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Townsend, Grant Clement Discal Attachments of the Human Temporomandibular Joint Australian Dental Journal, 2005; 50(3):152-160

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Townsend, Grant Clement Discal Attachments of the Human Temporomandibular Joint Australian Dental Journal, 2005; 50(3):152-160 PUBLISHED VERSION Christo, Jonathan Elias; Bennett, Sam; Wilkinson, Thomas Maynard; Townsend, Grant Clement Discal attachments of the human temporomandibular joint Australian Dental Journal, 2005; 50(3):152-160 PERMISSIONS This document has been archived with permission from the Australian Dental Association, received 18th January, 2007. Australian Dental Association: http://www.ada.org.au/ http://hdl.handle.net/2440/16785 ADRF RESEARCH REPORT Australian Dental Journal 2005;50:(3):152-160 Discal attachments of the human temporomandibular joint JE Christo,* S Bennett,* TM Wilkinson,* GC Townsend* Abstract INTRODUCTION Background: Despite its clinical significance, the The human temporomandibular joint (TMJ) is a anatomy of the human temporomandibular joint synovial joint that has several unique features.1 It (TMJ) and its relationship to the lateral pterygoid performs both gliding (arthrodial) and hinge muscle remains poorly described and often (ginglymal) movements, there is bilateral articulation, misrepresented in standard texts. The aim of this the articular surfaces are covered by fibrous tissue not study was to describe how the anterior and posterior hyaline cartilage, and the teeth limit as well as guide attachments of the TMJ disc vary between lateral, central and medial regions of the joint. certain movements. Methods: Ten left TMJs were removed en bloc from The TMJ provides articulation between the mandible cadavers and serial sections were made at 3-4mm via the condyle and the cranium via the temporal bone, intervals. Observations were made to ascertain the in particular, the mandibular fossa and the articular anterior and posterior attachments of the disc and eminence. The TMJ disc is interposed between the the joint structures were traced from standardized condyle and the fossa, separating them from direct photographs. articulation. The articular disc is composed mainly of Results: Laterally, the capsule and lateral discal ligament merged prior to their attachment at the dense fibrous connective tissue and it divides the joint condylar pole. Medially, muscle fibres, capsule and into an upper and lower compartment. The disc can be the disc converged on the medial pole of the condyle. divided into three regions based on thickness when There was no evidence that fibres of the upper head viewed from the lateral perspective; an anterior thick of the lateral pterygoid muscle inserted directly into zone, an intermediate thin zone and a posterior thick the disc. The upper head inserted into the condyle zone. either directly at the pterygoid fovea or via a central tendon or indirectly via the capsule. Posteriorly, the The disc attaches to the medial and lateral poles of superior part of the posterior attachment of the disc the condyle via discal ligaments. In centric occlusion attached to the cartilaginous meatus and tympanic the articular surface of the condyle faces the posterior part of the temporal bone. The inferior part of the slope of the articular eminence with pressure exerted posterior attachment of the disc attached to the through the intermediate thin zone of the disc. The posterior surface of the condyle. In four joints, this posterior band typically envelops the most superior attachment was folded beneath the posterior band of the disc, creating a wedge-shaped flap that ran portion of the condyle. medio-laterally. As in any synovial joint, the capsule defines the Conclusion: This study is in broad agreement with anatomical and functional boundaries of the TMJ. other anatomical TMJ studies but there are two Rees1 described a posterior wall of the capsule main points of difference. Firstly, a true muscle connecting the temporal bone with the mandibular insertion of the superior head of the lateral pterygoid condyle and he considered the tissue posterior to the muscle to the disc was not observed. Secondly, a wedge-shaped flap of retrodiscal tissue was articular disc, the so-called bilaminar zone, to be the identified between the condyle and the disc. fourth component of the disc. It was described as being separated into upper and lower laminae consisting of Key words: Temporomandibular joint, discal attachments, lateral pterygoid muscle. dense collagen fibres. The upper lamina attached to the posterior wall of the glenoid fossa and the squamo- Abbreviations and acronyms: ADD = anteriorly displaced tympanic suture, whilst the lower lamina attached to disc; CPA = condylar part of the posterior attachment; IPA = intermediate part of the posterior attachment; MRI = the posterior aspect of the condyle. The space between magnetic resonance imaging; PA = posterior attachment; the two laminae and the posterior wall was described as TMJ = temporomandibular joint; TPA = temporal part of being filled with loose connective tissue. Zenker2 the posterior attachment. described the retrodiscal tissues as a ‘retroarticular (Accepted for publication 1 November 2004.) plastic pad’ and did not describe a posterior wall as mentioned by Rees.1 Zenker2 indicated that collagen *Dental School, The University of Adelaide. fibres in the upper and lower stratum inserted into the 152 Australian Dental Journal 2005;50:3. temporal bone or condyle independently. Scapino3 described the retrodiscal tissues as the posterior attachment, the upper laminae as the temporal part of the posterior attachment (TPA) and the lower laminae as the condylar part of the posterior attachment (CPA). A posterior joint capsule was not described, however it was demonstrated that collagen fibres, termed fibres of the intermediate part of the posterior attachment (IPA), arose from the postglenoid process, tympanic bone, and cartilaginous meatus and descended to become continuous with the CPA. It was suggested that most of the expansion of the posterior attachment (PA) that Fig 1. Superior view of the condylar head. The intercondylar axis is indicated by the solid line through the medial and lateral poles. occurred during condylar movements took place within Sectional cuts, shown by the dotted lines, were made 3-4mm apart, the IPA. perpendicular to the intercondylar axis. L, C, M – represent the Rees1 claimed that the capsule was absent anteriorly lateral, central and medial sections. All sections were traced from a lateral view. but mentioned an independent temporal and mandibular attachment for the articular disc. He also described tendinous fibres of the lateral pterygoid meatus, superiorly by the floor of the middle cranial muscle that merged with the disc forming a true fossa, medially by the lateral pterygoid plate and insertion. Schmolke4 made similar findings concluding inferiorly to include the angle of the mandible. The that a small number of muscle fibres attached into the blocks were washed in running water for 48 hours to ‘anteromedial dip’ of the articular disc. However, other flush the preserving solution from the tissues and then researchers have described a different relationship frozen to -80ºC before sectioning. between the disc and the lateral pterygoid muscle. A precision band saw with a new fine-toothed metal Wilkinson and Chan5 reported that the superior head of cutting blade was used to make serial sections of the the lateral pterygoid muscle was attached to the medial deep frozen blocks. Cuts were made at 3-4mm intervals half of the condyle at the pterygoid fovea via a central in a direction perpendicular to the intracondylar axis, tendon or directly to the fovea, or indirectly by the axis between the lateral and medial poles of the blending with fibres of the capsule below the condyle, and parallel to the lateral pterygoid muscle. attachment of the disc to the capsule. They did not This produced five sections – three through the observe a direct insertion of the superior head of the condyle, with one cut being medial and one cut lateral lateral pterygoid muscle to the disc. to the condyle as shown in Fig 1. The anatomy and function of the TMJ is complex, The remaining five left cadaver TMJs (specimens and our knowledge of the joint is incomplete. Except 6-10) were prepared using the method described above. for the structure of the lateral wall of the joint capsule, However, an additional radiographic technique was connective tissue arrangements are by no means clear. utilized and the TMJ block was sectioned with the The anterior and posterior attachments of the disc have superior and inferior surfaces parallel to the Frankfort been studied extensively but there has been relatively horizontal and the anterior and posterior cuts little research on how the attachments vary between lateral, central and medial regions of the joint. Therefore, the aim of this study was to describe the nature of the anatomical relationships of the anterior and posterior attachments of the TMJ disc at a macroscopic level by comparing parasagittal sections across the human TMJ. MATERIALS AND METHODS Left TMJs were dissected from 10 cadavers used for teaching in the BDS course of the Adelaide Dental School. The cadavers’ ages ranged from 60-90 years with an average of 79.3 years. Cadavers were partially dentate or edentulous. There were three females and six males, and the identity of one cadaver head was unknown. Five of the joints (specimens 1-5) were utilized from a previous preliminary study. For these five cadavers, a block of tissue including the left TMJ was removed. Fig 2. A block of tissue including the left TMJ, indicated by the This block was bounded anteriorly by the posterior dashed box, was sectioned from cadaver heads. The sectioned block was aligned to the Frankfort horizontal, represented by the dotted wall of the maxilla, posteriorly by the external acoustic line. Australian Dental Journal 2005;50:3. 153 Fig 3. TMJ tracings of sections through the lateral, central and medial thirds of the condyle in specimens 1-5. Sections are viewed from the lateral aspect and are orientated so that comparisons can be made between the lateral, central and medial tracings within the same specimen. Arrows on specimen 1 indicate the capsules anterior and superior attachment to the articular eminence.
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