Tm joint
- 1. BIOMECHANICS OF TM JOINT D R . C A M Y B H A G AT ( P T ) M U S C U L O S K E L E TA L C O N D I T I O N S W I T H S P O R T S
- 2. INTRODUCTION • TM joint is unique within the body both structurally and functionally. • Structurally, the mandible is a horseshoe-shaped that articulates with the temporal bone at each end; thus, the mandible has two different but connected articulations • Each TM joint also has a disk that separates the articulation into discrete upper and lower joints that each function slightly differently.
- 3. INTRODUCTION
- 4. INTRODUCTION • Each TM joint is formed by the condyle (or head) of the mandible inferiorly and the articular eminence the temporal bone superiorly with an interposed articular disk
- 5. INTRODUCTION • The lower joint formed by the mandibular condyle and the inferior surface of the disk is a simple hinge joint. • The upper joint formed by the articular eminence and the superior surface of the disk is a plane or gliding joint.
- 6. INTRODUCTION • TM joint is classified as a synovial joint, although no hyaline cartilage covers the articular surfaces. • The disk increases stability while minimizing loss of mobility. The articular disk is necessary to reduce friction and avoid biomechanical stress on the joint • Mandibular motion plays a role in phonation, facial expression, mastication, and swallowing.
- 7. STRUCTURE Articular Surfaces • Above: Mandibular fossa and articular tubercle • Below: Head of Mandible Articular Disc • Biconcave • Anterior and Posterior portion of disc is Vascular and innervated • Middle Portion is Avascular and Not innervated
- 9. CAPSULE AND LIGAMENTS • Short capsular fibers running from temporal bone to disc and disc to neck of condyle. • Capsule is highly vascularized and innervated, which provide information about position and movements. • Ligaments: Temporomandibular ligament, Stylomandibular Ligament and sphenomandibular ligament
- 11. UPPER AND LOWER TEMPOROMANDIBULAR JOINTS • The TM disk divides the TM joint into two separate joint spaces, each with its own synovial lining. • Synovial fluid supplies the nutritional demands of the fibrocartilage covering the joint surfaces and the avascular middle portion of the disk. • The lower joint of the TM articulation functions effectively as a hinge joint. Allows free rotation and little Translatory movement
- 12. UPPER AND LOWER TEMPOROMANDIBULAR JOINTS • The upper joint of the TM articulation functions as a plane joint, with the loose attachment of the disk to the temporal bone allowing Translatory movement between the disk and articular eminence.
- 13. FUNCTIONS • The TM joint is one of the most frequently used joints in the body. • It is involved in talking, chewing, and swallowing. • Most TM joint movements are empty-mouth movements (e.g., talking); that is, they occur with no resistance from food or contact between the upper and lower teeth. • Speech requires fine control of the jaw, and the ability to chew requires great strength.
- 14. MANDIBULAR MOTIONS • The motions of the TM joint are mouth opening (mandibular depression), mouth closing (mandibular elevation), jutting the chin forward (mandibular protrusion),sliding the teeth backward (mandibular retrusion),and sliding the teeth to either side (lateral deviation of the mandible).
- 15. MANDIBULAR ELEVATION AND DEPRESSION • mouth opening can be found in two sequential phases: rotation and glide. • In the rotation phase of mouth opening, there is pure anterior rotation (spin) of the condyle on the disk in the lower joint . This has also been described as posterior rotation of the disk on the condyle. • Second phase involves translation of the disk-condyle unit anteriorly and inferiorly along the articular eminence. • This motion occurs in the upper joint between the disk
- 16. MANDIBULAR ELEVATION AND DEPRESSION • Normal mouth opening is considered to be 40 to 50 mm. • Of that motion, between 11 mm and 25 mm is gained from rotation of the condyle in the disk, whereas the remainder is from translation of the disk and condyle along the articular eminence. • fit of three PIP joints is considered normal
- 17. MANDIBULAR ELEVATION AND DEPRESSION • Mandibular elevation (mouth closing) is the reverse of depression. • It consists of translation of the disk-condyle unit posteriorly and superiorly and of posterior rotation of the condyle on the disk.
- 18. CONTROL OF THE DISK DURING MANDIBULAR ELEVATION AND DEPRESSION • The articular disk is controlled both actively and passively during mouth opening and closing. • The passive control is exerted by the capsuloligamentous attachments of the disk to the condyle. • Active control of the disk may be exerted through the disk’s attachment anteriorly to the superior portion of the lateral pterygoid muscle
- 19. CONTROL OF THE DISK DURING MANDIBULAR ELEVATION AND DEPRESSION • During mouth closing, the elastic character of the superior retrodiskal lamina applies a posterior distractive force on the disk. • The activity of the superior lateral pterygoid allows the disk-condyle complex to translate upward and posteriorly during mouth closing and then maintains the disk in a forward position until the condyle has completed its posterior rotation on the disk or until the disk has rotated anteriorly on the condyle.
- 20. MANDIBULAR PROTRUSION AND RETRUSION • This motion occurs when all points of the mandible move forward the same amount. • The condyle and disk together translate anteriorly and inferiorly along the articular eminence. • No rotation occurs in the TM joint during protrusion. • The motion is all translation and occurs in the upper joint alone.
- 21. MANDIBULAR PROTRUSION AND RETRUSION • Retrusion occurs when all points of the mandible move posteriorly the same amount. • Tension in the temporomandibular ligament limits this motion,
- 23. MANDIBULAR LATERAL DEVIATION • In lateral deviation of the mandible (chin) to one side, one condyle spins around a vertical axis and the other condyle translates forward. • For example, deviation to the right would involve the right condyle spinning and the left condyle translating or gliding forward
- 24. MUSCULAR CONTROL OF THE TEMPOROMANDIBULAR JOINT
- 25. MUSCULAR CONTROL OF THE TEMPOROMANDIBULAR JOINT • The primary muscle responsible for mandibular depression is the digastric muscle • The posterior portion of the digastric muscle arises from the mastoid notch, and the anterior portion arises from the inferior mandible. • The tendon that joins the anterior and posterior portions is connected by a fibrous loop to the hyoid bone in the neck.
- 26. MANDIBULAR DEPRESSOR • The lateral pterygoid muscles are considered to be mandibular depressors. • Gravity is also a mandibular depressor.
- 27. MANDIBULAR ELEVATOR • The temporalis muscle attaches to the inside of the coronoid process . • The masseter muscle is attached to the outer surface of the angle and ramus of the mandible. • The medial pterygoid muscle is attached to the inner surface of the angle and ramus of the mandible • the superior portion of the lateral pterygoid is also active during mouth closing assumed to be eccentric control of the disk
- 28. SUMMARY: MANDIBULAR ELEVATION AND DEPRESSION • Mouth opening (mandibular depression) is initiated by concentric action of the digastric muscles bilaterally, and by the inferior portion of the lateral pterygoid muscles. • Mouth closing (mandibular elevation) is produced by the collective concentric action of the masseter, temporalis, and medial pterygoid muscles, with eccentric control of the TM disks by the superior lateral pterygoid muscles
- 29. PROTRUSION, RETRUSION AND LATERAL DEVIATION • Mandibular protrusion is produced by bilateral action of the masseter, medial pterygoid and lateral pterygoid muscles. • Retrusion is produced through the bilateral action of the posterior fibers of the temporalis muscles with assistance from the anterior portion of the digastric muscle.
- 30. PROTRUSION, RETRUSION AND LATERAL DEVIATION • Lateral deviation of the mandible is caused by unilateral action of a selected set of these muscles. • The medial and lateral pterygoid muscles each deviate the mandible to the opposite side. The temporalis muscle can deviate the mandible to the same side.
- 31. RELATIONSHIP WITH THE CERVICAL SPINE • The cervical spine and the TM joint are intimately connected. • muscles that attach to the mandible also have attachments to the head (cranium), to the hyoid bone, and to the clavicle, atlanto-occipital joint and Cervical. • Head and neck position, too, may affect the tension in cervical muscles that, in turn, may affect the position or function of the mandible.
- 32. RELATIONSHIP WITH THE CERVICAL SPINE • Proper posture minimizes the force produced by the cervical extensors and other cervical muscles necessary to support the weight of the head. • Poor cervical posture over time may lead to adaptive shortening or lengthening in muscles around the head and cervical spine, affecting range of motion, muscular force production capacity, and joint morphology in the involved region.
- 33. TM/CERVICAL JOINT INTERRELATIONSHIPS • A forward head posture frequently involves extension of the occiput and the upper cervical spine, leading to compensatory flattening of the lower cervical spine and upper thoracic spine to achieve a level head position. • With the occiput extended on the atlas (C1), the suboccipital tissues adapt and shorten. • The suboccipital tissues include the anterior atlantoaxial and atlanto-occipital ligaments (cephalad continuations of the ligamentum flavum), the posterior belly of the digastric muscles, the stylohyoid muscles, and the upper fibers of the upper trapezius, semispinalis capitis, and splenius capitis muscles.
- 34. TM/CERVICAL JOINT INTERRELATIONSHIPS • The forces necessary to maintain the head against gravity with a poor cervical posture and forward head result in muscle imbalance and altered movement patterns. • Increased tension from shortening of the tissues may lead to headaches that originate in the suboccipital area, limitation in active range of motion of the upper cervical spine, and TM joint dysfunction. • Furthermore, pain in the TM region may be referred from the cervical region.
- 35. TM/RESPIRATORY/ CERVICAL DYSFUNCTION • a child with allergies who has difficulty breathing through the nose will often hyperextend the upper cervical spine to more fully open the upper respiratory tract. • Such a cervical posture places the upper and lower teeth in contact with each other and may affect the resting position of the TM joint. • muscles surrounding the TM joint complex expend greater energy to maintain this posture and have more difficulty resting and repair.
- 36. TM/RESPIRATORY/ CERVICAL DYSFUNCTION • Resistance to inspiration may also lead to use of accessory muscles of respiration (scalene and sternocleidomastoid muscles) to assist with breathing. • Use of these accessory muscles may lead to a forward head posture. • Such a posture contributes over time to a cycle of increasing musculoskeletal dysfunction, including repeated episodes of TM inflammation that can result in fibrosis of the TM joint capsule.
- 37. DENTITION • Occlusion, or contact of the teeth, is intimately involved in the function of the TM joint. • When the central incisors are in firm approximation, the position is called maximal intercuspation or the occlusal position. • This is not, however, the normal resting position of the mandible. Rather, 1.5 to 5.0 mm of “freeway” space between the upper and lower incisors is normally maintained • By maintaining this space, the intra-articular pressure within the TM joint is decreased, the stress on the articular structures is reduced, and the tissues of the area are able to rest and repair.
- 38. AGE-RELATED CHANGES IN THE TEMPOROMANDIBULAR JOINT • tissues are likely to become less supple, less elastic, and less able to withstand maximal forces with aging, leading to biomechanical changes in musculoskeletal tissues as one progresses through the life span.
- 39. DYSFUNCTIONS • dysfunctions are caused by direct trauma such as motor vehicle accidents or falls. • Others are the result of years of poor postural or oral habits such as forward head posture or bruxism (grinding of the teeth). • most common forms of TM joint complex dysfunction: inflammatory conditions, capsular fibrosis, osseous mobility conditions, articular disk displacement, and degenerative conditions.
- 40. INFLAMMATORY CONDITIONS • Inflammatory conditions of the TM joint include capsulitis and synovitis. • Individuals with inflammatory conditions may experience diminished mandibular depression as a result of pain and inflammation within the joint complex. • Inflammation can lead to adhesions that restrict the movement of the disk and limit the function of the TM joint
- 41. OSSEOUS MOBILITY CONDITIONS • Osseous mobility disorders of the TM joint complex include joint hypermobility and dislocation. • The hypermobility is a result of laxity of the joint capsules, tendons, and ligaments. • Joint noises occur at the end of mandibular depression and at the beginning of mandibular closing. • Hypermobility of one TM joint results in deflection of the mandible toward the contralateral side with mouth opening.
- 42. ARTICULAR DISK DISPLACEMENT • The articular disk of the TM joint may sublux, contributing to dysfunction in this joint. • Articular disk displacement conditions include disk displacement with reduction and disk displacement without reduction. • Individuals exhibiting disk displacement with reduction experience “joint noise” at two intervals: during mandibular opening and mandibular closing. • This joint noise is known as a reciprocal click and is a key sign in diagnosing disk displacement with
- 43. ARTICULAR DISK DISPLACEMENT • Individuals with disk displacement without reduction typically describe an inability to fully depress the mandible, as well as difficulty performing functional movements involving the jaw such as chewing, talking, or yawning. • The abnormalities of the lateral pterygoid muscle noted included hypertrophy, contracture, and atrophy of the superior and inferior bellies of the lateral pterygoid muscles of the involved TM joint. • Hypertrophy of this muscle indicates overactivity, which thus possibly leads to the excessive anterior
- 44. DEGENERATIVE CONDITIONS • Primarily two conditions affect the TM joint: osteoarthritis and rheumatoid arthritis • degenerative changes in the TM joint, including joint space narrowing, erosions, osteophyte formation, sclerosis, and remodelling. • Loss of posterior teeth may also contribute to degenerative changes because simple occlusion of the remaining teeth alters the forces that occur between the TM joint forces