4.

04

FEBRUARY 15, 2016

TOPIC: Temporal Fossa, Infratemporal Fossa, and TMJ

LECTURER: Dr. Wong

[PS. Fully italicized texts are not in the objectives]

TEMPORAL FOSSA

Temporal fascia
o
o

Boundaries of the temporal fossa

Posterior and superior
Temporal line
Anterior
Frontal and zygomatic bones
Lateral
Zygomatic arch
Inferior
Infratemporal crest

Forms the roof of the temporal fossa

Covers the temporalis, and arches superiorly to the
superior temporal line

Pterion
o
o
o

Forms the floor of the temporal fossa

Significance: weakest area and damage of the blood
vessels present in the area may lead to haemorrhage
Formed by parts of the four bones: frontal, parietal,
temporal and greater wing of the sphenoid.

INFRATEMPORAL FOSSA
Is an irregularly shaped space deep and inferior to the zygomatic
arch, deep to the ramus of the mandible, and posterior to the
maxilla

Fig 1. Lateral view of the temporal fossa

CONTENTS OF THE TEMPORAL FOSSA

It communicates with the temporal fossa through theinterval

between the zygomatic arch and to the cranial bones.

Lateral
Medial
Anterior
Posterior
Superior
Inferior
Fig 2. Temporal Region

Temporalis muscle
o The temporal fossa is occupied primarily by the
upper portion this muscle.
o Fan-shaped muscle from the bony floor and
overlies the temporal fascia
Origin
Insertion
Action

Floor of temporal fascia

Coronoid process and anterior
border of ramus of mandible
Elevates mandible (closing jaws);
posterior, more horizontal fibers
are primary retractors of
mandible

TRANSCRIBED BY: Patty, Ernest, Babes

Boundaries of the Infratemporal Fossa

Ramus of the mandible
Lateral pterygoid plate
Posterior aspect of maxilla
Tympanic plate and the mastoid and styloid
process of the temporal bone
Inferior (infratemporal) surface of the greater
wing of the sphenoid
Medial pterygoid plate attaches to the mandible
near its angle
CONTENTS OF THE TEMPORAL FOSSA
Inferior part of the temporalis muscle
Lateral and medial pterygoidmuscles
Maxillary artery
Pterygoid venous plexus
Mandibular, inferior alveolar, lingual, buccal, and chorda
tympani nerves
Otic ganglion

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MAXILLARY ARTERY
Maxillary artery is the larger of the two terminal branches
of the external carotid artery.

Division of maxillary nerve

st
1 (mandibular)
Division of maxillary nerve
st
1 (mandibular)

nd

2 (pterygoid)

rd

3 (pterygoid-palatine)

Course
Proximal (posterior) to lateral
pterygoid muscle; runs
horizontally, deep (medial) to
neck of condylar process of
mandible and lateral to
stylomandibularligament
Adjacent (superficial to deep) to
lateral pterygoid muscle;
ascends obliquely
anterosuperiorly, medial to
temporalis muscle.
Distal (anteromedial) to lateral
pterygoid muscle; passes
between heads of lateral
pterygoidand through
pterygomaxillaryfissure into
pterygopalatine fossa.

nd

2 (pterygoid)

rd

3 (pterygoid-palatine)

Branches
Deep auricular artery
Anterior tympanic artery
Middle meningeal artery
Accessory meningeal artery
Inferior alveolar artery
Masseteric artery
Deep temporal arteries
Pterygoid branches
Buccal artery
Posterior superior alveolar
artery
Infraorbital artery
Artery of pterygoid canal
Pharyngeal branch
Descending palatine artery
Sphenopalatine artery

DISTRIBUTION OF THE BRANCHES OF MAXILLARY ARTERY

(not included in the course objectives, but in Moore)
1st (mandibular) division

2nd(pterygoid) division

TRANSCRIBED BY: Patty, Ernest, Babes

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3rd(pterygoid-palatine) division

Communications

maxillary artery (20171D)

Receives branches that correspond with
the same branches of themaxillary artery
Its tributaries eventually converge to form
ashort maxillary vein (2017 1D)
Anastomoses anteriorlywith the facial vein
via the deep facial vein
pharyngeal venous plexus (20171D)
Superiorly with the cavernous sinus via
emissary veinsand ophthalmic veins
Snell: Emissary veins are valveless
veins which connect the veins of the
scalp to the venous sinuses
routes for the spread of infection
OTIC GANGLION

MUSCLES OF THE INFRATEMPORAL FOSSA

[Please check appendix for the OINA]

PTERYGOID VENOUS PLEXUS

venous equivalent of most of the maxillary artery (most of the
veins that accompany the branches of the maxillary artery drain
into this plexus)

Functional
classification
Relations

Roots

Branches
Distribution
(20171D)

Relations

Parasympathetic ganglion
located in the infratemporal fossa
inferior to the foramen ovale
medial to CN V3 (mandibular nerve)
posterior to medial pterygoid muscle
o Snell: the otic ganglion is adherent to the
nerve to the the medial pterygoid
Preganglionic fibers from glossopharyngeal
nerve reach the otic ganglion via the lesser
petrosal nerve(exits skull via jugular foramen
and innervates tympanic plexus)
Postganglionic secretomotor fibers reach the
parotid gland via the auricotemporal nerve
tensor tympani (passes backward, lateral to
auditory tube)
tensor velipalatini (arises from otic ganglion
near the origin of nerve to Pterygoidinternus,
directed forward)

located partly between the temporalis

and pterygoid muscles
nd
rd
Parallels the 2 and 3 part of the

TRANSCRIBED BY: Patty, Ernest, Babes

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MANDIBULAR NERVE (CN V3)

Mandible
External ramus, mandibular notch, coronoid process,
mentalforamen
Internal head of mandible, mandibular foramen, groove for
mylohyoid nerve
SUMMARY (2017 1D):
Bones Involved:
Condylar process or condyle of the mandible
Mandibular fossa
Articular eminence of the temporal bone

A.

arises from the trigeminal ganglion in the middle cranial fossa

Largest of the 3 divisions of the trigeminal nerve, it is a mixed
nerve(small motor and large sensory)

Exits the skull via foramen ovale

Motor

Sensory

[Please check appendix for the course and distribution of the branches of CN V3]

TEMPOROMANDIBULAR JOINT

(Snell)

B.

TYPE OF JOINT
The temporomandibular joint is synovial. The articular disc
divides the joint into upper and lower cavities.
According to morphology: synovial joint

Supplies skin of the lower lip, lower part of the face, temporal region,
part of auricle, muscles of mastication except buccinators (supplied by
facial nerve)

Divisions of the Mandibular Nerve

the motor root (of the trigeminal nerve) leaves the
skull via the foramen ovale to join the sensory root
form the trunk of mandibular nerve divides
into small anterior (mostly motor) and large
posterior division (mostly sensory)
Supplies the 4 muscles of mastication (masseter,
temporalis, medial and lateral pterygoids)
leaves the trigeminal ganglion and passes out of the
skull through the foramen ovale to enter the
infratemporal fossa

ARTICULATION (Snell)
Occurs between the articular tubercle and the anterior portion of
the mandibular fossaof the temporal bone above and the head
(condyloid process) of the mandible below. The articular surfaces
are covered with fibrocartilage.

not directly joined

the bones have a synovial cavity and are united by the dense
irregular connective tissue that forms the articular capsule that is
normally associated with accessory ligaments

According to mobility: diarthrosis

specifically as ginglymoarthrodial joint
referring to its dual compartment structure and function
(ginglymo- and arthrodial)
freely movable
all diarthrosis joints are synovial joints

C.

CAPSULE

(Snell)

The capsule surrounds the joint and is attached above to the

articular tubercle and the margins of the mandibular fossa and
below to the neck of the mandible.
Addtl notes from 2017 1D:
encloses the joint surfaces like a sleeve that runs from
the temporal bone superiorly, to the condyle of the
mandible inferiorly. The enclosed space between the
articular surfaces is the joint cavity
Superior attachment area surrounding the mandibular
fossa and articular eminence of the temporal bone.
Inferior attachment periphery of the mandibular
condyle

Temporomandibular joint is a complex articulation of the

movable mandible and the base of the skull
TRANSCRIBED BY: Patty, Ernest, Babes

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F. SYNOVIAL MEMBRANE
a layer of synovium lines the inner aspects of the joint capsule
does not line the actual articular surfaces of the joints because
synovial joints are generally weight-bearing joints
synovium secretes synovial fluids for lubrication and nourishment of
the opposing articular surfaces
2 layers of the synovial membrane

1.

An intimal cellular layer

contains type A cells which are phagocytic, and type B cells
which synthesize hyaluronate found in synovial fluid.

2.
D.

A vascular subintimal layer

contains blood vessels, and lymphatics within the

LIGAMENTS(Snell)

looseconnective tissue matrix.

1.

LATERAL TEMPOROMANDIBULAR LIGAMENT

strengthens the lateral aspect of the capsule
limits the movement of the mandible in a posterior direction
and thus protects the external auditory meatus

2017 1D:
[From here onwards, all boxes mean addtl/alternative info]
is a lateral thickening of the joint capsule and is similar to the
collateral ligaments of other joints
prevents posterior and inferior displacement of the condyle but
allows limited anterior movements of the condyle
fibers run downward and backward from the tubercle on the root
of the zygoma to the lateral surface of the neck of the mandible
2.

3.

SPHENOMANDIBULAR LIGAMENT
thin band that is attached above to the spine of the sphenoid
bone and below to the lingula of the mandibular foramen
represents the remains of the first pharyngeal arch in this
region
lies on the medial side of the joint
STYLOMANDIBULAR LIGAMENT
lies behind and medial to the joint and some distance from it
merely a band of thickened deep cervical fascia that extends
from the apex of the styloid process to the angle of the
mandible

E. ARTICULAR DISC
2018 1C:
divides the joint into upper and lower cavities
an oval plate of fibrocartilage that is attached circumferentially to
the capsule
attached in front to the tendon of the lateral pterygoid muscle and
by fibrous bands to the head of the mandible (ensure that the disc
moves forward and backward with the head of the mandible during
protraction and retraction of the mandible)
2017 1D:
composed of dense fibrous tissues and lies within the joint capsule,
intervening between the condyle and the mandibular fossa
biconcave disc that serves to provide reciprocal articular surfaces
between its inferior surface and the condyle, and its superior
surface and the mandibular fossa and eminence
Three zones of the articular disc:
a.
Posterior thickening sits atop the condyle and fills the
mandibular fossa above when the mandible is at rest.
b.
Anterior thickening lies just below the posterior slope of the
articular eminence.
c.
Intermediate zone lies between the two previous zones.

TRANSCRIBED BY: Patty, Ernest, Babes

G. NERVE SUPPLY OF TEMPOROMANDIBULAR JOINT

1.
2.
3.

Branches of temporalis nerve

Branches of auriculotemporal nerve
Branches of masseteric nerve

H. BLOOD SUPPLY OF TEMPOROMANDIBULAR JOINT

1.
2.

Superficial temporal artery

Muscular branch of the maxillary artery

I. RELATIONS OF TEMPOROMANDIBULAR JOINT

Anteriorly: mandibular notch and the masseteric nerve and artery
Posteriorly: tympanic plate of the external auditor meatus and the glenoid
process of the parotid gland
Laterally: parotid gland, fascia and skin
Medially: maxillary artery and vein and the auriculotemporal nerve

DISLOCATION OF TMJ (LOCKED JAW)

In this movement, the head of the mandible and the articular
disc both move forward until they reach the summit of the
articular tubercle.
Common dislocation is anterior type characterized by the
forward movement of the head of the mandible, sliding outside
of the mandibular fossa (opening of mouth)o result in
displacement of condyle anterior to the articular eminence of
the temporal bone.
When the mandible is depressed or if the mouth is widely
opened, as in laughing or yawning, the head of the mandible
might slide forward in front of the mandibular joint (slide
outside the mandibular fossa).
Moore:
In this position, the mandible remains depressed and the person is
unable to close his or her mouth.
Most common, a sideways blow to the chin by a clenched hand (fist)
when the mouth is open dislocates the TMJ on the side that received
the blow.
Dislocation of the TMJ may also accompany fractures of the mandible.
Posterior dislocation is uncommon, being resisted by the presence of
the postglenoid tubercle and the strong intrin- sic lateral ligament.
Usually in falls on or direct blows to the chin, the neck of the mandible
fractures before dislocation occurs.
Because of the close relationship of the facial and auriculotemporal
nerves to the TMJ, care must be taken during surgical procedures to
preserve both the branches of the facial nerve overlying it and the
articular branches of the auriculo- temporal nerve that enter the
posterior part of the joint.
Injury to articular branches of the auriculotemporal nerve supplying the
TMJ, associated with traumatic dislocation and rupture of the articular
capsule and lateral ligament, leads to laxity and instability of the TMJ.

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2017 1D:
Dislocation sometimes occurs when mandible is depressed.
Locked jaw or limited jaw movement is often a result of a bad-bite. If
the bite is not aligned correctly, it causes a problem in the jaw joint
(TMJ).
When the teeth, facial muscles and TMJ are out of alignment, the jaw
joint and muscles become locked.
Chewing is difficult, headaches develop, and opening and closing the
jaw can be painful.
Causes may include clenching teeth during sleep, arthritis, stress, and
injury to the jaw.

ANTERIOR DISLOCATION
Most common and result in displacement of the condyle
anterior to the articular eminence of the temporal bone. These
dislocations are classified as acute, chronic recurrent or
chronic.
Anterior dislocations are usually secondary to an interruption in
the normal sequence of muscle action when the mouth closes
from extreme opening.
The masseter and temporalis muscles elevate the mandible
before the lateral pterygoid muscle relaxes resulting in the
mandibular condyle being pulled anterior to the bony eminence
and out of the temporal fossa.
Spasm of the masseter, temporalis, and pterygoid muscles
causes trismus and keeps the condyle from returning into the
temporal fossa.
These dislocations can be both unilateral and bilateral.

References:
2018 1C Temporal Fossa, Infratemporal Fossa and Temporomandibular Joint
(lecture by Dr. de Jesus)
2017 1D Temporal Fossa, Infratemporal Fossa and Temporomandibular Joint
(lecture by Dr.Celaje)
Clinical Anatomy by Regions 9th edition by Richard Snell
Clinically Oriented Anatomy 7th edition by Keith Moore
Grays Anatomy

Movements of the Temporomandibular joint

Movements of Mandible Muscles
Temporal, masseter and medial
Elevation (close mouth)
pterygoid
Lateral pterygoid and suprahyoid and
Depression (open mouth)
infrahyoid muscles
Lateral pterygoid, masseter, and
Protrusion (protrude chin)
medial pterygoid

Retrusion (retrude chin)

Temporal (posterior oblique and near

horizontal fibers) and masseter

Lateral movements
(grindingand chewing)

Temporal of same side, pterygoids of

opposite side, and masseter

TRANSCRIBED BY: Patty, Ernest, Babes

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APPENDIX

th

Table 1. OINA: Infratemporal Muscles (Snell, 9 ed) [Moore also has a table but medj different from Snells]

**20171D: only lower part of the temporalis muscle is in the infratemporal fossa. Temporalis is in the temporal fossa

TRANSCRIBED BY: Patty, Ernest, Babes

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Table 2. Branches of the Divisions of the Mandibular Nerve (Snell, 9 ed)

DIVISION
Main Trunk of the Mandibular Nerve
Anterior
*All branches of the anterior division are
motor except the buccal nerve (sensory)

Branches
Meningeal branch
Nerve to medial pterygoid muscle
Masseteric Nerve
Deep temporal nerves
Nerve to lateral pterygoid
Buccal nerve

Auricotemporal nerve

Lingual nerve
Posterior
*All branches of the posterior division are
sensory (except the nerve to mylohyoid)

TRANSCRIBED BY: Patty, Ernest, Babes

Course
Supplies medial pterygoid and tensor velipalatini
Masseter
Temporalis
Lateral pterygoid
Skin and mucous membrane of the cheek (does not
innervate the buccinators muscle)
supplies the skin of the auricle, external auditory
meatus, the temporomandibular joint, and the
scalp.
conveys postganglionic parasympathetic
secretomotorfibersfrom the otic ganglion to the
parotid.
descends in front of the inferior alveolar nerve
enters the mouth runs forward on the side of
the tongue and crosses the submandibular duct.
joined by the chorda tympani nerve
supplies the mucous membrane of the anterior
two thirds of the tongue and the floor of the
mouth.
gives off preganglionic
parasympatheticsecretomotorfibersto the
submandibular ganglion

Inferior alveolar nerve

enters the mandibular canal to supply the teeth of

the lower jaw
emerges through the mental foramen (mental
nerve) to supply the skin of the chin
Before entering the canal, it gives off the
mylohyoid nerve which supplies the mylohyoid
muscle and the anterior belly of the digastric
muscle.

Communicating branch

frequently runs from the inferior alveolar nerve to

the lingual nerve

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Table 3. Branches, Couse and Distribution of the Sensory Division of the Mandibular Nerve (Moore)
Branch
Auricotemporal nerve

Inferior alveolar nerve

Lingual nerve

Course and distribution

Encircles the middle meningeal artery divides into numerous branches, the largest of which passes posteriorly,
medial to the neck of mandible supplies sensory fibers to the auricle and temporal region
sends articular (sensory) fibers to the TMJ
conveys postsynapticparasympathetic secretomotorfibers from the otic ganglionto the parotid gland.
enters mandibular foramen passes through the mandibular canal forms theinferior dental plexus, which sends
branches to all mandibular teeth on its side.
Another branch of the plexus, the mental nerve passes through the mental foramen and supplies theskin and
mucous membrane of the lower lip, the skin of thechin, and the vestibular gingiva of the mandibular incisorteeth
lies anterior to the inferior alveolarnerve
sensory to the anterior two thirds of the tongue, the floor of the mouth, and the lingual gingivae
enters the mouth between the medial pterygoidmuscle and the ramus of the mandible passes anteriorly under
cover of the oral mucosa, medial and inferiorto the 3rd molar tooth.
the chorda tympani nerve(from CN VII) carrying taste fibers from the anteriortwo thirds of the tongue, joins the
lingual nerve in theinfratemporal fossa

Table 4. Course and Distribution of The branches of the Sensory Division (Lifted from 2017 1D)

TRANSCRIBED BY: Patty, Ernest, Babes

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