Daily parafunctional activities such as smoking, bruxism, chewing gum, snoring, leaning on chin, biting nails, lip biting, clenching teeth can all cause or create symptoms. Work, household responsibilities, hobbies and/or recreational activities may involve repetitive stress and prolonged postures, e.g. computer work, that add to or exacerbate the presenting symptoms. Emotional stress can trigger nervous habits or poor postural responses, which can lead to TMJ symptoms.
Diagnostic imaging helps provide added information. It is very important to make sure the clinical objective findings correlate with any diagnostic imaging. For example, disc displacement is common in non symptomatic subjects, MRI evidence of disc displacement is not considered significant unless ROM is restricted or a nonreducing disc is suspected clinically.
A DENTAL PANORAMIC RADIOGRAPH
CONE BEAM SCAN
IMAGES OF CONE BEAM SCAN
MRI SCAN IMAGES
Opening and closing of mouthTeeth normally close symmetrically, the jaw is normally centered
Alignment of teethNote cross bite, under or over bite
Symmetry of facial structuresEyes, nose, mouth, length of mandible
PostureForward head posture, rounded shoulders and scapular protraction is common
Breathing patternDiaphragmatic breathing or accessory pattern, mouth breathing, short upper lip
Tongue or lip frenulum restriction
ROM – Range of MotionAROM: measure from top tooth edge to bottom tooth edge Opening and closing of mouth Normal opening ~ 40-50 mm Functional opening or necessary for most dental procedures ~ 36 mm or at least 2 knuckles between teeth
Listening for joint noises, clicks, pops or crepitus
Protrusion of mandibleNormal ~ 10 mm • Lateral deviation of mandible Normal ~ 10 mm • Note asymmetrical movements, snapping, clicking, popping or jumps
Record deviationsLateral movements with return to midline. The opening pathway is altered but returns to midline, usually indicative of a disc displacement WITH reduction or could be neuromuscular dysfunction.
Lateral movements without return to midline.
Deflections are usually associated with Disc Dislocations without reduction or a unilateral muscle restriction.
Cranial Loading of Mandible provides additional valuable informationPROM: apply overpressure at the end range of AROM to assess end feel
Assess muscles of mastication, deep cervical flexors and scapular stabilizers.
Assess upper quadrant dermatomes, C1, C2, C3, cutaneous nerve supply of the face, scalp and neck, cranial nerves V – XII
Joint MobilityLong axis distraction, Medial and Lateral glide
Load contralateral TMJ – bite on cotton roll/tongue blade
Assess chewing, swallowing, coughing, and talking. Either have patient demonstrate task or ask for patient’s subjective report. Include changes the patient has made to their own diet to accommodate for their pain and dysfunction.
Determine which movements cause pain, including opening or closing of mouth, eating, yawning, biting, chewing, swallowing, speaking, or shouting. The patient may also present with headaches and cervical pain. Pain may also be present in the distribution of one of the three branches of the trigeminal nerve.
These may include the feeling of fullness of the ear, tinnitus and/or vague dizziness. These symptoms are seen in approximately 33-40% of patients with TMJ and usually resolve after treatment.
Cervical Spine and Upper Quadrant ScreenAssess cervical A/PROM, muscle length including deep cervical flexors, myotomes, dermatomes and reflexes.
Upper Extremity Reflexes
Physical Therapy palpation of the muscles of mastication
Watch this video to learn how Physical Therapist palpate or find the muscles of mastication (chewing) including the temporalis, masseter and pterygoid pair. Treating these muscles helps reduce myofascial pain and TMJ issues.
Rocabado Synovial Pain Map
TMJ: compare bilaterally, assess joint integrity and structural deviations
Muscles of mastication: compare bilaterally, assess for pain and/or muscle spasm
This is only a partial list of which muscles are palpated and assessed