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.
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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
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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.
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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)
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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
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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
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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)
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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
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Palpation of teeth
Palpation of hyoid
bone
Palpation of thyroid
cartilage
Palpation of
mastoid process
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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.
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b. Joint play Assessment
Longitudinal cephalad and anterior glide
Lateral glide of the mandible
Medial glide of the mandible
Posterior glide of the mandible
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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
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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
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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:
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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:
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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
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III.
Other findings and differential diagnosis
Staging of
Temporomandibular Disc
Dysfunction
Diagnostic Classification of
Physical Conditions
Associated with TMD
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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:
•
•
•
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Headaches
Fibromyalgia
Heart conditions
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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.
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