Tenderness on palpation and occlusal abnormalities in

temporomandibular dysfunction
M. Ai, DDS, DDSc,* and S. Yamashita, DDS, DDScb
Tokyo Medical and Dental University, Faculty of Dentistry, Tokyo, Japan

Tenderness on palpation indicates objective painful symptoms. This study investi-

gated the tenderness of the temporomandibular joint, muscles and their relation to
occlusion in patients with temporomandibular dysfunction. Two hundred ten
patients were examined; 96% had tenderness and 80% of cases of tenderness were
diagnosed as occlusally related. The average number of tender areas was 5.4 per
patient, despite the contribution of occlusion. Tenderness was observed most
frequently in the lateral pterygoid muscle, followed by the insertion of temporal
muscle. There was no correlation of temporomandibular joint tenderness to muscle
tenderness, while tenderness of certain muscles to each other was correlated.
Differences were related to the state of occlusion in the number of tender areas, to
the ratio to tenderness of elevator muscles to horizontally acting muscles, and to
the frequency of unilateral tenderness. The association of muscle tenderness and
occlusion was suggested. (J PROSTHETDENT 1992;67:839-45.)

P.am is a frequent complaint of patients with tem-
poromandibular dysfunction. The pain is commonly caused
by a dysfunctional temporomandibular joint (TMJ) and
muscles of the masticatory system. It is essential when
making a diagnosis to identify pain according to the sites
or states of discomfort. For this reason, a systematic pal-
pation is fundamental in clinical examinations. Although
some problems related to palpation, such as the examiner’s
experience, the response of the patients, or the topographic
impossibility of palpation have been indicated, systematic
palpation’s role cannot be denied for comprehending the
painful symptoms and rendering a diagnosis.‘, 2 Actually,
numerous studies on temporomandibular dysfunction have
confirmed that palpation is essential in assessing symp-
toms of the dysfunction.3-10
TMJ and muscle tenderness on palpation and their re-
lation to occlusion were studied in this article to obtain
specific clues for diagnosis.
MATERIAL AND METHODS
Two hundred ten patients diagnosed as having temporo-
mandibular dysfunction from a population of 254 patients
complaining of various types of facial pain and mandibu-
lar disorders were invest.igated.
Forty-four men and 166 women were examined, diag-
nosed, and treated by one of the investigators from 1975 to
1989. The mean age was 39 years and the range was from
12 to 70 years. Clinical examinations were conducted and
aProfessor,The First Department of Prosthodontics.
bAssistantlecturer, The First Department of Prosthodontics.
10/l/35560
included a case history, inspection and palpation, auscul-
tation of the TMJ sound, measurement of jaw positions and
movements, radiographic assessment, a symptom provo-
cation test, and occlusal evaluations. Palpation of the TMJ
and muscles was performed according to Krogh-Poulsen
and Olssonl and the tenderness or discomfort was re-
corded. Occlusion was examined directly intraorally or on
the diagnostic casts, taking into consideration the signs and
symptoms, and the results were recorded in detail. A con-
sensus diagnosis was rendered after the accumulation of
data, with particular attention to the contribution of
occlusion as an etiologic factor. In some instances, the di-
agnosis was not initially recorded definitely but it was for-
malized during treatment to accommodate symptoms, or
after recovery.
In this study, tenderness was reported on palpation at
the initial clinical examination. Although palpation was
performed at 18 sites for one side, tenderness in the
following two sites was combined-lateral and dorsal sites
of TMJ, maxillary and anterior sites, middle and mandib-
ular sites of the superficial masseter muscle, and anterior
and mandibular sites of the medial pterygoid muscle.
Patients with occlusion as a contributing local factor
were classified into three groups.
I. Abnormal intercuspal position (IP), such as decreased
vertical dimension, instability, and deviation of occlusion
including tooth loss, attrition, or artificial crowns.
II. Abnormal tooth contact in the IP, such as premature
contact. or unbalanced tooth contacts in the IP.
III. Abnormal tooth contact in eccentric positions, such
as premature contact or occlusal interference in lateral jaw
movements, and protrusive and retrusive movements.

THE JOURNAL OF PROSTHETIC DENTISTRY 839

 AI AND YAMASHITA

20

18

16
14
12
% 10

8
6

4
2

0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Number of involved sites

q Occlusal group 0 Nonocclusal group

Fig. 1. Frequency of TMJ and muscle tenderness on palpation related to number of in-
volved sites (n = 210).

Table I. Distribution of patients according to The tenderness was generally unilateral. Unilateral ten-
contribution of occlusion and tenderness of TMJ and derness was most frequent in the TMJ and the deep mas-
muscles seter muscle, the ratio being 8.6, while in the lateral ptery-
Tenderness goid muscle and the anterior temporal muscle bilateral
Contribution of - tenderness was elevated but unilateral tenderness was
occlusion + Total more frequent, with the ratio being 1.1 and 1.4, respec-
tively.
+ 161 (77) 7 (3) 168 (80)
- 40 (19) 2 (1) 42 (20) Interrelationship of tenderness in each site
Total 201 (96) 9 (4) 210 (100)
The interrelationship between TMJ tenderness and
Numbers in parentheses are percentages. muscle tenderness was reviewed for all patients with tem-
poromandibular dysfunction, and it was found that TMJ
tenderness was noted in 69 (36%) of 192 patients with
RESULTS muscle tenderness, and in nine (50 % ) of 18 patients with-
Tenderness was observed in 201 of 210 patients with out muscle tenderness (Fig. 3). Thus the statistical inter-
temporomandibular dysfunction, and in 161 patients with relationship of tenderness was not positive. With 201 pa-
tenderness the contribution of occlusion was verified (Ta- tients having tenderness, the interrelationship of tender-
ble I). The patients with a contributing occlusion were se- ness in each site of palpation was calculated by the chi
lected for the occlusal group and the remaining patients square test. TMJ tenderness showed no correlation with
were classified as the nonocclusal group. tenderness of any muscles, but between various muscles
correlations were apparent (Table II). This was especially
Frequency of TMJ and muscle tenderness true of the deep masseter muscle, the anterior temporal
The frequency of TMJ and muscle tenderness on palpa- muscle, and the sternocleidomastoid muscle.
tion is illustrated by the number of involved sites in Fig. 1.
Certain patients (14 % ) had three sites of tenderness for 28 Frequency of TMJ and muscle tenderness
sites of palpation, but the average was 5.4 sites for all pa- in each occlusal group
tients, and 5.3 and 5.9 sites in occlusal and nonocclusal One hundred sixty-one patients with an occlusal contri-
group, respectively. bution were subdivided into groups I, II, or III according to
abnormal occlusal relationships, and the frequency of ten-
Frequency of tenderness according to sites derness was recorded in each group. A few differences were
of palpation observed between the three groups: the number of tender
The frequency of tenderness in each site of palpation was areas ranged from 1 to 19 in group I (with abnormal IP),
determined, with 201 patients exhibiting tenderness (Fig. while the number of tender areas ranged from 1 to 11 in
2). The most prevalent site for tenderness was the lateral group III (with abnormal tooth contact in eccentric posi-
pterygoid muscle (62%): followed by the insertion of tem- tions) (Fig. 4). There were few differences in frequency with
poral muscle and the posterior digastric muscle. limited. tender areas (1 to 10) between the three occlusal

840 JUNE 1992 VOLUME 67 NUMBER 6

TENDERNESS OF TMJ AND MUSCLES

100
90
80
70
60
% 50
40
30
20
10
0
01 02 03 04 05 06 07 08 09 10 11 12 13 14
Sites of palpation

Fig. 2. Frequency of TMJ and muscle tenderness according to each site of palpation
(n = 201). 01, TMJ; 02, deep masseter muscle; 03, superficial masseter muscle (maxillary
and anterior sites); 04, superficial masseter muscle (middle and mandibular sites); 05, an-
terior temporal muscle; 06, posterior temporal muscle; 07, insertion of temporal muscle; 08,
medial pterygoid muscle; 09, lateral pterygoid muscle; 10, posterior digastric muscle; 11,
insertion of sternocleidomastoid muscle; 12, middle of sternocleidomastoid muscle; 13,
mylohyoid muscle; 14, occipital muscle.

groups, but with a larger number of tender areas (11 to 19),

the frequency in group II (with abnormal tooth contact in
the IP) and in group III reduced remarkably, a significant
difference being observed between group I and groups II or
III (p < 0.05).

Frequency of tenderness in each site in

occlusal group and nonocclusal group
The frequency of tenderness in each site was determined
according to the patients in each occlusal and nonocclusal
group. A difference of frequency was recorded chiefly in the
elevator muscles, namely the masseter and the temporal
muscles, and in the horizontally acting muscles (the medial
and lateral pterygoid muscles and the posterior digastric
muscle) between each group (Fig. 5). The frequency in the
elevator muscles (43% and 44%) was greater than in the ci, (3
TMJ tend.
horizontally acting muscles (32 % and 35 % ) in groups I and TMJ tend.
II, while the frequency was approximately equal (37 % and Muscle tend. (-I-) Muscle tend. (-)
38% ) in group III. In the nonocclusal group, the frequency Fig. 3. Interrelationship of TMJ and muscle tenderness
of tenderness was seen more in the elevator muscle, similar (n = 210).
to its occurrence in group I.

Unilateral or bilateral tenderness in
occlusal group and nonocclusal group
The distribution ratio of unilateral and bilateral tender-
ness was determined in each occlusal and nonocclusal
group. Unilateral and bilateral tenderness displayed a
similar ratio of 53 % to 4’7% , and of 49 % to 51% in groups
I and II, while unilateral tenderness was higher than bilat-
eral tenderness (65% to 35% ) in group III (Fig. 6).
Conversely, unilateral tenderness was lower than bilateral
tenderness (34 % to 66%) in the nonocclusal group.
DISCUSSION
Temporomandibular dysfunction is a multifactorial dis-
order involving physical, psychological, emotional, social,
and local factors. Abnormalities of occlusion are included
in the local factor. The contribution of occlusion has long

THE JOURNAL OF PROSTHETIC DENTISTRY 841

 AI AND YAMASHITA

20

18

16

14

12

%lO

0
1’1 ’ 1’3’ 1’5’ 1’7’ lb’ il ’ i3’ 2’5’ i7’
Number of involved sites

q Group I (76) 0 GrouplI (51) Groupa (34)

Fig. 4. Frequency of TMJ and muscle tenderness by number of involved sites according
to occlusal group (n = 161).

Table II. Interrelationship of tenderness in each site of palpation (n = 201)

01 02 03 04 05 06 07 08 09 10 11 12 13

14 * - - - - - - t * -
13 - - * - - - - - * *
12 - * - - * - t
t - *
11 t * t t t * * t
10 - * - - * - -
09 - * * - * - t t
08 * - - - - -
07 * - - t -
06 - - - _ _

05 - * * t
04 * t
03 - t
02 -

*p < 0.05.
tp < 0.01.
01, TMJ; 02, deep masseter muscle; 03, superficial masseter muscle (maxillary and anterior sites); 04, superficial masseter muscle (middle and mandibular sites);
05, anterior temporal muscle; 06, posterior temporal muscle; 07, insertion of temporal muscle; 03, medial pterygoid muscle; 09, lateral pterygoid muscle; 10, pos-
terior digastric muscle: 11, insertion of sternocleidomastoid muscle; 12, middle of sternocleidomastoid muscle; 13, mylohyoid muscle; 14, occipital muscle.

been debated, but the conclusions are mixed.3y4,6lU-B In Frequency of tenderness

this study, various occlusal abnormalities were prevalent, It was discovered that an average patient had 5.4 tender
and 80 % of the patients were classified as having their oc- sites. Clomparing the occlusal and nonocclusal groups, the
clusion a contributing etiologic factor for causing symp- number of tender areas tended to be greater in the latter
toms, because they responded effectively to occlusal treat- than in the former. This may be related to a greater num-
ments such as an occlusal splint, occlusal adjustment, or ber of tender areas (10.8) previously observed in psychoso-
prostheses. However, this percentage appears inordinately matic .patients. This tendency suggested that certain pa-
high and may result from the fact that these patients were tients with psychosomatic characteristics were included in
coming to the Department of Prosthodontics and were the nonocclusal group.
naturally screened in advance. The percentage might be Regarding the frequency of tenderness in each site of
reduced with patients in the Department of Oral Surgery palpation, high percentages were obtained in the lateral
or in the TMJ Clinic. pterygoid muscle (62 % ), the insertion of temporal muscle

842 JUNE 1992 VOLUME 67 NUMBER 6

TENDERNESS OF TMJ AND MUSCLES

Occlus~l group Nonocclusal group

q Elevator muscles q Horizontally acting muscles

Fig. 5. Frequency of tenderness of elevator muscles and horizontally acting muscles in

each occlusal group and nonocclusal group (n = 201).

(52 % ), and the posterior digastric muscle (47 % ). Although

the frequency was different, the order of the sites was sim-
ilar to that observed in the studies of others.$ s 1g-23The
reasons remain obscure despite the various concepts pro-
posed, but it may be possible that the concentration of
forces and the proclivity to fatigue of the muscles or their
prolonged recovery could be responsible for the tenderness.
The lateral pterygoid muscle especially may tend to fall
into dysfunction because of its complex structure and de-
tailed function.24, 25There is also a problem regarding the
possibility of palpation of this muscle. Johnston and Tem-
pleton26 pointed out that it was impossible to palpate this
muscle using dissection and radiographic techniques. Our
anatomic examination revealed that in 44 % of the individ-
uals it was impossible to place pressure on the muscle by Occlusal group Nonocclusal group
conventional palpation techniques. Therefore the fre-
quency of tenderness may be actually more, if the question H Unilateral q Bilateral
tenderness tenderness
of palpability is taken into consideration. Further investi-
gations are required with respect to this problem. Fig. 6. Distribution ratio of uni!ateral and bilateral ten-
In addition, there were differences in the frequency of derness in each occlusal group and nonocclusal group
unilateral and bilateral tenderness according to the site of (n = 201).

palpation. This implies unique functional characteristics of

the TMJ and muscles in temporomandibular dysfunction.
Interrelationship of tenderness in each site
of palpation
The interrelationship of tenderness in each site was
evaluated in both the ipsilateral and contralateral sides and
it was found that there was no interrelationship between
the TMJ and the muscles. Seligman et a1.5 recently
suggested a significant association between muscle symp-
toms and TMJ tenderness in a study of dental students.
The difference in our study can be attributed to the selec-
tion of patients with pain or dysfunction, not subjects
drawn from a general population or dental students. More
muscle sites were also palpated in this research than in
similar reports.3*5,6 This investigation suggested that ten-
derness of the TMJ may have a different etiology from that
of the muscles, including the functional effects on the mas-
ticatory system.
Conversely, a significant interrelationship in tenderness

THE JOURNAL OF PROSTHETIC DENTISTRY 843

 AI AND YAMASHITA

was documented between numerous muscles. The deep
masseter muscle, the anterior temporal muscle, and the
sternocleidomastoid muscle were repeatedly identified as
tender in various other sites. This indicated that tender-
ness of these muscles seldom occurred independently, and
was mostly associated ,with tenderness in other sites.
Functional relationships between the sternocleidomastoid
muscle and the superficial masseter muscle were recently
4. Muscle tenderness demonstrated various patterns in
frequency and in site depending on occlusal abnormalities,
so an association of muscle tenderness and occlusion was
implied.
These findings may be helpful in rendering the diagno-
sis of patients with temporomandibular dysfunction.
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KM. TMJ and craniofacial pain: diagnosis and management. St Louis,
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5. Seligman DA, Pullinger AG, Solberg WK. Temporomandibular disor-
Group I included numerous patients with many tender ders Part III. Occlusal and articular factors associated with muscle ten-
areas compared with groups II and III. This implied that derness. J PROSTHET DENT 198&59:483-g.
the abnormality in the IP greatly influenced the TMJ and 6. Ingervall B, Mohlin B, Thilander B. Prevalence of symptoms of func-
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There were also differences in the frequency of tender- mandibular joint pain-dysfunction. J PROSTHET DENT 1983;49:809-15.
8. Helkimo M. Studies on function and dysfunction of the masticatory
ness of the elevator muscles and the horizontally acting system. Dissertation. University of Goteborg, Goteborg, Sweden, 1974.
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the ratio of unilateral and bilateral tenderness in groups I clusal interferences on signs and symptoms of craniomandibular disor-
and III, there were certain differences in the mechanisms der in young adults. J Oral Rehabil 1989;16:21-6.
11. Barghi N, Aguilar T, Martinez C, et al. Prevalence of types of temporo-
acting on the TMJ and the muscles between abnormal IP mandibular joint clickings in subjects with missing posterior teeth. J
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Krogh-Poulsen and CUsson stressed the importance of 12. DeBoever JA, Adriaens PA. Occlusal relationship in patients with
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844 JUNE 1992 VOLUME 67 NUMBER 6

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23. Franks AST. Masticatory muscle hyperactivity and temporomandibu- 27. Kohno S, Yoshida K, Kobayashi H. Pain in the sternocleidomastoid
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24. Mahan PE, Wilkinson TM, Gibbs CH, at al. Superior and inferior lat-
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1989;62:229-33. l-5-45 Y’IISHIMA, BUNKYO-KIJ
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The effect of age on condylar asymmetry in patients with

craniomandibular disorders of arthrogenous origin
Victor J. Miller, BSc, BChDa
University of Saskatchewan College of Dentistry, Saskatoon, Saskatchewan, Canada

A group of patients with a craniomandibular disorder of arthrogenous origin

demonstrated an age-related variation of condylar asymmetry with age. This may
reflect a greater depletion of the mesenchymal cell layer, which is responsible for
adaptation of the articular surface as age increases. This would then result in
greater deterioration of the articular surfaces and a consequent decrease in
condylar asymmetry. (J PROSTHET DENT 1992;67:846-6.)

I
t has been reported that condylar asymmetry (the Table I. Condylar asymmetry, sex, age, and right- or
comparison of vertical condylar height between left and left-handedness in a group of patients with arthrogenous
right condyles) is greater in patients suffering from cran- origin of pain
iomandibular disorders than in asymptomatic patients.l Sex Age (yr) AI Right- or left-handed
Condylar asymmetry has been associated with the over-
loading of the articular surfaces of the joints, and it affects Male 20 14.29 Right
Female 13 33.33 Right
the soft and hard tissue component of this surface, partic-
ularly the undifferentiated mesenchymal cell layer.2 A Female 21 -18.18 Left
Female 34 -12.50 Right
schema has been suggested to account for the progression
Female 42 -3.70 Right
to osteoarthrosis in these patients.3 Hyperactivity of mas- Male 22 -18.18 Right
ticatory muscles may lead to overloading of articular sur- Male 21 -22.22 Right
faces.4 This leads to thickening of soft and hard tissues. As Female 20 25.90 Right
a result, condylar asymmetry is increased, with a concom- Female 26 -16.29 Right
itant increase in muscle hyperactivity. This process can Female 25 -23.00 Left
continue until the adaptive capacity of the surface is % Female 80 Mean 25 Mean 18.76
exhausted. This is reflected in the diminishing of the un- SD 8.124 SD 8.0689
differentiated mesenchymal cell layer. At this point, dete- AI, Asymmetry index.
rioration of the articular surface and eventual osteoarthro-
sis occur. This suggests that condylar asymmetry would
decrease in patients with an arthrogenous origin of joint the condylar asymmetry index with a radiographic exam-
problems. The objective of this study was to concentrate on ination of symptomatic patients.

METHOD
aAssistant Professor, Depart.ment of Restorative and Prosthetic
Dentistry. This study included a group of patients referred to a
10/l/35883 University clinic complaining of craniomandibular disor-

THE JOURNAL OF PROSTHETIC DENTISTRY 845