Hesham N. Alrowayeh, P.T., Ph.D.

Assistant Professor of Physical Therapy

Kuwait University
Introduction
! TMJ is one most frequently used joints in the body
! It is involved in talking, chewing, and swallowing

Part I: Part II: Part II:

Structure of TMJ Function of TMJ Disorders of TMJ
1. Articular surfaces 1. Mandibular Motions 1. Development conditions
2. Articular disk 2. Control of TMJ motion 2. Inflammatory conditions
3. Capsule and ligament 3. Osseous Conditions
4. Muscles 4. Degenerative conditions
5. Vascular supply 5. Trauma conditions
6. Innervations 6. Muscular conditions
7. Articular disk conditions
8. Neoplasm conditions
 Part I:
Structure of TMJ
Structure - Articular surfaces

! A modified hinge type of synovial joint

! It is formed by
! Articular eminence of temporal bone
! Articular disk
! Condyle of mandible

! It is classified as a synovial joint,

although no hyline cartilage covers
the articular surfaces
 Structure - Articular surfaces
Mandible
! The mandible is the distal or moving articular segment of
TMJ.
! It is U-shaped bone that supports lower teeth and makes
up the lower facial skeleton
! It is divided into a body and two rami, with each ramus
having a coronoid process and a mandibular condyle
! Coronoid process serves as an attachment for the muscle
! The anterior portion of the mandibular condyle is the articular
portion and it’s composed of trabecular bone
 Structure - Articular surfaces
Temporal bone
! The mandibular condyles sit in the glenoid fossa of the temporal
bone
! The glenoid fossa is located between the posterior glenoid spine and
the articular eminence
! The bone in the glenoid fossa is thin and translucent*
! The articular eminence, however, has a major area of trabecular bone
and serves as the primary articular surface for the mandibular
condyle

*NOT appropriate for an articular surface

 Structure - Articular surfaces

! The articular surfaces of the articular eminence of the

temporal bone and the mandibular condyle are covered
with dense, avascular collagenous tissue that contains
some cartilaginous (Fibrocartilage), instead of hyline
cartilage
! Fibrocartilage can repair and remodel, and withstand
repeated and high-level stress Thus, the TMJ can
withstand tremendous bite forces
 Structure - Articular disk
! It is biconcave = bowtie, dense fibrous tissue
! 3 regions varies in thickness, vascularity, innervations:
! Anterior: 2 mm, vascular, innervated
! Center region : 1 mm, avascular, not innervated**
! Posterior: 3 mm, vascular, innervated
! The Variation: thick-thin-thick arrangement of the disk provides a
self-centering mechanism for the disk on the condyle
! It allows TMJ congruency (convex articular eminence and condyle )
! It reduces friction and biomechanical stress on joint

**Force-accepting segment
 Structure - Articular disk

! Posteriorly it attaches to the joint capsule and to the superior and

inferior laminae ‡
! Anteriorly it attaches to the joint capsule and to the superior
portion of the lateral pterygoid muscle †

‡ This control disk anterior translation and assists in its repositioning during mouth opening
† This restrict posterior translation of the disk
 Structure - Articular disk

! The articular disk ÷ the TMJ

" Lower joint: formed by mandibular condyle and inferior surface of the
disk
! It is hinge joint

" Upper joint: formed by articular eminence and superior surface of the disk
! It is plane joint
Structure - Capsule

Capsule
! Joint capsule is not well defined
! Thin and lose in its anterior *, medial, and posterior aspect
! Highly vascular and innervated**
! Strong and reinforced in its lateral aspect

*Lack of strength of the capsule anteriorly and the incongruence of the bony articular Anterior Dislocation of the joint
** Provides a great deal of information about position and movement
 Structure - Ligaments
Ligaments
Three functional ligaments (support TMJ):
! Collateral (diskal) ligaments
! Capsular ligament
! Temporomandibular ligament*
Two accessory ligaments:
! Sphenomandibular ligament*
! Stylomandibular ligament*

! Play important role in protecting the joint

! Collagenous connective tissue (do not stretch)
! Do not actively enter into joint function. Instead, they act as
passive restraining devices to limit border movements

* Primary ligaments
Structure - Ligaments
Collateral (diskal) ligaments ÷ *
" Medial diskal: Attaches the medial edge of disc to the medial pole of the condyle
" Lateral diskal : Attaches the lateral edge of the disc to the lateral pole of the condyle
" Serves to 1) divide the joint into superior and inferior joint cavities
2) restrict movement of disk away from the condyle.

Capsular ligament
" Encompass the entire TMJ
" Serves to 1) resist any medial, lateral, or inferior forces that tend to separate or dislocate the
articular surfaces
2) Retraining synovial fluid by encompassing the joint
3) Provides proprioceptive feedback regarding position and joint movement

*vascular and innervated, thus provides information regarding joint position and movement
 Structure - Ligaments
Temporomandibular Ligament ÷
" Outer Oblique: attaches to the neck of the condyle and articular eminence
" Serves as 1) Suspensory ligament and limits downward and posterior motion of mandible
2) control rotation of condyle during mouth opening
" Inner horizontal: attached to lateral pole of the condyle, posterior portion of disk,
and to articular eminence
" Serves to resist posterior motion of the condyle

Stylomandiblar Ligament
" band of deep cervical fascia
" runs from the styloid process of the temporal bone to the posterior border of the
ramus of mandible
" Serves to limits protrusion of the jaw†

Sphenomandibular Ligament:
" Attaches to the spine of the sphenoid bone and to the middle surface of the ramus of
mandible
" Serves to 1) suspend the mandible
2) check the mandible from excessive forward translation†
† controversy
Structure - Muscles
! The muscle surrounding TMJ create great force during biting or
chewing, yet they generate finely controlled motion that requires little
force during speaking and swallowing
! TMJ movements are produced mainly by
Temporalis* Medial and Lateral pterygoid *

Masseter * Digastric†

*Muscles of mastication
† Not generally considered as muscle of mastication
 Structure - Muscles
! Masseter
! Rectangular shape
! Originates from zygomatic arch and extends downward to lateral aspect of
lower border of the mandible
! Consists of two portions/heads:
a. Superficial portion
b.Deep portion

! Function:
! Powerful force to elevate the mandible for chewing food
! Superficial portion, aids in protruding the mandible.
! Deep portion, stabilization of the condyle.
 Structure - Muscles
!Temporalis
! Large fan-shaped muscle
! Originates from temporal fossa and lateral surface of the skull
! Inserts on the coronoid process and anterior border of the ascending
ramus
! Divided into three distinct areas (according to fiber direction and
function):
1. Anterior portion: vertical fibers
2. Middle portion: fibers run obliquely across lateral aspect of skull
3. Posterior portion: fibers almost horizontal, coming forward above the ear to join
with other temporal fibers under the zygomatic arch.
! Function
! Temporal muscle contracts: mandible is elevated and teeth brought into
contact
! If only certain portions contract; mandible moves according to fibers
direction which are activated
! Anterior portion: mandible raised vertically
! Middle portion: elevates and retrudes the mandible.
 Structure - Muscles
Medial pterygoid
! Originates from the pterygoid fossa and extends downward, backward, and
outward
! Inserts along the medial surface of the mandibular angle.

! Function:
! Along with the masseter, it forms a sling to support the mandible
! When it contracts, mandible is elevated
! Mandible protrusion
! Deviate mandible to opposite side
 Structure - Muscles
Lateral pterygoid: Two bellies which have opposite functions:
1. Inferior lateral pterygoid muscle
! Originates at the outer surface of the lateral pterygoid plate.
! Extends backward, upward, and outward and inserts onto the neck of the
condyle
! Function:
! Bilateral contraction: mandible protrusion
! Unilateral contraction: lateral movement of mandible
! Also functions as mandible depressor

2. Superior lateral pterygoid muscle†:

! Considerably smaller than the inferior
! Originates at the infratemporal surface of the greater sphenoid wing
! Extending almost horizontally, backward, and outward and inserts on the
articular capsule, the disk, and neck of condyle.
! Function:
! Active during the power stroke (closure of the mandible against resistance) such as
clenching the teeth together
†80% slow fibers (type 1): resistance to fatigue and bracing of condyle for prolonged periods of time
 Structure - Muscles
Digastric ÷ into two portions/bellies:
1. Posterior belly
! Originates from mastoid notch, extends forward, downward, and
inward to the intermediate tendon.
! Attaches to hyoid bone
2. Anterior belly:
! Arises from of the inferoer mandible, extends downward and
backward
! Inserts to the intermediate tendon.
Function:
! Depress* and pull the mandible backward
! When mandible is stabilized, digastric, infrahyoid, and suprahyoid muscles elevate
the hyoid bone (necessary for swallowing)

*the primary muscles responsible for mandibular depression

Vascular Supply

The vascular supply to entire

region of the deep face is
provided by the branches of
the maxillary artery along
with a small contribution
from the middle temporal
artery to the superior surface
of the temporalis muscle.

Supplies
Ear, TMJ, meninges, muscles of mastication, teeth and
supporting structures of mandible, buccinator muscle,
cheecks, and mucous membrane of mouth.
Innervation
Trigeminal nerve

Joint capsule is richly endowed

with sensory endings from
mandibular division of the
trigeminal nerve (mostly from
articular branches of the
auriculotemporal nerve)

Additional articular branches

supplying the joint are derived
from: masseteric branch (from
mandibular division of trigeminal
nerve)
 Part II:
Function of TMJ
 Function - Mandibular motions

! Mandibular motion plays a role in phonation,

Facial expression, mastication, and swallowing
! Movements of mandible include
! Mandibular depression: mouth opening
! Normal mouth opening is consider to be 40 to 50 mm
! Clinician may use proximal interphalangeal (PIP) joint to assess opening ‡
! Mandibular elevation: mouth closing
! Mandibular protrusion: Jutting the chin forward
! Mandibular retrusion: sliding the teeth backward
! Lateral deviation of the mandible: sliding the teeth to either side
! Normal lateral excursion is 8 mm
! Functional measure: width of two upper central incisors

! Movements of TMJ are created by various combinations of

rotation and gliding in the upper and lower joints
‡ 3 fingers or 2 knuckles between upper and lower central front incisors
 Function - Mandibular motions
Mandibular depression and elevation†
! 1st model describe two sequential phases:
! Rotation: there is pure anterior spin of the condyle on the disk in the lower
joint*
! 11 to 25mm is gained from rotation
! Gliding: there is translation of the disk-condyle unit anteriorly and inferiorly
along the articular eminence in upper joint
! 2nd model argues that rotation and gliding are concomitantly

* Also described as posterior rotation of the disk on the condyles

† Mandibular elevation is the reverse of depression
 Function - Mandibular motions

Control of disk during mandibular depression and elevation

Passive control: capsuloligamentous attachments of the disk to the condyle
Active control: superior portion of the lateral pterygoid muscle
 Function - Mandibular motions

Muscular control during mandibular depression and elevation

Mandibular depression:
1) Mainly gravity
2) Controlled by concentric action of digastric and the inferior portion of
lateral pterygoid muscles

Mandibular elevation:
1) Produced by concentric action of masseter, temporalis, and medial
pterygoid muscle
 Function - Mandibular motions
Mandibular protrusion and retrusion
During protrusion
! Condyle and disk translate anteriorly and inferiorly along the articular eminence *
! Translation motion occurs in the upper joint
! The posterior attachment (Bilaminar retrodiskal tissue) stretch 6 to 9 mm

During retrusion**
" Tension in the temporomanibular ligament AND Compression of soft tissue in
retrodiskal area between condyle and posterior glenoid spine limits this motion

* no rotation occurs
** Retrusion is the reverse of to protrusion
Function - Mandibular motions

Mandibular lateral deviation

! One condyle spins around vertical axis and the other one
condyle translate forward
Ex. deviation to R: R condyle spinning and L condyle translating
 Part III:
Disorders of TMJ
Introduction

Temporomandibular disorders (TMD): is an umbrella name that

includes acute and chronic dysfunctions and conditions affecting the
TMJ or masticatory muscles

! The TMJ is susceptible to many of the conditions that affect

other joints in the body, including: ankylosis, arthritis, trauma,
dislocations, developmental anomalies, and neoplasia
 Introduction

! TMD are common in the younger adults (20-40 years old)

! TMD are more common ♀ than ♂ (2:1)*
! It is estimated that 65% to 85% of population will develop TMJ
disorder1
! Approximately 12% will be chronic cases
! It is estimated that2
! 20% to 25% of population with symptoms
! 50% to 75% of population with signs
! 4% of population will seek treatment

1:!Erstad & Shannon, 2006

2: Davies, 2007
*especially women on hormonal therapy
 Introduction
! Possible causes of TMD are:
• Mechanical stress1 : most critical factor in the etiology
• Trauma (i.e. motor vehicle accidents)
• Poor oral habits (i.e. Bruxism: grinding teeth)
• Ligament laxity
• Poor posture
Head and neck position may affect the position or function of the mandible, because
many of the muscles that attach to the mandible also have attachment to the head
Example: Forward head position

1: Matsumoto M. et al, 2002; Tanka E. et al., 2000

Forward head posture Shortening of posterior cervical muscles
Due to postural habits or injury

1. Extension of head
2. Forward movement of shoulder
girdle complex

To adapt: move head forward to maintain

his horizontal plane

anterior neck muscle activity

Alter the occlusion

Tightness in throat and

swallowing difficulties

Mandible postured inferiorly

and posteriorly
General signs and symptoms of TMD
! Pain and tenderness in the area of
jaw
! Limited or altered mandibular
function. (i.e., hypermobility)
! Crepitation, clicking and popping
noises
! Deviation of the mandible on
opening
! Disturbed chewing patterns
! Locking of the jaw
TMJ Developmental Disorders
! Rarely cause TMD symptoms
! Main problem in function.
1. Aplasia: Incomplete or
faulty development of the
mandible or cranial bone.
• Common syndrome:
Hemifacial microsomia.
• Condyle and ramus of
mandible severely deficient
• Affects muscles and fascia
overlying bone
• Internal auditory mechanism
often affected
• Little or no articular fossa.
 TMJ Developmental Disorders

2. Hypoplasia: Underdevelopment of the mandible or cranial bone

• Common syndrome: Treacher-Collins (Mandibulofascial
dysostosis)
• Severe underdevelopment of maxilla and mandible
bones.
TMJ Developmental Disorders

3. Hyperplasia: Overdevelopment of the mandible or cranial bone.

• Common syndrome: Fibrous Dysplasia.
• Fibrous connective tissue in cortical bone and slow
growing of maxilla or mandible bones
TMJ Inflammatory Disorders
1. Capsulitis: Inflammation of joint capsule related to sprain of the
capsular ligaments due to trauma or joint dysfunction.
2. Synovitis: Inflammation of the synovial lining of the joint usually due
to infection, trauma or cartilage degeneration
3. Rheumatoid Arthritis (RA): Chronic systemic (autoimmune ) condition
with articular and extra-articular involvement
• TMJ RA signs and symptoms
o Pain around joint
o Stiffness
o Edema
o Warmth
TMJ Degenerative Disorders
Osteoarthritis (OA): is a degenerative disease that affect the TMJ, causing
deterioration of the articular surfaces with subchondaral bone
remodeling.
• OA is common among elderly (40% incidence around age 40 years)
• More common in women
• Based on etiology, OA ÷
• Primary Osteoarthritis: No identifiable etiological factor
o wear and tear associated with aging.
o overloading parafunctional habits.
• Secondary Osteoarthritis: Identifiable cause or etiological factor
o Direct trauma.
o TMJ Infection.
TMJ Degenerative Disorders – Osteoarthritis

• TMJ OA signs and symptoms:

o Aching pain around joint, pain increase during mastication
o Stiffness of jaw muscles around morning.
o Crepitation. (one or both joints)
o Sublaxation or locking of joint.
o Subchondaral sclerosis.
o Osteophyte formation.
TMJ Osseous Mobility Disorders

1. TMJ ankylosis: severely restricted joint movement

Two types:
! Fibrous: membrane hardening and fusion
! Bony: bony proliferation and fusion
TMJ Osseous Mobility Disorders

2. TMJ Dislocation: Translation of the condylar head beyond the crest

of the eminence
! Sudden onset (i.e. Whiplash injury)
! Involvement
! bilateral dislocation*: symmetrical open mouth
! unilateral dislocation: jaw deviate to unaffected side
! Signs
! Anterior displacement.
! Jaw open beyond limit
! X-ray: condyle out of fossa

* More common
TMJ Traumatic Disorders

Mandible Fractures: mostly fracture of the condyle neck †* or

subcondyle bone due to trauma
! Main etiological cause: RTA 43%
! Involvement
! Unilateral fractures are 3 times more than bilateral involvement
! Signs
! Severe pain,
! Movement interruption

*Because Condyle neck is thin area

†Possibly cause injury to the auriculotemporal nerve
TMJ Muscular Disorders
1. Myositis: acute inflammation
! Etiology
o direct hit or infection.
! Signs
o pain
o decreased ROM
o edema
2. Fibromyalgia: active trigger points >> diffused pain.
! Affect women more.
! Cause sleep disturbance.
TMJ Muscular Disorders
3. Myospasm: protective contraction due to trauma, sudden opening
of mouth.
4. Masticatory muscles contracture: develops if myospasm not
treated.
! Fibrous tissue develops in muscle.
! Decreased ROM.
Pain and tenderness of the masticatory muscles

Digastric

Lateral pterygoid

Masseter
TMJ Disk Disorders
Disk displacement is an internal derangement of TMJ, in which condylar head
articulating with the disc more posteriorly on its posterior zone instead of
intermediate zone
! It may be identified by diagnostic imaging or physical examination
! It is ÷
1. Disk displacement with reduction
2. Disk displacement without reduction
 TMJ Disk Disorders - Disk displacement with reduction

! It is the most common disk derangement

! It is usually due to trauma (i.e. whiplash, blow)
! Sign:
! May or may not report pain
! Possible deviation toward affected side
! Joint noise (reciprocal click ) during mouth opening and closing*
! Mechanism
! The superior lateral pterygoid muscle pull the disk anteriorly entirely out of the disk
space, so the condyle is no longer articulating with the disk
! Thus, the mandibular condyle is in contact with the retrodiskal tissue at rest
! On mouth opening, the condyle slips forward and under the disk to obtain normal
relationship with disk
! On mouth closing, the condyle slips out from under the disk
*Timing of click determine prognosis, early is better
TMJ Disk Disorders - Disk displacement without reduction

! It is usually due to previous trauma

! Patient is unable to recapture the disk into its normal position between the
condyle and fossa/eminence during its translatory movement , possibly
due to overstretched posterior attachment to the disk

! Sign:
! Permanent dislocation
! Jaw locking in open postiosn
! May or may not report pain
! Limited ROM, as well as difficulty performing functional movement
(chewing, talking, yawning)
! Imaging: arthritic changes
TMJ Neoplasm Disorders

! Uncontrolled growth of abnormal tissue arising in or effecting the

joint

! May be benign, malignant or metastatic.

! Bone or cartilage origin

TMJ Neoplasm Disorders

1. Osteoma:
• Neoplasm of Primary Bone Origin
• Well differentiated mature bone tissue: slow growth
• Benign neoplasm
• Occur in patients between 15-30 years old.
• Often asymptomatic
TMJ Neoplasm Disorders

2. Chondroma: is a benign tumor characterized by the formation

of mature cartilage
• Extremely rare in jaw
• If It exist: in maxilla
• Mostly in soft tissue: tongue
TMJ Neoplasm Disorders

3. Osteosarcoma: malignant tumor characterized by the direct

formation of bone tissue by the tumor
cells
• Seen in patients between 10-25 years old
• More in men
• Approximately 6% of all osteosarcomas are in jaw : in mandible.
• Most are centrally located in the bone
• Symptoms
• Swelling
• Mobile teeth
• Toothache