Anatomic Relationship Between Trigeminal Nerve and Temporomandibular Joint

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Eur opean Rev iew for Med ical and Pharmacol ogical Sci ences 2008; 12: 15-18 Anatomic relationship between trigeminal nerve and temporomandibular joint

F. PAPARO, F.M.G. FATONE, V. RAMIERI, P. CASCONE

Cattedra di Chirurgia Maxillo-Facciale, Università degli Studi “La Sapienza” – Roma

Abstract. – Temporomandibular joint ship with TMD. Nevertheless, other common disorders (TMD) is a collective term used to complains with uncertain pathogenesis are of - describe pathologic conditions involving tem - ten associated with TMD, such as earache, poromandibular joint (TMJ), masticatory mus - cles and associated structures. headache tinnitus and atypical trigeminal 2,3 Common related complaints include local symptoms . pain, limited mouth opening and TMJ noises Particularly, TMD trigeminal related symp - whereas symptoms often associated to TMD toms are complex, difficult to treat and have a with debated pathogenesis enclose earache, great impact on everyday life of the affected pa - headaches, tinnitus and trigeminal-like symp - tients thus suggesting a compound multimodal toms such as atypical orofacial pain. and multidisciplinary treatment. In particular, TMD trigeminal associated 4 symptoms are intricate, difficult to treat and James B. Costen , in 1934, was the first to exert a great impact on everyday life of the pa - depict a syndrome related to TMD in enclosing tients thus invoking a complex multidiscipli - all toghtether signs and symptoms such as per - nary treatment. ceived hearing loss, stuffy sensation in the ears, In this paper, the authors analyze the pain in the ear region, tinnitus, dizziness, si - anatomic and topographic relationships be - nusitis-like pain, burning sensation in the throat tween the mandibular branch of the trigeminal nerve and the medial aspect of the TMJ cap - and tongue, headache, trismus as well as tran - sule in 8 fresh adult cadavers thus resuming a sient paresthesia in the region of the mandibu - pathologic relationship between atypical lar nerve. trigeminal symptoms and TMD. According to the author’s hypothesis, the lack of posterior support of the alveolar ridge led to Key Words: mandibular vertical height loss which caused a Trigeminal nerve, Temporo-mandibular joint, Re - slipping backward of the condyles over the artic - lations, Anatomic relations, Pathologic relations, ular disc thus resulting in TMJ discal damage, Fresh cadavers dissection, Temporo-mandibular dis - erosion of the glenoid fossa bone, compression orders. of the Eustachian tubes and tympanic plates and consequent impingement of the auriculotemporal nerve (ATN), which runs on the postero-medial aspect of the TMJ capsule, and chorda tympani nerve 4. Introduction Costen’s theory was soon criticized since the first years of the 50’s when Sicher 5 and after - Temporomandibular joint disorders (TMD) is wards many Authors argued on it. As a conse - a collective term used to describe pathologic con - quence, Costen’s hypothesis lost support and ditions involving temporomandibular joint TMD became a multifactorial disease dealing (TMJ), masticatory muscles and related struc - with complex pathogenesis and physiopatholo - tures. There are three cardinal symptoms: pain in gy 6-9 . the preauricular region, limited mouth opening Nevertheless, this theories did not give a defin - and TMJ noises 1. itive answer to this complex series of clinical This cardinal triad is nowadays characterized manifestation and TMD syndrome still remains by having a well established pathologic relation - debated.

Corresponding Author : Francesco Paparo, MD; e-mail: [email protected] 15 F. Paparo, F.M.G. Fatone, V. Ramieri, P. Cascone

In this study the Authors analyse the anatomic to expose the infratemporal fossa thus identi - and topographic relations between the mandibu - fying the exit of the IIIrd branch of the trigem - lar branch of the trigeminal nerve and the medial inal nerve at the level of the middle cranial aspect of TMJ capsule in 8 adult fresh cadavers, base (foramen ovalis). thus resuming a pathologic relationship between atypical trigeminal symptoms and TMD. Once performed the anatomic dissection, the The study was approved by the local Ethical mandibular nerve was followed from its origin to Committee the medial aspect of the TMJ capsule. After either condyle or TMJ capsule removal, some measurements were performed, which were: Materials and Methods • Average distance between the medial aspect of Eight fresh adult cadavers were dissected for the glenoid fossa and the lateral border of the this study for an average total number of sixteen foramen ovalis; TMJs. For the dissection of the TMJ medial as - • Average distance between the ATN and the pect, the following technique was been per - medial aspect of the posterior and superior re - formed for each side: gion of the TMJ.

• Preauricular incision extended to the superior aspect of the temporal region; • TMJ capsule and related structures exposal to - Results gether with the mandibular ramus and the sig - moid notch; In all the 16 dissected joints, the mandibular • Mandibular ramus osteotomy from the nerve resulted as running closest to the anterior mandibular angle to the sigmoid notch aimed and the medial region of TMJ capsule. The av -

Figure 1. Relation between trigeminal nerve emergence (b) and TMJ. ( a) Glenoid fossa.

16 Anatomic relationship between trigeminal nerve and temporomandibular joint erage distance between the medial aspect of the Conclusions TMJ capsule and the foramen ovalis resulted 10.3 ± 2.8 mm with no significant differences for Over the years, many theories analyzing the both sides of each anatomic subject. complex series of symptoms related to TMJ were Moreover, according to International Litera - developed. Nevertheless, currently, no definitive ture 10-12 , NAT resulted as placed between the me - evidence is available and hypotheses are still de - dial aspect of the TMJ capsule and the medial bated 15-17 . border of the glenoid fossa. At this level, the This study shows that mandibular nerve is nerve lied on the posterior and inferior border of closest to the TMJ capsule, particularly at its an - the lateral pterygoid muscle and the horizontal terior and medial aspect. distance resulted 0 mm in all the dissected joints, At this level, an irritating or compressive oc - whilst the vertical distance accounted for 6.06 ± currence acting on the mandibular nerve might 2.12 mm. cause trigeminal-like symptoms even extended to the entire orofacial region which could even chronicize at CNS level for some predisposed subject. Discussion We believe that the future investigations should consider in-vivo series on mandibular In 1934, J.B. Costen 4 was the first to de - nerve involvement in TMD atypical manifesta - scribe a TMD related syndrome enclosing atyp - tions pathogenesis even taking into consideration ical trigeminal symptoms. Although Costen a pharmacological combination for chronic TMD was acclaimed for bringing the significant role patients in which a reverberant stimulus might be of the TMJ into the realm of awareness of established. physicians and dentists alike, he was soon Thus, only a modern evidence-based multi - judged by many to have been naïve in his es - modal and multitasking approach involving dif - pousal of the range of symptoms arising from ferent specialties dealing with cranio-facial dis - TMD, in his anatomical explanations and, trict could give a concrete contribution to diagno - above all, in his view of the pivotal role of mal - sis and treatment of TMD syndrome. occlusion even due to opponent anatomic series which showed that the posterior course of the auricolotemporal nerve did not lead itself to condylar compressions. References Nowadays, TMD is considered as a syndrome with complex pathogenesis and physiopathology 1) DIMOTROULIS G. Temporomandibular joint disor - with many risk factors but no real causes. ders: a clinical update. Br Med J 1998; 317: 190- On the basis of this study, it would not be in - 194. consistent to suppose that the anatomic relation - 2) SALVINELLI F, C ASALE M, P APARO F, P ERSICO AM, Z INI C. ships between NAT, mandibular nerve and the Subjective tinnitus, Temporomandibular joint dys - medial aspect of the TMJ might play an impor - function and serotonin modulation of neural plas - tant role in the atypical trigeminal symptoms on - ticity: causal or casual triad? Med Hypotheses set 12,13 . 2003; 61: 446-448. This could occur even more when an antero- 3) MAC FARLANE TV, G LENNY AM, W ORTHINGTON HV . medial disc displacement would shorten the Systematic review of population-based epidemio - logical studies of oro-facial pain. J Dent 2001; 29: average distance between the medial aspect of 451-467. the TMJ and the trigeminal nerve, thus provok - ing either NAT or mandibular nerve impinge - 4) COSTEN JB. A syndrome of ear and sinus symp - toms dependent upon disturbed function of the ment and symptoms onset in predisposed sub - temporomandibular joint. Ann Otol Rhinol Laryn - jects. In fact, as already stated in other studies gol 1934; 43: 1-15. regarding otologic symptoms related to 5) ICHER . Temporomandibular articulation in 2,14 S H TMD , the often invoked heterogeneity of mandibular overclosure. J Am Dent Assoc 1948; symptoms could be depend on an individual 36: 131-139. neural mediated predisposition, acting as a 6) FARRAR WB. Diagnosis and treatment of anterior modulating factor at the level of the central dislocation of the articular disk. N Y J Dent 1971; nervous system (CNS) . 41: 348-351.

17 F. Paparo, F.M.G. Fatone, V. Ramieri, P. Cascone

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