applied anatomy of TMJ 8. Surgical anatomical consideration 9. Surgical approaches to mandibular condyle and TMJ

Presented by
Dr Madhu Verma Department of Oral and Maxillofacial Surgery, Pb.Govt.Dental College and Hospital Amritsar

Introduction
The sites of junctions between bones are known as articulations or joints. It plays important role in bone growth phenomenon, initially during development and movement of body parts and their function during adult life. The joints can be divided functionally into 2 typesa. Movable joint (Diarthroses) b. Immovable joint (Synarthroses) Fibrous connective tissue-Syndesmosis Cartilage Bone -Synchondrosis -Synostosis

The TMJs are bilateral, diarthrodial, ginglymoid, and synovial and freely movable joints. TMJ is one of the most complex joints in the body and is the area in which the mandible articulates with the cranium. it provides for the hinge movement in one plane and therefore can be considered a ginglymoid joint. At the same time it also provides for the gliding movements, which classifies it as an arthroidal joint. Thus the TMJ has been technically considered a ginglymoarthroidal joint. The TMJ is also classified as a compound joint. By definition, a compound joint requires the presence of at least three bones, yet the TMJ is made up of only two bones. Functionally, the articular disc serves as a nonossified bone that permits the complex movements of the joint. Because the articular disc functions as a third bone, the craniomandibular articulation is considered a compound joint. The fundamental design of synovial joint is an adaption that promotes to free and forceful movement of the body parts. Consequently the bearing surfaces of the opposing bones are padded with smooth, slippery, highly resilient, hyaline cartilage. The articulating parts are connected by a flexible capsular sleeve, which completely encloses the joint cavity to contain its lubricating fluid. Development of TMJ The TMJ is secondary in development, both in its evolutionary and embryological history. The joint between the malleus and incus that develops

at the dorsal end of Meckels cartilage is phylogentically the primary jaw joint. With the development of middle ear chamber, this primary Meckels joint loses its association with mandible and reflects the adaptation of the bones of the primitive joint. The mammalian temporomandibular joint develops as an entirely new and separate jaw joint mechanism. It developes from widely separated temporal and condylar processes that grow towards each other. Between 10-12 weeks- secondary cartilages of condyle grows towards temporal bone. During 12th week i.u. 2 clefts develop in interposed vascular fibrous connective tissue and forming two joint cavities. After cavitation synovial membrane invasion occurs. At 22nd week i.u. - petrous and tympanic portions of the temporal bone fuse. At birth mandibular fossa is practically flat; there is no articular tubercle. Its only after eruption of deciduous dentition, articular tubercle begins and becomes prominent and does not complete its development until 12 th yr of life. Anatomy of temporomandibular joint The components of the TMJ are presented in the following sequenceMandibular component The articular part of mandible is ovoid condylar process seated atop narrower mandibular neck. The condyle is usually strongly convex anteroposteriorly and mildly convex mediolaterly, convexity increase towards the medial portion(58%). 25% of the condyles may be flat superiorly and approx. 12% are pointed or angular in shape and 3% are bulbous are rounded in shape. The condyle is broad laterally and narrower medially. Lateral pole- Roughened, bluntly pointed & projects only moderaly from plane of ramus. Medial pole-Often rounded, extend strongly inward from the plane of ramus. In lateral view condyle appears tilted forward on the mandibular neck.

The articular surface thus faces the posterior slope of articular eminence when jaw is held in complete occlusion. The articular surface continues medially down, faces entoglenoid process of temporal bone. The condyle is about 15 to 20mm from side to side & about 8 to 10mm from front to back. Its long axis lies at a right angle with the plane of the ramus & thus does not lies in frontal plane. Thus, if long axes of two condyles extended medially they meet approximately at basion at the anterior limit of foramen magnum, forming angle of 145-160 degree open towards front. Cranial component It is situated on the inferior surface of temporal squama. To elaborate this part, first we must understand distinction between articular tubercle and articular eminenceArticular tubercle Non-articulating, small, rough bony knob raised on outer end of anterior root of zygomatic process of temporal bone. It serves as attachment for collateral ligaments of the joint. Articular eminence: Its is entire transverse bony bar, forms anterior root of zygoma.It is strongly convex in anteroposterior direction & somewhat concave in transverse direction, the radius of curvature varies from 5-15mm. The preglenoid plane is slightly hollowed almost horizontal articular surface continuing anteriorly from the height of eminence. The pressure-bearing surface consists of three regions1. Posterior slope to height of convexity of articular eminence, just anterior to glenoid fossa. 2. Flattening preglenoid plane continuing anteriorly from height of eminence.

3. Enteglenoid process continuous with narrow medial glenoid plane on its inferior edge. The boundary between squama and temporal bone is formed byLaterally-by tympanosqamosal suture Medially-Tegmen tympani protrude between tympanic bone and temporal squama, dividing simple fissure into anterior petrosqamosal & posterior petrotympanic fissure. Posterior part of the joint fossa is elevated to form cone shaped prominence called postglenoid process. The roof of mandibular fossa separating it from the middle cranial fossa, is always thin & thus is not functionally stress bearing part of the craniomandibular joint. The function is normally between the condyle and disc on one hand, and disc and articular fossa on other side. In cross section, the fossa and the eminence form a lazy S Articular coverings It is the smooth, slippery, pressure bearing tissue carpenting the surface of bones. It is essentially a bed of tough collagen fibers bound by special glycoproteins. On condyle - thickest on anteroposterior convexity & Medial (0.8mm)> Lateral (0.37mm) On temporal component- thickest along slope & crest of eminence and preglenoid plane. Eminence Medial<Lateral 0.45mm 0.49mm Plane Medial<Lateral 0.34mm 0.36mm

Internal structure of fibrocartilage On the condyle, cartilage beings a highly active growth site in mandible of newborn. Thus, condyle of child has a plate of proliferating hyaline cartilage underlying its fibrous covering. When growth is completed, condylar disc is arranged in successive four layers from the articular surface to the cortical bone. 1. Articular - Surface layer composed of thick, strong, tightly packed collagen fiber rather than hyaline cartilage, which run parallel to the surface. It is thought that this fibrous connective tissue affords the joint several advantages over hyaline cartilage. It is generally less susceptible than hyaline cartilage to the effects of aging. It has a much better ability to repair than the hyaline cartilage. The importance of these two factors is significant in TMJ function and dysfunction. 2. Proliferative zone- A narrow transitional layer lies below. This is made up of less compactly packed fibers slanting obliquely up to the surface. It is mainly cellular. It is in this area that undifferentiated mesenchymal tissue is found which is responsible for the proliferation of of articular cartilage in response to functional demands. 3. Fibrocartilaginous zone- Below the oblique layer a zone of strong vertical fibers is found which may contain scattered cartilage cells between fibers. 4. Calcified cartilage zone - The vertical fibers third zone are anchored in the deepest layer, which is, calcified cartilage lying on the subjacent cortical bone. This zone is made up of chondrocytes and chondroblasts distributed throughout the cartilage. This surface provides an active site for remodeling activity. 5. On cranial component similar gradation of layers in seen.

Significance the articular cartilage is composed of chondrocytes and intercellular matrix. Proteoglycan aggregates that make up a great protein of the matrix are very hydrophilic and tend to bind water. So the matrix expands and the tension in the collagen fibrils counteracts the swelling pressure of the proteoglycan aggregates. The external pressure resulting from the joint loading is in equilibrium with the internal pressure of the articular cartilage. As the joint loading increases, tissue fluid flows outward until a new equilibrium is achieved. As loading is decreased, fluid is reabsorbed and the tissue regains its original volume. Articular Disc The articular disc is a roughly oval, firm, fibrous plate with its long axis oriented transversely. It lies in the foremost part of the joint space and divides it into upper and lower joint space. The volume of upper space is around 1.2ml and lower space is around 0.9ml. The articular disc is for the most part devoid of any blood vessel or nerve fibres. The extreme periphery of the disc, however, is slightly innervated. In the normal joint the articular surface of the condyle is located on the intermediate zone of the disc. It is thick all around its perimeter, especially around its posterior and anterior perimeter and considerably thinner in its central third. Also the disc is generally thicker medially than laterally. Rees reported that the shape of the articular disc is like a school boy or jockeys cap. Anteriorly- 2.0mm Central segment- 1.0mm Posteriorly -3.0mm During the movement the disc is somewhat flexible and can adapt to the functional demands of the articular surfaces. Flexibility and adaptability do not imply that the morphology of the disc is reversibly altered during function, however. The disc maintains its morphology unless destructive forces or structural changes occur in the joint.

The disc is attached all around to the joint capsule except that strong straps fix the disc directly to the medial and lateral condylar poles. Attachment to the capsule at the front is made directly by a forward projection of the disc. It is composed of transverse bundles of coarse fibers forming a band, thus anterior plate is designed for bearing pressure. Attachment at back is extended in two separate layers of fibers, so also has been called as the bilaminar zone. They emerge from the disc to fuse with the capsule above and below, sandwitching an expansible, loosely textured filling of blood vessels (venous plexus) called the vascular knee (genu vasculosa) and nerves in-between known as the retrodiscal tissue. So posterior pad is not meant for bearing pressure. Upper stratum is laced with elastic fibres and must exert retractile effect on the disc under certain conditions. Articular capsule: It is thin sleeve of tissue investing the joint completely. It extends from the circumference of the cranial articular surface to the neck of the mandible. In doing so it encloses two separate joint cavities, one above and one below the disc. On the cranial base it is attached from the articular tubercle along the lateral rim of mandibular fossa to the post glenoid process and turns medially along with the ridge extending from the process to the sphenoid spine. The capsule is not merely inserted to the crest of the process and the ridge, but is attached to their entire anterior surface. Opposite the spine it turns forward along the medial margin of the temporal bone at its suture with greater wing of sphenoid bone then it arcs forwardly anteriorly than back to articular tubercle. The outline of attachment on the mandibular neck lies a short distance below the edge of the articular surface in front and a considerable distance below the articular margin behind. Medial attachment to the condyle dips low beneath the medial pole, but laterally it sis attached to the lateral condylar pole.

Synovial membrane is a fragile but flexible layer of flattened endothelial like cell embedded in an amorphous matrix resting on a highly vascular bed. Its major functions are apparently to produce the fluid lubricating the joint. Repair the wear and tear. Drain the detritus accumulating from normal function. Synovial fluid lubricates the articular surfaces by way of two mechanisms. The first is called boundary lubrication, which occurs when the joint is moved and the synovial fluid is forced from one area of the cavity into another. The synovial fluid located in the border or recess areas is forced on the articular surface, thus providing lubrication. Boundary lubrication prevents friction in the moving joint and is the primary mechanism of joint lubrication. A second lubricating mechanism is called weeping lubrication. this refers to the ability of the articular surfaces to absorb a small amount of synovial fluid.during function of a joint,forces are created between the articular surfaces. These forces drive a small amount of synovial fluif in and out of articular surfaces. This is the mechanism by which metabolic exchange occurs. Under compressive forces, a small amount of synovial fluid is released which act as lubricant to prevent the sticking. This mechanism eliminates friction only in compressed but not moving joint. Thus prolonged compressive forces to the articular surfaces will exhaust this supply. Articular ligament: The ligaments of the joint are made up of collagenous connective tissue that has particular lengths. They do not stretch. However if extensive forces are applied, whether suddenly or over a prolonged period of time, the ligaments can be elongated compromising the function. Ligaments do not enter actively into the joint function; rather they act as passive restraining devices to limit and restrict border movements. Three functional ligaments support the TMJ 1. Thecapsular ligament 2. The collateral ligament

3. The temporomandibular ligament There are also two accessory ligaments 1. The sphenomandibular ligament 2. the stylomandibular ligament Collateral ligaments They are also called as discal ligaments and attach the medial and lateral borders of the articular disc to the poles of the condyle. They are medial and lateral discal ligaments, medial one attaching medial pole of the condyle to the medial edge of the disc and lateral one attaching the lateral pole to the lateral edge of the disc. They divide the joint space into upper and lower compartments. These are responsible for the hinging movement of the TMJ between disc and the condyle. Capsular ligament The entire TMJ capsule is surrounded by capsular ligament the fibres of which are attached superiorly to the temporal bone along the border of articular surfaces of mandibular fossa and the articular eminence and inferiorly to the neck of the condyle. They resist the medial, lateral or inferior forces that tend to dislocate TMJ. Temporomandibular ligament The temporomandibular ligaments on each side of skull are designed in two distinct layersa) Wide outer or superfacial layer b) Narrow inner or deep band The outer usually fan shaped, portion arises broadly from the outer surface of the articular tubercle. This area of the articular tubercle is roughened and raised for its attachment. It runs obliquely downward and backward to insert at the back of mandibular neck behind and below the lateral condylar pole. The inner layer arises from crest of articular tubercle. It runs horizontally back as a flap strop to the lateral pole of condyle.

The unique feature of the TM ligament, which limits rotational opening, is found in humans only. Slippage of condyle medially is prevented by entoglenoid process and laterally by collateral ligaments. Two additional bands of fibrous tissue are usually described as accessory ligament of the jaws: 1) Sphenomandibular ligament 2) Stylomandibular ligament Sphenomandibular ligament: is a ramanent of Meckels cartilage. It arises from the angular spine of sphenoid bone and petrotympanic fissure then run downward and outward to insert on the lingual of mandible. The ligament spread fan like to extend its insertion posteriorly below the mandibular foramen and lower limit of groove running down the mandibular neck. It remains passive during jaw movements. It is important landmark during surgery as maxillary artery and auriculotemporal nerve lies between it and the mandibular neck. Stylomandibular ligament: is a specialized band of deep cervical fascia, which stretches from the apex of the styloid process to the angle and posterior border of the mandible ramus. It is considered as accessory and its functional status is uncertain. It remains lax when jaw is closed and slackens when mouth is opened. It acts as a landmark for ligating the external carotid artery in the retromandibular fossa. Blood supply of TMJ The vascular supply of the joint is profuse. Every named vessel with in 3cm of radius contributes branches to the joint capsule. Major arterial contribution comes from the large superficial temporal from the posterior, the middle meningeal artery from the anterior and and internal maxillary artery from the inferior. Other important arteries are deep auricular, anterior tympanic, ascending pharyngeal, smaller posterior deep temporal, massetric and lateral pterygoid terminals anteriorly. The condyle receives its vascular supply through its marrow spaces by

the way of the inferior alveolar artery and by the way of feeder vessels that directly enter into the condylar head. The venous pattern is more diffuse forming a plentiful plexus all around the capsule. Posteriorly, the retrodiscal pad is copiously riddled with venous channels. These venous spaces fill and empty as condyle rocks rhymically forward and backward. Pterygoid plexus drain into the maxillary vein. Branching of vessels becomes prolific as they penetrate the capsule, forming capillary twigs hugging the thick rim of the avascular fibrous disc. Nerve Supply of TMJ: The mandibular nerve, the third and major decision of the fifth cranial nerve innervates the jaw joint. Three branches from the mandibular are found sending terminals to the joint capsule. The largest is the auriculotemporal nerve, which supplies the posterior, medial and lateral parts of the joint. Articular disc and articular coverings are non-innervated except where it attaches to bone or superior belly of lateral pterygoid. The free nerve endings are found anywhere in the joint capsule. Ruffinies like ending are found in the lateral part of the capsule. In the outer layers of the joint ligament end organs are found that resemble Golgi tendons and modified Pacini corpuscles like those in other joints the body. Hiltons law - the nerve, which supplies a joint, also innervates the muscles that move it. This is well demonstrated by TMJ. Relations of TMJ Superficial: Skin, superficial fascia and the branches of the facial nerve Auriculotemporal nerve. Superficial temporal artery. Glenoid lobe of parotid gland. Superior: Roof of mandibular fossa Tympanic cavity

Chorda tympani nerve and anterior ligament of malleus Inferior: Parotid gland Lower head of lateral pterygoid muscle Numerous venous channels and branches from the pterygoid plexus drain into the maxillary vein. Anterior: Lateral pterygoid muscle Masseteric and deep temporal nerves Posterior: Parotid gland Auriculotemporal nerve, close relation to superficial temporal and transverse facial artery Styloid process Medial: Medial capsule attached to the squamotympanic fissure and is continuous with ant. Ligament of malleus Spine of sphenoid Chordatympani- groove on the medial side of the spine of sphenoid Strs of middle and inner ear and auditory tube Directly medial to the joint within petrous temporal bone lies carotid canal containing internal carotid artery. Biomechanics of TMJ The function of TMJ can be divided into two distinct systems: 1. One joint system is the tissues that surround the inferior synovial cavity called the condyle-disc complex responsible for rotational movements of the TMJ. 2. The second system is made up of the condyle-disc complex functioning against the mandibular fossa i.e. superior joint space.

The articular disc has been referred to as a meniscus. However it is not a meniscus at all. By definition a meniscus is a wedge-shaped crescent of fibrocartilage attached to one side to the articular capsule and unattached on the other side, extending freely into the joint spaces. A meniscus doesnt divide a joint cavity, isolating the synovial fluid, nor does it serve as a determinent of joint movement. In TMJ the disc functions as a true articular surface in both joint systems and is therefore more accurately termed an articular disc. Postures and Movements:
Rest Postures:

It is the position of mandible when all the mandibular musculature is at rest. It is consistent habitual or repeatable posture of the mandible. The teeth are not in contact, the space in-between is known as free way space, which normally measures from 2mm to 5mm. The muscles are never totally atonal. The residual tension of muscle is known as resting tonus. It is essential for giving rest to soft tissue such as TMJ ligaments, mandibular musculature. It also maintains position of mandible against gravity. To achieve this subject must stand or sit at ease in upright posture with head held so that gaze is towards horizon. It is the posture in which condyle stop at their most retrudable limit when the teeth are barely free of occlusion. The limit is determind by length of tensed inner bands of TMJ ligament. In this posture the condyle press against the spongy retrodiskal pad in the articular fossa. The hinge movement rotates around a common transverse axis that runs through the approxiamate centers of the condyle. In this simple hinge swing of the mandible, the incisal point of the lower centrals describes a short arc. The location of hinge posture is said to be useful in certain clinical procedure. It specifies that the normal resting posture of the condyles must be anterior to the hinge posture because latter is a strained position. Centric occlusal posture: Centric occlusion expresses a concept of normal mandibular posture in which the dentition is occluded with all teeth fully interdigitated and with all the kinetic component of oral apparatus in harmonious balance. The condyles are rotated

slightly backward from the resting posture. Ideally this is the relation the mandible should come to when head and neck are in upright posture and the jaw is suddenly snapped shut. This condition is most likely to be found in a healthy young adult. Mandible can be retruded from this position for about 0.5mm to 1.0mm. Therefore the ability to shift the mandible back from centric occlusion posture is at least one sign of a normally balanced oral apparatus. Sometimes it is assumed same as hinge position but it is contradictory as hinge position is extreme position. Protrusive Occlusal Posture: In protrusive occlusion the incisal edges of upper central incisors are in contact with incisal edges of lower four incisors with all the posterior teeth out of acclusion. Condyles are rotated slightly forward from centric position and moved downward and forward to a position on or near the peak of the articular eminence. Lateral Occlusion Posture: In lateral occlusion the upper and lower posterior teeth on the ipsilateral side are in contact along the line of buccal and lingual cusps and on contralateral side the teeth are out of contact normally. Mandibular Movements and Muscle Activity: There are only two kinds of movements in the TMJ, which result in various mandibular positions such as protrusive, retrusive, occlusion, opening and closing and lateral position. These basic movements are:1) Rotation: Rotation is a motion in which moving body turns around an axis so that some points of the body have at any instant one direction of motion while other points have an opposite direction, according to latest concept mandible rotates around a common transverse axis passing though the articular eminences. It occurs in the lower joint cavity. 2) Translation:

It is defined as a motion in which all points of a moving body have at any instant the same velocity and direction of motion, in other words it is a bodily movement of an object. It occurs in the superior joint cavity.

3) Opening Movement: This movement is brought about by depressor action of the digastric and mylohyoid muscles in conjuction with contraction of the inferior head of the lateral pterygoid muscles. When the mandible is lowered the condyle rotates forward as disc and the condyle travel downward and forward around the articular eminences and on the preglenoid planes, the lower compartments of both sides of the joint acts as a common hinge. The hinge action swing around a common transverse axis that runs approximately through the centre of both condyles. Maximum mouth opening is around 50-60mm, dending on age and size of individual. An arbitrary lower limit for the normal is 40 mm. 4) Closing Movement: Elevators muscles accomplish this. Elevation of mandible without contact or resistance is brought about by contraction of masseter and medial pterygoid muscles. No activity is seen in temporalis. Elevation against resistance is affected by the temporalis, masseter and medial pterygoid muscle. Maximum closing is also aided by contraction of facial and neck muscles. During closing of mandible condyles rotate backward and upward around articular eminences along their posterior slopes. 5) Protrusion and Retrusion: Protrusion of mandible without occlusal contact results from contraction of lateral and medial pterygoid muscles and of masseter and suprahyoid muscle group. In forward projection of mandible, the disc and condyle slide downward along the slope of articular eminences, around the

emenential crests and ontowards preglenoid planes. As the movement progresses the condyle precede the discs, pulling the disc along with them by their attachments to the condylar poles. Maximum protrusive movement is aboput 8-11 mm depending upon the size of subject and skull morphology. Voluntary retrusion of mandible with mouth closed is brought about by the contraction of posterior fibers of temporalis muscle and by suprahyoid and infrahynoid muscles. In mandibular retrusion condyle travels backward and upward. Lateral pterygoid muscles attached to disc so that condylar movement precedes the disc. This prevents discs from being trapped behind the condyles so that they come again to rest normally on anterior condylar surfaces. Maximum voluntary retrusive movement of the mandible is about 1mm although 2-3 mm may be observed infrequently. 6) Lateral Movements: Lateral movement toward right side with or without occlusal contact is brought about by the posterior fibers of temporalis of the same side. Latreal movement right side against resistance is brought about by posterior fibers of temporalis of same side ipsilateral masseter and medial pterygoids. Lateral movement to the left side from retruded right side with or without resistance is caused by the contraction of contralateral medial pterygoid and masseter muscle of right side. Thus the lateral movement of jaw is achieved by ipsilateral contraction of posterior and middle fibers of temporalis muscle and by contralateral contraction of lateral and medial pterygoid muscles and anterior fibers of temporalis. In lateral movement, disc and condyle slide downward, forward and medially toward the deviation side but disc and condyle of opposing side do not travel far from their stating position on the slope of eminence. The

side to which the mandible is deviating is known as working side and opposite side in known as balancing side. In this side the condyle rotates slightly downward and outward in a short arch around a vertical axis somewhere behind the condyle. This rotates slightly downward and outward in a short arch around a vertical axis somewhere behind the condyle. This rotates the lateral pole of the condyle posteriorly till it pools the inner, horizontal band of TM ligament taut. At the same time, on the translating side the lateral pterygoid becomes more and more transversely oriented as the condyle moves forward the level of muscle origin. This combination of tensed ligament and medially directed muscle vector on the opposite side causes a short bodily shift of the mandible to the deviating side. This is called Bennetts shift or Bennetts movements. It is about 1-1.5mm Maximum lateral movement of mandible is about 10 to 12 mm. Chewing movements during normal function involve complex neuromuscular pattern originating in part in a pattern generator in the brain stem and modified by the influence from the higher center. The mean of vertical dimension of chewing cycle are between 16-20 mm and between 3-5mm for lateral movement. Average duration of chewing cycle varies between 0.6 to 1 second depending upon the type of food. Most important muscles are masseter and medial pterygoid. In chewing cycle lateral pterygoid are bilaterally active, both in alternating with and overlapping the elevating musculature. Distinctive features of TMJ: 1. Articular surfaces of TMJ are not covered by a hyaline cartilage, but by an avascular fibrocartilage and this is because of membraneous ossification by which mandible develops. Chewing movement:

2.

The mandible connects the right and the left articulations, the

movements are coupled. The individual movement of one articulation directly affects the other. 3. Mandible is stabilized by three functionally linked articulations- the dentition and the two TMJs . Any discrepancy of the occlusion will affect the movements of TMJ. 4. 5. 6. 7. The function of this unique joint is also dependent on delicate The TMJ is the only joint to have a rigid end point of closure, Functionally, cervical spine, the TMJ and the occlusion of the teeth The joint functions as a regional growth center and helps in the neuromuscular balance. produced as a result of teeth contact. are interrelated. Abnormalty of any these can affect the function. development of the mandible and middle third of the face, in response to the changes in the functional matrix of surrounding muscles and the soft tissues. The clinician must recognize dissimilarities between TMJ and other articulations in contemplating corrective or replacement surgery. The functional stresses on the TMJ are more subtle than any other joints, but they can be easily modified by extraneous factors. Reconstruction of many other articulations is impossible with anything but alloplasts. But it is not true with TMJ. The TMJ has more intimate proximity to vital structures than does any other articulation. Applied Anatomy of TMJ Dislocation of mandible: During excessive opening of the mouth, the head of the mandible of one or both sides may slip anteriorly into the infratemporal fossa as a result of which there is inability to close the mouth. Reduction is done by depressing the jaw with the thumbs placed on the last molar teeth, and at the same time elevating the chin.

Derangement of articular disk may result from any injury, like overclosure or malocclusion.This give rise to clicking or pain during movements of the jaw.

In about 18% of the population the mandible deviates on opening and in almost 86% of this group deviation is to the left.In about 35% of population the temporomandibular joint produces sound in opening movements.These points display palpable irregularities and produce popping and clicking noises.However the use of a stethoscope reveals that about 65% of TMJ produce these sounds. This feature therefore, by itself, is not a sign of disease and does not need treatment.

Thinness of the bone in the articular fossa is responsible for fracture, if the mandibular head is driven into the fossa by a heavy blow. In such cases injuries to the dura mater and brain have been reported.

The finer structure of the bone and its fibrocartilagenous covering depend upon mechanical influence. Abnormal functional activity produced injury to the fibrous covering and the articular bone. Compensation and partial repair may be accomplished by the development of hyaline cartilage on the condylar surface and in the disk.

In severe trauma the articular bone is destroyed and cartilage and new bone develop in the marrow space and at the periphery of the condyle. These leads to the ankylosis of temporomandibular joint. Then the function of joint is severely impaired.

When the tissues of retrodiscal pad are torn and their retractile function on disc is lost e.g. sudden blow, bite registration in extreme retruded position, strained opening for extended periods, there is displacement of the condyle posterosuperiorly and anteroinferiorly disc ruptures in advanced cases. There is sharp sound heard in forward and backward movements called reciprocal clicking. There is present closed lock due to muscle spasm.

Surgical Anatomical Considerations Anterior to the auricle, the muscle auricularis anterior and superior overlie the superficial temporalis fascia and the temporalis fascia. These muscles are incised in classic preauricular and endaural approaches. The fascia superficial to the muscle is thin and a dull white. This layer is confluent with the galea aponeurotica above and the parotideo messeterica fascia below. The temporalis fascia is a tough fibrous connective tissue structure, substantially thicker than the overlying superficial fascia. It is stark white and extend from the superfacial temporal line of the temporal bone, to the zygomatic arch. The superficial temporal vessels are typically located in superficial fascia below the auricular anterior muscle. The vessels are often visible, invested in the superficial fascia without incising the muscle. The superficial temporal vein lies posterior to the artery and the auriculotemporal nerve immediately behind the vessel. The superficial temporal vessels and auriculotemporal nerve will appear to take on a horizontal course once the flap is fully developed and reflected anteroinferiorly. Al-kayat and Bramley noted that the facial nerve bifurcated into temporofacial and cervicofacial component with in 2.3 cm (1.5 to 2.8 cm) inferior to the lowest concavity of te bony external auditory canal and within 3 cm (range 2.4-3.5 cm) in an inferoposterior direction from the postglenoid tubercle. The temporal nerve branches lies closest to the joint and are of the most commonly injured branches during surgery. These nerves are located in a condensation of superficial fascia, temporal fascia and periosteum as they cross the zygomatic arch. The most posterior temporal branches lies anteriorly to the post glenoid tubercle. Their location was measured by Al-Kayat and Bramley as 0.8 to 3.5 cm (mean 2 cm) from the anterior concavity of the bony external auditory canal. Thus the two potential sources of facial nerve injury are dissection anterior to the posterior glenoid tubercle where the temporal branches cross the arch and aggressive retraction at the inferior margin of the flap where the main trunk and temporofacial divisions are located.

Surgical approaches to mandibular condyle and its neck Surgical excess to TMJ is an exacting procedure. It requires technical skill and a through knowledge of the anatomy of the area. Several approaches to the TMJ have been prepared and used clinically. 1) Post auricular approach: The incision is begun near the superior aspect of the external pinna and extended to the tip of mastoid process. Placement of incision 3 to 5 mm posterior to the auricular flexure will facilitate closure. Advantages: 1. Uniform predictability of anatomical exposure. 2. Avoidance of salivary fistula or formation of sialocele. 3. No paresis of facial nerve. 4. Highly cosmetic. No distortion of anatomic landmarks. Disadvantages: 1. Stenosis of external auditory canal. 2. Infection involving the external auditory canal. 3. Paresthesia of external pinna. 4. Deformity of the auricle. 2) Lamports Endaural approach: This approach combines a short facial skin incision with extension into the external auditory meatus. The incision begins above the level of the zygomatic arch and extended downward and backward into the intercartilaginous cleft between the tragus and the helix. It then proceed inwardly along the roof of the auditory meatus for approximately 1 cm and is next continued in the saggital plane around the anterior half of the meatal circumference at the junction of the cartilaginous and bony canal. Advantages: Excellent cosmetics Disadvantages: 1. The limited excess 2. Possibility of meatal stenosis or chrondritis.

3) Submandibular (Risdon) approach: The incision for submandibular approach is placed about 1 cm below the angle of the manible. It extends forward, parallel to the lower border of the mandible and curved backward slightly behind the angle. Approach to the neck of condyle and shortly incising through the pterygomasseteric sling and reflecting the messeteric muscle laterally to expose the neck of condyle and sigmoid notch achieve ramus. Disadvantages: 1. Poor access to the condylar head region 2. Procedure involving the articular portion of the head and the meniscus cant be performed by this approach. 4) Postramal (Hind) approach: A skin incision is placed 1 cm behind the ramus of the mandible and extends from 1 cm below the lobe of the ear to an area opposite the angle of mandible. Communicating fascia between the sternomastoid muscle and the parotid gland and masseter muscle is carefully separate to expose the posterior border of ramus. Once posterior border of ramus has been exposed, the pterygomasseteric sling is incised at the angle and the masseteric muscle and parotid gland reflected upward and laterally to expose the neck od condyle. Advantages: 1. Good cosmesis 2. Excellent visibility and accessibility Disadvantages: Possible disadvantages are close proximity of the posterior facial vein and the trunk of the facial nerve and posterior border of the parotid gland may be involved in dissection. 5) Preauricular approach:

This is the most basic and standard approach to the TMJ. This incision is advocated and popularized by Dingman(1951). An incision 3 cm in length is made in the skin overlying the temporal fossa so that the long axis is inclined at 45o to the zygomatic arch, the posterior limit reaching the point where the free margins of helix is attached to the scalp. The incision then follows the grooves between anterior rim at the root of the helix and the facial skin anteriorly, passing downward and posteriorly between the inferior limit of helix and upper border of tragus. It is continued along or slightly behind, the crest of this structure to the upper limit of the intertragal notch, at which point it inclines forwards, turning down to follow the crease between the lobe and the face. Advantages: 1. The incision is an inconspicuous location and can be extended upward toward the temporal area to permit additional anterior mobilization of tissue if necessary. 2. Visibility and accessibility to the condyle are adequate. Disadvantages: In this approach dissection follows a route through an area rich in nerve and vascular supply. Modifications of Basic Preauricular Incision 1. Blair and Ivy in 1936 used an inverted hockey stick incision over the zygomatic arch, which give easy access and better visibility and also facilitated exposure of the arch along the condylar area. 2. Thoma in 1958 recommended an argulated vertical incision, whichis carried out across the zygomatic arch in the fold, directly in front of ear, extending down slightly above the ear lobe, to avoid the main trunk of the facial nerve. 3. Al-Kayat and Bramley (1979) described a modified preauricular approach to TMJ and zygomatic arch. Incision is given through the temporal fascia

and periosteum down to the arch, not more than 0.8 cm in front of anterior border of the external auditory canal. 4. Popowich and Crane (1982) further modified basic Al-Kayat and Bramleys temporal approach incision. A large incision shaped like a question mark was made in the temporal area and extended in the preauricular area. 6) Intraoral approach: It begins with a verticle incision down the anterior border of the ramus of the mandible. After the bone has been exposed, the soft tissues are stripped from the lateral aspect of the mandible as far upward as the sigmoid notch. Periosteal dissection is then continued to expose the condyle neck as well as the anterior face of condylar head. Advantages: 1. Avoidance of skin incision. 2. Safety of the procedure. Disadvantages: 1. Limitation of visibility and accessibility. 7) Coronal approach: Hemicoronal (unilateral incision) and bicoronal or coronal incision (bilateral incision) is more extensive, but versatile surgical approach to upper and middle region of facial skeleton, including the zygomatic arch and TM joint areas. It provides excellent access to these areas with minimum complications. Major advantage is that most of the scar is hidden within the hairline, when the incision is extended into the preauricular area the surgical scar is inconspicuous. This incision can be utilized for more extensive bilateral involvement.

Bibliography:
1. Grays Anatomy: Williams warwick, Dyson Bannister 2. Oral Anatomy:Sicher and DuBruls 3. Human Anatomy: B.D.Chaurasia 4. Snells Anatomy 5. Textbook of Oral and Maxillofacial Surgery-Neelima Malik 6. Current Advances in oral surgery-William B.Irby(vol.III) 7. Principles of oral and Maxillofacial surgery-Larry J.Peterson 8. Oral and Maxillofacial surgery-Raymond J.Fonseca 9. Orbans-Oral Histology and Embryology 10. Wheelers-Dental Anatomy 11. TMJ anatomy and disorders by Okayson.