protrude the lower jaw as far as possible and then make a maximal jaw-opening movement from the protruded position. During these movements both examiner and patient remain alert to any isolated grating sounds or grating sounds in combination with pain. As a rule, crepitus during protrusion comes from the temporal joint surfaces and crepitus during jaw opening from the condylar surfaces.
These active movements serve as a base of reference for the following tests.
For the dynamic compression test, the examiner places two or three fingers under the angle of the mandible on each side so that neither the facial blood vessels nor the medial pterygoid muscles are significantly disturbed. The examiner now exerts a superior or anterosuperior pressure while the patient again protrudes and then opens to the maximum. Under physiological conditions, neither rubbing sounds nor pain will occur during the movements.
170 Active protrusion followed by jaw opening
Left: Active movements serve as a reference (control) for the dynamic tests. As the examiner palpates the condyles, the patient executes a maximal protrusive movement
Right: From the position of maximal protrusion the jaws are then opened to the maximum. Both the examiner and the patient remain alert to any rubbing sensations that may arise, either with or without pain.
171 Positioning the middle and ring fingers at the angle of the jaw for performing dynamic compressions
Left: For dynamic compression two or three fingers are placed under the horizontal part of the angle of the mandible in such a way that the facial blood vessels and the insertion of the medial pterygoid muscle will be compressed as little as possible.
Right: Enlarged view showing the finger position at the angle of the jaw in greater detail.
172 Dynamic compression during protrusive and opening movement
Left: As the examiner presses superiorly or anterosuperiorly, the patient pushes the lower jaw forward as far as possible. Rubbing sounds that occur now usually arise from the temporal surface of the joint.
Right: Next, as the upward pressure is maintained, the patient opens the jaw as far as possible. Crepitus, pain, and any restrictions of movement that occur are recorded to help in making a differential diagnosis
Crepitus during the protrusive movement indicates osteoarthrotic changes in the temporal joint surface, while crepitus during the opening movement points to changes on the condyle.
If dynamic compression provokes crepitus with pain (osteoarthritis) or crepitus without pain (osteoarthrosis), the examination is continued with dynamic translations. These can be conducted with or without manual compression. In this section of the book dynamic translation without compression is depicted, while the technique with the addition of compression can be seen on page 105.
Dynamic translations in the lateral and medial directions are specific for evaluating the lateral and medial portions of the joint surfaces. This is especially important when there is incongruence of the joint surfaces in the frontal plane. The parameters that can be distinguished by the dynamic tests are summarized below.
• Osteoarthosis vs. osteoarthritis: the tests either proceed painlessly or they elicit pain
• Temporal vs. condylar: symptoms appear either during protrusion or during jaw opening
• Lateral vs. medial: symptoms appear either during lateral or during medial translation.
173 Hand position for dynamic translations
Left: To stabilize the head, one hand is placed flat against the back of the patient’s neck. This also stabilizes the cervical spine. The thumb is placed at the level of the angle of the mandible.
Right: The other hand braces the forehead from the opposite side. Now a force can be applied by the thumb medially toward the contralateral jaw angle. The result is a medial translation of the left condyle and a lateral translation of the right condyle.
174 Dynamic translation of the mandible to the right
Left The transitional force is continued as the patient moves the mandible forward as far as possible, peat the movement until a clear determination can be made. This tests the integrity of the lateral joint surfaces in the right joint and the medial surfaces of the left joint.
Right: from the position of maximal protrusion the patient makes a maximal opening movement, and any rubbing sounds that occur are recorded.
175 Dynamic translation of the mandible to the left
Left: The examination procedure is repeated in a similar manner for the opposite side. After the head is stabilized at the neck and forehead, pressure is applied to move the mandible bodily to the left. The protrusive movement tests the medial joint surfaces on the right side and the lateral joint surfaces on the left.
Right: Finally the patient makes a maximal active opening movement from the maximal protrusive position.
Examination of the Joint Capsule and Ligaments
Following the joint surface tests, those patients who have been experiencing pain are always examined Further using joint manipulation techniques. Like all orthopedic examination techniques, these can be traced back to the fathers of manipulative medicine, J Cyriax, F Kaltenborn, G Maitland, and J Mennell (Cookson and Kent 1979). The specific joint manipulation techniques for orthopedics were first described by Mennell (1970). Hansson et al. (1980) were the first to recommend their use on the temporomandibular joint in dentistry.
The joint manipulation techniques consist of:
• passive compression,
• translation, and
• caudal traction.
In perspective, these are the most important clinical tests for the differential diagnosis of inflammatory changes in the joint region (Friedman and Weisberg 1982, 1984; Palla 1992; Riddle 1992; Bumann et al. 1993; Bumann and Groot Landeweer 1996b; Hesse 1996). Because there is no “gold standard” against which to measure results, their precise scientific verification is difficult (Hesse 1996).
176 Form for recording the findings of the joint-play tests
Passive compression, translation, and traction are all included under the
