Axisgraphic tracings of temporomandibular joint movements

Joaehim Theusner, DMD,a Octavia Plesh, MD, DDS,b

Donald A. Curtis, DMD,b and John E. Hutton, DDSC
University of Munich, Germany; and University of California, School of Dentistry, San Francisco,
Calif.

Three-dimensional condylar movements of 49 symptomatic and asymptomatic

volunteers were recorded with a hinge axis tracing system axiograph during
maximal opening, protrusion, and mediotrusion. The tracings displayed in sagittal
and frontal planes were measured to evaluate biomechanics of the temporomandib-
ular joint. The only dilYerences in condylar tracings between symptomatic and
asymptomatic groups were in the right joint, recorded in the sagittal plane during
maximal opening, and the Bennett angle. The symptomatic group had a significantly
longer condylar path and a smaller Bennett angle compared with the asymptomatic
group. The results were interpreted as indications of adaptive morphologic instead
of pathologic changes. The alterations in condylar tracings as an indicator of joint
pathology should be considered cautiously. (J PROSTAETDENT 1993;69:409-16.)

c ondylar movements are the result of rotation and

translation arranged in a timing and spatial pattern and are
important in the biomechanics of the temporomandibular
joint.le3 Although substantial opening can be accomplished
by pure rotation,4 the condyles commonly rotate a few de-
grees in opening and then translate down the eminence.5
There is a dearth of information on the normal timing and
spatial pattern of rotation and translation in condylar
movement. Two factors have been considered fundamen-
tal in determining this pattern: a biomechanical joint con-
strain@ and a neurophysiological mechanism.3
Studies of condylar movements have used different
tracing devices that can be categorized as mechanic7-l2
or electronic.l, 13-17Certain electronic devices have been
suggested for the diagnosis of temporomandibular dys-
function (TMD),l, 14+I7 but their diagnostic accuracy has
been questioned recently. l8 Alteration of the joint’s bio-
mechanics, such as an increase in translation, has been
consideredIs predisposing to TMD. The signs and symp-
toms associated with TMD, such as joint sounds, muscle
and joint tenderness, and headaches, have also been
reported prevalent in the general population. The assump-
tion that TMD will eventually develop in such a “subclin-
ical population” has been questioned because of a lack of
longitudinal studies. 2oAn association between TMD signs
or symptoms and changes in joint biomechanics has not
been confirmed.
This study investigated the range of condylar move-
ments during deliberate maximal jaw movements to docu-
ment the biomechanics of the TMJ. Specifically, the spa-
tial patterns of condylar movements were investigated to
aPrivate practice, Munich, Germany.
bAssistant Professor, Department of Restorative Dentistry.
CAssociate Professor, Department of Restorative Dentistry.
Copyright 0 1993 by The Editorial Council of THE JOURNAL OF
PROSTHETIC DENTISTRY.
0022-3913/93/$1.00 + .lO. 10/l/43331
determine whether they differed between a group of indi-
viduals who have subclinical symptoms, and a symptom-
free group.
MATERIAL AND METHODS
Participants
Forty-nine volunteers (24 men and 25 women) between
the ages of 22 and 56 years were selected for the study. They
were staff members and students at the University of Cal-
ifornia and the University of Munich. The only criterion for
their selection was that they were not seeking TMD treat-
ment. Informed consent was obtained from each individ-
ual.
Clinical examination
Each participant was examined by an investigator to
document joint noises and tenderness, masticatory and
cervical muscle tenderness, and range of mandibular mo-
tion. Joint noises were determined directly by manual pal-
pation, and the jaw and neck muscles were evaluated by
palpation to confirm muscle tenderness or pain during
movement. The response to palpation was graded on a scale
of 0 to 3. A score of 0 indicated no response; 1, verbal re-
port of discomfort; 2, facial movement with report of pain;
3, retreat of head in anticipation of palpation with consid-
erable pain. Joint pain or tenderness was also evaluated on
the same scale for pain on palpation and movement. The
range of jaw opening was measured as the interincisal dis-
tance to the nearest millimeter. Headaches and facial pain
were verified with questionnaires, and the responses were
considered positive if the headache was unexplained and
occurred at least twice a week.
Instrumentation
Condylar movements were recorded with the SAS hinge
axis tracing system l2 (SAS-Vertrieb, Munich, Germany),
which included a modified SAM axiograph (Fig. 1). This

FEBRUARY 1993 209

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Hinge axis tracing system (SAS) attached to vol-
unteer. Paraocclusal clutch and stylus is attached to man-
dible and measuring foil is attached to magnetic flag holder
on upper region of face.
system12is based on a three-dimensional hinge-axis related
recording described by Lee7 and Slavicec and Lugner.21
The lower facebow (Fig. 1) was attached to the mandible
by an occlusal c1utch,22and the SAM axiograph was mod-
ified by the addition of surface magnets to the flags on the
flagholders. Graph paper was replaced by an electrical re-
sistive foil secured by a metal-backed frame that moved
freely on the magnetic surface of the flag.‘e 23The foil gen-
erated electrical signals proportional to the movement of
the caliper in the anterior to posterior (X) and vertical (Y)
directions. The transverse direction (2) was generated by
the inductive caliper, which transmitted an electrical ten-
sion to the measuring foil. The three signals were pro-
cessed,amplified, and displayed (Fig. 2) by a multichannel
X, Y, 2 analog recorder (YEW 3023, Yokogawa, Japan). All
registrations were recorded at x10 magnification.
Axiographic tracing procedure
Each volunteer was seated upright in a dental chair with
the head supported, and instructions were given in regard
to the desired movements. The following adjustments were
performed: (1) the hinge axis was determined in retruded
position centric relation (CR), and the participants were
asked to open and close within a 10 mm range avoiding
translation; and (2) the electrical foil was adjusted to the
hinge-axis infraorbital reference plane so that the record-
ings on the XYZ recorder were parallel to the Frankfort
plane.
210
THEUSNER ET AL
Fig. 2. Three-channel analog recorder that displays three
signals proportional to movement of caliper in anteropos-
terior (X), vertical (Y) , and transverse fZ) directions with
~10 magnitude for all of the displays.
Three types of voluntary movements were then per-
formed: (1) maximal protrusion and retrusion; (2) maximal
opening and closing; and (3) maximal mediotrusive and
medioretrusive. Each type of movement consisted of a se-
ries of five consecutive movements that started and ended
in CR. All movements were displayed in sagittal and hor-
izontal planes simultaneously, first on the right joint and
subsequently on the left joint.
The following parameters were measured from the
recorded tracings: (1) range of maximal protrusion in the
sagittal and horizontal planes (Fig. 3); (2) consistency of
protrusive movements, assessed at the midpoint of the
protrusive tracings by measurement of the cross section
from five tracings made in the sag&al plane (Fig. 3); (3)
range of maximal opening in sagittal and horizontal planes
(Fig. 4); (4) consistency of maximal opening, which was
evaluated at the midpoint of the opening tracings by mea-
surement of the width of the cross-sectional area from the
five tracings in the sagittal plane (Fig. 4); and (5) Bennett
movement and angulation recorded from the mediotrusive
tracings (Fig. 5) and correction made for the angulation in
the inclined horizontal plane.22*23
Statistical analysis
A comparison between two groups of participants, based
on the signs and symptoms in regard to all tracing param-
eters, was made with a two-sample t-test. One-way ANOVA
was computed to test whether these parameters were dif-
ferent on the basis of the type and number of signs and
symptoms.
RESULTS
Clinical examination
The results revealed that 1.2subjects (five men and seven
women, mean age of 30 years) were free of symptoms and
37 subjects (19 men and 18 women, mean age of 28 years)
VOLUME 69 NUMBER 2
AXIOGRAPHIC TRACINGS OF TMJ MOVEMENTS THE JOURNAL OF PROSTHETJC DENTISTRY

recorded one or more symptoms (Fig. 6). There was no sig-

nificant difference in age or gender distribution between
the two groups. In the symptomatic group, 32 volunteers
exhibited joint noises, distributed as 47 % bilateral, 34 %
left joint, and 19 % right joint. Joint tenderness was present
in 21 subjects and distributed as 57% bilateral, 29% left
joint, and 14% right joint. Muscle tenderness was evident
in 18 of the subjects. Both joint and muscle tenderness was
mild, approximately 1 on the scale of 0 to 3. Headaches were
present in 13 participants and all presented joint noises
with muscle and joint tenderness. The interrelationship of
the four clinical findings is represented in Fig. 7.

Maximal interincisal distance

The range of maximal interincisal distance was from 42
to 55 mm (mean 50.2 +- 3.9) for the asymptomatic subjects,
and from 31 to 63 mm (mean 50.3 f 8.2) for the symptom-
atic subjects. There was no statistical difference in the
maximal interincisal opening between the two groups
(t-test, p < 0.05).

Axiographic parameters
Table I lists the group means of all tracings for the
symptomatic and asymptomatic groups. For each volun-
teer, the axiographic tracings in the sagittal plane coin-
cided for the first 6 mm of movement (Figs. 4 through 6).
However, toward the end of the movement, they differed in
range and configuration. The protrusive and mediotrusive
movements were generally accomplished through transla-
tion with minimal condylar rotation. Conversely, opening
involved a rotational component. The opening movements
ยึดเยื้อ
were more protracted than the protrusive movements be-
cause rotation ปลดปล่อย
freed the translatory movements during
opening.
The group means of maximal protrusion and retrusion in
the sagittal plane for the asymptomatic group were Fig. 3. Maximal protrusive and retrusive tracings in lat-
eral and sagittal views in millimeters; consistency was as-
10.2 + 1.9 mm, right joint (RJ) and 10.6 + 2.2 mm, left
sessed at middle of tracings (C) by the width of tracings.
joint (LJ); and for the symptomatic group, 9.6 f 2.5 mm
(RJ) and 9.9 F 2.8 mm (LJ). The two groups were not sig-
nificantly different (t-test).
The group means of maximal protrusion and retrusion in ments that exhibit limited or no rotational component. The
the horizontal plane for the asymptomatic group were group mean lengths of the opening and closing tracings for
7.8 + 1.7 mm (RJ) and 9.2 f 1.9 mm (LJ); and for the the asymptomatic group were 12.1 k 2.5 mm (RJ) and
symptomatic group were 7.3 1 2.5 mm (RJ) and 8.0 + 3.1 14.3 + 3.7 mm (LJ) and for the symptomatic group,
mm (LJ). There was no statistical significance between the 14.7 + 3.4 mm (RJ) and 16.4 k 3.7 mm (LJ). There was a
two groups (t-test). statistically significant difference between the two groups
The group means of angulations of the protrusive and for the right joint (p 0.015). but not for the left joint (p
retrusive movement for the asymptomatic group were 0.092).
35 -r 9 degrees (RJ) and 35 + 6 degrees (LJ) and for the The group means of maximal opening in the horizontal
symptomatic group were 39 f 11 degrees (RJ) and 40 f 13 plane for the asymptomatic group were 10.5 -+ 2.9 mm (RJ)
degrees (LJ). There was no statistically significant differ- and 12.6 rt 3.7 mm (LJ) and for the symptomatic group
ence between the two groups (t-test). 12.7 +- 4.1 mm (RJ) and 14.8 + 4.3 mm (LJ). There was no
The maximal opening and closing in the sagittal plane statistical difference between the two groups.
was the longest recording. The end of the tracing curved The sagittal tracings during maximal opening were
cranially, determined by the eminentia (Fig. 5). In general, longer than the sagittal tracings during maximal protrusive
opening and closing movements involve a rotational com- movement. Both movements involved translation, but the
ponent as opposed to the protrusive and retrusive move- maximal opening also involved rotation &at freed transla-

FEBRUARY 1893 211

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 4. Maximal opening and closing tracings in lateral and sagittal views in millimeters,
with consistency assessedat middle of tracings (C).
tion from the biomechanic constraint of the ligaments to
allow extension. Because they were always longer, the dif-
ference between the maximal opening and closing and the
maximal protrusive and retrusive tracings in the sagittal
plane was calculated. For the asymptomatic group, this
difference was 1.9 f 2.6 mm (RJ) and 3.6 + 3.1 mm (LJ)
and for the symptomatic group it was 5.2 + 2.9 mm (RJ)
and 6.3 i 2.8 mm (LJ). There was a statistically significant
difference between the two groups for both right and left
joints (p < 0.05). The type of signs or symptoms made no
difference in regard to this parameter (ANOVA), but the
number of signs and symptoms made a significant differ-
ence (p < 0.05, ANOVA). The significant difference was
between the group presenting three or more signs, com-
pared with the group without symptoms (Newman-Keuls
test).
212
THEUSNER ET AL
The group means of Bennett movement for the asymp-
tomatic group were 0.50 + 0.70 mm (RJ) and 0.27 f 0.43
mm (LJ) and for the symptomatic group were 0.35 f 0.54
mm (RJ) and 0.25 + 0.40 mm (LJ). There was no differ-
ence between these two groups.
The group means of the ranges of Bennett angulation for
the asymptomatic group were 7.8 + 4.9 degrees (RJ) and
7.4 k 4.8 degrees (LJ) and for the symptomatic group was
5.2 + 4.2 degrees (RJ) and 7.2 f 4.3 degrees (LJ). There
was a significant difference between these two groups. The
symptomatic group presented a smaller Bennett angle and
this was significantly different for the right joint (p 0.043)
but not for the left joint.
The consistency of all movements measured as the width
at the midpoint tracings are reported in Table I. There was
no significant difference between the two groups with
VOLUME 69 NUMBER 2
AXIOGRAPHIC TRAClNGS OF TMJ MOVEMENTS THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 5. Maximal mediotrusion and medioretrusion tracings. Bennett shift and Bennett
angulation were assessedfrom single tracing with correction.

20

15

10

0
SYMPTOM SYMPTOM ASYMPTOM

MALE FEMALE
Fig. 6. Sex distribution in symptomatic and asymptomatic groups.

respect to the consistency (width) of movement at the
midpoint of the tracings.
DISCUSSION
This study recorded the range of condylar tracings in
volunteers who did not seek TMD treatment and deter-
mined that there were certain differences in these move-
ments based on TMD signs and symptoms. Seventy-four
percent of the participants presented one or more signs and
symptoms of TMD with joint noises as the highest preva-
lence, followed by joint and muscle tenderness. The posi-
tive muscle and joint response scores for this group were
mild (1 on a scale of 0 to 3) and most participants did not
consider treatment. Reviews of epidemiologic studiess4y””

FEBRUARY 1993 213

THE JOURNAL OF PROSTHETIC DENTISTRY THEUSNER ET AL

INTERRELATIONSHIP OF THE
4 CLINICAL SIGNS AND SYMPTOMS

Joint Pain

Joint Noises

b Muscle Pain

Fig. 7. Interrelationship of four clinical findings in symptomatic sample. Three symp-

toms were represented separately; headache is common with other three (n = 13); and
numbers represent actual numbers of participants.

Table I. Means and standard deviations of the axiographic tracings (n = 49)

Asymptomatic Symptomatic

Right joint Left joint Right joint Left joint

Axiographic parameters x SD x SD ’ x SD x SD

Range of maximum protrusion in sagittal 10.2 1.9 10.6 2.2 9.6 2.5 9.9 2.8
plane (mm)
Consistency of maximum protrusion in sagittal 0.27 0.09 0.45 0.57 0.36 0.22 0.24 0.12
plane (mm)
Range of maximum opening in sagittal 12.06 2.49 14.28 3.74 14.73 3.37 16.37 3.65
plane (mm)
Consistency of maximum opening in sagittal 0.42 0.36 0.53 0.28 0.72 0.53 0.74 0.47
plane (mm)
Angulation of protrusion in sagittal 35.0 9.0 35.0 6.0 39.0 11 40.0 13.0
plane (degrees)
Range of maximum protrusion in 10.5 2.9 12.6 3.7 12.7 4.1 14.8 4.3
horizontal plane (mm)
Range of maximum opening in horizontal 7.8 1.7 9.2 1.9 7.3 2.5 8.0 3.1
plane (mm)
Bennett movement (mm) 0.5 0.7 0.27 0.43 0.35 0.54 0.25 0.40
Bennett angulation (degrees) 7.8 4.9 7.4 4.8 5.2 4.2 7.2 4.3

disclosed that mild signs and symptoms of TMD are highly
prevalent in the general population for both sexes. The
relevance of mild muscle pain and tenderness to palpation,
detectable clinically but not anamnestically, has been con-
sidered an incidental finding and its diagnostic value is
questioned.24-27 Similarly, mere joint clicking may be an
adaptive modification instead of a regressive change within
the TM joint.27 The mean maximal opening did not differ
between symptomatic and asymptomatic groups; both
were in the range previously reported.20 However, for the
asymptomatic group the range of maximal opening was
more homogeneous (SD 3.9) than for the symptomatic
group (SD 8.2).
The group mean of the range of maximal protrusive and
retrusive tracings was approximately 10 mm, similar to
those previously reported.’ The tracings did not differ be-
tween the symptomatic and asymptomatic groups. The
protrusive and retrusive movements, generated by condy-
lar translation, had limited condylar rotation. This move-
ment has been reported to be influenced by the slope of the
ernjner~t~a and its maxima e restricted by the me-
chanical constraint o ligaments, namely the sty-
~oma~dib~lar ligament and ~apsule.~
The mean maximal opening and closing tracings in the
sagittal plane were longer than those in protrusive and
retrusive movements. However, these tracings were also
longer for the symptomatic group compared with the
~sym~tomatic group, and this difference was statistically
significant only for the right joint. The calculated differ-
ence between the maximal opening and closing tracing and
protrblsive and retrusive tracings was significantly greater
in the Syrn~tQrn~t~c group for both joints.
The maximal opening tracings are directly influenced by
the degree of jaw opening and the inclination of the emi-
nentia. Because neither the maximal opening nor the an-
gulation of the tracings differed between the two groups,
other factors probably contributed to this finding. The
condylar movements duri opening are generated by a
combination of rotation a translation, compared with
protrusion, which is mostly translation. Because protrusive
tracings were not different, the increased length of the
traciags during opening is probably influenced by the ro-
tational component. The timing or temporal pattern of ro-
tation has been considered either dominating with initial
movement2 or linearly distributed with the translation
during the movement3 A r and &born6 theoretical
model ofjoint biomechan onstrated that the degree
of translation was greatly influenced not only by the degree
of rotation but also by its temporal distribution during
translation. Both movements appeared limited by the
~em~oroma~dib~~ar ligament and capsule. An increase in
rotation on initial opening was reported for the TMD pa-
tients and is commonly associated with an increased
steepness uf the condylar path3 Wowever, this study dem-
onstrated no diiTerences in condylar path inclination and
therefore other factors contributed to this finding.
The shape of the condylar bead can greatly influence the
rotation, and because the opening and closing movement
involves rotation, the difference in opening and closing
tracings could account for these changes. In addition, be-
cause Bennett angulation was also different in the symp-
tomatic group, and significantly lower for the right joint,
changes in co~dylar shape could be responsible for the re-
หย่อน
sults. Other factors such as increased laxity of the tem-
~orornand~b~~ar ligament could also have contributed to
this finding,
Nevertheless, the association between condylar tracings
and signs or symptoms did not prove a cause-and-effect
relationship. The present signs and symptoms were mild
and considered possibly part of a physiologic adaptation
instead of regressive changes. The need for studies of the
natural history and epidemiology of T&ID has been re-
ressed.28 The alterations of condylar tracings
should be considered signs of adaptation due to possible
modifications in the shape ofthe condyle and/or ligaments.
Caution should be exercised in interpreting changes in
condylar tracings as indications of joint pathology, because
““subclinical” (&at is, healthy) populations can display
EPE 9
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