TEMPEROMANDIBULAR JOINT

Introduction

Temporomandibular joint or craniomandibular joint is a form of

articulation found only in mammals. This is called as Temporomandibular

joint because this joint is formed by the articulation of mandibular condyle

at the base of the cranium with the squamous part of temporal bone.

Also known as craniomandibular joint as the mandible is connected

to the cranium through this joint. Temporomandibular is by far the most

complex joint in the body.

As it provides hinging movement in one plane (ie) forward and

backward like hinge of a door it is called as gingumoid joint. However, at

the same time it also provides gliding movement which classifies it as an

arthrodial joint so known as ginglymoarthodial joint.

It is known as a modified ball socket type of joint as it allows

movements in three planes, sagittal, transverse and coronal. It is also

known as compound joint. Compound joint is the joint formed by these

articulation of three bones. As the articular disc functionally serves as a

non-ossified bone that permits the complex movements of the joints, the

joint is called even as a compound joint.

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 The physiologic activities in which the temporomandibular joint

plays a part may be voluntary or reflex and ranges from mastication,

deglutition and phonation, to such momentary actions such as grasping and

yawning.

Development of Temporomandibular Joint

The mammalian craniomandibular articulation develops

anterolateral to the otic capsule from the first branchial arch mesenchyme

and is therefore innervated by fifth cranial nerve. This is the early

embryonic joint.

This primary embryonic joint is formed by the joining or is the joint

between malleus and incus which develops from first branchial arch. The

malleus and incus are formed by differentiation of large islands of

cartilage, found in the middle ear cavity. This joint serves as the primary

TMJ joint up to 16 weeks of prenatal life. This joint is an uniaxial hinge

joint capable of no lateral motion.

By the end of 7-11 weeks of gestation the secondary TMJ begins to

develop. At about ninth prenatal week a condensation of mesenchyme

appears surrounding the upper posterior surface of rudimentary ramus.

This mass chondrifies at about 10-11 weeks to form cartilaginous

mandibular condyle. With progressive endochondral ossification the

cartilage fuses with the posterior part of the bony mandibular body. At

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about 9-10 weeks the muscle fibers become more differentiated

Bloodvessels, nerves etc. can be seen clearly present in the joint region at

about 10 weeks of gestation.

The appearance of mandibular fossa of the temporal bone is some

what earlier than that of the condyle (u) at about 7-8 weeks. Ossification of

the fossa is more prominent at about 10-11 weeks. Ossification continuous

in this region and at about 22 weeks the mandibular fossa shows both

medial and lateral walls and articular eminence is evident. The shape of the

fossa is concave at about the ninth week and it takes the definitive concave

shape to match the convex condyle. The differentiating mesenchymal cells

interposed between the condyle and mandibular fossa gives rise to the

capsular and intracapsular structures of the TM joints.

Articular Disc

Articular disc is first seen at about seven and one half weeks. By the

10th week first signs of collagenous fibers within the articular disc develops

and it becomes more pronounced by 12 weeks. From the 19-20 th week the

disc increasingly takes on its definitive fibro cartilaginous composition. At

this stage only the disc shows pattern of differential cell proliferation in

which central region becomes thinner than periphery.

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Articular Capsule

The articular capsule first appears at about 9-11 weeks. By the 17 th

week the capsule is seen as fully formed tissue boundary between

intracapsular and extracapsular components of the TMJ. By the 13 th week

the lower cavity of the fossa enlarges and the superior joint cavity becomes

more evident. The shapes of the joint cavities are reciprocal at the time

when the upper joint cavity is concave the lower joint cavity is convex.

Works done by Hooker (1954 and Humphrey (1968) shows that

actual mouth opening actions are observable as early as 7-8 weeks of

gestation.

But certain others like Symons (1952), Perry (1985), Moffet (1957)

said that only scattered muscle fibers of lateral pterygoid muscle are clearly

discernible at 7-8 weeks. Therefore, the prenatal jaw opening activity that

both Hooker and Humphery observed is said to have involved the

articulations of the primary TMJ.

Anatomy of the TMJ

The temperomandibular joint or craniomandibular articulations is

the articulation between the lower jaw and the cranium. The bony elements

of this joint are the squamous part of the temporal bone above and the

mandibular condyles below. This articulation consists of two synovial

joints, the left and right temporomandibular joint.

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 TMJ is complex both morphologically and functionally. An articular

disc composed of dense fibrous tissue is interposed between the temporal

bone and the mandible dividing the articular space into an upper and lower

compartment, gliding movement occurs in upper compartment and the

lower compartment functions as a hinge joint. The articulating surface of

the TMJ are lined by dense, avascular fibrous connective tissue.

Relations of TMJ
Laterally 1) Skin, Fasciae.

2) Parotid gland.

3) Temporal branches of the VII nerve.

Medially Tympanic plate separates TMJ from internal carotid

artery, spine of the sphenoid with upper end of
sphernomandibular ligament, Auriculotemporal and
chorda tympani. Middle meningel artery.

Anteriorly Lateral pterygoid muscles.

Massetric nerve and vessels.

Posteriorly The parotid gland separates it from external

acoustinc meatus.

Superiorly Middle cranial fossa

Middle meningel vessels.

Inferiorly Maxillary artery and vein

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Blood supply Superficial temporal artery and maxillary artery

Nerve supply Aurientotemporal nerve and massetered nerve.

FUNCTIONAL ANATOMY OF THE TMJ

Mandibular condyle

This is convex in shape and it articulates with the articular fossa

which is separated into the upper and lower compartments by the articular

disc. it present as an ovoid bony knob like process on a narrow mandibular

neck. The adult condyle is about 15-20mm mediolaterally and 8-10mms

anterio-posteriorly. The articular surface of the condyle faces upwards and

forwards so that in side view the neck of the condyloid process seems to

bend forward. The lateral pole of the condyle extends slightly beyond the

ramus and is roughened for the attachment of articular disc and

temporomandibular ligament.

Articular disc

Each human TMJ is essentially a double joint due to the presence of

an intra articular disc.

The articular surface are of fibrous tissue, condylar perichondrum

and temporal periosteum. Technically classified as a ginglymo arthrodial

joint. It adjusts itself to the changing contours of the condyle head as it

moves in the fossa. This is possible as the disc is not uniformly thick, but is

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modified in different regions. The underside of the disc is concave and fits

closely over the condylar head like a cap. This ensures the rotatory

movements of the condylar head in the fossa and the disc moves along with

the condyle.

In sagittal section, the disc is divided into three regions according to

thickness. The central area is the thinnest and is called intermediated zone.

In a normal condyle is located In the intermediate zone of the disc,

bordered by thicker anterior and posterior regions. From anterior to

posterior the disc shows five zones :

1) Anterior extension

2) Anterior band

3) Intermediate zone

4) Posterior extension

5) Posterior band

Posteriorly the disc is bilaminar. The thickened anterior and

posterior bands forms an ellipsoidal doughnut. This ellipsoidal

doughnut functions to stabilize the condylar head in the glenoid fossa with

the jaws at rest. The disc is thus considered as a flexible, viscoelastic

adapter which helps the moving joint surface achieve more off effective

articular surface congruity.

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Articular- fossa

This is the concavity within the temporal bone that houses the

mandibular condyle. The anterior wall of the fossa is formed by articular

eminence and posterior wall is formed by the tympanic plate.

The fossa is lined by articular tissue. The posterior part of the fossa

elevated to a ridges called the posterior articular lip.

The posterior articular lip is higher and thicker at its lateral end and

is known as post glenoid process. Medially the articular fossa is bounded

by a bony plate that leans against the spine of sphenoid sometimes

drawn into a triangular process and is known as the temporal spine.

Articular capsule

The capsule forms a thin, fibrous connective tissue sleeve about

the joint which tapers from above down to the condyle neck. It is

attached to squamous temporal bone just peripheral to the margins of the

articulating surfaces. They are vertically oriented and are of such a length

so as enable the normal range of joint movements. All the non articulating

surface within the capsule form sunovial membrane, the surface area of

which is increased by the formulation of villi and folds. The sinovial

fluid is a dialysate of plasma with added, mucins and proteins. The cells it

contains are mainly lymphoid or macrophage in type. The thickened

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anterolateral and lateral portions of the capsule which is attached to the

articular tubercles is called temperomandibular ligament.

Ligaments of temperomandibular joint

Ligaments limit the movements of temperomandibular joint. The

capsule is too delicate a structure to support the joint unaided and so joint

stability is achieved with intrinsic and extrinsic ligaments.

Intrinsic ligaments (directly involved with movement of joint and

attached in relation to joint).

The main intrinsic ligament is the temperomandibular ligament or

the lateral ligament. It is located lateral to the capsule. The fibers of the

ligament pass obliquely from its wide origin lateral to the articular

tubercle to a narrow insertion in the neck of the condyle, below and

behind the lateral pole of the condyle. Collateral ligaments also act as

intrinsic ligaments. These are rather narrow bands of collagen fibers that

run horizontally backwards on the inner aspect of the capsule from the

lateral and medial aspects of the articular eminence to the respective

condylar poles. These restrict the distal displacement of condylar head.

These collateral ligaments along with the temperomandibular ligaments,

helps to attain the clinical ligamentous position.

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Extrinsic ligaments

These are not directly involved with the joint, but they modify the

range of movements that are possible.

These are also known as accesory ligaments and they include -

1) Sphenomandibular ligament

2) Stylo mandibular ligament

3) Pterygomandibular raphe

4) Temporomandibular ligament of the opposite side which acts as

an extrinsic medial ligament.

Sphenomandibular ligament

Attached superiorly to the spine of the sphenoid and inferiorly it is

attached to the lingula of the mandibular foramen. It is a remnant of

the cephalic end of meckels cartilage.

Stylomandibular ligament

It is attached above to the lateral surface of styloid process and

below to the angle and posterior border of the ramus of the mandible.

Fibrous capsule and articular disc also serves as the ligaments of

TM joint.

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Muscles of mastication

Origin Insertion Action

Masseter a) Superficial layer Lower part of Elevation of

from anterior 2/3rd of lateral surface of mandible.
lower borer of the ramus of the
zygomatic arch and mandible
adjoining zygomatic
process of maxilla.

b) Middle layer Middle part of

anterior 2/3 of deep ramus
surface and posterior
1/3 of lower border
of zygomated arch

Deeplayer (origin) Insertion

From deep layer of With the upper part of ramus and

zygomated arch coronoid process

Temporalis Insertion

1) Temporal fossa Margins and deep surface of

excluding zygomatic coronoid process
bone Anterior border of ramus of
2) Temporal fascia mandible

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Action

1. Elevates mandible

2. Posterior fibers retrat the protruded mandible

3. Helps in side to grinding movements.

Lateral pterygoid origin Insertion

1. Upperhead from infra Pterygoid fovea on the anterior

temporal surface and crest of surface of the neck of the mandible.
greater wing of sphenoid.

2. Lower head from lateral Anterior margin of articular disc and

surface of lateral pterygoid capsule of temporomandibular joint.
plate.

Actions

1. With the help of suprahyoid muscles helps in depressing mandible

to open the mouth.

2. Helps in protruding mandible along with medial pterygoid.

3. With medial pterygoid of the same side and alternating with those of

the opposite side brings about side to side grinding movements.

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 Medial pterygoid Origin Insertion

1. Superficial head Roughened area on the medial

2. Deep head from medial surface of angle and adjoining

surface of lateral pterygoid ramus of mandible, below and
plate and adjoining process of behind the mandibular foramen and
palatine bone. mylohyoid groove.

Actions

1. Elevates mandible

2. Helps to protrude mandible

3. Brings about side to side grinding movements along with lateral

pterygoid.

Movement of the mandible

Both joints always act together, but may differ In movement

which include gliding, spinroll and angulation. The basic movements that

occur in TM joint are rotatory and translatory. Rotatory movements

occur in the lower chamber and translatory movements occur in upper

chamber. These movements occur symmetrically in both joints, when

mandible is raised lowered protruded or retruded.

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 Movements also occur in asymmetrical manner when

translation occurs on one side only to produce lateral jaw positions.

Various movements of the TMJ according to the movement of

mandible are -

1) Depression

2) Elevation

3) Protrusion

4) Retraction

5) Lateral chewing movemente and bonnet movement.

Depression of mandibular opening

The opening movement is caused by gravity, relaxation of the

elevator muscles and a combined action of lateral pterygoid,

ganiohyoid, mylohyoid and digastric muscles. Condyles rotate on a

common horizontal axis and also glide forwards and downwards, on

the interior surface of the articular disc which slides in the same

direction on the temporal bones due to their attachments to the

mandibular heads and due to the contraction of lateral pterygoide which

draw the heads and discs onto the articular tubercle.

When wide opening occurs the protracting force of the inferior

heads of the lateral pterygoid muscles acting upon the condyles and the

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disc combines with the depressing and retracting force of the

geniohyoid and degastric muscles acting upon the chin and action of

mylohyoid muscle on the body of the mandible. These combined

forces produce extensive rotatory and translatory movements.

Elevation or closing movements of the mandible

Closing movement is executed by the elevators of the mandible.

Condyles glides backwards and hinges on its disc and as lateral pterygoid

relaxes the disc glides back and up into the mandibular fossa.

The muscles involved are the temporalis, masetter, and medial ptarygoid

of both the sides. The condyles are retracted by posterior fibers of

temporalis during closure. The disc is pulled backwards by the bilammiar

elastic tissue.

Protrusion

In protrusive movements the lower teeth are drawn forward over the

upper teeth. This is primarily as a result of contraction of inferior

heads of lateral pterygoid muscles although there is slight activity of the

masseter and medial pterygoid muscles.

The condyle is pulled forward and downward along the articular

eminences while the elevators and depressors apparently stabilize the

position of the mandible related to maxilla.

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RETRACTION Of THE MANDIBLE

In this movement the obliquely aligned fibers of the middle

temporalis muscle combine forces with the depressors while the

remaining elevators exhibit varying amount of activity. The articular

disc and condyles are pulled backwards into the mandibular fossa by the

contraction of the posterior fibers of temporal is. deep fibers of the

masseter and geniohyoid and digastric play a minor role.

Retrusion is limited to a distance of 1 mm.

Lateral chewing movement

One head with its articular disc glides forwards rotating around a

vertical axis immediately behind the opposite head, then slides backward

rotating on the opposite direction, as the opposite head comes forward In

turn. This alternation swings mandible from side to side muscles involved

are medial and lateral pterygoids of each side acting alternatively.

BENNET MOVEMENT

Definition : The bodily lateral movement or lateral shift of the mandible

resulting from the movements of the condyles along the lateral inclines

of the mandibular fossa in lateral jaw movements.

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Bennet angle - The angle formed by the sagittal plane and the path of the

advancing condyle during lateral mandibular movements as viewed in

the horizontal plane.

When the mandible moves to one side or the other either in opening

or closing the condyle on the side to which the mandible is moving

rotates minimally and moves forwards downwards and laterally. For

example the mandible moves to the right, the left condyla moves

downwards, forwards and inwards while in contact with meniscus and

eminence. The right condyla is allowed only a small rotatory movement,

because its lateral pole is limited by the temperomandibular ligament and

cannot move backwards for more than 1 mm. It therefore moves laterally

and slightly forwards and downwards due to the combined action of the

left lateral and medial pterygoid and to the contacts that exists between

the condyles, menisci and fossa. The force causing the movement comes

from the left side and right condyles moves as it can within the limits of

its ligaments.

Bennet movement consists of an immediate translation which

takes place before the rotation and a progressive translation which

accompanies rotation.

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CONTROL OF TMJ MOVEMENTS

The muscle which move the TMJ like the muscles found

anywhere In the body are subject to both reflex controls and controls

arising from within the central nervous system. There are three principal

reflexes which control the vertical relationship between the mandible

and maxilla and hence TMJ movements. These are as follows :

1) Jaw jerk reflexes

2) Jaw opening reflexes

3) Jaw unloading reflexes.

Jaw Jerk Reflexes

The jaw jerk is analogous to the knee jerk and is a stretch reflex

whereby stretching the jaw closing muscles (u) usually by applying a

downward tap on the chin produces a reflex contraction of these

muscles. This demonstrates that there is feedback mechanism from jaw

closing muscles to their own motor neurons in the central nervous

system, as one rarely receives downward blows on the chin. This

feedback loop comes from muscle spindles within the muscles which

through their primary afferent nerves make direct connections with the

motorneurones in the trigeminal motor muscles. This feedback

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mechanism helps with the fine control of TMJ movements throughout

normal function, like taking account of different consistencies of food.

There is no such mechanism for the jaw opening muscles as they

contact few or no muscle spindles.

Jaw opening reflex

These are effected by inhibition of activity in jaw closing muscles,

but do not show any activation of jaw opening muscles. This reflex can

be triggered by stimulating mechanoreceptive nerves from most structures

within the mouth or nociceptive nerves from the mouth or face. The

pathway for jaw opening reflex is polysynaptic with the first synapse in

either the trigeminal sensory nuclei or the adjacent reticular formation

and the final one in the trigeminal motor nucleus. The importance of these

reflexes probably lies in their ability to prevent injury when biting or

chewing objects

liable to produce damage.

Jaw Unloading Reflex

This reflex also involves a cessation of activity in jaw closing

muscles, together with an activation of opening muscles.

This reflex is evoked when a hard object which is being bitten

breaks suddenly, thus unloading the jaw closing muscles of the resistance

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against which they were working. The result of which is that opposing

teeth do not forcibly hit into one another, thereby preventing damage. The

explanation for this is as follows. When biting on an object which one

knows or suspects might be brittle, one sends exatatory signals not only

to the jaw closing motor neurons but also as a precaution to those of the

jaw opening muscles.

The jaw closing motor neurons also receive positive feedback

from their own muscle spindles and there may be negative feedback to

the jaw opener motor neurones from this same source. This is called as

reciprocal inhibition.

When the object breaks the sudden shortening of the muscle

would result in a decrease in spindle activity and hence in the overall

excitatory drive to the jaw closing muscles as well as in a disinhibition

of the jaw opening motor neurones. Thus the decreases and increases in

activity in the jaw closing and opening muscles respectively would be

produced.

In addition to the vertical jaw reflexes there are also horizontal jaw

reflexes which involve lateral, protrusive, and may be retrusive

movements of the jaw in response to stimulation of mechanoreceptors

in the periodontium and oral mucosa and TMJ. These may be of great

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significance in the function and dysfunction of the TMJ as this may

be superimposed upon the normal chewing pattern.

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REFERENCES

1. Anatomy Of Head And Neck

- Chaurasia.

2. Applied Physiology Of Mouth

- Lave I ie

3. Functional Anatomy Of Oral Tissues

- Shaw J. H.

4. The Structure And Function Of Temperomandibular Joint

- G. S. Mackay, R. Yemm.

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