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 concept of joint-play techniques. Pain that can be repeatedly provoked is recorded with color coding In the appropriate box on the form. The various sections will be explained more fully on the following pages. The numbers indicate the sequence in which the steps are carried out.
With passive compression the bilaminar zone is examined for poorly adapted areas. Translation and traction serve to test the capsule and ligaments.
The examination always begins with passive compression (Bumann and Groot Landeweer 1996b). The rationale of the examination is based upon elicitating pain by loading various joint structures in different directions. In healthy joints, these manipulations are never painful (Palla 1986, Bumann and Groot Landeweer 1992, Curl and Stanwood 1993, McNeill 1993, Hesse 1996), because under physiological conditions the lateral ligament, acting as a motion-limiting structure, prevents injury to the bilaminar zone.
However, if the lateral ligament becomes overextended, pain sensations can emanate from the bilaminar zone because of its rich innervation (Scapino 1991a, b) or from various parts of the capsule. During passive compression the muscles of mastication are not active and are not loaded. Because the disk and the joint surfaces are not innervated, they can be ruled out as sources of pain that can be repeatedly provoked. Therefore pain that can be provoked through posterior (retrusive) and/or posterosuperior compression is evidence of inflammation in one or more areas of the temporomandibular joint (Palla 1992, McNeill 1993, Bumann and Groot Landeweer 1996b). The high level of diagnostic reliability of passive compression has been demonstrated in clinical studies (Lobbezoo-Scholte et al. 1994, de Wijer et al. 1995).
If the dynamic tests for evaluating a patient’s joint surfaces produce pain, then no diagnostically useful information can be gained through applying superiorly directed pressure during the same appointment.
Pain patients are able to report current pain with relative exactness (Cousins 1989. Bell 1991, Stacey 1991. Hewlett et al. 1995) and their reports can be useful in making a differential diagnosis. Seven passive compression tests are available and these are carried out in a definite sequence for ergonomic efficiency. Following each manipulation the patient is asked if pain occurred and if so, whether it was the same as that previously experienced or if it was elicited only by the momentary loading. In this way, as with the joint surface problems, three conditions of the bilaminar zone can be described:
• Adaptation (condition green): no history of pain and no pain evoked by compression.
• Compensation (condition yellow): no history of pain, but pain can be provoked repeatedly by passive compressions.
• Decompensation (condition red): history of pain, and individual pains can be provoked by compressions.
The three possible conditions of the tissues are noted in the patient’s chart with color coding:
• All painful symptoms fall under the term capsulitis in the tissue-specific diagnosis.
• “Conditions yellow” are designated as compensated capsulitis
• “Conditions red” are designated as decompensated capsulitis.
Finally, the exact loading vector, which indicates the direction of compression, is added to the diagnosis. For example, a finding of “condition yellow” pain resulting from posterolateral compression would give the diagnosis: decompensated capsulitis with a posterolateral loading vector. In this case, during clarification of the contributing factors (see p. 124) we would look for one or more causes for the posterolateral force on the involved condyle.
• “Condition green” indicates either that the relationships in the bilaminar zone are physiological or that there is perfect adaptation to nonideal conditions. Even if the morphology is completely different from normal, there is no pressing medical indication for treatment. This has been confirmed over the long term through a series of basic studies (Pereira et al. 1996a, b).
177 Possible endfeels with traction and protrusion
Under physiological conditions the movements of the temporomandibular joint, with the exception of jaw closure, are limited by ligaments and therefore produce a “hard ligamentary endfeel.” A number of structural changes can be responsible for different pathological endfeels. Above all else, muscle shortening and capsule shrinkage have the greatest therapeutic relevance because they can impose restrictions on the treatment.
After the bilaminar zone, the joint capsule and ligaments are tested specifically by means of translation and traction manipulations (Bumann and Groot Landeweer 1996b). These techniques serve on the one hand to determine if pain can be provoked, and on the other hand to evaluate the so-called “endfeel.” There is a relatively high correlation between the findings by various examiners (de Wijer et al. 1995).
The specialized structure of the ligaments with their dense connective tissue and parallel collagen fibers provides high tensile strength (Gay and Miller 1978). Ligaments can be stretched by approximately 5-8% of their original