Semiology and specific examination of a patient with TMJ disorder
I. Introduction
The study of the temporomandibular joint in humans shows that it is totally linked to the dental system, by its physiology, as by its pathology.
FREY, as early as 1902, defined this concept by speaking of the temporomandibular-dental joint. This notion was completed in 1957 by HELD under the name of the temporomandibular-syndesmo-dental joint, which includes the periodontal elements.
II. Definition
The temporomandibular joint is a bicondylar diarthrosis with an interposed disc.
It has articular surfaces, a synovium, a capsule and ligaments.
It can be the seat of all rheumatological conditions, like any other
joint .
III. Clinical examination
1. The interrogation:
It should take place in a calm and relaxed atmosphere in order to put the patient at ease and taking the time to listen to him before examining him, we should note:
- Name, first name, age, profession, family situation, address and telephone number.
- Family and personal osteoarticular history.
- Notion of recent or old cervicofacial trauma.
2. Oral exo-examination:
- Appreciate the appearance of the integuments.
- The symmetry of the face.
- Equality of the floors:
- DVO Review:
3. Examination of the masticatory system:
3.1-Examination of the masticatory and cervical muscles:
Patient relaxation as complete as possible, otherwise the information collected may be distorted.
A- Palpation: looking for hypo or hypertonicity and a painful point.
- The temporal:
03 bundles easily palpated through the scalp, the insertion at the level of the coronary is palpated by the endo-oral route.
- The medial pterygoid:
*Extraoral palpation: The seated patient is asked to lean their head forward, mouth closed, to release the tension in the integuments. The practitioner slides their index fingers along the inner surface of the gonial angle while the patient clenches their teeth.
*Intraoral palpation: the patient, with his mouth open, resists closing with three of his fingers placed on the free edge of the incisors. This produces a contraction of the muscle which will be easily explored along the internal surface of the ascending branch.
- Lateral pterygoid:
Is practically inaccessible to palpation. Only the lower edge of the lower head can be
reached by the tip of the index finger insinuating itself behind and above the tuberosity, asking
the patient to move his mandible laterally with an opening not exceeding 20mm.
- Tongue: The patient is asked to stick out his tongue.
- Digastric: This is facilitated by tensing the muscle. With a fist under the chin, the patient forces the mandibular opening to 15 mm.
- suprahyoid muscles:
- From the sternocleidomastoid:
- Neck, nape, spine
cervical and trapezius:
3.2 ATM Examination:
includes palpation at rest and during movement looking for pain and noise
joints.
palpation of the integuments allows us to appreciate:
The symmetrical and synchronous character or the differences.
The degree of openness or closure
Intra-auricular palpation reveals the noises. The pulp of the auricles reveals the differences in vibrations.
Auscultation with a stethoscope placed in the petragian region amplifies the perception of noises.
3.3 Examination of mandibular movements:
interests the following movements:
- Opening: the inter-incisal distance must be between 47mm plus or minus 7mm.
Cornu and Dechoux estimate it at 50 mm (± 6). The opening path must be straight.
- Closure: we study the path between the resting position and the OIM without forgetting the propulsion, retropropulsion and diduction movements.
3.4 Intraoral examination:
- Oral hygiene,
- Dental examination and formula (cavities, malpositions, edentulism, abrasion veneers).
- Examination of the mucous membranes,
- Examination of salivary swallowing (lingual impulse during atypical swallowing would be responsible for mandibular lameness),
- Study of occlusion:
1- Static occlusion:
Determination of occlusal type and search for prematurities.
2- Dynamic occlusion:
In search of occlusal interferences
- Propulsion causes the molars to disengage laterally and symmetrically.
- Diduction: the notion of canine or group protection.
4. General examination:
focuses on the myo-ligamentous apparatus by assessing the degree of myoligamentary hypotonia,
and on the general posture of the body, because we cannot dissociate the balance of the mandible from that
of the general posture of the body, due to the existence of reciprocal influences
indisputable.
Normal posture finds perfect balance by a line corresponding to the plumb line and
perpendicular to this line. The loss of parallelism of a perpendicular results in a
disorganization of perpendiculars.
5-Psychological examination:
The relationship between TMJ disorders and psychological disorders has been a major
For many years, this has been a controversial topic. These psychological factors play a significant role.
Sometimes, this role can be decisive in the genesis of this pathology.
VI. Additional examinations
1-Biological examinations:
1. Examination of inflammation and specific biochemical dosage:
*VS and CRP:
The presence of an inflammatory syndrome is not specific, but allows, in most cases
cases, to distinguish between degenerative or inflammatory damage.
*Serology research takes on its full value in the context of certain septic arthritis in
specific germs.
*Metabolic arthropathies also have their own signs: gout…
*Urea, crea, blood sugar.
*Waaler-Rose, latex test for rheumatoid arthritis.
2- Imaging:
TMJ imaging currently uses either computed tomography (CT) or
to nuclear magnetic resonance imaging (MRI). Other procedures have only
limited applications.
Plain X-rays are unable to provide accurate information
desired for proper management of disorders.
2.1.1-Incidences allowing to have both joints on the same image:
*From the front:
-the lower face with the mouth closed or better, with the mouth open.
-Sub-occipito-frontal incidence (Worms and Breton)
*Vertical:
Vertex-chin-Hirtz plate incidence.
*In profile:
they give a parasitic superposition on both sides and are of little interest.
*Orthopantomogram:
Panoramic X-rays are diagnostic images which, however, remain very useful and are part of the standard assessment.
2.1.2-Incidences allowing to obtain the two articulations separately:
*Schuller incidence.
Only the Schuller incidence, with the mouth closed and possibly with the mouth open, gives a precise image of the joint contours.
*Teleradiographs: (front, profile, and in Hirtz position) are almost always necessary to establish a diagnosis in the context of maxillomandibular-dental disharmony
*Tomographic sections:
This technique had the handicap of only showing the bone condition and the position of the disc should be deduced from the comparison of images obtained with the mouth closed or open.
2.1.3-Cone beam volume tomography:
Otherwise known as Cone Beam Computed Tomography (CBCT) is a new imaging technique introduced in 1998. It has the advantage of delivering minimal radiation doses with limitation of the irradiation field. It also offers the possibility of having more precise images and better resolution than CT and 2D reconstructions.
2.1.4-Arthrography:
Has long been the standard for judging disc position. Invasive and painful method,
requiring the puncture of at least one, or even two, levels of the joint, it had the merit
to give the disc an image that faithfully revealed its topography and certain
anomalies of his posterior brake.
2.1.5-The scanner:
The CT examination has raised great hopes, due to the image processing, suitable for making
appear successively from the same section the bony and tissue elements of the
region examined, which suggested the possibility of finally having an image of the disk
direct.
2.1.6-Magnetic resonance imaging:
It is currently the most suitable examination to show the disc and its tissue environment in a non-traumatic, painless and radiation-free manner, and also to give an increasingly precise image of the bone condition.
2.1 .7-Bone scintigraphy:
It has been proposed for the study of the TMJ. Its major drawbacks are, of course, its lack of specificity and its lack of resolution. Most lesions can be detected by hyperfixation, but the examination is unable to determine the nature of the lesion. Its only indication seems to concern certain benign bone tumors.
3-Arthroscopy:
The first temporomandibular arthroscopy was performed in 1964 by Ohnishi. For the temporomandibular joint, small diameter arthroscopes (1.7 to 2.4 mm in diameter) are used, coupled with a light optical fiber and a camera, allowing the surgeon to follow live or on a video screen the visualization of the joint parts (magnification up to 100 times). There is a joint irrigation system, which reduces the risk of sepsis and gives perfect visualization of the tissues.
The classic puncture point is located 2 mm below a line running from the tragus to the
external canthus, 10 mm anterior to the tragus.
only the upper compartment is explored (static and dynamic), there is no technique
reliable for puncture of the lower compartment.
It is thus possible to examine the articular surfaces at the condylar or glenoid level, the
anomalies of position, mobility or structure of the disc apparatus, synovial reactions
and any floaters.
Arthroscopy is performed under general anesthesia, although it is theoretically possible to
performed under local anesthesia.
4-Electrical examination:
There is no typical picture in electromyographic or electro alterations
physiological in ATM pathology.
Electromyographic examination can allow:
- To assess the existence of spastic activity,
- Analyze the symmetrical or non-symmetrical aspect of muscle contractions
- And also allows to check the quality of restoration work by comparing the results before and after treatment.
4-Occlusal contact analyzers:
Allows the recording of the chronology, pressure and distribution of occlusal contact points . The major interest of this type of device is also to keep track of these occlusal contact points and their evolution over time, either spontaneously or under the influence of therapy, but its cost means that it is not currently used.
5-Mandibular movement analyzer (mandibulography):
These devices allow for recording of mandibular kinematics. Magnetic waves or fields are captured by a receiving antenna (or camera) placed on the face. This detection device transmits signals to a computer that allows for a graphical representation of these movements, as a function of time, speed, and acceleration. Here too, this complementary examination is theoretically interesting, but not used in practice.
INFLAMMATORY AND DEGENERATIVE PATHOLOGY
Introduction :
Like any joint, the ATM can be affected by all conditions
rheumatological: septic arthritis, inflammatory rheumatism, lesions
degenerative, metabolic arthropathies.
These events remain rare, but it is essential to know about them in order to
diagnose certain pathologies expressed at the level of the ATMs and the management of which
This load does not differ fundamentally from the rheumatological conditions of other
joints.
1. Septic arthritis:
1.1 Definition :
Septic arthritis is the consequence of the invasion of the synovium by living microorganisms.
1.2 Etiology:
Contamination of the temporomandibular joint occurs through various routes, such as a septic graft in the context of septicemia, by contiguity from a parotid infection; otitis, cellulitis under masseterine or even by direct inoculation from a penetrating wound, trauma, or an iatrogenic act in relation to the joint.
1.3. Clinic:
Pain localized to the temporomandibular joint, especially when moving it,
Fever and hyperleukocytosis are often seen in the acute phase.
While in the chronic state, the patient may present spontaneous or localized pain
mouth opening, limited joint movement and sometimes swelling
jugal or trismus.
1.4. Diagnosis:
It is ensured by the puncture of the joint collection; most often frank pus in
which bacteriological examination can find the causative germ.
1.5. Treatment:
Treatment must be initiated quickly to avoid irreversible complications. It is
based on antibiotic treatment.
2. Inflammatory rheumatism:
2.1. Rheumatoid arthritis:
2.1.1 Definition:
It is a destructive, immune-mediated polysynovitis. This synovitis eventually causes cartilage, bone, and ligament damage.
RA progresses chronologically in three distinct phases
- An initiation phase of the immune response,
- A phase of inflammation of the joint
- A phase of destruction of cartilage and bone.
These destructions are due to an attack on the cartilage by inflammatory factors including metalloproteinases (MMPs), tumor necrosis factor α (TNFα), interleukin (IL6 and IL17) and an imbalance in the balance of bone remodeling.
2.1.2 Clinic:
Unilateral involvement at the onset of the disease, only becoming bilateral after several years
devolution.
Pain generally well localized on the joint space, sometimes radiating into the ear or into the temporal and subangular-mandibular regions, predominantly in the morning then fading during the day.
2.1.3 Radio:
Is normal for a very long time, because the initial damage is synovial; this is what we
called rheumatoid synovitis.
In advanced forms, periarticular erosions appear.
2.1.4. Biological diagnosis:
An inflammatory assessment including ESR, CRP
Specific tests to search for rheumatoid factors (latex reaction, Waaler-Rose)
2.1.5. Treatment:
- symptomatic treatments use analgesics and non-steroidal anti-inflammatory drugs.
- Background treatments should be used early. They include several therapeutic classes:
– Corticosteroid therapy;
– Gold salts
– Thiol derivatives
– Antimetabolites (methotrexate, etc.)
-targeted therapies: anti TNFα, interleukin inhibitors
– Local medical treatments and rehabilitation of the ATM:
local corticosteroid therapy.
the resting of the ATM.
2.2 Ankylosing spondylitis (AS):
2.2.1 Definition:
AS is a chronic inflammatory rheumatism that primarily affects the structures
axial with damage to the temporomandibular joints estimated at between 10 and 24%.
It is the only rheumatological condition likely to induce TM ankylosis.
2.2.2 Radio:
Objective condylar erosion on the anterior and posterior parts.
2.2.3 The diagnosis:
Based on pain, genetics, presence of HLA B27 antigen.
2.2.4 Treatment:
It is managed by rheumatologists. It is mainly based on NSAIDs, painkillers, and physiotherapy.
Surgical therapy is indicated in cases of ankylosis.
2.3. Juvenile chronic arthritis (JCA) or “STILL’s disease”: JCA is the leading cause of childhood rheumatism. It is a group of diseases characterized by isolated inflammatory joint disease or associated with extra-articular manifestations. The etiology is unknown.
2.4. Reactive arthritis
Reactive arthritis is a group of conditions that are referred to as
post-infectious rheumatism characterized by a genetic background
predisposed, with the presence of tissue antigen B27 and their
occurred following extra-articular infections with certain germs:
genital infections, intestinal infections, lung infections, etc.
This condition is not due to the presence of a germ in the joint, but to a distant infection.
Its treatment is that of the cause (etiological treatment) and the symptoms.
3. Degenerative lesions:
3.1 Osteoarthritis or Arthrosis:
3.1.1 Definition:
Osteoarthritis or degenerative joint disease is a chronic, non-inflammatory condition,
characterized anatomically by the deterioration and abrasion of articular cartilage with
concomitant formation of reactive bone on the articular surfaces (production
of osteophytes).
Just like in the hip or knee, temporomandibular arthritis reflects the wear and tear of all
joint structures (cartilage, bone and disc
3.1.2 Etiology:
The main cause is the disruption of dental articulation.
It is sometimes a consequence of certain fractures of the mandible (capital fracture of the condyle).
The many triggers of osteoarthritis are now better understood, particularly the role of occlusal overload.
3.1.3 Clinic:
It manifests itself by:
– joint pain aggravated by joint function, chewing or speaking,
– joint noises.
– When it is advanced, it leads to a limitation of joint ranges, a limitation of mouth opening.
3.1.4 Radiography:
Objective of skeletal alterations, in the context of a late observation we note a pinching or the disappearance of the joint space.
3.1.5 Treatment:
– Symptomatic: aims to relieve pain; NSAIDs, AIS, muscle relaxants.
– Etiological:
🡪occlusal rehabilitation
🡪surgical trt: modeling condyloplasty
4. Metabolic arthropathies:
4.1 Chondrocalcinosis:
Chondrocalcinosis is a rheumatic disease occurring in middle age and characterized by painful attacks due to the presence of calcium-containing crystals within the cartilage itself, which is part of the composition of the sliding surfaces of a joint, and more specifically the menisci (composed of fibrocartilage).
It also affects the ligaments of the joints and generally affects the joints symmetrically (on both sides at the same time).
This form is rare at the level of the temporomandibular joint
Chondrocalcinosis of the TMJ is diagnosed late, on average 5 years after the first manifestation.
4.2 Gout:
Gout is a common chronic disease related to the metabolism of uric acid. Without treatment, it progresses towards the deposition of uric acid in several sites of the body with a predilection for the joints (gouty arthritis).
Gouty attacks rarely affect the TMJ.
Therapeutic management of gout includes a symptomatic component (relief of attacks by non-steroidal anti-inflammatory drugs) and basic treatment (hygiene and dietary rules and in certain cases uric acid-lowering drugs).
Conclusion
ATM pathology is a multifaceted pathology, even if for educational purposes
grouped into dysfunctional and organic pathology it is not rare to see them intertwined and
to maintain each other.
Good management of ATMs necessarily involves a clinical examination
in-depth and further investigations in order to arrive at a
most appropriate therapeutic approach.
LIMITATIONS OF MOUTH OPENING
I – Introduction
Limitation of mouth opening results in a decrease in the amplitude of mouth opening.
It can be reversible and is trismus or fixed constituting a permanent constriction of the jaws.
II – Positive diagnosis:
is made from several elements:
1- examination of the patient
a- interrogation:
Age, addresses, profession
It is necessary to specify:
*the date and mode of appearance
*record medical and surgical history
*the mode of evolution
*associated signs: pain, dysphagia, muscle contraction, etc.
b-clinical examination:
The mouth opening must be assessed using a caliper measured between the upper and lower inter-incisal point.
Normal mouth opening must be greater than or equal to 47±7mm.
We speak of OB limitation when it is less than 30mm.
The clinical examination should include the rest of the face, ATM, muscles, salivary glands, lymph node chains.
Neurological exploration of V and VII must also be carried out.
Thorough examination of the entire oral cavity
ENT examination to explore deep structures
The clinical examination should include the rest of the face, ATM, muscles, salivary glands, lymph node chains.
Neurological exploration of V and VII must also be carried out.
Thorough examination of the entire oral cavity
ENT examination to explore deep structures
c- additional examinations:
Panoramic X-ray, CT, MRI, Schuller
Nasofibroscopy: examination of the cavum, oropharynx
Sometimes biopsy
III. TRISMUS:
1°Definition
Lockjaw is the temporary constriction of the jaws.
It manifests itself by the more or less great, temporary difficulty in opening the mouth.
This constriction, often painful, is a symptom that can accompany a local, loco-regional or general condition.
2° Physiopathology
The constriction of the elevator muscles responds to a reflex during neighboring affections.
Stokes-Spartan’s Law: “When there is inflammation near a muscle, it contracts reflexively.”
3°Etiology
A) general causes
a) Tetanus
It is a toxic infection caused by a gram-positive bacterium, Nicolaier bacillus or Clostridium tetanus.
Following a cutaneous-mucosal lesion (deep or superficial), the toxins of this germ will selectively attach themselves to the nervous tissue. This nervous excitation will be the cause of characteristic generalized painful muscular contractures (tonic, paroxysmal, painful), appearing on average 6 to 12 days after the injury.
Trismus is sometimes the first sign of this condition, hence the role of the dental surgeon.
Other contractures appear in the facial muscles and the patient presents the face of sardonic laughter.
If treatment is not initiated, the contracture, after a few hours or days, spreads to the muscles of the neck and spine, at the same time as more significant infectious signs appear, which can end in death.
You should always look for:
tetanus vaccination (which must be repeated every 10 years)
Concept of wound, surgery or dental care
Treatment:
Hospitalization in a medical intensive care unit
– anti-tetanus serum (specific gamma globulins)
-muscle relaxants
(b) other general causes:
- Poisonings:
Neuroleptics, barbiturates, strychnine, accidental ingestion of mole poison, drug addiction, etc.
Multiple sclerosis
Ethylism
Epilepsy
Central nerve damage
tetany crisis due to hypocalcemia
- Rage :
transmitted by the saliva of contaminated animals (dog or canine bites) and is due to an RNA virus.
B) Local causes
a).infectious :
Are the most frequent. In this case, trismus is the response to a nearby infection:
Cellulitis, osteitis, stomatitis, pericoronitis, skin infection (furuncle), muscle infection (myositis), arthritis, etc.
b)– traumatic:
Mandibular, maxillary, facial fracture.
Iatrogenic surgical procedures…
c)– tumor:
Benign tumors
Malignant tumors: articular, muscular, deep structures (cavum++)
d)DAM
4°. Characteristics of trismus of local causes
a) trismus of local cause mainly accompanies acute phase conditions,
it may persist and become chronic with the condition, or disappear.
If it does not go away, trismus becomes a muscle disease and no longer trismus.
b) the trismus is all the tighter the more posterior the condition is (the 8 is almost in contact with the elevator muscles compared to the 4)
5th Evolution
Lockjaw usually disappears when the cause disappears.
In some chronic accidents, despite the disappearance of the cause, an organic lesion of the elevator muscles sets in (myositis).
6°Diagnosis
The diagnosis is etiological:
Local cause: 95% of cases
General cause:
*sardonic tetanus laughter
*bite rage
*drug poisoning
Differential diagnosis:
Conditions that do not meet the definition of trismus should be eliminated.
Eliminate temporary ailments, permanent ankylosis and constrictions, TMJ dislocations, etc.
7° Treatment
The treatment is etiological.
The cause of trismus must be eliminated or treated.
If it becomes chronic, the myositis must be treated.
IV. PERMANENT CONSTRICTIONS OF THE JAWS
1° Definition
It is a complete or incomplete abolition of lowering of the mandible, therefore it is a partial or total impossibility of opening the oral cavity.
Constriction is an irreversible lesion (unlike trismus which is temporary).
It may be due to bone alteration or soft tissue alteration, or a combination of both etiologies at the same time.
2°Constriction by bone alteration = Temporomandibular Ankylosis
These ankyloses will be characterized by the fusion of the mandibular and temporal condyles.
A) Etiology
a) joint trauma:
Capital fractures of the mandibular condyle are often complicated by ankylosis.
TMJ trauma with or without foreign body penetration.
b) extra-articular trauma :
Low condylar fractures, especially when bilateral and when treated with prolonged bimaxillary blocking, can be complicated by ankylosis.
Fracture of the zygoma and injury to all the muscles that attach to it.
Fracture of the coronal-malar region.
c) Infections:
Arthritis of general causes: which can be rheumatic or specific.
Neighborhood infections that can spread to the ATM (suppurative otitis, osteitis of the tympanic bone, osteitis of the BM or upper jaw, osteomyelitis of the upper jaw).
B) Pathological Anatomy :
The destruction of the articular surfaces will bring the two condylar and temporal bones into contact, which will fuse together, forming a callus whose volume and size vary from one subject to another.
This bony bridge connecting the base of the skull to the mandible is called CRANIOMANDIBULAR SYNOSTOSIS.
C) Clinic a) In adults:
Whether it is unilateral or bilateral, we have the same symptoms:
More or less complete inability to open the oral cavity.
The endo-oral examination, which is very difficult, still allows us to see a mouth in a very poor state (cavities, tartar, gingival and periodontal infection and foul breath).
These patients are very prone to stomatitis due to the increased virulence of oral germs (due to a change in living conditions involving constant mouth closure).
Palpation at the level of the ATM will reveal the presence of craniomandibular synostosis and very slight movement when the ankylosis is partial.
b) In children:
It is very difficult to locate the onset of the disease.
It has a different appearance depending on whether it is unilateral or bilateral:
Unilateral ankylosis: (affects only one joint).
We have:
Facial asymmetry
The chin is deviated to the diseased side
Palpation reveals the presence of a callus at the level of the affected TMJ and very slight condylar movement at the level of the healthy joint.
Bilateral ankylosis:
injury to both joints.
The child has a characteristic appearance:
Face finished in a lower point
Bird profile (pathognomonic) due to inferior micrognathia and superior protrusion.
Palpation shows the presence of bone callus at both joints.
D) Diagnosis :
The diagnosis is easily made clinically and confirmed by radiographic examinations.
-the low face incidence allows you to see the width of the callus;
-other radiological examinations: profile view, maxillary defilement which show the length and condition of the BM and also the condition of the joints + Panoramic, scanner and tomography, MRI, Electromyography.
E) Treatment
a) prophylactic treatment
It consists, especially in the case of general or local infectious accidents, of avoiding joint damage. Therefore, treatment of the infection with antibiotics, drainage of purulent collections located near the ATMs.
When children fall, be particularly concerned about ATMs.
In the case of a condylar fracture, to avoid temporomandibular ankylosis, it is necessary to maintain a balance between blocking and mobilization when treating this fracture. It is sufficient to release the patient for a few minutes per week for the duration of treatment, and not to continue the restraint beyond one month.
b ) curative treatment = surgical treatment
The aim of the treatment is to recreate a new joint or pseudo-joint which can only be achieved by creating a pseudarthrosis in the area that has undergone an osteotomy (which can be low or high).
Noticed :
Adult ankyloses pose two problems:
-free mandibular movements
-restore masticatory function while respecting occlusion and mandibular kinetics.
In children, deformities must be treated and surgical treatment must be combined with functional rehabilitation.
3°Constriction due to alteration of the soft parts
They are characterized by the presence of retractile scars or bands that prevent mandibular lowering.
These flanges can be inserted only at the level of the mandible or form a craniomandibular bridge.
These are skin, mucous membrane and muscle lesions .
A) mucosal lesions:
These are mainly exuberant repairs constituting mucous flanges.
B) Skin lesions:
These are the most important ones.
These are all losses of substances following serious illnesses (syphilitic gumma, tuberculosis, malignant tumor, noma) or following major trauma which heals slowly, leading to progressive retractile sclerosis.
C) Muscle lesions:
These are the lesions of the masseter that cause permanent constriction.
Among these lesions of the masseter we can also have chronic myositis, a hematoma of the masseter that ossifies secondarily, syphilitic and tuberculous gummas and muscular sclerosis due to radiotherapy.
D) Treatment
Excision of retractile bands and scars followed by skin and mucosal grafts, and plastic surgery.