• In the second type of response, symptoms are brought forth only during application of the stress and are therefore not experienced during the patient’s normal activities. This condition is referred to as a compensated functional disturbance.
• The third possibility is the reproducible provocation of the same symptoms that brought the patient to the clinician and which were reported in the patient history. This indicates the presence of a decompensated or regressively adapted functional disturbance. It is caused either by overloading of a muscle (decompensation), traumatic tissue damage, or, most commonly, by inflammatory tissue destruction (regressive adaptation).
Specific and Nonspecific Loading Vectors
As soon as clinically reproducible symptoms are provoked by manipulation, the examiner knows that a functional disturbance is present that may be either compensated, decompensated, or regressively adapted. In any biological system, functional symptoms are caused by chronic non-physiological loading. Therefore, for the sake of treatment, it is important for the therapist to know the direction of the overloading. A nonphysiological load of a certain amount in a certain direction is called a loading vector. This may be specific or nonspecific.
A specific loading vector is present if symptoms appear only in one main direction during the tissue-specific examination. If, however, symptoms can be provoked in various directions, or even to some extent in opposite directions, then one is dealing with a nonspecific loading vector. In this case the second part of manual functional analysis, the specific clarification of the influences, would be nonproductive and should not be continued because of the ubiquitous manifestations of inflammation.
136 Treatment paths
Diagram of treatment paths based upon the findings arrived at through manual functional analysis. The musculoskeletal parts of the masticatory system are investigated by manipulative testing methods in which tissue-specific stress is applied to the structures being examined. This differentiates between adaptive and nonadaptive conditions. The latter (regressive adaptation, compensation, and decompensation) are then identified by the patient’s response to the mechanical loading. In this way an injured structure can be located by means of tissue-specific stress in either a single (specific) or in multiple (nonspecific) loading directions. Injuries with a nonspecific loading vector call for general, nonspecific muscle relaxation, while those with one specific loading vector require targeted neuromuscular deprogramming followed by occlusal reconstruction.
A patient with a nonspecific loading vector is first given only primary, nonspecific pain treatment by stabilizing the system with the aid of an occlusal splint fabricated at the least painful mandibular position, as determined by the patient. In some cases this is supplemented with analgesic and/or anti-inflammatory medication, and/or physical therapy. During this phase, physiotherapeutic measures can be effective only if there are joint-relaxing vectors present that are not painful. As a rule, this is not the case when nonspecific loading vectors are present. It is hoped that during the primary pain treatment phase the nonspecific loading vector will be converted into a specific loading vector or, better yet, completely eliminated.
With identification of a specific loading vector, “clarification of the influences” (static and dynamic occlusion, parafunction, dysfunction, trauma) is completed. Cause-directed occlusal treatment is possible only if static or dynamic occlusal influences can be demonstrated. This type of treatment almost always begins with an occlusal splint to eliminate the occlusion-related part of the overall loading vector. Depending upon the number of influences present, this measure may allow the previously damaged structures to become completely adapted or be transformed into a compensated status. If success cannot be attained, the patient should be referred to a specialist.
Examination Form for Manual Functional Analysis
In the past, only information that had very limited relevance to treatment could be derived from the tests of active movements then used and the palpation of the muscles of mastication.
An examination procedure that goes back to Cyriax (1947, 1979), Kaltenborn (1974), Maitland (1964, 1967), and Mennell (1970) was First recommended for use in dentistry by Hansson et al. (1980). At the end of the 1980s with the perspective gained through more than 10 years of application, this procedure was modified, systematically expanded, and optimized with a view to increasing its clinical relevance.
The front side of the examination form we use contains, in addititon to the patient’s clerical information and history, an overview of the current tissue-specific primary diagnosis (e.g. regressively adapted or decompensated functional disturbances) and secondary diagnosis (compensated functional disturbances) as well as their loading vectors and the individual harmful influences. This differentiation is important for treatment planning as well as for establishing the treatment goal for the patient. Furthermore it gives an overview of diagnostic procedures and specific musculoskeletal impediments in the direction of treatment.
Form for recording findings of manual functional analysis While the front of the examination form summarizes the diagnostic and therapeutic information, the reverse side is reserved for only the individual findings of the tissue-specific examination.
137 Front side of form
This side provides an overview of the tissue-specific primary and secondary diagnoses, etiological factors (influences), further diagnostic measures, and treatment planning.
The reverse side of the examination form serves to document tissue damage. After a brief intraoral and extraoral inspection, the active movements are recorded here and in some cases these are complemented by passive movements. Next the individual structures of the masticatory system are systematically tested in the following sequence:
• First, dynamic compressions and dynamic translations with compression are applied to test the joint surfaces.
• This is followed by testing of the bilaminar zone by means of passive compressions.
• Translations and traction allow specific loading of the joint capsule and ligaments.
• Functional testing of the muscles of mastication is accomplished through isometric contractions rather than by palpation.
• Joint play techniques and isometric contractions are used to help distinguish between arthrogenic and myogenic problems.
• Finally, dynamic tests are used to differentiate clicking sounds in the joints.
138 Reverse side of form
This side has spaces for all the information necessary for the tissue-specific examination of the extra-oral portions of the masticatory system. Entering the individual findings with a defined color-coding system allows a quick and convenient overview of which structures are adapted and which are not, as well as the corresponding loading vectors.
Patient History
The patient history is the foundation and a prerequisite for the diagnosis and treatment of functional disturbances. Together with the examination findings, it is used primarily in attempting to identify all regions of the masticatory system that have undergone structural damage (Okeson 1998). It serves further to help recognize the necessity for additional therapeutic measures and should protect both the patient and the clinician from failure (Nilges 1996). The history should be taken with the patient sitting upright in a quiet, relaxed atmosphere, ideally away from the treatment room.
As a rule, the general history can be adequately elicited by using a questionnaire. Eye contact and a friendly, interested demeanor on the part of the clinician promotes body language that will enhance nonverbal