Examination of temporomandibular joint

1. ANATOMY &
PHYSIOLOGY OF
TMJ-2
( E X A M I N AT I O N O F T M J )
P R E S E N T E D B Y :
D R . K A M I N I D A D S E N A
N E W H O R I Z O N D E N TA L C O L L E G E & R E S E A R C H I N S T I T U T E B I L A S P U R
C H H AT T I S G A R H .

2. SCREENING HISTORY & EXAMINATION
• 1. Difficulty and/or pain when opening mouth or yawning?
• 2. Jaw get “stuck” or “locked” or “go out”?
• 3. Difficulty and/or pain when chewing, talking
• 4. Noises in the jaw joints?
• 5. jaws regularly feel stiff, tight, or tired?
• 6. pain in the ears, temples, or cheeks?
• 7. Frequent headaches, neckaches, or toothaches?
• 8. Recent injury to your head, neck, or jaw?
• 9.Any recent changes in bite?
• 10. Previous treatment for any unexplained facial pain or a
jaw joint problem?

3. Features to Be Included in aThorough Orofacial Pain History
1. Chief complaint (may be more than one)
A. Location of pain
B. Onset of pain
• 1. Associated with other factors
• 2. Progression
C. Characteristics of pain
• 1. Quality of pain
• 2. Behaviour of pain
– a. Temporal
– b. Duration
– c. Localization
• 3. Intensity of pain
• 4. Concomitant symptoms
D.Aggravating and alleviating factors
• 1. Function and parafunction
• 2. Physical modalities
• 3. Medications
• 4. Emotional stress
• 5. Sleep disturbances
E. Past consultations and/or treatments
F. Relationship to other pain complaints
II. Past medical history
III. Review of systems
IV. Psychological assessment

4. Location and radiating pattern of pain

5. PSYCHOLOGICAL ASSESSMENT
1. Multidimensional Pain Inventory (MPI)-Turk and Rudy
2. Symptom Check List 90 (SCL-90). - Derogatis LR
3. IMPATH- Fricton JR, Nelson A, Monsein M
4. TMJ scale - Levitt SR, Mc Kinney MW
1.Turk DC, Rudy TE: Toward a comprehensive assessment of chronic pain patients: a multiaxial approach, Behav Res Ther 25:237-249, 1987.
2. Derogatis LR: The SCL 90R:administration, scoring and procedure manual, Baltimore, 1977, Clinical Psychology Research.
3.Fricton JR, Nelson A, Monsein M: IMPATH: microcomputer assessment of behavioural and psychosocial factors in craniomandibular
disorders, Cranio 5:372-381,1987.
4.Levitt SR, Mc Kinney MW: Validating the TMJ scale in a national sample of 10,000 patients: demographic and epidemiologic
characteristics, J Orofac Pain 8:25-35, 1994.

6. CLINICAL EXAMINATION OF TMJ
• Cranial nerve examination
• Eye examination
• Ear examination
• Cervical examination
• Muscle examination
• Maximum interincisal distance

7. CRANIAL NERVE EXAMINATION
1. The olfactory nerve:
2. Optic nerve:
3. Oculomotor,Trochlear, and Abducent Nerves (III, IV,VI)

8. • Trigeminal Nerve (V)
• Facial Nerve (VII)-
• Sensory
• Motor component

9. • Acoustic Nerve (VIII)
– Vestibular nerve
– Cochlear nerve

10. • Glossopharyngeal and Vagus Nerves (IX, X)
• Accessory Nerve (XI)
• Hypoglossal Nerve (XII)

11. • CERVICAL EXAMINATION

12. MUSCLE EXAMINATION
• Muscle palpation
Temporalis

13. • Masseter
• Sternocleidomastoid

14. • Posterior Cervical Muscles

15. • Functional Manipulation

16. FUNCTIONAL MANIPULATION BY
MUSCLE

17. MAXIMUM INTERINCISAL DISTANCE

19. EXAMINATION OF TM JOINT
• Temporomandibular joint pain
• Joint restriction

20. IMAGING OF TM JOINT
• Radiographic technique
1. Panoramic view
2. Lateral transcranial
3. Transpharyngeal
4. Anteroposterior tranorbital projection
5. submentovertex
6. Tomogrhy
7. Computed tomography
8. Magnetic resonance imaging
9. Bone scaning
• Other technique
1. Mounted cast
2. Electromyography
3. Sonography
4. Thermography

21. RADIOGRAPHIC TECHNIQUE

22. PANORAMIC PROJECTION

25. TRANSCRANIAL VIEW

26. TRANSCRANIAL VIEW

27. TRANSPHARYNGEAL VIEW

28. TRANSPHARYNGEAL VIEW

29. TRANSORBITAL VIEW

30. TRANSORBITAL VIEW

31. SUBMENTOVERTEX VIEW

32. CONVENTIONAL
TOMOGRAPHY
• Body section radiography, it is designed to image objects more clearly
lying within a plane of interest (focal trough).
• It produces, multiple thin image slices TMJ condylar axis, permitting
the visualization, free of superimposition.

33. CONVENTIONAL TOMOGRAPHY
Lateral sagittal & Frontal coronal Tomographic image

34. COMPUTED TOMOGRAPHY
• CT scan gives excellent definition of bony contours of condyle and
glenoid fossa.
• Multiple digital image slices are produced in both axial & coronal planes
• Data from axial & coronal scans can be manipulated to produce
reformatted sagittal sec.
• 3D structure can then be constructed

35. CONE BEAM TOMOGRAPHY

36. MAGNETIC RESONANCE
IMAGING
• Uses magnetic field and RF pulses rather than ionizing radiation to
produce multiple digital image slices
• Magnetic field strength ranges from 0.05 – 2.0T

37. MAGNETIC RESONANCE
IMAGING
Adv.
• No ionizing radiation
• Fewer artifacts from dense bone & metal clips
• Imaging possible in different planes
• Superior anatomic details of soft tissues
Disadv.
• High initial cost of scanner
• Claustrophobic feeling
• Inferior images of bone

38. MAGNETIC RESONANCE
IMAGING
Indications
• Depicts hard & soft tissue abnormalities of joint and its
surrounding structures
• Displacement of disk in medial or lateral aspect
• For integrity of articular disk
Contraindications
• Pts. with cerebral aneurysm clips
• With cardiac pacemaker
• Ferromagnetic foreign bodies in critical position
• Metallic prosthetic heart valves

39. MRI of Normal TMJ
Closed sagittal Open sagittal
Coronal Slice

41. MEDIAL DISK
DISPLACEMENT

42. HIGH RESOLUTION MRI
Has thinner slice thickness & smaller field of view
Advantage
• Improved spatial & soft tissue resolution
Imaging of
• Trabecular pattern of condyle
• Perforation of disk
• Osteophyte of condyle

43. HIGH RESOLUTION MRI

45. EROSION OF THE ARTICULAR
SURFACE OF THE CONDYLE

46. FLATTENING OF THE ARTICULAR
SURFACE OF THE CONDYLE.

49. EAGLE SYNDROME

51. CONDYLAR OSTEOPHYTES

53. BONE SCAN

54. Closed-mouth position. Maximum-mouth opening
The glenoid fossa (curved arrow), the disk (arrow), and the condyle
(small arrow) are visualized.

55. MOUNTED CAST
• Accurately mounted study casts may be helpful to further assess the
occlusal condition.
• Mounted casts may be necessary when future dental treatment will be
provided (e.g., prosthodontics, orthodontics) also for evaluating the
effects of bruxism over time.
• The clinician should keep in mind that acute muscle and joint pain and
joint edema can decrease the accuracy of the mountings.
• Therefore occlusal analysis is most reliable after acute disease
processes are resolved

56. ELECTROMYOGRAPHY
• use of electromyograhic (EMG) recordings in the diagnosis and
treatment of TMDs.
• it is believed that if a painful muscle was in spasm, increased EMG
activity would be recorded from the involved muscle.

57. THERMOGRAPHY:
• Thermography is a technique that records and graphically
illustrates surface skin temperatures.
• Various temperatures are recorded by different colors,
producing a map that depicts the surface being studied. It
has been suggested that normal subjects have bilaterally
symmetric thermograms.
• From this concept some have suggested that
thermograms that are not symmetric reveal a problem
such as aTMD

58. THANK YOU….