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CHAPTER 5

RELEVANT ANATOMY

Temporomandibular joint99,100,101,102

It is the articulation between the temporal bone and the mandible. More precisely, it is
the articulation of the condylar process of the interarticular disc with the mandibular
fossa of the squamous portion of the temporal bone. (Fig 5.1)

It is technically classified as a ginglymoarthroidal articulation, which by definition is

capable of hinge type movements (Ginglymos-a hinge) and gliding movements.
(Diarthrodial sliding joint)

The articulation of the lower jaw with the cranium and upper facial skeleton involves two
separate joints & the teeth when in occlusion. Though the joints are anatomically
distinct, but they function in unison & independent movement is not possible.

Its anatomy varies considerably among mammals depending on masticatory

requirements. In humans, the masticatory process demands that the mandible be
capable of not only opening and closing movement but also protrusive, retrusive and
lateral movements and combinations thereof. To achieve them, the condyle undertakes
translatory as well as rotatory movements. Therefore the human temporomandibular
joint is described as a synovial sliding ginglymoid joint.

The major components of the temporomandibular joint are the cranial base, the
mandible and the muscles of mastication with their innervations and nerve supply. An
articular disc separates the mandibular fossa and articular tubercle of the temporal bone
from the condylar process of the mandible.

The compound synovial joint occurs between the squamous part of temporal bone and
the mandibular condyle. A complete intra articular disc separates the two bones,

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matches the contour of their articular surface and subdivides the joint space into two
synovial compartments.

Upper compartment: Arthroidal / gliding joint

Lower compartment: Ginglymoid/ hinge joint (Fig 5.2)
The condyle is convex in both sagittal and frontal views, while the temporal element
consists of a glenoid mandibular fossa and an anteriorly located articular tubercle
(eminence).

Structure of the glenoid fossa

The glenoid fossa (mandibular fossa) is an oval depression in the temporal bone
located in front of and below the external auditory meatus. It runs forward to the articular
eminence, which is at the posterior end of the zygomatic arch.

The glenoid fossa is limited posteriorly by the squamotympanic and petrotympanic

fissures. Medially it is limited by the spine of sphenoid and laterally by the root of the
zygomatic process of the temporal bone. Anteriorly, it is bounded by a ridge of bone
described as the articular eminence, which is also involved in the articulation.

The glenoid fossa is divided into 2 parts by the petrotympanic fissure:

(i) Anterior portion: This portion of the fossa is the principle bearing surface upon which
the condyle presses through the disc and other structure.

(ii) Posterior portion: This portion of the fossa is more nearly perpendicular. The
condyle does not bear directly in the fossa because it is separated by the synovial
membrane and the articular disc. The registration of the condylar inclination is based on
the influence of the bony incline on the meniscus together with the influence of the
ligament and muscle pull. (Fig 5.3)

The middle part of the fossa is a fairly thin plate of bone whose upper surface forms the
middle cranial fossa. This indicates that the masticatory loads are not dissipated
through the mandibular fossa but through the teeth & thence to the facial bones & base

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of the cranium. This part is reinforced with thick bone so that it serves as a stop for the
upward force of the elevator muscles & inward force of the medial pterygoid muscles.

The roof of the mandibular fossa consists of a thin, compact layer of bone. The articular
tubercle is composed of spongy bone covered with a thin layer of compact bone

The postglenoid tubercle belongs to the squamous part of the temporal bone & forms
the posterior boundary of the mandibular fossa. Since the joint capsule attaches to the
margin of the tubercle, only the posterior part of the articular disc is interposed between
the tubercle and the condyle. In great majority of cases, a forced posterior displacement
of the condyle would be prevented by the postglenoid tubercle. When the postglenoid
tubercle is very small, the tympanic plate would mechanically prevent such a forced
displacement.

Structure of the condyle

The condyle is the articular surface of the mandible .Its anteroposterior dimension is half
the mediolateral dimension. Its articular surface is strongly convex in the anteroposterior
direction and slightly convex mediolaterally. The articular surfaces of the condyle are
the anterior and superior surfaces. The condyle projects mostly to the medial side of the
ramus. The lateral tip of the condyle lies about 13 mm beneath the skin and can be
located by palpation.

Its medial & lateral ends are termed poles. The lateral pole is mere pointed & does not
extend far beyond the lateral surface of the ramus. The medial end that projects further
medially is thicker, smoother & more rounded. The condylar head does not sit upright
on its neck but is inclined forwards. This forward inclination, combined commonly with a
more or less well defined transverse crest between the poles, results in a smaller
principal articular surface anteriorly and a larger, less functional, posterior articular
facet.(Fig 5.4)

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Buffer space for the condyle 103

When the condyle is in optimum position, a 0.2-0.3 mm space exists between the
condyle and fossa as stated by Dawson and Ramjford, and confirmed three-
dimensionally by Hobo and Iwata. This space is felt to be essential to healthy
maintenance of the TMJ. When heavy pressures are transferred to the condyle during
function, the space allows easy condylar mobility and helps prevent transmission of
direct pressure to the fossa. This space essentially could be considered a buffer.

In man the post glenoid process is not prominent and even if it were it would not limit
posterior border movement of the mandible. Because the condyle does not articulate
with the post glenoid process in man the meniscus and condyle do not completely fill
the glenoid fossa but are in intimate contact with the articular eminence, which creates a
potential space in the post part of the fossa. This space is filled with displacement
tissue.

Articular eminence

The articular eminence runs obliquely from the posterior root of the zygomatic arch to
the medial aspect of the joint. It is strongly convex anteroposteriorly, and is slightly
concave mediolaterally. The posterior slope of the eminence is much steeper than the
gradual slope anterior to the crest of the eminence; the latter referred to as preglenoid
plane. During closing, muscular activity will pull the condyle/disc superiorly and
posteriorly along this slippery incline towards centric relation.

Because of the convexity of the articular eminence, the condyles must move inferiorly in
a curvilinear path as they translate anteriorly during protrusion of the mandible. This
helps to disclude the posterior teeth during protrusion and the non-working side teeth
during lateral excursion - the so-called Christensen phenomenon.

Articular disc

The articular disc separates the two bones from direct articulation in the
temporomandibular joint i.e. the mandibular condyle fitting into the mandibular fossa of

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the temporal bone. The articular disc is a firm but flexible structure that will
accommodate the incongruities that exist between the shape of the articular surface of
the articular surface of the condyle and the articular eminence. It will change its shape
and position relative to these structures during condylar movement.

The articular disc is composed of dense fibrous connective tissue, for the most part
devoid of any blood vessels or never fibers. The extreme periphery of the disc however
is slightly innervated. According to the thickness of the disc in the sagittal plane, it can
be divided into 3 regions. The central area is the thinnest & is called the intermediate
zone. The disc becomes considerably thicker than the anterior border. In the normal
joint, the articular surface of the condyle is located on the intermediate zone of the disc
bordered by the thicker anterior & posterior regions. (Fig 5.5 and 5.6)

From an anterior view the disc is generally thicker medially than laterally, which
corresponds to the increased space between the condyle and the mandibular fossa
towards the medial portion of the joint. The precise shape of the disc is determined by
the morphology of the condyle & the mandibular fossa. During movement, the disc is
somewhat flexible & can adapt to the functional demands of the articular surfaces.

Retrodiscal tissue

The retrodiscal tissue attaches to the posterior edge of the articular disc & fills the space
between the disc & posterior wall of the articular capsule. Its superior lamina attaches to
the tympanic plate composed of connective tissue containing many elastic fibers; this
lamina has the quality of elasticity that counters the forward traction of the superior
lateral pterygoid muscle on the articular disc. Except during forward translation when
this superior lamina is stretched, the effect of muscle tonus in the superior lateral
pterygoid muscle is dominant & exceeds the elastic traction of the retrodiscal tissue. At
rest, the articular disc normally occupies the most forward rotated position on the
condyle that is permitted by the width of the articular disc space.

The inferior retrodiscal lamina attaches anteriorly to the articular disc & posteriorly just
below the posterior margin of the condylar articular facet. It is different from the superior

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Fig 5.1: Temporomandibular joint

Fig 5.2: Compartments of the TMJ

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Fig 5.3 : Boundaries of the glenoid fossa

Fig 5.4 : Cross section of the condylar head

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5.5 : Articular disc

Fig 5.6 : Subdivisions of the articular disc

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lamina in that it is composed chiefly of collagenous fibers, making it non-elastic. This

lamina serves as a check ligament that passively limits forward rotation of the disc on
the condyle. Like all ligaments, it does not enter actively into disc functioning.

Capsule of the joint

The capsule of a synovial joint is an important structure. It consists of dense

collagenous membrane that seals the joint space & provides passive stability. This is
enhanced by increased local thickenings in its walls to form anatomically recognizable
ligaments, as well as active stability from propioceptive nerve endings in the capsule.
(Fig 5.7)

The capsule of the temporomandibular joint can be described as a fibrous, non-elastic

membrane surrounding the joint, which is attached above to the squamotympanic
fissure posteriorly, the margins of the glenoid fossa laterally & the articular eminence
anteriorly. Inferiorly, the capsule is attached to the neck of the condyle. Above the disk,
the capsule is fairly lax, where as below it is tightly attached to the condyle. The lateral
aspect of the capsule is thickened to form a fanshaped ligaments known as the
temparomandibular ligament.

Disc contour

The contour of the articular disc is important from the standpoint of understanding of the
subject. As interarticular pressure from the osseous components of the joint narrows the
articular disc space & bears on the disc, the contour of the disc exercises an automatic
biomechanical self-centering effect, a rotatory movement of the disc to bring a thinner
portion between the bones. Conversely, when pressure between the bony parts is
decreased & the disc space widens, the disc is free to rotate a thicker portion to fill the
space. If disc contour is lost, it also loses this self-centering capability.

Disc contour prevents linear sliding movement between disc & condyle without inhibiting
rotatory movement. It is the thicker posterior margin of the disc that prevents linear

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displacement posteriorly. It is the disc contour that causes the disc & condyle to
translate together without displacement.

The articular disc is normally too dense to permit compression great enough to be
radiographically apparent. It has flexibility to maintain surfaces contact satisfactorily with
the articular eminence but does not appreciably alter its contour during translatory
movements.

Articular surfaces

Unlike most synovial joints, whose articular surfaces are covered with hyaline cartilage,
the temporomandibular joint is covered by a layer of fibrous tissue. This histological
distinction has been used to argue that the temporomandibular joint is not a weight-
bearing joint, but the reality for this distinction can be found in the developmental history
of the joint.

The posterior margin of the articular surface extends a considerable distance, permitting
more extensive rotation of the disc posteriorly then inferiorly. It is composed of dense,
non-vascularized, non-innervated fibrous tissue rather than cartilage. This tissue is quite
thin over most of the articular facet but thickens appreciably in the anterosuperior
aspect, indicating the area best suited to sustain maximum pressure.

Pressure bearing characteristic

There is considerable pressure applied on the anterior part of the condyle. The joint is
designed histological and morphologically to withstand pressure. The TMJ is the only
diarthroidal joint in the body of which the articular surface is covered by fibrous
connective tissue rather than hyaline cartilage. The disc is composed of white fibrous to
connective tissue that contributes to its roughness and flexibility. Blood vessels are
absent in the firm central area of the disc providing additional proof that there is
considerable pressure in the joint.

The direction of the fiber bundles and fibrous covering of the articular bone is
characteristic and evidence the pressure bearing adaptation of this joint. The fibers,

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according to Sicher, run at right angle to the bony surface in the deep layer and parallel
to the surface in the superficial layer. This direction of fibers is also characteristic of the
disc. The deep layer is adapted to pressure, the superficial layer to gliding under
pressure.

Biomechanics of TMJ

There are few topics in dentistry about which misunderstanding and misinterpretation
exist as that of the biomechanics of the temporomandibular joint. Despite this, it is
possible to present a clear and simple understanding of this topic:-

a) The TMJ is a typical diarthroidal joint.

b) All diarthroses consist of concave and convex functional surfaces. The head of the
condyle and the tubercular eminence, both convex, are the functioning osseous
surfaces of the joint. The articular disc provides the reciprocal concave surfaces. The
mandibular fossa is not a functional portion of this joint.

c) A typical diarthroses contains both functioning and nonfunctioning joint surfaces. The
former are covered with articular cartilage, the latter are not. The entire joint with both
functioning and non-functioning surfaces is enclosed within a synovial membrane.

d) All movements at diarthroidal joints are rotations about a mechanical axis.

e) If an articular surface is perfectly hemispherical, its axis of rotation will be fixed. If the
articular surface is ovoid, as is the case in almost all human condyles, the axis of
rotation will constantly shift, producing what is termed as an evolute that is, constantly
shifting axis of rotation.

f) The first action of muscle, which produced motion at a diarthroses, is to produce

compression of the articular surfaces, following which motion occurs. During function
(i.e. during either the isometric or isotonic contraction of any muscle which tends to
produce motion at that joint) there is always a compressive force exerted upon the
functioning joint surface; thus the temporomandibular joint is a load bearing joint.

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g) Once the muscle producing motion at a joint contracts and compresses the reciprocal
joint surfaces, the envelope of motion occurring at the joint is determined entirely by the
specific morphology of these same joint surfaces.

Gross anatomical, comparative, histological and analytical biomechanical studies

correctively establish that the almost cartilage-free mandibular fossa exists between the
condylar head and this fossa, nor in man is there every any functional articulation
between the condylar head and the posterior osseous wall of this joint (the post-
glenoid tubercle). By any functional definition, utilizing the commonly accepted principle
of biomechanics, the centric relation is not a functional position. Indeed, it may be
doubted if this relation of the condyle is other than iatrogenic.

Role of muscles and ligaments92,93,98,99

Centric relation is the considered the most important spatial relation of the mandible to
the maxillae. There is considerable disagreement over the reproducibility of the centric
position over a period of time. There has been much controversy over the structure that
limits the posterior movement of the condyle in the fossa. The force has shifted between
ligaments, muscles and the bony contour of the TMJ.

The reliability of the centric position is wholly dependent upon the limiting structure of
the TMJ. Anatomically, it would be far more consistent if the limiting strictures were
ligaments rather than muscles. But if one considered the physiology of the system, it is
conceivable that the neuromuscular mechanism can be precise and corrective.

Aprile and Saizor found that the symphysial angle could be traced on human cadavers
with the ligament of the joint left intact but with the muscle removed

Lockhart pointed out the interaction between muscles and ligament in protecting joints.
He stated that muscles are essential in the protection they offer the ligaments. The
ligament of a joint would have to be much stronger and bulkier were it not for the aid
given by the muscles. Muscle contraction prevents strain on the ligament. The myotactic

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or stress reflex is in effect a protective mechanism. Neuromuscular splinting is also a

protective mechanism. The neuromuscular complex protects the ligament and the
ligament serves as a last line of resistance to protect the joint. So, a ligamentously
limited position does not appear to be utilized. It may be a reserve system and not a
primary defense.

The term unstrained refers to only the strain on the ligaments. Unfortunately, many
assume and believe that it is the strain of the muscles which retrude the jaw. This is not
true. During normal contraction of muscle, strain always occurs. The term strain is
specifically used with reference to the ligaments and is not considered as strain on the
muscles. This interpretation does not find a place in the definition of centric relation. In
no way it should be considered a strain on the muscles.

The closing and retruding muscles are under some degree of strain in centric relation.
Rest position is the only unstrained position. When the mandible is in centric position,
maximum muscle contraction does occur as centric is a power position. Rest position of
the jaws is the only position of the mandible where there is minimum tonic contraction of
the muscles and truly an unstrained position. Centric relation is the most distal position
of the head of the condyle without causing strain on the ligaments. Ligaments limit the
mandibular movements and not the muscles and hence only the ligaments suffer strain
if the head of the condyle is taken posteriorly beyond centric relation position.

Ligaments of the joint

As with any joint system, ligaments play an important role in protecting the structures.
The ligaments of the joint are made up of collagenous connective tissues that do not
stretch. They do not enter actively into joint function but instead act as passive
restraining devices to limit and restrict border movements. Three functional ligaments
support the temporomandibular joint:

Collateral ligaments.

Capsular ligament.

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Temporomandibular ligament (Lateral ligament)

There are also two accessory ligaments:

Sphenomandibular

Stylomandibular

(i) Collateral (discal) ligaments

The collateral ligaments attach the medial & lateral borders of the articular disc to the
poles of the condyle. They are commonly called the discal ligaments. The medial discal
ligament attaches the medial edge of the disc to the medial pole of the condyle while the
lateral discal ligament attaches the lateral edge of the disc to the lateral pole of the
condyle. These ligaments are responsible for dividing the joint mediolaterally into the
superior & inferior joint cavities. The discal ligaments are true ligaments, composed of
collagenous connective tissue fibers; therefore, they do not stretch. They function to
restrict movement of the disc away from the condyle. The attachments of the discal
ligaments permit the disc to be rotated anteriorly & posteriorly on the articular surface of
the condyle. Thus these ligaments are responsible for the hinging movement of the
temporomandibular joint, which occurs between the condyle & the articular disk.

The discal ligaments have a vascular supply & are richly innervated. Strain on these
ligaments produces pain.

(ii) Capsular ligament

As previously mentioned, the entire temporomandibular joint is surrounded &

encompassed by the capsular ligament. The fibers of the capsular ligament are
attached superiorly to the temporal bone along the borders of the articular surfaces of
the mandibular fossa & articular eminence. Inferiorly, the fibers of the capsular ligament
attach to the neck of the condyle. The capsular ligament is well innervated & provides
proprioceptive feedback regarding position & movement of the joint.(Fig 5.8 and 5.9)

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Temporomandibular ligament/ Lateral ligament (and its relationship with condylar

rotation/translation)

The lateral aspect of the capsular ligament is reinforced by strong, tight fibers that make
up the lateral ligament or the temporomandibular ligament. The temporomandibular
ligament is composed of two parts:

(i) Outer oblique portion

(ii) Inner horizontal portion.

The outer portion extends from the outer surface of the articular tubercle & zygomatic
process postero-inferiorly to the outer surface of the condylar neck. The inner horizontal
portion extends from the outer surface of the articular tubercle & zygomatic process
posteriorly & horizontally to the lateral pole of the condyle & the posterior part of the
articular disc.(Fig 5.10)

The oblique portion of the temporomandibular ligament resists excessive dropping of

the condyle, therefore limiting the extent of mouth opening

During the initial phase of opening, the condyle can rotate around a fixed point until the
temporomandibular ligament becomes tight as its point of insertion on the neck of the
condyle is rotated posteriorly. When the ligament is taut, the neck of the condyle cannot
rotate further. If the mouth were to be opened wider, the condyle would need to move
downward & forward across the articular eminence.

This effect can be demonstrated clinically by closing the mouth & applying mild posterior
force to the chin. With this force applied, begin to open the mouth. The jaw easily
rotates open until the teeth are 20-25 mm apart. At this point, resistance is felt when the
jaw is opened wider. If the jaw is opened still wider, a distinct change in the opening
movement occurs, which represents the change from rotation of the condyle about a
fixed point to movement forward & down the articular eminence. This change in opening
movement is brought about by the tightening of the temporomandibular ligament. (Fig
5.11)

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As the mouth opens, the teeth can be separated some 20-25 mm (from A to B) without
the condyles moving from the fossae. At B, the TM ligaments are fully extended. As the
mouth opens wider, they force the condyles to move downward & forward out of the
fossa. This creates a second arc of opening. (from B to C).

This unique feature of the temporomandibular ligament, which limits rotational opening,
is found only in humans. In the erect postural position & with a vertically placed
vertebral column, continued rotational opening movement causes the mandible to
impinge on the vital submandibular & retromandibular structures of the neck.

The outer oblique portion of the temporomandibular ligament functions to resist this
impingement.

The inner horizontal portion of the temporomandibular ligament limits posterior

movement of the condyle & disc. When force applied to the mandible displaces the
condyle posteriorly, this portion of the ligament becomes tight & prevents the condyle
from moving into the posterior region of the mandibular fossa. The temporomandibular
ligament therefore protects the retrodiscal tissue from trauma created by the posterior
displacement of the condyle.

Thus the temporomandibular ligament restricts displacement of the mandible in three

different planes. It functions in a similar way to collateral ligaments of other joints
because of the bilateral nature of the articulation. By preventing lateral dislocation of the
joint, it prevents medial dislocation of the other. Its oblique components limit the amount
of inferior displacement, while its horizontal component prevents or limits posterior
displacement.

Sphenomandibular ligament

It is one of the two temporomandibular joint accessory ligaments. It arises from the
spine of the sphenoid bone & extends downward to a small bony prominence on the
medial surface of the ramus of the mandible called the lingula. It does not have
significant limiting effects on mandibular movement. It represents the residual

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perichondrium of Meckels cartilage. The sphenomandibular ligament is passive during

jaw movements maintaining relatively the same degree of tension during opening &
closing of the mouth. (Fig 5.12)

Stylomandibular ligament:

The second accessory ligament is the stylomandibular ligament. It arises from the
styloid process & extends downward & forward to the angle & posterior border of the
ramus of the mandible. The ligament becomes tense only in the extreme protrusive
posture. It therefore limits excessive protrusive movements of the mandible. (Fig 5.13)

Role Of Muscles 3,104

The masticatory system of the stomatognathic mechanism is made of a 3-linked chain.

The maxillae and the mandible supporting the teeth are one link, the TMJ the other. The
third link is the associated musculature with its nerve and vascular supply. The former
two are passive links, while the latter in the active link.

The muscles of mastication serve an important function in the mandibular suspension

system, particularly in counter balancing the pull from the supra and infrahyoid neck
muscles. The mere anatomic relation between the muscle groups supports this
assumption. The biodynamic nature of this muscle suspension system is, however
complex since the musculature has a series of rather independent functions such as
mastication, deglutition, respiration, head positioning, speech and facial expression.

The mandible is under the influence of gravity and neuromuscular forces. They interplay
between these forces is so great that unless some means is found to stabilize the
mandible in its relation to the skull during the period of observation & registration, many
errors are possible.

I. Temporalis muscle

The fan-shaped temporalis muscle has its broad origin in the temporal fossa and
the temporal fascia along the side of the head. The insertion is on the medial

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Fig 5.7 :Capsule of the joint

Fig 5.8 and 5.9: Capsular ligament

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Fig 5.10: OOP outer oblique portion; IHP inner

horizontal portion of TMJ ligament

Fig 5.11: As the mouth opens, the teeth can be separated some 20-25 mm (from A to B)
without the condyles moving from the fossae. At B, the TM ligaments are fully extended.
As the mouth opens wider, they force the condyles to move downward & forward out of
the fossa. This creates a second arc of opening. (From B to C).
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Fig 5.12: Sphenomandibular ligament

Fig 5.13: Sphenomandibular and Stylomandibular ligament

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surface, apex, and anterior border of the coronoid process of the mandible. (Fig 5.14)

The fibers of all three portions descend and converge on a tendon that passes deep into
the zygomatic arch. Posteriorly this tendon bends like a pulley around the root of the
zygomatic arch. This arrangement limits the angle of vectors that can be produced by
the contracting temporalis fibers, especially its posterior fibers.

The functions of the posterior part of these muscles are to retrude the mandible and
brace the condyle during lateral mandibular excursions to the same side. The function
of the middle parts is to elevate the mandible into centric position. (Fig 5.15)

II. Masseter muscle

This is a quadrilateral muscle having two portions, a larger superficial portion and a
much smaller, deep portion. The origin of the superficial masseter muscle is on the
zygomatic process of maxilla and the inferior border of the zygomatic arch. It has a
strong and tendinous attachment to these structures.(Fig 5.16)

The muscle tendon fibers of the superficial masseter run obliquely inferiorly and
posteriorly to the area of insertion on the area of insertion on the angle of the mandible
and the inferior half of the lateral side of the ramus. The fiber direction is roughly
perpendicular to the plane of occlusion.

The principle function of the masseter is to elevate the mandible vertically in order to
obtain maximum intercuspation.. The deep portion of the masseter muscle, because of
its different fiber orientation, also helps to retrude the mandible.

III. Lateral pterygoid Muscle

The lateral pterygoid (formerly called the external pterygoid) muscle arises from two
heads. The smaller superior head arises from the wing of the sphenoid bone and from
the infratemporal crest; the larger inferior head arises from the lateral surface of the
lateral pterygoid plate. All the fibers pass posteriorly and laterally to insert anterior to the

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neck of the mandible (pterygoid fovea), with a variable number of fibers from the
superior head inserting into the anteromedial margin of the articular disk. (Fig 5.17,5.18)

Besides its important role in opening of the jaws and protrusion of the mandible lateral
pterygoid also has an important role in determining the position of the condyles relative
to the eminence, and limits the degree of condylar retrusion.

IV.Medial Pterygoid Muscle

It is a thick quadrilateral muscle. Formerly called the internal pterygoid, is located on

the medial side of the ramus. It is similar to the superficial masseter in fiber direction,
and these two muscles function synergistically to form the muscular sling. While an
important elevator of the mandible, the medial pterygoid is not as powerful as the
masseter. The origin of the medial pterygoid muscle is in the pterygoid fossa and on the
medial surface of the lateral pterygoid plate. The triangular insertion is on the ramus and
the angle of the mandible, and on the inferior and posterior aspect of the medial
surface.(Fig 5.19,5.20)

V.Anterior digastric muscle

The diagastric muscle is a part of the suprahyoid group and consists of two bellies, the
anterior and the posterior. The longer posterior belly arises from the mastoid notch of
the temporal bone and passes inferiorly and anteriorly. The anterior belly arises from
the lingual side of the inferior border of the mandible, and then passes inferiorly and
posteriorly. The two bellies are joined by a common tendon.The digastric muscle helps
in retruding the mandible. (Fig 5.21)

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Fig 5.14: Temporalis muscle

Fig 5.15: Parts of the Temporalis (Anterior, Middle and Posterior)

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Fig 5.16: Masseter muscle

Fig 5.17 and 5.18: Lateral pterygoid muscle

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Fig 5.19 and 5.20: Medial pterygoid muscle

Fig 5.21: Digastric muscle

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Muscles Involved In Centric Relation105

1. Muscles of mastication have their origin and insertions in bone. Centric relation is
a bone-to-bone relation controlled by the attached musculature, the tissue lined
bony fosse, the ligaments and articular disc.

2. Related to the general statement that function and joint motion are significant
extrinsic determinants of condylar form and growth, recent data clearly
demonstrate that the lateral pterygoid muscle, which attaches to the condylar
process disc and acts as a type of functional matrix, plays a significant role in
the regulation of the mandibular condylar cartilage. The muscle plays a role in
the continuing adaptive morphological changes at this portion of the
temporomandibular joint. (Fig 5.22)

3. The anatomic attachments of posterior & middle parts of the temporal and
suprahyoid muscles together with electromyographic studies indicate that those
muscles move and stabilize the mandible in its most retruded position to the
maxilla.

4. The temporal, masseter and medial pterygoid elevate the mandible to a

particular vertical relation with the maxilla. The lateral pterygoid muscle shows
little activity when the mandible is in centric relation. Electromyogram indicates
electrical activity recorded from the muscles when mandible is moved from
resting position into centric relation and from centric relation back to resting
position. Increase in both frequency and amplitude of tracings indicate the time
during which mandible was in centric relation. Striking increase in activity from
middle and posterior parts of temporal muscles occur because these muscles are
responsible for positioning and holding mandible in centric relation. Anterior part
of temporal muscle, masseter muscle and lateral pterygoid muscle show little
increase above resting activity when mandible is in centric relation.

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Antero-superior bracing of condyle disc assembly in centric relation 98

Williamson investigated the pattern of muscle contraction in centric relation. From an

electromyography study he found that the contraction of the superior head of external
pterygoid, placed the disc in a braced position against the posterior slope of articular
eminence and the contraction of temporalis positioned the condyle superiorly in close
approximation to the articular disc.

This condyle-disc assembly was then finally seated against the posterior slope of the
articular eminence be the contraction of the masseter and the medial pterygoid during
centric power closure.

The direction of the medial pterygoid and the masseter during centric power closure
strongly suggest an anterior superior positioning of the condyle against the eminentia.
There is no muscle attached to the condyle to pull the condylar head vertically up
toward the center of the glenoid fossa. The temporalis that elevates the mandible is
situated anterior to the condyles.

Similarly there is no muscle attached behind the neck of the condyle to retrude the
mandible by opposing the action of external pterygoid muscle that is attached anteriorly
on the neck. Retrusion of the mandible is done by the muscles that are attached
anterior to the joint at the coronoid process (temporalis) and anteriorly in the inner
surface of the mandible (posterior belly of digastric).

Thus the anterosuperior bracing of the condyle disc assembly is justified on the basis of
the above arrangement of muscles.

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Mandibular Movements involved in centric relation106

Mandibular movement occurs as a complex series of interrelated three-

dimensional rotational and translational activities. It is determined by the combined and
simultaneous activities of both TMJs. Although the TMJs cannot function entirely
independently of each other, they also rarely function with identical concurrent
movements.

Types of movement: Two types of movement occur in the TMJ:

A. Rotational

B. Translational

A. Rotational Movement: Dorlands Medical Dictionary defines rotation as, the

process of turning around an axis: movement of a body about an axis. In the
masticatory system, rotation occurs when the mouth opens and closes around a fixed
point or axis within the condyles. In other words, the teeth can be separated and then
occluded with no positional change of the condyles. In the TMJs, rotational movement
occurs as movement within the inferior joint cavity. It is thus movement between the
superior surface of the condyle and the inferior surface of the articular disc. Rotational
movement of the mandible can occur in all three reference planes: horizontal, frontal
and sagittal. In each plane it occurs around a point, called the axis. The axis of rotation
for each plane is described as follows:

(i) Horizontal axis of rotation: Mandibular movement around the horizontal axis is an
opening and closing motion. It is referred to as hinge movement, and the horizontal axis
around which it occurs is therefore referred to as the hinge axis. The hinge movement is
probably the only example of mandibular activity in which pure rotational movement
occurs. In all other movements rotation around the axis is accompanied by translation of
the axis.

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When the condyles are in their most superior position in the mandibular fossae and the
mouth is purely rotated open, the axis around which movement occurs is called the
Terminal hinge axis.

a) Frontal axis of rotation: Mandibular movement around the frontal axis occurs when
one condyle moves anteriorly out of the terminal hinge position with the frontal axis of
the opposite condyle remaining in the terminal hinge position.

b) Sagittal axis of rotation: Mandibular movement around the sagittal axis occurs when
one condyle moves inferiorly while the other remains in the terminal hinge position.
Because the ligaments and musculature of the TMJ prevent an inferior displacement of
the condyle( dislocation), this type of natural movement does not occur naturally.

B. Translational Movement: Translation can be defined as movement in which every

patient of the moving object has simultaneously the same velocity and direction. In the
masticatory system it occurs when the mandible moves forward, as in protrusion. The
teeth, condyles, and rami move in the same direction and to the same degree.

Translation occurs within the superior joint cavity between the superior surface of the
articular disc and the inferior surface of the mandibular fossa. During most normal
movements of the mandible, both rotation and translation occur simultaneously- that is
while the mandible is rotating around one or more of the axes, each of the axes is
translating (changing its orientation in space). This results in extremely complex
movements that are difficult to visualize.

Single Plane Border Movements: Mandibular movement is limited by ligaments and

the articular surfaces of the TMJs, as well as by the morphology and alignment of the
teeth. When the mandible moves through the outer range of motion, reproducible and
discernible limits result, which are called border movements. Though the border
movements are generally described in three planes: sagittal, horizontal and frontal, an
explanation of the movements in the sagittal and horizontal planes is given here:

(i) Sagittal Plane Border and Functional Movements:

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Mandibular motion in the sagittal plane can be seen to have four distinct movement
components(Fig 5.23 and 5.24)

a) Posterior opening borders

b) Anterior opening border
c) Superior contact borders
d) Functional

a) Posterior opening border movements:

In centric relation the mandible can be rotated around the horizontal axis to a
distance of only 20-25 mm as measured between the incisal edges of the maxillary
and mandibular incisors. At this point of opening the TM ligaments tighten, after
which continued opening results in an anterior and inferior translation of the
condyles. As the condyles translate, the axis of rotation of the mandible shifts into the
bodies of the rami resulting in second stage of the posterior border movement. The
exact location of the axes of rotation in the rami is likely to be the area of attachment
of the sphenomandibular ligaments. During this stage in which the mandible is
rotating around a horizontal axis passing through the rami, the condyles are moving
posteriorly and inferiorly. Maximum opening is reached when the capsular ligaments
prevent further movement at the condyles. Maximum opening is in the range of 40-60
mm when measured between the incisal edges of the maxillary and mandibular teeth.

b) Anterior opening border movements:

With the mandible is maximally opened, closure accompanied by contraction of the

inferior lateral pterygoid muscles (which keeps the condyles positioned anteriorly)
generates the anterior opening border movement. Theoretically, if the condyles were
stabilized in this anterior position, a pure hinge movement could occur while the
mandible was closing from the maximally opened to the maximally protruded
position. Since the maximum protrusive position is determined in part by the
stylomandibular ligaments, tightening of the ligaments as closure occurs produces a
posterior movement of the condyles. Condylar position is most anterior in the

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maximally opened position but not the maximally protruded position. The posterior
movement of the condyle from the maximally open position to the maximally
protruded position produces eccentricity in the anterior border movement. Therefore
it is not a pure hinge movement.

c] Superior contact border movements:

Whereas the border movements previously discussed are limited by ligaments, the
superior contact border movement is determined by the characteristics of the
occluding surfaces of the teeth. Throughout this entire movement tooth contact is
present. Its precise delineation depends on:

(1) The amount of variation between centric relation and maximum intercuspation.

(2) The steepness of the cuspal inclines of the posterior teeth.

(3) The amount of vertical and horizontal overlap of the anterior teeth

(4) The lingual morphology of the maxillary anterior teeth, and

(5) The general interarch relationships of the teeth. Since this border movement is
solely tooth determined, changes in the teeth result in changes in the nature of the
border movement.

In the centric relation position, tooth contacts are normally found on one or more
opposing pairs of posterior teeth. The initial tooth contact in terminal hinge closure
(centric relation) occurs between the mesial inclines of a maxillary tooth and the distal
inclines of a mandibular tooth. If muscular force is applied to the mandible, a
superoanterior movement or shift results until the intercuspal position is reached.
Additionally, this centric relation-to-maximum intercuspation slide may have a lateral
component. The slide from centric relation to the intercuspal position is present in
approximately 90% of the population, and the average distance is 1.25+/- 1 mm.

When a person has no discrepancy between centric relation and maximum

intercuspation, the initial description of the superior contact border movement is altered.
From centric relation there is no superior slide to the intercuspal position. The beginning

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protrusive movement immediately engages the anterior teeth and the mandible moves
inferiorly, as detected by the lingual anatomy of the maxillary anterior teeth.

(d) Functional Movements:

Functional movements occur during functional activity of the mandible. They usually
take place within the border movements and therefore are considered free movements.
Most functional activities require maximum intercuspation and therefore typically begin
at and below the intercuspal position. When the mandible is at rest, it is found to be
located approximately 2 to 4 mm below the intercuspal position. This position has been
called the clinical rest position. Some studies suggest that it is quite variable. It has also
been determined that this so-called clinical rest position is not the position at which the
muscles have their least amount of EMG activity. The muscles of mastication are
apparently at their lowest level of activity when the mandible is positioned approximately
8mm inferior and 3 mm anterior to the intercuspal position.

At this point the force of gravity pulling the mandible down is in equilibrium with the
elasticity and resistance to stretching of the elevator muscles and other soft tissues
supporting the mandible. Therefore this position is best described as the clinical rest
position. In it the interarticular pressure of the joint becomes very low, and dislocation is
approached. Since function cannot readily occur from this position, the myotactic reflex,
which counteracts the forces of gravity and maintains the jaw in the more functionally
ready position 2 to 4 mm below the intercuspal position, is activated. In this position the
teeth can be quickly and effectively brought together for immediate function. The
increased levels of EMG muscle activity in this position are indicative of the myotactic
reflex. Since this is not a true resting position, the position in which the mandible is
maintained is more appropriately termed the postural position.

(ii) Horizontal Plane Border and Functional Movements:

Traditionally a device known as a Gothic arch tracer has been used to record
mandibular movement in the horizontal plane. It consists of a recording plate attached
to the maxillary teeth and a recording stylus attached to the mandibular teeth. As the

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mandible moves, the stylus generates a line on the recording table that coincides with
this movement. The border movements of the mandible in the horizontal plane can
therefore be easily recorded and examined.(Fig 5.25)

When mandibular movements are viewed in the horizontal plane, a rhomboid-shaped

pattern can be seen that has four distinct movement components plus a functional
component: (Fig 5.26)

a) Left lateral border.

b) Continued left lateral border with protrusion.

c) Right lateral border.

d) Continued right lateral border with protrusion .

a) Left Lateral border movements:

With the condyles in centric relation, contraction of the right inferior lateral pterygoid
muscle causes the right condyle to move anteriorly and medially (also inferiorly). If the
left inferior lateral pterygoid muscle stays relaxed, the left condyle remains situated in
centric relation and the result is a left lateral border movement (i.e., the right condyle
orbiting around the frontal axis of the left condyle). The left condyle is therefore called
the rotating condyle, since it is orbiting around the rotating condyle. The left condyle is
also called the working condyle, since it is on the working side. Likewise, the right
condyle is called the nonworking condyle, since it is located on the nonworking side.
During this movement the stylus generates a line on the recording plate that coincides
with the left border movement. (Fig 5.27)

b] Continued left lateral border movements with protrusion:

With the mandible in the left lateral border position, contraction of the left inferior lateral
pterygoid muscle along with continued contraction of the right inferior lateral pterygoid
muscle causes the left condyle to move anteriorly and to the right. Since the right

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 Relevant Anatomy 84

condyle is already in its maximum anterior position, the movement of the left condyle a
shift in the mandibular midline back to coincide with the midline of the face. (Fig 5.28)

c) Right lateral border movements:

Once the left lateral border movements have been recorded on the tracing, the
mandible is returned to centric relation and the right lateral border movements are
recorded.

Contraction of the left inferior lateral pterygoid muscle causes the left condyle to move
anteriorly and medially (also inferiorly). If the right inferior lateral pterygoid muscle stays
relaxed, the right condyle remains situated in centric relation. The resultant mandibular
movement is a right lateral border movement (e.g., the left condyle orbiting around the
frontal axis of the right condyle). The right condyle in this movement is therefore called
the rotating condyle, since the mandible is rotating around it. The left condyle during this
movement is called the orbiting condyle, since it is orbiting around the rotating condyle.
During this movement the stylus generates a line on the recording plate that coincides
with the right lateral border movement. (Fig 5.29)

d) Continued right lateral border movements with protrusion:

With the mandible in the right lateral border position, contraction of the right inferior
lateral pterygoid muscle along with continued contraction of the left inferior lateral
pterygoid muscle causes the right condyle to move anteriorly and to the left. Since the
left condyle is already in its maximum anterior position, the movement of the right
condyle to its maximum anterior position causes a shift back in the mandibular midline
to coincide with the midline of the face. This completes the mandibular border
movement in the horizontal plane.

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Lateral movements can be generated by varying levels of mandibular opening. The

border movements generated with each increasing degree of opening result in
succeedingly smaller tracing until, at the maximally open position, little or no lateral
movement can be made. (Fig 5.30)

Bennet movement 106,107

GPT - "Bodily Lateral movement or lateral shift of the mandible resulting from me
movements of the condyles along the lateral inclines along the mandibular fossa in
lateral jaw movement.
Bodily side shift of mandible which when it occurs may be recorded in the region
of translating condyle of the nonworking side.
During lateral movement mandible moves towards working side by 1- 4mm. This
side shift is called Bennett Movement. Shift is not associated with laterotrusion
and may occur before or along with it.
During this movement non-working condyle moves forward and medially while
working condyle rotates around the vertical axis and also moves laterally.

Classification-

Immediate Side Shift

Mandible shift before the forward movement of non working condyle occurs.
Shift ranges from 1-4mm.

Recurrent side Shift

Lateral translation that occurs in the first 2-3mm of forward movement of non
working condyle
The mandible begins to shift rapidly during first 2-3mm and then continues to
shift in a less rapid fashion

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Progressive Side Shift

Lateral translation that occurs after 2-3mm of forward movement of non-working

condyle. Shift of the mandible is gradual and does not change with time
Bennet Angle
GPT - Angle formed by the sagittal plane and the path of advancing condyle during
lateral mandibular movement as viewed in the horizontal plane.
Angle formed by between the path of non working condyle and sagittal plane
Bennet angle is about 7.5 - l2.8
Bennet angle is used in articulators with immediate lateral translation capability;
L= H/8 + 12.

Replicability of condylar position:

The replicability of the centric position is wholly dependent upon the limiting structures
of the TMJ. Anatomically, it would be far more consistent if the limiting structures were
ligamentous rather than muscular. But if one considers the physiology of the system, it
is conceivable that the neuromuscular mechanism can be surprisingly precise and
corrective as well.27Lockhart pointed out the interaction between muscles and ligaments
in protecting joints. He stated that muscles are essential in the protection they offer
ligaments. The ligaments of a joint would have to be much stronger and bulkier were it
not for aid given by the muscles. Muscle contraction from tonus to vigorous contraction
prevents undue strain on the ligaments. The neuromuscular complex protects the
ligaments and the ligaments serve as a last line of resistance to protect the joint.

Laminographic Study of condyle position when recording CR:108

Weinberg used transcranial radiography to locate the condyle in the fossa, and he
claimed that a centered position on the radiograph to be the most ideal for the location
of the mandibular condyle. However, clarity of the radiographs using this technique is
limited, as is the clarity of all transcranial radiographs due to the multitude of osseous

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structures through which the x-rays must pass. One radiographic procedure, which
eliminates the problem of poor clarity, is laminography, also known as Tomography. It
is a process whereby a slice may be made through an anatomic structure, eliminating
osseous structure on each side of the region in focus. A clear view of the desired
anatomy may then be seen from a direct lateral position. Another advantage of this
technique is the use of an orthodontic cephalostat for head positioning that allows
precise repositioning of the head in an upright position for serial laminography.

In a laminographic comparison between mandible forcefully retruded to centric relation

and with the mandible positioned by a closing force while an anterior guidance
prosthesis the condyles were found to be significantly more superior in the glenoid fossa
when anterior guidance was used.

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Fig 5.22: Muscles involved in centric relation

Fig 5.23 and 5.24 : Mandibular border movement in the sagittal plane, Posselt's three
dimensional representation of the total envelope of mandibular movement. 1, Mandibular
incisors track along the lingual concavity of the maxillary anterior teeth. 2, Edge-to-edge
position. 3, Incisors move superiorly until posterior tooth contact recurs. 4, Protrusive
path. 5, Most protrusive mandibular position.
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Fig 5.25: Horizontal plane border movements

and Gothic arch tracing thus formed

Fig 5.26: Rhomboid shaped pattern due to border movements of mandible in horizontal
plane
CR Centric relation;CO Centric occlusion;EC Area in early masication;LC Area in late
stages of mastication;EEP End to end position of anteriors

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Fig 5.27: Left lateral border movements

Fig 5.28: Continued left lateral border movements

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Fig 5.29: Right lateral border movements

Fig 5.30: Continued right lateral border movements

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