Tmj.ppt

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, SaundersCo., 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: Gray’s 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.

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.

Peculiarity of TMJ…….

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. It’s 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 Componentor

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 cone-shaped prominence called the post glenoid process immediately anterior to the external acoustic meatus.

E: Articular eminence; enp: entogolenoid process; t:articular tubercle; Co: condyle; pop: postglenoid process; lb: lateral border of the mandibular fossa; pep: preglenoidplane; Gf: glenoid fossa; Cp: condylar 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: Gray’s 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: Gray’s 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.

Harms SE, Wilk RM: Magnetic resonance imaging of the temporomandibular joint. Radiographics 7(3):521-542, 1987

• 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.

• 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.

• 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 condyle and the junction of the bilaminar zone, and the disk lies at the superior part of the condyle.


• The posterior band and retrodiskal tissue are best depicted in the open-mouth position.

Fibrous Capsule

• Thin sleeve of tissue completely surrounding the joint.

• 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

temporal, anteriorly it is attached to the preglenoid

plane

Patnaik VVG, Bala S,Singla Rajan K: Anatomy of temporomandibular joint? A review. J Anat Soc India 49(2):191-197, 2000

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.

• Medially and laterally- blends with the condylodiscal ligaments.

• This capsule is reinforced more laterally by an external TMJ ligament, which also limits the distraction and the posterior movement of the condyle.

• 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.

Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg 11(3):207-212, 1974

• 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.

Temporomandibular Ligaments Complex

Collateral Ligaments

• The ligament on each side of the 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.

McMinn, RMH: Last’s anatomy regional and applied, in Head and Neck and Spine. Churchill Livingstone, Edinburgh, London, 1994, p. 523

• 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 .

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 mandible’s 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 Surg11(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.

Hilton’s 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. Ruffini’s corpuscles (limited to capsule)

2. Pacini’s 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

http://www.kumc.edu/instruction/medicine/anatomy/histoweb/nervous/nervous.htm

“Onion-like encapusulated pressure receptors

Surrounding concentric lamellae respond to distortion, generate action potential in unmyelinated fiber in core

Bar = 100 microns

Ruffini’s & Golgi Corpuscle

Function:

Ruffini’s = 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 Temporomandibular Joint Area Journal of Oral and Maxillofacial Surgery. 2009;67 (2) : 369–371

http://www.sciencedirect.com/science/journal/02782391















http://www.sciencedirect.com/science/journal/02782391/67/2


RELATIONS

Posteriorly - parotid gland Superficial temporal vessels Auriculotemporal nerve

RELATIONS

Laterally –

Skin and fasciaParotid glandTemporal 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

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

1. Primitive articular disc

2. Upper cleft3. Lower cleft4. Temporal

blastema5. Condylar

blastema

4

33

1. Glenoid fossa2. Upper joint cavity3. Articular disc4. Lower joint cavity5. Condyle

CLINICAL CONSIDERATIONS

SURGICAL APPROACHES

TO TMJ

POST/ RETRO AURICULAR

ENDAURAL

SUBMANDIBULAR RISDON’S APPROACH

POSTRAMAL / HIND’S

INCISION

PREAURICULARDINGMAN’S INCISION

PREAURICULARDINGMAN’S INCISION

Dingman and Grabb (1962)

PREAURICULARTHOMA’S ANGULATED

INCISION

BLAIR’S INVERVED HOCKYSTICK INCISION

BLAIR & IVY 1936

BLAIR’S INVERVED PAPOWICH MODIFICATION

PAPOWICH & CARNE 1982

• 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.

AL-KAYAT & BRAMLEY 1979

• 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

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

• 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).

• 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.

1. Superior posterolateral

2. Superior anterolateral

3. Inferior posterolateral

4. Inferior anterolateral

5. Endaural approach

Approaches for the arthroscopiclysis and lavage of the TMJ

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 providesvisualisation of the superior joint space.


In the superior anterolateral approach the trocar is directedsuperiorly, posteriorly, and medially, along the inferior slope of the articular eminence. This approach allows visualisationof the anterosuperior joint compartment.


In the inferior posterolateral approach, the trocar isdirected against the lateral posterior surface of the mandibular head. This provides visualisation of the posterior condylar surface and the inferoposterior synovial pouch.


In the inferior anterolateral approach the trocar is insertedat a point anterior to the lateral pole of the condylar headand immediately below the articular tubercle. This techniqueallows observation of the lower anterior synovial pouch.


The endaural approach is initiated by entering the posterosuperiorjoint space with a trocar from a point 1 to 1.5 cmmedial to the lateral edge of the tragus through the anteriorwall of the external auditory meatus. The trocar is directedin an anterosuperior and slightly medial direction towardthe posterior slope of the eminence. The posterior superiorjoint space and medial and lateral paradiscal troughs can beexamined 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= 2–3mm in front of point A.

Ankylosis & Kaban’s protocol

• The 7-step protocol consists of

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.

A Protocol for Management of Temporomandibular Joint Ankylosis in Children. Leonard B. Kaban, Carl Bouchard

, Maria J. Troulis . Journal of Oral and Maxillofacial Surgery 2009;

67(9):1966–1978






http://www.sciencedirect.com/science/article/pii/S0278239109010957





• 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. Chaurassia’s human anatomy 4th edition vol. 3 The Head & Neck.

4. Williams PL: Gray’s 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

REFERENCES - ARTICLES1. Dorland WA: Medical Dictionary. Philadelphia and London, Saunders Co., 1957

2. Williams PL: Gray’s anatomy, in Skeletal System (ed 38). Churchill Livingstone, London, 1999, pp 578-582

3. Yale SH: Radiographic evaluation of the temporomandibular joint. J Am Dent Assoc 79(1):102-107, 1969

4. Patnaik VVG, Bala S,Singla Rajan K: Anatomy of temporomandibular joint? A review. J Anat Soc India 49(2):191-197, 2000

5. Harms SE, Wilk RM: Magnetic resonance imaging of the temporomandibular joint. Radiographics 7(3):521-542, 1987

6. Tallents RH, Katzberg RW, Murphy W, et al: Magnetic resonance imaging findings in asymptomatic volunteers and symptomatic patients with temporomandibular disorders. J Prosthet Dent 75(5):529-533, 1996

7. Helms CA, Kaplan P: Diagnostic imaging of the temporomandibular joint: recommendations for use of the various techniques. AJR Am J Roentgenol 154(2):319-322, 1990

8. Helms CA, Kaban LB, McNeill C, et al: Temporomandibular joint: morphology and signal intensity characteristics of the disk at MR imaging. Radiology 172(3):817-820, 1989

REFERENCES - ARTICLES

9. 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

10. Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg 11(3):207-212, 1974

11. McMinn, RMH: Last’s anatomy regional and applied, in Head and Neck and Spine. Churchill Livingstone, Edinburgh, London, 1994, p. 523

12. Roberts D, Schenck J, Joseph P, et al: Temporomandibular joint: magnetic resonance imaging. Radiology 154(3):829-830, 1985

13. Harms SE, Wilk RM, Wolford LM, et al: The temporomandibular joint: magnetic resonance imaging using surface coils. Radiology 157(1):133- 136, 1985

14. Edelstein WA, Bottomley PA, Hart HR, et al: Signal, noise, and contrast in nuclear magnetic resonance (NMR) imaging. J Comput Assist Tomogr 7(3):391-401, 1983

15. Westesson PL, Katzberg RW, Tallents RH, et al: Temporomandibular joint: comparison of MR images with cryosectional anatomy. Radiology 164(1):59-64, 1987

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