Logan Steele
The temporomandibular joint (TMJ) is the most functional and frequently used joint in the human body. It is used for a wide range of activities, including eating, talking, and kissing. Due to its frequent use, the TMJ is susceptible to various disorders, including myofascial pain-dysfunction syndrome (MPDS) and disc displacement. To diagnose and treat TMJ issues, a thorough examination is required, including palpation of the associated muscles. This involves applying gentle pressure to specific areas and observing the patient's reaction to identify any abnormalities, such as inflammation or muscle spasms.
| Characteristics | Values |
|---|---|
| Examination Type | Extra-oral and intra-oral |
| Patient History | Headaches, joint sounds, pain |
| Muscle Groups | Temporalis, Masseter, Medial Pterygoid, Lateral Pterygoid, Digastric, Trapezius |
| Palpation Technique | Gentle finger pressure, massage |
| Pain Referral | Above the eye, posterior teeth, mandible, in front of the ear |
| Abnormalities | Reduced jaw opening, pain during opening, deviation, staggered/strained movement |
| Inflammation Indication | Pain on palpation, particularly in retrodiscal tissues |
| Condyle Displacement | Felt as a click beneath the doctor's fingers |
| Diagnostic Tools | Stethoscope, tuning fork tests, radiographs, MRI |
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What You'll Learn
Palpating the masseter
The masseter muscle examination involves using the thumb on the inner aspect of the muscle as it is palpated from its attachment inside the zygoma down to the angle of the mandible. The masseter is palpated extra-orally and intra-orally. The patient is encouraged to open wide, close, and clench their teeth to determine when the muscles contract and if they are simultaneous. The masseter doesn't usually contract unless the posterior teeth touch.
When palpating the masseter, it is important to assess the relative tenderness of the muscle and identify any taut bands. This can be done by sliding the overlying skin back and forth across the muscle and applying firm pressure while asking the patient to report the most tender point. Once found, this point should be compressed for 5 seconds (with 2 kg pressure) to see if the pain radiates or refers.
The superficial masseter can be located by pointing out the insertion and origin on a dry skull. This site is anterior and inferior to the lateral condyle pole, posterior to the posterior edge of the superficial masseter, and beneath the zygomatic arch. The deep masseter can also be located on a dry skull, and its site is anterior and inferior to the lateral condyle pole, posterior to the posterior edge of the superficial masseter, and beneath the zygomatic arch.
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Palpating the temporalis
To begin the palpation, first explain the procedure to the patient and obtain their consent. Then, place your fingers on the temporalis muscle before it is activated. The anterior temporalis muscle is best palpated at the hairline, opposite the eyebrow. This site is just above the ear, and its direction is posterior from the coronoid process. The correct technique for palpating a muscle includes the sequence of muscle activation, relaxation of the muscle, placement of the fingers on the muscle before activation, activation of the muscle, and finally, relaxation of the muscle again.
When palpating the temporalis muscle, apply a pressure of 2kg with one finger for 2 seconds. Ask the patient to rate the pressure as none, mild, moderate, or severe. It is helpful to do one side of the head at a time to avoid confusion in how the patient is reacting. The temporalis muscle typically refers pain to its location, as well as above the eye and to the maxillary posterior teeth.
Palpation of the temporalis muscle can be used to diagnose temporomandibular joint (TMJ) disorders. Local and referred pain from myofascial trigger points in the temporalis muscle can contribute to a pain profile in chronic tension-type headaches.
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Palpating the medial pterygoid
The medial pterygoid muscle is located on the inner side of the jawbone. It is used to relieve pain and improve jaw function. It is one of the major muscles of mastication, alongside the masseter, temporalis, and lateral pterygoid muscles.
The medial pterygoid muscle can be approached in two ways: intraorally or extraorally. For an intraoral approach, the muscle can be palpated at the inner aspect of the mandibular ramus with the patient's mouth in an opening position. The needle should be inserted at the medial aspect of the mandibular ramus and angled posteriorly and superiorly, approximately 20 degrees to the occlusal plane. The EMG activity should confirm the corrected insertion area during the mouth-closing phase.
For an extraoral or mandibular approach, the needle is pointed from below and inserted about 0.5–1 cm anterior to the angle of the mandible along the interior aspect of the mandible. It is then angled perpendicularly to the mandible until it can be verified by EMG with the patient clenching their teeth. It is important to be cautious and avoid the facial artery, which lies anteriorly.
The medial pterygoid muscle is typically palpated at the end of the extra-oral exam, as it is much easier to palpate intraorally. It is also important to note that the medial pterygoid muscle is difficult to palpate manually, and assessment is often carried out using intra-oral palpation.
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Signs to look out for
Before palpating the TMJ muscles, it is helpful to get a history from the patient concerning headaches, joint sounds, and pain. During the palpation, the patient may experience pain or tenderness, which could indicate inflammation in the joint capsule, within the joints, or in the retrodiscal tissues of the TMJ. A click may also be felt beneath the fingers, indicating an abnormal state.
When palpating the masseter, this can be done extra-orally and intra-orally. The patient can be encouraged to open wide, close, and clench their teeth to determine when the muscles contract and if they do so simultaneously. The masseter usually doesn't contract unless the posterior teeth touch. The temporalis muscle can be palpated in the temporal fossa and intraorally along the ascending ramus of the mandible. The anterior portion of this muscle typically refers pain to its location and also above the eye and to the maxillary posterior teeth.
The medial pterygoid is palpated intraorally, and the lateral pterygoid is accessible intraorally posterior to the maxillary tuberosity. The mandibular condyle normally rotates and translates forward as the mouth is opened. If the condyle cannot move forward and downward along the slope of the joint fossa as the patient opens wide, it indicates that something is obstructing or preventing the forward condylar translation.
Abnormalities may also be indicated by a reduced capacity to open the mouth, opening with pain in the muscles or TMJ joints, or opening towards one side rather than straight down. The degree of mandibular opening can be measured using the distance between the incisal edges of the upper and lower anterior teeth; less than 35mm is considered abnormal in an adult. The opening pattern should also be observed for any deviation, which could be due to muscle spasm or mechanical locking by a displaced meniscus.
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Intra-oral vs extra-oral palpation
Palpation of the TMJ muscles can be done intra-orally and extra-orally. The intra-oral examination involves the medial pterygoid muscle, dental, perio, and soft tissue. The medial pterygoid muscle is much easier to palpate intraorally. The extra-oral examination involves performing muscle palpations on individual muscles, including the masseter, temporalis, and lateral pterygoid muscles.
The masseter is palpated extra-orally and intra-orally. It is important to encourage the patient to open wide, close, and clench their teeth to determine when the muscles contract and if they are simultaneous. The masseter refers pain to the upper and lower posterior teeth, the mandible, above the eye, and in front of the ear.
The temporalis is another muscle that is palpated during the extra-oral examination. The examination typically starts with the anterior portion of the muscle, which refers pain to its location, as well as above the eye and to the maxillary posterior teeth. The trapezius is the next muscle, located at the back of the neck.
The TMJ can also be palpated posteriorly by applying gentle finger pressure forward on the front wall of the outer ear canal. The doctor should listen to the TMJ with a stethoscope as the patient opens, closes, and moves the jaw from side to side. Sounds in the joints indicate abnormality.
The intra-oral examination also involves palpating and inspecting the labial and buccal mucosa, tongue, floor of the mouth, saliva, hard and soft palates/uvula, and tonsillar areas. The extra-oral examination can also include the palpation of the cervical lymph nodes to assess for palpable and/or tender lymphadenopathy.
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Frequently asked questions
Palpation is the act of applying gentle pressure to a body part, in this case, the TMJ muscles.
The temporomandibular joint (TMJ) is the most functional and frequently used joint in the human body. It is used for eating, talking, yawning, kissing, and sucking.
To palpate the TMJ, apply gentle finger pressure forward on the front wall of the outer ear canal. The forward wall of the ear canal is the rear wall of the TMJ. Palpate the masseter at its attachments to the zygomatic arch and angle of the mandible.
