3.16).
Figure 3.16 Determination of anterior guidance.
(M. Ziad Al‐Ani, Robin J.M. Gray.)
The anterior guidance in the mandible can be on the canine teeth, which is ideal because this means that the patient can move the mandible from side to side with immediate disclusion of the posterior teeth (Figure 3.17).
Figure 3.17 Canine guidance.
(M. Ziad Al‐Ani, Robin J.M. Gray.)
There can be group function where the canine, premolar, and molar teeth all contact during lateral excursion of the mandible. This is equally acceptable, preferably with the anterior contact being firmer than the posterior contact.
Posterior interferences
If posterior teeth ‘get in the way’ (interfere), this can be detected by immediate separation of the anterior teeth and guidance of the mandible is then transferred to the interfering tooth. It is thought that interferences, usually on the non‐working side (Figure 3.18a) but also on the working side (Figure 3.18b), can be responsible for initiating parafunction. Check for the presence of interferences up to maximum lateral excursions. Patients may parafunction with the mandible in very unlikely and extreme lateral positions, and this may not be clinically evident unless you are meticulous with your examination.
Figure 3.18 (a) Non‐working side interference; (b) working side interference.
(From Gray RJ, Davies SJ, Quayle AA. A clinical approach to temporomandibular disorders. 4. Examination of the articulatory system: the Occlusion. Br Dent J 1994;177:63–68.)
Freedom in centric occlusion
Check whether or not the patient has freedom to move the mandible back and forward with the teeth in light contact when in centric occlusion.
Temporomandibular disorders can be initiated by restorative dental treatment. One situation is for a patient to have anterior crowns placed when he or she has a very tight anterior occlusion such as seen in a patient with an Angle's class II, division II, basal bone and incisal relationship. If crowns are placed on the upper anterior teeth, which are even marginally thicker palatally than the natural teeth were, the effect is to push the mandible distally, thereby compressing the sensitive posterior bilaminar zone of the disc and producing, sometimes severe, pain.
Record‐keeping
It is important not only for clinical reasons but also for medicolegal reasons to keep accurate and contemporaneous notes of all aspects of your clinical examinations. Remember that it may be several months or even years later when you might be asked to produce them.
Further Reading
1 Al‐Ani, M.Z. and Gray, R.J. (2004). Evaluation of three devices used for measuring mouth opening. Dent Update 31: 346–348. 50.
2 Davies, S.J. and Gray, R.J.M. (2001). The examination and recording of the occlusion: why and how. Br Dent J 191: 291–296. 299–302.
3 Gallagher, C., Gallagher, V., Whelton, H., and Cronin, M. (2004). The normal range of mouth opening in an Irish population. J Oral Rehabil 31: 110–116.
4 Gray, R. and Al‐Ani, Z. (2010). Risk management in clinical practice. Part 8. Temporomandibular disorders. Br Dent J 209: 433–449.
5 Gray, R. and Al‐Ani, Z. (2013). Conservative temporomandibular disorder management: what DO I do? – frequently asked questions. Dental Update 40: 745–756.
6 Gray, R.J., Davies, S.J., and Quayle, A.A. (1994). A clinical approach to temporomandibular disorders. 2. Examination of the articulatory system: the temporomandibular joints. Br Dent J 176: 473–477.
7 Gray, R.J., Davies, S.J., and Quayle, A.A. (1994). A clinical approach to temporomandibular disorders. 3. Examination of the articulatory system: the muscles. Br Dent J 177: 25–28.
8 Gray, R.J., Davies, S.J., and Quayle, A.A. (1994). A clinical approach to temporomandibular disorders. 4. Examination of the articulatory system: occlusion. Br Dent J 177: 63–68.
9 Gray, R.J., Davies, S.J., and Quayle, A.A. (1994). A clinical approach to temporomandibular disorders. 5. A clinical approach to treatment. Br Dent J 177: 101–106.
10 Juniper, R.P. (1984). Temporomandibular joint dysfunction: a theory based upon electromyographic studies of the lateral pterygoid muscle. Br J Oral Maxillofac Surg 22: 18.
11 Klineberg, I. and Jagger, R. (2004). Occlusion and Clinical Practice: An Evidence‐Based Approach. London: Wright.
12 Turp, J.C. and Minagi, S. (2001). Palpation of the lateral pterygoid region in TMD – where is the evidence? J Dent 29: 475–483.
13 Wilson, P.H. and Banerjee, A. (2004). Recording the retruded contact position: a review of clinical techniques. Br Dent J 196: 395–402. quiz 426.
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