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Palpation of the lateral pterygoid region is a diagnostic procedure often included in study protocols and examination schemes of the masticatory system. However, the validity and reliability of this procedure have been questioned due to the inaccessibility of the lateral pterygoid muscle for intraoral palpation. As a result, other anatomical structures, such as the superficial head of the medial pterygoid muscle, may be palpated instead in this region. This article will review the evidence for the effectiveness of palpating the pterygoid muscles and discuss alternative approaches for assessing the masticatory system.
| Characteristics | Values |
|---|---|
| Palpability of the inferior head of the lateral pterygoid muscle | Practically inaccessible for intraoral palpation due to topographical and anatomical reasons |
| Palpability of the posterior belly of the digastric muscle | Qualitative systematic review of the literature |
| Intraoral palpability of the lateral pterygoid muscle | A prospective study |
| Validity and reliability of palpation of the lower head of the lateral pterygoid muscle | A systematic search was carried out using different electronic databases |
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What You'll Learn
Palpability of the inferior head of the lateral pterygoid muscle
Palpation of the inferior head of the lateral pterygoid muscle is a challenging procedure due to its anatomical location and the limitations of standard clinical palpation techniques. The intraoral palpation of the inferior belly of the inferior lateral pterygoid (ILP) muscle is a well-known diagnostic method for temporomandibular joint dysfunction syndrome. However, studies have produced inconsistent results, and it is challenging to palpate the ILP muscle anatomically.
The ILP muscle is located in the infratemporal fossa, and its origin lies behind a superficial, triangular-shaped fascicle of the medial pterygoid muscle. This anatomical position creates accessibility issues, and the standard clinical palpation technique often fails to overcome these topographical challenges. The high resistance to distension in this area further complicates the palpation process.
In a study, three dentists performed bilateral palpation of the ILP muscle in human cadavers and found it difficult to determine whether the muscle was palpable or not. The risk of false-positive findings, such as palpation of the medial pterygoid muscle instead, is also high. Therefore, it is recommended that the ILP muscle palpation technique should not be considered a standard clinical procedure.
However, some practitioners argue that indirect influence on the inferior lateral pterygoid muscle through layers of soft tissue can still be beneficial in treating patients with orofacial pain. They suggest that noting pain intraorally near the lateral pterygoid muscle can be an objective sign, and as patients' conditions improve, tenderness in the area tends to ease and eventually disappear.
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Superficial head of the medial pterygoid muscle
The medial pterygoid muscle is a square-shaped masticatory muscle, responsible for the elevation, protrusion and rotation of the mandible. It is located on the medial aspect of the lower jaw bilaterally, and is also known as the internal pterygoid muscle.
The medial pterygoid muscle has two heads, a superficial head and a deep head. The superficial head is smaller and arises from the maxillary tuberosity, with some fibres originating from the pyramidal process of the palatine bone. These fibres descend posterolaterally and insert into the triangular impression on the medial surface of the ramus and angle of the mandible. The fibres attach via a strong tendinous lamina, which extends from the inferior alveolar (mandibular) foramen superiorly, to the mylohyoid groove anteroinferiorly.
The superficial head of the medial pterygoid muscle is separated from the deep head by the lateral pterygoid muscle. The deep head has a larger origin from the medial side of a horseshoe-shaped extension of the sphenoid bone (the lateral pterygoid plate) at the base of the skull. Its fibres pass in a downward, lateral and posterior direction, inserting into the roughened area on the lower and posterior part of the medial surface of the ramus and angle of the mandible.
The medial pterygoid muscle is innervated by the medial pterygoid branches of the mandibular nerve (CN V3), a division of the trigeminal nerve. It receives its vascular supply from the maxillary artery via its pterygoid branches, and from the facial artery via its muscular branches.
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Intraoral palpation
When attempting intraoral palpation of the pterygoid muscles, it is important to understand the anatomy of the region. The pterygoid muscles are located in the posterior aspect of the jaw, and they play a crucial role in jaw movement and function. The medial pterygoid muscle is positioned more anteriorly compared to the lateral pterygoid muscle, which lies deeper and is more challenging to access.
To perform intraoral palpation of the pterygoid muscles, the examiner should don clean gloves and ensure good lighting and a comfortable position for both themselves and the patient. The patient should be seated upright, with their mouth open to provide access to the posterior region.
The examiner should insert their index finger into the patient's mouth and locate the medial pterygoid muscle first. This muscle is situated medially to the mandibular ramus and has two heads: a superficial head and a deep head. The superficial head is more easily palpable, and the examiner can feel it by gently palpating the soft tissues anterior to the mandibular ramus.
Due to its deeper position, palpating the lateral pterygoid muscle intraorally is more difficult. It lies posterior and inferior to the medial pterygoid muscle, and its palpation may be influenced by the patient's jaw position. While palpating this region, the examiner should be aware of the potential for tenderness, even in healthy individuals, and interpret any findings carefully to avoid incorrect conclusions regarding the need for treatment.
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Tenderness of the lateral pterygoid region
The lateral pterygoid muscle is a craniomandibular muscle with two heads: the superior and inferior. The inferior head is three times larger than the superior head. This muscle controls the movement of the temporomandibular joint (TMJ) and is the only muscle of mastication that depresses the mandible.
The lateral pterygoid muscle is often included in study protocols and examination schemes of the masticatory system. However, due to topographical and anatomical reasons, the muscle is practically inaccessible for intraoral palpation. Studies have shown that the palpability of the lateral pterygoid muscle is characterized by poor interexaminer agreement. Additionally, the lateral pterygoid region can be tender even in healthy individuals, which can lead to incorrect conclusions regarding the need for treatment.
The inferior lateral pterygoid arises from the lateral surface of the lateral pterygoid plate of the sphenoid bone and extends backward, upward, and outward through the infratemporal fossa. It inserts primarily on the anterior and medial aspects of the condylar neck. The superior head, meanwhile, originates at the infratemporal surface and infratemporal crest of the greater wing of the sphenoid bone and extends backward, downward, and outward to insert on the medial aspects of the pterygoid fossa.
The lateral pterygoid muscle is innervated by the muscular branches from the anterior division of the mandibular nerve, which is the third branch of the trigeminal nerve (CN V3). In some cases, it may also be innervated by the deep temporal nerves, the masseteric nerve, and the buccal nerve. The muscle is supplied by the second portion of the maxillary artery, which travels between the two heads of the pterygoid muscle and enters the pterygomaxillary fissure.
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Validity and reliability of palpation
The validity and reliability of palpation of the lateral pterygoid region have been questioned in several studies. The aim of these investigations was to search the medical and dental literature to find evidence for the validity and reliability of this diagnostic procedure. The studies concluded that the lateral pterygoid muscle is practically inaccessible for intraoral palpation due to topographical and anatomical reasons. The muscle is located deep within the anatomy and is largely covered by bone, making it difficult to palpate.
The determination of the palpability of the lateral pterygoid muscle is characterized by poor inter-examiner agreement. This means that different examiners may have varying opinions on whether the muscle is palpable or not, leading to inconsistencies in diagnosis and treatment plans. Studies have also found that the lateral pterygoid region is tender even in healthy individuals, and positive findings during palpation may lead to incorrect conclusions about the need for treatment.
Some authors have suggested alternative methods such as trigger point dry needling (TrPDN) and ultrasound imaging to evaluate and treat conditions associated with the lateral pterygoid muscle. These techniques have shown favorable results and may be more reliable than palpation alone.
In summary, the validity and reliability of palpation of the lateral pterygoid muscle are limited due to anatomical constraints and the subjectivity of the palpation technique. Alternative methods, such as TrPDN and ultrasound imaging, may offer more accurate and consistent results in the evaluation and treatment of conditions related to this muscle. However, further research and evidence are needed to establish the most effective diagnostic and therapeutic approaches for the lateral pterygoid region.
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Frequently asked questions
The pterygoid muscle is part of the masticatory system and can refer to the lateral pterygoid muscle or the medial pterygoid muscle.
The lateral pterygoid muscle is practically inaccessible for intraoral palpation due to topographical and anatomical reasons.
The superficial head of the medial pterygoid muscle may be palpated instead of the lateral pterygoid muscle.
The lateral pterygoid region is tender even among healthy subjects, which can lead to wrong conclusions regarding the need for treatment.
Yes, there is a lack of validity and reliability associated with the palpation of the lateral pterygoid area, which has led to suggestions that this diagnostic procedure should be discarded.
