Panoramic Radiograph (OPG) - Radiographic Report

Note: The "R" marker (bottom left) indicates the patient's right side. Image is viewed as if facing the patient.

Findings

• Maxillary third molars (#18 and #28) - absent bilaterally (previously extracted or congenitally missing).

• Suspected distal caries on #47 and #37 - radiolucencies present at the distal surfaces of both lower second molars, likely from food packing against the impacted third molars. Requires bitewing radiographs and clinical probing for confirmation.
• Localized vertical bone loss on the distal of both #47 and #37, caused by chronic plaque stagnation in the pocket created by the impacted teeth.

• Small radiopaque restorations visible on occlusal surfaces of several lower posterior teeth (amalgam or composite fillings).

• Alveolar bone height otherwise well-preserved throughout both arches.
• No generalized horizontal bone loss noted.

• No periapical radiolucencies identified.
• Lamina dura appears intact around all erupted teeth.
• No root canal-treated teeth visible.

• Bilaterally clear and normally pneumatized; no mucosal thickening or pathology.

• Both condyles appear symmetrical with smooth cortical margins (partially at image margin - clinical assessment recommended).

Structured Diagnosis

1. Bilateral mandibular third molar impaction (#38 mesioangular/horizontal, #48 mesioangular) - pericoronal involvement likely
2. Distal caries #47 and #37 (suspected - correlate clinically with bitewing X-rays)
3. Localized periodontal bone loss distal to #47 and #38 secondary to impaction
4. Missing maxillary third molars (#18, #28)

Recommendations

• Bitewing radiographs to assess caries depth on distal #47 and #37
• Surgical consultation for extraction of bilateral lower impacted third molars (#38, #48), given associated bone loss and secondary caries
• CBCT scan prior to surgical extraction to map the inferior alveolar nerve canal relationship with the roots
• Periodontal evaluation of the distal of #37 and #47 (pocket depth measurement)

Muscles of Mastication - Clinical Palpation Guide

1. TEMPORALIS

Extra-oral Palpation

• Ask the patient to clench their teeth to contract the muscle and locate it.
• Once located, ask them to relax, then palpate at rest.
• Palpate in three regions bilaterally:
  • Anterior fibers (above zygomatic arch, temporal region) - these are the vertical fibers responsible for elevation
  • Middle fibers (lateral temporal region)
  • Posterior fibers (behind the ear, above and behind the pinna) - these are more horizontal, responsible for retraction
• Use finger pads and sweep across the full length and width of the muscle.
• Ask the patient to report any tension or tenderness during palpation.

Intra-oral Palpation (Temporalis Tendon)

• Performed with the mouth open.
• Place your index finger on the antero-medial surface of the ramus at the level of the retromolar area.
• Slide your finger upward toward the coronoid process - the temporalis tendon is felt attaching here.
• Ask the patient if there is pain or tenderness at this tendon insertion point.

2. MASSETER

Extra-oral Palpation

• Ask the patient to clench firmly.
• Palpate the origin at the inferior border of the zygomatic arch (maxillary zygomatic region).
• Palpate the body by placing the thumb on the buccal surface and fingers on the angle of the mandible and gently pinching the bulk of the muscle.
• Palpate the insertion at the gonial angle of the mandible (angle of jaw externally).

• Ask the patient to open wide.
• Palpate just anterior and inferior to the tragus of the ear, pressing medially - this overlies the deep masseter.

Intra-oral Palpation (Deep Masseter)

• With the mouth open, place the index finger inside the mouth against the lateral surface of the ramus of the mandible, just below the insertion of the deep masseter at the gonial angle.
• Note: The deep masseter insertion on the gonial angle can be accessed intra-orally at the lower posterior corner of the ramus.

3. MEDIAL PTERYGOID

Extra-oral Palpation

• Palpate the medial aspect of the mandibular angle externally (inferior and medial to the angle of jaw).
• Best accessed from below the inferior border of the mandible near the angle.

Intra-oral Palpation (primary method)

• This is best assessed intra-orally - first ask if the patient has a gag reflex.
• With the mouth slightly open, keep your finger inside from the temporalis tendon assessment and press laterally to feel the medial pterygoid at the medial surface of the ramus.
• Alternatively: place finger tip at the medial side of the mandibular angle intra-orally, just below and behind the lower third molar region.
• Ask the patient to close slightly against your finger (muscle contracts) to confirm location, then palpate at rest.
• Tenderness here (especially unilateral) strongly suggests ipsilateral condylar displacement and TMD.

4. LATERAL PTERYGOID

"Extra-oral" Functional Test

• Place your thumb on the patient's chin.
• Ask the patient to protrude the mandible against resistance (resist the protrusion with your thumb).
• Pain provoked during this maneuver = likely lateral pterygoid involvement.
• Alternatively: apply posterior (distal) pressure to the jaw while the patient protrudes slightly.

Intra-oral Palpation (Limited)

• The inferior head may be partially accessed intra-orally.
• With the patient's mouth open, place a finger behind the maxillary tuberosity in the upper vestibule, directing the finger tip superiorly, posteriorly, and medially toward the pterygoid region.
• True palpation of the belly is limited; this more accurately accesses the pterygoid region and may elicit referred pain.

Summary Table

Clinical Pearls

• Record findings bilaterally and note whether pain is spontaneous, on palpation, or referred.
• Medial pterygoid tenderness on one side almost always indicates displacement of the condyle on that same side.
• Masseter and temporalis are the most commonly hypertrophied and tender in bruxism/parafunctional habits.
• Lateral pterygoid spasm is common in acute disc displacement; use the protrusion-resistance test rather than attempting direct palpation.
• Palpation should use approximately 1-2 lbs (0.5-1 kg) of pressure - firm but not forceful.
• Always palpate bilaterally and simultaneously (or in immediate succession) to compare sides.
• Combine with TMJ palpation (lateral pole via preauricular area and posterior attachment via external auditory meatus) for a complete TMD examination.