1.

Jaw Movements, Path of Closure, and Joint Sounds

When the head is in its natural postural position, the mandible reflexly closes on a smooth arc
with little deviation anteroposteriorly or mediolaterally (see Chapter 8). There are many reasons
for uneven or erratic jaw movements on closure-including past trauma to the joint, occlusal
interferences, an exfoliating primary tooth, pain, etc. Observe the patient closing the jaw in a
relaxed manner without prompting or guidance on your part, noting the amount, direction, and
timing of any deviations from a smooth closure path. Then, holding the fingers lightly over both
jaw joints, repeat the process to identify "clicks" or crepitus. A stethoscope is particularly useful
for identifying temporomandibular joint sounds: One or both condyles may slide over the edge
of the meniscus late on jaw opening, slipping back into place after the initiation of closure. In
other instances, the condyle 'may be felt to move onto the posterior edge of the meniscus very
late in closure. All abnormal closure movements and joint sounds must be correlated with
occlusal interferences and muscle and joint pain. The extent of maximal jaw opening should be
measured. Many authorities consider less than 40 mm to represent restricted jaw opening.
Brandt4 considers this an artificially high threshold for determining restricted jaw movements,
suggesting that 35 mm is more appropriate for children and adolescents.

2. Occlusal Interferences
It is essential to check for interferences in the retruded contact position and the intercuspal
position, and during protrusive and lateral occlusal contacts (see Chapters 8 and 11).
Interferences may be marked with articulation paper or registered in very thin wax. Children
with temporomandibular dysfunction may show disharmonious occlusal interferences in either
the retruded contact position (centric relation) or the intercuspal position (centric occlusion,
uswll occlusal position)., WilliamsonJO has noted the importance of posterior disclusion during
incisal guidance. The patient may be taught to move the jaw forward to edge-to-edge incisal
relationships. Interferences can be noted during this maneuver or during tapping in the incisal
position. Lateral working bite disclusion may not be seen until the permanent cuspid is fully
erupted, and working side interferences of an irregular nature are frequently observed in
malocclusion. Balancing (nonworking side) interferences are particularly troublesome at all ages,
irrespective of how nice the morphologic occlusal relationship may seem in the intercuspal
position.

3. Palpation of Muscles and Ligaments

Each muscle involved in mandibular movements should be routinely palpated at rest and in
isometric contractions (tell the patient to clench the teeth) in an attempt to educe reflex
responses to pain. Often, unbeknownst to the patient, muscles or parts of the muscles are
painful upon palpation. The masseter, lateral pterygoid, and temporal is are those which most
frequently demonstrate myalgia in patients with temporomandibular dysfunctions associated
with malocclusion. Inform the patient that you are going to press several of the muscles of the
face and jaws and you want him or her to respond if the pressure hurts. Then, with your finger,
press on the muscle at the base of the patient's thumb to show how pressure alone feels. I use a
four-point scale, asking the patient the score each time I press a muscle site or tendinous
attachment. The values are: o pressure only, no pain; I = pain on pressure only; 2 = chronic pain,
 pain prior to palpation-the pain is increased with pressure; , 3 = chronic pain-the patient flinches
and/or grabs the dentist's hand. Even though the patient acknowledges pain, it is necessary to
palpate carefully all muscles and their tendons in order to localize and corroborate. Wearing
rubber gloves, systematically and evenly press the bellies and then the attachments (as able) of
the masseter, medial pterygoid, temporalis, and lateral pterygoid muscles, in that order, noting
the patient's scoring for each muscle. It is especially important to separate temporal tendinous
pain and lateral pterygoid pain from joint capsular pain. Some patience and practice are
required to be certain of the anatomic site being pressed. For the temporal is tendon it is easier
if one begins by sliding the finger along the anterior border of the ramus. As the coronoid
process is approached, ask the patient to open and close the jaw gently, which movement
reveals the exact site of the tendinous attachment. When palpating the lateral pterygoid muscle
and tendon, make certain your finger is not pressing the joint itself. Palpation of the
temporomandibular joint and capsular ligament is also necessary (see Section 4, Palpation of
Joint Capsule, which follows)

4. Palpation of Joint Capsule

Palpations of the joint capsllles may reveal intracapsular pain, the timing of "clicks," and the
nature of orepitus. Begin by touching lightly both joints during unguided opening and closure.
Repeat the procedure while the.)aw is moved into protrusive and lateral eXj;~rsive positions.
Next gently maneuver the jaw into the retruded contact position with one hand 'lightly on the
chin and the other touching lightly each of the capsules (externally) in sequence. Then palpate
each of the joint capsules intraorally, noting the pain scores. If specific occlusal interferences
have been registered earlier, it is often particularly revealing to have the patient tap lightly on
the noted interference while pressing the capsular ligament. "Clicks" disclose a loss of intimacy
of condyle and meniscus relationships, and crepitus (rare in children) may point to early arthritic
symptoms. The significance of "clicking," though debated, is far better understood in adults than
in children. It is

5. Registration of Jaw Relationships in the Presence of Pain or Limited Movement

When any muscle or joint is painful, all of the muscles capable of moving that joint display
"splinting," the simultaneous contraction of all the muscles to reduce movement and further
damage to the joint. Splinting is sometimes called' 'guarding" in the dental literature, and lay
persons often speak of "stiff" joints after a sprain. All these terms refer to a naturallJrotective
reflex on the part of the body which makes registration of jaw relationships quite difficult.
Splinting must be differentiated from anxiety or too active attempts by the patient to cooperate
during jaw registration. If splinting is suspected, place a cotton roll between the molars on each
side and ask the patient to hold them lightly in place for a few minutes. Then gently remove the
cotton rolls, and obtain the registration before the patient brings the teeth together. This simple
procedure temporarily "deprograms" the memory of the occlusal interference which has been
shunting the jaw away from the reflexly determined position. When a serious and persistent
interference is present and temporomandibular dysfunction has been positively identified, it is
necessary to place a maxillary diagnostic splint to relieve all occlusion for a period. For such
diagnostic (not treatment) purposes, I do not use splints with occlusal coverage, preferring the
design shown in Fig 10-21. The splint shown is simple to construct and easy for the patient to
use. Further, it can be equilibrated quickly in the mouth. Note that its construction requires no
assumption on your part of a "correct" jaw relationship. Wearing it simply discludes the teeth,
allowing the muscles to relax since the affe;ent avoidance signal from the interfering tooth is
lost. Muscle tension and pain often diminish within 2 weeks, at which time the occlusal analysis
can be completed more accurately. Its use facilitates occlusal equilibration and it is especially
useful in those serious cases where the casts must be mounted on an articulator for more
precise analysis. See Chapters 8, 11, and 18 for other discussions of functional analysis, jaw
registrations, and occlusal equilibration techniques.