Manual Functional Analysis Lecture 1

بسم هللا الرحمن الرحیم (( و فوق كل ذي علٍم علیم ))

1935-1949 Charles Sidney Burwell

Dr. Burwell was a cardiologist who specialized in circulation changes associated with heart disease. He is credited with bringing attention to obstructive sleep apnea syndrome.

In 1944, Dean

"Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which."

ManualFunctionalAnalysis

Muscle Palpation

Tissue-specific diagnosis

Arthrogenous and/or Myogenous disorders Previously

Tissue-Specific Diagnosis

Anatomical structure which is responsible on patiant’s

pains and symptoms

Adaptation Compensation

Mechanisms of Biological System when it exposed to many influences

Adaptation

Mechanisms of Biological System when it exposed to many influences

Biological adaptation the adaptation of living things to environmental

factors for the ultimate purpose of survival, reproduction, and an optimal

level of functioning.

Compensation

Mechanisms of Biological System when it exposed to many influences

1. the counterbalancing of any defect of structure or function.

2. a mental process that may be either conscious or unconscious defense mechanism by which a person attempts to make up for real or imagined physical or psychological deficiencies.

3. in cardiology, the maintenance of an adequate blood flow without distressing symptoms, accomplished by such cardiac and circulatory adjustments as tachycardia, cardiac hypertrophy, and increase of blood volume by sodium and water retention.

Adaptation CompensationInfluences

Stat.occlusion Dyn.Occlusion Bruxism Dysfunction

Individual capacity for adaptation and compensation

Influences Duration Number Intensity Frequency

Dental treatment, including functional prophylactic measures

Physiological structures or progressive adaptation

Compensation

No definitive measures that affect the occlusion without further diagnostic

clarification

Dental treatment that will not upset the fragile equilibrium

Cause-related functional therapy prior to definitive dental treatment

Decompensationor

regressive adaptation

Functional therapy prior to definitive dental treatment

No occlusal functional therapy if thereare no occlusal etiological influences

Symptomatic functional therapy for the transition to a compensated status

1

3

2

The Role of Dentistry in Craniofacial Pain

psychological factors occlusal factorsVs

21

Every patient with head and neck pain should be seen by a dentist in order to clarify the following questions: Do the symptoms arise from a structure in the masticatory system (presence of a loading vector)? Is the loading vector related to the occlusion? Can the occlusion-related portion of the total loading vector be reduced with reasonable effort and expense? Would symptomatic treatment in the dental office be reasonable?

The Role of Dentistry in Craniofacial Pain

✤ Muscles ✤ Joint Capsule ✤ Disk

Craniomandibular System

The suprahyoidal musculature

Chewing muscles (temporal, masseter, medial pterygoid, and lateral pterygoid)

Perioral musculature

Jaw-closing

Muscles of Masticatory

The temporal, masseter, medial

The lateral pterygoid and

Jaw-opening

The muscle comprises a pars anterior (1), pars

media (2), and pars posterior (3).

The Temporal Muscle

Jaw

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The Masseter Muscle

Jaw

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Muc

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The Masseter

Jaw

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Muc

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Medial Pterygoid

Medial Pterygoid

Muscles (1) The Lateral Pterygoids

Jaw

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Muc

sles

Medial view

Medial Pterygoid

Jaw

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Muc

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Suprahyoid

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Posterior view

Suprahyoid Ja

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Lateral Pterygoid Muscle

1 Upper head 2 Lower headEMG activity of the

muscles of mastication at rest

and during jaw

EMG activity during grinding of the teeth

Jaw

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Muc

sles

?

the muscle becomes segmented into three parts in week 12 of embryonic development to form an upper (1), middle (2), and lower (3)

Lateral Pterygoid Muscle

Jaw

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Muc

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the upper head always inserts on the condyle (1), and in 60% of joints it also inserts into the

anteromedial portion of the disk-capsule complex (gray). The lower head always inserts into the Ja

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MRI showing the lateral pterygoid muscles (1) in the horizontal plane.

Lateral Pterygoid Muscle

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Muscle origins and insertions on the posterior mental protuberance

Histological preparation of the insertion of the digastric muscle. The insertion of this muscle is primarily periosteal, but it does have some regions of cartilaginous Ja

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The tendon inserts on the

coronoid process by means of

cartilaginous structural

Histological preparation of the

insertion of the lateral pterygoid

muscle in the pterygoid fovea.

Force Vectors of the

Muscle vectors in the frontal plane

Muscle vectors in the sagittal plane

loading vector of the lateral pterygoid muscleJa

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Muscles of

Mentalis muscle

Orbicularis oris muscle

Influence of head and body posture on the mandible . As an example, the sternocleidomastoid muscle is always active

during bruxism; however, an activity level of 50% is necessary in the masseter muscle before a 5% level is reached in the

articular eminence (1) and at the far left is the external auditory meatus (2). In the posterior portion of the fossa the squamotympanic fissure (3) is found laterally, and the

petrosquamous (4) and petrotympanic (5) fissures are found medially.

These fissures are ossified in more than 95% of patients with disk displacement, whereas in joints without disk displacement normal fissure formation prevails (Bumann et al. 1991).

Squamotympanic fissure is completely ossified

Inferior view of the temporal cartilaginous joint surface and capsule attachment

Positional Relationships of the Bony Structures

The physiological (i.e. centric) condylar position is defined as the most anterosuperior position with no lateral displacement (arrows), this

position depends upon the basic neuromuscular tonus.

Sagittal relationships

By applying artificial traction on the specimen, the anterior portions of the upper and lower joint capsules (arrows) have been made more clearly visible. Posteriorly the joint spaces are bounded

by the superior stratum (1) and inferior stratum (2). The posterior capsule wall lies behind the genu vasculosum. The type-Ill receptors of the capsule are only activated by heavy tensile loads

on the lateral ligament and serve then to stimulate the elevator muscles (Kraus 1994)

Joint capsule in the sagittal plane

21 mm

5.1mmAt

tachm

ent o

f the

caps

ule to

the

cond

yle

39 human temporomandibular joints (Brauckmann 1995)

Overdistended capsuleAnterior disk displacement requires not only a stretching of the inferior stratum (1), but also a distention of the lower anterior wall of the joint capsule (arrows). However, because the connective tissue of the anterior capsule wall is much looser, disk displacement depends almost exclusively on posterior loading

vectors and the adaptability of the inferior stratum. A downward movement of the condyle as shown here without downward movement of the disk is possible only

with extensive stretching of the inferior stratum.

(Solberg et al, 1985, Bermejo et al. 1992) identify two separate connective tissue structures for attachment to the condyle, one for

the disk (1) and the other for the capsule (2).

Disk

and c

apule

attac

hmen

ts in

the

fronta

l plan

e

"diskocapsular system" (Dauber 1987)

Dr.Samer F.Mheissen

Mac

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anat

omica

l pre

para

tion

With the jaws closed the bilaminar zone (1) fills the space posterior to both the pars posterior (2) and the condyle (3). The inferior stratum stabilizes the disk on the condyle in

the sagittal plane. An overextension of the bilaminar zone through posterosuperior displacement of the condyle is an essential precondition for an anterior disk displacement to

occur.

With the mouth open the genu vasculosum (1) fills with blood. The superior stratum (2) and inferior.stratum (3) can be easily identified

Inferior view Cranial view

Anterosuperior aspect of the disk-condyle complex

Anterolateral aspect of the disk-condyle complex

With the jaws closed the bilaminar zone (1) fills the space posterior to both the pars posterior (2) and the condyle (3). The inferior stratum stabilizes the

disk on the condyle in the sagittal plane. An overextension of the bilaminar zone through

posterosuperior displacement of the condyle is an essential precondition for an anterior disk

displacement to occur.

With the mouth open the genu vasculosum (1) fills with blood. The superior stratum (2)

and inferior stratum (3) can be easily.identified

Bila

min

ar Z

one

Three Main Functions: 1. Stabilization 2. Guidance of Movement. 3. Limitation of Movement

Ligaments

What is the most important function ???

Lateral ligament

Lateral ligament

The lateral ligament (arrows). The initial rotation during an opening movement is limited by the superficial part of the lateral ligament (von Hayek 1937, Burch

and Lundeen 1971). Further opening of the jaws can occur only after protrusion has relieved tension on the ligament, following which the ligament

is again stressed by renewed rotation (Osborn 1989).

Situation with jaws closed

Lateral ligament

Situation with jaws open

Jaw opening is restricted by the length of the lateral ligament from its origin to its insertion. However, if the condyle can slip past the apex of the tubercle (eminence), the ligament (arrows) will no longer have this limiting effect. In addition, the lateral ligament

will now impede retrusive and laterotrusive movements of the condyle (Posselt 1958, Brown 1975, Osborn 1989).

Stylomandibular ligament

Situation during rotational jaw opening

Situation with jaws closed

Situation during translation

Sphenomandibular ligament

Situation during opening rotation

Situation at the habitual condylar position

Situation during translation

Initial phase

The condyle makes a rotational movement with a small translational component, changing its position relative to the fossa only slightly. Because of the condylar rotation, the disk moves posteriorly relative to the condyle. The only part of the

lateral pterygoid muscle that is active is its lower head (1).

Jaw

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Intermediate phase

The disk moves anteriorly relative to the fossa, but posteriorly in relation to the condyle. Tension becomes steadily increased in the superior stratum of the

bilaminar zone and in the lower anterior wall of the joint capsule. The inferior stratum relaxes to the same extent. The venous plexus of the genu vasculosum

expands, creating a negative pressure, and fills with blood.

Jaw

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The condyle reaches the maximum extent of its rotation and translation. The translational component passively moves the disk farther forward, while the

rotation makes it lie farther posteriorly on the condyle. The superior stratum and the lower anterior capsule wall are now stretched to their maximum. The

retrocondylar space is filled by the blood flowing into the genu vasculosum. The inferior stratum is completely relaxed.

Terminal phaseJa

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Initial phase

The upper head (1) of the lateral pterygoid muscle retards distal movement of the condyle through eccentric muscle activity. The disk can only be passively guided posteriorly. In the initial phase this is brought about by the tension in the elastic

superior stratum. A physiological positive pressure arises in the genu vasculosum

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Tension in the superior stratum steadily diminishes, and the disk, because of the bulge of its pars posterior, is passively carried farther distally. A nonphysiological

increase of pressure in the genu vasculosum due to sympathetic or hormonal influences would exert an anteriorly directed force on the disk (Ward et al. 1990).

This can lead to increased tension in the inferior stratum and flattening of the disk.

Intermediate phaseJa

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Terminal phase

The inferior stratum becomes increasingly tense and finally prevents anterior disk displacement in case the condyle moves too far distally. Anterior disk

displacement can occur only in the presence of an overstretched inferior stratum, with or without flattening of the pars posterior (Eriksson et al. 1992).

Jaw

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Mov

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