Temporomandibular Disorders: A Translational Approach From Basic Science To Clinical Applicability 1st Edition Henry A. Gremillion
Temporomandibular Disorders: A Translational Approach From Basic Science To Clinical Applicability 1st Edition Henry A. Gremillion
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Henry A. Gremillion
Gary D. Klasser
Editors
Temporomandibular
Disorders
A Translational Approach
From Basic Science to
Clinical Applicability
123
Temporomandibular Disorders
Henry A. Gremillion • Gary D. Klasser
Editors
Temporomandibular
Disorders
A Translational Approach From Basic
Science to Clinical Applicability
Editors
Henry A. Gremillion Gary D. Klasser
School of Dentistry School of Dentistry
Louisiana State University Health Louisiana State University Health
Science Center Center
New Orleans New Orleans
Louisiana Louisiana
USA USA
vii
Preface
ix
x Preface
a pplications. Overall, we are all health care providers who have the privilege
and duty to serve our patients who put so much trust in our abilities.
Enjoy!
4 Musculature������������������������������������������������������������������������������������ 67
James M. Hawkins, Istvan A. Hargitai,
and A. Dale Ehrlich
5 The Temporomandibular Joint���������������������������������������������������� 91
Istvan A. Hargitai, James M. Hawkins,
and A. Dale Ehrlich
xi
Part I
Fundaments and Principles
Embryology of the Masticatory
System
1
Ronald C. Auvenshine
Abstract
The temporomandibular joint (TMJ) is the most unique and complex joint in
the body. The anatomy of the TMJ varies among mammals depending upon
masticatory requirements. Masticatory system function demands that the
mandible be capable not only of opening and closing but also of forward,
backward, and lateral movements and combinations thereof. In humans, the
TMJ is described as a ginglymoarthrodial type of diarthrotic joint. This means
that it is not only capable of rotation (movement around a single axis) but also
translation (movement around more than one axis at a time). This chapter will
provide a review of the growth and development of structures of the mastica-
tory system with special emphasis upon the osseous components.
Fig. 1.1 Stage 13, 4.5-week human embryo courtesy of Biology and Anatomy of LSU Health Sciences Center,
The Virtual Human Embryo Project. Production of the New Orleans, LA. http://virtualhumanembryo.lsuhsc.edu
Computer Imaging Lab (CIL) in the Department of Cell (The Stages of Human Embryonic Development 2012)
1.2 Pharyngeal Arch 1. A pharyngeal arch artery that arises from the
Components truncus arteriosus of the primordial heart
2. A cartilaginous rod that forms the skeletal
Each pharyngeal arch consists of a core of mes- support of the arch
enchyme (embryonic connective tissue) and is 3. A muscular component that differentiates into
covered externally by ectoderm and internally by muscles in the head and neck
endoderm. Originally, this mesenchyme is 4. Sensory and motor nerves that supply the
derived from mesoderm, but by the fourth week mucosa and muscles derived from the arch
post-conception (PC), most of the mesenchyme
is derived from neural crest cells that migrate into (Table 1.1) (Fig. 1.3) (Sadler 2000; Moore and
the pharyngeal arches. It is the migration of the Persaud 2008).
neural crest cells into the arches and their differ- The mandible is derived from intramembra-
entiation into mesenchyme that produce the max- nous ossification of an osteogenic membrane
illary and mandibular prominences. Coincident which begins condensation at 36–38 days of
with the migration of neural crest cells, myogenic development. Bone formation takes place lateral
mesoderm from paraxial regions moves into each to Meckel’s cartilage (Fig. 1.4) (Nanci 2008).
pharyngeal arch forming a central core of muscle A single ossification center at each half of the
primordium. Endothelial cells in the arches are mandible arises in the 6-week embryo (PC) in the
derived from lateral mesoderm. Invasive angio- region of the bifurcation of the inferior alveolar
blasts also move into the arches. nerve and artery. Ossification spreads below and
A typical pharyngeal arch contains: around the growing inferior alveolar nerve to
form a trough for the developing teeth. Spread of woven bone formed along Meckel’s cartilage is
the intramembranous ossification dorsally and soon replaced by the laminar bone, and typical
ventrally forms the body and ramus of the man- Haversian systems are already present at the fifth
dible. Ossification stops dorsally at the site that month (PC).
will become the mandibular lingula. From here,
Meckel’s cartilage continues into the middle ear
(Fig. 1.5) (Mendez 2017a). 1.3 Formation
The prior presence of a neurovascular bundle of the Temporomandibular
ensures formation of the mandibular foramen and Joint
canal as well as the mental foramen. Meckel’s
cartilage extends forward to almost meet its fel- A great deal of research has been published on
low of the opposite side in the midline. It diverges the development of the TMJ over the past several
dorsally to end in the tympanic cavity of each decades. However, there is disagreement about
middle ear and ossifies to form two of the audi- its morphological timing. The most controversial
tory ossicles, the malleus and incus (Fig. 1.6) aspects concern the moment of initial organiza-
(Merida-Velasco et al. 1999). The third ossicle, tion of the condyle and squamosal part of the
the stapes, is derived primarily from cartilage of temporal bone, the articular disc and capsule, and
the second pharyngeal arch (Reichert’s Cartilage also the formation of the joint spaces and onset of
(Merida-Velasco et al. 1999). condylar chondrogenesis (Moffett 1966).
Meckel’s cartilage is not found in the adult Merida-Velasco has identified three phases of
mandible. Its adult remnants are present in the TMJ development:
form of the sphenomandibular ligament and ante-
rior malleolar ligament. Meckel’s cartilage dorsal 1. Blastemic stage, weeks 7–8 of development
to the mental foramen undergoes resorption on its 2. Cavitation stage, weeks 9–11 of development
lateral surface at the same time as intramembra- 3. Maturation stage, after week 12 through term
nous bony trabecula are forming immediately
lateral to the cartilage. Thus, the cartilage from His study identified the critical period of TMJ
the mental foramen to the lingula is not incorpo- morphogenesis occurring between weeks 7–11 of
rated into ossification of the mandible. The inter- development (Merida-Velasco et al. 1999).
1 Embryology of the Masticatory System 7
Mandibular nerve
Long buccal
berve
Meckel’s
cartilage
Angular cartilage
Mental
ossicle Inferior alveolar nerve
Illustration by Michelle D. Mendez, Houton, TX 2017
growth in length. Therefore, the mandible grows tema, while the condylar blastema is still con-
in length much like the long bones of the body. densed mesenchyme (Fig. 1.9) (Perry et al.
Changes in mandibular position and form are 1985). A joint space between the two appears at
related to the direction and amount of condylar 10 weeks (PC) as a cleft immediately appears
growth. Condylar growth increases at puberty, above the condensed condylar blastema and
peaks between 12.5 and 14 years, and normally becomes the inferior joint cavity. The condylar
ceases at about 20 years. However, the continued blastema differentiates into cartilage (condylar
presence of cartilage provides for continued cartilage), and then a secondary cleft appears in
growth which is realized in conditions of abnor- relation to the temporal ossification and becomes
mal growth, such as acromegaly. the upper joint cavity (Edwards et al. 1994).
The condylar blastema grows rapidly in a With the appearance of the superior secondary
dorsolateral direction to close the gap. cleft, the primitive articular disc is formed
Ossification begins first in the temporal blas- (Fig. 1.10) (Merida-Velasco et al. 1999).
1 Embryology of the Masticatory System 9
Between the 10th and 14th week of gestation, month (PC) to form a variable number of mental
another secondary blastema appears in the region ossicles at the symphysis.
of the coronoid process. Secondary cartilage of Shape and size of the fetal mandible undergo
the coronoid process develops within the tempo- considerable transformation during its growth
ralis muscle as its predecessor. The coronoid and development. The ascending ramus of the
accessory cartilage becomes incorporated into neonatal mandible is low and wide. The coronoid
the expanding intramembranous bone of the process is relatively large and projects well above
ramus and disappears before birth. In the mental the developing condyle. The body is merely an
region on either side of the symphysis, one of two open shelf containing buds and partial crowns of
small cartilages appear and ossify in the seventh the deciduous teeth. The mandibular canal runs
low in the mandibular body. The initial separa-
tion of the right and left bodies of the mandible at
the midline symphysis is gradually eliminated
between the 4th and 12th months (Merida-
Velasco et al. 1999).
K, Meckel’s
cartilage
N, Nerve
phases. The first phase involves the formation of The temporal relationship between movement
cartilaginous anlagen and intervening interzones and skeletal development hints at a close func-
in which the joints will develop at a particular tional relationship between muscle activity and
location—that is limb patterning. joint formation.
The second phase involves the formation of the Synovial joint cavity formation must success-
articular cartilage synovium and other related struc- fully generate new non-adherent surfaces by a
tures within the joint. This depends on elaboration process involving the assembly of a cell-free
of the joint cavity containing synovial fluid, a pro- fluid-filled separation which will facilitate pain-
cess referred to as “cavitation” (Pitsillides 2006). less and almost frictionless articulation of the
A wealth of new information currently exists joint. As limb condensations are discrete, it is
to support mechanical stimulation as a vital fea- apparent that cavitation occurs between the ends
ture of healthy embryonic development particu- of predetermined cartilaginous elements to create
larly in the formation of joints. In the appendicular surfaces that are continuous with the synovial
skeleton, failure of synchronization between the lining and associated structures, including the
development of diarthroses and long bones menisci (Pitsillides 1999).
results in an embryo with limited movement. The Skeletal joint cavity development, or cavita-
embryo’s capacity to perform muscular move- tion, occurs along planes of the future articular
ments will effectively influence further develop- surfaces of synovial joints. A number of different
ment and later remodeling of the skeleton. Thus, markers have been shown to be present in the
proper skeletal formation is enabled by a full interzones at the time of cavitation, such as hyal-
range of embryonic movement. uronan and hyaluronan synthase. Fibroblast-like
Muscle-controlled movement begins early cells and adjacent chondrocytes with uridine
and continues throughout embryonic develop- diphosphoglucose dehydrogenase (UDPGD)
ment. In humans, the first fetal movement is activity contribute to glucosamine-glycan levels
recorded at 9 weeks (PC), just after innervation (increases in hyaluronan). These cells are located
of the forelimbs, as the skeletal rudiments are in the intimal surface of the synovial lining and
forming. Mouth opening has been demonstrated have been suggested as the possible cavitation
to occur (Hamburger and Balaban 1963) with mechanism switching from cellular cohesion to
evoked stimulation as early as 7.5 weeks (PC). disassociation (Edwards et al. 1994).
1 Embryology of the Masticatory System 11
A review of joint formation requires a brief (epiphysis) of adjacent rudiments and the inter-
overview of “limb patterning.” Limb patterning vening joint cavity, encapsulated by a synovial
involves dynamic relationships between the membrane. Thus, formation of the limb skeleton
thickened region of ectoderm, the apical ectoder- involves coordinated endochondral ossification,
mal ridge (AER), and the underlying distal limb differentiation of permanent cartilage at joint
mesenchyme or progress zone. The progress interfaces, and construction of functional cavi-
zone model predicts that the timing and location tated joints in addition to the development of
of the departure of each cell from the influence of associated structures such as tendons, ligaments,
the AER dictate its commitment to a specific fate. and menisci. As with the limb skeleton, the sec-
Therefore, limb patterning infers that different ondary blastema of the future condyle grows
limb segments are specified as distinct domains. through endochondral bone formation through
Therefore, when one considers the developing differentiation of permanent cartilage at the joint
TMJ, the two limb segments refer to the condylar interface. Joint cavitation is completed by move-
blastema and the squamosal or glenoid fossa. It is ment through muscle activity creating mouth
unclear why AERs develop at specific sites; how- opening.
ever, a major supposition is that the cavitation Research has now identified several important
process itself is achieved by a conserved mecha- factors necessary for interzones to remain iso-
nism in all joints. lated from neighboring chondrogenesis. These
The first evidence that the location for joint factors include stanniocalcin, parathyroid
formation has been specified involves elaboration hormone-related protein, as well as alpha 5 β-1
of an interzone of mesenchymal cells defining the integrin and other factors. Current research
boundary between the opposed skeletal elements strongly supports the notion that interzones must
(Shea et al. 2015). The fundamental role of inter- act to restrict local cartilage differentiation. It
vening mesenchyme is evident when one consid- appears that the cellular origin of skeletal ele-
ers that their specification interrupts what might ments is initially homologous, only losing their
otherwise develop into a single cartilaginous capacity to change once they have responded to
anlagen. In other words, movement is required exclusive differential stimulus, such as muscle
around the two developing blastemas in order to activity resulting in movement at the location of
create interzones leading to joint cavities. the future joint. The joint cavitation process
The first sign of skeletal development, in limb within the interzone requires extremely precise
buds, is the condensation of mesenchymal cells spatial control over the position at which separa-
at the core of the bud and the location of the tion between elements will occur. This is referred
future skeletal elements. In the proximal forelimb to as the “plane of cleavage.”
bud, for example, a Y-shaped condensation repre- Synovial joint formation can be divided into
sents the future humerus, radius, and ulna. Distal three distinct stages (Pacifici et al. 2006): (1) def-
condensations are progressively added, and inition of the joint site (specification) is followed
future joint sites become apparent as increased by (2) differentiation of joint cell territories
cell density, called interzones. Mesenchymal (patterning) and finally (3) formation of a joint
condensations prefigure immediately subsequent cavity (cavitation) (Fig. 1.11) (Mendez 2017b).
pattern of cartilage differentiation (chondrogen- The influence of movement on the process of
esis) indicated first by the expressions of a tran- joint formation has been demonstrated by sev-
scription factor (Bi et al. 1999). The merging eral researchers (Murray and Drachman 1969;
cartilage cells (chondrocytes) build up an extra- Narayanan et al. 1971). These studies, though
cellular matrix (ECM) of collagens, primarily done in the chick embryo, clearly show that the
types I and II, and structural proteoglycans in an continuous movements of the developing
avascular environment. At the joint interzones, embryo are not random but are specific for joint
cells are organized in three territories which later formation. Subsequently, immobilization of the
form the permanent articular cartilage at the ends developing joint has shown to produce an
12 R.C. Auvenshine
absence of joint cavities and further skeletal affecting earlier joint specification, outgrowth,
abnormalities. Few studies have demonstrated or patterning of the limb. Joint patterning is
lack of cavitation and joint formation by pure intrinsically regulated and independent of mus-
external immobilization. Most of the studies cular activity. However, cavitation appears to
which have been performed have utilized cer- be dependent on muscle activity.
tain drugs to bring about immobilization of the Animal models of embryonic immobilization
embryo. Auvenshine (1976) developed an intra- confirm that endochondral ossification in joint
uterine technique for immobilizing the TMJ by formation is profoundly affected by altered
physically preventing mouth opening in the rat movement. In both chick and mouse models,
fetus. A suture was placed through the snout of immobilization causes abnormal ossification
the 16-day-old rat fetus, preventing mouth (Nowlan et al. 2008) and mechanically substan-
opening. Mouth opening spontaneously occurs dard bone. In addition, failure of cavitation to
in the developing rat at 16.5 days. The animals occur will result in ankylosis of the joint and fail-
were reintroduced into the uterine horn and ure of the joint to move (Auvenshine 1976).
allowed to proceed in development for 24, 36, The influence of movement on the process of
and up to 72 h of gestation. Upon sectioning of joint formation has been demonstrated (Murray
the surgerized fetuses, it was clearly shown that and Drachman 1969; Drachman and Sokoloff
joint cavitation was not achieved and that anky- 1966), and immobilization has shown to produce
losis was present. In these surgerized fetuses, an absence of joint cavities and skeletal abnor-
the animal was unable to open its mouth even malities (Fig. 1.12) (Sperber 1989; Auvenshine
with evoked stimulation. This study suggests 1976). Similarly, joint movement stimulates con-
that movement does indeed contribute to the dylar chondrification (Perry et al. 1985; Sperber
alteration in ECM synthesis, which normally 1989), and the influence of the lateral pterygoid
accompanies tissue separation at the cleavage muscle on the process has been demonstrated
site. Immobilization inhibits cavitation without (Petrovic 1972).
1 Embryology of the Masticatory System 13
C, Condyle
Buccal movements are extremely important and feeding. The purpose for the early develop-
for the organization of the structures within the ment of these functions is that the newborn must
TMJ. In humans, buccal movements begin during immediately be able to feed. This also means that
the seventh and eighth week of development tactile stimulation around the perioral area must be
(Humphrey 1968). This movement first occurs at in place so the newborn must be able to identify
the level of the incudomalleolar joint (Merida- the mother’s mammary gland and begin sucking
Velasco et al. 1999; Merida-Velasco et al. 1990). and swallowing. These movements and reflexes
During the maturation stage, fascicles of the lat- cannot wait to develop late in gestation but develop
eral pterygoid muscle insert into the condyle and early so that they are mature and functioning at the
anteromedial two-thirds of the articular disc. moment of birth. The muscle activity required for
During the 13th week of development, invagina- suckling is complex, and coordination of 5 of the
tion of vascular mesenchyme in the external por- 12 cranial nerves necessitates the working in har-
tion of the condylar cartilage occurs. mony with one another.
The first joint space to form is the inferior By the 26th week (PC), all of the components
joint space. The process of joint cavitation is not of the TMJ are present except for the articular
synchronic since organization of the inferior joint eminence. Meckel’s cartilage still extends
cavity precedes that of the superior one. The infe- through the Glaserian fissure, but by the 31st
rior joint cavity begins to form at the end of the week, it has been transformed into the spheno-
ninth week (PC) with the appearance of small mandibular ligament. At first, the ligament
spaces or clefts between the articular discs and appears attached to the medial end of the tempo-
the condyle. The superior joint cavity begins to ral bone directly adjacent to the sphenoid bone,
form during week 11 of development and contin- but by the 39th week, ossification of the bones in
ues through week 12 (Merida-Velasco et al. 1999; the region has proceeded to the point where the
Merida-Velasco et al. 1990). ligament gains its apparent attachment to the
The trigeminal nerve is one of the first nerves to spine of the sphenoid bone just lateral and poste-
begin its development in embryogenesis. Both the rior to the foramen spinosum.
motor and sensory limb of the trigeminal nerve
and nuclear complex are markedly mature at the
time of birth. Movement of the TMJ begins during 1.5 Clinical Implications
the blastemic phase of development and continues
to mature through the cavitation and maturation A correct diagnosis is the key to managing orofa-
phases. Mouth opening and tongue thrusting are cial pain. Differentiating the many causes of oro-
important functions necessary for joint formation facial pain can be difficult for practitioners, but a
14 R.C. Auvenshine
through development, the more enabled the clini- of histopathological evidence of injury (Robinson
cian will be to better establish a more accurate et al. 2013).
diagnosis and, therefore, allow for a more rele- Even though the hyoid bone has no direct con-
vant management with predictable outcomes. tact with any other bone in the human body, it is
held in place by twenty muscles, ten on each side.
Therefore, the hyoid bone has connections with
1.9 Ear Symptoms muscles of the mandible, tongue, skull, thyroid
cartilage, sternum, and to the medial border of
Many patients appear in the office of an otolar- the scapula as well as the pharyngeal median
yngologist complaining of pain, pressure, stuff- raphe.
iness, hearing loss, dizziness, and ringing in the The hyoid bone, embryologically, is derived
ears. It is not uncommon for the specialist upon from the second pharyngeal arch with contribu-
examination to determine that there is an exter- tions from the third and fourth pharyngeal arches.
nal factor causing the symptoms for which the Due to the innervation in the area (both sensory
patient complains (Costen 1997). A referral is and motor), pain can be referred to locations dis-
then made to the dentist with the diagnosis of tant from the site of a possible injury or dysfunc-
TMD. Embryologically, the mandible develops tion (Stern et al. 2013).
from Meckel’s cartilage which contributes two
of the three middle ear ossicles: the malleus and
the incus. The adult remnant of Meckel’s carti- 1.11 Summary
lage is the condylar-malleolar ligament or
Pinto’s ligament. This ligament passes through Knowledge of the embryology of the head and
the petrotympanic fissure to the malleus. Thus, neck as well as that of the temporomandibular
an adult relationship is established between the joint forms the foundation or basic building
ear and the TMJ. One’s knowledge of this rela- blocks for a complete understanding of the adult
tionship will not only help to better render structure. This will allow the clinician to accu-
appropriate care but will enable the dentist to rately determine the root cause of the patient’s
better explain to the patient why their symp- complaints and enable the clinician to apply
toms are not within the ear itself but are associ- appropriate treatment modalities to resolve the
ated closely with a dysfunctional relationship problem. The fact that the TMJ is similar to other
of the TMJ. synovial joints allows it to be included in the
broad category of orthopedic disorders. These
disorders have no treatment that results in a com-
1.10 Hyoid Syndrome plete cure. Therefore, orthopedic problems must
be managed correctly in order for the patient to
The hyoid bone has been identified with a spe- enjoy as pain-free and functionally complete life
cific but not well-recognized pain syndrome for as possible. The clinician’s understanding of how
over 40 years (Lim 1982). The painful symptoms the head and neck develops is critical for treat-
are generally caused by trauma at the greater ment success and education of the patient.
cornu of the hyoid bone with pain radiating to
other sites. The pain usually radiates to the throat,
mandible, mandibular molar teeth, zygomatic References
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Anatomy of the Masticatory
System
2
Homer Asadi and Alan Budenz
Abstract
In order to appreciate the normal function and dysfunction of any system,
and more specifically the stomatognathic system, the starting point should
involve a complete and thorough understanding of the anatomy of this
system. The masticatory system is composed of an array of rather complex
anatomical structures that often operate in unison to provide unique and
selective daily functions. The orchestration and coordination of the mus-
cles, bones, nerves, and vessels allow human beings to perform functions
only capable by our species. However, when this finely tuned arrangement
is upset, the outcome, in some individuals, may involve pathosis involving
dysfunction, dysregulation, and/or pain. This chapter provides a descrip-
tive anatomical review of the masticatory system. Ultimately, this knowl-
edge will assist the clinician in recognizing specific disorders, their signs
and symptoms, diagnosis and treatments, and the relationship to the ana-
tomic structures of this intricate system.
2.1 Osteology of the Mandible and the horizontally oriented body anteriorly on
each side of the mandible. The ramus has two
The mandible is a “u” shaped, one-piece bone, projections arising from its superior aspect, the
bilaterally symmetrical in its normal state. It con- condylar and the coronoid processes. The condy-
sists of the vertically oriented ramus posteriorly lar process arises from the ramus of the mandible
posteriorly and consists of a head and a neck. into the body of the mandible. The anterior bor-
There is a shallow depression on the anterior der of the ramus and oblique ridge on the external
aspect of the condylar neck, the pterygoid fovea, surface of the body are referred to as the external
which serves as the attachment for the inferior oblique line or ridge.
head (belly) of the lateral pterygoid muscle and The upper portion of the mandibular body
the majority of the superior head (belly). The contains the bony support for the teeth, the alveo-
anteriorly located coronoid process is the site of lar process, in which individual bony sockets
attachment of the temporalis muscle of mastica- house the mandibular teeth. Other features on the
tion. The curved depression between the two pro- external body of the mandible are the mental
cesses on each side is the mandibular (sigmoid) foramen and the mental ridges and prominences
notch (Fig. 2.1). The posterior-inferior corner of of the chin (mental region). Although there are
the mandible is the angle (gonion) of the mandi- variations, the mental foramen is usually found in
ble. Anterior to the gonial angle along the infe- close proximity to the apex of the second premo-
rior border of the mandible, there is an upward lar tooth (Fig. 2.2).
depression of the inferior border, the antegonial The inner surface of the mandibular ramus has
notch. The masseter muscle attaches to the entire a second ridge that descends vertically just inside
lateral surface of the ramus and may produce from the anterior border/external oblique ridge.
roughness at the sites of insertion or a tuberosity This second ridge is the internal oblique ridge.
at the insertion at the angle of the mandible. The The depression that lies between the internal and
internal surface of the ramus shows a similar external oblique ridges is the retromolar fossa.
roughness in the region of the gonial angle due to Like the external oblique ridge, the internal
the attachment of the medial pterygoid muscle of oblique ridge gently curves anteriorly and inferi-
mastication. orly as it blends into the body of the mandible.
The anterior border of the coronoid process This portion of the internal oblique ridge is also
descends vertically and becomes the anterior bor- known as the mylohyoid line or ridge because it
der of the ramus. This edge has a distinct curved is the origin of the mylohyoid muscle, which
indentation just below the coronoid process, the forms the floor of the mouth (Fig. 2.3). Inferior to
coronoid notch. As the anterior border continues the mylohyoid ridge and posteriorly is a depres-
inferiorly, it thickens into an oblique ridge that sion in the bone referred to as the submandibular
gently curves anteriorly and inferiorly as it blends fossa, which houses the superficial portion of the
coronoid condylar
process process
Fig. 2.1 Lateral view of the mandible Fig. 2.2 Anterior view of the mandible
2 Anatomy of the Masticatory System 19
submandibular gland. Anteriorly, on the medial it courses anteriorly to supply the mylohyoid and
aspect of the mandible in the mental region is a anterior belly of the digastric muscles.
small depression located inferior to the mylohy-
oid ridge which is termed the digastric fossa.
This is the location where the anterior belly of the 2.2 steology of the Temporal
O
digastric muscle attaches to the mandible. Bone
Superior to the mylohyoid ridge on either side of
the midline on the medial aspect of the mandible The bilateral temporal bones form the lower lateral
are two projections, a superior and an inferior surfaces of the cranium and the cranial base. Each
mental spine (genial tubercle). The superior spine temporal bone articulates with the zygomatic bone
is the site of attachment of the genioglossus mus- anteriorly, the frontal bone anterosuperiorly, the
cle, and the inferior spine is the site of attachment parietal bone posterosuperiorly, and the occipital
of the geniohyoid muscle. bone posteriorly. The temporal bones also articu-
The blood supply and innervation of the man- late with the condyle bilaterally (Fig. 2.4).
dibular teeth are from the inferior alveolar neuro- Based upon its embryological origins from
vascular bundle. This bundle enters the bone of three separate centers of ossification, the temporal
the mandible through the mandibular foramen, an bone is comprised of the squamous, the petrous,
opening on the medial surface of the ramus. The and the tympanic portions. The squamous portion
lingula is a bony projection just medial to the forms the flat lateral wall of the lower cranial vault
mandibular foramen which serves as the attach- and projects anteriorly as a thin process to form the
ment of the sphenomandibular ligament. Inferior zygomatic arch in combination with the zygomatic
to the mandibular foramen, a bony groove, the bone. The petrous portion forms the dense base of
mylohyoid groove, runs inferiorly and anteriorly, the cranial vault which houses the auditory and
housing the mylohyoid neurovascular bundle as vestibulocochlear structures and separates the pos-
terior cranial fossa from the middle cranial fossa.
The mastoid process, with its air cells communicat-
ing with the middle ear cavity, projects inferiorly
from the petrous portion of the temporal bone. The
anteriorly located tympanic portion of the temporal
condylar
process Mandibular
(sigmoid)
notch fontal bone parietal
bone
temporal lines
sphenoid
bone
temporal bone
occipital
mylohyoid bone
groove mastoid
process
mylohyoid mandible
line
Fig. 2.3 Medial (inner) view of the mandible Fig. 2.4 Lateral view of the cranium and mandible
20 H. Asadi and A. Budenz
temporal line of the skull. At the lower end, as the der of the masseter muscle one to two finger-
temporalis fascia approaches the zygomatic arch, breadths below the zygomatic arch, and then
it splits into a superficial and a deep layer. The dives deep to pass through the buccinator muscle
superficial layer passes superficially over the to open into the buccal vestibule through the
arch, while the deep layer follows the temporalis parotid papilla adjacent to the first to second
muscle inferiorly to its attachment to the coro- maxillary molar tooth. The transverse facial
noid process of the mandible. The temporal fat artery, arising from the superficial temporal
pad is positioned between these two layers of the artery, is within a fingerbreadth inferior to the
temporalis fascia. zygomatic arch and also crosses the masseter
muscle. Additionally, branches of the facial
nerve (cranial nerve VII), motor branches to the
2.3.2 The Masseter Muscle muscles of facial expression, emerge from the
anterior border of the parotid gland to pass ante-
The masseter muscle arises from the inferior bor- riorly to enter the deep surfaces of the more cen-
der of the zygomatic arch from two heads. The trally located muscles of facial expression. The
larger, more superficial head arises from the ante- facial artery, the chief blood supply to the super-
rior two-thirds of the inferior border of the zygo- ficial face, crosses the inferior border of the
matic arch, and the smaller, deeper head arises mandible within the antegonial notch to traverse
from the more posterior one-third. The fibers of onto the face just anterior to the superficial mas-
the superficial head extend inferiorly and posteri- seter muscle.
orly from the arch to the ramus, while the more The neurovascular bundle supplying the
posterior deep head fibers run in a strictly vertical masseter muscle enters the deep surface of the
direction. The two heads of the masseter muscle muscle by passing through the mandibular
attach to the entire lateral aspect of the ramus, notch of the ramus. The masseteric nerve origi-
extending inferiorly to the gonial angle and the nates from the mandibular division of the tri-
inferior border of the mandible (Fig. 2.6a, b). geminal nerve. The masseteric artery is a
The masseter muscle is substantially covered branch of the maxillary artery within the infra-
by the parotid gland, which is cupped around the temporal fossa, and the masseteric vein drains
posterior border of the mandibular ramus and into the pterygoid venous plexus, which
projecting anteriorly over the masseter muscle. coalesces into the maxillary vein.
The parotid duct arises from the anterior border The masseter muscle is a primary elevator of
of the parotid gland, crosses to the anterior bor- the mandible. Because the fibers of the superfi-
cial head are also angled posteriorly, they aid in
protrusion of the mandible. The deep head of the
masseter, being more vertically oriented, also has
a minor role in retrusion of the mandible. It is
always important to remember that although the
muscles of mastication are bilaterally paired,
they all insert onto a single bone, the mandible,
and therefore all movements of the mandible
require coordination of both sets of masticatory
muscles.
Fig. 2.6 Masseter muscle, dissected view. DM deep mas- The temporalis muscle is often described as a
seter, SM superficial masseter large, fan-shaped muscle which originates from
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she is not shut up like an Arab woman.
Whilst the man journeys afar with the caravans, or on freebooting
expeditions, she remains at home to direct affairs. But this is not all,
for she studies old traditions, is highly enlightened, and far in
advance of the men in knowledge of old customs and manners, and
also of the art of reading and writing the Tuareg language. In short, it
is she who preserves their traditions and is acquainted with their
literature, and indeed sometimes ranks as the highest authority of
the tribe.
Duveyrier relates that amongst the eastern Tuareg the women
take part in the councils when the tribes assemble, just as did the
Iberian women in ancient days.
In the battlefield it is often dread of the women’s scorn which
drives the men to make the utmost efforts to return victorious.
“This trait reminds one of the Iberian maidens, who chose their
husbands from amongst the bravest warriors.”
Descent on the mother’s side alone ennobles, and the children
belong to the family of the wife.
For instance, the son of a nobly born woman and a slave is
acknowledged as free born, whereas the son of a slave and a free
man remains a slave. But, in favour of the latter, certain tribes have
created a particular caste called “Iradjenat,” who, though yet slaves,
are exempt from certain heavy labour.
It must be added that the women have entire control over their
own property.
Inheritance in the tribes goes from a man to his brother, and, in
default, to the son of a sister, but never to the direct progeny.
In such communities misconduct on the part of women is not
tolerated, it is simply punished with death. Captain Bissuel relates
that a native of the province of Setif killed his sister by order of his
father, they having learnt that she was leading a dissolute life. Both
father and brother mourned for the poor culprit, but were convinced
that they had only done their duty.
On the other hand, according to Duveyrier, the Tuareg lawfully
claim le droit du seigneur from their female slaves, before these
marry.
The same custom is mentioned by Herodotus as obtaining
amongst the Adyrmachidæ in the neighbourhood of Egypt.
The western Tuareg regard this custom as despicable.
The Tuareg have to give their wives a dowry, which varies in
amount. The western Tuareg, for instance, give at least six camels, a
negress, and a complete costume.
These are the principal features of Tuareg customs. They have
many points in common with those of the mystical Amazons and the
Iberians of antiquity.
Even now among the Basques the man plays a subordinate part.
The woman rules and controls the house. “The husband is her head
servant,” who brings to the house only himself and his labour,
together with a stipulation for progeny.
The Arabs.
The Arabs in Tunisia are, like those in Algeria, nearly all nomads.
They reside chiefly in the southern and central portions of the
Regency.
They are recognisable by their tall, slender figures, their lean,
muscular build, and by their dignified nobility of carriage.
The Arab cast of countenance is narrow, the nose curved, the lips
thin and graced by a delicate black beard, the black eyes are lively,
but the expression crafty.
The Arab woman is endowed with a pretty, well-formed figure, but
she is of small stature. She is, on the whole, attractive, but fades
early, being old and ugly through hard work by the time she attains
her twentieth year. Unlike the Berber woman, she is usually obliged
to go abroad veiled.
As the Bey was too weak to collect his own taxes, he united the
various groups of nomad Arabs to form his auxiliary troops. These
tribes were thence designated “Mahzen,” were almost exempt from
taxation, or only paid in kind, such as oil, dates, etc. In return they
bound themselves to fight the robber bands (Jish) who frequently
harassed the country. Were they victorious, all spoils were theirs.
Their ostensible duty was to assist the Bey’s own soldiers to recover
the taxes. This collection resolved itself into sheer plunder. The least
of their perquisites was the right to “diffa” and “alfa,” which means
hospitality for themselves and their horses; of this they took
advantage to the greatest extent, often pillaging wherever they
appeared.
For instance, the holy city of Kairwan was often compelled to raise
forced contributions under this pretext.
Their morals, as a rule, are very lax. The abduction of married
women and girls is common, and adultery a matter of course.
The upbringing that an Arab woman receives in a tent is not
exactly calculated to ensure in any way a moral tone. A young girl is
from the very outset of her innocent life apt to see and learn much
that to us appears offensive.
Whereas the man has every possible right of control over his wife,
she has only the “justice of God” (el hak Allah), meaning that he
must fulfil his obligations towards her as her husband, failing which
she can demand a divorce, not an infrequent occurrence.
After the enactment of the law emancipating slaves, the men in
some tribes married their negresses, with a view to thus evading the
law. But it befell that the former went into court and complained that
they were defrauded of their rights as wives.
Although the Arabs, as aliens, have always been in a minority in
the land of the Berbers, yet they were the masters until the arrival of
the French. They had steadily spread themselves over all the open
plains and lower tablelands, moving ever from east to west. Thus
each tribe continually changed its territory, one tribe ever pressing
another before it farther westward.
Long before Mohammed’s day this immigration had already
begun, but it was not until after his time that it made any real
headway, and the conquest of the country and its conversion to
Mohammedanism took place.
Not until much later, in the middle of the eleventh century, was the
great migration accomplished, in which both Mongols and Egyptians
were included. Such great waves, however, always cause a counter
wave. When the tribes reached the shores of the Atlantic on the
most distant coasts of Morocco, the tide turned. Thus the tribe that
claims to be the chief of all the tribes, namely, the Shorfa, or
“Followers of the Prophet,” is precisely that which, having been to
Morocco, returned eastwards.
Yet another receding wave brought back the “Arabs” who had
conquered Spain, and who were afterwards driven forth again.
These Spanish “Arabs” were for the most part Berbers who had
been carried westward by the tide, and who returned, after a long
sojourn on the Iberian peninsula, blended with other races—
Ligurians, Iberians, Celts, and Western Goths.
The greater proportion of these refugees, who are known in
Barbary as “Andaluz,” established themselves in the towns, where
they introduced a new strain into the already mixed race of Moors.
These Spanish Moors are more especially represented in Tunis.
It is quite natural that, in a country so often invaded and peopled
by foreigners who to this day have never really amalgamated, there
should be an entire lack of patriotism such as is found in Europe. It is
as Mussulmans that these races have united to make war against
the Christian. Amongst themselves they are often at enmity.
Mohammedanism.
Though it is an undoubted fact that the various races of Berbers
and Arabs have preserved much of their identity, it is also noticeable
that, to a stranger arriving in the country for the first time, the
inhabitants appear, as it were, to be fused into one race. This fusion
is the result of their creed, for Mohammedanism has been drawn like
a veil over the whole country.
Mohammed, through the Koran, gave to even daily labour the
stamp of religion, and in a marvellous way moulded all the various
races, who thus became “the faithful,” into one mode of thought and
life, which gradually shaped them all to one pattern, although
hereditary inclinations and customs contended, and are still
contending, against such constraint.
The features which appear most strongly marked in these various
races who have become Mussulmans, are their individual absorption
in their religion and their family organisation.
The stubborn influence of Islamism on the community is entirely
expressed in the phrase “Mektub” (it is written). Fatalism has
destroyed all initiative, all progress. How men may act is immaterial.
“It is written.”
To the Mussulmans, authority is of divine origin. Their creed
ordains that everyone must bow to authority. This has given rise to
the most complete absolutism, alike from the Bey, whose title is “The
chosen of God and the owner of the kingdom of Tunisia,” down to
the lowest of officials.
But yet the yoke may prove too heavy—then the oppressed revolt,
as has so often happened.
The influence of religion is manifest in the treatment of the insane,
whose utterances are held as sacred. The number of real and
pretended lunatics is consequently very great. Hospitality is not
exactly gladly offered to such afflicted persons, but they are
permitted to take whatever they please from a house, a liberty often
very widely interpreted. Latterly a madman in Tunis declared several
houses to be under a ban. All the inmates at once fled, and could not
be persuaded to return. This individual was also inspired with the
sublime idea of erecting a barricade in one of the most populous
streets, by means of doors which he lifted from their hinges.
The Prophet organised the family on the lines best adapted to the
nomad tribes, who were destined to be great conquerors. He
ordained the absorption of the vanquished into the family; while the
males were killed or, if fortunate, made slaves, the women were
allowed to enter the family.
This was the foundation of the rapid conquest of North Africa by
Islam.
To ensure unity in the family, composed of so many and varied
elements, the man is invested with the most absolute authority. He
does not marry but he buys his wife, who becomes his property. He
is unquestionably her lord and master, he can maltreat her, kill her if
she is untrue to him, without risking injury to a hair of his own head.
All that he owes her is the “hak Allah.”
Crimes against women are more rare now through fear of the
French; but as there is no legal census, many murders may be
committed which are never brought to light.
Religious influence first and foremost, also life in common under
equal conditions of many generations of different extraction, have
obliterated many of the characteristics of the natives of Tunisia.
Many Berber tribes have been entirely transformed into Arabs, and,
on the other hand, many Arab tribes have been Berberised. Indeed,
there are tribes forming a subdivision, of which it is well known some
are Berbers, some Arabs.
Of the religious brotherhoods, so numerous elsewhere under
Islam, there are comparatively few in Tunisia. We find the
“Tidyanya,” “Medaniya,” and the “Aissaua,” and, besides these,
many scattered “Shorfa.”
In the towns there is more fanaticism than in the country. In this
respect “those who can read and write are the worst.”
Yet many customs and reminiscences may be found of a former
age before Mohammedanism was forced on the Tunisians.
For instance, the people hang bits of rag all over sacred trees;
many fear the “evil eye,” or honour five as a peculiarly lucky number.
For this reason they set the mark of their own five fingers on their
houses to protect the latter. Indeed, it is not uncommon for a man
who has more than five children, if questioned as to their number, to
reply that he has five, rather than be obliged to name an unlucky
number.
If rain is long delayed, they take refuge in exorcism, and will on
occasion even dip their kaid in a fountain so that his beard may be
wetted—that surely brings rain.
The Moors.
Nowhere has all origin of race been so entirely effaced as in the
towns. There have sprung up the Moors—quite a new race of town
dwellers, which may be said to have absorbed all others.
Whereas the population of the interior of the country to a great
extent escaped intermixture with the new elements, up to the time of
the arrival of the Arabs, it has been quite otherwise in the towns,
where foreign traders settled and intermingled with the native
inhabitants.
Amongst the Moors in the towns are found, as has been said, the
so-called “Andaluz,” who were driven out of Spain. Several of these
distinguished families have carefully preserved the records of their
genealogy, and some of them still possess the keys of their houses
in Seville and Granada. They have certainly intermarried with other
families of different origin, but still cling to their traditions, and retain
and exercise to a certain extent the handicrafts and occupations of
their forefathers in Spain. The gardeners of “Teburka,” for instance,
are descendants of the gardeners of the Guadalquivir, and the
forefathers of the potters near Nebel were potters at Malaga.
The blood of slaves of all nationalities has also been introduced
into the people known as Moors.
The complexion of the Moor is fair, or, more rarely, olive; it
resembles that of the Southern Italian or Spaniard. The shape of the
head is oval the nose long, and they have thick eyebrows and very
black beards. Of medium height, they are well built, and their
carriage is easy and graceful. They are considered more honourable
than either Jews or Christians, and were noted formerly for their kind
treatment of their slaves. Though clever workmen and well educated,
their moral tone is not high. In old days the town of Tunis was the
great market frequented by the people of the Sudan; nothing was
considered worth having that had not been made by a Tunisian.
The Turkish element, as represented by the Bey and his
surroundings, has long since ceased to have any influence on the
Moorish race in Tunisia. No real Turks are now to be found in the
country. In the towns, however, are a few descendants of Turkish
soldiers and Tunisian women; they are called “Kurughis,” and are
lazy, vain, and ignorant, and consequently not much respected.
The Moors, or the town dwellers, on the whole, are, however, not
so vigorous and energetic as the nomads and the mountaineers;
their manners are more effeminate, and they are lazier.
Crimes against the person, such as assault or murder, are rare in
the towns, but drunkenness on the sly is common, and immorality is
prevalent.
The Jews.
The ancient conquerors of the country, the Carthaginians and
Romans, who covered it with towns, forts, and monuments, have left
no impress of themselves on the appearance of the present
inhabitants, nor do there survive amongst the tribes any traditions
concerning them.
No more remains to recall the Vandals and Goths, yet the latest
researches prove the existence in early days of other Semitic
peoples besides the Arab.
The earliest importation to the country of Semitic blood was
doubtless the Phœnician. To this is due the fact that many of the
types portrayed on Chaldaic and Assyrian ruins are now found
scattered throughout Tunisia.
At the same time as the Phœnicians may be mentioned the Jews,
the earliest of whom probably came to Barbary at the same time as
the former, but their number was largely added to later, after the
conquest of Jerusalem by Titus. Moreover, it is known that many
Berber tribes were converted to Judaism and remained Jews, even
after the Arab conquest. The classic type of European Jew is
therefore rarely met with in Tunisia.
After the Mohammedans the Jews are, numerically, most strongly
represented in Barbary. They form somewhat important
communities, not only in the town of Tunis, but also in all other
towns, even in the island of Jerba. Possibly with theirs has mingled
the blood of the ancient Carthaginians.
There are also a great number of Jews whose ancestors were
ejected from Spain and Portugal; these are called “Grana,” from their
former most important trading city in Spain.
These “Grana” were under the protection of the foreign consuls,
and therefore have had nothing to complain of; but the old Jews
were in a disastrous condition in former days, and suffered much, so
much that some isolated families abjured Judaism and became
Mohammedans; such they are still, but they always associate with
their former co-religionists. Other Jews—those of Jerba, for instance
—have modified their religious forms, pray to Mohammedan saints,
and hold their Marabouts in honour.
A peculiar head-dress distinguishes those Jews who are under no
protection, from those who are protected by the consuls. It is an
irony of fate that many Jews have placed themselves under Spanish
protection, because they knew that Spain was their home in old
days. Now they are protected by the country that formerly drove
them forth. Somewhat similar is the case of the Algerian Jews in
Tunis who seek French protection.
All the Jews of Tunis retain the ancient Spanish ritual. They are
peaceful and well behaved, and not so grasping as others of their
faith, but they are clever at taking advantage of a good opportunity
when there is a prospect of making money, or when their trade may
be extended. Commerce is therefore in great measure in their
hands.
In the whole Regency of Tunisia there are over fifty thousand
Jews, and their numbers increase rapidly. In the town of Tunis there
is a “ghetto,” the quarter formerly devoted to them, and where they
were compelled to dwell. It has long since become too small, and the
Jews have now spread over all the other quarters, and in the
bazaars have wrested from the Moors many of their shops.
This Jewish community is an interesting study, and one is
astonished to find how in many respects they so little resemble their
co-religionists in other countries.
COSTUMES
Berbers)