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by Dr. A. A. BIPAR, D.D.S., M.S.à
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Temporomandibular Joint (TMJ) dysfunction is a widely

publicized medical condition. Public as well as health practitioners
are overwhelmed by countless articles in both professional and
media publications which discuss this abnormality and various
treatment options.à

Indeed, TMJ dysfunction is a very frequent abnormality and

more than 20% of the American population exhibit different
degrees of TMJ symptoms (Morgan, 1996) and this condition
appears to be more common in women than men.

However, the clinical reality is less grim than it may appear

at first look. For many patients the diagnosis of TMJ dysfunction
does not automatically mean invasive therapy indeed sometimes
treatment isn't needed at all. Additionally TMJ dysfunction is a
very frequently misdiagnosed and consequently mistreated
condition.

Ironically enough, the subject of TMJ dysfunction and

treatment is one of the most examined and still controversial
subjects in dentistry. I may quote Dr. Greene (1980) who
examined the evolution of TMJ dysfunction concept in modern
dentistry and concluded that: "Rarely in the history of dentistry
have so many labored for so long, only to end with such extreme
disagreement". This article will give our readers comprehensive
outlines of TMJ dysfunction and discuss treatment options the
patients have. In the first part I will review the anatomy and
physiology of TMJ.

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The TMJ is a hard working joint. The average person opens

and closes the jaw about 2000 times per day. The TMJ is formed
by the mandible or lower jaw and temporal bone (see Fig. 1). The
TMJ is a very unique joint because it contains an î
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 (see Fig.2) placed between the mandible and temporal bone
which form the TMJ. This fibrocartilaginous disk greatly reduces
friction between both articular surfaces and protects the hard
working joint from wear and tear. Despite their differences we
can observe a parallel between the anatomical arrangement of
TMJ and knee joint where meniscus serve the same purpose of
extra cushion and protection of the articular surfaces.

Another equally important function of the articular disk is its

role in the greater flexibility of the TMJ which allows a significant
range of motion. The articular disk is attached to the mandibular
condyle of the mandible and follows the movements of the lower
jaw during chewing or talking. Thus freedom of movement of
mandible without any obstruction is a most important factor in
the normal function of TMJ.

Another important concept which needs to be considered

during the evaluation and treatment is a 
. The upper jaw
forms the facial skeleton and it is a fixed anatomical structure,
while the lower jaws has great mobility. Thus the bite is the
arrangement of the lower and upper teeth against each other and
it reflects the position of the lower jaw in regard to the upper jaw.
The bite is unique for each person and may slightly change with
age. A healthy functioning bite is one in which the person is
totally unaware of the bite.

During chewing we are able to slightly change the bite by

adjusting the lower jaw according to the amount and structure of
the food. These changes are possible because of the great
flexibility of the TMJ and complex anatomical arrangement of the
masticatory muscles and their precise biomechanical interactions.

The posterior teeth as a group support the normal bite. This

is why the excessive clasp of the posterior teeth or so-called
posterior bite increases the pressure inside of TMJ especially on
the articular disk and triggers the spasm in the masticatory
muscles. The excessive wear, hypermobility or absence of
posterior teeth are equally important factors which contribute to
extraoral symptoms including the TMJ dysfunction (Oral et al.,
2009). Fig. 1 illustrates general view of TMJ.
 
 General view of TMJ

Fig. 2 presents the anatomical orienteers in the area of TMJ


 Anatomical orienteers in the area of TMJ

 - temporalis muscle
 - condyloid process of TMJ (under zygomatic arch)
 - zygomatic arch
 - coronoid process
 - mastoid process
 - mandible
 - masseter muscle à

Fig. 3 presents the inner structure of TMJà

 
 Inner structure of TMJ

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The anatomical arrangement and function of masticatory

muscles is a very important subject for the practitioner. The
spasm in the masticatory muscles is a direct cause of pressure on
the articular disk inside TMJ (Inoue et al. 2010). The evaluation of
the lower jaw position and individual assessment of each
masticatory muscle during the patient's examination allows the
practitioner to develop a quick and efficient treatment protocol.
Thus the information presented below has important practical
value and it is vital for understanding and implementing the
second and third parts of this article.

All masticatory muscles are innervated by the motor part of

the mandibular division of the trigeminal nerve except posterior
part of the digastric muscle which is innervated by the facial
nerve. There are five masticatory muscles (see Fig. 4-7):

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The masseter muscle is arranged in two layers: superficial

and deep. They both start from the zygomatic arch but insert into
the mandible into slightly different areas: the superficial layer
attaches into the inferior part of the mandibular ramus while the
deep layer inserts into its superior part. Fig. 4 illustrates the
anatomical location of the masseter muscle. See also Fig.2.


 Anatomy of masseter muscle

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The fibers of the temporalis muscle are arranged in three

directions: the fibers of the anterior part of the temporalis muscle
have almost vertical direction, the fibers of the middle part of the
temporalis muscle have an oblique direction while the fibers of
the posterior part are almost horizontally oriented. Fig. 3 and 4
illustrate the anatomical location of the temporalis muscle. See
also Fig.2.
 
 Anatomy of temporalis muscle

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The ability of the LPM to pull the articular disk forward when
the mouth is closed is very important for the normal function of
TMJ. By pulling the disk forward the LPM keeps it from smashing
between both articular surfaces of the TMJ. Failure of the LPM to
do it quickly during the sudden lift of the lower jaw may entrap
the articular disk and smash or even fracture it. Fig. 6 illustrates
the anatomical location of lateral pterygoid muscle. See also Fig.
5.
 
 Anatomy of lateral and medial pterygoid muscles

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Masseter and MPM form a hammock which supports the

lower jaw: the masseter muscle is on the outside while MPM is on
the inside of the lower jaw. Fig. 5 illustrates the anatomical
location of the medial pterygoid muscle.


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The digastric muscle participates only in the forced opening

of the mouth when the lower jaw must be farther pulled down
(e.g. during oral examination). Also this muscle is a very
important participant in swallowing and coughing. Fig. 7
illustrates the anatomical location of the digastric muscle.
 
 Anatomy of digastric muscle

In Part II of this article, in the next issue of JMS, we will

discuss the clinical symptoms and the evaluation of a patient with
TMJ dysfunction.

    
   Myofascial Pain-Dysfunction Syndrome: The
Evolution of Concept. In The Temporomandibular Joint. Edited by
B.G. Sarnat, D.M. Laskin. 'Charles C. Thomas', 1980.
  
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îî c c The Relationship
Between Temporomandibular Joint Pathosis and Muscle
Tenderness in the Orofacial and Neck/Shoulder Region. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod., Jan;109(1):86-90,
2010.


î The Great Imposter Disease of the Mandibular
Joint. ÷ M , 235, 2395, 1976.
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   Etiology of
Temporomandibular Disorder Pain. gri, Jul;21(3):89-94, 2009.à