ANATOMY OF TMJ,MUSCLES OF MASTICATION,TONGUE,PHARYNGEAL AIRWAYS

By:Dr.N.Shivaram

Contents
Anatomy of TMJ Anatomy of muscles of mastication Anatomy of Tongue Anatomy of pharyngeal airway Conclusion

TMJ

TERMINOLOGIES OF TMJ
Bicondylar Bilateral, unison functioning Ginglymoarthroidal Hinge type movement Compound More than one articular surface Complex Presence of intracapsular disc Secondary Ontogenetically Evolution Phylogenetically embryological Developmentally Growth Synovial

Components
Bony components 1. Glenoid fossa 2. Condylar head 3. Articular eminence Soft tissue attachments 1. Articular disc 2. Joint capsule 3. Ligaments

Muscle attachments 1. Muscles of mastication

2. 3. 4. Muscles attached to the joint Muscles of facial expression Muscles of the neck

Evolution

AGNATHA

GNATHOSTOMATA

OSTIECTHYES

AMPHIBIANS

REPTILES

MAMMAL LIKE REPTILE

MAMMALS

Embryology

GLENOID FOSSA
7-8 weeks - Develops earlier than the condyle 10th week- ossification 22 weeks- medial and lateral walls Shape of the fossa

ARTICULAR CAPSULE
9-11 Weeks- first appearance 17th Week- differentiation 26th Week- completion

ARTICULAR EMINENCE
7TH month- Formation of the trabeculae 8-9 months- Completion

 The mandible develops from the Meckels cartilage, which provides the basic skeletal support for the lower jaw, and terminates dorsally into MALLEUS It articulates with the incal cartilage (Quadrate in nonmammals) and any movement of the early jaw, if any, occurs between these two cartilages

 At 3 months of gestation the secondary joint begins to form with the appearance of two distinct mesenchymal condensations, which are initially positioned some distance from each other.

 Temporal blastema appears first, begins to ossify first and the second cleft which appears in relation to the temporal ossification becomes the superior joint cavity. Condylar blastema appears after temporal blastema, begins ossifying second and the first cleft appears immediately above it to form the inferior joint cavity while it is still in condensed mesenchyme

 The condylar blastema grows rapidly to decrease the intervening gap between the two blastemas. The appearance of clefts and formation of inferior and superior joint cavities gives rise to the primitive articular disk in the centre.

Anatomy

GLENOID FOSSA/ MANDIBULAR FOSSA

 The mandibular fossa is limited in front by the articular eminence of the zygomatic process. It presents an anterior articular area, formed by the squamous part, and a posterior non-articular area, formed by the tympanic element

CONDYLAR HEAD

 The mandibular condyle varies considerably both in size and shape. When viewed from above, the condyle is roughly ovoid in outline, the anteroposterior dimension of the condyle (c.1 cm) being approximately half the mediolateral dimension.

ARTICULAR CARTILAGE
The articular surface of both temporal bone and condyle are covered by fibrocartilage- a dense fibrous connective tissue. The fibro cartilage has the capacity to regenerate and to remodel under functional stress Deep to the fibro cartilage in condyle is the proliferative zone of cells-cartilage and osseous The articular cartilage is composed of chondrocytes an inter cellular matrix of collagen fibres Water and non fibrous filler material(the ground substance)

ARTICULAR EMINENCE

 Immediately anterior to the glenoid fossa is a convex bony prominence at the base of the zygomatic process of the temporal bone called the articular eminence. The eminence appears saddle-shaped with a central shallow depression that is the path of the condyle, when viewed from below

CAPSULAR LIGAMENT

 Thin structure reinforced by ligaments Inner surface lined by synovial membrane

ARTICULAR DISC
The transversely oval articular disc is composed predominantly of dense fibrous connective tissue. It has a thick margin which forms a peripheral annulus and a central depression in its lower surface that accommodates the articular surface of the mandibular condyle.

Attachments of articular disk 1. Posteriorly disc attached Retrodiscal tissue 2. Medial and lateral parts attached to condyle through DISCAL / COLLATERAL LIGAMENTS or Joint capsule, 3. Anteriorly Joint capsule, Lateral pterygoid muscle fibres Sphenomeniscus fibres - stabilize disk during mastication & deglutition

RETRODISCAL TISSUE
POSTERIOR ATTACHMENT Between bilaminar zone of disc SRL Menisco-temporal frenum IRL Menisco-mandibular frenum Loose connective tissue,Compressible Rich blood supply & nerve supply

SUPERIOR

INFERIOR

SYNOVIAL MEMBRANE
Lines inner surface of capsule villi Functions: 1. Medium for metabolic exchange to avascular articulating surfaces 2. Lubricant minimizes friction

LIGAMENTS

True ligaments:
1. COLLATERAL / DISCAL LIGAMENTS 2. CAPSULAR LIGAMENT 3.TEMPOROMANDIBULAR / LATERAL LIGAMENT Accessory ligaments: 1. SPHENOMANDIBULAR LIGAMENT 2. STYLOMANDIBULAR LIGAMENT

COLLATERAL / DISCAL LIGAMENT

2 Medial & distal Attach edges of disc to condylar poles Joint 2 compartments Functions: 1. Restricts movement of disc away from condyle 2. Disc moves passively with condyle 3. Hinge movement between condyle & disc

TEMPOROMANDIBULAR (LATERAL) LIGAMENT

 This broad ligament is attached above to the articular tubercle on the root of the zygomatic process of the temporal bone. It extends downwards and backwards at an angle of c.45 to the horizontal, to attach to the lateral surface and posterior border of the neck of the condyle, deep to the parotid gland. It appears to be poorly developed in the edentulous. A short, almost horizontal, band of collagen connects the articular tubercle in front to the lateral pole of the condyle behind. It may function to prevent posterior displacement of the resting condyle.

SPHENOMANDIBULAR LIGAMENT
The sphenomandibular ligament is medial to, and normally separate from, the capsule. It is a flat, thin band that descends from the spine of the sphenoid and widens as it reaches the lingula of the mandibular foramen. Some fibres traverse the medial end of the petrotympanic fissure and attach to the anterior malleolar process. This part is a vestige of the dorsal end of Meckel's cartilage.

STYLOMANDIBULAR LIGAMENT
The stylomandibular ligament is a thickened band of deep cervical fascia that stretches from the apex and adjacent anterior aspect of the styloid process to the angle and posterior border of the mandible. Its position and orientation indicate that it cannot mechanically constrain any normal movements of the mandible and does not seem to warrant the status of a ligament of the joint

MUSCLES OF MASTICATION

DIRECT MUSCLES OF MASTICATION

MASSETER TEMPORALIS LATERAL PTERYGOID MEDIAL PTERYGOID

ACCESSORY MUSCLES OF MASTICATION

MYLOHYOID ANTERIOR BELLY OF DIGASTRIC TENSOR VELI PALITINI TENSOR TYMPANI

Masseter

 Masseter consists of three layers which blend anteriorly The superficial layer arises by a thick aponeurosis from the maxillary process of the zygomatic bone and from the anterior two-thirds of the inferior border of the zygomatic arch insert into the angle and lower posterior half of the lateral surface of the mandibular ramus.

 The middle layer of masseter arises from the medial aspect of the anterior two-thirds of the zygomatic arch and from the lower border of the posterior third of this arch. It inserts into the central part of the ramus of the mandible. The deep layer arises from the deep surface of the zygomatic arch and inserts into the upper part of the mandibular ramus and into its coronoid process.

 Vascular supply :Masseter is supplied by the masseteric branch of the maxillary artery, the facial artery and the transverse facial branch of the superficial temporal artery. Innervation : Masseter is supplied by the masseteric branch of the anterior trunk of the mandibular nerve.

Temporalis

 Temporalis arises from the whole of the temporal fossa up to the inferior temporal line - except the part formed by the zygomatic bone - and from the deep surface of the temporal fascia. Its fibres converge and descend into a tendon which passes through the gap between the zygomatic arch and the side of the skull

 Vascular supply:deep temporal branches-the second part of the maxillary artery-anterior deep temporal artery supplies c.20%- posterior deep temporal supplies c.40%-posterior regionm-middle temporal artery supplies c.40%-midregion. Innervation:deep temporal branches of the anterior trunk of the mandibular nerve.

Lateral pteygoid

 Lateral pterygoid consists of upper head arises from the infratemporal surface and infratemporal crest of the greater wing of the sphenoid bone. The lower head arises from the lateral surface of the lateral pterygoid platefovea).

 From the two origins, the fibres converge, and pass backwards and laterally, to be inserted into a depression on the front of the neck of the mandible (the pterygoid

 Vascular supply:pterygoid branchesmaxillary artery-given off -artery crosses the muscle-ascending palatine branch of the facial artery. Innervation:The nerves to lateral pterygoid-anterior trunk of the mandibular nerve, deep to the muscle.

 Upper head and the lateral part of the lower head receive their innervation fromthe buccal nerve. Medial part of the lower head has a branch arising directly from the anterior trunk of the mandibular nerve.

Medial pterygoid

 Medial pterygoid is a thick, quadrilateral muscle with two heads of origin. The major component is the deep head which arises from the medial surface of the lateral pterygoid plate of the sphenoid bone and is therefore deep to the lower head of lateral pterygoid.

 The small, superficial head arises from the maxillary tuberosity and the pyramidal process of the palatine bone, and therefore lies on the lower head of lateral pterygoid

 Vascular supply:Medial pterygoid derives its main arterial supply from the pterygoid branches of the maxillary artery Innervation:the medial pterygoid branch of the mandibular nerve

Mylohyoid

 Mylohyoid lies superior to the anterior belly of digastric and, with its contralateral fellow, forms a muscular floor for the oral cavity. It is a flat, triangular sheet attached to the whole length of the mylohyoid line of the mandible.

 The posterior fibres pass medially and slightly downwards to the front of the body of the hyoid bone near its lower border. The middle and anterior fibres from each side decussate in a median fibrous raphe that stretches from the symphysis menti to the hyoid bone

 Vascular supply:sublingual branch of the lingual artery, the maxillary artery, via the mylohyoid branch of the inferior alveolar artery, and the submental branch of the facial artery. Innervation:mylohyoid branch of the inferior alveolar nerve.

Tensor veli palatini

 Tensor veli palatini arises from the scaphoid fossa of the pterygoid process and posteriorly from the medial aspect of the spine of the sphenoid bone.

 Vascular supply:The blood supply of tensor veli palatini-ascending palatine branch of the facial artery-greater palatine branch of the maxillary artery. Innervation:The motor innervation of tensor veli palatini is derived from the mandibular nerve via the nerve to medial pterygoid

Tensor tympani

 Tensor tympani is a long slender muscle which occupies the bony canal above the osseous part of the pharyngotympanic tube, from which it is separated by a thin bony septum. It arises from the cartilaginous part of the pharyngotympanic tube and the adjoining region of the greater wing of the sphenoid, as well as from its own canal.

 It passes back within its canal, and ends in a slim tendon which bends laterally round the pulley-like processus trochleariformis and finally attaches to the handle of the malleus, near its root

 Vascular supply:Tensor tympani receives its arterial blood supply from the superior tympanic branch of the middle meningeal artery. Innervation:nerve to medial pterygoid-a ramus of the mandibular nerve-which traverses the otic ganglion without interruption to reach the muscle.

Tongue

Embryology

Anatomy
It is partly oral and partly pharyngeal in position, and is attached by its muscles to the hyoid bone, mandible, styloid processes, soft palate and the pharyngeal wall. It has a root, an apex, a curved dorsum and an inferior surface.

MUSCLES OF THE TONGUE

Extrinsic muscles Intrinsic muscles

Genioglossus
Genioglossus is triangular in sagittal section, lying near and parallel to the midline. It arises from a short tendon attached to the superior genial tubercle behind the mandibular symphysis, above the origin of geniohyoid..

 Vascular supply Genioglossus is supplied by the sublingual branch of the lingual artery and the submental branch of the facial artery. Innervation Genioglossus is innervated by the hypoglossal nerve

Hyoglossus
Hyoglossus is thin and quadrilateral, and arises from the whole length of the greater cornu and the front of the body of the hyoid bone. It passes vertically up to enter the side of the tongue between styloglossus laterally and the inferior longitudinal muscle medially

 Vascular supply:Hyoglossus is supplied by the sublingual branch of the lingual artery and the submental branch of the facial artery. Innervation :Hyoglossus is innervated by the hypoglossal nerve

Styloglossus
Styloglossus is the shortest and smallest of the three styloid muscles. It arises from the anterolateral aspect of the styloid process near its apex, and from the styloid end of the stylomandibular ligament.

 Vascular supply:Styloglossus is supplied by the sublingual branch of the lingual artery. Innervation:Styloglossus is innervated by the hypoglossal nerve.

Palatoglossus
Palatoglossus is narrower at its middle than at its ends. Together with its overlying mucosa it forms the palatoglossal arch or fold. It arises from the oral surface of the palatine aponeurosis where it is continuous with its fellow

 Vascular supply:ascending palatine branch of the facial artery-from ascending pharyngeal artery Innervation :cranial part of the accessory nerve via the pharyngeal plexus

Intrinsic muscles

Intrinsic muscles
The superior longitudina muscle:constitutes a thin stratum of oblique and longitudinal fibres lying beneath the mucosa of the dorsum of the tongue. It extends forwards from the submucous fibrous tissue near the epiglottis and from the median lingual septum to the lingual margins

 The inferior longitudinal muscle:narrow band of muscle close to the inferior lingual surface between genioglossus and hyoglossus. It extends from the root of the tongue to the apex. Some of its posterior fibres are connected to the body of the hyoid bone. Anteriorly it blends with styloglossus.

 The transverse muscles: pass laterally from the median fibrous septum to the submucous fibrous tissue at the lingual margin, blending with palatopharyngeus.

 The vertical muscles extend from the dorsal to the ventral aspects of the tongue in the anterior borders.

 Vascular supply:The intrinsic muscles are supplied by the lingual artery. Innervation:All intrinsic lingual muscles are innervated by the hypoglossal nerve

Vascular supply and innervation

Lingual artery : dorsal lingual artery sublingual artery deep lingual artery

Veins
Lingual veins: lymphatic drainage marginal vessels central vessels dorsal vessels

Innervation
The muscles of the tongue, with the exception of palatoglossus, are supplied by the hypoglossal nerve. It distributes fibres to styloglossus, hyoglossus and genioglossus and to the intrinsic muscles of the tongue Palatoglossus is supplied via the pharyngeal plexus

 The lingual nerve is sensory to the mucosa of the floor of the mouth, mandibular lingual gingivae and mucosa of the presulcal part of the tongue (excluding the circumvallate papillae).

 The glossopharyngeal nerve is distributed to the postsulcal part of the tongue and the circumvallate papillae. It communicates with the lingual nerve.

PHARYNGEAL AIRWAY

PHARYNGEAL AIRWAY
The pharyngeal airway is kept patent in the patient who is awake by the combined dilating action of genioglossus, tensor veli palatini, geniohyoid and stylohyoid, which act to counter the negative pressure generated in the lumen of the pharynx during inspiration. The tone in the muscles is reduced during sleep, but is also affected by alcohol and other sedatives, hypothyroidism and a variety of neurological disorders.

 If the dilator muscle tone is insufficient, the walls of the pharynx may become apposed. Intermittent pharyngeal obstruction may cause snoring, and complete obstruction may cause apnoea, hypoxia and hypercarbia which lead to arousal and sleep disturbance

Airway-compromising conditions
Congenital Pierre-Robin syndrome Micrognathia, macroglossia, cleft soft palate Treacher-Collins syndrome Auricular and ocular defects, malar and mandibular hypoplasia Goldenhars syndrome Auricular and ocular defects, malar and mandibular hypolasia

 Downs syndrome Poorly developed or absent bridge of the nose, macroglossia Kippel-Feil syndrome Congenital fusion of a variable number of cervical vertebrae, restriction of neck movement Goiter Compression of trachea, deviation of larynx/trachea

Acquired Infections Supraglottis Laryngeal oedema Croup Laryngeal oedema Abscess (intraoral, retropharygeal) Distortion of the airway and trismus Ludwigs angina Distortion of the airway and trismus

Specific tests for assessment

Mallampatti test The Mallampati classification correlates tongue size to pharyngeal size. This test is performed with the patient in the sitting position, head in a neutral position, the mouth wide open and the tongue protruding to its maximum. Patient should not be actively encouraged to phonate as it can result in contraction and elevation of the soft palate leading to a spurious picture. Classification is assigned according to the extent the base of tongue is able to mask the visibility of pharyngeal structures into three classes

Obstructive Sleep Apnea

Broadbent (1877), described Obstructive Sleep Apnea as there will be perfect silence through two, three, or four respiratory periods, in which there are ineffectual chest movements; finally air enters with a loud snort, after which there are several compensatory deep inspirations

Predisposing factors
Obesity airway is compromised because of more fat deposits in soft palate, tongue and surrounding pharynx Alcohol ingestion decrease in hypoglossal nerve output while phrenic nerve output is spared REM sleep muscles of airway are most hypotonic in this stage of sleep Pharyngeal length was found to be longer in apnea patients in supine position compared with upright position

Anatomic alterations reducing airway

Posteriorly positioned maxilla and mandible Steep occlusal plane Overerupted anterior teeth Large gonial angle Anterior openbite associated with large tongue Posteriorly placed pharyngeal walls

 Retrognathic mandibles Large tongue and soft palate Large anteroposterior discrepancies between maxilla and mandible Micrognathia Acromegaly Downs syndrome

Hereditary variables
Adenoid and tonsillar hypertrophy Glottic webs Vocal cord paralysis Lymphoma or Hodgkins disease Ectopic thyroid Systemic disease involving mandible like Rheumatoid arthritis Severe Kypho-Scoliosis Cushing syndrome

 Types based on the level of obstruction Retropalatal Retroglossal Retropalatal + Retroglossal

 The features of retrognathia, micrognathia, and skeletal Class II tendency were most pronounced in the Rp + Rg group. Pronounced to a somewhat lesser extent in the Rp group The tendency for a long face was dominant in the tonsillar hypertrophy group, and the presence of a long and large soft palate was very pronounced in the Rp group All of the groups shared the characteristics of having an inferior position of the hyoid bone.

 Oropharyngeal airway size was positively correlated to -the length of the mandible (Go-Me) -the distance between 3rd cervical vertebra and the hyoid bone (C3-Hy) -the cranial base angle (NSBa)

Clinical features
Nocturnal symptoms 1. Snoring 2. Drooling 3. Xerostomia 4. Diaphoresis 5. Choking or gasping Daytime symptoms 1. Excessive sleepiness 2. Morning headaches 3. Gastro-esophageal reflux disease 4. Impaired concentration 5. Depression 6. Decreased libido 7. Irritability

Conclusion
Though anatomy of head and neck or for say human body as a whole have been described in detail many years back there are always changes in the perception of the clinician towards the subject and a person should be updated in his knowledge of anatomy , as anatomy is one of the important subjects which effects the treatment plan in all specialties' even in orthodontics

Bibliography
1. 2. 3. 4. Text book of Greys anatomy Atlas of Human Anatomy by Netters Craniofacial development , SPERBER Applied Anatomy and Physiology of the Airway and Breathing Dr. Rajagopal M. R,Dr. Jerry Paul.

5. Relationship Between Cephalometric Characteristics and Obstructive Sites in Obstructive Sleep Apnea Syndrome Un Bong Baik, DDS; Masaaki Suzuki MD, PhD; Katsuhisa Ikeda, MD, PhD;Junji Sugawara, DDS, PhD; Hideo Mitani, DDS, PhD 6. Craniofacial profile in Asian and white subjects with obstructive sleep apnoea B Lam, M S M Ip, E Tench, C F Ryan

7. Indian J Med Res 131, February 2010, pp 188-195 Consequences of obstructive sleep apnoea, Indira Gurubhagavatula 8. MAGICALDENTISTRY FORUMS / PGArena / PG-Dental / ORTHODONTIA, PEDODONTIA / Evolution of Temporomandibular Joint

Q &A
Diaphoresis is excessive sweating commonly associated with shock and other medical emergency conditions. Physiological causes: physical exertion, menopause, fever, spicy foods, and high environmental temperature. Strong emotions (anger, fear, etc.) and remembrance of past trauma can also trigger profuse sweating