TEMPOROMANDIBULAR

JOINT
ANATOMY,
DEVELOPMENT
&

SURGICAL
ANATOMY

By Dr. Sheetal Kapse

 Contents
INTRODUCTION
PECULIARITY OF TMJ
DEVELOPMENT
COMPONENTS
MOVEMENTS
VASCULAR SUPPLY
INNERVATIONS
AGE CHANGES
SURGICALY ANATOMY
REFERENCES
 Introduction
The most important functions of the temporomandibular
joint (TMJ) are mastication and speech and are of great
interest to dentists, orthodontists, clinicians, and
radiologists.

The TMJ is a ginglymoarthrodial joint, a term that is

derived from ginglymus, meaning a hinge joint, allowing
motion only backward and forward in one plane, and
arthrodia, meaning a joint of which permits a gliding
motion of the surfaces.

Dorland WA: Medical Dictionary. Philadelphia and London, Saunders

Co., 1957
 The right and left TMJ form a bicondylar
articulation and ellipsoid variety of the synovial
joints similar to knee articulation.

The common features of the synovial joints

exhibited by this joint include a disk, bone, fibrous
capsule, fluid, synovial membrane, and ligaments.
However, the features that differentiate and make
this joint unique are its articular surface covered
by fibrocartilage instead of hyaline cartilage.

Williams PL: Grays anatomy, in Skeletal System (ed 38).

Churchill. Livingstone, London, 1999, pp 578-582
 Peculiarity of TMJ

1. Bilateral diarthrosis right & left function together

2. Articular surface covered by fibrocartilage

instead of hyaline cartilage

3. Only joint in human body to have a rigid endpoint

of closure that of the teeth making occlusal contact.
 Peculiarity of TMJ.

4. In contrast to other diarthrodial joints TMJ is last

joint to start develop, in about 7th week in
utero.

5. Develops from two distinct blastema.

Components
 Mandibular condyle

Articular surfaces of Temporal bone

Capsule
Articular disc

Ligaments

Muscular component
 THE MANDIBULAR
CONDYLE
An ovoid process seated atop a
narrow mandibular neck. Its the
articulating surface of the
mandible.

It is convex in all directions but

wider latero-medially (15 to 20
mm) than antero-posteriorly (8 to
10mm).
It has lateral and medial
poles:
The medial pole is directed
more posteriorly.

Thus, if the long axes of two

condyles are extended
medially, they meet at
approximately the basion
on the anterior limit of the
foramen magnum, forming
an angle that opens toward
the front ranging from 145
to 160
 The lateral pole of the
condyle is rough, bluntly
pointed, and projects only
moderately from the plane
of ramus, while the medial
pole extends sharply inward
from this plane.

The articular surface lies on

its anterosuperior aspect,
thus facing the posterior
slope of the articular
eminence of the temporal
bone.
 It further continues
medially down and
around the medial pole of
the condyle to face the
entoglenoid process of
the temporal bone where
the jaw is held in an
occluded position.
 Cranial Component
or
Articular surfaces of Temporal bone

The articular surface of the

temporal bone is situated on
the inferior aspect of
temporal squama anterior to
tympanic plate.

Various anatomical terms of

the joint are elaborated
 (a) Articular eminence:
This is the entire
transverse bony bar that
forms the anterior root of
zygoma. This articular
surface is most heavily
traveled by the condyle
and disk as they ride
forward and backward in
normal jaw function.
(b) Articular tubercle: This is a
small, raised, rough, bony knob
on the outer end of the articular
eminence.

It projects below the level of the

articular surface and serves to
attach the lateral collateral
ligament of the joint.

(c) Preglenoid plane: This is the

slightly hollowed, almost
horizontal, articular surface
continuing anteriorly from the
height of the articular eminence.
(d) Posterior articular ridge and the
postglenoid process:

The posterior part of the mandibular

fossa is an anterior margin of the
petrosquamous suture and is
elevated to form a ridge known
as the posterior articular ridge or
lip.
This ridge increases in height
laterally to form a thickened E: Articular eminence; enp: entogolenoid
cone-shaped prominence called process; t:articular tubercle; Co: condyle;
pop: postglenoid process; lb: lateral border
the post glenoid process of the mandibular fossa; pep: preglenoid
immediately anterior to the plane; Gf: glenoid fossa; Cp: condylar
external acoustic meatus. process
(e) Lateral border of the
mandibular fossa: This structur
is usually raised to form a slight
crest joining the articular
tubercle, in front, with the
postglenoid process behind.

(f) Medially the fossa narrows

considerably and is bounded by
a bony wall that is the
entoglenoid process, which
passes slightly medially as the
medial glenoid plane.
 The roof of the mandibular
fossa, which separates it
from the middle cranial
fossa, is always thin and
translucent, even in the
heavy skull.

This demonstrates that,

although the articular fossa
contains the posterior rim
of the disk and the condyle,
it is not a functionally
stress-bearing part of the
craniomandibular
articulation
Patnaik VVG, Bala S,Singla Rajan K: Anatomy of temporomandibular joint? A
review. J Anat Soc India 49(2):191-197, 2000
 Articular Disc
The articular disc is the most important
anatomic structure of the TMJ.

It is a biconcave fibrocartilaginous
structure located between the
mandibular condyle and the temporal
bone component of the joint.

Its functions to accommodate a

hinging action as well as the gliding
actions between the temporal and
mandibular articular bone.
 The articular disc is a roughly
oval, firm, fibrous plate.

1. anterior band = 2 mm in
thickness,
2. posterior band = 3 mm thick,
3. thin in the centre intermediate
band of 1 mm thickness.
More posteriorly there is a
bilaminar or retrodiscal
region.

It is shaped like a peaked cap that divides the joint into a

larger upper compartment and a smaller lower
compartment.
 Hinging movements take place
in the lower compartment and
gliding movements take place
in the upper compartment.

The superior surface of the disc - saddle-shaped

to fit into the cranial contour,

The inferior surface - concave

to fit against the mandibular condyle.
 The disc is attached all around the
joint capsule except for the strong
straps that fix the disc directly to
the medial and lateral condylar
poles, which ensure that the disc
and condyle move together in
protraction and retraction.

Williams PL: Grays anatomy, in Skeletal System (ed 38).

ChurchillLivingstone, London, 1999, pp 578-582
 The anterior extension of the
disc is attached to a fibrous
capsule superiorly and
inferiorly.

In between it gives insertion

to the lateral pterygoid
muscle where the fibrous
capsule is lacking and the
synovial membrane is
supported only by loose
areolar tissue.

Williams PL: Grays anatomy, in Skeletal System (ed 38).

ChurchillLivingstone, London, 1999, pp 578-582
 The anterior and posterior
bands have predominantly
transversal running fibers,
while the thin intermediate
zone has anteroposteriorly
oriented fibers.

Posteriorly, the bilaminar

region consists of two layers
of fibers separated by loose
connective tissue.
 The upper layer or
temporal lamina is
composed of elastin and
is attached to the
postglenoid process,
medially extended
ridge, which is the true
posterior boundary of
the joint. It prevents
slipping of the disc
while yawning.

The inferior layer of the fibers or inferior lamina curve down

behind the condyle to fuse with the capsule and back of the
condylar neck at the lowest limit of the joint space. It prevents
excessive rotation of the disc over the condyle.
Harms SE, Wilk RM: Magnetic resonance imaging of the
temporomandibular joint. Radiographics 7(3):521-542, 1987
 In between the two layers, an
expansile, soft pad of blood
vessels and nerves are
sandwiched and wrapped in
elastic fibers that aid in
contracting vessels and
retracting disc in recoil of
closing movements.

The volume of retrodiscal tissue must increase

instantaneously when the condyle translates
anteriorly.

Harms SE, Wilk RM: Magnetic resonance imaging of the

temporomandibular joint. Radiographics 7(3):521-542, 1987
 On sagittal MR imaging, the
disk - biconcave structure with
homogeneous low signal
intensity that is attached
posteriorly to the bilaminar
zone, which demonstrates
intermediate signal intensity.

The anterior band lies

immediately in front of the
The posterior band
condyle and the junction of the
and retrodiskal tissue
bilaminar zone, and the disk lies
are best depicted in
at the superior part of the
the open-mouth
condyle.
position.

Harms SE, Wilk RM: Magnetic resonance imaging of the

temporomandibular joint. Radiographics 7(3):521-542, 1987
 Thin sleeve of tissue completely
Fibrous surrounding the joint.
Capsule Extends from the circumference of the
cranial articular surface to the neck of the
mandible.

The outline
anterolaterally to the articular tubercle,
laterally to the lateral rim of the mandibular
fossa,
posterolaterally to the postglenoid process,
posteriorly to the posterior articular ridge,
medially to the medial margin of the
Patnaik VVG, Bala S,Singla Rajan
K: Anatomy of temporomandibular
temporal,
joint? A review. J Anat Soc India anteriorly it is attached to the preglenoid
49(2):191-197, 2000
plane
The outline of attachment on the
mandibular neck -

Laterally- the lateral condylar pole but

Medially - dips below the medial pole.

On the lateral part of the joint, the capsule

is a well-defined structure that
functionally limits the forward translation
of the condyle.
 This capsule is reinforced more laterally by an
external TMJ ligament, which also limits the
distraction and the posterior movement of the
condyle.

Medially and laterally-

blends with the
condylodiscal ligaments.
 Anteriorly, the capsule has an
orifice through which the lateral
pterygoid tendon passes. This area
of relative weakness in the
capsular lining becomes a source
of possible herniation of intra-
articular tissues, and this, in part,
may allow forward displacement
of the disk.

Kreutziger KL, Mahan PE: Temporomandibular degenerative joint

disease. Part II. Diagnostic procedure and comprehensive management.
Oral Surg Oral Med Oral Pathol 40(3):297-319, 1975
 The synovial membrane lining the
capsule covers all the intra-articular
surfaces except the pressure-bearing
fibrocartilage.

There are four capsular or synovial sulci situated at the posterior

and anterior ends of the upper and lower compartments.

These sulci change shape during translatory movements, which

requires the synovial membrane to be flexible.

Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg

11(3):207-212, 1974
Temporomandibular
Ligaments Complex
Collateral The ligament on each side of the
Ligaments jaw is designed in two distinct
layers.

The wide outer or superficial

layer is usually fan-shaped and
arises from the outer surface of the
articular tubercle and most of the
posterior part of the zygomatic
arch.

There is often a roughened, raised

bony ridge of attachment on this
area.
 The ligamentous fascicles run obliquely
downward and backward to be inserted on
the back, behind, and below the mandibular
neck.

Immediately medial to this layer, a narrow

ligamentous band arises from the crest of the
articular tubercle continuously, with
attachment of the outer portion at this site.

This narrow inner or deep band runs

horizontally back as a flap strap to the lateral
pole of the condyle.

An upper part of this band continues on to

attach to the back of the disk, lateral to the
condylar pole.
 Medial slippage of the condyle
is prevented medially by the
entoglenoid process and
laterally by the
temporomandibular ligament.

The outer oblique band becomes taut in the protraction of

the condyle, which accompanies the opening of the jaw,
thereby limiting the inferior distraction of the condyle in
forward gliding and rotational movements, while the inner
horizontal band tightens in retraction of the head of the
mandible, thereby limiting posterior movement of the
condyle .
McMinn, RMH: Lasts anatomy regional and applied, in Head and Neck
and Spine. Churchill Livingstone, Edinburgh, London, 1994, p. 523
 Sphenomandibular Ligament
Arises from the angular spine
of the sphenoid and
petrotympanic fissure.

Runs downward and outward.

Insert on the lingula of the

mandible.
 The ligament is related
1. Laterally - lateral pterygoidmuscle.
2. posteriorly - auriculotemporal nerve.
3. anteriorly - maxillary artery.
4. Inferiorly - the inferior alveolar nerve
and vessels a lobule of the parotid
gland.
5. Medially - medial pterygoid with the
chorda tympani nerve and the wall of
the pharynx with fat and the
pharyngeal veins intervening.
 The ligament is pierced by
the myelohyoid nerve and
vessels.

This ligament is passive

during jaw movements,
maintaining relatively the
same degree of tension
during both opening and
closing of the mouth.
 Stylomandibular Ligament
This is a specialized dense,
local concentration of deep
cervical fascia extending from
the apex and being adjacent to
the anterior aspect of the
styloid process and the
stylohyoid ligament to the
mandibles angle and
posterior border.
 This ligament then extends
forward as a broad fascial
layer covering the inner
surface of the medial
pterygoid muscle.

The anterior edge of the

ligament is thickened and
sharply defined.
 It is lax when the jaws are closed and slackens
noticeably when the mouth is opened because the
angle of the mandible swings up and back while
the condyle slides downward and forward.

This ligament becomes tense only in extreme

protrusive movements. Thus, it can be considered
only as an accessory ligament of uncertain
function.
 Lubrication of the Joint
The synovial fluid comes from two sources: first, from
plasma by dialysis, and second, by secretion from type A
and B synoviocytes with a volume of no more than 0.05
ml.

However, contrast radiography studies have estimated that

the upper compartment could hold approximately 1.2 ml of
fluid without undue pressure being created, while the
lower has a capacity of approximately 0.5 ml.

Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg

11(3):207-212, 1974
 Synovial fluid
It is clear, straw-colored viscous fluid.
It diffuses out from the rich cappillary network of the
synovial membrane.

Contains:
Hyaluronic acid which is highly viscous
May also contain some free cells mostly macrophages.

Functions:
Lubricant for articulating surfaces.
Carry nutrients to the avascular tissue of the joint.
Clear the tissue debris caused by normal wear and tear of
the articulating surfaces.
 Muscular Component
The masticatory muscles surrounding the joint are groups
of muscles that contract and relax in harmony so that the
jaws function properly.

When the muscles are relaxed and flexible and are not
under stress, they work in harmony with the other parts of
the TMJ complex.

The muscles of mastication produce all the movements of

the jaw.

These muscles begin and are fixed on the cranium

extending between the cranium and the mandible on each
side of the head to insert on the mandible.
 Teeth and Occlusion
The way the teeth fit together may affect the TMJ
complex.

A stable occlusion with good tooth contact and

interdigitation provides maximum support to the muscles
and joint, while poor occlusion (bite relationship) may
cause the muscles to malfunction and ultimately cause
damage to the joint itself.

Instability of the occlusion can increase the pressure on the

joint, causing damage and degeneration.
VASCULARISATION
Branches of External Carotid Artery
Superficial temporal artery
Deep auricular artery
Anterior tympanic artery
Ascending pharyngeal artery
Maxillary artery
VASCULARISATION
The Blood supply to TMJ is only Superficial,
i.e. there is no blood supply inside the capsule

TMJ takes its nourishment from Synovial fluid

 Innervations

Movements of synovial joint initiated & effected by muscle coordination.

Achieved in part through sensory innervation.

Hiltons Law:
The principle that the nerve supplying a joint also supplies both the
muscles that move the joint and the skin covering the articular insertion of
those muscles.

Therefore: Branches of the mandibular

division of the fifth cranial nerve supply the TMJ (auriculotemporal, deep
temporal, and masseteric)
Innervations

4 Types of nerve endings:

1. Ruffinis corpuscles (limited to capsule)
2. Pacinis corpuscles (limited to capsule)
3. Golgi tendon organs (confined to ligament)
4. Free nerve endings (most abundant)
 PROPIOCEPTION

Ruffini Endings
Position the mandible
Pacinion Receptors
Accelerate movement during Reflexes
Golgi tendon Organs
Protection of ligaments Around TMJ
Free Nerve Endings
Pain receptors
 Pacinian Corpuscle

Onion-like
encapusulated pressure
receptors
Surrounding concentric
lamellae respond to
distortion, generate
action potential in
unmyelinated fiber in
core
Bar = 100 microns

http://www.kumc.edu/instruction/medicine/anatomy/hi
stoweb/nervous/nervous.htm
 Ruffinis & Golgi Corpuscle

Function:
Ruffinis = Posture (proprioception), dynamic and static balance

Golgi tendon organ = Static mechanoreception, protection (ligament)

Free nerve endings = Pain (nociception) protection (joint)

www.anatomyatlases.org/ MicroscopicAnatomy/Section06/Section06.shtml
 HISTOLOGY
OF
ARTICULAR SURFACE OF TMJ
1. The articular zone
. Dense fibrous
connective tissue
. Poor blood supply
. Better ability to
repair
Good adaption to sliding movement
Shock absorber
Less susceptible to the effect of aging
time & breakdown over time.
2. The proliferative
zone

Mainly cellular
zone
Undifferentiated
mesenchymal cells
Proliferation &
regeneration
throughout life
3. The cartilagenous
zone
Collagen fibers
arranged in criss
-cross pattern of
bundles

Offers considerable resistance against

compressive & lateral forces

But becomes thinner with age.

4. The calcified zone

Deepest zone
Chondrocytes,
chondroblasts &
osteoblasts
Active site for remodeling activity as bone
growth proceeds.
 RELATIONS

Anteriorly - Mandibular notch

Lateral pterygoid
Masseteric nerve and

artery
 A careful dissection of 16
intact human cadaveric
head specimens revealed
The location of the
masseteric artery was
then determined in
relation to 3 points
process:

1) the anterior-superior
aspect of the condylar
neck = 10.3 mm;
2) the most inferior aspect of
the articular tubercle =
11.4 mm;
3) the inferior aspect of the
sigmoid notch = 3 mm.
Bashar M. Rajab, Ammar A.
Sarraf, A. Omar Abubaker
, Daniel M. Laskin Masseteric
Artery: Anatomic Location and
Relationship to the Temporomand
ibular Joint Area Journal of Or
al and Maxillofacial Surgery
. 2009;67 (2) : 369371
 RELATIONS

Posteriorly - parotid gland

Superficial temporal vessels
Auriculotemporal nerve
 RELATIONS

Laterally

Skin and fascia

Parotid gland
Temporal branches of facial nerve
Medially - Tympanic plate (separates from ICA)
spine of sphenoid
Auriculotemporal & chorda tympani nerve
middle meningeal artery
maxillary artery
Superiorly
middle cranial fossa
middle meningeal vessels
Inferiorly
maxillary
artery
&
vein
Inferiorly
maxillary
artery
&
vein
Inferiorly
maxillary
artery
&
vein
MOVEMENTS
OF
TMJ
 Movements
Rotational / hinge movement in first 20-
25mm of mouth opening

Translational movement after that when the

mouth is excessively opened.
 Translatory movement in the superior part of the joint as the
disc and the condyle traverse anteriorly along the inclines of
the anterior tubercle to provide an anterior and inferior
movement of the mandible.
 Mouth closed Mouth open

Hinge movement the inferior portion of the joint between

the head of the condyle and the lower surface of the disc to
permit opening of the mandible.
TMJ and the American Society of Temporomandibular Joint Surgeons.mp4
1. Depression Of Mandible
Lateral pterygoid
Digrastric
Geniohyoid
Mylohyoid
2. Elevation of Mandible
Temporalis
Masseter
Medial
Pterygoids
3. Protrusion of Mandible
Lateral Pterygoids
Medial Pterygoids
4. Retraction of Mandible
Posterior fibres of Temporalis
 Age changes of the TMJ:
Condyle:
Becomes more flattened
Fibrous capsule becomes thicker.
Osteoporosis of underlying bone.
Thinning or absence of cartilaginous zone.

Disk:
Becomes thinner.
Shows hyalinization and chondroid changes.

Synovial fold:
Become fibrotic with thick basement membrane.

Blood vessels and nerves:

Walls of blood vessels thickened.
Nerves decrease in number
 These age changes lead to:
-Decrease in the synovial fluid formation

-Impairment of motion due to decrease in the disc

and capsule extensibility

-Decrease the resilience during mastication due to

chondroid changes into collagenous elements

-Dysfunction in older people

Development
 At week 12 of gestation:
temporal/ glenoid blastema
Ossifies and becomes glenoid fossa
condylar blastema
Becomes the condylar cartilage
Clefts are formed
lower joint cavity
upper joint cavity
 4
1. Primitive
articular disc
2. Upper cleft
3. Lower cleft
4. Temporal
blastema
5. Condylar
blastema
33
1. Glenoid fossa
2. Upper joint cavity
3. Articular disc
4. Lower joint cavity
5. Condyle
CLINICAL CONSIDERATIONS
 SURGICAL
APPROACHES
TO
TMJ
POST/ RETRO AURICULAR
ENDAURAL
 SUBMANDIBULAR
RISDONS APPROACH
POSTRAMAL /
HINDS
INCISION
 PREAURICULAR
DINGMANS INCISION
 PREAURICULAR
DINGMANS INCISION

Dingman and Grabb (1962)

 PREAURICULAR
THOMAS ANGULATED
INCISION
 BLAIRS INVERVED
HOCKYSTICK INCISION

BLAIR & IVY 1936

 BLAIRS INVERVED
PAPOWICH MODIFICATION

PAPOWICH &
CARNE 1982
AL-KAYAT & BRAMLEY 1979
For a wider exposure.
A question mark shaped skin incision which
avoids main vessels and nerves.
About 2 cm above the malar arch, the temporalis
fascia splits into 2 parts, which can be easily
identified by fat globules between 2 layers which
form an important landmark.
In this, temporal facia and superficial temporal
artery are reflected with skin flap. Later helps in
better healing of the flap.
Under no circumstances should the inferior end
of the skin incision be extended below the lobe
of the ear as it increases the risk of damage to
main trunk of facial nerve. It is particularly
important in children where it may be quite
superficial.
 The length of the facial nerve which is visible
to the surgeon is about 1.3 cm.
 In 30 patients study of
precise location of the
temporal branch of the
facial nerve in relation to
the most anterior aspect of
the bony external acoustic
canal was done by
Miloro et al

mean distance from most posterior ramus of the temporal

branch of the facial nerve to the most anterior aspect of the
external acoustic canal was 2.12 cm 0.21 cm (range, 1.68 to
2.49 cm).
Michael Miloro, Scott Redlinger, Diane M. Pennington, Tommy Kolodge, In Situ Location of the
Temporal Branch of the Facial Nerve. Journal of Oral and Maxillofacial Surgery. 2007; 65(12):2466
2469
 Intraoral approach: It was described by Sear
(1972) for removal of hyperplastic condyles. The
incision commences at the level of upper occlusal
plane and passes downwards and forwards
between the internal and external oblique ridges of
mandible and then forwards as necessary along
mandibular body. Upper end should not be
extended beyond the level of upper molar teeth,
otherwise buccal pad of fat is encountered and
prolapses in the wound decreasing the visibility
 Arthroscopy
Arthroscopy of the TMJ was first introduced by
Ohnishi in 1975.
Approaches for the arthroscopic
lysis and lavage of the TMJ
1. Superior posterolateral
2. Superior anterolateral
3. Inferior posterolateral
4. Inferior anterolateral
5. Endaural approach

1 = Superior anterolateral approach;
2 = endoaural approach;
3 = superior posterolateral approach;
C= condyle;
G= glenoid fossa.
The superior posterolateral
approach is the most common.
In this technique, the mandible
is distracted downward and
forward, producing a triangular
depression in front of the tragus.

The trocar is inserted into the roof of this depression to

outline the inferior aspect of the glenoid fossa. This provides
visualisation of the superior joint space.

1 = Superior anterolateral approach;
2 = endoaural approach;
3 = superior posterolateral approach;
C= condyle;
G= glenoid fossa.
In the superior anterolateral
approach the trocar is directed
superiorly, posteriorly, and
medially, along the inferior
slope of the articular
eminence. This approach
allows visualisation
of the anterosuperior joint
compartment.

1 = Superior anterolateral approach;
2 = endoaural approach;
3 = superior posterolateral approach;
C= condyle;
G= glenoid fossa.
In the inferior posterolateral
approach, the trocar is
directed against the lateral
posterior surface of the
mandibular head. This
provides visualisation of the
posterior condylar surface and
the inferoposterior synovial
pouch.

1 = Superior anterolateral approach;
2 = endoaural approach;
3 = superior posterolateral approach;
C= condyle;
G= glenoid fossa.
In the inferior anterolateral
approach the trocar is inserted
at a point anterior to the lateral
pole of the condylar head
and immediately below the
articular tubercle. This
technique
allows observation of the
lower anterior synovial pouch.

1 = Superior anterolateral approach;
2 = endoaural approach;
3 = superior posterolateral approach;
C= condyle;
G= glenoid fossa.
The endaural approach is initiated
by entering the posterosuperior
joint space with a trocar from a
point 1 to 1.5 cm
medial to the lateral edge of the
tragus through the anterior
wall of the external auditory
meatus. The trocar is directed
in an anterosuperior and slightly
medial direction toward
the posterior slope of the eminence.
The posterior superior
joint space and medial and lateral
paradiscal troughs can be
examined with this technique
LC = lateral canthus; T = tragus; A = 10mm from the middle of
the tragus and 2mm below the canthotragal line. B = 10mm
further along the canthotragal line and 10mm below it; C= 7mm
anterior from the middle of the tragus and 2mm inferior along
the canthotragal line; and D= 23mm in front of point A.
Ankylosis & Kabans protocol
 A Protocol for Management of Temporomandibular J
oint
Ankylosis in Children. Leonard B. Kaban, Carl Bouchard
, Maria J. Troulis .
Journal of Oral and Maxillofacial Surgery 2009;
The 7-step protocol consists of 67(9):19661978

1) Aggressive excision of the fibrous and/or bony ankylotic

mass,
2) Coronoidectomy on the affected side,
3) Coronoidectomy on the contralateral side, if steps 1 and 2
do not result in a maximal incisal opening greater than 35
mm or to the point of dislocation of the unaffected TMJ,
4) Lining of the TMJ with a temporalis myofascial flap or
the native disc, if it can be salvaged,
5) Reconstruction of the ramus condyle unit with either
distraction osteogenesis or costochondral graft
6) Rigid fixation,
7) Early mobilization of the jaw.
 If distraction osteogenesis is used to
reconstruct the ramus condyle unit,
mobilization begins the day of the
operation. In patients who undergo
costochondral graft econstruction,
mobilization begins after 10 days of
maxillomandibular fixation. Finally (step
7), all patients receive aggressive
physiotherapy
Dislocation
 Conclusion
The temporomandibular joint (TMJ), also known
as the mandibular joint, is an ellipsoid variety of
the right and left synovial joints forming a
bicondylar articulation.

The common features of the synovial joints

exhibited by this joint include a fibrous capsule, a
disk, synovial membrane, fluid, and tough
adjacent ligaments.
 Not only is the mandible a single bone but the cranium is
also mechanically a single stable component; therefore, the
correct terminology for the joint is the craniomandibular
articulation.

The term temporomandibular joint is misleading and

seems to only refer to one side when referring to joint
function.

Magnetic resonance imaging has been shown to accurately

delineate the structures of the TMJ and is the best
technique to correlate and compare the TMJ components
such as bone, disk, fluid, capsule, and ligaments with
autopsy specimens.
 REFERENCES - TEXTBOOK
1. Sicher and Dubrul's Oral Anatomy by E. Lloyd Dubrul
2. The Tmj Book by Andrew S. Kaplan, Jr. Williams Gray
3. B.D. Chaurassias human anatomy 4th edition vol. 3 The
Head & Neck.
4. Williams PL: Grays anatomy, in Skeletal System (ed 38).
Churchill Livingstone, London, 1999, pp 578-582
5. Fonseca volume 2 by Robert D. Marciani
6. Temporomandibular Disorder, A Problem Based
Approach by Dr Robin J. M. Gray & Dr M. Diad Al
Ani
7. Surgical Approaches To Facial Skeleton By Edward
Ellis III & Nmichael F. Zide
8. Surgery Of TMJ 2nd ed. by David A. Keith
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