Temporomandibular Joint movement in the lower part of the joint.

The synovial membrane

lines the capsule in the upper and the lower cavities.
It is articulates above with the mandibular fossa and the articular
tubercle of the temporal bone. It articulates below with the head NERVE SUPPLY: Auriculotemporal and masseteric nerves,
of the mandible. The joint is a synovial joint. The branches of the mandibular division of the trigeminal nerve.
fibrocartilaginous disc divides the joint into upper and lower
MOVEMENTS:-
cavities. The capsule encloses the joint.
 Protrusion: The head of the mandible and the articular
LIGAMENTS:-
disc move forward in the upper part of the joint. Lateral
 Lateral Temporomandibular Ligament: is attached pterygoid muscle.
above to the articular tubercle at the root of the zygomatic  Retraction: The head of the mandible and the articular
arch and below to the neck of the mandible. The fibers disc move backward in the upper part of the joint.
extend downward and backward. This ligament limits the Posterior fibers of the temporalis muscle.
posterior movement of the mandible.  Depression of mandible (mouth is opened): The head of
 Sphenomandibular Ligament is attached above to the the mandible rotates on the undersurface of the articular
spine of the sphenoid and below to the bony projection disc around a horizontal axis. Digastrics, geniohyoids, and
(lingula) of the mandibular foramen. Its function is mylohyoid muscles.
unknown.  Elevation of mandible (mouth is closed): The head of the
 Stylomandibular Ligament: is attached to the styloid mandible rotates on the undersurface of the articular disc.
process above and to the angle of the mandible below. Its At the same time, the posterior fibers of the temporalis
function is unknown. muscle pull back the head of the mandible, and the
articular disc is pulled backward by fibroelastic tissue,
Articular Disc:-
which connects the disc to the temporal bone posteriorly.
The articular disc is an oval disc of fibrocartilage. It is attached Temporalis, masseter, and medial pterygoid muscles.
in front to the tendon of the lateral pterygoid muscle and  Lateral chewing movements: Alternate protruding and
posteriorly by fibrous tissue to the head of the mandible. The retracting of the mandible on each side.
circumference of the disc is attached to the capsule. The disc
permits gliding movement in the upper part of the joint and hinge
Evaluation:- TMJ, cranial facial area. Any increase in the
sternocleidomastoid angulation or distance from the thoracic
History:-
apex to midcervical region manifested by forward inclination
A few pertinent questions that apply particularly to TMJ of the head and neck. Optimal posture is 4 to 8 cm from the
disorders include the following: apex of the thoracic kyphosis to the deepest point in the
1. Does the joint grate, click, pop, snap, or lock? cervical spine. Angulation of the sternocleidomastoid is
considered to be minimal at 60°, moderate at 60 to 75°, and
2. Do you have difficulty opening and closing your mouth? maximal at 75 to 90°.Internal rotation of the glenohumeral
3. Do you have frequent headaches? What area of the head? joint and protraction of the shoulder girdle may also be
How long do they last? observed. The scapulae may be protracted, retracted,
elevated, or winged.
4. Have you ever had a severe blow to the head or a whiplash
injury? II. Inspection: of the Head, Face, and Neck
A. Skin. Examine the face for blemishes, moles,
5. Are your jaws clenched or your teeth sore when you awaken pigmentations, scars, and texture.
from sleep?
B. Soft tissue. Note any swelling. Swelling of the joint must
6. Do you have frequent headaches? be moderate or significant before it is apparent on
inspection. If swelling is detectable, it appears as a rounded
Physical Examination:-
bulge just anterior to the external meatus. The face should
I. Observation: The appearance, general posture, and be further examined for atrophies and hypertrophies. Asking
characteristics of bodily movement. the patient to clench his or her jaws together may help to
Physically the typical patient with TMJ pain–dysfunction, disclose asymmetry.
with an emotional overlay, has a posture of elevated C. Bony structure and alignment. The profile of the face in
shoulders, forward head, stiff neck and back, and shallow, both the frontal and sagittal planes will reveal the relative
restricted breathing. development of the skull, face, and mandible. The size of
The patient is observed for facial expression and habits of the the mandible should be compared with that of the skull and
jaw (e.g., clenching or grinding the teeth, biting the fingers, abnormal positions or asymmetry of the jaw noted.
or twitching the jaw muscles). The most common Asymmetry may be indicative of a growth or developmental
abnormality in the cervical spine with direct impact on the problem or unusual muscular activity.
D. Functional mechanics. Take particular note of the the maximum opening the patient can achieve without
occlusal and rest positions of the jaw. Note the pain is measured. Lateral movements to the left and
following: right, using the bite position as the control as well as
1. Respiration, alteration in nasal diaphragmatic protrusion–retrusion, again using normal bite as control, should be recorded when restricted.
breathing Lateral
2. Swallowing pattern motions may be lost earlier and to a greater degree
3. Tongue rest position than vertical motions.
4. Lip closure position A T bar is often used for recording active motion and
5. Mandibular and condylar rest position abnormal tracking of the mandible during opening.
6. Presence of tongue thrust 1. Mandibular opening and closing. The client should
Part the patient’s lips (or use a lip separator) to be able to put at least two of his or her knuckles
reveal the alignment of the incisors as well as any between the upper and lower incisors for normal
evidence of abnormal resting position of the tongue jaw opening. Measurement of maximal voluntary
or a deviant swallow (see section on dynamics of the mandibular opening can be obtained by measuring
mandible and TMJ). between the maxillary and mandibular incisal edges
The examiner should briefly inspect the upper with a ruler scaled in millimeters (Fig. 17-21). Measurements may be recorded on the vertical
spine, shoulder girdles, and arms for obvious muscle plane of
atrophy or deformities. the T bar. Normal mandibular opening has been
III. Joint Tests reported to be between 35 and 50 mm1,2,104 when
Joint tests include active and passive physiologic movements, joint-play (accessory) using this method, and from 48 to 52 mm when
movements, and other relevant joints. If instability of the upper cervical spine is measured from acquired occlusion (including vertical
suspected, stress tests should be carried out; these are overlap).70,71,119 To complete 40 mm of functional
described in Chapter 19, Cervical Spine, on the examination of the upper cervical spine. range, 25 mm is rotational and 15 mm occurs with
A. Active physiologic joint movements. Observe the general anterior and inferior translational glide.111,174,204
patterns of active physiologic movements (depression, The vertical path of the mandible during opening
elevation, lateral deviation, protraction, and retraction) and closing should be recorded for deviations or
for freedom of movement, range, quality of movement, deflections. A deviation is defined as a lateral movement of the mandible that returns to
deviations, crepitus, or clicking on opening and/or closing midline prior to
the mouth. Ascertain if any pain accompanies active maximal opening, whereas a deflection is a lateral
movements and in what part of the range it occurs and movement without return to midline.264 If deflection
where. Pain may be felt in the area of the joint and about occurs to the right on opening with limited motion,
the ear, but often it is felt diffusely through the face, the right TMJ is said to be hypomobile. If the mandible
teeth, jaws, and mouth. Masticatory pain is typically not abnormally tracks (deviates) out of midline (i.e., in
well localized. (During the palpation portion of the examination, actual sites of tenderness can an S-type curve) the problem is probably caused by
be established.) muscle imbalance.
Abnormal movements such as “jumps” or “facet slips” 2. Lateral characteristics (range of motion [ROM] and
should be noted. In particular the patient is asked to open deviations or deflections). Lateral movements are
the mouth to a limited extent (approximately 1 cm) while normally 8 to 10 mm when the midline of the maxillary and mandibular incisors is viewed in
the examiner observes whether the mandible is making the normal
an initial rotation or translatory movement. Forward
movement will be revealed by a reduction in incisal overjet and by excessive prominence of
the condylar heads.
The restriction of movement, deviations to one side,
and asynchronous patterns of movement are recorded;