EXAMINATION OF THE TEMPRO-MANDIBULAR JOINT AND RELATED MUSCLES

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EXAMINATION OF THE TEMPRO-MANDIBULAR JOINT AND
RELATED MUSCLES

• Dr. Sahar Taha, BDS, MS, Dip-(ABOD)

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Reference

• Management of Temporomandibular Disorders and
  Occlusion, 6th edition
• Jeffery Okeson

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Before you start the examination

• 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.
  
• Report patients expectations.
• 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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Critical questions to be asked!

• Seven critical questions as defined in the 1983
  ADA Presidents Conference on Temporomandibular
  Disorders
• 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 uncomfortableor 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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Also report

• History of previous treatment
• Other associated symptoms

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• Symptoms like headache, neck pain, shoulder pain,
  or earache should be reported.

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Clinical examination

• Aims to detect masticatory dysfunction through
  examining
• The muscles
• The joints
• The teeth

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Patient positioning for the examination
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• Dentist either standing or sitting at the 12
  oclock position (range 11-1). The patient is
  semi-reclined or fully-reclined. The third
  position is probably the best.

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Neuromuscular examination

• 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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Muscle plapation

• 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
• 2definite discomfort or pain
• 3 evasive action or eye tearing, or a desire to
  not have the area palpated again.

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Temporalis muscle palpation
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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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Masseter muscle palpation
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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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Medial Pterygoid palpation
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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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Lateral Pterygoid palpation
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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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Also palpate..

• Posterior neck muscles
• 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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Functional manipulation

• 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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TMJ evaluation

• Palpation
• Auscultation

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TMJ palpation

• Extrameatal
• 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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Joint sounds

• Click
• 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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Evaluation of madibular movements

• Determination of maximum interincisal opening
  (53-58 mm)
• lt40 mm

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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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Evaluation of madibular movements

• 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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Evaluation of madibular movements

• Determination of protrusion (5mm or gt)

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Examination of the teeth and occlusion

• Inspect the teeth and their supportive structures
  for any signs of breakdown.
• Common signs and symptoms
• 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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Examination of the teeth and occlusion

• Centric occlusion (MIC)/centric relation
  discrepancies

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Supplementary diagnostic tools

• 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.

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