INDIAN JOURNAL OF DENTAL ADVANCEMENTS

J o u r n a l h o m e p a g e : w w w. n a c d . i n

REVIEW
Trismus
Vaishali M R1, Roopashri G2, Maria Priscilla David3, Indira A P4

Oral Medicine and Radiology ABSTRACT:

M.R Ambedkar Dental College and Hospital Trismus, a severely restricted mouth opening is a problem
Bangalore commonly encountered by the dental practitioners. It is very
important that dentists are familiar with the differential diagnosis
of limited jaw opening. Treatment of trismus may be easy or
complicated. It is important to remember that multiple potential
Senior lecturer1, 2
causes exist. Trismus is a condition that impairs eating, interferes
Professor and head3 with oral hygiene, restricts access for dental procedures and may
Professor4 adversely affect speech and facial appearance.

Article Info
Received: April 5, 2010
Review Completed: May 10, 2010
Accepted: June 15, 2010
Key words: Trismus, extra articular and intra articular
Available Online: July, 2010
NAD, 2010 - All rights reserved

INTRODUCTION The knowledge about normal range of mouth

opening is very essential in the diagnosis of trismus.
The term trismus denotes a motor distribution
It varies from patient to patient within a range of 40-
of the trigeminal nerve, especially spasm of the
60mm.
masticatory muscle, with difficulty in opening the
mouth.1,2 According to Dorlands illustrated dictionary 2 finger breadth (40mm) and 3 finger breadth
trismus means (Greek trimos; grating, grinding)2,3 (54-57mm) is usual width of opening.
Trismus has a number of potential causes which Trismus has been defined variously as a mouth
could range from simple and non progressive to opening less than 20mm. other authors have used a
those that is potentially life threatening. In a busy classification for trismus such as
practice, it is not unusual to see several patients each
Mouth opening of > 30 mm indicated light trismus
month with a complaint of trismus.2
Mouth opening of 15-30mm indicated moderate
Trismus impairs the ability to incise and masticate
trismus
the food, interferes with the oral hygiene and restricts
access to dental procedures. It may adversely affect Mouth opening of < 15 mm indicated severe trismus
speech and it can also compromise or prevent the Etiology
construction and use of removable or fixed
appliances.1 The etiology of trismus may be classified as Extra
articular and Intraarticular
Email for correspondence:
[email protected]

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Trismus Vaishali M.R., et, al.

Extra articular causes trismus. This interferes with patients normal oral
Infections hygiene and eating habits. Patients should be warned
that they will be unable to open their mouths
The hallmark of masticatory space infection is normally after surgery. The trismus gradually
limited jaw opening.2,8 Infections causing trismus may resolves.13
be of an odontogenic nature. Odontogenic infections
are Pulpal, periodontal and pericoronal and non Post anesthetic infections.
odontogenic causes include tetanus which is a life Limitations of oral opening and occasionally
threatening infection and is rare in the developing paresthesia after local anesthetic injections for dental
world. Trismus and dysphagia are the most common treatment continue to be problems in dentistry.
presenting symptoms.4, 9, 10 Although the incidence of such morbidity is low, it is
Tetanus is an infectious disease that results from accompanied often by distress for both patient and
wound contamination with clostridium tetani, an attending clinician and could lead to litigations.14
anaerobic, gram positive, motile, spore forming rod It is hypothesized that the barbing of the needles
which may survive for years in some environment. at the time of the injection followed by tissue damage
Trismus is the common presenting symptom, but on withdrawal is a likely explanation for some rare
patients often develop dysphagia as well as pain and cases of post injection persistent paresthesia. Post
stiffness of the musculature. Markedly increased tone injection trismus is related to tearing of masticatory
in the central muscle (face, neck, chest, back and muscle by penetration of the needle during injection
abdomen) with superimposed generalized spasm
into the muscle. Most commonly involved muscle is
strongly suggest tetanus.4
medial pterygiod during inferior alveolar nerve block.
Sustained contraction of the facial muscle causes Good injection technique by staying lateral to the
risus sardonicus- the so called sneering grin pterygomandibular raphae during penetration will
expression. With severe trismus there is opisthotonos, avoid the medial pterygiod muscle, since this muscle
caused by generalized spasm and resulting in flexion lies medial to the raphe.15
of the arms, extension of the legs and rigidity of the
Drug therapy
abdominal wall, followed by rigidity of the trunk and
limbs4. Some drugs are capable of causing trismus as a
secondary effect. Phenothiazine, Succinyl choline and
The spatula test is the simple bedside test to
tricyclic antidepressants being more among the most
diagnose tetanus. The posterior pharyngeal wall is
common.
touched with spatula and reflex spasm of the
masseter occurs (positive) instead of the normal gag Trismus can be seen as extra pyramidal side
reflex (negative). effects of metaclopromide, Phenothiazine and other
Trauma medications.

1. Surgical extraction of the mandibular molars Radiotherapy

2. Post anesthetic injections; inferior alveolar nerve Radiotherapy is commonly used to treat
block, posterior superior alveolar nerve block squamous cell carcinoma of head and neck
malignancy and regional lymphomas. The primary
3. Direct trauma advantage of using radiotherapy to treat oral cancer
Fracture of the mandible. is the preservation of normal tissue and function,
however complications may develop, depending
Other facial fractures.
upon which healthy tissue are in the path of radiation
Patients who have had mandibular third molar beam, the amount of radiation given and the course
surgically removed frequently have mild to moderate of treatment.2

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Trismus Vaishali M.R., et, al.

Osteoradionecrosis may occur, resulting in pain, combination of hand, foot, mouth abnormalities and
trismus, suppuration and occasionally a foul smelling trismus.
wound. When the muscles of mastication are within
Miscellaneous causes
the field of radiation, fibrosis may lead to trismus
reducing the range of movements. Fibrosis and Oral submucous fibrosis is a potentially
trismus have been attributed to the ischemia caused malignant condition, commonly seen in people from
by endarteritis obliterans. Trismus complicates post indian subcontinent. Patients presents with trismus
radiation dental care. due to fibrosis of the submucosal tissue in the oral
cavity. This causes blanching of the mucosa and can
Trismus is present at the time of diagnosis in
affect speech by restricting the tongue and soft palate
about 2% of the patients suffering with a head and
movements2.
neck cancer due to tumor growth. For Tumors of
nasopharynx, trismus may be the first sign.6 Hysterical trismus refers to muscular limitation
that is a consequence of psychological trauma17. The
Trauma
presentations are varied and include paralysis,
Fracture of the mandible may cause limited jaw blindness, anesthesia, anorexia and vomiting. The
opening. Backland et al defined as devastating events onset of hysteria is usually before the age of 35 and
e.g. sports injury, administration of general anesthesia occurs mainly in women.2
and performance of dental procedure such as difficult
A muscle in spasm is acutely shortened grossly
extractions requiring lengthy appointments.2
limited in range of motional and painful. Other terms
Trismus has also been reported due to accidental for this disorder include myospasm, acute trismus,
incorporation of foreign bodies because of external charley horse or cramp. If left in a contracted state,
traumatic injury.11 pain decreases, but fibrous scarring and contracture
will begin developing in several weeks as a result of
Another relatively rare cause of trismus is trauma
decreased function. Contracture is also referred to as
to the zygomatic arch and zygomaticomaxillary
chronic trismus or muscle fibrosis.17
complex, which interferes with movements of
coronoid process Differential diagnosis
Temporomandibular joint disorder A systemic approach using a disciplined and
organized process is more likely to yield an accurate
Temporomandibular joint disorder may be
diagnosis. To diagnose trismus, the clinician must be
divided into extra articular and intra articular
able to determine the cause from variety of
problems (including disc displacement, arthritis,
possibilities. A thorough history and clinical
fibrosis.) intracapsular problem are often caused by
examination has to be taken and appropriate
trauma2.
radiograph has to be taken to arrive at a definitive
Congenital/developmental cause diagnosis.
Trismus have been reported as a result of Possible causes are summarized in table-1
hypertrophy of the coronoid process causing
Management of trismus
interference of coronoid against the anterior medial
margin of the zygomatic arch. Coronoid exostosis, The success of treatment depends on the
congenital or acquired coronoid hyperplasia, recognization of the cause and initiation of
coronoid osteochondroma, osteoma also results in appropriate management. To manage the initial
limited mouth opening. 5 Trismus phase of muscle spasm, the practitioner should
pseudocamptodactyly syndrome is a rare prescribe the following

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Trismus Vaishali M.R., et, al.

Heat therapy Dynamic bite opener; this appliance was

described by Drane and later by Brown. This appliance
Analgesics
provides continuous elastic forces to depress the
Soft diet mandible, and the amount and direction of the force
Muscle relaxants. can be controlled.

Heat therapy consists of placing moist hot towel Threaded, tapered screw: this appliance is
on the affected area for 15-20 minutes every hour. constructed of acrylic resin and is placed by the
patient between the posterior teeth. With gradual
Analgesics- aspirin is usually adequate in pain turns of the screw, the mandible is depressed and the
management associated with trismus in managing maxillary and mandibular teeth are forced apart.
trismus associated pain.
Screw type mouth gag: employs a screwtype
Diazepam (2.5-5mg 3 times daily) or component similar to the type incorporated into
benzodiazepam may be prescribed for muscle orthodontic palatal expansion appliance. It provides
relaxation.2 continuous, unilateral and inelastic force.
When the acute pain is over the patients should Fingers: patient should use the finger to depress
be advised to initiate physiotherapy for opening and the mandible, stretch the muscular to the maximum,
closing the jaws and to perform lateral excursions of and then maintain the position for a slow count of
the mandible for 5 minutes every 3-4 hours. Sugarless ten. This exercise is repeated by the patient
chewing gums is another means of providing lateral throughout the day.
movements of the TMJ. When trismus is the
presenting feature and if any infected tooth has to Tongue blades: for years, tongue blades have been
be removed then closed mouth nerve block usually recommended for use as a wedge or as a mouth prop
provides relief. to sustain maximal opening. Tongue blades are
effective only in a dentate patient.
If the trismus is suspected to be associated with
the infection, appropriate antibiotics should be Continuousdynamic jaw extension apparatus:
prescribed. this appliance consist of a contra rotating extending
screw attached to the maxillary and mandibular
In addition, trismus appliances are used in arches by two resilient stainless steel wire arms that
conjunction with physical therapy and are most are connected to acrylic resin splints. The apparatus
effective when the condition is the result of muscle distributes the forces generated by the screw over the
fibrosis or scar tissue that is not yet matured. Trismus entire dental arch covered by the splints. The force
appliance act either externally or internally and the provided is continuous, bilateral and elastic.1
forces they impart and the force they impact can be
continue or intermittent, light or heavy and elastic or II. Internally activated appliances: rely on the
inelastic.1 patients depressor muscle to stretch the elevator
muscles. Since the elevator muscles can generate
Treatment objectives are to remove edema, forces that are ten times greater than those generated
soften and stretch fibrous tissue, increase the range by the depressor muscles, the mechanical advantage
of joint motion, restore circulatory efficiency, increase gained through the use of depressor muscle is limited.
muscular strength.
The amount of force delivered depends on the
Seven appliances have been described in strength and motivation of the patient, as do the
literature. frequency and duration of stretching.

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Trismus Vaishali M.R., et, al.

Examples include mouth opening and inserting more spatulas is

repeated.
Tongue blade: Tongue blade can be employed so
that force delivered is imparted by the depressor The mouth opening occurs in the transverse axis
muscle alone, and thus the tongue blades are not of the head of the mandible the distance between
used as a wedge. A stack of tongue blades held the upper and lower molar teeth will always be
together with adhesive tape can provide a goal or smaller than between the incisors spatulas are around
standard for opening the masticatory muscles. 2mm wide, therefore only 3-7 spatulas are needed for
an opening range of 20-30mm.
Plastic tapered cylinder: this simple, carrot-
shaped appliance has proven effective and it allows Recommended activities of daily living
the patient to easily identify the maximal maxillo- Self regulating activities performed at home,
mandibular distance on initial stretching, by noting during work significantly influence craniofacial
which ring on the taper is reached when both the muscular pain in both the short and long term. Three
maxillary and mandibular teeth come into contact principles of mechanical influence, reflex inhibition
with the tapered cylinder. This appliance relies on the and facilitation of sensomotor cortex apply. They may
patients depressor muscles to depress the mandible. be performed with or without appliance.
Modified spatula technique: Trott described, this With appliance.
method for patients with severe, non irritable but long
standing temporomandibular restriction of mouth Cork and spatula exercise: with a cork cut to the
opening. Clinically this method is also useful for appropriate size, exercise may be performed in end
patients with disc displacement without reduction of range aperture. For example, performing rolling
and for trismus patients16. movements with the cork may have a positive
influence on maximum aperture. Changes of neck
The principle is that the elevator muscles are
position in flexion and extension may also lead to
inhibited by contract-relax technique including
positive results.
passive forces towards mouth opening.
Without appliance
Starting position and method
Thumb depression technique is ideal. This
The patient opens the mouth as far as possible.
exercise can be performed anywhere without
The clinician inserts as many spatulas as can be fitted
appliance and without neck appliances.
between the upper and lower molar teeth. The patient
will experience an increased tension in the Conclusion:
masticatory muscles and the muscle relief becomes Trismus, in many ways is mostly harmless, but it
clearly visible. could give rise to many constraints for the patient,
A contract relax technique is applied. The including social injunctions that can cause anxiety
patient is asked to gradually increase the closing force and danger. Therefore, it is important for the clinicians
for a few seconds. to be aware of this significant condition, its causes
After asking the patient to open the mouth wider, and the treatment for trismus should primarily be
the clinician attempts to insert another spatula directed towards its cause and unless treated
between two others. The patient usually reports an properly, trismus may lead to permanent impairment
increase of muscle tension that will decrease after a of function. Treatment objectives are to remove
few seconds due to decreased activity in the edema, soften and stretch the fibrous tissue, increase
contractive tissue. the range of joint motion, restore circulatory
efficiency increase the muscular strength and retain
Afterwards, passive mobilization, contract relax, muscular dexterity.

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Trismus Vaishali M.R., et, al.

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Table-1: Trismus (Aetiology and differential diagnosis)

Intra-articular Extra-articular
1. Ankylosis 1. Infection a. Odontogenic, Pulpal, Periodontal, Pericoronal
b. Non- Odontogenic
Tonsillitis (peritonsillar abscess)
Tetanus, meningitis
2. Arthritis 2. Trauma Brainabscess, parotidabscess
synovitis
Fracture mandible
Fracture zygomatic arch
Incorporation of foreign bodies
3. Meniscus 3. Dental treatment related Post extraction, Local anesthetic injection
pathology
4. TMD Trauma toTMJ, Myofacialmusclespasm, Internal derangement
5. Tumor Primary and secondary tumors, of epipharyngeal and parotid region
6. Drugs Phenothiazine, Succinylcholine, Tricyclic antidepressants
7. Radiotherapy & Osteoradionecrosis, Postradiation fibrosis
chemotherapy
8. Congenital Hypertrophy of coronid, Trismus pseudo-camptodactyly, syndrome
9. Miscellaneous Hysteria, Lupus erythematosis

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