Extraoral Examination of Temporomandibular Joint

Dr.Urusa Inamdar1 Comment

Written by : Dr.Urusa I Inamdar

The importance is to determine deviation of jaw from the midline during the opening and closing of the jaws.

Causes of jaw deviation:

  • Traumatic injuries of the joint
  • Infection of the jaw
  • Fractures of the jaw
  • Muscular hypertrophy and hypotrophy

The lateral mandibular range of motion or movement is assessed ” Normal 8 to 10 mm ” by having the patient to occlude the teeth and then slide the jaw in both directions. The range of movement from midline and any pain, location and severity is recorded.

Maximum interincisal opening: As a general guide, mobility is considered to be reduced if the subject is unable to open his or her jaw to the width of two fingers ( <30 mm ).

Palpation

  • Bimanual and bidigital Palpation or extra-auricular or intra-auricular.
  • Palpation may reveal pain and irregularities during condylar movement , described as clicking or crepitus. Clicking reveals the internal derangement of TMJ.
  • The lateral pole of condyle is most accessible for palpation during mandibular movements.
  • Palpation just anterior and posterior to the lateral pole detects pain associated with TMJ capsular ligament.
  • The comparison between both condyles must be assessed by palpation.

TMJ muscles :

Gravity muscles ( Depression of mandible )

  • Geniohyoid
  • Digastric
  • Mylohyoid

Anti-gravity muscles ( Elevation of mandible )

  • Medial , oblique , anterior , vertical of temporalis.
  • Medial Pterygoid , masseter .

Protrusion of mandible

  • Medial pterygoid.
  • Lateral pterygoid.

TMJ disorders :

Developmental

  • Hypoplasia/aplasia of condyle
  • Hyperplasia of condyle
  • Bifid condyle

Traumatic

  • Dislocation of condyle
  • Fracture of condyle
  • Injury to articular disc

Inflammatory

  • Osteoarthritis
  • Rheumatoid arthritis
  • Septic arthritis

Neoplastic

References:

  • A practical manual of Public Health Dentistry – C M Marya
  • Slide share – Diagnosis of Temporomandibular disorder- Kelly
  • TMJ Anatomy – Geeky medics

Plummer Vinson syndrome

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Plummer Vinson triad :

  • Postcricoid dysphagia
  • Upper esophageal webs
  • Iron deficiency anemia

High risk of “squamous cell carcinoma”

Risk factors :

  • Race – White and Scandinavian
  • Age – 40-70 years
  • Sex – Females more than males. Especially in postmenopausal women.

Pathophysiology :

  • Iron deficiency anemia
  • Nutritional deficiency
  • Genetic predisposition
  • Autoimmunity causes may include rheumatoid arthritis , pernicious anemia and thyroiditis.

Signs :

  • Angular cheilitis
  • Glossitis (Atrophic bald tongue)
  • Pallor – Palmer pallor and conjunctival pallor
  • Platynychia (Flattened nails)
  • Koilonychia (Spoon shaped nails)
  • Splenomegaly
  • Edentia (loss of teeth due to esophageal reflux)
  • Enlarged nodular thyroid gland
  • Gastritis with acholorhydia
  • Post cricoid webs
  • Picca
  • Beeturia
  • Restless leg syndrome

Symptoms :

  • Dysphagia
  • Odynophagia
  • Choking spells and aspiration due to proximal location of webs
  • Weakness and fatigue
  • Weight loss
  • Hair loss
Treatment

References – Shafer’s textbook of oral pathology , SN Chugh – Textbook of clinical medicine for dental students , slideshare.com

Image reference : Google images.

TEETHING

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Teething is a term limited by common usage to eruption
of primary dentition. Since the time of Hippocrates (460-
377 BC) teething is blamed for ailments such as fever, convulsions, bronchitis, otitis media and diarrhea, for
causing 12% of the deaths in children under four years.
Complete opposite views are also available. It is seen
that these local and systemic factors are associated with
the disease somewhere else also and just as a coinci-
dence appear with teething.

Eruption of primary dentition usually begins in the 4-6th month of a child’s life. The appearance of normal teeth is eagerly awaited by the parents since it represents an important early milestone in development. In most cases eruption of teeth causes no distress to the child or parents, but sometimes the process causes local
irritation, which is usually minor but which may be severe enough to interfere with the child’s sleep.

CLINICAL FEATURES OF TEETHING

LOCAL SIGNS

1. Hyperemia or swelling of the mucosa overlying theerupting teeth.
2. Patches of erythema on the cheeks.
3. Flushing may also occur in the skin of the adjacen cheek.

SYSTEMIC SIGNS

1.General irritability and crying
2.Loss of appetit.

3.Sleeplessness

4.Increased salivation and drooling

5.Insanity
6.Meningitis

7.Increased thirst
8.Circumoral rash
9.Cough

Associated Problems
Systemic

Fever,convsions, diarrhea,vomiting, bronchitis, cholera, tetanus

Local

Eruption hematoma, eruption sequestrum, ectopic eruption, transmigration , transposition

MANAGEMENT

PREVENTIVE MEASURES

1. Maintain child’s oral and general body health.

2.Gums should be wiped after each meal with cotton soaked in a weak antiseptic.

3. Adequate quantities of vitamins, minerals , proteins, are given to the child for increasing body’s resistance .

GENERAL MANAGEMENT

1. Hard , non sweetened rusks

2. Use of toasted bread helps in providing gingival stimulation.

3. Use of hard fruits such as appleor guava .

MEDICAL MANAGEMENT

demulcent and mild antiseptic.

1. Topical application of glycerin: It acts as a protective demulcent and mild antiseptic.
2. Topical application of lignocaine hydrochloride which provide relief in the interval before the analgesic is effective .
3. Topical application of benzyl alcohol can also be effective.

SURGICAL MANAGEMENT

Surgical treatment is sometimes recommended for the relief of pain from an eruption cyst or a hematoma. The technique advocates is to make 2 semilinar incisions over the crowns of the tooth , which meet at their extremities. The intervening portion of the tissue , which lies over the occlusal surface of unerupted tooth is then removed with a pair of tissue foreceps.

REFERENCES:TEXTBOOK OF PEDODONTICS SHOBHA TANDON 2ND EDITION

PULP CAPPING

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So what is the pulp – in simple words it’s a tissue that forms the inner tooth structure along with the blood vessels and contains nerves .

Pulp capping is the process of placing a specialized agent in contact with or in a close proximity to the pulp with the intention to encourage formation of new dentin ( secondary dentin) and also promote healing of the pulp.

Even before the discovery  pulp capping agents, exposure lead to pulpitis or pulpal infection and ultimately pulp necrosis.

Examples of a very common pulp capping agent used – calcium hydroxide cement.

Source- slideshare

What’s the criteria for pulp capping?

  1. When the pulp is healthy and non infected.
  2. When the area of exposure is not more than 0.5mm.
  3. After exposure the dentist should make all attempts and isolate the tooth and prevent infection.

Types of pulp capping –

  1. Direct pulp capping
  2. Indirect pulp capping

What is direct pulp capping? When is it done?

Placement of an agent directly on the exposed pulp is direct pulp capping.

It is done in the following situations-

  • Traumatic fracture of the tooth .
  • Iatrogenic exposure during cavity preparation.
  • Exposure when the tooth is under rubber dam isolation.
  • When bleeding is controlled at the exposure site.

Note- direct pulp capping is considered oy for immature permanent teeth or for future permanent teeth

Direct pulp capping

Source – Google

What is indirect pulp capping ? When is it done?

Procedure where gross caries are removed from the lesions and cavity is sealed for a time with a biocompatible material.

And secondary dentin formation is induced even when pulp is not exposed but is near exposure.

This induces new dentin formation.

It is done in the following situations-

  • When deep caries lesions are close to the pulp.
  • Exposure exposure of the pulp when there is traumatic fracture of the tooth.
  • During excessive crown preparation the pulp is visible through the remaining dentin .

Note – it promotes formation of reparative dentin, promotes dental sclerosis and remineralizing the carious dentin.

Indirect pulp capping

Source-google

Requirements of an ideal pulp capping material.-

•Stimulate reparative dentin formation.

•Preserve pulp vitality

•Release fluoride to prevent secondary caries .

•Bactericidal or bacteriostatic

• Adhere to dentin and restorative material

•Resist forces during mastication .

•Provide bacterial seal.

Materials used in pulp capping-

•Calcium hydroxide

•Zinc-Oxide – Eugenol

• GIC and adhesive resins

• MTA

• Biodentine

•Tricalcium phosphate ceramic

•Polycarboxylate cements

Source – Sturdevant’s art and science of operative dentistry ,slide share and manappallil

Image source – Google and slide share