1. The document discusses manual functional analysis techniques for examining patients with temporomandibular joint (TMJ) pain or limitations. 2. Key examination techniques discussed include active and passive range of motion tests, isometric contraction tests, and analysis of endfeel and limitations of movement to help differentially diagnose muscular, joint or neurological issues. 3. Case examples are presented to demonstrate how findings from manual functional analysis exams can help identify specific conditions, such as non-reducing disc displacement, joint capsule shrinkage, gout of the TMJ.

1. Manual Functional Analysis
Lecture 3

2. your practice
Manual Functional AnalysisAfter
Alter

3. NO Diagnosis TreatmentNO
Diagnosis TreatmentWrong Wrong

4. Pt. 52 year old
Chief compliant: pain in the left side during eats
Active Movements
Deflection to Left Side.
Limitation in Mouth opining
Passive Movements Rebounding endfeel
Isometric Contraction
Pain In the Left Side during
Test in centric position

5. Pt. Female, 51 year old
Chief compliant: pain in the left pre-auricular and mandibular region,
accompanied by swelling, earache, hearing loss(chewing and yawning)
Active Movements
Rubbing sounds,Limitation
mouth opening(22 mlm),
deflection to left
Passive Movements
painful endfeel
24 mlm
Isometric Contraction
Pain In the Left Side during
Test

6. Manual Functional Analysis
1. Initial Examinations
Active Movements
Isometric Contraction
Passive Movements

7. Manual Functional Analysis
✤ Initial Examinations
Passive Movements

8. All the mandibular movements were followed by tests of further
passive movement.
Previously
Passive tests are applied only to the jaw-opening movement.
Now
Passive Movements

9. Passive Movements
Simple excess to active movement limits
to get pain or endfeel.

10. By active movement we arrive in the end to
physiological functional limits
but by passive movement we arrive to
anatomical limits
Passive Movements

11. Based points
Painful response
Endfeel
Passive Movements

12. The feeling that the examiner detects at
the end of passive jaw opening
Endfeel
Passive Movements
Hard ligamentary

13. Endfeel distance
The extent of passive jaw opening (Hesse et al. 1990)
Passive Movements

14. Passive Movements
passive jaw opening

15. Effected Anatomical Structures
1-Superior Ligament
2- Elevator Muscles
3-Capsule Distal Wall
4-Capsule Mesial Wall
5-Lateral Ligament restrict jaw opening
6-Posterior Part of Capsule
7-Sphenomandibular ligament
8-Joint Surfaces
Passive Movements
passive jaw opening

16. Passive Movements
Restricted Movement
Pain

17. Differential Diagnosis of pain
Passive Movements
3-There is pain
2- There is pain (Similar to pain,
which appeared in isometric
contraction)
1- There is no pain
Pain

18. Differential diagnosis by
Isometric Contraction
Differential Diagnosis of pain
Passive Movements
2- There is pain (Similar to
pain, which appeared in
isometric contraction)

19. Painful lesion in joinit structures
Differential Diagnosis of pain
Passive Movements
3-There is pain

20. Joint Structure
✤Joint Surfaces
✤Ligaments
✤Joint Capsule
✤Bilaminar zone
Differential Diagnosis of pain
Muscles Structres
✤muscle belly
✤Attachment point between the
belly and tendon
✤Muscle Tendon
✤Insertion & Origin
Passive Movements

21. Manual Functional Analysis
Passive Movements
Restricted Movement
Pain
Differential Diagnosis
Nervous Lesion
Muscle Lesion
Joint lesion

22. ✓The Ligaments
✓Capsule
✓Intra-Articular Structures
✓Muscles
✓Fascia
✓The Skin
Passive Movements
Restricted Movement

23. Joint Structure
Joint ankylosis
Hyperplasia of the coronoid process
Capsule shrinkage
Ligament shrinkage
Anterior disk displacement
Acute painful lesion
Muscles Structres
Shortening of the muscles
Acute painful lesion
Nervous Structures
Innervation disorders
Passive Movements
Restricted Movement

24. Endfeel
Physiological
endfeel
Structurally
pathological endfeel

25. limitations of movement
Pathological Endfeel
Structurally pathological endfeel
✤Bony
✤Too hard
✤Soft
✤Rebounding
✤Painful soft
✤Sudden
✤Empty
Physiological painful endfeel

26. Painful Response
Endfeel in the end of movement
1- Pain
2- Restricted movement
3-Non restricted movement
limitations of movement & Endfeel
Differential Diagnosis
limitations of movement & Endfeel

27. Soft
(Shortening of the muscle )
Too hard
(Shrinkage of the capsule)
Rebounding
(Nonreducing anterior disk
displacement )
Bony
(Hyperplasia of the coronoid
process, ankylosis )
limitations of movement & Endfeel
Differential Diagnosis
1- Pain
3-Non restricted movement
2- Restricted movement
limitations of movement & Endfeel

28. limitations of movement & Endfeel
Differential Diagnosis
1- Pain
2- Restricted movement
3-Non restricted movement
✤Normal (hard ligamentary )
Ligaments
✤Too hard
shortened Capsule
✤Soft
Muscles limit the movement
when there is lengthening or
overstretching of the capsule
and ligaments.
limitations of movement & Endfeellimitations of movement & Endfeel

29. Restricted Movement
3- Nervous lesion
2- Joint lesion
Endfeel
1- Muscular lesion

30. Restricted Movement
1- Muscular lesion
3- Nervous lesion
2- Joint lesion
Endfeel
✤Too hard
✤Rebounding
✤Bony
Endfeel

31. No development in force
Isometric Contraction
(Restricted active movement)
Restricted Movement
1- Muscular lesion
2- Joint lesion
3- Nervous lesion
Endfeel

32. Too hard
Scleroderma
Structurally pathological endfeel
30-35 mm
Dermatology Referral

33. Too hard endfeel
with restricted jaw opening
Structurally pathological endfeel
The shortened capsule
and ligaments are
limiting jaw opening
joint-play test

34. Too soft
Structurally pathological endfeel
Shortened elevator muscles
Condylar hypermobility
Overstretching of the capsule
and ligaments.

35. Rebounding
Nonreducing anterior disk displacement
Structurally pathological endfeel
MRI

36. Examination sequence when there is a nonpainful limitation of jaw opening
passive jaw opening Scleroderma
Dermatology ReferralEndfeel
Too soft (with limitation):
muscle contracture
Too hard:
capsule shrinkage
Joint Play test

37. Examination sequence when there is a nonpainful limitation of jaw opening
Rebounding:
nonreducing disk
displacement
MRI
Bony: hyperplasia of
the coronoid process,
ankylosis
Orthopantogram, 3DCT
isometric contraction of
the jaw- opening
muscles.
Disturbance of innervation
Neurology referral

38. Pt. Male, 62 year old
Chief compliant: pain in the right side and increase during eats
He feel with pain when he palpate the region anterior the ear.
Active Movements
Mouth opiniong 48mm
Pain during palpation the
lateral wall of the right TMJ
Passive Movements
Hard ligamentary endfeel
with pain in the right side
Isometric Contraction No pain
Lateral ligament

39. Pt. 52 year old
Chief compliant: pain in the left side during eats
Active Movements
Deflection to Left Side.
Limitation in Mouth opining
Passive Movements Rebounding endfeel
Isometric Contraction
Pain In the Left Side during
Test in centric position
Nonreducing anterior
disk displacement in
the left side

40. Pt. Female, 51 year old
Chief compliant: pain in the left pre-auricular and mandibular region
(chewing and yawning), accompanied by swelling, earache, hearing loss.
Active Movements
Rubbing sounds,Limitation
mouth opening(22 mlm),
deflection to left
Passive Movements
painful endfeel
24 mlm
Isometric Contraction
Pain In the Left Side
during Test
Gout of the
Temporomandibular
Joint

41. Three-dimensional
volumetric rendering
of the lesion showing
osteolysis and
peripheral extension
Axial computed
tomographic (CT) scan
showing destruction of
the left condyle and
extension of the mass to
adjacent areas (arrows).
B. Axial CT scan
showing multiple
coalescent foci of
crystal growth (arrows).
J Am Dent Assoc. 2010 Aug;141(8):979-85.

42. A. Panoramic reconstruction showing destruction of the left temporomandibular
joint (arrows). B. Panoramic reconstruction showing perforation of the glenoid
fossa (arrows)

43. A. Photomicrograph of incisional biopsy specimen of a temporomandibular joint lesion
demonstrating multiple gouty tophi surrounded by a dense, chronic, inflammatory cell
infiltrate (hematoxylin-eosin stain, magnification ×10). B. A higher- magnification
photomicrograph exhibiting the eosinophilic, amorphous, somewhat crystalline and
fibrillar urate crystal deposition