SURGICAL ANATOMY OF

TEMPOROMANDIBULAR JOINT

Haritha K R
JR-1
OMFS
King George’s Medical Univers
 • Introduction
CONTENTS:

• Superiority of joint

• Components

• Vascular supply

• Nerve supply

• Applied aspect
INTRODUCTION
The Temporomandibular joint ( craniomandibular
joint/articulation) is composed of the glenoid fossa of the
squamous temporal bone, the condylar head of the
mandible, and a specialized dense fibrous connective tissue
structure, the articular disk, as well as several ligaments

and associated muscles .

Diarthroidal joint
Anatomically Synovial joint

Compund joint
Functionally
Ginglymoarthrodial joint
 COMPOUND JOINT

• By definition, a compound joint requires the presence of at

least three bones, yet the TMJ is made up of only two bones.

• Functionally, the articular disc serves as a nonossified bone

that permits the complex movements of the joint.

Ginglymoarthroidal joint
ypes of movements takes place in single joint….

lower compartment permits hinge motion or rotation and, hence

med ginglymoid.

superior compartment permits sliding (or translatory) movemen

refore, called arthrodial.

 Superiority of joint
highly specialized unique joint and has got many

nctive characteristics:

sc -avascular fibrous cartilage

rticular surfaces-dense fibrous

cartilage
Stabilization of joint is based on:

1)continuation between 2 joints

2)dentition

3)neuromuscular balance
e Rigid end point- The TMJ is the only joint to hav
d end point of closure, produced as a consequen
h contacting.

le in growth of mandible:
Growth centre
Adaptive growth centre
• The TMJ has more intimate proximity to vital structures

than any other articulation (except portions of the vertebral column).

COMPONENTS
OF TMJ

• Bony components

• Articular disc

• Ligaments

• Cartilage and synovium

• Retrodiscal tissue.

• Musculature-active
component
 Bony components

• Articular tubercle

• Anterior part of mandibular

fossa

• Posterior nonarticulat part

formed by the tympanic plate.

• The inferior articular surface is

formed by the head of the

mandible.
 components
l components:

icular or mandibular fossa of squamous temporal bone

ncave structure extending from posterior surface of articular
nence to post glenoid tubercle

surface of mandible fossa of temporal bone is very thin and

or stress bearing area for TMJ.
icular eminence : Transverse bony prominence on zygomatic

continuous across articular surface mediolaterally.

gly convex anterolaterally ,somewhat concave mediolaterally.

lar surface is usually thick and serves as a major component of T

5)Posterior articular ridge and post glenoid

process-

• The posterior part of mandibular fossa is

anterior margin of petrotympanic fissure

and is elevated to form a ridge known as

posterior articular ridge or lip.

• The ridge increase in height laterally to form

a thickened cone shaped prominence called

post glenoid process immediately anterior

to external acoustic meatus.

dylar component of mandibular bone:
articular part of the mandible is an ovoid condylar proc
d) with narrow mandibular neck.

nsion -
olaterally:13-25mm
roposteriorly :5.5-16mm
e articular surface lies on its anteriosuperior surface, the facing

osterior slope of articular eminence.

urther continues medially down and around medial pole of cond

ce entoglenoid process where jaw is held in occluded position.

• Morphologic changes occur in condyle due to

simple developmental variability as well as

remodelling of condyle to accomodate trauma,

malocclusion or other developmental

abnormalities.
 Histology of articular surface of
condyle:

Layers :

1)Articular zone

2)Proliferative zone

3)Chondroblastic zone

4)Hypertrophic zone

5)Erosive zone
ular layer:
most superficial layer

sists of fibrous connective tissue with scattered cells,

ontinuation with outer layer of periosteum

ctions as a protective covering for the underlying cartilaginous tis

Proliferative layer:
• The cells have multilineage potential, can differentiate into

osteoblasts or chondrocytes or fat progenitor cells

• Under physiological conditions, differentiate into

chondrocytes.

• Under non-functional conditions, during excessive tensile

loading undergo chondrogenic differentiation and replaced

by intramembranous bone.
Chondroblastic layer
• Contain chondrocytes
and chondroblasts
distributed through out
the zone.
• This zone shows active
deposition of cartilage
characteristic matrices.
Hypertrophic cell layer

• Terminal differentiation of

chondrocytes leads to replacement of

cartilage with bone(endochondral

ossification).

• Chondrocyte hypertrophy contribute

most to condylar growth.

 Articular disc
• Biconcave dense fibrous connective tissue,
nonvascularized and noninnervated; as an
adaptation to resist pressure.

• It receives nourishment from synovial fluid.

• It divides the cavity into larger upper and small

lower compartment.
natomically (from lateral view):
Anterior band -thicker-2mm
Central intermediate zone-thinnest-1mm
Posterior band-thickest -3mm

• Superior surface of disc- saddle shaped to fit

cranial contour ,

inferior surface is concave to fit the condyle.

• Disc is flexible and adapts to functional demands

of articular surfaces.
• The articular disk is attached to the capsular ligament

anteriorly, posteriorly, medially, and laterally.

• Some fibers of the superior head of the lateral pterygoid

muscle insert on the disk at its anteromedial aspect,

serving to stabilize the disk

• When the mandible is in closed mouth position ,the

posterior band of disc lies immediately above

condyle in 12’o clock position.

ompartments of joint space
ular disc divides the joint space in 2 compartments

volume of the upper joint space is about 1.2 mL and of th

r joint space is about 0.9 mL.

uperior compartment or temporodiscal compartment:

Between disc and temporal bone /glenoid fossa

Permits translatory or gliding movements.

ferior compartment or condylodiscal compartment:

Condylodiscal complex between condyle and disc

permits rotational movements

tional/hinge movements occurs during initial 20-25mm

slatory movements occurs when mouth is excessively op

etrodiscal tissue (Bilaminar zone)
• Highly vascular and highly innervated structure, involved
in production of synovial fluid.

• Superior retrodiscal lamina-contains elastic fibers, which

attaches to post glenoid process

• Functions as restraint to disc displacement in extreme

translatory movements (yawning)
Above the posterosuperior aspect of the condyle and anterior to
the bilaminar zone, the disk is very vascular and this region is
called the vascular knee (genu vasculosa).
The articular surfaces of temporal bone

and condyle is covered by fibrocartilage

• Capacity to regenerate and remodel

under functional stress

• Deep to the fibrocartilage layer,

particularly on the condylar head, is a

proliferative zone of cells that may

develop into either cartilaginous or

osseous tissue, based upon functional

• Receives nourishment primarily by diffusion from the synovial fluid.
loads.
• Capsular ligament is lined by synovial membrane ,a
Synovial fluid:
thin smooth, richly innervated vascular tissue .

• Synovial cells are thought to be site of production of

hyaluranoic acid.

• Synovium is capable of rapid and complete

regeneration after injury.
.

• Usually less than 2 ml is present in each healthy

functional TMJ.
ovial fluid- an ultrafiltrate of plasma
ntents -hyaluronic acid ( responsible for viscosity )
Proteins identical to plasma proteins(high percentage
albumin and less alpha2 globulin
Alkaline phosphatase
Leucocytes(count being less than 200/mm3
Functions:
• Lubrication of joint
Boundary lubrication
Weeping lubrication
• Phagocytosis
• Nourishment of articular cartilage
igaments-limits the TMJ movements
Accessory
unctional ligaments/necessary ligaments – ligaments -
Collateral ligament • Sphenomandibular ligament
Capsular ligament • Stylomandibular ligament
Temporomandibular ligament
Collateral or discal ligament:

• Short ,paired structures

attaching the disc to lateral and

medial poles of each condyle.

• Function- restrict movement of

disc away from condyle thus

allowing smooth synchronous

motion of disc -condyle complex.

Capsular ligament
• Attaches superiorly to temporal bone along
border of mandibular fossa and eminence and
inferiorly to neck of condyle.

• Surrounds joint space and disc ,attaching

anteriorly and posteriorly as well as medially and
laterally ,where it blends with collateral
ligaments.
• Functions-
Resist medial ,lateral and inferior forces thereby
holding the joint together.
Contain synovial fluid with joint spaces.
• Anteriorly the capsule has an orifice through which tendon

of lateral pterygoid passes

• This area of relative weakness in the capsular lining can

become a source of possible herniation of intraarticular

tissue and this in part may allow forward displacement of

disc.
mporomandibular ligament:
• Located on lateral aspect of each TMJ

• Outer oblique portion-limit the inferior distraction of

condyle during function-translatory and rotational

movements

• Inner horizontal portion-limits posterior movement of

condyle, during function- pivoting movements like lateral

movement while chewing.

• Serves to protect retrodiscal tissue

• Medial slippage of condyle is prevented medially
by entoglenoid process and laterally by
temporomadibular ligament.

• It mainly limits the anterior excursion of the jaw as

well as prevents posterior dislocation, hence, it is
called as “check ligament” of TMJ.
phenomandibular ligament:
Arise from spine of sphenoid and descends to fan

like insertion on lingula of mandible as well as

lower portion of medial side of condyle.

Remnant of Meckel's cartilage.

Relations:

Laterally- lateral pterygoid muscle

Posteriorly- auriculotemporal nerve

Anteriorly- maxillary artery

Inferiorly- inferior alveolar nerve and vessels ,lobule of parotid

gland

Medially -medial pterygoid with chorda tympani nerve,

Function
pharyngealofwall
sphenomandibular
and veins. ligament

• serves to some degree as a point of rotation during activation of the

lateral pterygoid muscle, thereby contributing to translation of the
mandible
tylomandibular ligament:
• Specialised dense local concentration of deep cervical fascia.

• Descends from the styloid process to the posterior border of the angle
of the mandible and also blends with the fascia of the medial
pterygoid muscle.

• Function as a point of rotation and also limits excessive protrusion of

the mandible.

• This ligament becomes tense only in extreme translatory movements,

hence considering it only as accessory ligament.
Musculature:
• Temporalis

• Masseter

• Medial pterygoid

• Lateral pterygoid
Temporalis :
• The temporalis muscle is a large, fan-shaped muscle taking its
origin from the temporal fossa and lateral aspect of the skull.

• Its fibers pass between the zygomatic arch and the skull and
insert on the mandible at the coronoid process and anterior
border of the ascending ramus down to the occlusal surface of
the mandible, posterior to the third molar tooth.
In an anteroposterior dimension,
the temporalis muscle consists of
three portions:
• anterior, whose fibers are
vertical;
• middle, with oblique fibers;
• posterior, with semihorizontal
fibers passing forward to bend
under the zygomatic arch.
Function :

• Elevate the mandible for closure.

• Contraction of the middle and posterior portions of the temporalis

muscle can contribute to retrusive movements of the mandible.

• To a small degree, unilateral contraction of the temporalis assists in

deviation of the mandible to the ipsilateral side.

Masseter

• Short rectangular muscle taking its origin from the

zygomatic arch and inserting on the lateral surface of
the mandible,

• Most powerful elevator of the mandible and functions to

create pressure on the teeth, particularly the molars, in
chewing motions.
• Composed of two portions

Superficial portion: originates from the lower border of the zygomatic bone and

the anterior two thirds of the zygomatic arch and passes inferiorly and posteriorly

to insert on the angle of the mandible.

Deep portion: originates from the inner surface of the entire zygomatic arch and on

the posterior one third of the arch from its lower border, insert on the mandible on

its lateral aspect above the insertion of the superficial head.

Electromyographic studies show that the deep layer of the masseter
is always silent during protrusive movements and always active
during forced retrusion, whereas the superficial portion is active
during protrusion and silent during retrusion.

Similarly, the deep masseter is active in ipsilateral movements but

does not function in contralateral movements, whereas the
superficial masseter is active during contralateral movements but not
in ipsilateral movements.
Medial pterygoid
Origin- pterygoid fossa and lateral pterygoid plate, some fibers
from the tuberosity of the maxilla and the palatine bone
Insertion- medial surface of the mandible, inferiorly and posteriorly
to the lingula.
Function:
• elevation of the mandible
• unilateral protrusion in synergism
with the lateral pterygoid to promote
rotation to the opposite side.
Lateral pterygoid

Has 2 portions
The superior head
• Origin-infratemporal surface of the greater sphenoid wing,
• Insertion- superior aspect of the pterygoid fovea, the articular
capsule, and the articular disk at its medial aspect, the medial pole
of the condyle.

The larger inferior head

• Origin- lateral surface of the lateral pterygoid plate. 9

• Insertion - neck of the mandibular condyle(pterygoid fovea)

Functions :

Superior head: retrusion , closure and ipsilateral movement

of mandible

Inferior head: protrusion ,opening ,contralateral movement of

mandible .
Predominant vessels:
• superficial temporal artery from the
posterior
• middle meningeal artery from the
anterior
• internal maxillary artery from the
inferior
Other important arteries are :
• deep auricular
• anterior tympanic
• ascending pharyngeal arteries.

Condyle receives its blood supply

by inferior alveolar artery and
feeder vessels that enter directly
into condylar head from larger
vessels.
Venous drainage:

Venous blood drain through superficial temporal vein and

maxillary vein.

Veins follows the arteries.

Lymphatic drainage
Anterior surface-parotid lymph nodes

Posterior surface-submandibular lymph nodes

Medial surface-submandibular lymph nodes

Lateral surface-preauricular lymph nodes

•Branches
Nerve of the mandibular nerve (V3) provide the affere
supply
innervation.
• Most innervation is provided by the auriculotemporal
nerve as it leaves the mandibular nerve behind the joint
ascends
laterally and superior to wrap around the posterior regio
the
joint.
• Additional innervation is provided by the deep temporal
masseteric nerves.
Applied anatomy
Anatomical variations which may predispose the joint

for internal derangement are;

1)morphological changes in the condylar head

and glenoid fossa

2)steepness of the articular eminence

3)laxity of ligament

4)changes in associated structures like

muscles,teeth etc.
Facial nerve
Extra cranial course -passes near the neck of condyle
before dividing into terminal branches.
One should be accurately aware of relationship and the
facial planes through which this nerve pass in order to
avoid facial nerve paralysis
Freys syndrome/auriculotemporal nerve syndrome

Damage to auriculotemporal nerve lead to inappropriate

regeneration and innervation of this nerve to near by sweat
glands leading to gustatory sweating.
atment :
nticholinergics
otulinum toxin
ympanic neurectomy
heet of fascia lata between skin and underlying fat
Superficial temporal artery :
It runs posterior to neck condyle and
ascends to reach temporal fossa.

Any upward extension of incision kept in

posterior area leads to a blood filled
operation.

Incision should be placed close to the

cartilage of external auditory meatus and if
any temporal extension is needed this is
taken high up before bringing incision
forward to develop the flaps that only
peripheral branches are cut and main
nternal maxillary artery
• Arises behind the neck of the mandible;

• It passes forward between the mandible and the

sphenomandibular ligament, and then runs, either superficial

or deep to the lateral pterygoid muscle, to the

pterygopalatine fossa.

• Lies very close to the condylar neck and is at risk during

section of condylar neck.

Internal maxillary artery is site of massive haemorrhage

intraoperatively

To prevent damage to this structure subjacent soft tissue

should be protected by sub periosteal guard prior to

section either with bur or osteotome.

Packing is suggested as the first

attempt to tamponade the

hemorrhage.

Several techniques have been

suggested to control bleeding

from the internal maxillary artery

such as ligation of the external

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