PT-REH 303 / PT-SEM 303 EXAMINATION AND EVALUATION OF THE HEAD, FACE, AND TMJ STUDY GUIDE Head and Face Head and Face are made up of the cranial vault and facial bones. Assessment of this region involves the bony aspects of the head and face as well as the soft tissues. Soft tissue assessment involves primarily the sensory organs, such as the skin, eyes, nose and ears, whereas the muscles are tested only as they relate to injury to these structures. ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Temporomandibular joint Temporomandibular joints are two of the most frequently used joints in the body. Problems in this joint would severely hinder talking, eating, yawning, kissing, or sucking. Temporomandibular disorders (TMDs) consist of several complex multifactorial ailments involving many interrelating factors including psychosocial issues. Three cardinal features of TMD are: 1. Orofacial pain 2. Restricted jaw motion, and 3. Joint noise. If there are any neurologic signs and symptoms present in the patient, this warrants further neurologic evaluation and referral. Arthrokinematics of opening the mouth: - Early phase – The mandibular condyle rolls posteriorly and slides anteriorly on the surface of the articular disc of the mandibular fossa Late phase – The mandibular condyles translate anteriorly on the articular disc of the mandibular fossa ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. In the human, there are 20 deciduous, or temporary (“baby”) teeth and 32 permanent teeth. The temporary teeth are shed between the ages of 6 and 13 years. Adult teeth: - Canine teeth (2 maxillary and 2 mandibular) – longest permanent teeth, cut, and tear food. - Premolar teeth (8 in all, two on each side, top, and bottom) – have two cusps to crush and break down food. Molar teeth (2 or 3 on each side, top, and bottom) – four or five cusps, crush, and grind food. 3rd molars are called wisdom teeth. Missing teeth, abnormal tooth eruption, malocclusion, or dental caries (decay) may lead to problems of the temporomandibular joint. ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. I. Subjective Assessment For the complete general subjective assessment, please review Section II, Examination and Evaluation, Dutton, M., 5th ed. (2020) and Principle and Concepts, Chapter I, Magee, D., 6th ed. (2014) a. General Data • Age - Children between 3 to 17 years old – continuous increase in ROM where; - Mouth opening increases by 0.4 mm; - Lateral excursion increases by 0.1 mm, and; - Protrusion either decreases by 0.1 mm or no changes at all. - 17 years old onward – mouth opening, lateral excursion and protrusion tends to decrease - Degenerative and overuse syndromes are more frequent in the age over 40 age group - Osteoarthritis is more often associated with older population • Sex - M > F in ROM, with mouth opening being 1.8 mm larger in males than females b. Chief complaint c. History of present illness • Head and Face Assessing injuries to the head and face is as crucial as checking for neurologic affectation considering that this structure houses the brain. You may refer to reading Head and Face, Chapter 2, Magee, D., 6th Ed (2014) for further reading. • TMJ Is there pain or restriction on opening or closing of mouth? Fully opened position (pain associated with yawning, biting an apple, etc.) – extra-articular in origin Biting firm objects (pain associated with biting nuts, raw fruit, and vegetables) – intra-articular in origin What movements of the jaw cause the pain? Do the symptoms change over a 25-hour period? Osteoarthritis – history of stiffness on waking with pain and disappears as the day goes Do any of these actions cause pain or discomfort: yawning, biting, chewing, swallowing, speaking, or shouting? If so, where? Soft tissues/muscles – these actions cause movement, compression, and/or stretching of the soft tissues of the temporomandibular joints Does the patient breathe through the nose or the mouth? Normal breathing – through the nose with the lips closed or no “air gulping” Mouth breather – the tongue does not sit in the proper position against the palate. Has the patient complained of any crepitus or clicking? Clicking – is the result of abnormal motion of the disc and mandible Early clicking – developing dysfunction Late clicking – chronic condition Disc displacement with reduction – disc is displaced anteriorly and/or medially, causing the condyle to override the posterior rim of the disc later than normal during mouth opening, and a click is produced. Reciprocal clicking – if clicking occurs in both directions (mouth opening and closing) ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Has the mouth ever locked? Locking – mouth does not fully open, or it does not fully close. Usually preceded by reciprocal clicking. Closed lock – functional anterior dislocation of the disc without reduction. Implies anterior and/or medial displacement of the disc. Open lock – probably caused by subluxation of the joint or possibly by posterior disc displacement Does the patient have any habits, such as smoking pipes, using cigarette holder, leaning on the chin, chewing gum, biting nails, chewing hair, pursing or chewing lips, continually moving the mouth or any other nervous habits? Places additional stress on the temporomandibular joints Does the patient grind the teeth or hold them tightly? Bruxism – forced clenching and grinding of the teeth, especially during sleep. May lead to facial, jaw, or tooth pain, or headaches in the morning along with muscle hypertrophy For further readings, you may check on Temporomandibular Joint, Chapter 4, Magee, D., 6th Ed (2014) d. Ancillary procedures • X ray – bony contours and fractures. • MRI – bone and soft tissue, especially the articular disc of the TMJ. • CT Scan – bone and soft tissue. e. Past medical history • Diabetes Mellitus • Immunosuppression • Rheumatologic disorders • Cancer • Tuberculosis • Infection • MVA • Trauma/Injury/Fractures f. Family history g. Personal, Social, and environmental history ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. II. Objective Assessment: For the complete general objective assessment, please review Section II, Examination and Evaluation, Dutton, M., 5th ed. (2020) and Principle and Concepts, Chapter I, Magee, D., 6th ed. (2014) a. Inspection and Palpation of the Head, Face and TMJ • The examiner should note any tenderness, deformity, crepitus, or other signs and symptoms that may indicate source of pathology. For further readings of the examination of the Eye, Nose, Teeth and Ear, you may check on Head and Face, Chapter 2, Magee, D., 6th Ed (2014) Inspection Face symmetry Is the face symmetrical horizontally and vertically and are facial proportions normal? Fractures Patients with skull fractures usually experience - Malocclusion of the teeth - Alterations in smell (CN I) in frontobasal and nasoethmoidal fracture - Clear nasal discharge (spinal fluid rhinorrhea) - Clear ear discharge (otorrhea) - (+) halo effect on a collected blood on a gauze pad if cerebrospinal fluid is present ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Teeth alignment and Malocclusion • The examiner should note whether the teeth are normally aligned upon full contact (occlusion) or there is any cross bite, under bite, overbite or malocclusion. Malocclusion is defined as any deviation from normal occlusion. • Class I malocclusion – affected incisors and overjet slightly larger • Class II malocclusion – overbite • Class III malocclusion – underbite Signs and Symptoms that may warrant further neurologic evaluation and referral. Palpation Fractures • To test for maxillary fracture, the examiner grasps the anterior aspect of the maxilla with the fingers of one hand and places the fingers of the other hand over the bridge of the patient’s nose or forehead. The examiner gently pulls the maxilla forward. Le Fort Classification - Le Fort I – upper tooth-bearing segment moves alone. - Le Fort II – nasal bones, midportion of the face, and maxilla move - Le Fort III – middle third of the face separates from the upper third of the face / cranio-facial separation Patient with Maxillary fracture may experience - lip or cheek anesthesia - double vision (diplopia) ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Palpation cont.. Fractures To test for mandibular fractures, the examiner asks the patient to open his or her mouth slightly. The examiner applies pressure bilaterally at the angles of the mandible. Fractures - To chech for zygomaticus fractures, the examiner firmly but carefully depresses the fingers into the edematous soft tissue while palpating along the infraorbital area. They may also cause unilateral epistaxis, double vision, anesthesia, and eye injuries Palpation of mandible ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Palpation of teeth Palpation of hyoid bone Palpation of thyroid cartilage Palpation of mastoid process ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Auscultation Auscultation Normal – a sound would only be heard upon occlusion. - Opening, closing, and lateral deviation of the mouth to This is a single solid sound, not a “slipping sound”. the left and right. Slipping sound – teeth are not hitting. Clicking Most likely to occur in hypermobile joints. - Single click happens when condyle gets caught behind the disc on opening or if the condyle slips behind the disc on closing. Reciprocal clicking occurs when the mouth opens and when it closes due to reduction or subluxation. - During opening – the later the click occurs, the more anteriorly displaced is the disc and the more likely it is to lock - During closing – a closing click is usually caused by loosening of the structures - Adhesive clicks – may also be caused by adhesions, especially in people who clench their teeth (bruxism). If adhesion occur in the superior or inferior joint space, translation or rotation will be limited, presenting as a temporary closed lock, which then opens with a click - Soft or popping clicks – usually result from muscle incoordination and sometimes heard in normal joints that are caused by ligament movement, articular separation or sucking of loose tissue behind the condyle as it moves forward. Hard or cracking clicks – joint pathology or joint surface defects, arthritic changes in the joints. ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. b. Joint play Assessment Longitudinal cephalad and anterior glide Lateral glide of the mandible Medial glide of the mandible Posterior glide of the mandible ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. c. ROM – TMJ For specific instructions on how to perform ROM testing, you may refer to Norkin, C.C., & White, D.J., 5th ed. (2016), Measurement of joint motion: A guide to goniometry. Motion Testing position Stabilization Testing Motion (N) End feel and Measurement Range method Active pain free mouth Depression of opening: Mandible (mouth opening) Active mouth opening: Passive mouth opening: Overbite ( amount that the upper teeth extend over the lower teeth when mouth is in occlusion; usually added to the mouth opening Active protrusion: Protrusion of Mandible Passive protrusion: Lateral excursion of the Mandible Active Lateral excursion: Passive Lateral excursion: Mandibular measurement Swallowing and tongue position ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Magee, D., 6th ed. (2014) • Mouth opening and closing – normal mouth opening, and closing should occur in a straight line. If deviation occurs, hypomobility is evident to the side of the deviation. • Full active opening – 35 – 55 mm or have the patient try to place two or three flexed proximal interphalangeal joints within the mouth opening. • Functional opening – 25 to 35 mm • Protrusion of the mandible – more than 7 mm, measured from resting position to the protruded position • Retrusion – 3 to 4 mm • Lateral deviation or excursion of the mandible – 10 to 15 mm ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. h. MMT We will use Hislop, H.J. et.al., 9th ed. (2014), Daniels and Worthingham's muscle testing: Techniques of manual examination and performance testing as main reference. F: Functional; appears normal or only slight impairment WF: Weak Functional; moderate impairment that affects the degree of active motion NF: Non-functional; severe impairment 0: Absent Muscle (with innervation Test Manual Resistance Instructions Grading and action) Levator Palpebrae F: WF: NF: 0: Superioris (CN III; Eye opening) F: WF: NF: 0: Orbicularis Oculi (CN VII; Closing the eye) F: WF: NF: 0: Corrugator Supercili (CN VII; Frowning) F: WF: NF: 0: Occipitofrontalis, Frontalis part (CN VII; Raising the eyebrows) F: WF: NF: 0: Procerus (CN VII; Wrinkling the bridge of the nose) F: WF: NF: 0: Orbicularis Oris (CN VII; Lip closing) F: WF: NF: ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. 0: Buccinator (CNVII; Cheek Compression) F: WF: NF: 0: Lateral Pterygoid (CN V) and Supprahyoid muscles (Jaw opening or Mandibular depression) F: WF: NF: 0: Masseter, Temporalis, Medial Pterygoid (CN V; Jaw closure or Mandibular elevation) F: WF: NF: 0: Lateral and Medial Pterygoid (CN V; Lateral jaw deviation) F: WF: NF: 0: Lateral and Medial Pterygoid (CN V; Jaw protrusion) F: WF: NF: 0: ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Opening of mouth (Depression) Closing of mouth (Elevation or Occlusion) Lateral deviation of the jaw d. Functional Assessment and outcome measures • Limitation of Daily Function Questionnaire for Patients with TMD (LDF-TMD-Jaw Function Scale) • Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) • Limitations of Daily Function Questionnaire (TMJ) • Jaw Functional Limitation Scale • Mandibular Function Impairment Questionnaire • History Questionnaire for Jaw Pain • TMJ scale ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. III. Other findings and differential diagnosis Staging of Temporomandibular Disc Dysfunction Diagnostic Classification of Physical Conditions Associated with TMD ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved. Differential diagnosis of Cervical Spondylosis and Temporomandibular Joint Dysfunction Temporomandibular joint pain and other conditions If temporomandibular joint pain is accompanied by associated symptoms (sudden onset of fatigue, breathlessness, or weakness, this may suggest a cardiac condition in origin (angina) and may warrant immediate medical attention and referral. Other conditions associated with temporomandibular joint pain: • • • ©DLSMHSI - JKDPABLO Headaches Fibromyalgia Heart conditions No part of this document may be reproduced or transmitted in any form. All rights reserved. References Dutton, M. (2012). Dutton's Orthopedic Examination, Evaluation, and Intervention (3rd edition ed.). The McGraw-Hill Companies, Inc. Goodman, C. a. (2007). Differential Diagnosis for Physical Therapists Screening for Referral. St. Louis, Missouri: Elsevier Saunders. Magee, D. (2014). Orthopedic Physical Assessment (6th edition ed.). St. Louis, Missouri: Elsevier Saunders. Norkin, C. a. (2016). Measurement of Joint Motion A Guide to Goniometry (5th edition ed.). Philadelphia: F. A. Davis Company. ©DLSMHSI - JKDPABLO No part of this document may be reproduced or transmitted in any form. All rights reserved.
