| Clinical
examination
The scrupulous devising of a
rigorous protocol that is as objective as possible, for the evaluation of the
masticatory system is therefore a task that begs attention.
Such a protocol
is of fundamental importance when undertaking any methodologically sound
investigation that attempts to evaluate the relationship between masticatory
disorders, malocclusion and the efficacy of dentofacial treatment of an
orthopaedic or orthodontic nature. Moreover a research protocol in line with a
state of the art diagnostic technology and with current notions of the
masticatory system in physiopathologic terms, is important not just for a
therapeutic programme, but also for necessary medico–legal
documentation.
Many clinical reports and a fair number of experimental
results seem to give importance to the role of particular parafunctional habits,
such as habitual noxious postural attitudes of the head, neck and jaw, and of
the spine in general, as being important factors involved in the pathogenesis of
dentofacial anomalies.
The etiological importance of the above conditions is
moreover widely accepted as causing masticatory disorders.
A correct
diagnostic approach that takes into consideration parafunctional habits and
pre-clinical conditions of dysfunctional pathology, would therefore, especially,
in the case of a child still in the growth stage, permit a favourable
modification of a noxious behavioural pattern. It could divert the pattern away
from one of physical development and evolution towards malocclusions correlated
with arthromuscular functional disorders.
Clinical examination (physical and instrumental)
A
protocol is now described that illustrates in detail a clinical and instrumental
examination that permits an accurate evaluation of paediatric mandibular
function.
This protocol includes clinical and instrumental methods of
evaluation.
The clinical examination should include various phases
that are described below:
1. Examination of physical posture. The
patient’s posture should be examined from a lateral and frontal position, to
check for any eventual asymmetries, deformities or postural alterations, not
just in the craniomandibular area, but also in the spine as a whole.
From a
systematic examination of the patient from a frontal position, one can ascertain
the bipupillary axis, the maxillary and mandibular occlusal axis and also the
interzygomatic and intergonionic axes of the maxilla. One can also check the
axis between the shoulders. All the above axes should be evaluated in a
mediosagittal orthogonal plane against a constant horizon.
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| Examination of axes. Subject in
natural head position. Note the inclination of the bipupillary axis and
the correct position of the occlusal plane with the
horizontal. |
The examination of the
spine can make use of some of the basic procedures of palpation of the
back as well as standard tests used in physical therapy to reveal any back
problems. These can be a useful adjunct to the full spinal X ray in standing,
frequently requested in school medical screening for childhood scoliosis.
2. Examination of active movement; rotation, flexion
and extension, and lateral flexion of the head and neck. A brief examination of
head and neck function and of the cervical spine should be included in an
evaluation of mandibular function.
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Cervical
side flexion (illus: Kapandj)
Test for AROM of superior and
inferior cervical spine and range and limitation of movement in head
rotation. |
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Cervical
flexion - extension (illus: Kapandj)
Test for AROM of the
whole of the cervical spine (superior and inferior) and range and
limitation of movement of flexion – extension of the
head. |
While an in depth examination
may well go beyond the competence of the dental clinician, the relative ease of
analysis of flexion – extension / rotation and lateral flexion movements of the
head can be very informative. It can reveal:
- A reduction or increase in
normal range of movement (hypo/hypermobility of the head and neck);
- The
presence of localized pain, spreading or referred to adjoining areas of the head
and neck, or more distally, in the thoraco- lumbar region;
- The presence of
abnormal joint sounds;
- Asymmetries in head movement.
The above signs may indicate a problem that
is intrinsic to the cervical or craniocervical joint areas (displacement/
arthropathy), or may well be related to a muscle contraction/spasm often due to
tension or even to an iatrogenic reaction.
Should one or more of the above
pathological signs be present, the patient should be referred for examination to
a specialist in physical therapy.
3. Examination of Occlusion.
This is carried out by checking the relationship between the deciduous
molars and canines, and if already erupted, the occlusal relationship of the 1°
permanent molar. It is also useful to verify the amount of overbite and of
anterior and posterior overjet.
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ervical
1. X ray of cervical spine normally aligned in extension of the
head.
Cervical 2. X ray of the cervical spine with
alteration of the normal curvature.
Cervical 3. X ray
of the cervical spine showing inversion of the normal
curvature. |
4. Examination of the range
of movement of opening and closing of the mouth on a frontal plane and of
eccentric border excursions on the horizontal plane.
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TMJ FUNCTIONS OPENING
CLOSING JOINT NOISES LATERAL MEDIAL EXCURSIONS PROTRUSION. |
It is useful to compare the
degree of aperture of the mouth with body size. The degree of normal maximum
aperture corresponds on average to the width of three fingers (index, middle and
ring), held together vertically. The degree of protrusion and lateral excursion
to the right and to the left is generally related to the degree of maximum
aperture of the mouth, in a ratio of 1:4.
5. Palpation of the muscles of mastication and of the head. A
light bimanual and symmetrical palpation of the musculature can allow the
evaluation of tone, wasting, and of any eventual nodules (myogeloses), that
correspond to areas of inflamed muscle.
The evaluation of muscle pain can be
made by applying firmer, and more localized pressure with the finger-tips,
especially to those areas with nodular thickening. Findings from palpation are
important in the light of investigations that have shown a correlation between
muscle pain and degree of temperomandibular arthropathy.(* )
6. Palpation and auscultation of the
temperomandibular joints. Palpation should be carried out in the
pre-auricular area and in the intrameatal area. In this examination, both hands
are placed symmetrically and held still during active movements of the mouth. It
gives one the opportunity to ascertain approximately, any annomalies in
structure, limitations of movement, and any noises and pain from the
condyles.
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Palpation of the TMJ with
both hands placed symmetrically (in the intermeatus) mouth
open
Palpation of the TMJ with both hands placed symmetrically (on the
lateral skin area) mouth open. |
The auscultation of the
temperomandibular joint is a useful adjunct to palpation. It allows one to
localize more accurately the precise area of any noise produced with movement
and its characteristics (clicks, thuds or crepitus).
7. Resisted static and
dynamic muscle testing of the mandible. Static tests carried out in lateral
excursion, protrusion and opening and closing of the mouth against sustained
resistance given by the clinician (isometric tests), have been claimed by some
authors, as in the testing of other body musculature by physical therapists, to
give information on the possible myogenous origin of the pathology. Dynamic
tests, on the other hand, based on the execution of movements in the same
direction of the static tests, but against a limited resistance provided by the
clinician, can indicate joint involvement as a possible cause. But the
difficulty in carrying out the above tests in a reliable way can make them
difficult to replicate accurately, and are therefore recommended only with
reservations.
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Isometric test: examination
of the muscles of protrusion of the
mandible. |
8. Test for displacement of
the mandible. This clinical test, simple and fairly accurate, can allow one
to track the positioning of a mandibular condyle that is not functioning in
coordination with the disc. The reduction (repositioning), or the increase in
dislocation of the condyle with respect to the disc are produced by the patient
himself, or by the clinician, by moving the mandible in different directions.
With each movement, the disappearance or increase in functional incoordination
(displacement/ joint noise), and pain, can be assessed.
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Test for dislocation: medial
projection (1) and lateral (2) of the left
TMJ. |
9. Instrumental
Examination. Once the physical examination is completed one can proceed to
the phase of instrumental analysis. This is especially advisable with those
patients found to have problems during an objective examination. But, in our
opinion, it should ideally be extended to all patients who are undergoing
orthopaedic treatment of the maxillae.
The instrumental procedures
include:
1. A record of excursion movements of the
mandible (Fig. pri file) (right lateral excursion, left lateral excursion,
protrusion) with an intraoral tracing, recorded using resin plates fitted to the
palate and inferior arch. The upper one has a recording axis, and the lower, a
plate that records in negative, the line of track of the mandibular excursion
that is made by the recording axis (mounted on the opposing arch), when the
patient is asked to perform free active lateral excursions and protrusion. A
normal tracing is made up of three converging lines that correspond to the
uneven or mean movements of lateral right and left excursion, and of protrusion
or retrusion. The analysis of the line traced by each mandibular
movement……XXXXX?
2. A record of occlusal and postural indices of the
mandible during maximal bite and in a position of rest, using stable resin
(e.g. Duralay), silicone for occlusion (e.g. Occlufast) or wax check bites (e.g.
Halluvax).
| 1. Upper recording plate. |
2. Lower recording plate coated with a spray
dye. |
3. Recording of an intraoral tracing and location
of the central bearing point. |
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| 4. Recording of an intraoral tracing showing two
distinct central bearing points. |
5. Intraoral recording with a vertical
raise. |
6. Intraoral recording: example of neuromuscular
incoordination. |
3. Radiographic
examination of the temperomandibular joints taken with jaws closed, at rest,
and with maximum opening of the mouth. The x ray provides useful information
about the position of the condyle with respect to the glenoid fossa and shows up
eventual condylar displacements, hypo/hypermobility of the joints (in the
tomograms with maximum aperture of the mouth), and any changes in
temperocondylar structure.
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A. X
ray (tomogram) of a temperomandibular joint with hypermobility
(subluxation), mouth closed. |
B. X ray
(tomogram) of a temperomandibular joint with hypermobility (subluxation),
mouth open.. |
4. EMG recordings of the
electrical potential of the masticatory muscles, at rest and during maximal
contraction. Recent studies (from Clinical signs of TMJ arthritis and masseteric
maximal clenching EMG recording R. Ciancaglini e coll. J. Dental Research vol:
70 330.1991) have demonstrated that maximal electromyographic activity of the
masseter muscle is reduced with the increase in degree of temperomandibular
arthropathy. Electromyography could therefore be used as a diagnostic tool able
to objectify the degree of arthritic involvement and to predict the evolution of
the arthropathy.
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Electromyographic (EMG) recording of electrical
potentials of the masticatory
muscles.
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5. An electromyographic
analysis of the silent period elicited by the application of different
stimuli (calibrated percussion of the chin with a small electromagnetic hammer,
with teeth in contact). Clinical electromyographic studies have in the past
suggested the use of the values of latency and duration of the silent period as
a diagnostic or prognostic index of dysfunctional pathology of the masticatory
system (from Clinical significance of masseteric silent period elicited by
different trigeminal stimulations R. Ciancaglini e coll.); from
‘Electromyography of jaw reflexes in man’ Leuwn University Press, 1988).
Nowadays the indication for the use of such a parameter should be limited only
to those neurological pathologies of a congenital or acquired origin with
serious trigeminal nerve involvement. This test is not considered of much use in
describing and quantifying the existence of an orthopaedic mandibular
disorder.(* )
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Electromyographic analysis
of the silent period. |
6. Analysis of sounds produced during opening and
closing movements of the mouth by digital phonoarthometry of the
temperomandibular joints.
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From: Digital
phonoarthrometry of temperomandibular joint sounds; a preliminary report
R. Ciancaglini et coll. J. Oral Rehabilitation, 6: 385-392
1987 |
1&2. Sound emitted by a tuning fork
recorded by a microphone and converted into an electrical signal by the
digital oscilloscope (note the regularity /periodicy of the
signal).
3&4. Noise produced by crumpling paper,
captured on microphone and converted into an electrical signal by the
digital oscilloscope (note the extreme irregularity of the
signal).
5. Clicking sound produced by a dysfunctional
temperomandibular joint (without arthrotic changes), captured on
microphone and converted into an electrical signal by the digital
oscilloscope (note the regularity/periodicy of the signal, quite similar
to the sound emitted by the tuning fork).
6. Crepitus
produced by an arthrotic temperomandibular joint, captured on microphone
and converted into an electrical signal by the digital oscilloscope (note
the extreme irregularity of the signal), very similar to the noise
produced by crumpling paper. |
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Recording
of joint sounds with microphones (phonoarthrometry). |
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| B.
Phonoarthrometric tracings using Fast Fourier Transformed analysis,
as used in the technique proposed by R. Ciancaglini et al.: the
spectrum frequency generated by sounds (Fig. above left) and noises
(Fig. above right) is similar for joints with functional problems
(respectively, single noise below left, and two noises, below
right). | |
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A. Summary of
the digital phonometric procedure used in the diagnosis/recording of joint
sounds developed by C. et
al. |
Journal of Oral
Rehabilitation, 1987, Volume 14, pages 385—392
Digital
phonoarthrometry of temporomandibular joint sounds: a preliminary
report
R. CIANCAGLINI, M. SORINI, L.
DE CICCO and F. BRODOLONI
Department of Stomatognathic
Physiology, Institute of Clìnical Dentistry and Stomatology, San
Paolo Hospital, School of Medicine and Dentistry, University of
Milan
Summary
A new technique
is presented for recording and evaluating the dysfunctional TMJ
sounds on an objeetive basis. The physical implieations related to
TMJ phonoarthrometry (PAM) are diseussed and three cases are
presented. The phonoarthrography and the digital phonoarthrometry
presented in this paper can be a useful harmless diagnostic tool.
Differential diagnosis of TMJ pathology is possible on the basis of
an acoustieal analysis and it is hoped that future investigation
will eonfirm these observations. |
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Journal of
Craniomandibular Disorders: Facial & Oral
Pain
Assessment of Arthropathy of TMJ by Digital
Phonoarthrometry
R.
Ciancaglini, M.D., D.D.S.
Director TMI Clinic and
Professor
Pathophysiology of Occlusion
M. Sonni Resident
L.
de Cicco Resident
L. Panizzari Resident
Section of TMI
Pathophysiology
Stomatologic Clinic
Istituto di Scienze
Biomediche
Ospedale San Paolo
University of Milan
Milan,
Italy
Summary
The acoustical
characteristics of TMJ noises and their possible dia gnostic value
in masticatory disorders were evaluated. Nine patients with
unilaterally noisy joints were selected at random and evaluated by a
clinica! and radiologica! arthropathic index (CRAI) that includes
the duration of the occurrence of noise, pain in the TMJ area, the
tenderness on lateral palpation of the TMJ, and linear and computer
tomographv of the craniomandibular complex. The CRAI ranged from O
(no arthropathy) to 13 (severe arthropathy). A microphone recorded
the TMJ noise as the patient rhythmically opened his mouth as wide
as possible to elicit the noise. The frequencv spectrum of the noise
was submitted to calculation of the differential and RMS
cornputer-assisted analvsis (digital phonoarthrometry of TMJ). There
was a high degree ofcorrelation (r = 0.9934) between the
phonoarthrometric values and the arthropathic indexes recorded Jòr
all nine patients. Digital phonoarthrometry ofTMJ is a safe, rapid,
and reliable dia gnostic device for TMJ pathologv, especially for
early detection of TMJ arthropathy. |
 CRAI and Digital
Phonoarthrometry Assessments of nine Patients with
Unilaterally Noisy Joints (Ciancaglini and Sorini,
1986) |
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Linear correlation of the
clinical radiological arthropathic indexes (CRAI) and
phonoarthrometric (PAM) assessments of the nine patients
reported in this study. RMS = root mean square; DIFF =
differential calculation; and FFT = Fast Fourier
Transform | | | |
This technique can record and
evaluate noises originating from the temperomandibular joint which are then
computer elaborated or rectified (Fast Fourier Transformed). (*) The analysis of
the tracing obtained can describe the type of noise, can locate its exact
origin, can quantify the number of intracapsular dysfunctional problems, as well
as indicating their probable origin (functional or organic). Phonoarthrometry is
therefore a useful diagnostic tool, especially so, because of its non-invasive
nature.(*)
These procedures can also help indicate preventative and
therapeutic measures, including physical therapy for the craniomandibular and
craniocervical areas, and for the spine in general. Moreover, the above
systematic approach to an orthopaedic examination of a patient´s mandibular
function can be chosen as a model for a standard approach in the assessment of
the natural course of a pathology, and for the indication and efficacy of
treatment measures that need to comply with medico-legal
requirements.
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