Anatomy of the structures medial to the temporomandibular joint

Nojan Talebzadeh, DMD, MD,a Tracy P. Rosenstein, DMD,b and M. Anthony Pogrel, DDS, MD, FRCS, FACS,c San Francisco, Calif
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

Objective. To define the relationship of the branches of the trigeminal nerve and the infratemporal vessels to the zygomatic
arch and medial capsular ligament of the temporomandibular joint (TMJ).

Material and method. In a study of 20 cadaveric dissections of the infratemporal fossa, measurements were obtained in anterior-posterior and transverse directions to identify the relationship of the trigeminal nerve, carotid artery, internal jugular vein, and middle meningeal artery to the zygomatic arch. The distance from the lateral to the medial aspect of the glenoid fossa was measured to further delineate the proximity of these structures to the medial portion of the capsule of the TMJ. Results. The mean transverse distance from the zygomatic arch to the middle meningeal artery was 31 mm (range, 21 mm to 43 mm). The mean anterior-posterior distance from the height of the glenoid fossa to the middle meningeal artery was 2.4 mm (2 mm to 8 mm). The transverse distance from the carotid artery to the zygomatic arch was a mean of 37.5 mm (29 mm to 48 mm) with the mean anterior-posterior distance of 6.5 mm (21 mm to 6 mm). The mean distance from the internal jugular vein to the zygomatic arch was 38.3 mm (31 mm to 49 mm). The mean anterior-posterior distance was 8.7 mm (20 mm to 7 mm). The transverse distance from the trigeminal nerve to the arch was a mean distance of 35 mm (24 mm to 46 mm). The mean anterior-posterior distance was 9.2 mm (1 mm to 25 mm). The mean medial to lateral width of the glenoid fossa was 18.7 mm (16 mm to 23 mm). Conclusion. The arteries, nerves, and veins are close to the medial aspect of the TMJ. A knowledge of these relationships can guide the surgeon on the medial aspect of the TMJ and can help to prevent complications associated with these structures.

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:674-8)

The proximity of the medial aspect of the temporomandibular joint (TMJ) to the structures of the infratemporal fossa raises the possibility of complications associated with TMJ surgery on the medial aspect of the joint. Weinberg et al1 demonstrated a 4% involvement of the inferior alveolar and lingual nerves after arthroscopic surgery. Moses et al2 reported an unusual arteriovenous fistula associated with arthroscopic TMJ surgery. Loughner et al3 demonstrated risk to the auriculotemporal nerve, which is interposed between the medial pole of the mandibular condyle and an elongated wall of the glenoid fossa. A number of studies have examined complications associated with TMJ surgery.4-7 Other studies have indirectly explored the anatomic relationships of the infratemporal fossa by describing techniques for resection of infratemporal tumors.8-11 Most reports have focused on the surgical approach to this region without anatomic consideration of the medial aspect of TMJ. The medial capsule of the TMJ is the most lateral
Resident, Department of Oral and Maxillofacial Surgery, University of California, San Francisco. bResident, Department of Oral and Maxillofacial Surgery, University of California, San Francisco. cProfessor and Chair, Department of Oral and Maxillofacial Surgery, University of California, San Francisco. Received for publication May 11, 1999; returned for revision July 1, 1999; accepted for publication Aug 3, 1999. Copyright 1999 by Mosby, Inc. 1079-2104/99/$8.00 + 0 7/12/102224
aChief

aspect of the infratemporal fossa. The results from most of these studies indicate that the majority of temporomandibular complications occur either lateral to the joint or within the joint itself. Holmlund et al12 and Westeson et al13 demonstrated the close proximity of an arthroscopy puncture site to the superficial temporal artery and vein. Pseudoaneurysm and arteriovenous malformation of the superficial temporal artery and vein have also been described.14 Few have reported concern with the tissues medial to the TMJ.15 Understanding the anatomic relationship of the main vessels and nerves to the TMJ can prevent intra-operative or postoperative complications. There are few reported cases of injury to the maxillary artery.16 Those cases that are described were associated with aggressive surgical technique and necessitated ligation of the external carotid artery to control hemorrhage. It is also known that the middle meningeal artery may be encountered during TMJ surgery (for example, in eminectomy or during release of TMJ ankylosis). The close proximity of the middle meningeal artery to the medial capsule could increase the risk of hemorrhage during TMJ surgery. Radical condylectomy, as required for release of ankylosis of the TMJ, could predispose the middle meningeal artery to injury. The carotid sheath is also close to the joint and therefore at risk for injury. Chuong et al17 reported several cases of sinus bradycardia associated with the close proximity of the TMJ to the carotid artery.

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Fig 1. Lateral view of dissection with condyle head still in place. Black arrow indicates superficial temporal artery, and white arrow indicates internal maxillary artery. C, Condyle.

An understanding of the anatomic position of nerves and vessels in the infratemporal fossa is vital to guide the clinician during the surgical approach to the temporomandibular region. This study looks at 4 major infratemporal structures: the middle meningeal artery, the carotid artery, the internal jugular vein, and the main trunk of the third division of the trigeminal nerve. This study also examines the relationships of those structures to the TMJ.

MATERIAL AND METHODS These data were gathered from 20 formalin-fixed cadaveric specimens. Gross dissection The preparation was carried out after removal of the superficial skin and subcutaneous tissue from the zygomatic arch to the premolar region. The mandibular ramus was exposed by means of sharp dissection through the masseter muscle. The masseter muscle was dissected free of the lateral ramus of the mandible. The condylar neck and the ipsilateral mandibular body were sectioned by using an oscillating saw (Fig 1). The proximal mandibular ramus and condyle were removed after sharp dissection of the medial and lateral pterygoid muscles. To preserve the position of the infratem-

poral structures, sharp dissection was carried out from the medial pterygoid muscle to the vertebral column, and all the inferior soft tissue was removed. The middle meningeal artery, carotid artery, internal jugular vein, and the third division of the trigeminal nerve trunk were identified in the axial plane (Fig 2). Two sets of measurements were carried out in order to identify the position of these structures in the transverse plane. The first measurement was made from the outer aspect of the zygomatic arch to the first contact with each vessel or nerve. All the measurements were obtained at a tangent at the height of the glenoid fossa. The anteroposterior (AP) position of the vessel or nerve was determined by measuring the distance perpendicular to the line transecting the maximum height of the glenoid fossa. Any measurement anterior to this line was given a positive value, and any measurement posterior to this point was given a negative value (Fig 3).

RESULTS The mean distance from the outer aspect of the zygomatic arch to the middle meningeal artery was 31 mm (SD 4.9 mm; range, 21 mm to 43 mm). The AP distance from the artery to the height of glenoid fossa was 2.4 mm (SD 2.9 mm; range, 2 mm to 8 mm).

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Fig 2. Axial view of dissection of right side at level of condyle head. Small arrow indicates middle meningeal artery and large arrow indicates trigeminal nerve. c, Condyle; a, carotid artery; v, jugular vein.

The mean distance from zygomatic arch to the carotid artery was 37.5 mm (SD 5.0 mm; range, 29 mm to 48 mm). The AP distance was 6.5 mm (SD 15; range, 21 mm to 6 mm). The distance to the internal jugular vein was 38.3 mm (SD 4.9 mm; range, 31 mm to 49 mm). The AP distance measured at 8.7 mm (SD 6.3; range, 20 mm to 7 mm). The third division of the trigeminal nerve was measured at 35 mm (SD 4.9 mm; range, 24 mm to 46 mm) from the outer aspect of the zygomatic arch. The mean AP distance of the third division of the trigeminal nerve from the height of the glenoid fossa was 9.2 mm (SD 5.6 mm; range, 1 mm

to 25 mm) (Tables I and II). The mean width of the glenoid fossa was 18.7 mm (range, 16 mm to 23 mm).

DISCUSSION Although complications associated with the medial aspect of the TMJ are rare, they are potentially devastating. We selected the zygomatic arch as a reference point because it is always visible during TMJ operations. We report mean values with a range of measurements. Clinically, attention should be paid to the values in closest potential relationship to a surgical site (ie, smallest zygomatic arch distance of 21 mm to middle

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Fig 3. Diagram showing measurements taken. Left side of diagram shows AP measurements from height of glenoid fossa. Right side shows direct measurements from outer aspect of zygomatic arch at height of glenoid fossa to first contact with structure of interest.

Table I. Oblique measurements from zygomatic arch to each selected anatomic landmark
Z-MMA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 25 28 34 27 30 27 32 32 21 31 30 36 31 30 43 36 37 28 27 29 Z-TGN 32 31 41 31 31 35 33 35 24 36 32 41 30 37 46 40 39 35 34 35 Z-ICA 31 33 42 35 37 38 42 35 30 35 39 44 41 35 41 48 42 39 29 34 Z-IJV 35 36 40 31 38 35 39 39 33 35 40 46 40 37 47 49 43 34 33 36

Table II. Anterior-posterior measurements from TMJ articular eminence to each selected anatomic landmark
G-TGN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 10 14 10 5 7 18 1 9 3 10 10 5 11 5 5 8 3 14 25 11 G-MMA 8 1 8 3 0 0 3 6 1 0 5 3 3 0 3 7 2 1 2 3 G-ICA 6 1 3 10 5 10 5 0 13 13 5 8 0 15 21 0 6 3 14 4 G-IJV 7 3 3 12 10 15 7 2 11 11 11 10 4 16 20 3 8 8 18 9

Z-MMA, Zygomatic arch to middle meningeal artery; Z-TGN, zygomatic arch to third branch of trigeminal nerve; Z-ICA, zygomatic arch to internal carotid artery; Z-IJV, zygomatic arch to internal jugular vein.

G-TGN, TMJ glenoid fossa to third branch of trigeminal nerve; G-MMA, TMJ glenoid fossa to middle meningeal artery; G-ICA, TMJ glenoid fossa to internal carotid artery; G-IJV, TMJ glenoid fossa to internal jugular vein.

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7. Carls FR, Engelke W, Lochler MC, Sailer HF. Complications following arthroscopy of the temporomandibular joint: analysis covering a 10-year period (451 arthroscopies). J Craniomaxillofac Surg 1996;24:12-5. 8. Vrionis FD, Cano WG. Microsurgical anatomy of infratemporal fossa as viewed laterally and superiorly. Neurosurgery 1996;39:777-85. 9. Cass SP, Hirsch BE, Stechison MT. Evolution and advances of the lateral surgical approaches to cranial base neoplasms. J Neurooncol 1994;20:337-61. 10. Catalano PJ, Bederson J, Turk JB, Sen C, Biller HF. New approach for operative management of vascular lesions of the infratemporal internal carotid artery. Am J Otolaryngol 1994;15:495-501. 11. Ayeni SA, Ohata K, Tanaka K, Haduba A. The microsurgical anatomy of the jugular foramen. J Neurosurg 1995;83:903-9. 12. Holmlund A, Hellsing G. Arthroscopy of the TMJ: an autopsy study. Int J Oral Surg 1985;14:169-72. 13. Westesson P, Eriksson L, Liedbert J. The risk of damage to facial nerve, superficial temporal vessels, disk and articular surfaces during arthroscopic examination of the temporomandibular joint. Oral Surg 1986;62:124-7. 14. Manning MP, Marshall JH. Aneurysm after arthroscopy. J Bone Joint Surg 1987;69:151-2. 15. Dolwick MF, Armstrong JW. Complication of temporomandibular joint surgery. Oral Maxillofac Surg Clin North Am 1990;1:89-103. 16. Cheynet F, Chossegros C, Blanc JL, Gola R, Lanchard J. Complications of temporomandibular arthroscopy. Report of 100 arthroscopies. Rev Stomatol Chir Maxillofac 1992;93:252-7. 17. Chuong R, Piper MA. Sinus bradycardia related to temporomandibular joint surgery. Oral Surg Oral Med Oral Pathol 1991;71:423-5. Reprint requests: M. Anthony Pogrel, DDS, MD, FACS, FRCS Department of Oral and Maxillofacial Surgery University of California, San Francisco 521 Parnassus Ave, C522 San Francisco, CA 94143-0440

meningeal artery, 29 mm to carotid artery, 31 mm to internal jugular vein, and 24 mm to trigeminal nerve). Because the mean AP width of the glenoid fossa was 18.7 mm (16 mm to 23 mm), the potential distance of the structures measured to the medial aspect of the TMJ can be seen. At these outlying values, any of these structures may be encountered, leading to significant intra-operative or postoperative complications. One of the major findings of this study is the variability in the location of these vital structures, which may make surgery in this area even more hazardous than might be anticipated.
REFERENCES
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Abstract Intermaxillary fixation is not usually necessary to reduce mandibular fractures A.M. Fordyce, A. Lalani, A.K. Songra, A.J. Hidreth, A.T.M. Carton, J.E. Hawkesford. Brit J Oral Maxillofac Surg 1999;37:52-7 The authors of this publication observe that prior to the advent of bone plates, mandibular fractures were reduced and stabilized through the use of intermaxillary fixation (IMF). That practice was continued once bone plate stabilization became available, even though anatomic reduction was usually possible. Many surgeons have begun reducing and plating mandibular fractures without the assistance of IMF intra- or post-operatively. The study reported here retrospectively examined 115 patients having isolated mandibular fractures, 66 of which were managed without use of IMF in the perioperative period. The remainder of the patients were placed into IMF prior to the open reduction and plating, but had this IMF released postoperatively. The results revealed that occlusal problems were present in 6 of 66 non-IMF patients compared to 16 of the 49 IMF patients (P = .002) in the early postoperative period, but there was no difference in the occlusal outcome of the two groups by two weeks. The necessity for IMF at any stage in the management of isolated mandibular fractures is questioned by the authors, and they conclude that time, money, patient discomfort, and operator risk are all reduced by eliminating the step of placing mandibular fracture patients into IMF if open anatomic reduction and rigid plating is feasible and planned. James R. Hupp, DMD, MD, JD University of Maryland