Just to review what we began last time if you remember, this lecture is about oral physiology so we are not

going to deal the anatomy or histology of TMj

Anything related to anatomy or histology in the slides is not included in this lecture since it will be covered in H&N anatomy and Oral Histology. Just remember the things we need to focus on are physiology.

Last time we said that we have 3 ligaments that are important in stabilizing the TMJ, these are the : Lateral temporomandibular ligament: Important for stabilizing, remember this ligament only occurs on lateral aspect, you can see it from lateral aspect, but on lingual aspect of TMJ we cant see ligament, so we only have a lateral ligament, we dont have lingual tempromandibular ligament But why is that? Simply because we dont need a lingual ligament, if we apply force on a tooth, if this force was external (lateral), if we pull the ramus to certain way, this ligament is going to support and stabilize the joint, but what will happen if I apply reverse force (push the ramus of mandible), which one is going to resist? The lateral tempromandibular ligament of the other side, thats why we dont have lingual tempromandibular ligament, but we have one only buccaly, why? Because two joints are reciprocal joints, they are connected together . Sphenomandibular ligament Stylomandibular ligament These two ligaments are important, they have manifest tension, when they are pulley tension, then the fulcrum point buckle, when you open the

mandible the first 20 mm of the incisal separation, what happens during that period? Joints are moving around an active * through joints themselves, and after that because we want to protect the vital structures in the neck, we want the condyle to truckle forward, how can I make it truckle forward? So I want the head of condyle be on the apex to open the mandible for 20 mm, after that when the mandible continues opening and the axis or hinge of the opening is still here, the mandible would stress on vital structures. So what you need to do is to move the hinge from one point to another point and this is the function of the ligament, they support the mandible and when they are pulley tension they move the hinge (or fulcrum of rotation) from the head of condyle to an area within the ramus of the mandible. Thats why after 20 mm of separation this becomes the hinge for mandibular opening, so as a hinge it will continue moving, the condyle start to move forward and the body of mandible , this is needed to protect the vital structures which are the common and internal carotid artery, the vagus nerve, the internal jugular vein, all of these are important and vital structures within the neck that need to be protected. Now a student may ask, in carnivores (like lions and cats) the type of TMJ doesnt allow for moving the condyle, in their joint the condyle all the time rotate around the hinge through the condyle itself, the question is, will this endanger the vital structures ? the answer is no, because in those animals are not erect, the neck is not located below their head, its located posterior to the head, thats why they can freely open the mandible and still the mandible is not actually trans-locating, its rotating still with the head actually starting through joint itself, thats why they can open freely without any trouble and open for huge distance. But in mammals, like humans and apes, they cant open the mouth freely without moving the condyle forward after 20 mm of incisal separation. When the mandible move forward, what happens? In normal situation when you close your mouth, so the head of condyle is actually fitting against a fossa which is the glenoid fossa or the mandibular

fossa , when we start opening for about 20 mm the situation will remain as in normal, it just will rotate the mandible or the condyle will rotate but the condyle will remain in the same place because the fulcrum of opening is actually through the condyle itself, after 20 mm of incisal separation the condyle stops moving forward against the articular eminence and notice that the disc also moves with the condyle, the disc is found between the condyle and the fossa, thats why the disc should be attached to the mus cle that moves the condyle forward which is lateral pterygoid, its attached to the neck of the condyle of pterygoid to adjust it to the condyle, and also its attached to the anterior part of the disc, the disc and the condyle will come forward together until the maximum opening, when the mandible is fully open, the head of condyle is rotated against the articular eminence, it has traveled forward for some distance, and this happens after 20 mm of incisal separation. If you try to feel the condyle, its anterior to external auditory meatus, try to open for the first 20 mm, you will notice the condyle is in its place just rotating, after 20 mm the condyle starts to move and finally when your mouth is fully open the condyle is located just below the articular eminence . What happens when we have something wrong? In some people, around 5-10%, they have a click, what happens in this click? In the normal situation, the disc should be above the head of condyle , the disc should be between the condyle and fossa, but in some people (not all), the head is displaced anteriorly, we call it anterior displacement of disc . when we start to open the mouth, the condyle will start to hit the disc, this will make a click( a sound), when the condyle moves it hits the disc and then the disc bind the condyle, then they continue * together, in the way back they move together until where the disc cant move further, thats why the condyle leave the disc producing another click, so people having click, they have a click on opening and a click on closure . but this problem is called anterior displacement with reduction ( the relationship between the disc and the condyle is reduced) so when the two structures are brought back to their normal relationship this is called reduction.

Usually people who have displacement with reduction suffer a click on opening and on closure, it its not severe its something physiological but if left untreated it might turn to anterior displacement without reduction, In this situation its permanently anteriorly displaced , but when the condyle move it hit the disc but cannot actually bring the disc forward, thats why the condyle cannot move beyond the rotation of the disc (the disc restrict the movement of the condyle), in anterior displacement without reduction we dont have a click, people who have displacement without reduction suffer from pain on opening and limited mouth opening on both sides, but if its only in one side, imagine if its in one side only( right side) the mouth starts opening in left side with no problem, the condyle on left will function properly, but on the tight there will be rotation of the mandible to the right side, people who have unilateral anterior displacement without reduction suffer pain from opening and deviation of the mandible toward the side with the problem, but if it was bilateral its limited mouth opening, people with this condition have no option but surgery, but in anterior displacement with reduction we can have different treatment . What are the reasons that make this happen? - malocclusion : - some people while they sleep, they clinch their teeth, people who have * may clinch while they are awake , all the time they overload the TMJ, leading to moving the disc forward, people who have malocclusion when they bite the load should be distributed by all teeth but when they have malocclusion some teeth may hold more load than other teeth so this leads to increased load on TMJ more than normal, if you lose some teeth you might end up with one tooth holding the load, there should be a harmony between TMJ and teeth otherwise there will be problem

Treatment :We have different modernity, sometimes with therapy, we have something called occlusal plate, we put it inside the mouth separating the upper and lower teeth, it has a certain thickness due to stress . Nerve supply of TMJ: (not really important) Auriculotemporal nerve Messetric nerve Deep temporal Nerve to lateral pterygoid What is important is the receptors, TMJ is important because it send info to the brain telling the brain about what is happening in the mouth or the load carried by TMJ, that =s why we have specialized receptors, we have : Corpuscular endings Mechanoreception Signal joint position & movement to trigeminal nuclei: they are very important to sending information to the brain about joint position and movement of the mandible Synapse with trigeminal motor neurons Non-corpuscular unmyelinated free nerve endings In lateral TM ligament C fibers - nociceptive Fine myelinated plexus throughout the capsule A fibers - nociceptive

Corpuscular ending has : Ruffini or Meissner : globular or ovoid, scattered in the capsule, low threshold which means they can be activated easily with small stimulus, slowly adapting Pacinian corpuscles : thickly laminated, in deeper layer of the capsule and near blood vessels, low threshold which means they can be activated easily with small stimulus, rapidly adapting Golgi-type endings : beta fibers, fusiform, in joints ligament & tendon, high threshold which means high stimulus to stimulate it, very slow adapting, alpha fibers Slow adapting: like in taste when you eat something tasty then after it drink tea, you probably wont feel the taste of tea because you have slow adaptation. In other words, it needs longer time to adapt to new stimulus

Nothing is impossible, the word itself says Im possible

Contristatur pro ens nuper ad perficiendum hoc breve script Bonus fortuna in vestri probationes scribendae, et contristatur pro populatio vestri temporis hic

Done by Mohammad Al Sughayer