Temporomandibular Dysfunctions – Part 2 History, Clinical Examination and Diagnosis

1. Temporomandibular
Dysfunctions – Part 2
History, Clinical Examination and
Diagnosis
Presented by:
Bishow Prakash Thakur
PG Resident
Department of orthodontics and Dentofacial orthopaedics
Peoples Dental College and Teaching Hospital
Kathmandu, Nepal

2. Contents
Part I
• Etiology of Functional Disturbances in the Masticatory
System
• Signs and Symptoms of Temporomandibular Disorders
Part II
• History of and Examination for Temporomandibular
Disorders
• Diagnosis of Temporomandibular Disorders
2

3. History and Examination
for TMDs
NOTHING IS MORE CRITICAL TO SUCCESS THAN BEGINNING
WITH ALL THE NECESSARY DATA
—Jeffrey P Okeson

4. Topics
• Screening History and Examinations
• History taking for TMDs
• Clinical examination
• Cranial nerve examinations
• Eye, ear and Neck examination
• Masticatory structures examinations
• Muscle examinations
• TMJ examinations
• Diagnostic tests
4

5. Screening History and Examinations
• Prevalence of TMDs is high
• Purpose is to identify patients with subclinical signs
• Should consist of several short questions that will help alert
clinician to any TMDs
• Asked personally by clinician or included in dental
questionnaire to be filled by patient completes prior to
treatment
5

6. Screening History
Questions should include:
1. 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 jaw joints?
5. Do your jaws regularly feel stiff, tight, or tired?
6. Do you have pain in or about 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? 6

7. Screening Examinations
• Short screening examinations to identify any variation from
normal anatomy and functions
• Begins with:
• Inspection of facial symmetry
• Observation of jaw movements (restriction, irregular
movements)
• Palpation of structures of masticatory system (temporal ,
masseter muscle, and lateral aspect of TMJ)
• If positive findings if observed during screening history and
Examination, more thorough and detailed history and
examination for TMDs should be done
7

8. Detailed History Taking for TMDs
• History is key in making accurate diagnosis
• 70-80% of information for diagnosis of TMDs with pain comes
from detailed history
• Most often patient will provide essential information that
cannot be acquired from examination procedures
• Should include complete medical history, for eg: arthritic
condition
• Can be obtained in 2 ways:
1. Direct conversation
2. Written questionnaire
8

9. Pain
• Most common chief complain for TMDs
9

10. Pain
• Most common chief complain for TMDs
10

11. Pain
• Most common chief complain for TMDs
11

12. Pain
• Most common chief complain for TMDs
12

13. Pain
• Most common chief complain for TMDs
13

14. Pain
• Most common chief complain for TMDs
14

15. Pain
• Most common chief complain for TMDs
15

16. Pain
• Most common chief complain for TMDs
16

17. Pain
• Most common chief complain for TMDs
17

18. Pain
• Most common chief complain for TMDs
18

19. Pain
• Most common chief complain for TMDs
19

20. Pain
• Most common chief complain for TMDs
20

21. TMJ Scale
21

22. TMJ Scale
22

23. Clinical Examination
• Due complexity of head and neck pain disorders, certain
nonmasticatory structures should also be grossly examined
to rule out other possible disorders, if any abnormal
findings found, immediate referral needed
• Categorised into:
1. Cranial nerve examination
2. Eye examination
3. Ear examination
4. Cervical examination
5. Muscle examination
6. TMJ examination
23

24. 1. Cranial Nerve examination
24
Olfactory Nerve:
• Ask patient to detect differences between odour of
pipperment, vanilla, chocolate
• Before examination, any obstruction in nose should be
assessed by asking to exhale nasally into mirror and look
for fogging

25. 1. Cranial Nerve examination
25
Optic Nerve:
• Sensory fiber in retina
• Cover one eye and read sentence
• Visual field should be assessed by standing behind patient
and slowly bringing fingers from behind into view
• Normal : No variation in right and left eyes

26. 1. Cranial Nerve examination
26
Oculomotor, Trochlear and Abducens nerves:
• 3rd, 4th and 6th CN, Motor fiber to extraocular muscles
• Patient should follow examiner’s finger as it make “X”
(both eye should move smoothly and similarly)
• Pupilary reflex , Accomodation reflex, Consensual light
reflex

27. 1. Cranial Nerve examination
27
Trigeminal nerve:
• 5th CN, Motor (Muscle of
mastication), Sensory ( face, scalp,
nose and mouth)
• Sensory: cotton tipped applicator
B/L in forehead, cheek and lower
jaw
• Motor: Clench teeth and examiner
should feel masseter an temporal
muscles

28. 1. Cranial Nerve examination
28
Facial nerve:
• 7th CN, Motor (Muscle of facial expression), Sensory
(anterior 2/3rd of tongue)
• Sensory: Distinguish between sugar and salt using just tip
of tongue
• Motor: raise both eyebrows, smile, and show the lower
teeth

29. 1. Cranial Nerve examination
29
Vestibulocochlear nerve:
• 8th CN, senses balance and hearing
• Balance: walk heel to toe along straight line
• Hearing: rubbing strand of hair between fingers near
patient ear and noting any difference

30. 1. Cranial Nerve examination
30
Glossopharyngeal and Vagus nerve:
• 9th and 10th CN, supply fibers to back of throat
• Patient is asked to say “ah” and soft palate is observed
for symmetrical elevations
• Gag reflex is tested by touching each side of pharynx

31. 1. Cranial Nerve examination
31
Spinal accessory nerve:
• 11th CN, supply fibers to
trapezius and
Sternocleidomastoid
• Trapezius: asking patient to
shrug shoulders against
resistance
• Sternocleidomastoid: move
head first to right and then to
left against resistance

32. 1. Cranial Nerve examination
32
Hypoglossal nerve:
• 12th CN, supply fibers to tongue
• Patient is asked to protrude tongue; any uncontrolled or
consistent lateral deviation is noted

33. 2. Eye examination
• Patient is questioned about vision and any recent changes,
requiring treatment
• Simple techniques as used in cranial nerve examination will
be suffcient in testing gross vision
• Any diplopia or blurriness of vision is noted
• Pain felt in or around eyes is noted
33

34. 3. Ear examination
• 70% of patients reporting with
TMJ pain also complain of ear
discomfort
• Infection of otitis externa should
be assessed which is painful
• Dentist’s role should be merely to
attempt to rule out gross ear
disease if found proper referral
should be done
34

35. 4. Cervical examination
• Cervicospinal pain and dysfunction can refer pain to
masticatory apparatus
• Mobility of neck is examined for range and symptoms
• 70 degrees of rotation in right and left direction
• Extension 60 degrees and flexion downward 45 degrees
• 40 degrees during bending right and left
35

36. 4. Cervical examination
• Any pain and limitation of movement carefully investigated
to determine whether its source is muscular or vertebral
• When patients with limited range of movement can be
passively stretched to a greater range, source is usually
muscular
• Patients with vertebral problems cannot normally be
stretched to a greater range
• If craniocervical disorder is suspected, proper referral for
more complete (cervicospinal) evaluation is needed as
craniocervical disorders are closely associated with TMDs
36

37. 5. Muscle Examination
• Frequent clinical sign of compromised muscle tissue is pain
• Most often muscles of mastication become compromised
through increased activity
• In early stages, myalgia is noticed only during function of
muscle
• If hyperactivity continues, it can result in a dull, aching pain
that often radiates over entire muscle
• Later, pain can eventually become severe limiting
mandibular function
• Muscle examination can be done by:
A. Direct Palpation: Temporalis, Masseter, SCM, Posterior
cervical
B. Functional Manipulation: medial and lateral pterygoid 37

38. A. Direct Palpation
• Deformation of compromised muscle tissue by palpation
can elicit pain
• Firm thrust of 1 or 2 seconds in small circular motion is
given and asked for discomfort of pain
When a muscle is palpated, the patient’s response is placed
in one of 4 categories:
i. 0 : No pain or tenderness
ii. 1 : Uncomfortable ( Tenderness or soreness)
iii. 2 : Definite discomfort or pain
iv. 3 : Evasive action or eye tearing or verbalizes no to
palpate again
38

39. A. Direct Palpation
• Not only generalized muscle tenderness and pain but also
presence of any trigger points should also be assessed
• Generalized muscle pain may not exist in muscle with
trigger points
• Thus, during palpation generalized muscle pain and trigger-
point pain should be differentiated
• Done for Temporalis, Masseter, Sternocleidomastoid, and
posterior cervical (Splenius capitis and Trapezius)
39

40. Temporalis
• Divided into 3 functional areas:
i. Anterior : Above zygomatic arch and
anterior to TMJ, Vertical fibers
ii. Middle : Above TMJ and superior to
zygomatic arch, Oblique fibers in
lateral aspect of skull
iii. Posterior: Above and behind ear,
Horizontal fibers
40

41. Temporalis
• If a trigger point is located, it should be identifed along with
any pattern of referred pain
• Palpation of its tendon should also be done , because
Temporalis tendinitis may cause referred pain behind eye
(retro orbital Pain)
41

42. Tendon of Temporalis
• Temporalis tendon is palpated by
• Placing finger of one hand intraorally on anterior border of
ramus and finger of other hand extra orally on same area
• Intraoral finger is moved up anterior border of ramus until
coronoid process and tendon are palpated
42

43. Masseter
• Palpation at origin and insertion
• Deep masseter: just anterior to
TMJ on zygomatic arch
• Superficial masseter: inferior
attachment on inferior border of
ramus
43

44. Sternocleidomastoid
• No direct effect on mandibular
function
• Palpated entire length from mastoid
fossa behind ear (insertion) to
clavicle (origin)
• Any trigger point present or not
44

45. Posterior cervical muscle
Splenius capitis:
• Palpated just posterior to mastoid fossa and move
inferiorly
45

46. Posterior cervical muscle
Trapezius muscle:
• Major purpose is to search for “active trigger points”
• Commonly has trigger points that refer pain to face
• Palpated from behind SCM inferolaterally to shoulder
46

47. B. Functional Manipulation
• For muscles that are impossible or nearly impossible to
palpate manually
• For years an intraoral technique was suggested for
palpating the lateral pterygoid muscle, but this has not
proven effective, So functional manipulation is needed
• Principle: “as a muscle becomes fatigued and symptomatic,
further function will elicit more pain”
47
Johnstone DR, Templeton M: The feasibility of palpating the lateral pterygoid muscle, J
Prosthet Dent 44(3):318 323, 1980
Stratmann U, Mokrys K, Meyer U, et al: Clinical anatomy and palpability of the inferior
lateral pterygoid muscle, JProsthet Dent 83(5):548–554, 2000

48. Inferior Lateral pterygoid
Contraction:
• Causes protrusion and opening of
mandible
• Ask patient to protrude against
resistance and assess whether it will
increase pain or not
48
Stretching:
• ILP stretches during maximum intercuspation, so pain
should be during clenching
• When tongue blade is placed between posterior teeth,
maximum intercuspation cannot be reached; so ILP donot
fully stretch,so biting on separator willnot increase pain
but may even decrease or eliminate it

49. Superior Lateral Pterygoid
Contraction:
• Elevator muscle so during
clenching will increase pain
• If tongue blade is placed, on
clenching pain will increase
49
Stretching:
• Clenching will increase pain (seen in other elevators also)
• SLP pain can be differentiated from elevator pain by asking
patient to open wide:
• If pain, then SLP and other elevators are involved
• If no pain, then pain of clenching is from SLP

50. Medial Pterygoid
Contraction:
• Elevator muscle so clenching will increase pain
• Biting on tongue blade: still increase pain
Stretching:
• Opening of mouth increases pain
Thus , all information needed is obtained by having
i. Wide mouth opening
ii. Protrude mandible against resistance
iii. Clench teeth, and then
iv. Bite on a separator
50

51. Functional Manipulation by Muscle
51

52. Intracapsular disorders
• If source of pain is Intracapsular, it can confuse previously
mentioned functional manipulation
• Functional manipulation not only affects muscle, but it also
increases interarticular pressure and moves condyle
creating confusion
52
Fig: When a patient bites unilaterally on a hard
substance, joint on biting side has a sudden reduction in
interarticular pressure while opposite joint has a sudden
increase in pressure. Therefore a patient with
intracapsular pain will often report increased pain when
biting on the teeth; but when a tongue blade is placed
between the teeth, the pain is reduced. Biting on
opposite side will often increase pain in involved joint
Intracapsular Vs ILP disorders is evaluated
by “unilateral biting on tongue blade
followed by Protrusion”

53. Functional Manipulation by Activity
53

54. Maximal interincisal distance
• Normal interincisal opening 53-58 mm
• Even 6 year old child has 40mm or more mouth opening
• If no pain, Maximal comfortable opening = Maximum
opening
54

55. Restricted mouth opening
• Less than 40 mm
• If restricted opening, it is helpful to test “end feel”
55
• Soft end feel : Associated
with muscle-induced
restriction
• Hard end feel :
Associated with
intracapsular sources
(e.g., a disc dislocation)

56. Lateral movement of mandible
• Any lateral movement less than 8 mm is recorded as a
restricted movement
• Protrusive movement is also evaluated in a similar manner
56

57. Deviation Vs Deflection
• Deviation: Any shift of jaw
midline during opening
that disappears with
continued opening
• Due to disc derangement
57
• Deflection: Any shift of midline
to one side that becomes
greater with opening and does
not disappear at maximal
opening
• Due to restricted movement of
joint

58. Examination of TMJ
• Examined for Pain and Dysfunction
• Radiographs and Other imaging techniques can be used
TMJ PAIN:
• Palpation during static and dynamic movement
58
Fig: Palpation of the TMJ.
A, Lateral aspect of the joint with the
mouth closed

59. Examination of TMJ
TMJ PAIN:
59
Fig: B Lateral aspect of the joint during
opening and closing
Fig: C, With the patient’s mouth fully
open, the clinician moves a finger behind
the condyle to palpate the posterior
aspect of the joint

60. Examination of TMJ
TMJ DYSFUNCTION:
• Joint sounds:
• Click (Single sound of short duration)
• Pop (Single sound relatively loud)
• Crepitations (Gravel like grating, associated with
osteoarthritic changes in articular surface)
• Sound occurs during opening (single click) or closing
(reciprocal click)
Absence of sounds does not always mean normal disc
position. 15% of silent, asymptomatic joints were found to
have disc displacements on arthrogram
(Westesson PL, Eriksson L, Kurita K: Reliability of a negative clinical temporomandibular
joint examination: prevalence of disk displacement in asymptomatic temporomandibular
joints, Oral Surg Oral Med Oral Pathol 68:551–554, 1989.) 60

61. Additional Diagnostic Tests
• Used only to gain additional information and never to
establish diagnosis
• Includes:
A. Radiographic techniques
B. MRI
C. Bone Scanning
D. Mounted Cast
E. Mandibular Tracking devices
F. Sonography
G. Vibration analysis
H. Thermography
61

62. • Complicated by several anatomic and technical
circumstances that superimposes joint
• Pure lateral view of condyle is impossible to achieve with
conventional radiographs
• Only CT can view lateral view of condyle
• 4 basic Radiographic technique:
1. Panoramic
2. Lateral Transcranial
3. Transpharyngeal
4. Transmaxillary (Antero-Posterior)
A. Radiographic techniques
62

63. Panoramic View
• Good screening of condyle as it results in minimum
superimposition over condyle
• Limitations: to view condyle mouth should be opened
maximally, so in patient with restricted mouth opening
superimposition occurs
63

64. Panoramic View
• Since panoramic radiograph is infracranial view, lateral pole
of condyle becomes superimposed over condylar head
• Area that appears to represent superior subarticular
surface of condyle is actually only subarticular surface of
medial pole
64
Fig: Area that appears to be superior subarticular surface of condyle is actually
medial pole. Lateral pole is superimposed inferiorly over body of condyle. Fossa is
also superimposed over condyle, which complicates interpretation of radiograph

65. Lateral Transcranial View
• Good visualization of both condyle and fossa
• X-rays are directed inferiorly across skull (above midface) to
contralateral TMJ and recorded during maximum
intercuspation and maximum opening
65
Fig: Transcranial projection.
A, Teeth together.
B, Maximal open position.
C, The condyle can be visualized
in the fossa with the articular
eminence directly anterior. The
relatively round (dark) area
posterior to the condyle is the
external auditory meatus.
D, The condyle has translated out
of the fossa during an opening
movement.

66. Lateral Transcranial View
• Since x-rays pass downward across skull, this angulation
superimposes medial pole of condyle below central
subarticular surface and lateral pole
• It is more acceptable than infracranial view for visualizing
articular fossae
66
Fig: Transcranial projection superimposition. The area that appears to be superior
subarticular surface of condyle is actually lateral pole. Medial pole is superimposed inferiorly
over body of condyle. In this projection fossa is not superimposed over condyle; thus a
clearer view of condyle is usually obtained

67. Transpharyngeal
• Similar to Panoramic view
• X ray notch directed below angle of mandible or through
sigmoid notch
• Mandibular fossa is not usually visualized as well as in this
view (same as OPG)
67

68. Transmaxillary (AnteroPosterior) view
• Obtained from anterior to posterior with mouth wide open
and condyles translated out of fossae
• If correctly taken, good view of superior subarticular bone
of condyle, medial and lateral poles is obtained
• Excellent view for evaluating a fracture in neck of condyle
68

69. Tomography
• It utilizes controlled movement of head of x-ray tube and
film to obtain a radiograph of desired structures that
deliberately blurs out other structures
• It is neither infracranial or transcranial projections but true
lateral projections
69
• Helpful in evaluating articular
surface of condyle
• Advantages:
• More accurate than OPG and
transcranial view
• True sagittal view
• Condylar position in fossa is
evaluated accurately

70. Tomography
70
Fig: A lateral tomography view of the TMJ. A, Closed position. B, Open position. C, An AP
tomogram. Note the fine clarity provided by tomography
Disdvantages:
• High cost
• Hight exposure to radiation

71. Computed Tomography
• Developed in past decade
• CT scanners produce digital data after measuring extent of
x-ray transmitted through various tissues, data is
transformed into density scale and used to generate or
reconstruct visual image
• Can reconstruct 3D image
71

72. Cone beam tomography
• Allows visualization of condyle in multiple plane
• Can image hard and Soft tissue both, disc condyle
relationship can be obtained
• Disadvantages: Expensive , more radiation exposure (In
CBCT, radiation exposure is less comparect to CT)
72
Fig: 3D image reconstructed from a cone beam image. These 3D
images can be rotated on computer screen so that clinician can
visualize precise area of interest. (Courtesy of Dr. Allan Farmer
and Dr. William Scarf, Louisville, KY.)

73. B. Magnetic Resonance Imaging
• Gold standard for evaluation of soft tissue of TMJ
• Uses strong magnetic field to create changes in energy
level of soft tissue molecules (principally hydrogen ions),
These changes in energy level create image similar to that
of a CT scan
• Better visualization of soft tissue than in CT scans
73

74. B. Magnetic Resonance Imaging
• Advantage: No harmful effects
• Disadvantage:
• Expensive
• Technology varies from site to site changing quality of
images
• Static image
• Cine MRI is beginning to provide information on disc and
joint movements
74

75. C. Bone scanning
• Helps to know if there is active inflammatory process in
TMJs
• Obtained by injecting a radiolabeled material into
bloodstream that concentrates in areas of rapid bone
turnover, and emission image is taken
75
Fig: Bone scan of head and neck reveals a high concentration of radiolabeled material
present in TMJ and maxillary regions. This finding suggests increased cellular activity
in these regions
• SPECT (Single photon emission
computed tomography) is similar
technique to identifiy increased bone
activity

76. D. Mounted cast
• To assess occlusal condition
• Semi adjustable or fully adjustable articulator needed
• Indicated only when future dental treatment is planned
(i.e., prosthodontics, orthodontics, etc)
• Provide better visualization of occlusal contacts (especially
in lingual view) and remove influence of neuromuscular
control from eccentric movements
• Should be mounted using accurate Facebow transfer and
CR record
76

77. E. Mandibular Tracking devices
• Exact movement of mandible can be recorded
• Can be used to diagnose and monitor treatment of TMDs
• Should be used only in conjunction with history and
examination findings
77
• No evidence to suggest that
sensitivity and specifcity of
these devices are reliable
enough to be used for
diagnosis and management of
TMD

78. F. Sonography
• Technique to record and graphically demonstrate joint
sounds
• Doppler Ultrasonography uses ultrasound echo recordings
• Although these devices may accurately record joint sounds,
significance of these sounds has not been well established
• It does not provide any additional diagnostic information
over manual palpation or stethoscopic evaluation
78

79. G: Vibration analysis
• Was used in diagnosing intracapsular TMD—internal
derangements in particular
• Measures minute vibrations made by condyle as it
translates and has been shown to be reliable
• It diagnoses 25% of normal joints as derangements, and
misclassifies many deranged joints as normal, especially if
joint sounds are not audible or if derangement has
advanced to nonreducing stage
• Thus due to high cost and the results, it is not test of
choice for suspected internal derangement 79

80. H. Thermography
• Technique that records and graphically illustrates surface
skin temperatures
• It has been suggested that normal subjects have bilaterally
symmetrical thermograms. From this concept some have
suggested that thermograms that are not symmetrical
reveal a problem, such as a TMD
• Sensitivity and specifcity of identifying myofascial trigger
points with thermography has not been demonstrated to
be reliable
80

81. Diagnosis of
Temporomandibular
Disorders
THE MOST IMPORTANT THING YOU CAN DO FOR YOUR PATIENT IS TO MAKE THE
CORRECT DIAGNOSIS. IT IS THE FOUNDATION FOR SUCCESS
- Jeffrey P Okeson

82. Topics
• Diagnosing Pain Disorders
• Diagnostic Analgesic Blocking
• Indications
• Muscle injections
• Nerve blocks
• Intracapsular injections
• Keys to making differential diagnosis
• Classification of Temporomandibular Disorders
82

83. Diagnosing pain disorders
• Primary pain: Source and site of pain is same
• Referred pain: Heterotopic, patient will have attention to
site of pain
• On Local provocation,
• If pain doesn’t increase: Referred pain
• If pain increases : Source and site is same, Primary pain
83
Fig: Local provocation of site
of pain does not increase pain
Fig: Local provocation of source of pain
increases the pain not only at source
but may also increase pain at site

84. Diagnosing pain disorders
• Sometime it is difficult to differentiate “site” from
“source” of pain : Anesthetic blockade recommended
84
Fig: Local anesthesia at site of pain
fails to reduce pain
Fig: Local anesthesia at source of
pain reduces pain at source as well as
site

85. Diagnosing pain disorders
Thus 4 rules to summarize examination techniques used to
differentiate primary pain from referred pain:
1. Local provocation of site of pain does not increase pain
2. Local provocation at source of pain increases pain not
only at source but also at site
3. Local anesthetic blocking of site of pain does not
decrease pain
4. Local anesthetic blocking of source of pain decreases
pain at source as well as site
85

86. Diagnostic Analgesic Blocking
INDICATIONS:
• To diagnose primary from secondary (referred) pain
• Therapeutic value in some pain disorders
• Educate patients about site and source of pain
GENERAL RULES:
1. Clinicians should have sound knowledge of anatomy in that
region
2. Sound knowledge of pharmacology of drugs used
3. Injecting into inflamed or diseased tissue should be avoided
4. Avoided in patient with bleeding disorders and anti
coagulatant therapy
5. Strict asepsis should be followed
6. Always aspiration before injecting the solution should be
done
86

87. Analgesic blocks
Diagnostic and therapeutic anesthetic blocks are divided
into three types according to structures targeted:
1. Muscle injections
2. Nerve block injections
• Dental Block
• Auriculotemporal nerve block
• Infraorbital nerve block
3. Intracapsular injections
87

88. Muscle injections
• Valuable in determining source of a pain disorder
• Trigger point can be injected with local anesthetic, which
results in shut down of pattern of referred pain
88
Procedure:
A. Trigger point (tight band) is located,
finger is moved up and down, until
most painful area is located
B. Tissue over trigger point is cleaned
with alcohol, trapped between two
fingers so that when needle is placed,
tight band will not move away

89. Muscle injections
89
Procedure:
C. Needle tip is inserted into tissue
superficial to trigger point and
advanced to depth of tight band
D. Initial anesthetic solution should be
deposited and “fanning” of needle
tip is done and solution deposited
E. Once injection has been completed,
needle is withdrawn and sterile
gauze is held over injection site
with slight pressure for 10 to 20 s to
ensure hemostasis

90. Muscle injections
• Can be done for :
90

91. Nerve Blocks
• Short-acting local anesthetic should be used without
vasoconstrictor
• Therapeutically, in chronic pain, Long acting LA can be
used
DENTAL BLOCKS:
These blocks are useful in separating dental pain
from muscle or joint pain since they block only dental
structure
• Inferior alveolar nerve
• Mental nerve
• Posterior superior alveolar
• Infiltrations
91

92. Nerve Blocks
AURICULOTEMPORAL NERVE:
• Very important nerve block with which all orofacial pain
clinicians should become very familiar
• TMJ innervation :
• Primary innervation Auriculotemporal nerve
• Secondary innervation Masseteric and Deep temporal
nerves
92

93. Nerve Blocks
AURICULOTEMPORAL NERVE:
Procedure:
93
Fig A: Tissue at site of
injection is thoroughly
cleansed
Fig B: Drawing showing
position of nerve as it
transverses around posterior
aspect of condyle. It also
demonstrates proper needle
placement
Fig C: Needle is placed
slightly anterior to junction
of tragus and earlobe and is
advanced until posterior
neck of condyle is felt

94. Nerve Blocks
AURICULOTEMPORAL NERVE:
Procedure:
94
Fig D: Needle is then repositioned in
more posterior direction until its tip
is able to pass posterior to neck of
condyle
Fig E: Once needle tip has passed beyond neck of
condyle, syringe is again positioned in a more
anterior direction and tip is inserted behind neck
of condyle, total depth of needle is approx 1 cm
The syringe is aspirated; if no blood , anesthetic
solution is deposited
* Placement of needle in this manner will minimize the risk of anesthetizing facial nerve

95. Nerve Blocks
INFRAORBITAL NERVE
95

96. Intracapsular Injection
• Indicated for therapeutic purpose to introduce some
medication to joint structures
• Normally, superior joint space is target because it is
largest joint space and is simplest to locate consistently
96
Fig A: Joint can be entered by locating lateral pole of condyle
(asking patient to open and close mouth), Once pole is
located, patient is asked to open slightly and examiner
palpates directly above to locate zygomatic arch. Tissue is
cleaned and tip of needle is placed just below zygomatic arch
and slightly behind posterosuperior aspect of condyle
Fig B: Needle is angulated slightly
anterosuperiorly to avoid retrodiscal
tissues. Once capsule has been
penetrated, tip of needle will be in
superior joint space

97. Keys to making differential diagnosis
• Besides Pain, most common masticatory problems
include:
• Masticatory muscle disorder
• Intra capsular joint disorder
• It is extremely important that they be differentiated, since
their treatments are quite different
• The clinician who cannot routinely separate them is likely
to have relatively poor success in managing TMDs
97

98. Keys to making differential diagnosis
There are 7 areas of information acquired during history
and examination that will assist in separating them:
1. History
2. Mandibular Restriction
3. Mandibular interference
4. Acute malocclusion
5. Loading of joint
6. Functional manipulation, and
7. Diagnostic anesthetic blockade
98

99. 1. History
• History is always helpful in distinguishing joint from
muscle disorders
• Any Trauma present in past or not
• Muscle disorders appear to fluctuate and cycle from
severe to mild with no apparent initiating event
• Muscle problems are more closely related to changes in
levels of emotional stress; therefore periods of total
remission are common when stress is low
99

100. 2. Mandibular Restriction
During mouth opening:
• Intracapsular problem (dislocated disc without reduction):
• 25 to 30 mm, presence of “Hard End Feel”
• Muscle Problem:
• 8 to 10 mm, presence of “Soft end feel”
During eccentric movement:
• Intracapsular:
• Limited contralateral eccentric movement
• Normal ipsilateral movement
• Muscle:
• Normal range of eccentric movement exists
100

101. 3. Mandibular Interference
• Any deviation or deflection
Deviation
• If speed of opening alters location of deviation:
Disc displacement with reduction
• If speed of opening does not alter location of deviation:
Structural incompatibility
• Subluxation (Intra capsular, not necessarily pathologic)
101

102. Movement Capsular Muscular
Protrusive - Ipsilateral side No deflection
Lateral
Eccentric
- Restricted to contralateral movement
- Normal Ipsilateral movement
No deflection
3. Mandibular Interference
Deflection:
Can be seen in
• Intracapsular disorders
eg: Disc dislocation without reduction,
Adhesion problem
• Myospasm of unilateral elevator
muscles
eg masseter
102Table to differentiate between deflection due to intracaspsular or muscular defect

103. 3. Mandibular Interference
Deflection:
• If deflection is due to shortened muscle, direction in
which mandible moves will depend on position of
involved muscle with respect to joint
• If muscle (i.e., masseter or temporalis) is lateral to joint,
deflection will be toward involved muscle
• If muscle (i.e., medial pterygoid) is medial to joint,
deflection will be away from involved muscle
103

104. 4. Acute malocclusion
• ILP spasm: Condyle will be brought slightly forward in
fossa on involved side resulting in disocclusion of
ipsilateral posterior teeth & heavy contact on contralateral
canine
104
• Elevator muscles spasm: Patient report
feeling teeth “suddenly don’t fit right,”
clinically may be difficult to visualize
any change
• Intracapsular disorder : If disc is
suddenly displaced anteriorly, thicker
posterior border may be superimposed
between condyle and fossa and cause
sudden increase in discal space,
resulting clinically as a loss of ipsilateral
posterior tooth contact

105. 5. Loading of Joint
• When there is orthopaedic stability, Loading of structures
with manipulative force does not produce pain in healthy
joint
• If Pain is produced, one should be suspicious of
intracapsular source of pain
105

106. 6. Functional Manipulation
• No pain during Functional manipulation: No muscle
disorder
106
• Biting on Tongue blade unilaterally:
• Interarticular pressure and pain is
reduced ipsilateral TMJ
For eg: If Right side TMJ pain,
clenching normally will increase pain,
• If tongue blade kept right side and
bite, it will decrease pain
• But if tongue blade kept on left side,
increased loading in right side will
result in pain in preauricular region
in right side

107. 6. Functional Manipulation
In primary muscle pain (eg: right-side masseter pain)
107
• When asked to clench teeth , right
masseter will produce pain
• If tongue blade is placed on right
molar and bite on it, pain will also
be increased due to increase
activity of painful masseter muscle
• If tongue blade is moved to left side
and bite on it, there will be
reduction in pain on right

108. 7. Diagnostic Anesthetic Blockade
• Indicated for patients in whom preceding 6 procedures
didn’t help in making a differential diagnosis
• Anesthetic blocking of auriculotemporal nerve can quickly
rule in or out an intracapsular disorder
• Dentist working with pain disorders should be very
familiar with this injection technique and use it without
hesitation to assist in diagnosis
108

109. Classification of Temporomandibular disorders
109
Adapted from Okeson JP: Orofacial Pain: Guidelines
for Assessment, Diagnosis, and, Management, 3rd
ed. Chicago: Quintessence;1996:45-52.
* The code number after each disorder has been
established by American Academy of Orofacial Pain
in cooperation with International Headache Society

110. Conclusion
• Methods to aid in identification and diagnosis of TMDs
has been presented which does not include all disorders
that cause pain and dysfunction of head and neck
• Diseases of Dental origin, vascular origin (e.g., arteritis or
migraine headache), neural origin (e.g., neuralgias,
neuropathies), craniocervical disorders as well as ear and
eye diseases have not been addressed
• This classification is useful in identifying common
functional disturbances of masticatory system
• When a patient’s problems do not fit into one of these
categories, more extensive examination procedures are
indicated
110

111. References
• Jeffrey P. Okeson, Management of Temporomandibular
disorders and occlusion, 2013, 7th edition
• Costen JB: Syndrome of ear and sinus symptoms
dependentupon functions of the temporomandibular
joint, Ann Otol RhinolLaryngol 3:1–4, 1934
• Pullinger AG, Seligman DA, Gornbein JA: A multiple logistic
regression analysis of the risk and relative odds of
temporomandibular disorders as a function of common
occlusal features, J Dent Res 72(6):968–979, 1993
• Ware JC, Rugh JD: Destructive bruxism: sleep stage
relationship, Sleep 11(2):172–181, 1988
111

112. References
• Rugh JD, Solberg WK: Electromyographic studies of bruxist
behavior before and during treatment, J Calif Dent Assoc
3(9): 56–59, 1975
• Kieser JA, Groeneveld HT: Relationship between juvenile
bruxing and craniomandibular dysfunction, J Oral Rehabil
25(9):662–665, 1998
• Johnstone DR, Templeton M: The feasibility of palpating
the lateral pterygoid muscle, J Prosthet Dent 44(3):318
323, 1980
• Stratmann U, Mokrys K, Meyer U, et al: Clinical anatomy
and palpability of the inferior lateral pterygoid muscle,
JProsthet Dent 83(5):548–554, 2000
112

113. References
• Westesson PL, Eriksson L, Kurita K: Reliability of a negative
clinical temporomandibular joint examination: prevalence
of disk displacement in asymptomatic temporomandibular
joints, Oral Surg Oral Med Oral Pathol 68:551–554, 1989
113

114. THANK YOU
114