Temporomandibular Joint

Aditi
PGT 1st Year
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CONTENT

1. Introduction
2. TMJ Anatomy
3. Embryology and Histology
4. Biomechanics of TMJ
5. Clinical Significance
6. Conclusion

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 INTRODUCTION

• The area where the mandible articulates with the temporal bone of the
cranium is called the temporomandibular joint (TMJ).

• Ginglymoarthrodial joint

• Compound Joint

• The major function of theTMJ includes the

coordination of
individual tooth
positions and other
features of the
orofacial system.

A. Bony structures of the temporomandibular joint (lateral

view). B. Articular fossa (inferior view). AE, Articular
eminence; MF, mandibular fossa; STF, squamotympanic 3
fissure.
 TMJ ANATOMY
• The TMJ is composed of and is associated with following structures anatomically:-
1. Articular eminence
2. Glenoid Fossa/Mandibular Fossa
3. Articular Disk
4. Joint Compartments
5. Joint capsule/Articular capsule
6. TMJ Ligaments (Major and Accessory Ligaments)
7. Condylar Head
8. Lateral Pterygoid muscle

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 Blood supply-Branches of Superficial temporal artery
-Branches of deep part of Maxillary artery

 Nerve supply- Mainly by Auriculotemporal nerve

-Branches of Massetric nerve and Posterior deep temporal nerve

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1.Articular eminence 2.Glenoid Fossa/Mandibular
Fossa

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4. Joint Compartments 3.Articular Disk

A/c to Rees (1954),disc is

divided into 4 parts:-
1)Anterior band
2)Intermediate band
3)Posterior band
4)Bilaminar zone

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5. Joint capsule 6.TMJ Ligaments

Major ligaments Accessory ligaments

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 7.Condylar Head 8.Lateral Pterygoid muscle

 Covered with fibrocartilage.

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 EMBRYOLOGY AND HISTOLOGY
Embryologic development of TMJ:-
 Barx-1 homeobox gene.
 By approximately 8 weeks gestation, the condylar process appears as a
separate carrot-shaped blastema of cartilage extending from the ramus
proximal to the mandibular foramen and extending up, to articulate with the
squamous (membranous) portion of the developing temporal bone.
 By about 12 weeks of gestation, Formation of the upper joint cavity is
completed.
 It is referred to as a secondary cartilage as the cartilage comprising the
mandibular condyle arises “secondarily” within a skeletogenic membrane and
apart from the primary embryonic cartilaginous anlagen.
 The mandibular condyle and condylar processes obviously are essential for
normal articular function of the TMJ and movements of the mandible, while at
the same time playing a significant role in mandibular growth for most of the
first two decades of life.
 Variation in the function of the TMJ, which might occur in association with
differences in mastication, jaw movements, and jaw position, is highly likely to
affect its growth and form.
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 Chronology of events in embryologic development of TMJ

Timing Structures developed

Approximately 7- First sign of appearance of
7.5 weeks Temporal articular fossa
Approximately 7- Beginning signs of
7.5 weeks mesenchymal condensation
and shaping of mandibular
condyle.
7.5 weeks Appearance of biconcave
articular disk
10 weeks Formation of Inferior joint
compartment
9-11 weeks Articular capsule
development initiated
11.5 weeks Formation of Upper joint
compartment
17.5 weeks Fully formed joint cavity

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•Avascular dense fibroelastic
connective tissue whose collagen
fibers are oriented
parallel to the TMJ Histomorphology
articular surface. •Comprised of a
• Varies in series of cellular
thickness along zones
the condylar head representing the
and temporal Subarticular Layer various stages of
Articular Layer
joint surface, (Growth Layer)
chondrogenesis
• Increased thickness in secondary
is seen in the cartilage.
superior aspect of
the condyle and on
the articular
eminence of the
glenoid fossa
where compressive
forces associated
with mastication
are greatest. 12
Precondroblastic Zone Zone of Maturation
• Outer Portion-Undifferentiated • Larger,spherical,maturing
mesenchymal cells-Prechondroblast. chondrocytes arranged in random
• Spindle shaped cells. fashion.
• Newly formed cartilage cells express • undergo very few mitoses.
Type I collagen. • Cartilage cells capable of switching
• High expression of FGF-13, FGF-18, their Phenotype to express Type II
TGF-β2, Igf-1, and VEGF. collagen.
• Less extracellular matrix.

Zone of Hypertrophy Zone of Endochondral Ossification

•Progressively large cartilage cells •Initiation of mineralization of the
through osmotic activity and intercellular matrix within the
absorption of water. distal-most three to five layers of
•Genes for procollagen, aggrecan, hypertrophying cells.
Sox9, and Ihh are highly expressed in •matrix is subsequently eroded away
the chondroblastic layer by osteoclastic activity & replaced
by bone.

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 Terminologies used to describe histomorphology of Condylar Cartilage

Blackwood Durkin Wright and Petrovic Thilander Carlson

Moffett
Articular Resting Articular Layer Fibrous capsule Surface Fibrous
Zone surface articular articular
articular Layer tissue
layer
Intermediat Transitional/ Proliferative Prechondroblas Proliferative Prechondrobl
e zone Proliferative layer tic layer layer Arrangement of tissues in
astic(Prolifera
layer tive layer) TMJ. A— Articular disk;B—
mandibular or glenoid
Hypertroph Hypertrophi Zone of matrix Zone of Hypertrophic Chondroblasti fossa; C—condyle of
ic cartilage c cartilage Production maturation zone(non- c zone mandible; D— capsule of
mineralized) (maturation joint; E— lateral pterygoid
and muscle; F— articular
hypertrophy)
eminence
Erosion zone Zone of cell Zone of Erosion Hypertrophic Zone of
Hypertrophy zone(minerali endochondral
zed) ossification

Subchondral Zone of Zone of

bone calcification Endochondral
and resorption ossification
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 BIOMECHANICAL FUNCTION OF TMJ

Two distinct systems

Defines structure and function of TMJ

Joint system for Translational movement (Condyle-disk

Joint system for Rotational movement(Condyle-disk complex)
complex in mandibular fossa)

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 TMJ exhibits rotation and translation bilaterally and is classified as having
3° of freedom during mandibular movement per joint, but not functionally
independent of one other.
 The articular surfaces of the joint have no structural attachment or union, yet
contact must be maintained constantly for joint stability.
 The width of the articular disc space varies with interarticular pressure.
 Proper morphology plus interarticular pressure results in an important self-
positioning feature of the disc.
 Biomechanics of joint is affected if the disc morphology is greatly altered.
 Superior lateral pterygoid exerts slight anterior and medial force on the disc.

Increased Decreased
interarticular interarticular
pressure pressure

Disc space narrows Disc space widens

Intermediate zone Posterior zone in

comes in contact contact
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Normal biomechanical function of the TMJ must follow the orthopedic
principles.

1.Ligaments do not actively participate in normal function of the TMJ.

They act as guide wires, restricting certain joint movements while
permitting others. They restrict joint movements both mechanically and
through neuromuscular reflex activity.

2. Ligaments do not stretch. If traction force is applied, they can become

elongated.(Stretch implies the ability to return to the original length.)
Once ligaments have been elongated, normal joint function is often
compromised.

3. The articular surfaces of the TMJs must be maintained in constant

contact. This contact is produced by the muscles that pull across the
joints (the elevators: temporal, masseter, and medial pterygoid).

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 CLINICAL SIGNIFICANCE

1. Soft Tissue Limitation

2. Condylar Growth

3. Temporomandibular Joint Disorders

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 Soft Tissue Limitation

Masticatory Retrodiscal tissues &

Articular disc capsular ligaments
muscles
 condyle should not be displaced during treatment by more than a very
small distance.

 Repositioning the mandible by more than a small amount likely to fail in

long-run due to musculature returning the mandible to a seated condylar
position.

 Establish occlusal relationships in harmony with neuromuscularly

determined position of mandible.

 There can be several anatomically correct occlusal relationships that can

operate in harmony with normal TMJ function.

 Neuromuscular harmony is at risk when condyles are not within 1 mm or

so of a seated position,when the teeth are in maximum intercuspation.
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 Condylar Growth

Growth factors

Cytokines

Cellular Factors
Extracellular matrix

Factors Influencing Other Proteins

Condylar Growth

Transcription Factors

Novel Genes Specific

Molecular Factors
for Condylar Growth

Other Intracellular
Proteins
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 VEGF PTHrP Ihh Sox-9

 Hypertrophic  Transition zone  Proliferative

layer  Delays layer
 Coordination of transition from  Serves as
the death of condrogenesis both
chondrocytes to cellular and
 Function of osteogenesis. molecular
chondroblasts  Induces factors.
 Remodeling of differentiation
ECM of
 Secretion of mesenchymal
growth factors cells through
and cytokines. SOX-9.
 Angiogenesis as
well as formation
of the bone

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 Growth Relativity Hypothesis

A. Displacement

B. Viscoelasticity

C. Transduction of force
The resultant increase in new bone
formation appears to radiate as
multidirectional finger like processes
beneath the condylar fibrocartilage and
significant appositional bone formation is
seen in the fossa.

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 Temporomandibular Joint Disorders
Musculoskeletal
Joint Pain
Issues TMJ disc
displacements

Disk displacement Arthralgia

Myofascial Pain
with reduction

Disk displacement
Myofascial Pain Osteoarthritis of
without
with limited the TMJ
reduction,with
opening
limited opening

Ankylosis Osteoarthrosis of
Disk displacement
the TMJ
without
reduction,without
limited opening

 Other External Causes:- a)Inflammation

b)Tumors
c) Systemic conditions 23
 According to Rinchuse et al orthodontics was considered TMJ neutral; it neither
caused, prevented, nor cured TMD.
 The trend has been in the direction of better diagnostic procedures, more
scientific concepts of etiology, and more conservative treatments for TMD.

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 Management of TMD Signs and Symptoms in the Orthodontic Practice

Biopsychosocial model-integrates biologic,clinical & behavioural factors that may

account for onset,maintenance and remission of TMD.

Patient self-directed care and education

Home care instructions

Psychological approach to treatment

Oral appliances (Splints)

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 CONCLUSION

The human temporomandibular joint is a diarthrodial joint allowing both

hinging and gliding movements within a three-dimensional framework. The
articular capsule defines the anatomical and functional boundaries of
the TMJ.The articulating surface of TMJ unlike other synovial joint consists of
fibrocartilage rather than hyaline cartilage which makes it less susceptible to
effect of ageing. It acts as both growth and articular cartilage.
TMD signs and symptoms are common in the general population, but
only a small percentage of those require treatment. Orthodontists need to
be aware about the normal functioning of TMJ so,that any form of
dysfunction can be evaluated and timely treatment can be directed.

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 REFERENCES
• Okeson JP. Management of temporomandibular disorders and occlusion-E-book.
Elsevier Health Sciences; 2014 Jul 21.
• Graber LW, Vanarsdall RL, Vig KW, Huang GJ. Orthodontics-E-Book: current principles
and techniques. Elsevier Health Sciences; 2016 Jul 15.
• Rinchuse DJ, Greene CS. Scoping review of systematic review abstracts about
temporomandibular disorders: Comparison of search years 2004 and 2017.
American Journal of Orthodontics and Dentofacial Orthopedics. 2018 Jul
1;154(1):35-46.
• Rabie BM, Ho J, Li Q. Temporomandibular Joint Pathology and Its Indication in
Clinical Orthodontics. InTemporomandibular Joint Pathology-Current Approaches
and Understanding 2017 Dec 20. IntechOpen.
• Manfredini D, Nardini LG. Current concepts on temporomandibular disorders. Berlin:
Quintessence; 2010.
• Ide Y, Nakazawa K. Anatomical atlas of the temporomandibular joint. Quintessence;
1991.

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