THE

TEMPOROMANDIBULAR
JOINT

DR. AMINAH KHAN

OMFS RESIDENT
 CONTENTS
 HISTORY- Screening questions
Cheif complaint
History of presenting Illness
 EXAMINATION- Inspection
palpation
auscultation
occlusal evaluation
 RADIOGRAPHIC EXAMINATION- OPG
tomography
Arthrography
CT
CBCT
Nuclear imaging
 Patients come for consultation regarding pain and dysfunction
 Most common cause are muscular disorders referred to as Myofascial pain and dysfunction
 Other causes:
Osteoarthritis
Rheumatoid arthritis
Chronic recurrent dislocation
Ankylosis with in TMJ
Neoplasia
Infection
 1) HISTORY
 CHEIF COMPLAINT:
Statement of the patient`s reasons for seeking consultation

 HISTORY OF PRESENTING ILLNESS:

Accurate description of symptoms,

location remitting factors,

quality and severity exacerbating factors,
quantity setting
timing associated manifestation
 Screening questions

Do you have difficulty and/or pain opening your mouth, for instance, when yawning?

 2. Does your jaw get “stuck,’’ “locked,’’ or “go out’’?

 3. Do you have difficulty and/or pain when you are chewing, talking, or using your jaws?

 4. Are you aware of noises in the jaw joints?

 5. Do your jaws regularly feel stiff, tight, or tired?

 6. Do you have pain in or about the ears, temples, or cheeks?

 7. Do you have frequent headaches, neck aches, or toothaches?

 8. Have you had a recent injury to your head, neck, or jaw?

 9. Have you been aware of any recent changes in your bite?

 10. Have you previously been treated for any unexplained facial pain or a jaw joint problem?
 PAIN
 LOCATION
ASK THE PATIENT TO POINT IT OUT FOR YOU

 SIGNIFICANCE:
POINTING TO A SPECIFIC LOCATION OF PAIN OF ORIGIN IS
MORE RELIABLE THAN DRAWING CIRCLES AND SHOWING AN AREA. Radiating pattern
should also be asked.
CONT`D
QUALITY QUANTITY
 SIGNIFICANCE:  Visual Analog Scale
Provide a clue to origin of pain

 Dull and achy- Muscular origin

 Sharp and shooting- Acute condition
CONT`D
TIMING SETTING
 SIGNIFICANCE: Determining the cause.  A stressful situation may initiate a
parafunctional habit e.g nail biting, nocturnal
bruxism
 Morning- Systemic arthritis ( RA)  Immediately after trauma during eating
Nocturnal Bruxism
Or Facial trauma

 End of day/ Night- Osteoarthritis

CONT`D
REMITTING FACTORS EXACEBRATING FACTORS
 Rest  Activity
 Previous treatments
 Medications
CONT`D
 ASSOCIATED FACTORS:
 Headaches
 Limited mouth opening
 Clicking
 Crepitations
 Dislocation
 Subluxation
 2) EXAMINATION
 4 STEPS:

 Inspection

 Palpation

 Auscultation

 Occlusal examination
 INSPECTION
 FACE: asymmetry
 SKIN: scars, swelling, redness

 MANDIBULAR FUNCTION:
Mouth opening
Protrusion
Excursion
Deviations and deflections
 MOUTH OPENING:
 Normal- 42 -57mm

 Value less than 40mm is considered

restricted mouth opening
Mouth opening should be checked actively and passively.

 Mild to moderate but steady pressure is

applied with the index finger and thumb.
 Technique used to measure the quality of
limitation/ restriction of muscle and joint
by mean of “end feel”
 The values of both can be compared.
 END FEEL:
 Describes characteristic of restriction.

 Muscular restriction- soft end feel

more than 5mm of passive opening is achieved

 Joint disorders- non reducing disc displacement

hard end feel
no increase in passive mouth opening
 LATERAL EXCURSION:
 8-10mm
 After examining midlines
 Measure displacement between mandibular
and maxillary central line midlines
 Note if movements are asymmetric
 Values less than 8 are considered restricted
 DEVIATION DEFLECTION
 Any shift of jaw midline during opening that  Any shift of jaw midline to one side that
disappears upon continued opening- becomes greater and does not disappear at
maximal opening-
 Towards the affected side
 Towards affected side in late stages of opening
Disc derangement
Restrictive movements of joint
Muscle spasm
non reducing disc displacement
Mechanical locking
Subluxation
 Note if limitations to movements is because of pain or
stiffness
 Limitations albeit a sign of TMJ disorder may be
caused by intracapsular pathology, muscle dysfunction
or both.
 PALPATION
 JOINT:
 Palpate joint when mouth is opened and closed.
 Load each TMJ separately- wooden tongue depressors placed on molars

 MUSCLES:
 Muscle of mastication - temporalis, masseter, lateral and medial pterygoid
 Sternocleidomastoid
 Trapezius

 Note tenderness on superficial and deep palpation.

 Note any trigger points.
 LATERAL PALPATION
 The lateral aspect of the joint is palpated by pressing gently over the immediate preauricular
area, both at rest and during motion
 INTRA- AURICULAR PALAPTION
 TMJ pain and tenderness are mainly related to the
area of the posterior bilaminar zone of the disc and
the posterior aspect of the capsule.
 Place the little finger in the external auditory
meatus on one side at a time and applying gentle
forward pressure, while asking the patient to open
and close the mouth
 if there is acute disc displacement, this method of
examination can be very uncomfortable for the
patient
 Temporalis:
 EXTRAORAL:
 Palpate anterior ( verticle ), middle (oblique) and posterior fibers (horizontal)when the patients
teeth are firmly clenched
 Intraoral:
 It is common for some TMDs to produce a
temporalis tendinitis
 which can create pain in the body of the
muscle as well as referred pain behind the
adjacent eye
 Clinician’s finger is moved up the anterior
border of the ramus until the coronoid
process and the attachment of the tendon of
the temporalis are felt.
 MASSETER:
 Fingers are placed on each zygomatic arch (just anterior to the TMJ). They are then dropped
down slightly to the portion of the masseter attached to the zygomatic arch, just anterior to the
joint ( Deep Portion)
 The fingers drop to the inferior attachment on the inferior border of the ramus
 STERNOCLEIDOMASTOID:
 done bilaterally near its insertion on the outer surface of the mastoid fossa, behind the ear
 The entire length of the muscle is palpated, down to its origin near the clavicle
 POSTERIOR CERVICAL MUSCLES:
 Trapezius, longissimus [capitis and cervicis], splenius [capitis and cervicis], and levator
scapulae) do not directly affect mandibular movement; however, they do become symptomatic
during certain TMDs and therefore are routinely palpated.
 They originate at the posterior occipital area and extend inferiorly along the cervicospinal
region. Because they are layered over each other, they are sometimes difficult to identify
individually.
 Right hand palpate the right occipital area and those of the left hand palpate the left, at the
origins of the muscles.
 TRAPEZIUS:
 The major purpose of its palpation is not to evaluate shoulder
function but to search for active trigger points that may be
producing referred pain to face.
 In fact, when facial pain is the patient’s chief complaint, this
muscle should be one of the first sources investigated.
 The upper part is palpated from behind the SCM
inferolaterally to the shoulder and any trigger points are
recorded.
 FUNCTIONAL MANIPULATION
 Three muscles that are basic to jaw movement but
impossible or nearly impossible to palpate are the inferior
lateral pterygoid, superior lateral pterygoid, and medial
pterygoid.
 Each muscle is contracted and then stretched.
 If the muscle is a true source of pain, both activities will
increase the pain
 INF. LAT. PTERYGOID
 CONTRACTION
Having the patient make a protrusive movement against
resistance, since this muscle is the primary protruding muscle.

 STRETCHING:
The inferior lateral pterygoid stretches when the teeth are in
maximum intercuspation.
 When a tongue blade is placed between the posterior teeth, the
intercuspal position cannot be reached; therefore the inferior
lateral pterygoid does not fully stretch
 SUP. LAT. PTERYGOID
 CONTRACTION:
 The superior lateral pterygoid contracts with the
elevator muscles, especially during a power stroke
(clenching).
 tongue blade is placed between the posterior teeth
bilaterally and the patient clenches on the separator,
pain again increases with contraction of the superior
lateral pterygoid.
 These observations are exactly the same as for the
elevator muscles.
 STRETCHING:
 Occurs at maximal intercuspation.
 Therefore stretching and contraction of this muscle occur during the same activity. If the
superior lateral pterygoid is the source of pain, clenching will increase it.
 Superior lateral pterygoid pain can be differentiated from elevator pain by having the patient
open wide.
 This will stretch the elevator muscles but not the superior lateral pterygoid. If opening elicits no
pain, then the pain of clenching is from the superior lateral pterygoid. If the pain increases
during opening, then both the superior lateral pterygoid and the elevators may be involved.
 It is often difficult to differentiate pain in the former from pain in the latter unless the patient
can isolate the location of the painful muscle.
 MEDIAL PTRYGOID
 CONTRACTION:
 Clenching teeth

 STRETCHING:
 OPENING MOUTH
INTRACAPSULAR VS EXTRACAPSULAR
 Functional manipulation both increases
interarticular pressure and moves the condyle.
Therefore this pain is easily confused with muscle
pain.
 When a patient bites unilaterally on a hard
substance, the joint on the biting side has a
sudden reduction in interarticular pressure
while the opposite joint has a sudden increase
in pressure. 
 The patient is asked to close on the separator and
then protrude the mandible against resistance.
 AUSCULATAION

 With a stethoscope- CLICKING and CREPITATIONS during all mandibular movements

 CLICK CREPITUS
 A single explosive noise of short duration  Continuous grating sound
 Created by sudden distraction of 2 wet surfaces  Created by worn joint surfaces
 A loud click is called “POP”  Appreciated with stethoscope
Left/ right/ bilateral
Painless / painful
Consistent / intermittent
 A click in later stages of mouth opening points
towards greater degree disc displacement
 OCCLUSAL EXAMINATION
 Dental relationship
 Presence of centric relation
 Loss of posterior support
 Tooth interference
 Dental midlines coincide
 Fracture and craze lines on teeth
 Line alba
 Scalloping of lateral boarders of tongue
 3) RADIOGRAPHIC EXAMINATION

 HELPFUL IN DIAGNOSIS of intra-articular, osseous and soft tissue pathological conditions

 Based on patient signs and symptoms
 OPG:
 One of the best screening evalutation
 Can view both TMJs on the same film
 Can be taken with mouth open or closed
 Provides a clear assessment of the bony anatomy of the glenoid fossa, condyke and surrounding
structures like coronoid

 DISADVANTAGE:
Bony superimposition
 TOMOGRAPHS:
 Deatiled than OPG
 Radiographic sectioning of the joint at different levels of the condyle and fossa complex
producing the images in slices from the medial to the lateral pole
 Overcomes bony superimposition
 TEMPOROMANDIBULAR JOINT ARTHOGRAPHY:
 The first technique available to indirectly visualize the intraarticular disc
 Involves injection of contrast medium into superior or inferior joint space and the joint is
radiographed
 Evaluation of the configuration of the dye in the joint space allows evaluation of position and
morphology of the articular disc
 Can detect perforations and adhesions of the disc and its attachments

 DISADVANTAGE:
 Invasive- hence rarely used
 COMPUTED TOMOGRAPHY (CT):
 Combination of tomographic views of the joint combined with computer enhabcementof hard
and soft tissues
 Provides most accurate radiographic assessment of bony components
 CONE BEAM COMPUTED TOMOGRAPHY (CBCT):
 Popular because of it convenience, accuracy and reduced cost
 Three dimensional reconstructions of themandibular condyle and articular eminence.

 ADVANTAGE:
 Less exposure to radiation

 DISADVANTAGE:
 Does not provide soft tissue images
 MRI:
 Most effective imaging technique to evaluate TMJ soft tissues
 Intra-articular soft tissue disc position and morphology can be appreciated.
 Images can be taken in dynamic joint function

 ADVANTAGE:
Does not use ionizing radiation
 NUCLEAR IMAGING:
 Intravenous injection of technetium-99 ( gamma emitting isotope which concenrates in areas of
active bone metabolism) is given 3 hours prior to exposure
 Images are obtained using a gamma camera.

 DISADVANTAGES:
Highly technique sensitive.
Difficult to interpret results- as normal regeneration/repair can be confused with degeneration.
Images should be evaluated along with clinical findings.