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The Temporomandibular Joint-The Temporomandibular Joint-Anatomy/PhysiologyAnatomy/PhysiologyEvaluation/TreatmentEvaluation/Treatment
Lori Steinley P.T., M.S.Lori Steinley P.T., M.S.
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AnatomyAnatomy
TemporomandibularTemporomandibularjoint (TMJ)joint (TMJ)•• Temporal boneTemporal bone
•• MandibleMandible
•• Relationship with boneyRelationship with boneylandmarks on skulllandmarks on skull
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CondyleCondyle Medial/lateralMedial/lateral
measurementmeasurementtwice thetwice theanterior/posterioranterior/posterior•• Not pure hingeNot pure hinge
movementmovement•• Rotation withRotation with
translation forwardtranslation forward
AttachmentsAttachments•• CollateralCollateral
ligaments-ligaments-medial/lateralmedial/lateral
•• Further anteriorFurther anterior––temporalistemporalisinsertion oninsertion oncoronoid processcoronoid process
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DiscDisc
CharacteristicsCharacteristics•• Posterior portionPosterior portion
thickestthickest
•• IntermediateIntermediateportionportion
In contact withIn contact withcondylecondyle
ThinnestThinnest
Avascular, aneuralAvascular, aneural
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DiscDisc
AttachmentsAttachments•• Posterior ligamentPosterior ligament
ElasticElastic
Passive-tensionPassive-tensiontissuetissue
•• Lateral pterygoid-Lateral pterygoid-Superior fibersSuperior fibers
•• Capsule-Capsule-anterior/posterioranterior/posterioronlyonly
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Normal disc movementNormal disc movement Moves as unit withMoves as unit with
condylecondyle Held in place on condyleHeld in place on condyle
by ligaments (collateralsby ligaments (collateralsand posterior)and posterior)
First 11 mm of opening,First 11 mm of opening,disc stationary, whiledisc stationary, whilecondyle rotatescondyle rotates
>11 mm, disc and>11 mm, disc andcondyle translate forwardcondyle translate forward
Disc rotates backward byDisc rotates backward bytension of posteriortension of posteriorligamentligament
Condyle always in contactCondyle always in contactwith intermediate portionwith intermediate portion
Opening door analogyOpening door analogy1010
1111
CapsuleCapsule
SynovialSynovialmembranemembrane•• Produces synovialProduces synovial
fluidfluid
•• Lubrication andLubrication andmetabolic exchangemetabolic exchangefor avascular jointfor avascular jointtissue (disc)tissue (disc)
TemporomadibularTemporomadibularligamentligament
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Muscles-TemporalisMuscles-Temporalis Origin-temporal fossa,Origin-temporal fossa,
superior to zygomatic archsuperior to zygomatic archinsertion-coronoid processinsertion-coronoid processof mandibleof mandible
Anterior, middle andAnterior, middle andposterior fibersposterior fibers
Elevation of mandibleElevation of mandible
Posterior fibers-retrusion,Posterior fibers-retrusion,and deviation to same sideand deviation to same side
Postural musclePostural muscle
Large muscle 53% of totalLarge muscle 53% of totalmass of elevatorsmass of elevators
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TemporalisTemporalis
Referral pattern-Referral pattern-temple, alongtemple, alongeyebrow, behindeyebrow, behindthe eye or upperthe eye or upperteethteeth
Perpetual clencherPerpetual clencher
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Muscles-MasseterMuscles-Masseter Origin-zygomatic archOrigin-zygomatic arch
insertion-mandibularinsertion-mandibularangle and ramusangle and ramus•• Sling with medialSling with medial
pterygoidpterygoid•• Together make up 57%Together make up 57%
of cross section ofof cross section ofelevators-power chewerelevators-power chewer
Synergist withSynergist withtemporalis fortemporalis forelevation but alsoelevation but alsoretrudes jaw, lateralretrudes jaw, lateraldeviation to same sidedeviation to same side
Chewing-first muscleChewing-first muscleto activateto activate
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MasseterMasseter
Referral pattern-Referral pattern-lower jaw, molarlower jaw, molarteeth and gum,teeth and gum,maxilla, lowermaxilla, lowerportion ofportion ofmandible, templemandible, templeeyebrow and toeyebrow and toear (externally)ear (externally)
““SinusitisSinusitis””
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Muscles-Medial PterygoidMuscles-Medial Pterygoid Origin-inner surface ofOrigin-inner surface of
lateral pterygoid platelateral pterygoid plate(under lateral(under lateralpterygoid) insertion-pterygoid) insertion-ramus of mandible byramus of mandible bythe anglethe angle
Elevation, protrusionElevation, protrusionand lateral deviationand lateral deviationto opposite sideto opposite side
Close relationship withClose relationship withlateral pterygoidlateral pterygoid
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Medial PterygoidMedial Pterygoid Referral pattern-Referral pattern-
posterior mandible,posterior mandible,mouth, below andmouth, below andbehind TMJ includingbehind TMJ includingear (internally)-notear (internally)-notteethteeth
Stuffiness in ear dueStuffiness in ear dueto tensor veli palatinito tensor veli palatinimuscle unable to pushmuscle unable to pushmedial pterygoid outmedial pterygoid outof the way to dilateof the way to dilatethe Eustachian tubethe Eustachian tube
Swallowing difficult asSwallowing difficult asrestriction inrestriction inprotrusion of jawprotrusion of jaw 2020
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Muscles-Lateral PterygoidMuscles-Lateral Pterygoid
Origin-lateralOrigin-lateralpterygoid plate ofpterygoid plate ofsphenoid,sphenoid,insertion-condylarinsertion-condylarneck, ramus ofneck, ramus ofmandible and discmandible and disc
Elevation,Elevation,protrusion, lateralprotrusion, lateraldeviation todeviation toopposite side (alsoopposite side (alsoinitial opening)initial opening)
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Lateral PterygoidLateral Pterygoid Referral pattern-Referral pattern-
zygomatic arch, TMJzygomatic arch, TMJ
Major myofascialMajor myofascialsource of painsource of pain
Cause disc and jaw toCause disc and jaw tobe unable to return tobe unable to return tonormal restingnormal restingpositionposition
Malocclusion of teethMalocclusion of teeth
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Muscles-DigasticMuscles-Digastic Origin-mastoidOrigin-mastoid
notch(posterior)-notch(posterior)-symphysis of mandiblesymphysis of mandible(anterior) insertion-join(anterior) insertion-joinby a common tendon toby a common tendon tothe hyoid bonethe hyoid bone
Depression and retrusionDepression and retrusionof jawof jaw
Less forceful movement-Less forceful movement-assisted with long leverassisted with long leverarm and gravityarm and gravity
Active with swallowing andActive with swallowing andcoughingcoughing
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DigastricsDigastrics
Referral pattern-Referral pattern-behind mandiblebehind mandibletowards back oftowards back ofear, lower incisorsear, lower incisors
Rarely in spasmRarely in spasmdue to forwarddue to forwardhead posturehead posture(stretch weakness-(stretch weakness-Kendall)Kendall)
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Disc DisorderDisc DisorderInternal DerangementInternal Derangement
Abnormal relationshipAbnormal relationshipof the articular disc toof the articular disc tothe mandibularthe mandibularcondyle, fossa andcondyle, fossa andarticular eminencearticular eminence
Review of normalReview of normalbiomechanics-condylebiomechanics-condylealways in contact withalways in contact withintermediate portionintermediate portionof discof disc
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Disc DisorderDisc DisorderInternal DerangementInternal Derangement
Disc is passiveDisc is passivestructure held in placestructure held in placeby the collateralby the collateralligaments and theligaments and theposterior ligament,posterior ligament,with movementwith movementdictated by lateraldictated by lateralpterygoidpterygoid
Posterior ligament isPosterior ligament iselastic so whenelastic so whenstretched allows discstretched allows discto move medially andto move medially andanteriorlyanteriorly
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