SOTO-USA Seminars - Recently Updated Pages

Dental Chiropractic Co-Treamtent

DrCBlum — Fri, 09 Sep 2011 10:31:30 CDT

The following are good articles to acquaint yourself with how the dental and chiropractic professions can work together:

Blum CL. Dentists and Chiropractors Help TMJ Patients. News 'n Views: TMData Resources. Jul-Sep 2010; 82:3-4.

Blum CL. TMD Functional Integrative Approach: Dental and Chiropractic Approach to Forward Head Posture. Journal of the American Academy of Craniofacial Pain. Fall 2009; 22(2):18,31,39.

Blum CL. Sleep Apnea, Forward Head Posture (FHP), and its Relationship to Temporomandibular Joint Dysfunction (TMD). TMJ Bioengineering Conference Proceedings, Boulder, CO. November 4-7, 2009: 47

Blum CL. Chiropractic, Dentistry and Treatment of TMD. Dynamic Chiropractic. October 21, 2009; 27(22).

Blum CL. The relationship between the pelvis and stomatognathic system. 2008.

Blum CL. SOTO-USA Spinal-Cranial-TMJ Position Paper. 2004.

Blum CL, SOT and the Treatment of TMJ: Why Dentists and Chiropractors Need to Work Together. Journal of the California Chiropractic Association. Sum 2007 32(3): 12-3.

Blum CL, Chiropractic and Dentistry in the 21st Century: Guest Editorial The Journal of Craniomandibular Practice Jan 2004; 22(1): 1-3.

Blum CL, Panahpour A. TMD - Chiropractic and Dentistry: Two Case Reports. J Chirop Ed. 2009;21(1): 104.

Blum CL, Globe G, Assessing the Need for Dental – Chiropractic TMJ Co-Management: The Development of a Prediction Instrument, Journal of Chiropractic Education Sum 2005;19(2).

Blum CL, A Chiropractic Perspective of Dental Occlusion’s Affect on Posture, Journal of Chiropractic Education Spr 2004;18(1): 38.

Blum CL. Forward head posture (FHP) and its relationship to temporomandibular joint dysfunction (TMD) and he sacro occipital technique (SOT) category system. Journal of Vertebral Subluxation Research. May 7, 2008: 7.

Blum CL, Non-Synaptic Messaging: Piezoelectricity, Bioelectric Fields, Neuromelanin and Dentocranial Implications Journal of Vertebral Subluxation Research, Jan 2007: 1-6.

Blum Cl, A Survey of State Scope of Practice Laws for Chiropractic - Cranial Therapy and TMJ - 2003. Proceedings on the 2006 Conference on Chiropractic Research, Chicago, Illinois, September 15-16, 2006: 164-6.

Blum CL, Cuthbert S, Cranial Therapeutic Care: Is There any Evidence?, Journal of Chiropractic and Osteopathy, 2006; 14(10).

Blum CL, TMJ Exercises for Patients. The dural connection, July 2002;4(1).

dal Bello F, Borilli F. Pain Alterations on the Temporo Mandibular Joint in Individuals with Malocclusion after Chiropractic Treatment. WFC’S 10th Biennial Congress. International Conference of Chiropractic Research. Montreal, Canada. Apr 30 – May 2, 2009: 287-8.

dal Bello F, Borilli F. A Research on the Effects of the Chiropractic Treatment on Individuals with Malocclusion as an aid to the Orthodontic Treatment. WFC’S 10th Biennial Congress. International Conference of Chiropractic Research. Montreal, Canada. Apr 30 – May 2, 2009: 257-8.

Kalamir A, A Randomised Controlled Pilot Study of Chiropractic Craniomandibular Treatment for Chronic TMD. International Conference on Chiropractic Research. Vilamoura, Portugal – May 17-19, 2007: CM14.

Kalamir A, Pronation Associated with Temporomandibular Joint Sounds.International Conference on Chiropractic Research. Vilamoura, Portugal – May 17-19, 2007: SI10.

Getzoff HI, Chinappi AS. Possible Manifestation Of Temporomandibular Joint Dysfunction On Chiropractic Cervical X-Ray Studies [Letter; Comment] J Manip Physiol Ther 1999 Nov/Dec; 22(6): 421-422.

Howat J, Varley P, Complementary Therapies: Chiropractic Dentistry Monthly Feb 1998; 4(2): 16-25.

Chinappi, AS, Getzoff, H, Chiropractic/Dental Cotreatment of Lumbosacral Pain with Temporomandibular Joint Involvement, Journal of Manipulative and Physiological Therapeutics, Nov/Dec 1996; 19(9): 607-12.

Chinappi, AS, Getzoff, H, The Dental-Chiropractic Cotreatment of Structural Disorders of the Jaw and Temporomandibular Joint Dysfunction, Journal of Manipulative and Physiological Therapeutics, Sep 1995; 18(7): 476-81.

Chinappi, AS, Getzoff, H, A New Management Model for Treating Structural-based Disorders, Dental Orthopedic and Chiropractic Co-Treatment, Journal of Manipulative and Physiological Therapeutics, 1994; 17: 614-9.

Arcadi V, Birth Induced TMJ Dysfunction: The Most Common Cause of Breastfeeding Difficulties Proceedings of The National Conference on Chiropractic. 1993 Oct: 18-22.

Sleep Apnea - Forward Head Posture and TMD

DrCBlum — Fri, 09 Sep 2011 10:29:52 CDT

Please click on the hyperlinks for pdf versions of the following articles for your review. The Dental article is one article in three parts (due to its megabyte size) and is quite informative about both sleep apnea diagnosis and treatment as well as dental appliance use.

Sleep Apnea, Snoring, and Dentistry, Part One, Part Two, and Part Three

Sleep Apnea and the Cervical Angle

Sleep Apnea and Cervical Curves

Obstructive Sleep Apnea

Blum CL. Dentists and Chiropractors Help TMJ Patients. News 'n Views: TMData Resources. Jul-Sep 2010; 82:3-4.

Blum CL. TMD Functional Integrative Approach: Dental and Chiropractic Approach to Forward Head Posture. Journal of the American Academy of Craniofacial Pain. Fall 2009; 22(2):18,31,39.

Blum CL. Sleep Apnea, Forward Head Posture (FHP), and its Relationship to Temporomandibular Joint Dysfunction (TMD). TMJ Bioengineering Conference Proceedings, Boulder, CO. November 4-7, 2009: 47

Blum CL. Chiropractic, Dentistry and Treatment of TMD. Dynamic Chiropractic. October 21, 2009; 27(22).

Blum CL, Chiropractic and Dentistry in the 21st Century: Guest Editorial Cranio View. Sum 2009;18(2):15-7.

Blum CL. The relationship between the pelvis and stomatognathic system. 2008.

Blum CL, SOT and the Treatment of TMJ: Why Dentists and Chiropractors Need to Work Together. Journal of the California Chiropractic Association. Sum 2007 32(3): 12-3.

Blum CL. Forward head posture (FHP) and its relationship to temporomandibular joint dysfunction (TMD) and he sacro occipital technique (SOT) category system. Journal of Vertebral Subluxation Research. May 7, 2008: 7.

Cranial Level One

DrCBlum — Fri, 09 Sep 2011 10:26:28 CDT

Training will consist of basic theory and treatment of cranial bone dysfunction. Introduction to cranial bone dynamics and palpation exercises to develop cranial manipulative expertise. Presentations will include Cranial Mandibular Balancing Technique, Sphenobasilar Balancing Technique, and common hand positions for cranial treatment.

Please review the section on Cranial Osteology to become familiar with the various cranial bones, sutures, and landmarks, these will be necessary to become familiar with landmarks, location of bone and cranial sutures, and related terminology.

Cranial Level One is the first part in the four part SOT Cranial Technique Certification Series.

Cranial Level Two

DrCBlum — Fri, 09 Sep 2011 10:25:51 CDT

Training will consist of Basic Theory and Treatment of Tempormandibular Joint Dysfunction (TMJD) and its implication in a chiropractic practice. Along with an introduction to dental concepts this seminar teaches the comprehensive 1977 DeJarnette Sutural Technique and all of DeJarnette TMJ treatments and techniques. Learn important techniques and concepts to work with dentists.

In this section there will be an introduction to TMJ anatomy, physiology, and biomechanics, cranial anatomy related to SOT Sutural and TMJ Techniques, and sections for information on dental chiropractic co-treatment and sleep apnea.

Cranial Level Two is the second part in the four part SOT Cranial Technique Certification Series.

SOTO-USA Promotion

DrCBlum — Sun, 31 Oct 2010 11:49:15 CDT


	To hear Dr.Charles L. Blum being interviewed by Lisa Garr relating to SOT on The Aware Show, KPFK, October 16, 2010. Download mp3 file.
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SOTO-USA Seminars Home

DrCBlum — Sat, 31 Jul 2010 21:13:15 CDT


Sacro Occipital Technique Organization - USA • Seminars
For Correspondence: PO Box 1357 Sparta, NC 28675	For shipping purposes: 771 South Main Street Sparta, NC 28675
Sacro Occipital Technique Organization - USA is a non-profit, professional organization formed to promote the awareness, understanding and utilization of the Sacro Occipital Technique method of chiropractic as founded and developed by Major Bertrand DeJarnette, DO, DC. We invite you to review the site to discover how to best prepare for upcoming seminars, certification classes, and facilitate review of material covered in our various seminars. Leading the way for an "Evidence Based" Sacro Occipital Technique.
336-793-6524 Voice	336-372-1541 Fax
www.SOTO-USA.org
SOT CERTIFICATION	SOT SEMINARS

TMJ Magnetic Resonance Imaging (MR)

DrCBlum — Wed, 27 May 2009 00:33:08 CDT

Magnetic resonance (MR) can also be used to diagnose internal derangement and other disorders of the TMJ. The patient is scanned in the sagittal plane using a surface coil and a high resolution technique. The low intensity cortex of the condyle surrounds the high signal fat in the marrow. The meniscus is a low intensity structure which is attached posteriorly by the intermediate intensity bilaminar zone. Normally, the anterior band lies immediately in front of the condyle. The junction of the bilaminar zone and the meniscus normally lies at the superior aspect of the condyle.

normal TMJ MR showing normal meniscus (m) posterior and superior to condyle (C) -- the articular eminence (E) and auditory canal (AC) are also shown
In internal derangement, the meniscus is abnormally positioned anterior to the condyle.

displaced meniscus (arrows, m) anterior to the condyle (C) and auditory canal (AC) and beneath the articular eminence (E)
QuickTime movies of Normal and Abnormal Menisci (Disc)
Normal (31K)
Anteriorly Displaced With Reduction (39K)	Anteriorly Displaced Without Reduction (37K)

TMJ Computerized Tomogram (CT)

DrCBlum — Wed, 27 May 2009 00:32:09 CDT


Computed tomography (CT) can be used to diagnose internal derangement and other disorders of the TMJ. The patient is scanned in either the transverse or direct sagittal plane using thin sections (1-2 mm) and a soft tissue technique. If transverse sections are obtained, sagittal reconstructions are made through the condyle. The meniscus can be visualized on CT since it is slightly higher in density than the surrounding muscle and soft tissue. Since there is only a small difference in density between the meniscus and soft tissue , then either narrow window settings or the Identity Mode[trademark] (or equivalent) must be used to identify the meniscus.
normal TMJ CT showing normal disk posterior and superior to condyle (C)
Normally, there is only a small amount of increased soft tissue density anterior to the condyle on CT. In internal derangement, the anteriorly displaced meniscus results in abnormally increased soft tissue density anterior to the condyle.
displaced meniscus (arrow) anterior to the condyle

TMJ Arthrography

DrCBlum — Wed, 27 May 2009 00:31:21 CDT

A 25 or 23 gauge needle is placed into the inferior joint space immediately posterior to the condyle. Small amounts of iodinated contrast are injected under fluoroscopy. The contrast tracks along the posterior, superior and anterior portions of the condyle. The anterior collection of contrast, called the anterior recess, normally has a smooth, tear-drop shape.
If the meniscus or disc is perforated, contrast flows into both the superior and inferior joint recesses. However, the arthrographic needle can inadvertently puncture the meniscus and cause iatrogenic filling of both joint spaces.
QuickTime movies of Joint Injections
Normal Inferior Joint Space (11K)	Perforated Meniscus (13K)
As the condyle translates anteriorly, the contrast usually empties from the anterior recess and flows posteriorly.
When the meniscus is anteriorly displaced, the anterior recess becomes abnormally elongated. Often the displaced meniscus is deformed or buckled, which results in a mass effect against the contrast in the anterior recess. As the condyle translates anteriorly, the mass effect against the anterior recess often increases. When the meniscus reduces, the anterior recess returns to a normal appearance.
If the meniscus does not reduce, the anterior recess remains deformed in the fully open mouth position.
QuickTime movies of TMJ Arthrogram
Normal Joint (30K)	Anteriorly Displaced Meniscus with Reduction (32K)

TMJ Synovial Membrane & Spaces

DrCBlum — Wed, 27 May 2009 00:30:19 CDT

The synovial tissue of the TMJ is the internal lining of the external capsule. Thus, one would normally expect to find synovial tissue at the periphery of the joint. Generally, it is accepted that synovial tissue may be of several types, depending on what intra-articular tissue it covers. For example, most joints have loose connective tissue, dense fibrous or an adipose type of synovial tissue. Therefore, that part of the synovium that rests on the non-articulating retrodiscal attachment would be of the loose connective type. More fibrous synovial tissue would be found around the medial and lateral condylodiscal ligaments and the tendinous insertion of the upper belly of the lateral pterygoid muscle. Where villi of synovial tissue project into the joint space from the perimeter, there usually is fatty tissue in the stalks of the villi, and this is classic adipose synovial tissue. Larger villous folds will be found to contain blood vessels. The synovial fluid is generally a dialysate of blood that also contains mucin, lymphocytes, monocytes, and macrophages. The non-vascularized tissues of the joint are dependent on synovial fluid for nutrition. Hence, the thinner mid-portion of the disc and the articular cartilage covering the condyle, fossa and eminence are dependent on the pumping of synovial fluid. As in most other synovial diarthroses, the synovial fluid must be compressed by the articulating surfaces and thereby be driven into deeper layers of these tissues. Thus, the mechanism of synovial nutrition in the TMJ is dependent on three factors: First, the disc must be compressed against the adjacent articulating surfaces in normal juxtaposition between the condyle and the opposing superior osseous structures. Second, there must be compressive loading of structures against each other, and the articulating structures must be firm yet pliable enough to drive the synovial fluid into the tissues effectively. Third, the tissue being penetrated by synovial fluid must be relatively thin. Thus, the thicker anterior and posterior bands of the disc will have their own internal blood supply. Additionally, in most synovial joints, the intra-articular cortical bone is nourished at least in part by synovial fluid.

The synovial tissue of the TMJ is the internal lining of the external capsule. Thus, one would normally expect to find synovial tissue at the periphery of the joint. Generally, it is accepted that synovial tissue may be of several types, depending on what intra-articular tissue it covers. For example, most joints have loose connective tissue, dense fibrous or an adipose type of synovial tissue. Therefore, that part of the synovium that rests on the non-articulating retrodiscal attachment would be of the loose connective type.

More fibrous synovial tissue would be found around the medial and lateral condylodiscal ligaments and the tendinous insertion of the upper belly of the lateral pterygoid muscle. Where villi of synovial tissue project into the joint space from the perimeter, there usually is fatty tissue in the stalks of the villi, and this is classic adipose synovial tissue. Larger villous folds will be found to contain blood vessels.

The synovial fluid is generally a dialysate of blood that also contains mucin, lymphocytes, monocytes, and macrophages. The non-vascularized tissues of the joint are dependent on synovial fluid for nutrition. Hence, the thinner mid-portion of the disc and the articular cartilage covering the condyle, fossa and eminence are dependent on the pumping of synovial fluid.

As in most other synovial diarthroses, the synovial fluid must be compressed by the articulating surfaces and thereby be driven into deeper layers of these tissues. Thus, the mechanism of synovial nutrition in the TMJ is dependent on three factors:

First, the disc must be compressed against the adjacent articulating surfaces in normal juxtaposition between the condyle and the opposing superior osseous structures.

Second, there must be compressive loading of structures against each other, and the articulating structures must be firm yet pliable enough to drive the synovial fluid into the tissues effectively.

Third, the tissue being penetrated by synovial fluid must be relatively thin.

Thus, the thicker anterior and posterior bands of the disc will have their own internal blood supply. Additionally, in most synovial joints, the intra-articular cortical bone is nourished at least in part by synovial fluid.


TMJ Spaces
One cannot consider the synovial fluid without also defining the normal spaces of a joint. An open space must be maintained in both the upper and lower joint cavities so that synovial fluid can access the intra-articular structures for nutrition and lubrication. Ultimately, the superior space will be bounded by the attachments of the articular capsule medially, and laterally by the origination of the retrodiscal attachment posteriorly, and by the blending of epimysium, capsule and periosteum anteriorly. The capsule is primarily a medial and lateral joint structure. Medially, it will generally course along an area approximating the squamosphenosal suture line. Laterally, the capsule will originate from the inferolateral edges of the fossa and eminence. In the anterior of the upper joint cavity, the space will be limited generally to the eminence at its most prominent portion or slightly, onto the anterior slope of the eminence.
	This reflection comprises a blending of epimysium with the periosteum of the anterior eminence through an orifice of the capsule. As such, this boundary is usually obliquely oriented medially and anteriorly. There is no true capsule in the posterior portion of the TMJ. Therefore, the posterior boundary is limited by the posterior and superior origin of retrodiscal attachment. This tissue generally originates just anterior to the squamotympanic and petrotympanic fissures. The inferior joint cavity is bounded medially and laterally by the insertion of the medial and lateral collateral ligament onto the condylar surface. Anteriorly, this cavity is limited to the blending of capsule and tendon between the part of the superior belly of the lateral pterygoid muscle that inserts into the disc and the part that inserts into the condyle. Posteriorly, the retrodiscal tissues normally blend with periosteum approximately 10 mm down onto the neck of the mandibular condyle.

TMJ Retrodiscal Tissue

DrCBlum — Wed, 27 May 2009 00:22:19 CDT

The retrodiscal attachment tissues are the intra-articular part of the joint posterior to the condyle and disc. Functionally, this statement pertains to whether the condyle and disc are seated in the fossa or whether in fact they are seated more anteriorly. Hence, this tissue must have a volume that is very strictly defined when the condyle and disc are in centric relation, and this volume must increase instantaneously when the condyle translates anteriorly. Thus, there is a rather prominent vascular shunt in the upper part of the retrodiscal attachment, and this vascular network is contained within loosely organized fat, collagen and elastin.
	Perhaps because the disc tends merely to rotate against the condyle (as opposed to translating, as the disc does against the upper articular surface), there is a need for the disc to be tethered to the condyle posteriorly. Hence, there is a stratum at the interior portion of the retrodiscal attachment that is composed of relatively inelastic and tightly packed collagen. In fact, this interior stratum of collagen blends medially and laterally with the condylodiscal ligaments, and functionally, this inferior stratum may be considered a separate ligament structure that must maintain a certain length to keep the disc and condyle in proper alignment.

TMJ Muscles of Mastication

DrCBlum — Wed, 27 May 2009 00:19:44 CDT

Muscles acting on the Temporomandibular Joint
• Movements of the temporomandibular joint are chiefly from the action of the muscles of mastication. • The temporalis, masseter, and medial pterygoid muscles produce biting movements. • The lateral pterygoid muscles protrude the mandible with the help from the medial pterygoid muscles and retruded largely by the posterior fibres of the temporalis muscle. • Gravity is sufficient to depress the mandible, but if there is resistance, the lateral pterygoid, suprahyoid and infrahyoid, mylohyoid and anterior digastric muscles are activated.

Muscles acting on the Temporomandibular Joint

• Movements of the temporomandibular joint are chiefly from the action of the muscles of mastication.

• The temporalis, masseter, and medial pterygoid muscles produce biting movements.

• The lateral pterygoid muscles protrude the mandible with the help from the medial pterygoid muscles and retruded largely by the posterior fibres of the temporalis muscle.

• Gravity is sufficient to depress the mandible, but if there is resistance, the lateral pterygoid, suprahyoid and infrahyoid, mylohyoid and anterior digastric muscles are activated.

Actions

Muscles

Depression (Open mouth)

Lateral pterygoid

Suprahyoid

Infrahyoid

Elevation (Close mouth)

Temporalis

Masseter

Medial pterygoid

Protrusion (Protrude chin)

Masseter (superficial fibres)

Lateral pterygoid

Medial pterygoid

Retrusion (Retrude chin)

Temporalis Masseter (deep fibres)

Side-to-side movements (grinding and chewing)

Temporalis on same side

Pterygoid muscles of opposite side

Masseter

Masseter Muscle	Temporalis Muscle
Origin and insertion of the two heads The masseter is a thick, somewhat quadrilateral muscle, consisting of two portions, superficial and deep. The fibers of the two portions are continuous at their insertion. Superficial The superficial portion, the larger, arises by a thick, tendinous aponeurosis from the zygomatic process of the maxilla, and from the anterior two-thirds of the lower border of the zygomatic arch.Its fibers pass downward and backward, to be inserted into the angle and lower half of the lateral surface of the ramus mandibulæ. Deep The deep portion is much smaller, and more muscular in texture.It arises from the posterior third of the lower border and from the whole of the medial surface of the zygomatic archIts fibers pass downward and forward, to be inserted into the upper half of the ramus and the lateral surface of the coronoid process of the mandible.The deep portion of the muscle is partly concealed, in front, by the superficial portion; behind, it is covered by the parotid gland. Innervation It elevates and protrudes the mandible, closes the jaws and the deep fibres retrude it. Action Along with the other three muscles of mastication (temporalis, medial pterygoid and lateral pterygoid), the masseter is innervated by the mandibular division of the trigeminal nerve.	Origin and insertion It arises from the temporal fossa and the deep part of temporal fascia. It passes medial to the zygomatic arch and inserts onto the coronoid process of the mandible.The temporal muscle is covered by the temporal fascia, also known as the temporal aponeurosis. The muscle is accessible to palpation over the greater wing of the sphenoid and squamous portion of the temporal bones. It can be seen and felt contracting while the jaw is clenching and unclenching. Innervation As with the other muscles of mastication, control of the temporal muscle comes from the third (mandibular) branch of the trigeminal nerve. Specifically, the muscle is innervated by the deep temporal nerves. Action The temporalis elevates the mandible, closing the jaws; and its posterior fibres retrude the mandible after protrusion.
Lateral and Medial Pterygoid Muscles
Origin and insertion of Lateral Pterygoid The upper/superior head originates on the infratemporal surface and infratemporal crest of the greater wing of the sphenoid bone, and the lower/inferior head on the lateral surface of the lateral pterygoid plate. Inferior head inserts onto the pterygoid fovea under the condyloid process of the mandible; upper/superior head inserts onto the articular disc and fibrous capsule of the TMJ. Innervation The mandibular branch of the fifth cranial nerve, the trigeminal nerve, innervates the lateral pterygoid muscle. Action Acting together, these muscles protrude the mandible and depress the chin. Acting alone and alternately, they produce side-to-side movements of the mandible.	Origin and insertion of Medial Pterygoid It consists of two heads.Its fibers pass downward, lateral, and posterior, and are inserted, by a strong tendinous lamina, into the lower and back part of the medial surface of the ramus and angle of the mandible, as high as the mandibular foramen. The insertion joins the masseter muscle to form a common tendinous sling which allows the medial pterygoid and masseter to be powerful elevators of the jaw. Innervation Like the lateral pterygoid, and all other muscles of mastication, the medial pterygoid is innervated by the mandibular branch of the trigeminal nerve (V3). Actions It closes the jaw and helps in mastication along with lateral pterygoid in side to side movement of jaw and protrusion. It elevates the jaw, and in some aspect pulls it forward. The bulk of the muscle arises as a deep head from just above the medial surface of the lateral pterygoid plate. The smaller, superficial head originates from the maxillary tuberosity and the pyramidal process of the palatine bone.
The lateral pterygoid muscle has upper and lower bellies that are separated by the epimysial tissue. The upper head originates from the infratemporal surface of the greater wing of the sphenoid bone. The lower head originates from the lateral surface of the lateral pterygoid plate. The upper and lower bellies have distinctly different electromyographic activity. On mandibular opening, the inferior head contracts and the superior head maintains resting activity. On closure of the mandible, the superior head contracts while the inferior is at rest. Functionally, then, it is the superior head that may influence discal position. Hence, because the superior head inserts both into the condyle and into the disc, it is felt to function by making rapid adjustments in the relative positioning of the disc and condyle during closure. Thus, the relative alignment of the disc over the condyle becomes more than merely mechanically dictated by the shape of the anterior and posterior bands of the disc.

TMJ Anatomy

DrCBlum — Wed, 27 May 2009 00:17:52 CDT


The temporomandibular joint, or TMJ, is the articulation between the condyle of the mandible and the squamous portion of the temporal bone.

The condyle is elliptically shaped with its long axis oriented mediolaterally.

The articular surface of the temporal bone is composed of the concave articular fossa and the convex articular eminence.

The MENISCUS or also known as the temporomandibular DISC is a fibrous, saddle shaped structure that separates the condyle and the temporal bone. The meniscus varies in thickness: the thinner, central intermediate zone separates thicker portions called the anterior band and the posterior band. Posteriorly, the meniscus is contiguous with the posterior attachment tissues called the bilaminar zone. The bilaminar zone is a vascular, innervated tissue that plays an important role in allowing the condyle to move foreward. The meniscus and its attachments divide the joint into superior and inferior spaces. The superior joint space is bounded above by the articular fossa and the articular eminence. The inferior joint space is bounded below by the condyle. Both joint spaces have small capacities, generally 1cc or less.

TMJ Ligaments

DrCBlum — Wed, 27 May 2009 00:17:02 CDT

There are three ligaments associated with the TMJ: one major and two minor ligaments. The major ligament, the temporomandibular or condylodiscal ligament, is actually the thickened lateral portion of the capsule, and it has two parts: an outer oblique portion (OOP) and an inner horizontal portion (IHP). The minor ligaments, the stylomandibular and sphenomandibular ligaments are accessory and are not directly attached to any part of the joint. The stylomandibular ligament separates the infratemporal region (anterior) from the parotid region (posterior), and runs from the styloid process to the angle of the mandible. The sphenomandibular ligament runs from the spine of the sphenoid bone to the lingula of mandible.
The condylodiscal ligaments are intracapsular support structures that are responsible for maintaining the general posture of the disc superior to the condylar surface. These ligaments occupy the medial and lateral poles of the mandibular condyles, and they blend with the fibrous connective tissue of the medial and lateral portions of the disc. These ligaments are not weight-bearing structures. However, they play a vital role in maintaining the disc in proper alignment at both poles. Furthermore, these internal ligaments must remain tight enough to tether the disc, but at the same time, they must have enough laxity to allow the disc to assume a more posterior relation with respect to the condyle during forward translation. Like other ligaments, if the joint is hyperextended, these structures must hold up to these forces. Finally, although the condylodiscal ligaments function in harmony to hold the disc in alignment, they are independent structures and are functionally distinct. Hence, they may break down independently.

There are three ligaments associated with the TMJ: one major and two minor ligaments.

The major ligament, the temporomandibular or condylodiscal ligament, is actually the thickened lateral portion of the capsule, and it has two parts: an outer oblique portion (OOP) and an inner horizontal portion (IHP).

The minor ligaments, the stylomandibular and sphenomandibular ligaments are accessory and are not directly attached to any part of the joint.
- The stylomandibular ligament separates the infratemporal region (anterior) from the parotid region (posterior), and runs from the styloid process to the angle of the mandible.
- The sphenomandibular ligament runs from the spine of the sphenoid bone to the lingula of mandible.

The condylodiscal ligaments are intracapsular support structures that are responsible for maintaining the general posture of the disc superior to the condylar surface. These ligaments occupy the medial and lateral poles of the mandibular condyles, and they blend with the fibrous connective tissue of the medial and lateral portions of the disc.

These ligaments are not weight-bearing structures. However, they play a vital role in maintaining the disc in proper alignment at both poles. Furthermore, these internal ligaments must remain tight enough to tether the disc, but at the same time, they must have enough laxity to allow the disc to assume a more posterior relation with respect to the condyle during forward translation.

Like other ligaments, if the joint is hyperextended, these structures must hold up to these forces. Finally, although the condylodiscal ligaments function in harmony to hold the disc in alignment, they are independent structures and are functionally distinct. Hence, they may break down independently.

Lateral View of TMJ	Medial View of TMJ
The temporomandibular ligament (external lateral ligament) consists of two short, narrow fasciculi, one in front of the other, attached, above, to the lateral surface of the zygomatic arch and to the tubercle on its lower border; below, to the lateral surface and posterior border of the neck of the mandible. It is broader above than below, and its fibers are directed obliquely downward and backward. It prevents posterior displacement of the mandible and prevents the condyloid process from being driven upward by a blow and fracturing the base of the skull.	The sphenomandibular ligament (internal lateral ligament) is a flat, thin band which is attached above to the spina angularis of the sphenoid bone, and, becoming broader as it descends, is fixed to the lingula of the mandibular foramen. The function of the sphenomandibular ligament is to limit distension of the mandible in an inferior direction.
	The stylomandibular ligament is a specialized band of the cervical fascia, which extends from near the apex of the styloid process of the temporal bone to the angle and posterior border of the angle of the mandible, between the Masseter and Pterygoideus internus. This accessory ligament along with the sphenomandibular ligament is responsible for limitation of mandibular movements (limit excessive opening).

TMJ Function

DrCBlum — Wed, 27 May 2009 00:12:53 CDT

Normal TMJ Function
When the mouth opens, two distinct motions occur at the joint. The first motion is rotation around a horizontal axis through the condylar heads. The second motion is translation. The condyle and meniscus move together anteriorly beneath the articular eminence. In the closed mouth position, the thick posterior band of the meniscus lies immediately above the condyle. As the condyle translates forward, the thinner intermediate zone of the meniscus becomes the articulating surface between the condyle and the articular eminence. When the mouth is fully open, the condyle may lie beneath the anterior band of the meniscus.
QuickTime movie of Normal TMJ motion (37K)

TMJ Dysfunction
Internal derangement of the TMJ is present when the posterior band of the meniscus is anteriorly displaced in front of the condyle. As the meniscus translates anteriorly, the posterior band remains in front of the condyle and the bilaminar zone becomes abnormally stretched and attenuated. Often the displaced posterior band will return to its normal position when the condyle reaches a certain point. This is termed anterior displacement with reduction.
When the meniscus reduces the patient often feels a pop or click in the joint. In some patients the meniscus remains anteriorly displaced at full mouth opening. This is termed anterior displacement without reduction. Patients with anterior displacement without reduction often cannot fully open their mouths'. Sometimes there is a tear or perforation of the meniscus. Grinding noises in the joint are often present.
QuickTime movies of Anteriorly Displaced Meniscus
With Reduction (39K)	Without Reduction (31K)

TMJ Articular Cartilage & Capsule

DrCBlum — Tue, 26 May 2009 22:24:55 CDT

The fibrocartilage covers the intra-articular osseous surfaces. This tissue is therefore entirely dependent on synovial fluid for its nourishment. Furthermore, the joint must be free of adhesions so that the synovial fluid will have access to the articular cartilage. This tissue is generally thicker on the loaded portions of the joint surfaces.
	There is greater thickness of fibrocartilage on the anterosuperior condyle and on the proximal slope of the eminence. Likewise, it is these areas that receive the primary compression during normal joint movement, and hence as synovial fluid is driven into these surfaces, a thicker tissue layer can be maintained.
The capsule is a fibrous membrane that surrounds the joint and incorporates the articular eminence. It attaches to the articular eminence, the articular disc and the neck of the mandibular condyle. The articular disc is a fibrous extension of the capsule in between the two bones of the joint. The disk functions as articular surfaces against both the temporal bone and the condyles and divides the joint into two sections, as described in more detail below. It is biconcave in structure and attaches to the condyle medially and laterally.
	The anterior portion of the disc splits in the vertical dimension, coincident with the insertion of the superior head of the lateral pterygoid. The posterior portion also splits in the vertical dimension, and the area between the split continues posteriorly and is referred to as the retrodiscal tissue. Unlike the disc itself, this piece of connective tissue is vascular and innervated, and in some cases of anterior disc displacement, the pain felt during movement of the mandible is due to the condyle pressing on this area.

TMJ Capsule
	It is important to realize that this capsule is an incomplete structure. That is, the capsule does not extend posterior of the condyle. In fact, the posterior part of the TMJ is bounded by the tympanic plate on the medial two-thirds of the joint and by external ear cartilage on the lateral third. On the lateral part of the joint, the capsule is a well-defined structure that functionally limits the forward translation of the condyle.
This capsule is reinforced more laterally by an external TMJ ligament, which also limits the distraction and the posterior movement of the condyle. Medially and laterally, the capsule blends with the condylodiscal ligaments. Anteriorly, the capsule has an orifice through which the lateral pterygoid tendon must pass. This area of relative weakness in the capsular lining becomes a source for possible herniation of intra-articular tissues, and this in part may allow for forward displacement of the disc.

Craniometric Points

DrCBlum — Mon, 06 Apr 2009 10:21:30 CDT

Craniometry is the technique of measuring the bones of the skull. Craniometry uses specific points, called craniometric landmarks or points to systematize the analysis of the cranium. It is commonly used in some aspects of dentistry particularly involved with orthopedic or orthodontic changes and their effect on the facial bones and associated cranial bones.

Craniometric Landmarks:

A auriculo-infraorbital plane		B alveo-condylean plane
1 metopion	6 orbital point	11 pogonion	16 mastoidale	21 obelion
2 ophryon	7 malar point	12 gnathion	17 auricular point	22 bregma
3 glabella	8 acanthion	13 coronion	18 asterion	23 pterion
4 nasion	9 prosthion	14 condylion	19 inion	24 crotaphion
5 dacryon	10 symphysion	15 gonion	20 lambda	25 jugal point

Cranial Landmarks in a Median Plane

DrCBlum — Mon, 06 Apr 2009 10:13:36 CDT

Most Common:

• Bregma. The meeting point of the coronal and sagittal sutures.

• Lambda. The point of junction of the sagittal and lambdoidal sutures.

• Inion. The external occipital protuberance.

• Nasion. The central point of the frontonasal suture.

• Glabella. The point in the middle line at the level of the superciliary arches.

Less Common (Craniometric Points):

* Mental Point. The most prominent point of the chin.

• Alveolar Point or Prosthion. The central point of the anterior margin of the upper alveolar arch.

• Subnasal Point. The middle of the lower border of the anterior nasal aperture, at the base of the anterior nasal spine.

• Ophryon. The point in the middle line of the forehead at the level where the temporal l ines most nearly approach each other.

• Obelion. A point in the sagittal suture on a level with the parietal foramina.

• Occipital Point. The point in the middle line of the occipital bone farthest from the glabella.

• Opisthion. The mid-point of the posterior margin of the foramen magnum.

• Basion. The mid-point of the anterior margin of the foramen magnum.

Primarily Visible from Below or Inside

DrCBlum — Mon, 06 Apr 2009 10:09:42 CDT

* Frontoethmoidal suture - beteween the ethmoid bone and the frontal bone.

* Sphenopetrosal suture - between the sphenoid bone and the petrous portion of the temporal bone.

* Petrosquamous suture - between the petrous portion and the squama of the temporal bone.

* Sphenoethmoidal suture - between the sphenoid bone and the ethmoid bone.

Glossary of Terms

DrCBlum — Mon, 06 Apr 2009 09:57:47 CDT

Osteology terms:

* Cranium: The cranium of the skull comprises all of the bones of the skull except for the mandible.

* Skull: The skull refers to all of the bones that comprise the head.

* Calvaria: The calvaria refers to the cranium without the facial bones attached.

* Calotte: The calotte consists of the calvaria from which the base has been removed.

* Splanchocranium: The splanchocranium refers to the facial bones of the skull.

* Neurocranium: The neurocranium refers only to the braincase of the skull.

* Endocranial: Refers to the interior of the braincase.

* Ectocranial: Refers to the exterior of the braincase.

* Axial: Refers to the head and trunk (vertebrae, ribs and sternum) of the body.

* Suture: The saw-like edge of a cranial bone that serves as joint between bones of the skull.

* Aperture: An opening or space between bones or within a bone.

* Cavity: An open area or sinus within a bone or formed by two or more bones.

* Condyle: A rounded enlargement or process possessing an artculating surface.

* Fissure: A narrow slit or gap.

* Foramen: A hole in a bone usually for the transmission of blood vessels and/or nerves.

* Fossa: A pit, depression, or concavity, on a bone, or formed from several bones.

* Process: A general term describing any marked projection or prominence.

* Spinous: Descriptive of a sharp, slender process.

* Tubercle: A small process or bump, an eminence.

* Tuberosity: A large rounded process or eminence.

Anatomical terms:

* Mid-sagittal plane: The imaginary plane that transects the the body along the mid-point into mirrored left and right sides.

* Anterior: A relative term meaning nearer the front of the body, in a biped it also means ventral.

* Posterior: A relative term meaning nearer the back of the body, in a biped it also means dorsal.

* Inferior: The relative term meaning below or of the lower portion of the body.

* Superior: The relative term meaning nearer the top or of the upper portion of the body.

* Proximal: A relative term indicating a point nearer the trunk or axial skeleton, a point nearer the mid-sagittal plane.

* Distal: A relative term indicating a point that lies farther from the trunk or away from the mid-sagittal plane.

* Medial: The relative term indicating a point lying nearer the mid-sagittal plane.

* Lateral: The relative term indicating a point lying farther from the mid-sagittal plane or the midline of the body.

* Lingual: Areas nearer the tongue or oral cavity.

* Labial: Areas nearer the lips or cheeks.

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TMJ Magnetic Resonance Imaging (MR)

TMJ Computerized Tomogram (CT)

TMJ Arthrography

TMJ Synovial Membrane & Spaces

TMJ Retrodiscal Tissue

TMJ Muscles of Mastication

Origin and insertion of the two heads

Superficial

Deep

Innervation

Action

Origin and insertion

Innervation

Action

Origin and insertion of Lateral Pterygoid

Innervation

Action

Origin and insertion of Medial Pterygoid

Innervation

Actions

TMJ Anatomy

TMJ Ligaments

TMJ Function

TMJ Articular Cartilage & Capsule

Craniometric Points

Cranial Landmarks in a Median Plane

Primarily Visible from Below or Inside

Glossary of Terms