This presentation is done by Prof. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surg., Former Dean, Faculty of Dental Medicine, Al-Azhar University, Cairo, Egypt. The presentation is about the chapter of Temoromandibular Joint in Oral Surgery which includes definition, anatomy, diseases and its surgical treatment.

2. Temporomandibular
Joint
Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

3. Temporomandibular
Joint
The temporomandibular joint is a unique joint in
body. Being diarthrodial (which permits freedom of
movement) and the articular surfaces are covered by
fibrous tissues instead of cartilage like other joints
in the body. It is the only joint in human body to
have a rigid endpoint of closure
Dr. Ahmed M.Adawy

4. Anatomy of the Temporomandibular
Joint
The TMJ is composed of the following structures:
1. The mandibular condyle
2. Articular (glenoid) fossa and eminence
3. The disc (Meniscus)
4. TMJ capsule
5. Temporomandibular joint ligaments
Dr. Ahmed M. Adawy
(1)

5. The size & shape of the condyle varies between
individuals, the superior surface could be; flat,
convex, round or angled. A roughened area is present
on the lateral and medial walls of the condyle known
as condylar poles that give attachment to the disc
Dr. Ahmed M. Adawy

6. The articulator surface is composed of dense cartilaginous, non-
innervated connective tissues
Histologically five different zones could be seen in the condyle
starting from the articular surface:
1.Fibrous connective tissue layer
2.Proliferative undifferentiated mesenchymal layer containing
cartilage responsible of growth
3.Transitional layer
4.Layer of compact bone
5.The rest of the condyle is composed of spongy bone
Dr. Ahmed M. Adawy

7. 2. Articular (glenoid) fossa and
eminence
It is the concave area of the squamous temporal bone
holding the condyle. The anterior part of the fossa is
projected making the articular eminence. The articular
surface is covered by nonvascularized, noninnervated
dense fibrous tissue layer
Dr. Ahmed M. Adawy

8. 3. The disc (Meniscus)
Generally, the shape of the disc is oval when viewed
from above. It is pear shape with the apex projects
anteriorly. The disc is attached anteriorly to the lateral
pterygiod muscle which pulls the disc anteriorly
during mouth opening keeping always the disc
between the fossa and the moving condyle. The
meniscus is attached to the condyle by collateral
ligaments
Dr. Ahmed M. Adawy

9. 3. The disc (Meniscus)
The disc is composed of four transverse zones
anterior, intermediate, posterior bands and the
bilaminar zone. The intermediate zone is avascular
and thinnest in the middle lacking healing capacity.
The bilaminar zone is composed of two distinguished
layers; the upper stratum, which is attached to the
posterior wall of the glenoid fossa, and the lower
stratum, which is attached to the back of the condyle
Dr. Ahmed M. Adawy

10. 3. The disc (Meniscus)
The upper stratum consists of a meshwork of elastic
and collagen fibers and it is responsible of returning
the disc posteriorly. The lower stratum is composed of
C.T reach in collagen fiber and it is responsible of
keeping the disc attached to the condyle. The zone
between the two strata is reach in blood vessels and
nerves
Dr. Ahmed M. Adawy

11. Tmj, lateral view
Dr. Ahmed M. Adawy

12. 4. TMJ capsule
The different component of the joint is enclosed
within fibrous capsule. The attachment of the disc to
the capsule divides the joint space into two
compartments; upper and lower. The joint cavity is
filled synovial fluid secreted by the lining synovial
membrane for lubrication
Dr. Ahmed M. Adawy

13. 5. Temporomandibular joint
ligaments
The TMJ ligament is the main ligament of the joint
while stylomandibular, sephenomandibular, and
capsular ligaments are accessory ligaments helping
in prevention of condyle from traveling far away
from the glenoid fossa
Dr. Ahmed M. Adawy

14. Temporomandibular joint
ligaments
Dr. Ahmed M. Adawy

15. Temporomandibular joint
ligaments
Dr. Ahmed M. Adawy

16. Blood supply
Branches from Superficial
temporal & Maxillary Artery
Nerve supply
Auriculotemporal
& Masseteric Nerve
Temporomandibular joint
Dr. Ahmed M. Adawy

17. Muscles of mastication
Dr. Ahmed M. Adawy

18. Diseases of the Joint
1. Myofacial pain dysfunction (MPD)
syndrome
It is not a disease entity rather than set of
etiologically related disorders. It is defined as a
functional disorder characterized by facial pain
and jaw dysfunction and is independent of local
disease involving the teeth or mouth
Dr. Ahmed M. Adawy
(2)

19. Myofacial pain dysfunction (MPD) syndrome
Signs and symptoms
1. Facial pain especially with jaw movement. The pain
my be acute or chronic
2. Tenderness of the masticatory muscles and muscles
of the neck especially strenomastiod and trapezius
3. Limited mouth opening
4. Absence of radiological or clinical evidence of
organic changes of the TMJ as disc displacement or
disc dislocation
Dr. Ahmed M. Adawy

20. Myofacial pain dysfunction (MPD) syndrome
Etiology
The etiology of the MPD syndrome is controversial, but mostly
associated with some predisposing factors like:
1. Occlusal disharmony
2. Psychological stress
3. Bruxism
4. Loss of vertical dimension due to teeth loss
All these factors exert abnormal stress on the masticatory
muscles leading to their spasm due to lactic acid accumulation.
The long-standing muscle spasm causes pain and tenderness as
well as limit movement of the joint.
Dr. Ahmed M. Adawy

21. Myofacial pain dysfunction (MPD) syndrome
Treatment
The condition should be treated once diagnosed.
Otherwise, the joint will suffer more serious
pathological changes as internal derangement. The
treatment of this case is totally conservative
involving correction and removal of the etiologic
factors and control of pain and muscle spasm
Dr. Ahmed M. Adawy

22. 1. Occlusal rehabilitation.
2. Splint therapy usually eliminate the muscle spasm
and pain caused by hyperactive muscles.
Myofacial pain dysfunction (MPD) syndrome
Treatment
Dr. Ahmed M. Adawy

23. 3. Physiotherapy in the form of muscle exercise to
remove muscle spasm or by application of
ultrasound or short waves to increase blood flow into
the affected muscles helping in removal of the
accumulated toxic products inside the spastic
muscles.
4. Medication. Analgesic, anti-inflammatory and muscle
relaxants are prescribed to control pain and break the
pain-spasm-pain cycle.
5. Psychological counseling in some cases
Myofacial pain dysfunction (MPD) syndrome
Treatment
Dr. Ahmed M. Adawy

24. Diseases of the Joint
2. Internal derangement
It is defined as abnormal relationship of the articular
disc to the condyle so that the disc no longer moves in
harmony with it.
Etiology
1.Untreated MPD syndrome
2.Acute trauma to the mandible
3.Bruxism
4.Malocclusion
Dr. Ahmed M. Adawy

25. Diseases of the Joint
2. Internal derangement
These factors cause spasm of the superior belly of
the lateral pterygiod muscle with chronic anterior
pull of the meniscus leading to elongation and
dysfunction of the collateral ligament as well as
the distortion of the elastic fibers of the upper
stratum of the bilaminar zone. Finally they will
not be able to retract the disc posteriorly
Dr. Ahmed M. Adawy

26. So, the disc is either anteriorly displaced but is
reduced to normal position during mouth
opening (disc displacement with reduction) or is
completely located anterior to the condyle with
no reduction (disc dislocation)
Diseases of the Joint
2. Internal derangement
Dr. Ahmed M. Adawy

27. Signs and symptoms of anterior disc
displacement with reduction
1. Initial limited mouth opening with pain
2. Pain associated with wider opening followed
by click sound
3. Deviation of the jaw to the affected side
4. After clicking the jaw return to normal path
resulting in zigzag condylar path
Dr. Ahmed M. Adawy

28. Disc position, normal
Anteriorly displaced disc
with reduction
Dr. Ahmed M. Adawy

29. Signs and symptoms of disc dislocation
without reduction
1. History of clicking sound of the joint before
limitation of mouth opening
2. Limited mouth opening in bilateral cases
3. Pain is experienced by attempts to increase
the range of the opening
4. Jaw deviation to the affected side
Dr. Ahmed M. Adawy

30. Displaced disc without reduction
Dr. Ahmed M. Adawy

31. Diagnostic aids
1. Clinical data
2. Plain radiographs provide information about the bony
component of the joint
3. Tomogram, eliminates superimposition
4. Computerized tomogram is considered the best
technique for evaluating the bony architecture of the
TMJ
5. Arthrogram is an invasive technique and rarely used
now It is useful in diagnosis of disc perforation
Dr. Ahmed M. Adawy

32. 6. Magnetic Roasence imaging MRI . Recently it
becomes the technique of choice to visualize the
disc position. It is precise and noninvasive
technique
Diagnostic aids
Normal MRI disk: Low signal intensity.
"Bow tie" configuration in sagittal plane
Dr. Ahmed M. Adawy
(3)

33. Closed mouth
Open mouth
Closed
Open
Dr. Ahmed M. Adawy

34. Treatment of internal derangement
1. Conservative treatment
It attempt to remove muscle spasm helping in return of the disc
to normal function.
2. Surgical Treatment of internal derangement
This is undertaken if the conservative treatment fails or the
disc is dislocated.
3. Arthrocentesis
Arthrocentesis is often the first surgical procedure that will be
done for a patient who has a displaced disc. It can be done as
an in-office procedure. The main principle has been releasing
the “stuck” disc from the fossa by irrigation of the superior
joint space under local anesthesia
Dr. Ahmed M. Adawy
(4)

35. Arthrocentesis, Tmj (lysis & lavage)
Dr. Ahmed M. Adawy

36. Surgical exposure of the TMJ
The joint could be approached through several incisions:
1. Preauricular incision
2. Endaural approach
3. Post auricular approach
Dr. Ahmed M. Adawy
(5)
(6)
(7)

37. Surgical Treatment of internal
derangement
A. Disc repositioning procedure
The technique involves excision of a wedge of tissue from
the posterior band and re-sutures the disc in posterior
position
B. Disc decompression
The goal of the procedure is to remove a small part of the
articular surfaces, either from the condyle (High condylar
shave) or from the articular eminence called eminectomy,
to relieve the pressure on the nerve-rich posterior band
Dr. Ahmed M. Adawy

38. Surgical Treatment of internal
derangement
C. Menisectomy
If the disc is completely distorted it is totally removed.
The joint is either left without replacing the disc or grafted
with cartilage from the ear or nasal septum or other
biomaterial
D. Repair of disc perforation (meniscoplasty)
The disc is exposed and the perforation edges are excised
and the disc is grafted with dermal graft larger than the
circumference of the perforation
Dr. Ahmed M. Adawy
(8)

39. Diseases of the Joint
3. Condylar Hyper mobility
A. Hyper translation: excessive movement of the condyle
during opening
B. Dislocation: movement of the condyle anterior to the
articular eminence from which it cannot be reduced
voluntary
C. Sublaxation: It is incomplete dislocation of the condyle
in which the condyle moves anterior to the articular
eminence and the patient is able to return it back to the
fossa either spontaneously or after self manipulation
Dr. Ahmed M. Adawy
(9)

40. Signs & symptoms of dislocation
1. In bilateral cases the mandible is fixed in anterior
opened position
2. In unilateral case the patient cannot close his mouth
with deviation of the jaw to the unaffected side
3. Depression anterior to the ear in the affected joint
4. Pain in the TMJ area
5. Plain X-ray or C.T will reveals that the condyle is
anteriorly displaced with empty glenoid fossa
Dr. Ahmed M. Adawy

41. Dr. Ahmed M. Adawy

42. Treatment of dislocation
1. Immediate (emergency) treatment
The mandible is manipulated to allow the condyle to move
posteriorly and reposition them in the fossa
Reduction of a dislocation of several-days duration is
facilitated by injection of local anesthesia in the fossa and
sedating the patient with diazepam
In resistant case the manipulation is carried out under
general anaesthesia
After reduction the jaw is immobilized with intermaxillary
fixation for two weeks
Dr. Ahmed M. Adawy

43. Reduction of dislocation
Dr. Ahmed M. Adawy

44. 2. Non surgical treatment
Injection of sclerosing solution e.g. sodium
psylliate into the TMJ and supporting
structures can limit condylar hypermobility.
This could be done with a needle or more
precise with arthroscopy
Treatment of dislocation
Dr. Ahmed M. Adawy

45. 3. Surgical treatment of recurrent dislocation
The approach for treatment of condylar hypermobility
is divided into two main categories. The first is to
make an obstacle against excessive translation. While
the second is to remove any obstacle to the condylar
translation
Treatment of dislocation
Dr. Ahmed M. Adawy

46. A. Surgical procedure to obstruct movement
Increasing the height of the articular eminence will
prevent excessive movement of the condyle. This is
accomplished by many means; fracture the zygomatic
arch and fixing it inferiorly in front of the condyle;
augmentation of the eminence by bone graft or
alloplastic material
Treatment of dislocation
Dr. Ahmed M. Adawy

47. B. Surgical procedures that removes blocking factors
Either total removal of the articular eminence
(eminectomy) or partial removal of the articular
eminence (eminenoplasty) will remove the blocking
factor to condylar movement. This will not correct
excessive movement but let the condyle to move
anteriorly and return back without any hindering. The
advantage of this procedure is that it does not need
opening the joint capsule
Treatment of dislocation
Dr. Ahmed M. Adawy

48. Diseases of the Joint
4. TMJ ankylosis
It is defined as bony or fibrous union between the condyle
and the glenoid fossa. It should be differentiated from
pseudoanklosis which is inability to open the mouth due
to causes outside the joint capsule e.g. muscle trismus,
excessive scarring due to burn, and depressed fractured
zygomatic arch
Dr. Ahmed M. Adawy

49. Etiology of ankylosis
1. Trauma mostly to chin with fracture condyle
and intra-capsular hemorrhage followed by
organization of the formed blood clot
2. Infection especially from the ear
3. Rheumatoid arthritis
4. Post-operative complication of TMJ surgery
Dr. Ahmed M. Adawy

50. Signs and symptoms
The clinical appearance of the patients with TMJ
ankylosis depends largely upon the age of the patient at
the time of affection and the duration of the ankylosis.
The earlier the onset of the ankylosis the more severe is
the facial disfigurement due to affection of the condylar
growth center. Also the longer the duration of
ankylosis, the severe is the deformity. Such deformity
is due to destruction of the condoler growth center as
well as loss of growth stimulated by mandibular
function
Dr. Ahmed M. Adawy

51. 1. Inability to open the mouth without pain
2. In unilateral children there is facial asymmetry
with deviation of the jaw to the affected side,
accentuated antegonial notch, flattening of the
unaffected side and canting of the occlusal plane
3. In bilateral cases there is severe mandibular
micrognathia sometimes with apnea especially in
early childhood
4. Rampant caries
Signs and symptoms
Dr. Ahmed M. Adawy

52. Facial disfigurement, micrognathiamicrognathia
(bird face(bird face)
Dr. Ahmed M. Adawy

53. Radiographically, ankylosed joint is characterized
with obliterated joint cavity, short ramus, and
accentuated antigonial notch
Dr. Ahmed M. Adawy

54. Treatment of ankylosis posesTreatment of ankylosis poses
a significant challenge to thea significant challenge to the
anesthesiologist and to theanesthesiologist and to the
maxillofacial surgeonmaxillofacial surgeon
Treatment of ankylosis
Dr. Ahmed M. Adawy

55. Treatment of ankylosis
Excision of the ankylosed structure (condylectomy)
and creation of 1-1.5 cm gap (gap arthroplasty)
between superior margin of the ramus and the
zygomatic arch to prevent re-ankylosis. Placement of
interpositional material has been recommended to
prevent recurrence. Different materials and tissues
have been tried e.g., temporal fascia, skin or dermal
grafts
Dr. Ahmed M. Adawy
(10)

56. Dr. Ahmed M. Adawy

57. References:
1. Alomar X, et al: Anatomy of the temporomandibular joint. Seminars in
Ultrasound, CT, and MRI 28, 170, 2007.
2. Dworkin SF, LeResche L: Research diagnostic criteria for temporomandibular
disorders: review, criteria, examinations and specifications, critique.
J Craniomandibular Disorders. 6, 301, 1992.
3. CUNHA AL, et al : Magnetic Resonance Imaging in Temporomandibular Joint:
Review of anatomy and major disorders in joint dysfunction. Poster No.:
C-1702,Congress: ECR 2011.
4. Nitzan DW, Dolwick MF.: An alternative explanation for the genesis of closed-
lock symptoms in the internal derangement process. J Oral Maxillofac Surg; 49:
810, 1991.
5. Al-Khayat A, Bramley P: A modified preauricular approach to the
temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1980.
6. Rongetti JR: Menisectomy: a new approach to temporomandibular joint. Arch
Otol 60:566, 1975.
7. Alexander RW, James RB: Postauricular approach for surgery of the
temporomandibular articulation. J Oral Surg 33:346, 1975.
Dr. Ahmed M. Adawy

58. References:
8. Trumpy IG , Lyberg T.: Surgical treatment of internal derangement of the
temporomandibular joint. Long-term evaluation of three techniques.
J Oral Maxillofac Surg 53:740, 1995.
9. Kim CH, Kim H: Surgical correction of recurrent habitual temporomandibular
joint dislocation. J Korean Assoc Oral Maxillofac Surg 24:365,1998.
10. Vasconcelos B, et al: Surgical treatment of temporomandibular joint
ankylosis: follow-up of 15 cases and literature review. Med. Oral Patol. Oral
Cir. Bucal 1: 34,2009.
Dr. Ahmed M. Adawy