SURGICAL ANATOMY OF THE TEMPOROMANDIBULAR JOINT

The Temporomandibular Joint

Craniomandibular

joint

Paired

joint Synovial type of joint

Ginglymo
(gliding/translatory)

Arthroidial di
Joint
Hinge/rotatory

Consists of A mandibular or glenoid fossa An articular eminence A condyle A separating disc A fibrous joint capsule Extracapsular check ligaments

Bony Structures of the Joint

The articular portion of the temporal bone is composed of three parts: The largest is the articular or mandibular fossa, a concave structure extending from the posterior slope of the articular eminence to the postglenoid process, which is a ridge between the fossa and the external acoustic meatus. This is not a major stress-bearing area.

The second portion, the articular eminence, is a transverse bony prominence that is continuous across the articular surface mediolaterally. The articular eminence is usually thick and serves as a major functional component of the TMJ.

The third portion of the articular surface of the temporal bone is the preglenoid plane, a flattened area anterior to the eminence.

145-160o

15-20mm

8-10mm

The mandible is a U-shaped bone that articulates with the temporal bone by means of the articular surface of its condyles, paired structures forming an approximately 145 to 160 angle to each other. The mandibular condyle is approximately 15 to 20 mm in width and 8 to 10 mm in anteroposterior dimension. The condyle tends to be rounded mediolaterally and convex anteroposteriorly.

 On

its medial aspect just below its articular surface is a prominent depression, the pterygoid fovea, which is the site of attachments of the lateral pterygoid muscle.

Cartilage and Synovium

Two

types of tissues line the inner aspect of synovial joints:

articular cartilage synovium

The

space bound by these two structures is termed the synovial cavity, which is filled with synovial fluid. This fibrocartilage covering has the capacity to regenerate and to remodel under functional stresses.

 Articular

cartilage is composed of chondrocytes and an intercellular matrix of collagen fibers, water, ground substance. Chondrocytes are enclosed in otherwise hollow spaces, called lacunae, and are arranged in three layers characterized by different cell shapes.

The superficial zone contains small flattened cells with their long axes parallel to the surface. In the middle zone the cells are larger and rounded and appear in columnar fashion perpendicular to the surface. The deep zone contains the largest cells and is divided by the tide mark below which some degree of calcification has occurred. There are few blood vessels in any of these areas, with cartilage being nourished primarily by diffusion from the synovial fluid. Collagen fibers are arranged in arcades with an interlocking meshwork of fibrils parallel to the articular surface joining together as bundles and descending to their attachment in the calcified cartilage between the tide mark.

 Functionally

these arcades provide a framework for interstitial water and ground substance to resist compressive forces encountered in joint loading. Functions of the synovial fluid are lubrication of the joint, phagocytosis of articulate debris, and nourishment of the articular cartilage.

The synovial tissueis a connective tissue membrane, which lines the joint cavities or spaces and secretes synovial fluid for lubrication of the joint. The upper and lower joint spaces are bathed in a viscous synovial fluid.

Synovial Fluid
This fluid is an ultrafiltrate of blood plasma plus a mucin. It is composed chiefly of highly polymerized hyaluronic acid which is responsible for its viscous quality and is capable of absorbing tremendous shearing forces applied to the joint. The synovial membrane is the innermost layer of the fibrous capsule

 Function

of the synovium (besides lubrication) is to provide nutrition, phagocytosis and immunological response (Synovitisproliferation of the synovial cells with the concomitant release of prostaglandins and large quantity of collagenasepain).

Articular Disc or Meniscus The TMJ is a diarthroidial synovial paired joint. This means that there are two joint movements, which occur in separate compartments of this synovial joint and that one joint cannot operate without the other.

The meniscus or an intervening disc divides the articular space into two compartments: 1. The lower or inferior compartment condylodiscal complex between the condyle and the disc. 2. The upper (ternporodiscal) or superior compartment between the disc and the temporal bone or glenoid fossa .

Biconcave in the sagittal section Superior surface is concavoconvex to match the anatomy of the glenoid fossa and inferior surface is concave to fit over the condylar head.

detailed study by Rees in 1954 reported that the shape of the articular disc or meniscus is like a school boys or jockeys cap which overlaps the condylar head

Medially and laterally, the disc blends with the capsule. Anteriorly, it is attached to :

Above; articular eminence Below: articular margin of the condyle.

 It

is confluent anteriorly with the capsule as well as with the fascia of the superior head of the lateral pterygoid muscle.

Posteriorly, the disc is attached to the posterior wall of the glenoid fossa above and to the distal aspect of the neck of the condyle below. This area is called as the posterior bilaminnar zone or retro discal tissue which has a rich neurovascular supply. Sensory branches of auriculotemporal nerve are abundant here.

 The

upper joint space always extends farther anteriorly than the lower joint space, which is smaller and more tightly reinforced by the disc attachments, whereas the upper joint space is larger and not as well-reinforced.

 The

volume of the upper joint space is about 1.2 ml and of the lower joint space is about 0.9 ml.

Rees in 1954 described three zones posterior band, intermediate zone and anterior band. The anterior band is moderately thick (about 2 mm), but narrow anteroposteriorly. The thickest and widest is the posterior band (3 mm), whereas the intermediate band is the thinnest (1 mm). The inter position of the thin intermediate zone between the two thicker zones gives the meniscus more flexibility and enables it to alter shape from concave to convex during forward movement.

The posterior attachment tissues are highly innervated by the auriculotemporal nerve. Histological examination of this tissue reveals that it is not designed for loading. Above the posterosuperior aspect of the condyle and anterior to the bilaminar zone, the disc is very vascular and this region is called the vascular knee (genu vasculosa). The anterior extensions of the disc at its attachment to the superior belly of the lateral pterygoid is also vascular.

Retrodiskal Tissue
Posteriorly the articular disk blends with a highly vascular, highly innervated structurethe bilaminar zone, which is involved in the production of synovial fluid.

 The

superior aspect of the retrodiskal tissue contains elastic fibers and is termed the superior retrodiskal lamina, which attaches to the tympanic plate and functions as a restraint to disk movement in extreme translatory movements.

 The

inferior aspect of the retrodiskal tissue, termed the inferior retrodiskal lamina, consists of collagen fibers without elastic tissue and functions to connect the articular disk to the posterior margin of the articular surfaces of the condyle. Serves as a check ligament to prevent extreme rotation of the disk on the condyle in rotational movements.

Ligaments
Ligaments

associated with the TMJ are composed of collagen and act predominantly as restraints to motion of the condyle and the disk.

Three functional ligaments collateral, capsular, temporomandibular ligaments

because they serve as major anatomic components of the joints.

Two accessory ligaments sphenomandibular stylomandibular

because, although they are attached to osseous structures at some distance from the joints, they serve to some degree as passive restraints on mandibular motion.

The collateral (or diskal) ligaments

The collateral (or diskal) ligaments are short paired structures attaching the disk to the lateral and medial poles of each condyle. Their function is to restrict movement of the disk away from the condyle, thus allowing smooth synchronous motion of the diskcondyle complex. Although the collateral ligaments permit rotation of the condyle with relation to the disk, their tight attachment forces the disk to accompany the condyle through its translatory range of motion.

The capsular ligament The capsular ligament surrounds each joint, attaching superiorly to the temporal bone along the border of the mandibular fossa and eminence and inferiorly to the neck of the condyle along the edge of the articular facet. It surrounds the joint spaces and the disk, attaching anteriorly and posteriorly as well as medially and laterally, where it blends with the collateral ligaments. The function of the capsular ligament is to resist medial, lateral, and inferior forces, thereby holding the joint together. It offers resistance to movement of the joint only in the extreme range of motion. A secondary function of the capsular ligament is to contain the synovial fluid within the superior and inferior joint spaces.

The Temporomandibular (Lateral) Ligaments Located on the lateral aspect of each TMJ. Single structures that function in paired fashion with the corresponding ligament on the opposite TMJ.

Two distinct portions, that have different functions. outer oblique portion inner horizontal portion

 The

outer oblique portion descends from the outer aspect of the articular tubercle of the zygomatic process posteriorly and inferiorly to the outer posterior surface of the condylar neck.

It functions in limits the amount of inferior distraction that the condyle may achieve in translatory and rotational movements.

 The

inner horizontal portion also arises from the outer surface of the articular tubercle, just medial to the origin of the outer oblique portion of the ligament, and runs horizontally backward to attach to the lateral pole of the condyle and the posterior aspect of the disk.

The function of the inner horizontal portion of the temporomandibular ligament is to limit posterior movement of the condyle, particularly during pivoting movements, such as when the mandible moves laterally in chewing function. This restriction of posterior movement serves to protect the retrodiskal tissue.

The Sphenomandibular Ligament

It

arises from the spine of the sphenoid bone and descends into the fan-like insertion on the mandibular lingula, as well as on the lower portion of the medial side of the condylar neck.

The sphenomandibular ligament serves to some degree as a point of rotation during activation of the lateral pterygoid muscle, thereby contributing to translation of the mandible.

The Stylomandibular Ligament

The stylomandibular ligament descends from the styloid process to the posterior border of the angle of the mandible and also blends with the fascia of the medial pterygoid muscle.

It functions similarly to the sphenomandibular ligament as a point of rotation and also limits excessive protrusion of the mandible.

Blood Supply
Lateral aspect is supplied by superficial temporal branch of the external carotid artery. Rich vascular supply to the deep and posterior aspect of retrodiscal capsular part by deep auricular, posterior auricular and masseteric branches of the maxillary artery. Vascular supply to the lateral pterygoid muscle also supplies to the head of the condyle by penetration of numerous nutrient foramina vessels. The venous pattern is more diffuse, forming a plentiful plexus all around the capsule.

Nerve Supply

The mandibular nerve, the third division of the fifth cranial nerve innervates the jaw joint. Three branches from the mandibular nerve send terminals to the joint capsule.
1.

2.
3.

The largest is the auriculotemporal nerve which supplies the posterior,medial and lateral parts of the joint. Masseteric nerve, and A branch from the posterior deep temporal nerve, supply the anterior parts of the joint.

Musculature
All

muscles attached to the mandible influence its movement to some degree. A total of 12 muscles actually influence mandibular motion, all of which are bilateral.

Muscles influencing mandibular motion are divided into two groups based on anatomic position
Supramandibular Inframandibular

Supramandibular Muscles

Inframandibular Muscles
Suprahyoids

Digastric Geniohyoid Mylohyoid Stylohyoid

Infrahyoids

Omohyoid Thyrohyoid Sternothyroid Sternohyoid

Biomechanics of the TMJ Movements

are of three types

Depression/Elevation
Protraction/

Retraction Sideways/rotatory movements

Depression or Elevation Movement takes place mainly in lower compartment (Menisco-mandibular) of the joint. Axis Rotation of head of mandible around a transverse axis with gliding forward of the head in lower and disc in upper compartment in depression. Reverse movements in elevation and consists gliding backward and rotation of head in upper and gliding of disc in upper compartment.

Muscles responsible for the movements Elevation (Closing the mouth)

(a) Masseter (b) Temporalis (c) Medial pterygoid of both sides. They act as powerful antigravity muscles. (a) Mainly Lateral pterygoid of both sides. (b) Helped by Geniohyoid, Mylohyoid and Digastric muscles. (c) Gravity helps also. (d) Infrahyoid muscles help by fixing the hyoid bone.

Depression

Protraction and Retraction

It

is the protrusion of lower teeth beyond upper teeth and drawing backwards to position of rest. Mechanism Movement takes place in the upper (Menisco temporal) compartment.

In protrusion it is the gliding advance movement of mandibular teeth more or less in occlusal position from position of rest. In retraction drawing backward to resting position.

Muscles responsible for the movements Retraction

(a) Mainly posterior fibres of Temporalis (b) Middle and deep fibres of Masseter (c) Digastric (d) Geniohyoid muscles.

Protraction

(a) Lateral and (b) Medial pterygoids both sides.

Chewing or rotatory movements, grinding or side to side movements

Mechanism Head of mandible of one side glides forward in upper and rotates around a vertical axis, which passes through the posterior border of the opposite ramus of the mandible. Then the head moves backward to original position and the other head moves forward. These alternate movements result in producing side to side grinding or chewing movement.

 Muscles

responsible Lateral and Medial pterygoids of one side acting alternately with other side.

Range of movements
Maximum

range of protrusion of mandible about 10 mm. Maximum opening of Jaw is 50 mm Functional range of opening is 40 mm.
Of this 40 mm opening 25 mm by rotation. 15 mm by forward gliding.

of mandible Occluded position increased stability. Role played by bones Prevention of forward displacement by articular eminence and backward by Pterygoid tubercles. Accessory ligament Temporomandibular (Lateral) ligament prevents backward displacement. Muscles Tendon of Temporalis prevents protrusion and Lateral pterygoid prevents retraction.
Position

Factors for stability of the joint

Surgical Anatomic Considerations

The superficial temporal vessels are typically located in the superficial fascia below the auricularis anterior muscle. The vessels are often visible, invested in the superficial fascia without incising the muscle. The superficial temporal vein lies posterior to the artery and the auriculotemporal nerve immediately behind the vessels. The superficial temporal vessels and auriculotemporal nerve appear to take on a horizontal course once the flap is fully developed and reflected anteroinferiorly.

Relationship Of Facial Nerve

Al-Kayat and Bramley noted that the facial nerve bifurcated into temporofacial and cervicofacial components within 2.3 cm (range 1.52.8 cm) inferior to the lowest concavity of the bony external auditory canal and within 3.0 cm (range 2.4 3.5 cm) in an inferoposterior direction from the postglenoid tubercle. The temporal nerve branches lie closest to the joint and are the most commonly injured branches during surgery. These nerves are located in a condensation of superficial fascia, temporalis fascia, and periosteum as they cross the zygomatic arch.

The most posterior temporal branches lie anteriorly to the postglenoid tubercle.Their location was measured by Al-Kayat and Bramley as 3.5 0.8 cm from the anterior margin of the bony external auditory canal The two potential sources of facial nerve injury are dissection anterior to the posterior glenoid tubercle where the temporal branches cross the arch, and aggressive retraction at the inferior margin of the flap where the main trunk and temporofacial division are located.
Br J Oral Surg 1979-80;17;91

Surgical Approaches to the TMJ

Surgical access to the TM joint is an exacting procedure. It requires technical skill and a thorough knowledge of anatomy of the area. TMJ has got close proximity to the main trunk of the facial nerve with its branches in the temporal and facial areas. It has also got close proximity to the auriculotemporal nerve and the abundant vascular supply. Several approaches to the TMJ have been proposed and used clinically.

The classic surgical approaches to the TMJ may be classified as Preauricular Endaural Postauricular. Submandibular/Risdon`s approach Post Ramal approach(Hind`s) Hemicoronal Coronal/bicoronal The choice of approach is usually a matter of surgeons preference and is based on his or her ability and experience. Cosmetic considerations may also influence the choice of approach.

Preauricular Approach
This

is the most basic and standard approach to the TMJ. Many have modified this basic incision for avoiding injury to the Auriculotemporal nerve and for having better exposure to the TMJ. This basic incision is advocated and popularized by Dingman (1951).

Preparation of the Surgical Site Preparation and draping should expose the entire ear and lateral canthus of the eye. Shaving of the preauricular hair is optional. Cotton soaked with antibiotic ointment may be placed into the external auditory canal. The incision is outlined at the junction of the facial skin with the helix of the ear. A natural skin fold along the entire length of the incision from the helix to the upper border of the tragus can be used.

 Infiltration

of Vasoconstrictor

A vasoconstrictor can be injected subcutaneously, in the area of the incision to decrease the intraoperative bleeding.

 Skin

Incision

The incision is made through the skin, subcutaneous connective tissue to the depth of superficial layer of temporalis fascia. Any bleeding superficial vessels are cauterized before deeper dissection proceeds.

Dissection to the TMJ Capsule Blunt dissection with periosteal elevator undermining the superior portion of the incision (that above the zygomatic arch), so that a flap can be retracted anteriorly for approximately ito 1.5cm. This flap is dissected anteriorly at the level of the superficial layer of temporalis fascia. Below the zygomatic arch, dissection proceeds bluntly adjacent to the external auditory cartilage. Scissor dissection proceeds along the external auditory cartilage in an avascular plane between it and the glenoid lobe of the parotid gland.

 Retraction

is accomplished by use of self retaining retractor(Weitlaner/ Dolwick-reich type)

Modifications of Basic Preauricular Incision

All these modifications of basic preauricular incision were made to have better access and visibility, and wider exposure and to prevent injury to the auriculotemporal nerve and the branches of the facial nerve. 1. Blair and Ivy in 1936 used an inverted hockey stick incision over the zygoma tic arch, which gave easy access and better visibility and also facilitated exposure of the arch along with condylar area.

2. Thoma in 1958recommended an angulated vertical incisionwhich is carried out across the zygomatic arch in the fold, directly in front of the ear, extending down slightly above the earlobe, to avoid the main trunk of the facial nerve. 3. Al-Kayat and Bramley in 1979 described a modified preauricular approach to TMJ and zygomatic arch considering the main branches of the vessels and nerves in the viscinity 4. Popowich and Crane in 1982 further modified basic Al Kayat and Bramleys incision. A large incision shaped like a question markwas made in the temporal area and extended in the preauricular area .

The incision is taken behind the external ear in the crease near the superior aspect of external pinna and extended to the tip of the mastoid process.

Postauricular Approach

 Several

disadvantages.

Main are small surgical exposure with poor access and visibility stenosis of the external auditory canal, infection involving the external auditory canal or cartilaginous framework or both, paraesthesia (temporary or permanent) of the external pinna and deformity of the auricle.

Endaural Approach

Short facial skin incision with extension into the external auditory meatus. The incision begins above the level of the zygomatic arch and extends downward and back ward into the intercartilaginous cleft between the tragus and the helix and then extends inwards along the roof of the auditory meatus for approximately 1 cm.

 Advantages:

Excellent cosmetics. Disadvantages :The limited access and possibility of meatal stenosis or chondritis.

Submandibular (Risdon) Approach Here the incision is taken about 1 cm below the angle of the mandible. It extends forward, parallel to the lower border of the mandible and curves backward slightly behind the angle. Approach to the neck of the condyle and ramus is achieved by sharply incising through the pterygomasseteric sling and reflecting the masseter muscle laterally to expose the neck of the condyle and sigmoid notch. Poor access to the condylar head region. Procedures involving the articular portion of the head and the meniscus cannot be performed by this approach.

Postramal (Hind) Approach

Indicated

for surgeries involving the condylar neck and ramus area. Highly cosmetic procedure. Excellent visibility and accessibility. A skin incision is placed 1 cm behind the ramus of the mandible and extends 1 cm below the lobe of the ear to an angle of the mandible.

Communicating fascia between the sternomastoid muscle and the parotid gland and masseter muscle (parotido masseteric fascia) is carefully separated, to expose the posterior border of the ramus. Perforation of the posterior facial vein and injury to the main trunk of the facial nerve is avoided. Once the posterior border of the ramus has been exposed, the pterygomasseteric sling is incised at the angle and the masseter muscle, parotid gland are reflected upward and laterally to expose the neck of the condyle. After completion of the surgical procedure, the pterygomasseteric sling is reapproximated and sutured and the wound is closed in layers.

Popowich Incision
This is an approach to the zygomatic arch and joint andgives excellent visibility with safety The incision is longer and wider than the conventional.

Advantages of Popowich (1982) modfication of Al-Kayat and Bramleys (1979) incision

1. Reduction in incidence of facial nerve palsy. 2. Provision of donor site for temporalis fascia. 3. Decreased haemorrhage (dissection through avascular zone). 4. Improved visibility and easier identification of fascial planes. 5. Reduction in postoperative edema and discomfort. 6. Potential complications of muscle herniation arid fibrosis avoided. 7. Good cosmetic results. 8. Avoidance of auriculotemporal nerve anaesthesia & paraesthesia. 9. Reduction in total operating time.

Coronal Approach
Hemicoronal

(unilateral incision) and bicoronal or coronal incision (bilateral incision) is more extensive, but versatile surgical approach to the upper and middle regions of the facial skeleton, including the zygomatic arch and the TM joint areas. It provides excellent access to these areas with minimum complications.

major advantage is that most of the scar is hidden within the hairline, when the incision is extended into the preauricular area, the surgical scar is inconspicuous. This incision can be utilized for more extensive bilateral involvement.

Refrences:
Principles of Human Anatomy by G.J. Tortora Human Anatomy by J.W.Hole and k. Koos Petersons Principles of Oral and maxillofacial surgery Oral and Maxillofacial Surgery by Neelima Mallik Human anatomy by Bd Chaurasia Human Anatomy by Chakraborthy

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