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Evaluation of Mandibular Movement Functions Using Instrumental

Ultrasound System

Article in Journal of Prosthodontics · October 2015

DOI: 10.1111/jopr.12389

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Journal of Prosthodontics, 2017 February, Volume 26, Issue 2, Pages 123–128, Impact Factor 1.133

Evaluation of Mandibular Movement Functions Using Instrumental

Ultrasound System
Anna Sójka, DDS, PhD,1 Juliusz Huber, MSc, PhD,2 Elżbieta Kaczmarek, MSc, PhD,3 &
Wiesław Hedzelek,
˛ DDS, PhD1
1
Department of Prosthodontics, University of Medical Sciences, Poznań, Poland
2
Department of Pathophysiology of Locomotor Organs, University of Medical Sciences, Poznań, Poland
3
Department of Bioinformatics and Computational Biology, University of Medical Sciences, Poznań, Poland

Keywords Abstract
Temporomandibular joint; mandibular
movement recordings; clinical and
Purpose: The article deals with routinely performed instrumental temporomandibu-
instrumental measurements; healthy lar joint (TMJ) examinations and interpretation of findings obtained from the Arcus
subjects. Digma ultrasound device in individuals with or without clinical symptoms of tem-
poromandibular disorders (TMD). The aim of this study was to analyze mandibular
Correspondence movement functions and the relationship between incisors and condylar movement
Anna Sójka, Department of Prosthodontics, parameters during jaw opening, which may be helpful for clinical evaluation in these
University of Medical Sciences, Bukowska patients.
70 Str Poznań 60–812, Poland. Materials and methods: The study group consisted of 84 young students with no
E-mail: [email protected] dental problems and other serious acute or chronic diseases in the medical history;
the students were examined both clinically and with the Arcus Digma ultrasound
The authors deny any conflicts of interest. device.
Accepted June 14, 2015
Results: Helkimo Di = I was the most common score in 49 participants, and Helkimo
Di = II in a significantly (p < 0.01, Di = I vs. Di = II) smaller number of participants.
doi: 10.1111/jopr.12389
Medical history revealed symptoms of unilateral mastication in 15 participants and a
statistically significant increased (p < 0.02, participants with symptoms of unilateral
mastication vs. asymptomatic) condylar range of motion parameter during retrusion.
Also a significant decrease (p < 0.03, participants with symptoms of unilateral mas-
tication vs. asymptomatic) of the incisal and condylar ranges of motion during mouth
opening was found. Limitation of mouth opening, defined as a decrease of inter-
incisal distance, appeared in 19 participants (22.6%) and in 25 participants (29.8%)
measured instrumentally with the Arcus Digma device. A comparison of instrumental
result examinations of the right and left TMJs showed positive correlations of the
range of mandible opening movement with the Posselt opening movement (r = 0.75)
and opening/closing movements with the Posselt closing movements (r = 0.70). A
correlation was demonstrated (r = 0.81) between the condylar range of motion studied
on the left and on the right TMJ during mandible opening movement. Correlations
were also found between opening-closing movements and the condylar range of mo-
tion of the left TMJ, and between the opening-closing movement and the condylar
range of motion of the right TMJ during the opening movement.
Conclusions: According to the results of this study with instrumental Arcus Digma
ultrasound device measurements of mandibular movements, data were provided on
irregularities in TMJ function not detected in participants with or without clinical
symptoms of TMD.

Assessment of mandibular movement parameters has been an ticatory system and the subjective report of pain can indicate
important clinical variable used in the diagnosis of current the presence or absence of the above-mentioned conditions.3-6
and possible future temporomandibular disorders (TMD).1,2 Limitations in mouth opening may be an indication of temporo-
In the diagnostic process, jaw movement measurements com- mandibular joint (TMJ)-related diseases.7 Due to the difficulty
bined with an objective and clinical examination of the mas- of measuring direct movements of the mandibular condyle,

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border movements of the mandibular incisors have been used as

surrogate measures of TMJ movements.8-11 Because mandibu-
lar condyles and incisors are part of the same rigid bony system,
it has been assumed that they move together, and that incisor
movements provide accurate information about condylar trans-
lation as assessed by Travers et al12 and Naeije.13 While max-
imum opening has been most commonly used for diagnostic
purposes, protrusion and laterotrusion have also been used to
determine the irregularities of the TMJ function.14 Interpreta- Figure 1 Photograph showing the principles of Arcus Digma system
montage.
tion of axiographic tracings allow for diagnosis of TMD and
for illustrated assessment of joint function. This method also
allow for tracing the pathways of jaw movement.15-17 with the Gsellmann’s Occlusal Index. Ai was scored based on
The Arcus Digma device (KaVo, Leutkirch, Germany) has the different symptoms of dysfunction in the masticatory sys-
been reported to provide measurable and functional parame- tem (subjective symptoms) reported by the individuals during
ters of mandibular movements.18 Measurable parameters such history taking.3,4 This index has three levels: Ai-0, individuals
as Bennett angle and horizontal condylar inclination or angle free from dysfunction symptoms; Ai-I, individuals with mild
shift could be used for setting individual articulators. Func- dysfunction symptoms (joint noises, jaw muscle fatigue, jaw
tional parameters such as incisal range of motion, right and stiffness); Ai-II, individuals with severe dysfunction symptoms
left laterotrusion, range of opening movement, condylar range (difficulties in opening the mouth wide, pain during mandibular
of motion during opening and retrusion, Posselt movement, movement, pain in TMJ region or in masticatory muscles).
opening/closing movement, and Gothic arch tracing allow the Functional examination of the masticatory system using the
graphical representation of mandibular movements in the eval- Helkimo Clinical Index of TMD (Di) was performed by a den-
uation of stomatognathic system function.18,19 tist with 25 years of experience.4,5 Helkimo Di = 0 indicated no
The aim of this study was to analyze mandibular movements clinical signs of TMD, Helkimo Di = I mild signs or symptoms,
and to determine the relationship between incisors and condy- Helkimo Di = II moderate symptoms, Helkimo Di = III severe
lar movements during jaw opening obtained from 84 healthy symptoms. In accordance with the presence and/or severity of
individuals with or without TMD symptoms using the Arcus TMD clinical symptoms, individuals were assigned a score of
Digma device. Participants with presumed TMD frequently ex- 0, 1, or 5 points. Recordable symptoms were limited range
hibit early changes in mandibular movements.10,20-22 The null of mandibular motion defined as slightly impaired movement
hypothesis for this study was that there would be no differ- (30 to 39 mm), severely impaired movement (ࣘ29 mm), and
ences in mandibular movements between healthy individuals normal range of movement (ࣙ40 mm). The other symptoms
and those presumed to have TMD. were TMJ function impairment (unilateral or bilateral clicking
during ࣙ2 mm laterotrusion, opening/closing of the jaws), lux-
Materials and methods ation/locking during movement described as severely impaired
function, or smooth movement without sound effect. Muscle
The study included 84 healthy participants (66 women; tenderness was tested during palpation and described as minor
18 men), students from the universities (medical including disorder (with sensitivity to pressure in 1 to 3 places), severe
dental as well as polytechnical) in Poznań (Poland) aged disorder (with sensitivity to pressure in 4+ places), or no sensi-
from 19 to 27 years (mean 23 ± 2 years) with full denti- tivity to pressure. Pain in TMJ during palpation was defined as
tions and similar anthropometric properties, which included a minor disorder with sensation to lateral pressure, severe disor-
height and weight. They were recruited randomly and expressed der with reaction to posterior pressure, or no sensitivity to pres-
an interest in checking the function of their stomatognathic sys- sure. Pain during movement of the mandible was ascertained
tem. The study was done in the Department of Prosthodontics with two movements, one movement, or no movement. Ac-
at the University of Medical Sciences in Poznań. Ethical con- cording to the score obtained, participants were classified into
siderations were in agreement with the Helsinki Declaration. one of four groups: Di-0, 0 points—participants clinically free
Approval was also received from the Bioethical Committee from dysfunction signs; Di-I, 1 to 4 points—participants with
of the University of Medical Sciences (including studies on mild dysfunction symptoms; Di-II, 5 to 9 points—participants
healthy people). Each participant was informed about the aim of with moderate dysfunction symptoms; Di-III, 10 to 25 points—
the study and gave her/his written consent for data publication. subjects with severe dysfunction symptoms.
At the stage of obtaining their medical history, participants Medical histories included a question regarding the occur-
who had sustained injury to either head and neck or those with rence of unilateral chewing habit. The range of mouth opening
concurrent systemic diseases and also those undergoing phar- defined as the inter-incisal distance was measured with a ruler
macological therapy with drugs that might have affected their in millimeters. Mandibular movements were recorded with
psycho-physical condition were excluded from the study. Acute an ultrasound electronic Arcus Digma device. Mandibular
or chronic pains in TMJs and head movement discomfort were border movements were recorded in the frontal, horizontal,
exclusion criteria as well. Objective and subjective evaluation and sagittal planes.
of symptoms was carried out by a dentist with 25 years of The principles of the diagnostic, instrumental setup are
experience. Objective signs were evaluated using the Helkimo shown in Figure 1. First the head frame with the movement sen-
Anamnetic Index (Ai); subjective symptoms were evaluated sors was attached. Then the maxillary position was determined

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Sójka et al Mandibular Movement Analysis

Figure 2 Example of graphic representation of movements of the mandible made with Arcus Digma system.

Table 1 Functional parameters of mandibular movements (mm) measured in a group of 84 individuals (upper part) and in a group of 15 individuals
with unilateral mastication (lower part)

N = 84

Parameter Mean SD Minimum Maximum

Incisal range of motion during opening 44.2 7.7 20.0 63.0

Incisal range of motion during right movements 6.9 2.4 1.0 12.0
Incisal range of motion during left movements 7.5 2.8 0.0 20.0
Condylar range of motion during left side opening 10.9 3.3 3.0 18.0
Condylar range of motion during right side opening 10.9 3.5 3.0 17.0
Condylar range of motion during left side retrusion 0.6 0.8 0.1 5.0
Condylar range of motion during right side retrusion 0.8 0.8 0.1 4.8
Posselt protrusive movement 5.6 2.2 0.5 12.5
Posselt opening movement 43.8 7.4 24.6 64.7
Posselt closing movement 44.5 6.7 27.2 61.8
Gothic arch tracing protrusive movement 5.2 1.7 2.3 11.5
Lateral Gothic arch tracings right 8.3 2.3 2.9 13.7
Lateral Gothic arch tracings left 8.7 2.4 4.5 15.0
Incisal open/close movement 37.0 5.0 17.6 51.2
Range of opening—clinical measurement 42.4 4.9 30.0 56.0
N = 15

Incisal range of motion during opening 40.2 6.6 20.0 56.0

Condylar range of motion during left side retrusion 1.5 2.3 0.1 6.0
Condylar range of motion during right side opening (mm) 9.1 3.9 3.0 15.0

with a bite plate, which had previously been individualized close your mouth, move mandible maximally to the right and
with a hard silicone (EliteHD+Putty; Zhermack, SpA, Badia to the left, move mandible maximally forward.” Every move-
Polesine, Italy). Mandibular brass clutches were customized ment was performed three times, and the average was com-
with acrylic resin Structur 2 SC (VOCO GmbH, Cuxhaven, puter calculated. The maximum anterior movement distance
Germany). The clutches were cemented with polycarboxylate and the maximum lateral movement distance in the horizontal
cement (Harvard Dental International GmbH, Hoppegarten, plane were recorded with the analysis of Gothic arch tracing
Germany) to the facial surfaces of the mandibular premolar (the maximum mouth opening, the lengths of lateral Gothic
and anterior teeth. arch tracings, the lengths of the protrusion tracing). Values of
Examples of a graphic representation of functional pa- the functional parameters were referred to the values found in
rameters made with the Arcus Digma device are shown in healthy volunteers (N = 50).
Figure 2. All measured parameters included incisal range The results obtained from the report of each subject (Helkimo
of motion, right and left laterotrusion, opening movement, and Gsellmann’s Occlusal Index) and from clinical examina-
condylar range of motion during opening, and retrusion, tions (occlusal parafunctions, TMJ dysfunctions) were pre-
sagittal and frontal Posselt movement diagram (Figs 2A,B), sented as absolute numbers. The minimal and maximal values
opening/closing movement (Fig 2C), and Gothic arch tracings (ranges), means (in cases of parametric variables) with standard
(Fig 2D). Every movement of the patient was performed three deviations (SD), or modes (in cases of nonparametric variables)
times, and the computer calculated the average value. were described. Frequencies of incidences were expressed in
Prior to data collection, participants were instructed by the percentages. The values of parameters recorded from the left
researchers how to do the jaw movements “open your mouth, and right sides were compared with a nonparametric test by

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Mandibular Movement Analysis Sójka et al

Wilcoxon. Correlations between the results of TMJ parameters

on the left and right sides were verified using a Spearman’s cor-
relation ratio. Statistical results were considered as significant
at p < 0.05. All statistical calculations were performed using
Statistica v.8.0 (Stat Soft Inc, Tulsa, OK).

Results
Subjective and periodic pains were not reported by any of the
participants. Twenty-three participants (27.4%) presented no
subjective TMJ complaints Ai = 0; 61 (72.6%) reported slight
subjective complaints Ai = I. In the studied group, Di = I
(49 cases, 58.33%) was most common. Di = II was noted in a
significantly smaller number of participants (20 cases, 23.81%)
(p < 0.01; Di = I vs. Di = II). Medical history revealed the
symptoms of unilateral mastication in 15 participants (17.86%).
Figure 3 Correlation of the condylar range of motion of the left TMJ with
the condylar range of motion of the right TMJ during opening movement
Functional parameters of the TMJ mandibular
of the mandible (r = 0.81, p < 0.05).
movements obtained with Arcus Digma
Functional parameters of mandibular movements in the group
of 84 participants are presented in Table 1. The individuals
with unilateral mastication revealed a significant increase
of asymmetry (p < 0.02, those with symptom of unilateral
mastication vs. asymptomatic) in the parameter of left TMJ
range of motion during retrusion (1.5 ± 2.3 mm) as well as
a decrease (p < 0.03) of the incisal range of motion during
opening (40.2 ± 6.6 mm) and the condylar range of motion
(p < 0.03) during opening movement (9.1 ± 3.9 mm).
Comparing limitations of mouth opening (the normal base-
line was 40 to 54 mm)5 measured clinically and instrumentally
with the Arcus Digma device, clinical measurements revealed
mouth opening outside the normal range in 19 participants
(22.61%). Instrumental measurements revealed limitations of
mouth opening in 25 participants (29.76%). The average num-
ber of the incisal range of motion during opening in 18 men was
50.20 ± 7.6 mm, which was significantly higher than in women
42.60 ± 7.0 mm (p < 0.05, men vs. woman). The average range
of opening for the whole group measured clinically was 42.40
± 4.9 mm when measured instrumentally (Table 1).
Figure 4 Correlation between opening/closing movement of the
Comparison of functional parameters mandible and the Posselt opening movement (r = 0.67, p < 0.05; blue
of the right and left TMJs line) and Posselt closing movement (r = 0.70, p < 0.05; red line).

There were no statistically significant differences between the

results and asymmetries of the right and left TMJs in all range of motion during laterotrusion on the left at r = 0.60 (p <
84 participants in the following parameter values of TMJ func- 0.05) and Gothic arch measurements toward the right (r = 0.53,
tion: incisal range of motion during right and left laterotrusion, p < 0.05). The mean and standard deviation for laterotrusion
condylar range of motion during opening for the right and left to the right was 6.95 ± 2.4 mm, and to the left 7.56 ± 2.8 mm,
TMJ, condylar range of motion during retrusion for the right while lateral Gothic arch tracings to the right were 8.37 ± 2.3
and left TMJ, and Gothic arch in the right and left TMJ. mm and lateral Gothic arch tracings to the left was 8.72 ± 2.4
mm (Table 1).
Analysis of values of right and left TMJ
Positive high correlations between the condylar range of mo-
functions for all participants
tion of the left TMJ and of the right TMJ during the opening
Results of measurement of the incisal range of motion during movement (r = 0.81; p < 0.05) were demonstrated (Fig 3) as
laterotrusion on the left correlated with the range of motion well as a positive high correlation of opening/closing movement
during incisal laterotrusion on the right at r = 0.60 (p < 0.05) of the mandible with the Posselt opening movement (r = 0.67;
and with Gothic arch measurements toward the left (r = 0.55, p < 0.05) (Fig 4). Correlations of opening/closing mandibular
p < 0.05). Correlation was also revealed between the range movements with the Posselt closing movements were calcu-
of movement during incisal laterotrusion on the right and the lated to be r = 0.70 (p < 0.05).

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Figure 6 Correlation of the Posselt opening movement with the Posselt

closing movement (r = 0.97, p < 0.05).

TMD frequently exhibit changes in these mandibular move-

ments, as do clinically asymptomatic patients with probable
Figure 5 Correlation between the range of incisal opening movement future TMJ problems.6 Previous electronic jaw recording sys-
and Posselt opening movement (r = 0.75, p < 0.05; blue line), the Posselt tems in patients with TMD were able to find changes in patterns
closing movement (r = 0.77, p < 0.05; red line) and the opening/closing of movements, such as shortening or asymmetry in the condylar
movement (r = 0.79, p < 0.05; green line). pathways.3,18
In this study, clinical examinations revealed that 23 par-
The mean and standard deviation for the condylar range of ticipants (27.4%) presented no subjective TMD complaints
motion during opening movement of the left TMJ was 10.9 ± (Ai = 0), and 61 (72.60%) reported slight subjective com-
3.3 mm, and 10.92 ± 3.5 mm in the right TMJ. The incisal plaints (Ai = I). In the studied group Di = I (49; 58.33%)
opening/closing movement was 37.03 ± 5.0 mm, the range of was most common. Di = II was noted in a significantly (p <
Posselt opening movement was 43.82 ± 7.4 mm, and Posselt 0.01) smaller number of people. The clinical index Di = 0 was
closing movement was 44.50 ± 6.7 mm (Table 1). present in 17.86%, insignificantly different from Di = II. Many
Positive correlations between opening-closing movements factors can affect the movements of the mandible. Unilateral
and condylar range of motion of the left TMJ during opening chewing may lead to TMD. Miyake et al10 showed a greater
movement (r = 0.60; p < 0.05) and between the opening- risk of pain, acoustic symptoms, and movement anomalies in
closing movement and the condylar range of motion of the the participants who showed unilateral chewing and bruxism.
right TMJ during the opening movement (r = 0.54; p < The study group under this examination showed an approx-
0.05) were demonstrated. The range of mandibular opening imately 27% to 33% incidence of unilateral chewing. In the
movements correlated with Posselt opening movements of the patients where unilateral mastication asymmetry was present,
diagram (r = 0.75, p < 0.05), with Posselt closing movements a statistically significant increase (p < 0.02) of the parameter
(r = 0.77; p < 0.05), and with opening/closing movements of condylar range of motion during retrusion and a decrease (p
(r = 0.79; p < 0.05) (Fig 5). The Posselt opening movement < 0.03) of the incisal range of motion during opening and the
showed a high positive correlation with the Posselt closing condylar range of motion (p < 0.03) during opening movement
movement (r = 0.97, p < 0.05) (Fig 6). were shown.
Some studies have reported that measurements of maximum
Discussion mouth opening play an important role in the clinical diagnosis
of masticatory system dysfunctions, while other studies
The temporomandibular system consists of two fundamental showed contradictory findings. In a study of four TMJ mobility
components: the TMJ and the associated neuromuscular sys- assessment methods, Dijkstra et al11 doubted the clinical use of
tem. A TMD can result from any defect in one or both of them.2 maximum mouth opening as a reliable indicator for condylar
Recordings of mandibular border movements are important translation. Moreover, Travers et al12 and Buschang et al,14
indicators of the health status and functional efficiency of the while studying associations between incisor and mandibular
stomatognathic system.20 In that regard, analysis of mandibular condylar movements, did not find any correlation between
border movements may offer valuable data in the diagnosis of maximum incisor opening and condylar translation. Maximum
TMD.18 Mandibular movement occurs as a complex series of laterotrusion and protrusion certainly provided better estimates
interrelated 3D rotational and translational activities.8 Individ- of the limits of condylar translation than maximum opening
ual recording of mandibular movements is possible with the did.12,14 However, Naeije13 showed that condylar translation
help of electronic jaw recording systems,9 so that both qual- is weakly correlated with the maximum mouth opening.
itative and quantitative evaluation of mandibular movements This supports similar findings provided in our study, which
is possible as demonstrated in the present study. Patients with demonstrate positive correlations between the parameter

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Mandibular Movement Analysis Sójka et al

of opening-closing movement and the condylar range of 2. Kafas P, Leeson R: Assessment of pain in temporomandibular
motion of the left TMJ during opening movement at r = 0.60 disorders: the bio-psychosocial complexity. Int J Oral Maxillofac
(p < 0.05) and between the opening-closing movement and the Surg 2006;35:145-149
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movement (at r = 0.54, p < 0.05) and high positive correlation of condylar pathways measured with computerized axiography
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(Cadiax ) and occlusal index in patients and volunteers. J Oral
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Our study also demonstrates a positive high correlation of the masticatory system. II. Index for anamnestic and clinical
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TMJ during the opening movement r = 0.81 (p < 0.05) (Fig 2). 5. Helkimo M: Studies on function and dysfunction of the
The comparison of jaw motion investigations in the literature masticatory system. III. Analyses of anamnestic and clinical
presents diverse results. Nilner21 reported a 5-mm difference in recording of dysfunction with the aid of indices. Swed Dent J
the vertical mandibular opening among 15- to 18-year-old boys 1974;67:165-182
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27-year-old men and women was different by ca. 2 mm. Nielsen
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The results of studies by Ioi et al16 are consistent with 2003;90:503-509
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