Manual Functional Analysis
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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.
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Manual Functional Analysis
- 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
- 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
- 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