The Temporomandibular Joint
The Temporomandibular Joint
The Temporomandibular Joint
TEMPOROMANDIBULAR
JOINT
3. Do you have difficulty and/or pain when you are chewing, talking, or using your jaws?
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
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
MUSCLES:
Muscle of mastication - temporalis, masseter, lateral and medial pterygoid
Sternocleidomastoid
Trapezius
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
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.