11 Intraoral inspection
Dentition of a 35-year-old patient exhibiting severe damage from caries and periodontal disease. There is diffuse radiating pain in the right half of the face.
12 Diagnosis of caries
Transillumination by placing a cold light probe (by EC Lercher) interproximally reveals caries extending into the dentin of the second premolar as evidenced by the increased opacity of the carious tootl structure.
Right: The same region as in the left photograph under regular lighting. The proximal caries on the mesial of the second premolar cannot be seen without the help of a diagnostic aid. Contributed by K. Pieper
13 Fractured Filling and fractured dentin
A functionally inadequate filling with poor marginal integrity is the cause of dentinal pain.
Right: The dentinal fracture on this first premolar was detected only after the occlusal base under the filling was removed. The patient had been experiencing paroxysmal pain in this area upon occlusal loading.
With mucosal lesions of unknown origin or ulcerations that fail to heal after the presumed cause is removed, a malignant tumor should be suspected. Mistaking an oral carcinoma for a pressure sore from a denture is tragic and inexcusable ! In case of doubt, a specialist should be consulted. A prolonged course of functional therapy for the masticatory system should be complemented by a repeated dental examination of the mucosa and dentition for the early detection of any new pathology. Normally, during the initial patient evaluation the intraoral examination is supplemented by a radiographic survey (orthopantogram, periapical films).
Caveat: The dentist has an absolute duty to organize and preserve the results of the examination.
14 Periodontal findings
Acute necrotizing gingivitis (periodontitis) in a patient with full-blown AIDS.
Left: Pronounced localized gingival recession with severe hypersensitivity at the neck of the tooth.
15 Traumatic mucosal defects
Left: The same region as shown in the center photograph. The mucosal defect caused a neuralgia-like pain radiating to the right eye.
Center: The mucosal lesion was caused by occlusion of the opposing tooth against the alveolar ridge.
Right: Iatrogenic ulcer in the midline at the transition from hard to soft palate as the result of a posteriorly overextended denture border.
16 Radiographic findings
This panoramic radiograph shows extensive atrophy of the edentulous mandible with exposure of the left mental foramen (circled). Mechanical irritation of the mental nerve by the lower denture caused pain encompassing the left temporomandibular joint region.
Overview of Dental Examination Techniques
Before beginning the specific functional diagnostic procedure for a patient with pain in the jaws and face or with limited mandibular mobility, all possible intraoral causes for the reported symptoms should be investigated. The goal of conventional dental evaluation is to rule out periodontal and dental structures, as well as intraoral hard and soft tissues, as the source of the pain. The process is similar in principle to manual functional analysis, in that it should be possible to repeatedly initiate or intensify the symptom through probing and/or judicious loading of the tissues. Patient history, extraoral and intraoral inspection (e.g. for trauma, redness, swelling) and radiographic interpretation (e.g. inflammatory processes) complete the primary dental examination. If there is no significant pathology present that could explain the patient’s problem, or if the patient’s pain cannot be elicited during the primary dental examination, initial dental treatment procedures are not indicated. Blind action is to be avoided.
17 Overview of dental examination techniques
For patients with acute or chronic jaw and facial pain, a primary dental diagnosis is always performed before the joint-specific examination techniques are carried out.
Anatomy of the Masticatory System
A rational clinical examination of the masticatory system requires a sound basic knowledge of the anatomy. As will become clear later in the discussion of clinical examination procedures, the foundation of manual functional analysis is a good knowledge of the functional anatomy. In this chapter the individual anatomical structures will be described in a sequence corresponding to the later examination steps and separated according to their physiology and stages of adaptation and compensation. Knowledge of the different progressive and regressive tissue reactions is not only relevant to the diagnostic interpretation of the findings, but it also decisively influences the treatment strategy. The division into physiological, compensated, and adapted masticatory systems is necessary not only for diagnostic purposes but, more importantly, for the determination of what treatment goals are attainable for the individual.
The human jaw articulation is a so-called secondary joint (Gaupp 1911) because it developed separately and not as a modification of a primary joint (Dabelow 1928). The essential morphogenetic events in the formation of the joints of the jaw occur between the seventh and twentieth embryonic weeks (Baume 1962, Furstman 1963. Moffet 1957, Baume and Holz 1970, Blackwood et al. 1976. Keith 1982, Perry et al. 1985, Burdi 1992, Klesper and Koebke 1993. Valenza et al. 1993, Bach-Petersen et al. 1994. Ögütcen-Toller and juniper 1994, Bontschev 1996, Rodriguez-Vazquez et al. 1997). The critical period for the appearance of malformations in the joints of the jaw is reported differently in different studies. According to Van der Linden et al. (1987) it is between the seventh and eleventh weeks, according to Furstman (1963) between the eighth and twelfth weeks, and according to Moore and Lavelle (1974), between the tenth and twelfth weeks.
Formation of the bony mandible begins in weeks 6-7 lateral to Meckel’s cartilage in both halves of the face. A double anlage of Meckel’s cartilage is extremely rare (Rodriguez-Vazquez et al. 1997). Its effect on embryonic development is unknown. By about the twelfth week the two palatal processes have united at the midline to complete the separation of the oral and nasal cavities. At the same time, bony anlagen of the maxilla form in the region of the future infraorbital foramina. These spread rapidly in a horizontal direction and progressively fill the space between the oral cavity and the eyes. When the crown-rump length (CRL) is approximately 76 mm (weeks 10-12), the anlagen of the maxillary bone, the zygomatic bone, and the temporal bone come into contact with one another. Ossification of the base of the cranium and of the facial portion of the skull follows in a strict, genetically determined sequence (Bach-Petersen et al. 1994). First to ossify is the mandible, followed by the maxilla, medial alar process of the sphenoid bone, frontal bone, zygomatic bone, zygomatic arch, squamous part of the occipital bone, greater wing of the sphenoid bone, tympanic bone, condyles of the occipital bone, lesser wing of the sphenoid bone, and finally the dorsolateral portion of the sphenoid bone.
In an embryo with a CRL of approximately 53 mm the coronoid process and the condylar process can