temporomandibular joint/ fellowships in orthodontics

TEMPOROMANDIBULAR
JOINT

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INDIAN DENTAL ACADEMY

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CONTENTS
INTRODUCTIONCLASSIFICATION OF JOINTSDEVELOPMENT HISTOLOGYCOMPONENTS BONESCARTILAGESLIGAMENTSCAPSULEARTICULAR DISCSYNOVIAL MEMBRANEMUSCLESBIOMECHANICSINNERVATIONBLOOD SUPPLYEXAMINATIONIMAGING MODALITIESDISORDERSCONCLUSION


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INTRODUCTION



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Temporomandibular Joint
The area where the craniomandibular articulation occurs is called the temporomandibular joint Bilateral diarthrodial joint Atypical synovial jointGinglymoarthrodial jointCompound joint


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CLASSIFICATION
FibrousCartilaginous Synovial


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Fibrous joints
SuturesSyndesmosesGomphoses


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Cartilaginous joints
SynchondrosesSymphysis


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Synovial joints



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DEVELOPMENT
PRIMARY JOINT- 4 MONTHSMALLEUS AND INCUSSECONDARY JAW JOINT - 3 MONTHSTEMPORAL BLASTEMACONDYLAR BLASTEMA


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DEVELOPMENT
Articular Disc:Earliest appearance in 6 week old embryoAt 7 weeks: the future condyle is still only a condensation of mesenchyme resting on osseous lamella, which forms the mandibular ramus.12 week condylar growth cartilage makes its 1st appearance and begins to develop a hemi-spherical articular surface
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By 13th week condyle and articular disc having moved up into contact with temporal bone.


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DEVELOPMENT
Only when such articular contact has been made do the joint cavities develop.Inferior space appearing first.Disc begins to get compressed.When central portion of disc is compressed this part becomes avascular.


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DEVELOPMENT

By 26th week:
All components of TMJ present except articular eminence.Meckels cartilage still extends through GF, but by thirty-first week is transformed into sphenomandibular ligament.
By 39th week:
Ossification of bones in this region has proceeded to the point where; ligament gains its apparent attachment to spine of sphenoid.


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DEVELOPMENT



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HISTOLOGY OF ARTICULAR SURFACES
The Articular surface of the condyle and mandibular fossa are composed of four distinct layersArticular zoneProliferative zoneFibrocartilaginous zoneCalcified cartilaginous zone


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HISTOLOGY



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Condylar cartilage
Similar to epiphyseal cartilageEndochondral ossificationAbsence of ordered column of cellsUnidirectional and multidirectional growth pattern


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Bony components

Condylar head

Glenoid fossa

Articular eminence

Muscles

Muscles involved in mastication.

Facial muscles.

Muscles of the neck

Soft tissue

Articular disc

Joint capsule

Ligaments

Muscles attached to joint

FUNCTIONAL ANATOMY



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BONY COMPONENTS



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SQUAMOUS PART OF THE TEMPORAL BONE
Mandibular or articular or glenoid fossaDegree of the convexity- dictates the pathway of the condyle Posterior roof of the mandibular fossa is thin


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BOUNDARIES



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Condyloid process
It is the portion of the mandible that articulates with the cranium around which movement occursAnterior view it has a medial and lateral projection s which are called as poles ML length - 15 to 20 mm AP length - 8 to 10mm.


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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 and lateral pterygoid muscle insert on the mandible.


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Condyloid process

Anterior

Posterior



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ARTICULAR DISC
Dense fibrous connective tissue devoid of blood vessels and nervesSagittal plane divided into three regions according to the thicknessCentral area is thinnest and it is called intermediate zone


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Anterior is thickPosterior is thickArticular surface of the condyle located on the intermediate zone of the disc bordered by the thicker anterior and posterior regionsShape of the disc governed by the morphology of the condyle and the mandibular fossa


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Articular disc



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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.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.


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Capsule
Seals joint spacePassive stabilityAnatomically recognizable ligamentsExtension into jointActive stability from proprioception


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Joint capsule (attachment)



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


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3 functional ligaments that support the TMJ
Collateral ligamentsCapsular ligamentsTemporomandibular ligament
3 accessory ligaments
Sphenomandibular ligamentStylomandibular ligamentRetinacular ligament


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Collateral ligaments
Discal ligamentsThey 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 condyleLateral discal ligament-attaches the lateral edge of the disc to the lateral pole of the condyle


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These ligaments are responsible for dividing joint mediolaterally into superior and inferior joint cavitiesThe discal ligaments are true ligaments, composed of collagenous c.t fibers they do not stretchRestrict the movement of disc away from the condyle that means they allow the disc to move passively with condyle as it glides anteriorly and posteriorly


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The attachment of discal ligaments permit the disc to be rotated anteriorly and posteriorly on the articular surface of the condyle thus the these ligaments are responsible for the hinging movements of the TMJ.The discal ligaments have a vascular supply and are innervatedThis innervation provides information regarding joint position and movement Strain on these ligaments produce pain


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Anterior view



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Capsular ligament
Entire TMJ is surrounded and encompassed by the capsular ligamentThe fibers of capsular ligament are attached superiorly to the temporal bone along the borders of articular surfaces of the mandibular fossa and articular eminenceInferiorly attach to the neck of the condyle


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


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Mesial

aspect



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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
Outer oblique portion

Inner horizontal portion



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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.


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The inner horizontal portion of TM ligament limits posterior movement of the condyle and disc.When force applied to the mandible displaces the condyle posteriorly,this portion of ligament becomes tight and prevents the condyle from moving into the posterior region of mandibular fossa by which it protects the retrodiscal tissues from trauma.The inner horizontal portion also protects the the lateral pterygoid muscle from over lenghtening or over extension


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TM Ligaments



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RETINACULAR LIGAMENTS
Recently it has been described in association with TM joint.Arises from the articular eminence, descends along the ramus of the mandible.Insertion: fascia overlying the masseter muscle at the angle of the mandible. As the ligament is connected to the posterolateral aspect of the retrodiscal tissues and contains an accompanying vein.Action: It maintains blood circulation during the masticatory movements.


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Accessory ligaments



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Synovial membrane
Specialized fringe located at the anterior border of the retrodiscal tissues produces a synovial fluid which fills the joint cavities thus it is turned as a synovial joint.Capsule lined on its inner surfaceMembrane does not cover articular disk except for posterior bilaminar regionConsists of 2 layers
Cellular intima

Vascular sub-intima -prevents folding of membrane



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Synovial fluid
Since articular surfaces of joint are nonvascular, the synovial fluid acts as a medium for providing metabolic nutrients to these tissues The synovial fluid also serves as a lubricant between articular surfaces during function Composition - dialysate of plasma with some added protein of mucin


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BLOOD

SUPPLY



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Innervatiom

4 types of receptors

Ruffini end organ

Paccini corpuscle

Golgi tendon organ

Free nerve ending



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Hiltons law



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To be continued
TO BE CONTINUED.



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GOOD MORNING



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Shapes of condyle



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TYPES OF MUSCLES
Muscle cells are mainly of three types
1. STRIATED MUSCLE

a. SKELETAL OR VOLUNTARY

2. NON-STRIATED,SMOOTH OR

INVOLUNTARY

3. CARDIAC MUSCLE



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Muscle



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MUSCLES OF MASTICATION
Mastication forces The aev maximum sustainable biting force is 756N{170 pounds}.Molar region: Biting force range 400-890NPremolar region: Biting force range 222-445NCuspid region: Biting force range 133-334NIncisor region:Biting force range 89-111N {20-55 pounds}


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PRIMARY MUSCLES OF MASTICATION
MASSETERTEMPORALISMEDIAL AND LATERAL PTERYGOID
SECONDARY MUSCLES OF MASTICATION

The suprahyoid group of muscles being used as secondary or supplementary muscles they are
DigastricMylohyoidGeniohyoid


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THE MASSETER
Quadrilateral and and consist of three layers.
ATTACHEMENTS
Superficial Layer: Arises by thick aponeurosis. From zygomatic process of maxilla and anterior 2/3 of lower border of zygomatic arch, pass downward and back wards at an angle of 45degree and inserted into lower part of lateral surface of ramus of mandible


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MIDDLE LAYER: Arises from anterior 2/3 of the deep surface and posterior 1/3 of the lower border of the zygomatic arch,pass vertically downwards and and inserted into middle part of ramus.DEEP LAYER: Arises from deep surface of the zygomatic arch, pass vertically downwards and inserted into the upper part of the ramus and into the coronoid process.


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Nerve supply:
MASSETRIC NERVE, a branch of anterior division of mandibular nerve (which is the 3rd part of V cranial nerve- trigeminal nerve).
Blood supply:
Maxillary artery, which is a branch of external carotid artery.



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ACTIONS OF MASSETER

Actions:
Elevates the mandible to close the mouth and to occlude the teeth in mastication.Its activity in the resting position is minimal. It has a small effect in side-to-side movement, protraction and retraction.


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THE TEMPORALIS

TEMPORAL FASCIAE
Thick aponeurotic sheet that roofs over the temporal fossa and covers the temporalis muscle
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ATTACHEMENTSFan shapedArises from whole of temporal fossa.(except the part formed by zygomatic bone) and deep surface of temporal fasciaFibers converge and descend into a tendon .It passes through the gap between the zygomatic arch and the side of the skullAttached to medial surface,apex,anterior and posterior border of coronoid process and anterior border of the ramus of the mandible as far as last molar.


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BLOOD SUPPLY
Deep temporal part of maxillary artery
NERVE SUPPLY
Temporalis is supplied by the deep temporal branches of the anterior trunk of mandibular nerve.



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ACTIONS OF TEMPORALIS
Elevates the mandible,this movement requires both the upward pull of anterior fibers and backward pull of the posterior fibers.Posterior fibers draw the mandible backwards after it has been protruded.It is also a contributor to side to side grinding movement.


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POSTERIOR FIBER DRAWS MANDIBLE BACKWARDS



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SIDE TO SIDE GRINDING MOVEMENT



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MEDIAL PTERYGOID

ATTACHEMENTS
It is a thick quadrilateral muscleAttached to medial surface of lateral pterygoid plate and grooved surface of pyramidal process of the palatine bone.A more superficial slip from the lateral surface of pyramidal process of the palatine bone and tuberosity of maxillaIts fibers pass downwards laterally and backwardsAttached by a strong tendinous lamina ,to the postero-inferior part of the medial surfaces of the ramus and the angle of the mandibleIt is attached as high as mandibular foramen and as far forward as the mylohyoid groove


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NERVE SUPPLY
Branch of the main trunk of the mandibular nerve
BLOOD SUPPLY
Pterygoid branch of 2nd part of maxillary artery



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Actions of medial pterygoid
Assits in elevating the mandibleActing with the lateral pterygoid they protrude itActing with medial pterygoid of same side advances the condyle ,while the jaw rotates through the opposite condyle(when the medial and lateral pterygoid of the two sides contract alternatively to produce side to side movements of mandible eg chewing)


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Medial and lateral pterygoid act together to protrude the mandible



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LATERAL PTERYGOID
ATTACHMENTS It is a short thick muscle with two parts or headUPPER head arise from infratemporal surface and infratemporal crest of greater wing of sphenoid boneLOWER head arise from lateral surface of lateral pterygoid plate.Its fibers pass backwards and laterally to be inserted into a depression(pterygoid fovea)on the front of the neck of the mandible and into the articular capsule and disc of the temporomandibular articulation.


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NERVE SUPPLY
The lateral pterygoid is supplied by a branch of anterior division of the mandibular nerv
BLOOD SUPPLY
Pterygoid branch of 2nd part of maxillary artery



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ACTIONS OF LATERAL PTERYGOID
Assists in opening the mouth with suprahyoid muscle.Slow elongation while closing the mouth with masseter and temporalisActing with medial pterygoid of same side advances the condyle ,while the jaw rotates through the opposite condyle(when the medial and lateral pterygoid of the two sides contract alternatively to produce side to side movements of mandible eg chewing).


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When the medial and lateral pterygoids of two sides act together they protrude the mandible so that the lower incisors project in front of the other.Some authorities have ascribed different actions to the two parts of pterygoid muscle.The upper (superior)head being involved in chewingThe inferior in protrusion,electromyographic records in rhesus monkey favors this view.


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Medial and lateral pterygoid act together to protrude the mandible



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Secondary muscles taking part in the mastication

The 4 primary muscles of mastication are in turn supported or supplemented by few secondary muscles known as SUPRAHYOID GROUP of muscles they are
DIGASTRICMYLOHYOIDGENIOHYOIDSTYLOHYOID is other suprahyoid muscle, which does not take part in mastication


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DIGASTRIC- The muscle has secondary role in mastication as a depressor muscle adding to the action of lateral pterygoid muscle when mouth is to be opened against resistance. Elevation of hyoid boneMYLOHYOID- The secondary role of this muscle is evident as a depressor seen in action when mouth is to be opened against resistance.It elevates the floor of mouth to help in degluttition.


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GENIOHYOID- Geniohyoid elevates the hyoid bone and draws it forward, thus acting as a partial antagonist to stylohyoid.When the hyoid bone is fixed, it depresses the mandible


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Cervical Group:
Indirectly involved in mandibular function
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They are Trapezius, Sternocleidomastoid ,Anterior vertebral muscles,the lateral vertebral muscles and other deep posterior cervical muscles.They act to stabilize head posture during the active contraction of the masticatory ,suprahyoid and infra hyoid muscles during the mastication and swallowing


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BIOMECHANICS
Complex joint system.Compound joint Its structure and function can be divided into 2 distinct system:Condyle disc complex.Condyle disc complex and articulating surface of mandibular fossa.Constant contact between joint surfaces for stability is required.Disc space more at rest, decreases with an increase in pressure of the joint


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Movement involving the joints has been divided different phases
Occlusal or rest position

Retruded opening phase or rotation

Early protrusive opening phase or functional opening

Late protrusive opening phase or translation

Early closing phase

Retrusive closing phase



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OCCLUSAL OR REST POSITION
The rest position is the first step and involves a static jaw position In this, the joint is in loose pack position,the connective tissue at restThe posterior band occupies the deepest part of the mandible fossa The intermediate zone and the anterior band lies between the condyle and posterior slope of the eminence


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RETRUDED OPENING PHASE OR ROTATION
The condyle rotates and moves 5 to 6 mm inferior to the intermediate zoneThe condyle joint surface glides forward and the medial pole of the condyle moves anterosuperiorly and the lateral pole moves posteroinferiorly The shape of inferior compartment changes the mostThe upper lateral pterygoid relaxes and the lower lateral pterygoid contractsThe posterior connective tissues is in a functional state of rest


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EARLY PROTRUSIVE OPENING PHASE OR FUNCTIONAL OPENING
The condyle moves inferiorly and anteriorly approximately 6 to 9 mm below the intermediate zone.The disk and the condyle experience the short anterior translatory glideThe upper and lower head of lateral pterygoid contract to guide the disk and the condyle shortly forwardThe posterior connective tissues is in a functional tightning


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LATE PROTRUSIVE OPENING PHASE
OR TRANSLATION
The condyle moves inferiorly and anteriorly beneath the anterior band i.e there is full opening more, space develops in the superior compartment The upper and lower head of Lateral pterygoid contract to guide the disk and the condyle fully forwardThe posterior connective tissues tightens


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EARLY CLOSING PHASE
The condyle translates posteriorly, about 6 to 9 mm, to the intermediate zoneThere is simultaneous reduction of space posteriorly in the superior compartment


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RETRUSIVE CLOSING PHASE
The condyle rotates superiorly but remains inferior to the posterior band This movement reduces the space in the inferior compartment The upper head of the lateral pterygoid contracts and The lower head of the lateral pterygoid relaxes This tightens the mandibular attachment, and forces blood from the posterior compartments The posterior connective tissues returns to the functional rest movements


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Is it difficult or painful to open the mouth (e.g., yawning)?

Does the jaw get stuck, locked, or go out?

Is it difficult or painful to chew, talk, or use the jaws?

Do the jaw joints make noises?

Do the jaws often feel stiff, tight, or tired? Is there pain in or about the ears, temples, or cheeks?

Are headaches, neck aches, or toothaches frequent?

Has there been a recent injury to the head, neck, or jaw?

Have there been any recent changes in bite?

Has there been previous treatment for any unexplained facial pain or a jaw joint problem?

QUESTIONAIRE



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Examination of TMJ



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MASSETER



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TEMPORALIS



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Lateral pterygoid



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Measurement of mouth opening



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To be continued.



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Sternocleidomastoid



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Cervical group



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Splenius and trapezius



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HORIZONTAL PLANE BORDER &
FUNCTIONAL MOVEMENTS

When mandibular movements are viewed in the horizontal plane, a rhomboid-shaped pattern can be seen that has a functional component, & 4 distinct movement components:-

1) Left lateral border

2) Continued left lateral border with protrusion

3) Right lateral border

4) Continued right lateral border with protrusion



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Left Lateral Border Movements
With the condyles in the centric relation position, contraction of the right inferior lateral pterygoid move the right condyle - anteriorly and medially. If left inferior pterygoid stays relaxed, with the left condyle still in the CR & result will be left lateral border movement. Left condyle- working or rotatory
Right condyle- non-working or

orbiting



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Continued Left Lateral Border Movements With Protrusion
With the mandible in the left lateral border position, contraction of the left inferior lateral pterygoid along with continued contraction of right inferior lateral pterygoid will cause the left condyle to move anteriorly to the right.


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Right Lateral Border Movements
Left condyle-orbitingRight condyle- rotatory


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Continued Right Lateral Border Movements With Protrusion



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LATERAL MOVEMENT
When lateral movement is executed the working condyle rotates & moves outward while, other non working condyle translates forward, medially downward orbiting around the rotating working condyle. The orbiting condylar path is known as sagittal lateral condylar path. Lateral condylar path is longer & more steep than the protrusive condylar path.


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PROTRUSIVE MOVEMENT
condylar translations


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Imaging
Trans-cranialTrans-pharyngealTrans-orbitalOPGSMVReverse-townesConventional tomographyComputed tomographyArthrographyMRI


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TRANS-CRANIAL



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Diagnostic information
Lateral aspect of joint space , glenoid fossa, articular eminence, condylar headPosition of the head of condyleShape of glenoid fossa and articular eminenceCondition of articular surface Gross osseous changes on the lateral aspect of condyleDisplaced condylar feacture


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TRANS-PHARYNGEAL



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Trans-pharyngeal



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Medial aspect of condyleErosive changes of condyle


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TRANS-ORBITAL



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Trans-orbital



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Entire mediolateral dimension of articular eminence, condylar head and neck is visibleCondylar neck fracturesMorphology of convex surface of condylar head can be evaluatedGross degenerative changes


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OPG



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Reverse-townes



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Diagnstic information
Shape of the condylar head and condition of articular surface from posterior aspectDirect comparison of both condylesFractures of head and neckCondylar hypo/hyper-plasia


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SMV



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AP Trans-maxillary



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Linear tomographyMulti-directional hypocycloidal tomographyMulti-directional computer controlled spiral tomography


Advantages
Assesment of whole jointPosition of the head of condyleShape of the head of condyleInformation of all aspects of jointPosition and orientation of fracture fragments


ARTHROGRAPHY



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Computed tomography



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Advantages
Images both hard and soft tissuesDisc condyle comlex can be evaluated3 D imageNo physical trauma


MRI



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MANDIBULAR TRACKING DEVICES
Disc displacement with reductionClick with deviationExact movement of mandible can be recordedDiagnose and monitor TMDSensitivity and specifity


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Sonography
Recording and graphically demonstrating joint soundsAudio-amplifying devicesUltra-sound echo recordingsSpecific disc derangementNo additional diagnostic information


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Vibration analysis
Intra-capsular and internal derangementMinute vibrations by condyleIdentifying disc displacementSelection of appropriate patient therapyPositve findingNon reducing derangement


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Thermography
Records and graphically illustrates skin temp.Various temperatures recorded by different colorsBilateral symmetrical thermogramAsymmetric thermogram associated with TMDIdentifying myo-facial trigger pointsShow greater variability of normal temp. In 2 sides of face


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CLASSIFICATION

I Masticatory muscle disorders

Protective co-contraction (11.8-4)*

Local muscle soreness (11.8.4)

Myofascial pain (11.8.1)

Myospasm (11.8-3)

Centrally mediated myalgia (11.8.2)

II Temporomandibular joint disorders

1. Derangement of the condyle-disc complex
Disc displacements (11.7.2.1) Disc dislocation with reduction (11.7.2.1) Disc dislocation without reduction (11.7-2.2)
2. Structural incompatibility of the articular surfaces

a. Deviation in form (11.7.1)

i. Disc

ii. Condyle

iii. Fossa



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b. Adhesions (11.7.7.1)

i. Disc to condyle

ii. Disc to fossa

c. Subluxation (hypermobility) (11.7.3)

d. Spontaneous dislocation (11.7.3)

3. Inflammatory disorders of the TMJ

a. Synovitis/capsulitis (U.7-4.1)

b. Retrodiscitis (11.7.4.1)

c Arthritides (11.7.6)

i. Osteoarthritis (11.7.5)

ii. Osteoarthrosis (11.7.5)

iii. Polyarthritides (11.7.4.2)

d. Inflammatory disorders of associated structures

i. Temporal tendonitis

ii. Stylomandibular ligament inflammation

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III Chronic mandibular hypomobility

1. Ankylosis (11.7.6)

a. Fibrous (11.7.6.1)

b. Bony (11.7.6.2)

2. Muscle contracture (11.8.5)

a. Myostatic

b. Myofibrotic

3. Coronoid impedance

IV. Growth disorders

1. Congenital and developmental bone disorders

a. Agenesis (11.7.1.1)

b. Hypoplasia (11.7.1.2)

c. Hyperplasia (11.7.1.3)

d. Keoplasia (11.7.1.4)

2. Congenital and developmental muscle disorders

a. Hypotrophy

b. Hypertrophy (11.8.6)

c. Neoplasia (11-8.7)



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TMJ DISORDERS

Classification:

1) Growth disorders and the joint
Developmental disorders.Acquired disorders.Neoplastic disorders.
2) Masticatory muscle disorders:
Protective muscle splinting.Muscle hyperactivity or spasm.Myositis (muscle inflammation).
3) Disk interference disorders (internal derangement)
Incoordination.Deformation of articular disk.Partial anterior disk displacement.Anterior disk displacement with reduction.Anterior disk displacement without reduction.Anterior disk displacement with perforation.Posterior disk displacement.


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4) Problems that result from extrinsic trauma:
Tendonitis.Myositis.Traumatic arthritis.Dislocations.Fracture.Internal derangements.
5) Degenerative joint disease:
Arthrosis (non-inflammatory phase).Osteoarthritis (inflammatory phase).Osteochondritis disecans.
6) Inflammatory joint disorders:
Synovitis and capsulitisRetrodiskitis.Inflammatory arthritis


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7) Chronic mandibular hypomobility:
Ankylosis.Fibrosis.Contracture of elevator muscle.Internal disk derangement.
8) Post surgical problems



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Acc. To fricton

I) Causalgic Disorders
Posttraumatic reflex sympathetic dystrophy Causalgia
II) Muscular Disorders
Myofascial pain syndrome (MPS) Myositis Fibromyalgia Contracture Recurrent spasm Secondary to collagen disease
III) Joint Disorders
TMJ capsulitisTMJ internal derangementTMJ ankylosisTMJ hypermobilityTMJ degenerative joint disease
Polyarthritis

Infectious

Traumatic

Metabolic

Rheumatoid



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Cervical degenerative joint disease

Cervical disk disorder

Disorder secondary to rheumatic disease



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ALDERMAN'S CLASSIFICATION OF TMD

Extracapsular

1. Psychlologic: Tension, anxiety, oral habits

2. latrogenic: Misdirected mandibular nerve block, excessive depression of mandible during anesthesia or oral procedures.

3. Traumatic: Blow to .face not involving fractures.

4. Dental: Occlusal abnormalities, periapical or periodontal lesion mobile, sensitive or damaged teeth and ulcerations.

5. Infections: Secondary or arising outside the joint.

6. Otologic: Otitis media or external ear infection.

7. Neoplastic; Parotid gland, neoplasm or tumor.



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Congenital: Agenesis, hyperplastic or hypoplastic condyle.

Infections: Primary bacterial infection within the joint

Arthritic: Rheumatoid arthritis, osteoarthritis, psoriatic arthritis, uvenile chronic arthritis

Traumatic: Fractures, disc tears.

Functional: Subluxation, dislocation, disc derangements, Hypermobility, ankylosis.

Neoplastic: Benign or malignant tumors.

Intracapsular



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CONCLUSION



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