TEMPOROMANDIBULAR

JOINT
Lecture by:

Dr. Suhasini G P
Lecturer
Dept. of Oral Pathology & Microbiology
Dr. Suhasini GP, Subharti Dental College, SVSU
Dr. Suhasini GP, Subharti Dental College, SVSU
 Temporomandibular Joint
• The area where the craniomandibular articulation occurs is
called the temporomandibular joint

• Articulation is defined as a loose joining or connecting

together so as to allow motion between the parts.

• When the two objects are the bones of a skeleton, the

articulation is called a Joint.

• One of the most complex joints in the body

Dr. Suhasini GP, Subharti Dental College, SVSU

• Provides for hinging movement in one plane-
ginglymoid
• However, at the same time it also provides for
gliding movements, which classifies it as an
arthroidal joint.
• Thus, technically considered a
ginglymoarthroidal joint.
• By definition, a compound joint requires the
presence of at least 3 bones, yet the TMJ is made
up of only 2 bones. Functionally, the articular
disc functions as a 3rd bone- compound joint

Dr. Suhasini GP, Subharti Dental College, SVSU

• Temporomandibular joint
• Craniomandibular joint
• Bilateral diarthrodial joint
• Atypical synovial joint
• Compound joint
• Ginglymoarthrodial joint
• Modified ball socket joint

Dr. Suhasini GP, Subharti Dental College, SVSU

 CLASSIFICATION OF JOINTS
• Fibrous

• Cartilaginous

• Synovial

Dr. Suhasini GP, Subharti Dental College, SVSU

 Fibrous joints
• In fibrous joint 2 bones are connected by fibrous
tissue. They are 3 types:

• 1. Sutures: Its function is to permit growth as its

articulating surfaces are covered by osteogenic
layer responsible for new bone formation. It
permits little or no movement. Eg- skull bones

• 2. Syndesmoses: Two bony compartments are apart

from each other but are joined by an intraosseous
ligament. It permits limited movement. Eg- b/n tibia
& fibula, b/n radius & ulna
Dr. Suhasini GP, Subharti Dental College, SVSU
 Fibrous joints
• 3. Gomphoses: It is the joint that gives
socketed attachment of tooth to bone by
fibrous periodontal ligament. Movement is
restricted to intrusion and recovery in
response to biting force.

Dr. Suhasini GP, Subharti Dental College, SVSU

 Cartilaginous joints
• Primary cartilagenous joint : Bone and
cartilage are in direct apposition.
eg - costochondral junction

• Secondary cartilagenous : Tissues in

articulation occur in sequence as bone-
cartilage-fibrous tissue-cartilage-bone.
eg – pubic symphysis

Dr. Suhasini GP, Subharti Dental College, SVSU

 Synovial joints
• In a synovial joint, which generally permits significant
movement, two bones (each with an articular surface
covered by hyaline cartilage) are united and surrounded
by a capsule that thereby creates a joint cavity. This
cavity is filled with synovial fluid formed by a synovial
membrane that lines the nonarticular surfaces. They are
classified as under :

A. On the number of axis in which bones involved can

move – uniaxial ,biaxial, multiaxial.

B. By the shapes of articulating surfaces – planar,

gingylmoid, pivot, condyloid, saddle, ball and socket.

Dr. Suhasini GP, Subharti Dental College, SVSU

Dr. Suhasini GP, Subharti Dental College, SVSU
 DEVELOPMENT
• PRIMARY JOINT- exists for about 4 MONTHS

• MALLEUS AND INCUS

• SECONDARY JAW JOINT – at about 3 MONTHS of gestation it

appears.

• TEMPORAL BLASTEMA

• CONDYLAR BLASTEMA

Dr. Suhasini GP, Subharti Dental College, SVSU

Dr. Suhasini GP, Subharti Dental College, SVSU
 ANATOMY OF THE
TEMPOROMANDIBULAR JOINT

• Articular fossa

• Mandibular condyle

• Articular disc

• Articular Capsule

• Ligaments of TMJ
Dr. Suhasini GP, Subharti Dental College, SVSU
Dr. Suhasini GP, Subharti Dental College, SVSU
 Glenoid fossa / Articular Fossa/ Mandibular fossa
• Concave shape depression in squamous part of
temporal bone
Post. Squamo & pterygo tympanic fissure
Medial spine of sphenoid
Lateral root of the zygomatic process of the
temporal bone
Anterior ridge of bone
(articular eminence)
Middle part- thin, upper surface
forms the middle cranial fossa
Dr. Suhasini GP, Subharti Dental College, SVSU
 Condyloid process
• It is the portion of the mandible that articulates with the
cranium around which movement occurs

• Anterior view- it has a medial and lateral projections which

are called as poles

• ML length - 15 to 20 mm

• AP length - 8 to 10mm.

Dr. Suhasini GP, Subharti Dental College, SVSU

 Condyloid process
• Posterior articulating surface is greater than
anterior surface.
• The articulating surface of condyle is quite convex
anteroposteriorly and only slightly convex
mediolaterally.
• Pterygoid fovea on the antero-medial aspect of the
mandibular neck where inferior head and most
fibres of the superior head of lateral pterygoid
muscle insert on the mandible.

Dr. Suhasini GP, Subharti Dental College, SVSU

 HISTOLOGY OF THE
ARTICULAR SURFACES
• Articular surface of the condyle (and the mandibular
fossa) are composed of 4 zones
1. Superficial layer- articular zone
– Unlike most other synovial joints, this articular layer is made of
dense fibrous CT, rather than hyaline cartilage
– Tightly packed Col fibers –arranged parallel to the articular
surafce
– Advantage of fibrous covering over hyaline cartilage- less
susceptible to aging effects, less likely to break down over
time, better repairing ability

Dr. Suhasini GP, Subharti Dental College, SVSU

2. Proliferating layer
- cellular
-responsible for proliferation of articular
cartilage in response to functional demands
placed on articular surface
-undifferentiated mesenchymal cells found

Dr. Suhasini GP, Subharti Dental College, SVSU

3.Fibrocartilagenous zone
-Collagen fiber bundles in crossing pattern
- fibrocartilage in random orientation , provides 3
dimensional network that offers resistance against
compressive & lateral forces

4. Calcified zone
-deepest zone, made up of chondrocytes
&chondroblasts distributed throughout the articular
cartilage
- chondroblasts become hypertrophic, endochondral
ossification occurs, loss of chondrocytes, differentiation
of osteoblasts

Dr. Suhasini GP, Subharti Dental College, SVSU

Dr. Suhasini GP, Subharti Dental College, SVSU
• Condyle of mandible- cancellous bone covered
by a thin layer of compact bone
• Trabeculae are grouped in such a way that
they radiate from neck of mandible & reach
cortex at right angles; max. strength to
condyle
• Large marrow spaces decrease in size with
progressing age
• Red marrow in the condyle is of the myeloid
type

Dr. Suhasini GP, Subharti Dental College, SVSU

 CARTILAGE
• Condylar cartilage
• Proliferative layer of replicating cells functioning as
progenitor cells for growth of cartilage
chondroblasts type II collagen (extracellular
matrix of cartilage)
• Endochondral ossification
• Mineralized cartilagenous framework is formed

Dr. Suhasini GP, Subharti Dental College, SVSU

• Fibrous layer covering the articular surface of
temporal bone-
thin in articular fossa
thick on post. slope of articular surfaces
in thickened region – fibrous tissue is arranged
in 2 layers

Dr. Suhasini GP, Subharti Dental College, SVSU

 ARTICULAR DISC
• Dense fibrous connective tissue devoid of
blood vessels and nerves
• Plate of flexible dense connective tissue
• Bi-concave 1-2mm thick in centre & 3-4mm
thick at its periphery
• Devoid of blood vessels and nerves in the
centre
• Vascular peripherally
• Divides joint cavity into upper & lower
compartment
Dr. Suhasini GP, Subharti Dental College, SVSU
• Sagittal plane divided into 3 regions according to the
thickness

• Central area is thinnest and it is called intermediate zone

• Anterior and posterior - thick

• Articular surface of the condyle located on the intermediate

zone of the disc bordered by the thicker anterior and
posterior regions

• Shape of the disc governed by the morphology of the

condyle and the mandibular fossa

Dr. Suhasini GP, Subharti Dental College, SVSU

 Articular disc

Dr. Suhasini GP, Subharti Dental College, SVSU

• The articular disc is attached posteriorly to the
region of loose connective tissue that is highly
vascularized and innervated which is called as
retrodiscal tissue or posterior attachments or
bilaminar region.

– Superior retrodiscal lamina is fibrous & elastic

that attaches AD posteriorly to tympanic plate
– Inferior retrodiscal lamina is non-elastic that
attaches AD to posterior margin of articular
surface of the condyle

Dr. Suhasini GP, Subharti Dental College, SVSU

Anterior region of the disc is attached to the capsular
ligament
Superior attachment is to the anterior margin of the
articular surface of temporal bone
Inferior attachment is to the articular surface of the
condyle

The articular disc is attached to the capsular ligament

not only anteriorly and posteriorly and also medially
and laterally this divides the joint into two distinct
cavities.

Dr. Suhasini GP, Subharti Dental College, SVSU

 ARTICULAR DISC HISTOLOGY
• In young adults
-Disc is composed of dense fibrous tissue
interlacing fibres are straight & tightly packed
elastic fibres found in small no.
-Fibroblasts in the disk are elongated and send
cytoplasmic processes b/w bundles

Dr. Suhasini GP, Subharti Dental College, SVSU

• Chondrocytes, with typical territorial matrices
stains heavily with basic dyes

• increase the resistance & resilience of fibrous

tissue

• Fibrous tissue covering articular eminence &

condyle & in central area of the disc
-- Avascular, no nerves
-- Limited reparative ability
Dr. Suhasini GP, Subharti Dental College, SVSU
 JOINT CAPSULE
Fibroelastic sac
– ascending slope of the articular eminence
anteriorly
– Squamotympanic fissure posteriorly
– Glenoid fossa superiorly
– Neck of the condyle inferiorly
• Synovial membrane of capsule lines all
nonarticular surfaces of upper & lower
compartments of the joint

Dr. Suhasini GP, Subharti Dental College, SVSU

• Posterior part of the capsule is highly
vascular –pis vasculosa
• Parotid gland is found in posterior
portion of glenoid fossa b/w posterior
capsule of the joint & postglenoid
tubercle
• Inner surface of the capsule is smooth &
glistening b’coz of a synovial membrane

Dr. Suhasini GP, Subharti Dental College, SVSU

• Seals joint space

• Passive stability

• Anatomically recognizable ligaments

• Active stability from proprioception

(Maintain position of the disc over the joint
during functional movements)

Dr. Suhasini GP, Subharti Dental College, SVSU

 Ligaments
• As with any joint system, ligaments play an
important role in protecting the structures

• The ligaments of joints are made up of collagenous

connective tissues which do not stretch.

• They do not enter actively into joint function but

instead act as a passive restraining devices to limit
and restrict border movements

Dr. Suhasini GP, Subharti Dental College, SVSU

3 functional ligaments that support the TMJ
• Collateral ligaments
• Capsular ligaments
• Temporomandibular ligament

3 accessory ligaments
• Sphenomandibular ligament
• Stylomandibular ligament
• Retinacular ligament

Dr. Suhasini GP, Subharti Dental College, SVSU

 Collateral ligaments
• Discal ligaments

• They attach the medial and lateral borders of the

articular disc to the poles of the condyle

• Medial discal ligament –attaches the medial edge of

the disc to the medial pole of the condyle

• Lateral discal ligament-attaches the lateral edge of

the disc to the lateral pole of the condyle
Dr. Suhasini GP, Subharti Dental College, SVSU
• The attachment of discal ligaments permit
the disc to be rotated anteriorly and
posteriorly on the articular surface of the
condyle thus these ligaments are responsible
for the hinging movements of the TMJ.

• The discal ligaments have a vascular supply

and are innervated

• This innervation provides information

regarding joint position and movement

• Strain on these ligaments produce pain

Dr. Suhasini GP, Subharti Dental College, SVSU
 Capsular ligament

• Entire TMJ is surrounded and encompassed by the

capsular ligament

• The fibers of capsular ligament are attached

superiorly to the temporal bone along the borders
of articular surfaces of the mandibular fossa and
articular eminence

• Inferiorly attach to the neck of the condyle

Dr. Suhasini GP, Subharti Dental College, SVSU

• Capsular ligament acts to resist any medial,
lateral or inferior forces that tend to separate
or dislocate articular surfaces

• A significant function of the capsular

ligament is to encompass the joint, thus
retaining the synovial fluid.

• The capsular ligament is well innervated and

provides proprioceptive feedback regarding
position and movement of the joint.
Dr. Suhasini GP, Subharti Dental College, SVSU
 Temporomandibular ligament
• The lateral aspect of the capsular ligament
is reinforced by strong, tight fibers that
make up lateral ligament or
temporomandibular ligament.

• The temporomandibular ligament is

composed of 2parts-
1. Outer oblique portion
2. Inner horizontal portion

Dr. Suhasini GP, Subharti Dental College, SVSU

• Outer oblique portion-extends from the outer
surface of the articular tubercle and zygomatic
process posteroinferiorly to the outer surface of
condylar neck.

• Inner horizontal portion-extends from outer surface

of the articular tubercle and zygomatic process
posteriorly and horizontally to the lateral pole of
the condyle and the posterior part of the articular
disc.

Dr. Suhasini GP, Subharti Dental College, SVSU

 Sphenomandibular ligament
• Arises from sphenoid process & extends
downwards & forwards to the lingula of the
mandible.
• limits excessive protrusive movements of the mand.

Dr. Suhasini GP, Subharti Dental College, SVSU

 Stylomandibular ligament
• Arises from styloid process & extends downwards &
forwards to the angle & posterior border of the
ramus of the mand.
• Limits protrusive movement of the mandible.

Dr. Suhasini GP, Subharti Dental College, SVSU

 Synovial membrane
• Lines the articular capsule
• Contain synovial villi which project into joint
space
• Contain internal cells which do not form a
continuous layer i.e. gap b/w cells

• Ability to regenerate

• Membrane does not cover articular disk except

for posterior bilaminar region

Dr. Suhasini GP, Subharti Dental College, SVSU

Consists of 2 layers
1. Cellular intima- 1-4 layers of synovial cells

2. Vascular sub-intima -prevents folding of

membrane- loose connective tissue contains vascular
elements with fibroblasts, macrophages, mast cells & fat
cells

• Cells forming the cellular intima are of 3 types

1.fibroblast like or B-cell type (secretory or S cell)
2.macrophage like or A-cell type
3.between type A and type B.

Dr. Suhasini GP, Subharti Dental College, SVSU

 Synovial fluid
• Clear, straw coloured viscous fluid found in articular
spaces

• Liquid environment for joint surface

• Lubricant (increases efficiency & reduce erosion.)

• Nutrient fluid for avasular tissues covering condyle,

articular tubercle & disc

Dr. Suhasini GP, Subharti Dental College, SVSU

 SYNOVIAL FLUID
• Composition - dialysate of plasma with some
added protein of mucin
• Cells:
Monocytes
Lymphocytes
Free synovial cells
PMN leukocytes
• Protein mucin & hyluronic acid

Dr. Suhasini GP, Subharti Dental College, SVSU

Dr. Suhasini GP, Subharti Dental College, SVSU
 INNERVATION
• Movements of synovial joint initiated & effected by muscle
coordination.
• Achieved in part through sensory innervation.

• Hilton’s Law:
• The muscles acting on a joint have the same nerve supply as
the joint.

• Therefore:
Branches of the mandibular division of the fifth cranial
nerve supply the TMJ (auriculotemporal, deep temporal, and
masseteric)

Dr. Suhasini GP, Subharti Dental College, SVSU

 INNERVATION

capsule

capsule

most abundant

Dr. Suhasini GP, Subharti Dental College, SVSU

 Vascularization of TMJ
• Predominant vessels:
Superficial temporal artery (post.)
Middle meningeal artery (ant.)
Inferior maxillary artery
• Other arteries
 Deep auricular
Ant. Tympanic
Ascending pharyngeal

Dr. Suhasini GP, Subharti Dental College, SVSU

 CLINICAL CONSIDERATIONS
• FRACTURES results because of thinness of bone in articular
fossa injury to the dura mater & brain.

• Change in force/ direction of stress degeneration of

fibrous covering of articulating surfaces & disc

• Remodelling of the articular surface- functional demands,

loss of teeth, attrition, othodontic treatment.

• Abnormal functional activity injury to fibrous covering &

articular disc

Dr. Suhasini GP, Subharti Dental College, SVSU

• Deviation of mandible on opening & closing
popping & clicking noise

• Internal DISC DERRANGEMENT or dislocation.

• DISLOCATION of TMJ

• TMJ ANKYLOSIS

• MYOFACIAL PAIN SYNDROME : dysfunction of

TMJ, consists of
• Masticatory muscle tenderness
• Limited opening of mandible < 37 mm.
• Joint sounds

Dr. Suhasini GP, Subharti Dental College, SVSU

 Diagnostic techniques
• CT scan
• MRI
• Arthroscopy
• X rays

Dr. Suhasini GP, Subharti Dental College, SVSU

 REFERENCE
• Fundamentals of occlusion and TMJ disorders
- Okeson
• Williams PL: Gray’s anatomy, in Skeletal
System (ed38).
• Orban's oral histology and embrology 13th ed.
• Ten Cate's Oral Histology, 8ed

Dr. Suhasini GP, Subharti Dental College, SVSU

 THANK U

Dr. Suhasini GP, Subharti Dental College, SVSU