TMJ - ANATOMY & DISORDERS

TEMPEROMANDIBULAR JOINT
DISORDERS
Guided by: Dr.Anish Tiwari,
Dr.Adarsh Desai,
Dr.Ravi Kalola,
Dr.Nirav Patel.
Prepared By: Krupa Chudasma(13),
Noori Dalwadi(14),
Meera Dobariya(15),
Prianka Dodia(16)

ANATOMY
• THE TEMPOROMANDIBULAR JOINT IS ALSO KNOWN AS THE
CRANIOMANDIBULAR JOINT or BILATERAL DIARTHROIDIAL.
• IT IS THE ARTICULATION BETWEEN THE SQUAMOUS PART OF THE
TEMPORAL BONE AND THE HEAD OF THE MANDIBULAR CONDYLE.
• IT IS ALSO CONSIDERED AS COMPLEX JOINT BECAUSE IT INVOLVES TWO
SEPARTE SYNOVIAL JOINT, IN WHICH THERE IS A PRESENCE OF
INTRACAPSULAR DISC OR MENISCUS.

THE TMJ ARTICULATION CONSIST OF:
• GLENOID FOSSA
• ARTICULAR EMINENCE
• CONDLYE
• SEPARATING DISC
• JOINT FIBROUS CAPSULE
• EXTRACAPSULAR LIGAMENTS

ARTICULATORY SYSTEM
• COMPRISES OF
• Temporomandibular joint
• Masticatory and accessory muscles
• Occlusion of teeth
• The function is governed by
sensory and motor branches of
the third division of trigeminal
nerve.

• MANDIBULAR FOSSA(GLENOID)
• IT HAS AN ANTERIOR ARTICULAR AREA BY THE INFERIOR ASPECT OF TEMPORAL SQUAMA.
• THE FOSSA IS LINED BY A DENSE AVASCULAR FIBROCARTILAGE.
• ARTICULAR EMINENCE
• IT SEPARATES THE ARTICULAR SURFACE OF THE FOSSA LATERALLY FROM THE TYMPANIC PLATE.
• THE EMINENCE IS COVERED BY DENSE, COMPCT, FIBROUS TISSUE THAT CONSISTS PRIMARILY OF
COLLEGEN WITH AFEW FINE ELASTIC FIBERS
• TMJ CAPSULE
• IT IS A THIN SLEEVE OF FIBROUS TISSUE INVESTING THE JOINT COMPLETY
• IT IS A FUNNEL SHAPED CAPSULE,WHICH BLENDS WITH THE PERIOSTEUM OF THE MANDIBULAR
NECK AND ENVELOPS THE MENISCUS

TEMPOROMANDIBULAR LIGAMENTS
• IT REINFORCE THE TMJ CAPSULE
• IT EXTENDS DOWNWARD & BACKWARD FROM THE ARTICULAR EMINENCE
TO THE EXTERNAL AND POSTERIOR SIDE OF THE CONDYLAR NECK
• ITS POSTERIOR FIBER ARE UNITED WITH THE CAPSULAR FIBERS
• THIS LIGAMENT IS COMPOSED OF COLLAGENOUS FIBERS THAT HAVE
SEPIFIC LENGTH AND POOR ABILITY TO STRETCH, HENCE IT MAINTAINS
THE INTEGRITY AND LIMITS THE MOVEMENT OF TMJ
• IT MAINLY LIMITS THE ANTERIOR EXCURSION OF THE JAW AS WELLAS
PREVENTS POSTERIOR DISLOCATON , ALSO CALLED CHECK LIGAMENT.

• SPHENOMANDIBULAR
LIGAMENT
• A FLAT BAND ARISING FROM
THE APHENOID SPINE AND
PETROTYMPANIC FISSURE,
RUNS DOWNWARDS AND
MEDIAL TO THE TMJ
• INTERNAL MAXILLARY ARTERY
AND AURICULOTEMPORAL
NERVE LIES B/W IT AND
MANDIBULAR NECK
STYLOMANDIBULAR LIGAMENT
IT IS DENCE THICK BAND OF THE DEEP CERVICIVAL FASIA EXTENDING FROM THE STYLOID
PROCESS TO THE MANDIBULAR ANGLE.

ARTIULAR DISC/ MENISCUS
• THE MENISCUS DIVIDES THE TWO ARTICULAR SPACE INTO TWO
COMPARTMENT
• LOWER OR INFERIOR COMPARTMENT- condylodiscal complex b/w the condyle and the
disc
• UPPER OR SUPERIOR COMPARTMENT – b/w disc and the glenoid fossa.
• The disc is biconcave in the sagital section.
• The superior surface is concavoconvex to match the anatomy of the glenoid
fossa.
• The inferior surface is concave to fit over condylar head
• The disc blends medially and laterally with the capsule, which is attached to
the medial and lateral poles of the condyle.
• Anteriorly the disc is attached to the articular eminence above & to the
articular margin of the condyle below.
• Posteriorly disc is attached to the posterior wall of glenoid fossa

• The disc is a meshwork of firmly woven avascular fibrous connective tissue
& it is also noninnervated with possible exceptions around its periphery.
• These collagen fibers impart flexibility to the disc.
• The disc is designed to transmit the forces generated through the condyle
to the articular eminence.
• It promotes lubrication energy absorption and joint range of motion. It acts
as a main shock absorber enabling the articulating bones to move against
each other with minimum friction and heat production.
• Disc has a very little potential for repair after inult.

BLOOD SUPPLY
• Lateral aspect is supplied by
superfical temporal branch of the
external carotid artery.
• Rich vascular supply to the deep and
posterior aspect of retrodiscal
capsular part by deep auricular,
posterior auricular & masseteric
branches of the internal maxillary
artery
• Vascular supply to the lateral
pterygoid muscle also supplies to
the head of the condyle by
penetration of numerous nutrient
foramina vessels

NERVE SUPPLY
• THE MANDIBULAR NERVE, THE THIRD
DIVISION OF THE FIFTH CRANIAL
NERVE INNERVATES THE JAW JOINTS:-
• The largest is the auriculotemporal nerve
which supplies the posterior, medial and
lateral part of the joint
• Masseteric nerve
• A branch from the posterior deep
temporal nerve, supply the anterior parts
of the joint

MOVEMENTS
• The movements of tmj are manifold. It is ginglimus diarthroidai type of
joint, as it sis capable of rotating around more than one axis and is
capable of translatory movement.
• MUSCLE FUNCTION- The functions of the muscles of mastication in jaw
movement are coordinated and balanced by normal muscle tone.
• The muscle of mastication (medial and lateral pterigoid,masseter,
buccinator, mylohyoid, temporalis & anterior belly of the digastric) are
assisted by the suprahyoid and digastric muscle.

• JAW OPENING It is dominated by daigastric muscle contraction, which
depress the body of the mandible. This action is assisted by the
suprahyoid, sternohyoid and geniohyoid muscles.
• JAW CLOSURE It is accomplished by the simultaneous contraction of the
masseter, medial pterigoid muscles.

• PROTRUSIVE MOVEMENT- It requires equal simultaneous contracture of
lateral and medial pterygoid muscle.
• RETRUSION -It is brought about by posterior fibers of temporalis
muscles, assisted by middle and deep parts of the masseter, digastric and
geniohyoid muscles.
• LATERAL MOVEMENT- These are carried out by unilateral contracture of
medial and lateral pterygoid of each side acting alternatively.

TEMPOROMANDIBULAR JOINT DISORDERS
CLASSIFICATION
• Intra –articular origin or intrinsic disorder
• Extra –articular origin or extrinsic disorder

DISORDER DUE TO EXTRINSIC FACTORS
• MASTICATORY MUSCLE DISORDER
• Protective muscle splinting
• Masticatory muscle inflammation
• Masticatory muscle spasm
• PROBLEMS DAT RESULT FROM EXTRINSIC TRAUMA
• Traumatic arthritis
• Fracture
• Internal disc derangement
• Tendonitis
• Contracture of elevator muscle

DISORDER DUE TO INTRINSIC FACTORS
• TRAUMA
• Dislocation, subluxation
• Haemarthrosis
• Intracapsular fracture, extracapsular fracture
• INTERNAL DISC DISPLACEMENT
• Anterior disc displacement with reduction
• Anterior disc displacement without reduction
• ARTHRITIS
• Osteoarthritis
• Rheumatoid arthritis
• Juvenile rheumatoid arthritis
• Infectious arthritis

• DEVELOPMENTAL DEFECTS
• Condylar agenesis or aplasia- unilateral/bilateral
• Bifid condyle
• Condylar hypoplasia
• Condylar hyperplasia
• ANKYLOSIS
• NEOPLASM
• Benign tumours
• Malignant tumours

HISTORY
• History of onset, duration, frequency & dental treatment are
important to assess the acute or chronic nature of the disease.
• Factors like pain, click or dysfunction are to be considered while
eliciting the history.
• History of trauma & history of dental treatment can usually pinpoint
the etiology of the disease.

CLINICAL EXAMINATION
• INSPECTION
• DENTAL EXAMINATION
• OCCLUSAL EVALUATION
• RANGE OF MANDIBULAR MOVEMENT
• PALPATION
• NEUROLOGICAL TESTS
• AUSCULTATION

INSPECTION
• Interincisal distance on mouth opening
• Facial asymmetry
• Deviation of mouth on
opening or closing
• Preauricular swelling
• Occlusal cant
• Malocclusion
• Occlusal derangements
• Improper dental restoration or prosthesis
• Attrition of teeth decreasing vertical dimension

DENTAL EXAMINATION
• Bruxism-attrition of teeth
• Cheek or lip ridges caused by trapping of mucosa during clenching
habits
• Any premature occlusal contacts or high points in restoration should
be checked for degenerative condition of TMJ

OCCLUSAL EVALUATION
• Angle’s classification (Class I, Class II,
Class III)
• It provides information about
occlusal relationship, freeway space,
overjet & overbite, prosthesis, the
evidence for bruxism or other oral
habits & their possible effects on
dentition (attrition and wear facets) ,
periodontium or other oral
structures
• No. of missing teeth , loss of
posterior occlusal contact
predispose the TMJ to degenerative
joint disease

RANGE OF MANDIBULAR MOVEMENTS
• The distance b/n the incisal edges of uppar & lower teeth is measured
together with overjet & overbite normally,35-50mm
• Lateral motion 7-10mm to both right & left
• Normal protrusive range is 7-10mm
• Subluxation or recurrent dislocation of one or both condyles can be
determined by abnormal palpation during movement

• Limitation may be due to:
-contracture of one or more of muscles associated with jaw closure
-nonreducing anterior displacement of articular disc(closed lock)
-coronoid process interference
-haematoma or infection
-fibrous ankylosis or scleroderma

PALPATION
• Tenderness suggests the presence of
- fracture
- synovitis
- capuslitis of the joint
• Palpated for evidence of enlargement (muscle,mandible) & movement of
disc(hypermobility)
• Overlying skin is checked for temperature and consistency in case of
inflammatory condition

Muscle tenderness
• Masseter – palpated with finger & thumb
• Temporalis – examined while the patient is clenching the teeth and at
the same time, attempting to move the jaws sideways
• Lateral pterygoid – palpated with a finger pushed into the retromolar
area of the maxilla
• Indicated in case of muscle related disorders( myospasm ,myalgia,
myofascial pain dysfunction syndrome)

NEUROLOGICAL TESTS
• Trigeminal nerve supplies sensation to the superficial and deep
structures of head and face and motor function to the muscles of
mastication
• Sensory nerve activity is assessed by applying pressure, cotton wool
and pin-pricks to the distribution areas of the trigeminal nerve which
helps in diagnosing myofascial pain

AUSCULTATION
• Noise is assessed by stethoscope and classified as either click (closed
click or open click) or crepitus though it may be difficult to determine
whether a noise is from one joint or both

SPECIAL INVESTIGATIONS
• RADIOGRAPHIC EXAMINATION
• LABORATORY INVESTIGATION
• ELECTROMYOGRAPHIC INVESTIGATION
• DRUGS
• OCCLUSAL SPLINTS
• INTERMAXILLLARY FIXATION
• LOCAL ANAESTHESIA

RADIOGRAPHIC EXAMINATION
• CT SCAN - In TMJ disorders involving articulating surface that include
hard tissues
• MRI & ARTHROGRAPHY – In TMJ disorders including the disc

LABORATORY INVESTIGATION
• Indicated in case of TMJ disorders where primary disease are
diagnosed by
- biochemical & serological tests
• E. g - gout
-infectious arthritis/suppurative arthritis (TB , syphilis)
-rheumatoid arthritis

ELECTROMYOGRAPHIC INVESTIGATION
• Use of electronic instruments or devices helps in monitoring the
activity of disordered TMJ
• E.g. -surface electromyography(EMG)
-thermography
-sonography
-mandibular kinesiology(jaw tracking)

DRUGS
• Antinflammatory agents
• Tranquilisers
• Muscle relaxants
• Antidepressants
are used in case of myofascial pain dysfunction syndrome (MPDS)
where diagnosis of root cause is very difficult

OCCLUSAL SPLINTS
• Used as a test to diagnose MPDS
• In dentulous patients,
splint may be placed over the abraded teeth to check out the
etiology
• In full denture wearers,
occlusal splint may be used to establish/detect whether over
closure is contributing to an osteoarthrosis (osteoarthritis)

INTERMAXILLARY FIXATION
• IMF - Used when there is severe pain of uncertain origin
- It relieves pain if the source is TMJ (condylar fracture ) or
masticatory muscle (prevents overstretching of muscles)

LOCAL ANAESTHESIA
• When pain is suspected as arising from an area
of muscle, injection of small amount of LA into
respective muscles is advised to establish the
diagnosis
• E.g. Injection in the masseter muscle may be
indicated to detect myospasm of masseter ;
thus this test should be correlated with clinical
findings, signs & symptoms

Structural and developmental disorders of the condyle

1) Condylar hyperplasia:
 It is condition of mandibular condyles creating overgrowth of the
mandible.
 Bilateral: can causes progressive prognathism.
 Unilateral: can causes facial asymmetry & articular disc dislocation.
 Three type (obwegeser & makek):-
i. Hemimandibular hyperplasia: enlargement of the condyle, Condylar
neck, ramus, body, with tilting of the occlusal plane.
ii. Hemimandibular enlargement: condyle neck enlargement, displacement
of the ramus without tilting the occlusal plane.
iii. Condylar hyperplasia: only hyperplastic condyle with no associated
mandibular changes.

Two pattern of overgrowth
Condyle itself may become enlarged
Associated with lengthening of ramus
Open bite on affected side
Asymmetry of mandible
condyle is of normal size & shape
Excessive growth at cartilage-bone interface
Elongation of condylar neck
Shift of mandibular midline to the contra lateral
side & crossbite
Radiograph: standard multiview cephalometric
films, CT scan, MRI, bone scan etc.
Treatment:
Condylectomy to ensure removal of the growing cartilage.
Condyloplasty
Orthognathic procedure for correction of facial asymmetry.

2) Hemimandibular elongation:
Clinical features:
Horizontal displacement of the mandible & chin towards the
unaffected side.
Mild mandibular protrusion.
Lip line slopes down towards the affected side.
Lateral crossbite on the unaffected side.
Occlusal plane sometimes slopes upward to affected side.
In severe cases, a lateral open bite is occasionally seen on the
affected side.
The displacement of the midline is greater at the anatomical mid-
chin than at the incisor midline, so that there appears to be an
apical drift of the incisors towards the unaffected side.

Radiograph:
 Posteroanterior view:
 Orthopantomograph: demonstrates the length & any gross enlargement of the
neck of condyle.
 Scintigraphy: during the period of active growth demonstrates hyperactivity in
the condyle of the affected side.
Treatment:
 In case of hemimandibular elongation condylar surgery is necessary.
 It is advisable to wait till the cessation of mandibular growth before surgery.
 In the fully developed condition any presurgical orthodontics, spatial
correction is required.
 In the simpler cases where there is no cant of the occlusal plane, a bilateral
mandibular ramus osteotomy is usually sufficient to achieve a resonable
result. In addition a genioplasty is sometimes necessary to achieve symmetry
of the chin.
 In patient with occlusal cant occlusal plane can be corrected by Le Fort I
osteotomy in addition to the mandibular surgery.

Hemimandibular hyperplasia
• This condition is characterized by a 3D enlargement of one side of the
mandible,thus there is enlargement of the condyle,the condylar neck
& the ascending ramus & the body

• The abnormal growth terminates precisely at the
symphysis,giving rise to a sharp ‘step’ in the mandible
at that site & justifying the term hemimandibular
hyperplasia
• 1. one side of the face appears to be enlarged
• 2.unilateral ‘bowing’ of the inferior border of the
mandible is seen on the affected side
• 3.lipline slopes downward on the affected side

• 4.gross occlusal discrepancies like lateral open bite on the affected
sid,overeruption of posterior theeth in the maxilla with occlusal cant &
increased vertical maxillary height on the affected side may be seeen
• 5.Associated TMJ pain symptoms may be present

Radiographically,
• Entire hemimandibleon the affected side is enlarged & the inferior
dental canal is displaced towards the lower border.the OPG
demonstrates a pathognomonic appearance.
• 1. the elongation of ascending ramus(unilateral)
• 2.elongation & thickening of the condylar neck(unilateral)
• 3.an irregular & deforming enlargement of thr condyle(unilateral)

• 4.the angle is characteristically rounded off(unilateral)
• 5.typical ‘bowing’ of the inferior border of the mandibular body-
(unilateral)
• 6.increased height of the body of thr mandible(unilateral)

3) Condylar hypoplasia and aplasia:
it is characterised by facial deformity expressed on the affected
side by a short mandibular ramus.
May be unilateral or bilateral.
a) Unilateral condylar hypoplasia:-
o Clinical feature:
• Shortening of mandibular vertical height occurs on the affected
side.
• A midline shift towards the same side.
• Shifting of the chin towards the shorter side of the face.
• Deviation of the mandible on mouth opening.
• Occlusal cant.

oCause:
• Condition may occur from birth due to pharyngeal first or second arch
malformation.
• It may result from trauma, infection or irradiation during the growth period.
• Syndromes with hemimandibular hypoplasia as a component are:
 Goldenhar-Gorlin syndrome.
 First and second branchial arch syndrome.
 Craniofacial microsomia.
 Dyke-Davidoff-Masson syndrome.
 Femoral-facial syndrome.

Condylar hypoplasia and aplasia

b.) Bilateral condylar hypoplasia:
• When mandibular shortning occurs on the both sides, it results in micrognathia or
small mandible.
• Bird like face, retruded chin with a small mandibular arch characterises this
condition.
• When this occurs congenitally, it causes respiratory distress due to obstruction of
the pharyngeal airway by falling back of the tongue.
• Bilateral condylar hypoplasia is seen in:
Pierre Robin syndrome.
Treacher Collins syndrome.
Nager’s syndrome.
Townes-Brocks syndrome.
Branchio-oto-renal syndrome.
Branchio-oculo-facial syndrome.
Stickler’s syndrome.

Treatment:
 Should be treated earlier in the growing period itself to avoid secondary
deformities.this can be achieved either by:
• Growth center transplantation.
• Graft.
• Distraction osteogenesis.
• Orthognathic surgery.

1.) Traumatic arthritis:
Any traumatic incident involving the TMJ may lead to acute arthritis.
Chronic trauma to the joint due to trauma from occlusion is also responsible
for osteoarthrosis.
Traumatic arthritis characterised by tenderness of the affected joint and
restriction of movement, which cause the mandible to swing to the affected
side on opening.
There may be oedema around the joint and restricted mouth opening due to
pain presenting as classic trismus.
Treatment of trismus is usually treating the cause followed by physiotherapy.
Long term trismus may require surgical removal of the coronoid processes
and the temporalis muscle attachment, followed by physiotherapy.

2.) Osteoarthritis:
It is a chronic noninflammatory and degenerative disease affecting the
articular cartilage of joints.
Clinical feature:
 Usually 5th decade-slow onset of disease with mild symptom.
 Usually one TMJ is involved.
 Women are more likely to be affected with TMJ involvement.
 Pain in the joint and muscles of mastication, causing limitation of mandibular
motion.
 Joint noises, especially crepitus.
 Osteophyte formation and marginal bone thickening leads to palpable masses
over preauricular region.

Treatment:
 Moderate exercise and physical therapy should be started to strengthen the
musculature supporting the joints.
 NSAIDs to reduce pain.
 In severe case, thermal therapy can be obtained with ultrasonography and
infrared heat.
 Orthopedic procedures(debriding loose bodies, osteotomy and prosthetic
replacement) should be reserved for patients with retractable pain.

3.) Rheumatoid arthritis(RA):
It is autoimmune disease predominantly affecting
disarthroidal joint.
It can affect the joint at any age.
Juvenile rheumatoid arthritis(Still’s disease) may be of
varying severity.
Etiology:
Genetic susceptibility.
Autoimmune response.
increased HLA-DR4 antigen, correlated with increased levels
of rheumatoid factor.

Intermittent pain, swelling and progressive limitation of
joint motion.
Characteristically, the joint of the hands and feet are first
affected.
Preauricular joint pain on chewing and moving.
Advanced disease leads to decreased range of motion and
stiffness.
Decreased bite force, muscle tenderness.
Clicking,crepitus and tenderness of the joint on paplation.
Progressive class II malocclusion develops.

Treatment:
a.) Conservative method:
Antiinflammatory drugs(salicylates, NSAIDs,
corticosteroids), soft diet, avoiding extreme jaw movement.
If NSAIDs are ineffective, disease modifying antirheumatic
drugs like hydroxychloroquine, penicillamine or the
cytotoxic agents like methotrexate or cyclophosphamide are
considered.
In juvenile RA : Methotrexate.

b.)Surgical methods:
High condylectomy .
Arthroplasty for total joint reconstruction using alloplast.
Synovectomy.

4.) Psoriatic arthritis:
It resembles rhemumatoid type , but it is associated with psoriasis, a
dermatologic disease.
Etiology:
 Genetic component.
 Presence of HLA-B27 antigen.
 TMJ involvement is described as episodic, sudden and usually
unilateral.
 Limitation of mandibular movements.
 Morning stiffness, crepitus, eventual loss of interincisal opening.
 In advanced disease, ankylosis can occur.

Treatment:
 Systemic treatment should be undertaken.
 Reduce loading on the joint.
 In severe cases, immunosupressive agents such as Methotrexate have
been used.

5.) Ankylosing spondylitis (Marie-Strumpell disease):
This is a chronic inflammatory disease involving the
articulation of spine and adjacent soft tissue.
It has high risk ratio of male:female (8:1).
Symptoms are due to imperfect head posture caused
by the vertebral lesions.
The most common complaints are of pain, stiffness,
decreased range of motion and eventually ankylosis.
Extra-articular manifestations such as iritis, uveitis,
and cardiac symptoms are commen in patient with
TMJ involvement.

Treatment:
The load must be reduced across the joint by the use
of acrylic splints.
The drug with proven efficacy is sulphasalazine.
Surgical intervention should be limited to those
patients with severe crippling disease.

MYOFACIAL PAIN DYSFUNCTION SYNDROME

Synonym: Facial arthromyalgia, MPDS,
temporomandibular joint dysarthrosis, mandibular pain
dysfunction syndrome & temporomandibular joint
arthrosis, Costen’s syndrome.
Definition: “It is pain disorder, in which unilateral pain is
referred from the trigger points in myofascial structures,
to the muscles of the head & neck. Pain is constant, dull
in nature, in contrast to the sudden sharp, shooting,
intermittent pain of neuralgias(chronic pain).but pain
may range from mild to intolerable.”

Pathophysiology
MPDS can be visualized as a vicious cycle of several contributing factors
such as:
• Muscular hyperfunction.
• Physical disorders.
• Injuries to the tissues.
• Parafunctional habits.
• Disuse.
• Nutritional problems.
• Physiological stress.
• Sleep disturbances.

It is very difficult to know the initiating point, since it arises from the
multifactorial origin.
So etiology can be of 3 major type:
1. Psycholgic or central etiology.
2. Occlusal or peripheral etiology.
3. The third group is recently considered is due to intrinsic joint disorder
etiology.
 Psychogenic cause: it is possible that certain psychologically
unbalanced individuals, due to unusual habits, muscular disturbance
leading to occlusal disharmony & thereby affecting the TM joints.

oPersistent tension relieving oral habits:
• Pipe smoking.
• Sleeping on stomach with the mandible supported by the forearm.
• Teeth clenching.
• Teeth grinding/bruxism.
• Lip licking.
• Jaw thrusting.
• Nail biting.
• Tongue thrusting.
• Pencil/pen biting.
• Constant chewing of tobacco & chewing gum.

Occlusal disharmony: it can be;
oInherent malocclusion.
oAcquired malocclusion.
oIatrogenic occlusal disharmony.

Pathological changes
TMJ:
• No changes can be detected clinically. In early lesions, there is loss of the
usual smooth surface zone & development of an uneven surface.
• In later stages there is total loss of the entire amorphous layer & the
superficial collagen masses consist only of small diameter fibrils.
• Disorganisation of the articular surface occurs in case of more severe &
prolonged disorder.

Muscles:
• Pathological changes in muscles are indefinite.
• Raised intramuscular pressure attributing to oedema.
• Increased blood flow.
• Degranulating mast cells seen in histological examination of painful
muscle.

Symptoms
Pain: this can be localised to the joint or referred to the head, neck or
shoulders. Pain is mostly dull aching.
Limitation of mandibular movement: mouth opening is limited, which
may be either constant or intermittent.
Muscle hyperactivity.
Abnormal muscle activity.
Clicking: mostly bilateral.
Locking.

Signs
Joint tenderness: tenderness of the joint when palpated either in the
preauricular region or from within the external auditory meatus.
Muscle tenderness: tenderness of the masticatory muscles may be
noted, especially the masseter, anterior part of temporalis & lateral
pterygoid.
Abnormalities of mandibular movement: lateral deviation are
diagnostically helpful.

Radiography
When degenarative disease is not suspected, standered lateral
transcranial views help to reveal that no unsuspected pathological
feature is present.
When degenerative disease is suspected, then a special view such as
transpharyngeal might be needed.
Tomography will also helpful.
Function of the joint can be assessed by arthrography(injection of
radiopaque fluids) or by studying images during movements.

Treatment
Two type
i.) conservative management.
ii.) surgical management.

Conservative management.
1.) Placebo: by using splints and by mock adjustment of the occlusion.
2.) Reassurance: doctor/patient relationship is very important for the
success of the treatment.
3.) Occlusal correction: patient should perform bilateral mastication. Any
dental pain, missing teeth should be treated. Habits can be corrected by
exercises.
4.) Soft diet: To reduce loading forces on joint and reduce muscle activity.
5.) Splints: It inactivates facial muscles, decompresses intracapsular tissue,
establishes balance occlusal plane, stabilises the disc and restore the
vertical dimension.

Types
Stabilisation splint Resilient splint(soft splint) Bite plane splint
Anterior bite splint Full occlusal splint
Pivot splint Mandibular repositioning splint

6.) Drugs:
• NSAIDs are helpful in reducing pain and inflammation.
• Antiinflammatory effect of corticosteroids is greater than NSAIDs. Can be
given intra-articular and orally.
• Anxiolytics to reduce anxiety.
• Muscle relaxants:Methocarbamol, Chlorzoxazone.
• Antidepressants: Tricyclic antidepressant.
7.) Thermal agent: They help in decreasing pain, increasing muscle
relaxation.
a.) Superficial moist/dry heat.
b.) Ultrasonography-deep.
8.) Intermaxillary fixation.
9.) Cold: Cold can be used to control inflammation by application of ice
packs to TMJ.

10.) Iontophoresis: It is a battery-powered system used to deliver
water soluble ionizing drugs through skim.
11.) TENS: Transcuteanous electric nerve stimulation provides
symptomatic pain relief.
12.) Home exercise programme for hypomobility.
13.) Pressure-point techniques.
14.) Muscle injection: it is given to inactivate the trigger point, reduce
muscle pain and enhance muscle relaxation.
15.) Intra-articular injection: Mostly steroid injection is used.

Surgical management
1. Arthrocentesis and lavage.
2. Arthroscopy.
3. Disc repositioning.
4. Disc removal.
5. Disc removal and
• Autologous graft disc replacement.
• Alloplastic disc replacement.
6. Condylotomy.
7. Condylectomy.

INTRODUCTION
• Temperomandibular joint ankylosis(TMJ) is a
unique condition of the joint that restricts the
joint mobility progressively thus limiting the jaw
moments.
• Ankylosis is greek word meaning ‘stiff joint’.
• The jaw function gets affected because of
immobility of the joint.
• Hypomobility to immobility of the joint can lead
to inability to open the mouth from partial to
complete.
• Onset is usually seen before the age of 10 years.

AETIOLOGY
1.Trauma
 At birth (with forceps)
 Haemarthrosis
 Blow to the chin (causing haemarthrosis)
 Condylar fracture
 Congenital
Trauma
Haemarthrosis
Haematoma
organisation
Activate the bone
healing process
Fibrosis
Induced osteoblastic
differentiation
May fascilitate the
calcification process
Gradual bone formation
from the disrupted
periosteum
Mechanical
destruction
of surfaces
of condyle
and glenoid
fossa
Disc removal
Appropriate
environment
for bone
formation

2.Infections and Inflammatory
A.PRIMARY INFLAMATION OF THE JOINT
 Tuberculosis
 Staphylococcus aureus
 Neisseria gonorrhoeae
 Haemophilus influenza
B.SECONDARY INFLAMMATION
 Mastoiditis
 Otitis media

3.Arthritis
 Rheumatoid arthritis
 Ankylosing spondylitis
 Psoriatic arthritis
4.Others
 Malignancies
 Post radiology
 Post surgery
 Prolonged trismus
5.Rare causes
 Polyarthritis
 Measles

CLASSIFICATION OF ANKYLOSIS
• LOCATION
1.Intra articular
2.Extra articular
• TYPES OF TISSUE INVOLVED
1.Bony
2.Fibrous
3.Fibro osseous
• EXTENT OF FUSION
1.Complete
2.Incomplete

A.KAZANJIAN CLASSIFICATION
1.Extra articular or false ankylosis- due to pathological changes in the
structures surrounding the TMJ causing limitations in mouth opening
.Radiographic findings evaluate normal appearing TMJ and joint space.
2.Intra articular or true ankylosis- caused by the fibrous or bony adhesions
between the articular surfaces of the mandibular condyle and glenoid
fossa.The diagnosis of true ankylosis in a patient with limited mouth opening
is evident by condylar deformation ,loss of joint spaces and abnormal bone
formation in and around the TMJ in the radiographs.

B.SAWHNEY CLASSIFICATION
For classification of primary ankylosis on basis of
radiographic evidence
1.True (intra articular)
i)Type I -the condyle is medially angulated and
associated with a deformed articular fossa together with a
mild to moderate amount of new bone formation.
ii)Type II - no recognisable condyle or fossa but instead
a large mass of new bone extending from the ramus to
the base of the skull.
iii)Type III - a medially displaced fracture dislocation
with bone bridging the mandibular ramus to the
zygomatic arch.
iv)Type IV - the joint architecture is replaced
completely by bone with fusion of the condyle ,sigmoid
notch and coronoid process to the zygomatic arch and
glenoid fossa.
2.False (extra articular)
Type I Type II
Type III Type IV

Modification of SAWHNEY classification for REANKYLOSIS(as in
reankylosis after gap anthroplasty have very little resembalance to
normal bone anatomy)
Type I – fibrous ankylosis ,reduction in joint space with clear
demarcation of the borders of the temporal and condylar component.
Type II - bony ankylosis between the condylar region and temporal
bone ,without involving the coronoid process or the sigmoid notch.
Type III a – ankylosis between condyle and temporal bone with
hyperplasia of the coronoid process without ankylosis
Type III b – ankylosis involving the coronoid and the condylar region
without obliteration of the sigmoid notch.
Type IV – complete bony union of the condyle and coronoid process to
the temporal component ,in which sigmoid notch could not be
delineated
Type V- ankylosis involving zygomatic arch.

C.JORAM RAVEH ,THIERRY VUILLEMIN
CLASSIFICATION
1.CLASS I –ankylotic bony tissue limited to the condylar process and
articulate fossa.
2.CLASS II- the bone mass extends out of the fossa involving the medial
aspect of the skull base upto the carotid jugular vessels .
3.CLASS III- extension and peneteration into the middle cranial fossa
4.CLASS IV- combination of class 2 and 3.

D.NINTH SHANGHAI CLASSIFICATION
Type AI- fibrous ankylosis without bony fusion of the joint
Type A2- ankylosis with bony fusion on the lateral side of the joint
,while the residual condyle fragment is bigger than 0.5 of the condylar
head in the medial side.
Type A3- similar to A2 but the residual condylar fragment is smaller
than 0.5 of the condyle head.
Type A4- ankylosis with complete bony fusion.

DIAGNOSIS
• It depends more upon clinical examination, rather than the diagnostic
test.
• Restricted or nil oral opening is seen.
• Patient will complain of difficulty in mastication.
• Protrusive movements are not possible on the involved side.
• Partial mobility or complete immobility of the condyle is readily
noticed.
• Pain is totally absent
• In young patient a nature of facial deformity will help to differentiate
b/w unilateral and bilateral involvement

CLINICAL PRESENTATION
UNILATERAL TMJ ANKYLOSIS
• Obvious facial asymmetry
• Convex profile
• Deviation of the mandible and chin on the affected side
• The chin is receded with hypoplastic mandible on the affected
side
• The appearance of the flatness and elongation on the
unaffected side
• The lower border of the mandible on the affected side has a
concavity that ends in a well- defined antegonial notch
• In unilateral ankylosis some amount of oral opening may be
possible. Interincial opening will vary depending on whether it
is fibrous or bony ankylosis
• Cross bite may be seen
• Classic angles malocclusion on the affected side plus unilateral
posterior cross bite on the ipsilateral side seen
• Condylar movements are absent on the affected side

BILATERAL TMJ ANKYLOSIS
• Inability to open the mouth progresses by gradual
decrease in inter incisal opening. The mandible is
symmetrical but micrognathic. The patient
develops typical 'bird face' deformity with
receding chin.
• The neck chin angle may be reduced or almost
completely absent
• Antegonial notch is well defined bilaterally
• Class ii malocclusion can be noticed
• Upper incisors are often protrusive with anterior
open bite. Maxilla may be narrow
• Oral opening will be less than 5mm or many times
there is nil oral opening
• Multiple carious teeth with bad periodontal health
can be seen
• Severe malocclusion, crowding can be seen and
many impacted teeth may be found on the x-rays.

RADIOLOGIC ASSESSMENT
Clinical examination is the prime method of diagnosing
ankylosis though radiological investigation helps in
• Differentiating fibrous ankylosis from bony ankylosis
• Degree of involvement of joint
• Extra articular involvement of bone
• Medial extent of ankylotic mass
a.mediolateral width
b. relation of the mass to the vital structures medially
such as mandibular nerve ,internal carotid artery
• Preoperative surgical planning.

The suggested radiologic aids are
1. Orthopantomograph- will show both the joints picture which can be compared in unilateral
cases.
2. Lateral oblique view- will give anteroposterior dimension of the condylar mass. Elongation
of coronoid process can be seen.
3. Cephalometric radiograph- is taken to evaluate the associated skeletal deformities
4. Posteroanterior radiograph- will reveal the medio lateral extent of the bony mass. It will
also highlight the asymmetry in unilateral cases
5. CT scan- very helpful guide for surgery. Relation to the medial cranial fossa, the
anteroposterior width, mediolateral depth can be assessed. Any presence of fractured
condylar head on the medial aspect of ramus can be located
• FIBROUS ANKYLOSIS- in fibrous ankylosis, reduced joint space and hazy appearance can be seen
.But ,still the normal anatomy of the head and glenoid fossa can be appreciated.
• BONY ANKYLOSIS – complete obliteration of joint space .Normal TMJ anatomy is distorted
.Deformed condylar head or complete bony consolidation replacing the joint space can be seen
.Elongation of the coronoid process on the side of hypomobility will be seen.

SEQUELAE OF UNTREATED ANKYLOSIS
• Normal facial growth and development affected.
• Speech impairment.
• Nutritional impairment.
• Respiratory distress, especially in bilateral involvement with severe
micrognathia.
• Malocclusion.
• Poor oral hygiene.
• Multiple carious and impacted teeth

MANAGEMENT
The treatment of TMJ ankylosis is always surgical correction of the
ankylosed joint.
Surgical stratergy adopted depends on the following
1.Age of onset of ankylosis
2.Extent of ankylosis
3.Whether it is unilateral or bilateral
4.Associated facial deformity

AIMS AND OBJECTIVE OF SURGERY
1.Release of ankylosed mass and creation of a gap to mobilize the joint .
2.Creation of a functional joint
3.To improve patients nutrition.
4.To improve patients oral hygiene
5.To carry out necessary dental treatment.
6.To reconstruct the joint and restore the vertical height of the ramus.
7.To prevent recurrence.
8.To restore normal facial growth pattern
9.To improve esthetics.

The Internationally Accepted Protocol For The Management Of Tmj
Ankylosis By Kaban, Perrot And Fisher In 1990
Early surgical intervention
• Aggressive resection: a gap of atleast 1- 1.5cm should be created. Special attention should be
given to fusion on the medial of the ramus.
• Ipsilateral coronoidectomy and tempralis myotomy: in most of these cases there is always
association of elongated coronoid process. After carrying out gap arthoplasty. The
coronoidectomy on the same side should be carried out either separately or in combination with
the gap arthroplasy cut from the same etraoral incision.
• Lining of the glenoid fossa region with temporalis fascia
• Reconstruction of the ramus with a costochondral graft.
• Early mobilization and aggressive physiotherapy for the period of at least six months
postoperatively
• Regular long-term follow-up
• To carry to cosmetic Surgery at the later date when the growth of the patient is completed
• Release of the jaw movements is quite dramatic, upon competion of coronoid rather than release
it and allow it to be pulled up superior process is removed, there is potential for reankylosis after
reattachment.

THREE BASIC METHODS
1.Condylectomy
2.Gap arthroplasty
3.Interpositional arthroplasty

SURGICAL APPROACHES
• Surgical access to the TMJ is an exacting procedure.
• TMJ has got close proximity to the main trunk of the facial nerve with its
branches in the temporal and facial areas
• It has also got close proximity to the auriculotemporal nerve and the
abundant vascular supply
Following approaches are usefull
1.Preauricular
2.Post/retro auricular
3.Post ramal(HIND approach)
4.Endaural approach
5.Popwich incision

1.PREAURICULAR APPROACH
ADVANTAGES
• Inconspicuous location of the incision
• Standard approach to the TMJ
DISADVANTAGES
• The dissection follows a route
through an area which is rice in nerve
and vascular supply.
• BLAIR AND IVY INCISION
• THOMA’S ANGULATED INCISION
• AL- KAYAT AND BRAMLEY
Blair’s Inverted
Hockey Stick
Incision
Thoma’s Angulated
Incision
Dingman’s Incision

2.POST/RETRO AURICULAR
ADVANTAGES
• Uniform predictability of anatomic
exposure & avoidance of a salivary fistula.
• Negligible hemorrage
• No distortion of anatomic landmarks
DISADVANTAGES
• Infection involving the external auditory
canal
• Paresthesis of the external pinna
• Small surgical exposure with poor access
and visibility

3.POST RAMAL(HIND) APPROACH
ADVANTAGES
• Excellent cosmesis
• Excellent visibility and accessibility
DISADVANTAGES
• Close proximity of the posterior
facial vein and trunk of the facial
nerve
• Proximity of the posterior border
of the parotid gland
• Ideal approach to the condyle neck
and ramus

4.ENDAURAL APPROACH
ADVANTAGES
• Excellent cosmetics
• Excellent lateral and posterior
exposure with intermediate
anterior exposure
DIADVANTAGES
• Limited access
• Possibility of meatal stenosis

5.POPWICH INCISION
ADVANTAGES OF POPWICH’S MODIFICATION
• Reduction in incidence of facial nerve palsy
• Deceased haemorrhage
• Improved visibility
• Good cosmetic results
• Reduction in total operation time
• Avoidance of auriculotemporal nerve
anaesthesia
• Reduction in postoperative oedema and
discomfort

SUGICAL PROCEDURES
1.CONDYLECTOMY
• It is advocated in cases of fibrous ankylosis, where joint
space is obliterted with deposition of fibrous bands ,
but there is not much deformity of the condylar head.
• Radiologically and clinically after surgical exposure one
can see the demarcation between the roof of the
glenoid fossa and the head of the condyle.
• The procedure can be done via preauricular incision
• The unilateral condylectomy tends to cause devation of
the mandibule towards the operated side on oral
opening and if bilateral, anterior open bite will be
caused as a result of the loss of the height in the
vertical rami.
• Therefore. When the site of the fused joint is mobilized
via condylectomy. Then after recontouring by
arthroplasty, an alloplastic material can be used to
maintain the joint space, satisfactory occlusion and
joint movement.

2.GAP ARTHROPLASTY
• In the extensive bony ankylosis, a broad,thick
area of bone deposition obliterates the entire
joint, sigmoid notch and coronoid process
• Identification of the previous joint structure is
impossible and mobilization at level of joint
become difficult
• In this operation the level of section is below
that previous joint space
• The section consist of two horizontal
osteotomy cuts and removal of a bony wedge
for creation of a gap between the roof of the
glenoid fossa and ramus.
• Minimum gap of 1cm is recommended to
pervent reankylosis

3.INTERPOSITIONAL ARTHROPLASTY
• It involves the creation of gap , but in addition a barrier is inserted
between the cut bony surfaces to minimize the risk of recurrence and
to maintain the vertical height of the ramus
AUTOGENEOUS
1.Cartilaginous graft
 Costochondral
 Metatarsal
 Sternoclavicular
 Auricular cartilage
2.Temporalis muscle
3.Temporal fascia
4.Fascia lata
5.Dermis
HETEROGENOUS
1.Chromatized submucosa of pig bladder
2.Lyophilized bovine cartilage
(still under research)
ALLOPLAST
1. Metallic
 Tantalum foil /plate
 316L stainless steel
 Titanium
 Gold
2.Nonmetallic
 Silastic
 Teflon
 Acrylic
 Nylon
 Proplast
 Ceramic implants

ARTIFICIAL REPLACEMENT OF JOINT
• Prefabricated condylar prosthesis made of steel
,vitallium or titanium have been also used
extensively .
• Fossa liners along with specially constructed
TMJ prosthesis reconstruct the entire joint .
• These are commercially available or custom
made.

 LINING OF THE GLENOID FOSSA SIDE BY TEMPORALIS MYOFAICIAL
FLAP
• Tamporalis fascia along with a varying
thickness of temporalis muscle may be
harvested as an axial flap based on the
middle and deep temporal arteries and
veins
• The dependable blood supply, the
proximity to the tmj and the ability to alter
the arc of rotation by basing the flap
inferiorly or posteriorly, makes this a
versitile flap for lining the glenoid fossa.
• It is used as an interpositional material
after release of ankylosis of tmj.

 INTERPOSITION ARTHROPLASTY USING AUTOGENOUS
COSTOCHONDRAL GRAFT
Basic three goals;
1. To replicate structurally normal joint anatomy
2. To provide functional articulation
3. To establish an area , where adaptive growth can occurs.
• Costochondral graft is harvested through the infra-mammary incision
• Either 5th, 6th, or 7th rib is harvested.
• Costochondral junction of rib is chosen along with some amount of length of the rib.
• The length of the total graft will depend on the height of ramus to be restored
• Minimum of 1.5cm of costochondral junction should be included in the graft
• The graft should be fixed on the lateral aspect of the rammus with the screws.
• A minimum gap of 0.5 - 1 cm should be kept between the graft and the glenoid fossa
side, so that free movement is possible without any friction

Disadvantages;
• Increased operating time
• Additional surgical site
• Donor site morbidity
• Graft over growth
• Possible potential for reankylosis

FALSE ANKYLOSIS
• It is a restriction of mandibular movement due to extra articular afflictions.
• Miller et al 1975 classified into 6 groups,
I. Myogenic causes include fibrosis within muscles possibly due to an
organisation of an intramuscular haematoma.
II. Neurogenic group includes central nervous system lesions or
cerebrovascular accidents ,which produce an inhibition of masticatory
muscle activity.
III. Psychogenic group refers to hysterical trismus .
IV. Bone impingement will be caused by extra articular malformations such as
exotosis of the coronoid process ,zygomatic fracture impinging on the
mandibular movements.
V. Fibrous scar tissue can form in any soft tissue ,which has been subjected
to trauma.
VI. Due to tumours depends upon their site and nature.
Treatment
Use of mechanical aids from simple acrylic screw wedge to more complicated
exercises is beneficial
Acrylic screw wedge

COMPLICATIONS DURING TMJ ANKYLOSIS
SURGERY
1.DURING ANAESTHESIA
• As the patient cannot open the mouth, awake blind intubation has to be
done, where patients cooperation is required, which is very difficult to obtain
from younger group of patients
• Because of small mandible and altered position of the larynx .intubation
poses a problem
• Aspiration of blood clot tooth or foreign body during extubation as throat
cannot be packed prior to surgery
• Danger of falling back of tongue and obstructing airway is always there after
extubation

2.DURING SURGERY
• Haemorrage due to damage to any of the superficial temporal vessels,
transverse facial artery, inferior alveolar vessel and internal maxillary vessels,
pterygoid plexus of veins
• Damage to external auditory meatus
• Damage to zygomatic and temporal branch of facial nerve
• Damage to glenoid fossa and thus leading entry into middle cranial fossa
• Damage to auriculotemporal nerve
• Damage to parotid gland
• Damage to the teeth during opening of the jaws with jaw stretcher
3.DURING POSTOPERATIVE FOLLOW-UP
• Infection
• Open bite
• Recurrence of ankylosis

TMJ - ANATOMY & DISORDERS

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