Transcript Examination of the tempro-mandibular joint and related muscles

Dr. Sahar Taha, BDS, MS, Dip-(ABOD)
Management of Temporomandibular
Disorders and Occlusion, 6th edition
Jeffery Okeson
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A complete medical and dental history should be
taken.
The history should be taken with the patient sitting
upright in a quiet, relaxed atmosphere, ideally away
from the treatment room.
Use a questionnaire.
Eye contact and a friendly, interested demeanor on
the part of the clinician promotes body language that
will enhance nonverbal communication.
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The history and examination should be directed
toward the identification of masticatory pain
and dysfunction. Masticatory pain is
charachterized by two features: it originates in
the masticatory structures and it is related to
masticatory function.
Some medical conditions might be associated
with temporomandibular disorders like arthritis.
The use of a questionnaire that the pt fills on
their own can lead to a general evaluation of
the condition then the dentist can focus on
certain aspects of the history that pertain most
to the condition and ask some more problem
specific questions.
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Whenever a pain symptom is reported, special
attention must be given to its location,
behavior, quality, duration and degree.
The more vaguely a patient localizes the pain,
the more specific the examiner's inquiry must
be.
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Report patient’s expectations.
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Report the social history of the patient.
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Some patients may want only to
know what is their problem, others
may want to relief their current
symptoms only.
Social history is very important as
you can evaluate the psychological
status of the patient. It is important
to ask about the level of education,
marital status, and employment.
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Seven critical questions as defined in the
1983 ADA President’s Conference on
Temporomandibular Disorders:
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Difficulty in mouth opening?
Pain or clicking in the jaw joint?
Pain on chewing, yawning or wide opening?
Pain in or about the ears or cheeks?
A bite that feels “uncomfortable”or “unusual”?
A jaw that “locks,” “gets stuck” or “goes out”?
Noises in or from the jaw joints?
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It is also very important to ask when
the dysfunction happened.
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History of previous treatment
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Other associated symptoms
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Symptoms like headache, neck pain,
shoulder pain, or earache should be
reported.
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Aims to detect masticatory
dysfunction through examining:
The muscles
 The joints
 The teeth
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Dentist either standing or sitting at
the 12 o’clock position (range 11-1).
The patient is semi-reclined or fullyreclined. The third position is
probably the best.
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There is no pain usually associated
with the function or palpation of a
healthy muscle.
The muscles can be examined by
palpation or functional manipulation.
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When pain is felt during muscle
palpation, it can be deduced that the
muscle tissue has been compromised
by either trauma or fatigue.
Accomplished by the palmer surface
of the middle finger, with the index
and forefinger testing the adjacent
areas.
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Soft but firm pressure should be applied
with a slight circular motion.
The patient is asked to classify the response
to palpation into one of four categories (get
away from subjectivity):
0= no pain felt at all
1= uncomfortable
2=definite discomfort or pain
3= evasive action or eye tearing, or a desire
to not have the area palpated again.
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the temporalis muscle is divided into
three functional areas. The anterior
part is palpated above the zygomatic
arch anterior to the TMJ.
The middle part is palpated directly
above the TMJ and superior to the
zygomatic arch.
The posterior part is palpated above
and behind the ears.
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Superior and inferior attachments of
the muscle should be palpated.
The fingers are placed on the
zygomatic arch then dropped down
slightly to palpate the deep masseter
just anterior to the TMJ.
The inferior attachment (superficial
masseter) is palpated on the inferior
border of the ramus.
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This muscle is palpated at its insertion on
the medial surface of the angle of the
mandible.
The fingers are placed on the inferior border
of the mandible and rolled medially and
superiorly.
If uncertainty arises during palpation of this
muscle, the pt can be asked to clench the
teeth together, thereby, the medial
pterygoid can be felt easier.
A lot of false positive results for this
method.
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This muscle is palpated intra-orally. It is best be seated in front of
the patient.
The index finger is placed in the maxillary buccal vestibule and
the patient is instructed to close partially and to move the
mandible to the side being examined.
Having the patient partially close and moving the mandible to the
site of palpation moves the coronoid process away from the site of
examination.
Palpation of this muscle leads to the highest false positive results.
It is a narrow area and doing the palpation forcefully in the area
may elicit pain. Sharp fingernails may also elicit pain. In addition,
evidence suggest that this technique does not actually reach the
attachment of the lateral pterygoid muscle to the lateral
pterygoid plate. Therefore, this muscle can not be examined
clinically. The discomfort caused by palpating this area is thought
to be from the superior attachment of the medial pterygoid
muscle.
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Posterior neck muscles
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Sternocleidomastoid
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Although these muscles do not directly affect
mandibular movements, they can become
symptomatic during certain TM disorders.
Trapezius, splenius, capitis, semispinalis capitis.
It is at this stage to evaluate any possible
craniocervical disorders. The patient can be
asked to rotate his head to the right and left
and move it up and down. This is done to
distinguish muscular from vertebral problems,
and referring the patient to the right physician.
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Useful in case muscles are difficult to
palpate.
Relies on the fact that function will
induce or increase pain in fatigued or
traumatized muscles.
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Medial pterygoid, inferior and superior
lateral pterygoids.
Medial pterygoid is resnposible for closing
the mouth. So pain will be elicited when the
patient is asked to close his mouth or biting
down on an object. Also, stretching of the
muscle during opening the mouth would be
painful.
Pain would be elicited in the inferior lateral
pterygoid if the patient is asked to protrude
the mandible against resistance from the
operator.
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Palpation
Auscultation
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Extrameatal
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Intrameatal
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In the extrameatal joint examination the finger tips are
placed on the lateral aspect of the TMJ on both sides
simultaneously. And the patient is asked to open and
close his mouth and if any pain was elicited it should
be recorded using the same pain scale for the muscles.
In the intrameatal joint examination the little finger of
both hands is placed in the external auditory meatus,
pushing slightly forward, pain should be evaluated in
the static position, while opening and closing.
The intrameatal examination aims to evaluate
symptoms from the posterior and lateral aspects of the
joints.
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Click
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Crepitation
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Sounds may be heard by the stethoscope or
felt by placing the fingertips at the lateral
aspect of the TMJs.
It should be noted the severity of such
sounds, unilateral or bilateral, on closing,
opening or both.
A click is a single sound of short duration,
relatively loud, also referred to as a pop.
Crepitation is a gravelike sound described
as grating and complicated.
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Determination of
maximum interincisal
opening (53-58 mm)
<40 mm
Deviation ?
Deflection ?
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Even a child can open to 40mm. The average
mandibular opening measured interincisally is 53-58
mm.
If the patient opens comfortably to a certain
measurement and then opens more but with pain,
both measurements should be recorded.
The crude measurement of the opening is three
fingers.
Less than 40mm is restricted.
Deviation in mandibular movement is a shift from the
midline during opening that disappears with continued
opening.
Deflection is a shift from the midline that becomes
greater when opening and does not disappear at
maximum opening.
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Determination of lateral
excursions (approximately
10mm)
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Movements of less than 8mmis considered
restricted.
Measure the distance moved from the
midline.
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Determination
of protrusion
(5mm or >)
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Inspect the teeth
and their
supportive
structures for any
signs of
breakdown.
Common signs and
symptoms:
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Tooth mobility
Pulpitis
Tooth wear
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It is important to distinguish functionally
optimal occlusion and normal occlusion.
Normal occlusion could be a deviation
from ideal occlusion; however, it does not
induce pathology.
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Centric occlusion
(MIC)/centric
relation
discrepancies
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TMJ radiographs
 Used to gain additional
insights especially when
pathology is expected
to rule out malignancy.
 Provide information
regarding:
 Morphological
characteristics of the
bony components of the
joint
 Certain functional
relationships between
the condyle and the
fossa.