Controversies on and Function of the Associated With the Temporomandibular : A Literature Survey

Hironobu Sato, DDS, PhD Varying opinions are found in the literature regarding the role of Associate Professor the ligaments associated with the , eg, Department of Removable with respect to recording of mandibular positions and diagnosis Prosth odontic s and to treatment of patients witb temporomandibular disorders. A Nagasaki University literature survey was done to explore controversies of anatomy Schooi of Nagasaki. Japan and function of the temporomandibular joint ligaments. Only 20 researcb-based anatomic/functional articles were registered in tbe Dan Ström, DDS, Odont Dr Index Medicus system under the selected headings from 1897 to Associate Professor. Researcb Faculty 1995. By examining the reference lists of tbe articles found, 22 Laboratory of Craniofacial Biology more articles not included in Index Medicus were identified. Thus, Department of Prosthetic Dentistry tbe total number of original publications concerning the temporo- Göteborg University mandibular ligaments was limited. Although the conventional Faculty of Odontology Göteborg. Sweden textbook descriptions of the anatomy of tbe ligaments are fairly consistent, tbere are several controversies and unanswered ques- Gunnar E. Carlsson, DDS, Odont Dr tions. Information about the functional role of the ligaments is Professor especially insufficient. The results of this survey indicate that there Department of Prosthetic Dentistry is a need for additional anatomic and functional investigations of Göteborg University ligaments associated with the temporomandibular joint. Faculty of Odontology J ÜRÜHACIAL t'AlN t995;9:308-316. Göteborg, Sweden Correspondence to: key words: temporomandibulat joint, , anatomy, Dr Dan Strom fnnction, masticatory system Laboratory of Oral Pbysiology Department of Prosthetic Dentistry Göteborg University Faculty of Odontology Medicina regatan 12, S-413 90 Göteborg, Sweden ome autbors have regarded ligaments associated witb the temporomandibular joint (TMJ), especially the temporo- Smandihular (lateral) ligament, as itnportant in tbe function of the masticatory system, and others have considered the function of these ligaments less important. An example of the suggested clini- cal importance is rhe possible influence on mandibular positions (ligamentous position)' and temporomandibular disorders (TMD), eg, for clicking- and disc dtsplacement (constrained or slack liga- ments).^'" Much attention and debate have also been addressed to the possible association between ear symptoms and TMJ dysfunc- tion resulting from the presence or lack of presence of a tissue connection between the and the TMJ, tbe discomaileolar

Even if tnost current textbooks describe the anatomy of liga- ments associated with TMJs in a similar way, there seem to be conflictitig results in the literature. According to recent reviews, the functton of these iigatnents is uncertatn, physiologic experi- ments are rare, and opinions appear to be based mainly on theo- retical analyses.''"^ Furthermore, the knowledge of the role of the ligaments seems to be limited in comparison to that of other struc-

308 Volume 9, Number 4, 1995 Sato et al

Table 1 Distribtition of Articles Identified From Index Medicus Anatomic/ Theoretic functional analyses Clinical Rcviev Tota 1879 to 1935 1936 to 1945 1 1946 to 1955 1956 to 1965 1 1966 to 1975 4 1 1976 to 1985 3 1986 to 1995 II 3

tures of the TMJ. Therefore, the aim of this study included in the search systems, some standard text- is to survey the literature focusing on research- books on TMJ anatomy have been consulted.^"'^ based information on anatomy and fnnction of lig- aments associated with the TMJ. Results Materials and Methods Distribution Over Time and Topics The literature survey covered the period 1879 to Twenty anatomic/functional articles about the March 1995, and was conducted at the Biomédical TMJ ligaments were identified in the Index Library, Göteborg University, Göteborg, Sweden, Medicus system. Two articles"'^'' were found by by applying rhe Index Medicus and Medline sys- hand searching articles from the period of 1879 tems (National Library of iVIedicine, Bethesda, to 1965. Furthermore, 18 articles''-^''^"-'^ were MD¡. However, none of the ligaments associated identified hy the Medline database from 1966 to with the TMJ, such as the temporomandibular (lat- 1995. Besides these anatomic/functional articles, eral], the stylomandibular, the sphenomandibular, 18 more papers were identified from 1879 to and the discomalleolar (the fibrotis connection 1995: four theoretical analyses; seven clinical between the malleus and the TMJ) ligaments are reports; and seven review articles. Thus, a total of separate key words in the Index Medicus system. 38 articles focusing on TMJ ligaments, all pub- To identify these items, the key word ligaments was lished after 1936, had been listed in Index used in combination witb tbe Medical Subject Medicus systems (Table 1). Headings (MeSH) terms temporomandibular joint, A manual search of these articles and some stan- malleus, and sphenoid bone. From 1S79 (the first dard textbooks'*''-'"'^ identified 22 ana- year of the Index Medicus system) to 1965, the pre- tomic/functional articles.^•^'"^' When the 42 sent literature survey was conducted manually. anatomic/functional articles were classified accord- Additionally, the free text (non-MeSH) words liga- ing to the selected topics, 17 were found to focus ment, temporomandibular, spheno, and styloid on ligaments and mandibular movement/position were used from 1976 to 1995. A computerized sur- (Table 2) and 25 on the anatomic relation between vey by the Medline database was possible for 1966 the TMJ and the (Table .3). Three arti- to 1995. The survey was limited to human material. ^1^58.31,31 combined information about the tem- The articles, which contained information about poromandibular and the discomalleolar ligaments. the temporomandibular (lateral), sphenomandibu- These were classified based on the predominance of lar, stylotnandibular, and discomaileolar liga- the content to the mandibular movement/position ments, were registered, and the reference lists were group. The other articles''^-'-^""*'^^^" concentrated further analyzed. The obtained articles were sepa- on the temporomandibular ligament. One author'^ rated into anatomic/functional studies, theoretical investigated the srylomandibular ligament in com- analyses, clinical reports of surgical or physical bination with the temporomandibular and spheno- treatments, and review articles. They were divided mandibular ligaments. Of the articles focusing on according to type of ligament and also to mandib- the connection between the TMJ and the middle ular movements/positions and the connection ear, 11 articles^-^''"'^''-^^-'*'''*^ described both the dis- between the TMJ and the middle ear. Even if not comalleolar ligament and the sphenomandibular

Journal of Orofaciai Pain 309 Sato et al

Table 2 Anatomic/Functional Articles Focnsing described, in general, as a reinforcement of tbe lat on Mandibular Movement/Position eral wall of the capsule, attached above to the tubercle and below to tbe mandibular T T, D T, SP, ST Total neck.^-'^-'^'^^'^« Several articles"^-"''* claimed that 1879 to 1905 the lateral ligament consisted of two parts: a 1906 to 1915 I 1 superficial oblique portion running laterally from 1916 to 1925 1926 to 1935 the to the condylar neck, and a 1936 to 1945 1 1 deeper more horizontal part from the same origin 1946 to 1955 3 I 4 to tbe lateral pole of the and the postero- 1956 to 1965 3 3 lateral margin of the disc. A controversial opinion 1966 to 1975 2 1 3 was presented by Savalle,^* who identified only 1976 to 1985 1986 to 1995 4 1 5 three specimens with a distinguishable lateral liga- mentous formation in his macroscopic and micro- Total 13 3 1 17 scopic study of 16 human TMJs. More recently, T ^ leniporomardibular ligamenl, D = discomalleolar ligament: Schmolke*^ used a sophisticated 3-dimension analy- SP ^ sphenomandibular ligament: ST = . sis based on five hutnan heads and confirmed that the lateral wall of the capsule is stronger than in other regions. This reinforcement was interpreted as the lateral ligament, which partly inserted into the temporal fascia. Table 3 Anatomic/Functional Articles Focusing Althotigh most textbooks seem to agree on the on the Relation Between the TlvIJ and the Middle anatomic configuration of the lateral ligament, Ear there is no consensus among researchers on a simi- D D, SP Total lar reinforcement of the other capsule areas.

1879 to 1905 1 1 Dauber^^ found strong connective tissue enforce- i 906 to 1915 1 1 ment in tbe medially, posteriorly, and 1916 to 1925 laterally, consisting of the pterygoid, parotid, and 1926 to 1935 masseteric fasciae. Tbis finding contrasted with 1936 to 1945 1 1 that of Fenol et al,""* who, in a histologie study of 1946 to 1955 1 1 1956 to 1965 4 1 5 five TMJs, identified reinforcements medially and 1966 to 197S 2 2 4 laterally but not anteriorly or posteriorly. A thick- 1976 to 1985 2 1 3 ening of the posterior part of the capsule was ob- 1986 to 1995 3 6 9 served by Arstad.^' On the other hand, Schmolke^ Total 14 11 25 emphasized that capsular elements that directly connected the and the D = disco mall eolar ligament, SP = sphenomandibuiar ligarr were seen only on the lateral side of the joint, lack- ing medial reinforcement in the capsule. A diplo- matic solution of this controversy is to consider the capsule a ligament, as proposed by Ten Cate.** ligament. The other researchers^''-^'''''^-^' limited In contrast to the conventional description of their studies to the discomalleolar ligament. one single TMJ on each side, it has been claimed All four theoretical articles""*^ as well as the by Fenol et al"" that each side consists of two artic- seven clinical reports^-'^"^' focused on the tem- ular complexes (a "supra and inframeniscal com- poromandibular ligament and its influence on partment" or a "meniscotemporat and a condy- mandibular movement/position. Six^'*^'** of the lomeniscal" joint) acting independently. This seven reviews covered the relation between the finding was substantiated by the description of temporomandibutar ligament and mandibular separate capsules for each of these : a "series movement/position, and one'''' concentrated on the of short bands passing from the meniscal circum- connection between the TMJ and the middle ear. ference to the periphery of the articulating surface of the temporal bone and from the condylar neck to the meniscal circumference.'""^ This opinion has Anatomic and Futictional Aspects not been verified by other investigators. Function. It is usually proposed that the main Temporomandibular Ligament. Anatomy. The biomechanical function of the temporomandibular temporomandibular (lateral) ligament was ligament is to control and limit condyle-disc move-

31O Volume 9, Number 4, 1995 Sato et ai

meats—a function similar to that of the collateral Function. From theoretical analyses using a ligatnents of other joints,'''" The pltcation of the mathetnatic approach, it has heen assumed that slack capsular itgament in patients with recurrent the sphenomandihular ligament controls the late dislocatton of the TMJ ts a clinical approach based phase of -opening, while the first phase is con- on the assumed hinction of ligaments to limit joint trolled by the temporomandibular ligament,^"''^^ movements.''"' In recent years, it has been hypoth- No direct experimental evidence of its functional esized that general |Otnt laxity may be a predis- role seems to exist. In an experitnent ustng artifi- posing factor in TMD,"'' although these results cial ligaments of unelastic bands on a , the have not been replicated consistently. The possible sphenomandibular ligament had no effect on jaw association between the loose joitits and the TMD opetiing but provided a limitation of lateral move- should be studied further,-"-O-^i Functional analy- ment,'- A current opinion is that the role of the ses of the mechanical contribution of ligaments to sphenomandibular ligament in mandibular me- jotnt motion have been presented'-'—'"' based on chanics is negligible.'- iotnt rnorphology and biomecbanical assumptions, Stylomatidibular Ligament. Anatomy. The eg, that the Itgaments are inextenstble. However, stylomandibular ligament is generally described as there is no such consensus, and a textbook'^ of a reinforced part of a fascial lamella that extends anatomy stated that the ligaments are "slightly from the styloid process and styloid ligament to elastic and protected from excessive tension by the region of the mandibular angle, partly attached teflex contraction of appropriate muscles." These to the mandible, but with the majority of fibers analyses may be a useful foundation for further blending into the fascia on the medial surface of research, but the hypotheses have not yet been the ."* Although several tested in direct experiments on living subjects.^ articles concerning the stylohyoid ligament were One study'*" reported electromyographic activity found, only one study, which was done by from muscle tissue located in the tetnpotomandib- Burch,'^ concerned the anatomy of the stylo- ular ligament, wbich the authors had discovered in mandibular ligament. an earlier study. This result is questionable because Function. The stylomandibular ligament muscle fibers in the temporomandibular ligaments becomes slack during mouth opening but is tight- have not been reported by other researcbers. How- ened during protrusion and mandibular overclo- ever, Thilandet^^ identified Golgi tendon organs in sure.'"'''-' Burch" observed in his study on one the superftctal layers of the temporomandibular cadaver that the contralateral ligament was tight- ligament. These endings are important for ened dunng maximal lateral excursion. This has the neuromuscular control of ¡aw movement.'•'•' been supported later by Hesse and Hansson^^ in Sphcnomandibtilar Ligament. Anatomy. The their teview. However, in experiments with artifi- common textbook'^'^' describes the sphetio- cial ligaments, Rossow'- showed that the stylo- mandibular ligament as a ligament that connects mandibulat ligament had no influence on jaw rhe media! side of the mandible with the cranium movements, not even protrusion. This review sup- by running from the lingula above the opening of ports the opinion expressed by Williams et al'^ the mferior alveolar canal to the spine of the sphe- that tbis ligament has uncertain function. noid. However, early observations by one tnvesttga- Discomalleolar Ligament. Anatomy. A con- tor**'' maintained that the cranial attachment is nection of fibrous tissue between the TMJ and the located on the inner side of the glaserian fissure, middle ear passing through the petrotympanic fis- and on its way to that structure, it is atrached to the sure was described early.""^ In a histologie study of sphenoid spine only at its inner edge. This investi- 20 TMJ specimens, Pinto^ observed "a tiny liga- gator stated that some sphenomandibular fibers ment, ..connecting the neck and anterior process pass into the tympanum submerging into the of the malleus to the medioposterosuperior part of fibrous layer of the membrana tympani, better the capsule, the interatticular disc, and the spheno- known as the anterior ligament of the malleus. mandibular ligament." Ihe consistency and espe- These observations were later verified,^'' In the cially [he functional importance of this observation study by Burch^" on 25 adult human cadaver heads, have been much debated,— Loughner et al*" found about one third of the sphenomandihular ligament a separate and dtstmct structure corresponding to attachment was found to be inserted into the sphe- a discomalleolar ligament in only 15 of 52 speci- noid spine. The remaining part was continuous mens. Cesarani et aP" demonstrated the y-shapcd with the medial TMJ capsular tissue or entering the form of the anterior ligament of the malleus, one .^ A similar finding was pre- arm of whtch reaches the capsule of the TMJ and sented by Schmolke^ using htstologic secttons. the other the pin of the sphenoid botie.

Joumal of Orofaciai Pain 311 Sato et al

Eckerdahl"*- emphasized in his large material tbe research existed before that. In fact, some of the great individual variation of both the size of tbe early textbooks referred to investigations from the petrotympanic fissure and its fibrous content. 18th and 19th centuries. As shown recently,^^ cur- Function. Pinto's observation' of a functional rent anatomic research can find interesting contri- connection between tbe middle ear and tbe TMJ butions for the study of TMJ anatomy by scrutiny (movement of tbe tiny ligament, the chain of ossi- of sucb early observations. This was, bowever, cles, and tbe tympanic membrane by movement of beyond our ambitions with tbis review. tbe TMJ capsule) \\ä.s, supported by Coleman,"" During tbe period February 1993 to March However, it bas been refuted by several investiga- 1994, the Medline system had registered 397 tors wbo conid not find that tension applied to the articles on the ligaments associated with the knee ligament caused any movement of middle ear joint but only 8 articles on TMJ ligaments. During structures,'''--"^ EckerdahH- concluded that his tbe same period, 202 articles were found on the results regarding the morphologic pattern of the TMJ, Literature on TMD is even more prolific, A soft tissues within [he petrotympanic fissure did recent review'*" showed that about 4,000 refer- not support the opinion tbat forces may be trans- ences to TMD were identified from 1980 to I 992, ferred from the joint to the middle ear. This opin- In consideration of tbe many unanswered ques- ion was supported by Scbmolke,** who stated tbat tions on tbe role of the TMJ ligaments, the number tbe connective tissue fibers bad no functional rele- of studies identified seems to be limited, and fur- vance but were probably merely developmental tber investigations of tbe anatomy and function of remnants. Adding to tbe confusion in this matter is tbesc structures appear to be warranted. the connection found by some investigators between tbe discomalleolar and sphenomandibular Ligaments Associated With the TMJ ligaments. In a study on cadavers, tension of the sphenomandibular ligament moved tbe malleus in The most commonly described ligament associated tbree of 52 specimens,^ These authors'" concluded, witb tbe TMJ is tbe temporomandibular or lateral based on these observations and reports of middle ligament. It is interesting to note tbat the existence ear damage during TMJ surgery, tbat extensive of tbis standard textbook ligament has been ques- distraction of the mandible during TMJ surgery tioned.'^ Tbere is also lacking consensus on the should be avoided. issue whether there are ligamentous structures in From tbe survey it may be concluded that most the other parts (eg, medially or posteriorly) of the authors deny any functional importance of the dis- capsule. The sphenomandibular and styloman- comalleolar ligament in relation to TMD. dibular ligaments are sometimes called accessory ligaments of tbe TMJ. Tbey did not receive much researcb interest in tbe period covered by our Discussion review, and tbeir functional importance is uncer- tain. The discomalleolar ligament, although not mentioned in many anatomic texts on the TMJ, Number of Articles and the Index Medicus was in fact more frequently studied than tbe ptevi- and Medline Systems ous ones, because of the suggested connection In 1995, the Medline system contained information between TMD and ear symptom, from approximately 3,700 journals from more than Otber names of ligaments associated with the 70 countries. It corresponds to the printed Index TMJ bave also appeared in the literature, eg, con- Medicus, These systems give excellent possibilities dylomeniscal ligament.^^ menisco-ligament,^' to find relevant literature for overviews in specific medial capsular ligament,^^ retrodiscal ligament,'^ areas. The computerized Medline system is impres- and hilaininar posterior ligament.^^ The tiny liga- sive and efficient and makes otherwise unattainable ment that Pinto^ presented has later been called tbe literature easily accessible.'•^•''^ It must be remem- discomalleolar ligament.^-^^ It is obvious tbat tbere bered, however, that these search systems do not is a lack of uniformity of terminology and defini- cover all literature, and this was even more so in tions of the ligaments associated witb rhe TMJ. earlier years. Additional hand searching of refer- ences of the registered articles and selected text- books should complete the survey. Temporomandibular Disorders and Ligaments Our survey covered the period from 1879, ic, the Associated Witb the TMJ year when the Index Medicus was started, to the Subluxation or recurrent dislocations are often present. It is evident that much valuable anatomic attributed ro inadequate capsular and ligamentous

312 Volume 9, Number 4, 1995 Sato et a[ properttes. Slackness of the joint capsule has also influence on mandibular movements. Unilateral been suggested to be treated surgically by a plica- and bilateral anesthesia of the lateral part of the tion procedure.'-''' A more dubious method some- TMJ increased the active maximum jnouth open- times recomtnended for tbe same purpose was the ing hy 10% and 15%, respectively.**- No changes intra-arttcuLir and pertarticular injection of scle- of the other mandihular horder tiiovements were rosing solutton. Disc-mterference disorders have reported. It is not clear from this experiment if the heen suggested to he associated with general joint result was an effect of inhibition of a protective laxity and hypermobility. Pinkert' indicated that mechanism, eg, reflex activity of tbe jaw closing clicktng may result from overstraining of tbe lat- muscles, or a direct influence on the capsule and eral ligament of the TMJ. Tbe role of TMJ liga- the temporomandtbular ligament. The possible ments in such a relationship bas not heen substan- functions of the otber ligaments on mandibular tiated,^ but tbis seems to be an area that should be mobility described ahove are largely hased on mor- researched. Early anatomic studies-*'-''*' stated that phologic and theoretic analyses, or in a few cases if the sphenomandihtilar ligament was not on cadaver experimettts, and they lack direct evi- attached to the sphenoid bone, some control of dence from living subjects.^ mandibular movemertt would be lost and a medi- Since the end of the 1940s, much interest has ally sideway displacement of tbe mandihle mtgbt been focused on the possible role of the temporo- occur. However, we could not find any documen- mandibular hgament in litnitation of the retrusion tation of a relarion hetween tbis ligament and of the mandtble. It h well established, by tbe work TMD. of Posselt'"' and others, that in the great majority The great number of articles about the discomai- of people it is possible to retrude the mandible to a leolar arid sphenomandibular ligaments and their positton posterior to the intercuspal position by connection with the malleus can be explained by applying an external force. This retruded posidon the interest evoked by the suggested relationship is reasonably well teproducibie and recordable and hetween TMJ dysfunction and the middle was considered hy Posselt^'' and Arstad^-^ to be a Ç3|. 5,so,8i •pj^g fibrous tissue connection between posterior border position because of the stretching the TMJ and the middle ear through the petrotym- of [he practically nonelastic capsule and deep por- panic fissure is well documented not only in tbe tioti oí tbe temporomandihular ligament. The most embryologie stage hut also in the adult. The func- rerruded tnandibular position was referred to as tional significance of this connection as suggested the ligamcntous position.^ The itnportatice of the by Pinto^ is not accepted any longer. However, ligaments for rhis retrusion has been questioned some experimental evidence exists tbat tension of because of experimental sectioning of the ligament the sphenomandibular ligament can move the on cadavers with conflicting results^^'^'*''"-'^ and trial leus.*''-" Eckerdahl"- emphasized the great indi- tbe ftber orientation of the temporomandibular lig- vidual variarion in his large material of both the ament.'' In recent years, the tertn ligamentous size of tbe petrotympanic fissure and its fibrous position ts hardly used. Tbe forceful retrusion of conrent, whicb might explain differences in obser- the mandible m |aw-recording procedures has heen vations and interpretations found in tbe literature. questioned, and it is tiot considered appropriate The common sensor;' innervatioti of rhe rwo areas for obtatntng a centrtc relatioti position of the ¡the tensor t>'mpany muscle and muscles of masti- mandible.*^' cation), the common embryologie developmenr, The stretching of the superficial part of the tem- and a remaining connection in the adult may poromandibuiar ligatrtent has been shown to limit explain some ear symptoms tn relation to the posterior opentng (hinge movement) of the TMD. 11-"^ mandible.'-'''" Both restriction of mandibular move- ment and retruded mandihular position might be Mandibular Movements/Positions related to the flexibility of the TMJ capsule and/or atid Flexibility of the TMJ the ligametits associated with the TMJ. It is no rea- son to question the textbook description that the The capsule and Iigatnents are generally considered role of ligaments is to control excessive movements, to give hiomechanical constratnts to protect the prevent the joint from suhluxation or dtslocatton, joint against excessive movetnents in dii^ferent and constrain and guide joinr motion.'"-'''^'' However, directions. Analogically, the temporomandibular there is no consensus on whether the ligaments are ligaments are described to control and limit move- nonelastic or ligbtly elastic collagenous struc- ments of rhe condyle-disc complex of the TMJ. tures.'^-'^ The observation hy Savelle"^ that some There is only little experimental evidence of this individuals lacked temporomandibular ligaments

Journal of Orofaeial Pain 313 Sato et ai

and the different descriptions by many authors of Puswillo D. Surgery of rhe temporomandibular joinr. Oral ligamentous reinforcements in other parts of the Sd Rev 1974;6:87-IIS. capsule may partly help to explain tbe varying joint Srohler CS. Disc-interference disorders, in: Zarb GA, flexibility. Carlsson GE. Sessle BJ, Mohl ND ¡eds). lemporo- mandibiilar Joint and Masticatory Muscle Disorders. Copeiilnagen: Munksgaard, t994;271-2'>7. Pinto OF. A new structure and function of the mandibular Conclusion joint. J Prosthet Dent I 962;12;95^]Il3. Loughner BA, Larkin LH, Mahan PH. Discomalleolar and The Inde^ Medicus and Medline systems offer anterior malleolar ligaments^ Possible causes of middle ear damage during temporomandibular joint surgery. Oral excellent possibilities for literature surveys. It must Suri; Oral Med Oral Pathol 1989;é8;14-22. be remembered, however, that not all rhe relevant Hannam AG. Musculoskeletal biomechanics in the buman literature is covered, and several of the registered jaw. In: Zarb GA, Carlsson GE, Sessle BJ, Mohl ND ¡eds). articles are not accessible in conventional libraries Temporomandibular Joint and Masticatory Muscle of universities. An additional manual search in tbe Disorders. Copenhagen: Munksgaard. 1994:101-127. Schmoike C. The relationship between the temporo- references of the recorded articles and in selected niandihular ]oinr capsule, articular disc and jaw muscles. J textbooks is necessary. Anall994;184;33.5-345. The conventional textbook descriptions of the Ten Cate AR. Gross and microanatomy. In; Zarb GA, anatomy of cbe TMJ ligaments are fairly consis- Carlsson GE, Sessle BJ. .Mohl ND (eds). Temporo- mandibular Joint and Masticatory Muscle Disorders. tent, but tbere are still some controversies and Copenhagen: Munksgaard, 1994:48-66. unanswered questions. Recent anatomic research Sicber H, DuBrul EL. Oral Anatomy. Sr Louis: Mashy, has revealed new findings, eg, on capsular rein- 1975:160-191. forcement and connections between the TMJ and Mohl ND. The teniporompndibular joint. In: Mohl ND, the middle ear. However, there is a lack of modern Zarb GA, Carlsson GE. Rugh JD (eds). Textbook of Oc- clusion. Chicago: Quintessence. 1988:81-96. micromorphologic and biocbemical methods in tbe Williams PL, Warwick R, Dyson M, Bannister LH. Ar- study of TMJ ligament structure. This indicates thrology. In: Gray's Anatomy, ed 37. London: Logman, that new approaches and methods are desirable to 1985:459-544. give answers to still debatable issues with respect von Hayek H. Temporomandibular opening of . Z to TMJ anatomy. Anat Entwickl Gescb 1937;107;232-234. Bossy J, Gaillard L. Les vestiges ligamentaires du cartilage Knowledge of the function of TMJ-reiated liga- de Meckel. Acta Anat ¡Basel) 1963;52:282-290. ments is incomplete and is mainly based on specu- Saizer P. Centric relation and condylar movement: lations from morphologic and rlieoretic analyses Anatomic mecbanism. J Prostbet Dent 1971;2é:581-591. from cadaver or skull experiments. More direct König B Jr. An electromyographic analysis of the muscle experimentation is needed to better elucidate liga- of rhe hgamenruni laterale of rhe remporomandibular joint in humans. Electromyogr Clin Neurophysiol 1973; ment function concerning, for example, influence 13:573-580. of ligaments on mandibular movement and posi- Kurokawa E. Histological observation on the structure of tion, and on the possible relationship between the human temporomandibular ligament. Kokubyo TMJ dysfunction and ear symptoms. GakkaiZassbi 1 986;53:508-535. Savalle WP. Some aspects of rhe morphology of the human temporomandibular joint capsule. Acta Anat 1988;131:292-296. Burch JG. Activity of the accessory ligaments of the tem- poromandibular joint. J Prosthet Dent 1970;23: 621-628. Acknowledgment Burch JC. Tbe cranial attachment of tbe sphenomandibu- lar (tympanomandibular) ligament. Anat Rec 1966;156: This study was supported by grants from the Japanese Ministry 433^37. of Education (Overseas Researcher, Projecr No. 6-KOU-239) Toledo Filho JL, Zorzetro NL, Navarro JA. Srruciures and and the Swedish Medical Research Council (Project No. 10415). relationships of the anterior malleus ligament. Anat Anz 1985;ii8:13-22. Komori E, Sugisaki M. Tanabe H, Katoh S. Discomal- leolar hgamenc in the adult human. J Craniomandib References Disord Eadal Oral Pain 1Í1B6;4:299-3O5. Robert R. Lebur PA, Bordure T. demain P, Faure A, de 1. Brill N, Lammie GA, Osbone J, Perry HT. Mandibular Kersaint-Gilly A, Legenr F. Anatomical study of the positions and mandibular movements. A review. Br Dent J infrateniporal fossa. Ann Otolaryngol Chir Cervicofac 1991;10B:69-7é. 2. Pinkerc R. Determining tlie cause of clicking from clinical, Rodriguez Vaiqueï JF, Merlda Velasco JR, Jimenei roentgenoliigical. and histological results. Zahn Mund Collado J. Development of tlie buman sphenomandibular Kieferheilkd 1979;67:10-20. ligamenr. Anar Rec 1992;223:453^60.

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25. Rodriguez Vaiquez JF, Merida Velasco JR, Jimenez 47. Ricbany SF, Bast TH, Anson BA, The development uf the Collado J. Relationships between the tcmpuromandibiil.ir first branchial arch in man and the fate of Meckel's carti- joint and tlie middle ear in hutnan fetuses. J Dent Res lage. Q Bull Northwest Univ Med School 1956;3Ü: 331-335, 26. Proops D, Hawke M, Berger G, MacKay A. The anierior 48. Moffett BC. Conrribiitions to emhryology. Carnegie process of rlie malleus. J Oto!aryngol 19S4;13:39-43. Institution, 1957;36:19-28. 27. Toledo Fillio JL, Zorietto NL, Navarro JA. Relarionship 49. Furstnian L. The early development of the human rem- between anterior malleus ligamenr and nerve chorda tym- poromandibular joint. Am J Orthod 1963;49:672-682. pani, AnatAnz J984;155tES-SS. 50. Yuodehs RA, Tbe morphogenesis of the human temporo- Smeele LE. 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Resumen Ztisatntnetifassutig

Controversias sobre la anatomía y función de los iiga- Kontroversen um Anatomie und Funktion der Ligstnente mentos asociados con la articulación ternporomandibu- des Kiefergeienkes. Eine Literaturübersicht iar- Revisión de la iiterstura Man findet in der Literatur verschiedene Meinungen betreffend Se encuentran varias opiniones en ia iiteratura en reiación al der Roiie der Ligamente des Kiefergelenkes, zutn Beispiei iiin- papel de ios ligamentos asociados a la articuiación temporo- sichtlich der Aufzeichnung von Kiefergeienkpositionen und mandibuiar (ATM), por ejemplo, con respecto ai registro de ias Diagnosen und der Bebandlung von Palienten mit posiciones niandibulares y al diagnóstico lo mismo que al Myoarthropathien des Kausystems (MAP) Es wurde eine tralamiento de pacientes con desórdenes temporomandibu- Literaturübersicht ersteilt, um kontroverse Meinungen bezúglicb iares. Se reaii^ó una revisión de ia iiteratura para expiorar ias Anatomie und Funktion der Kiefergeienkligamente zu sammein. controversias de \s anatomía y ia furición de los ligamentos de Nur 20 auf Forschung basierende Artikel über Anatomie und la ATM. Sólo se encontraron 20 articuios basados en investiga- Funktion waren im System ivjischen 1397 und 1995 unter den ciones anatómicas/funcionaies en ei sistema, bajo les ausgesuchten Titeln registriert. Nach Durchsicht der encabezamientos seleccionados entre 1897 y 1995. Al exami- Literaturiisten der gefundenen Artikel konnten 22 weitere nar las listas de referencia de los artículos encontrados, se Literatursteiieri gefunden werden, die nicht im Index Medicus identificaron 22 artíouios no inciuidos en ei index Medicus, Por eingetragen waren. Die totale Anzahl der Original Publikationen io tanto, ei número total de pubiicaciones originales con- über die Ligamente des Kiefergeienkes war aiso recht limitiert. cernientes a los ligamentos temporomandibuiares fue iimitado. Obwohl die anatomischen Beschreibungen der Ligamente in Aunque las descripciones convencionaies de ios textos sobre den Lehrbuchern ziemlich konsistent sind, bleiben einige ia anatomía de las ligamentos son claramente consistentes, Kontroversen und unbeantwortete Fragen. Vor aliem ist die existen varias controversias y preguntas no respondidas La information über die funktionelle Rolle der Ligamente ungenü- información acerca dei papei funcional de los iigamentos es par- gend. Ais Resuitat foigt aus dieser Literaturstudie, dass ein ticuiarmente insuficiente Los resuitados de esta revisión indi- Bedürfnis nach mehr anatomischen und funktioneiien can que existe una necesidad de realizar investigaciones fun- Untersuchungen der Kiefergeienkligamenle besteht cionaies y anatómicas adicionales de los iigamentos asociados a la ATM.

316 Volume 9, Number 4, 1995