Diagnostic Classification of Temporomandibular Disorders (Part 2 of 3)I

DTAP1007_14_16-17_GuzmanGremillion 30.10.2007 15:15 Uhr Seite 1

14 Trends & Applications DENTAL TRIBUNE Asia Pacific Edition TM Disorders: Diagnostic Classification of Temporomandibular Disorders (Part 2 of 3)i

Ulises A. Guzman & Henry A. Gremillion, U.S.A.

The head, face, masticatory while awake or sleep, are true soreness, autonomic effects tissue, and in this case arising in sytem, and cervical region are considerations in our patient and protective splinting (co- or involving the TM joint. Neo- Editorial Note common sites in which pain evaluation. contraction).8 Although there is plasms can be categorized as is experienced. Many condi- significant evidence that these benign, malignant or metastatic Some of the editorial corrections tions present with similar Myofascial pain is a regional conditions exists, there are few from a distant site. Approxi- intended for Part I of this article signs and characteristic pat- pain, usually dull and achy with reliable clinical characteristics mately 1% of malignant neopla- in Dental Tribune Asia Pacific, terns that may lead to diag- the presence of localized ten- that can be used to distinguish sia metastasize to the jaws.9,10 No. 9 Vol. 5, September 2007 did nostic confusion and ulti- derness in firm bands of mus- them from each other. Squamous cell carcinomas of not make into the final print. mately misdirected care. De- cle, tendons and/or fascia that the head and neck region, Please e-mail r.goodman@dental- fined, validated classification reproduce pain when palpated Myofibrotic contracture re- nasopharyngeal tumors, neo- tribune.com for a corrected PDF systems relating to the multi- and may produce a characteris- fers to the painless shortening plasm arising from the parotid of this article, which will also be plicity of painful entities can tic pattern of regional referred of a muscle. Previous terms gland (adenoid cystic carci- posted to our Web site for those simplify and enhance diag- pain and/or autonomic symp- used include chronic trismus, noma) and mucoepidermoid subscribers who have access. nostic outcomes. Due to the toms on provocation.3,4 Patients muscle fibrosis and muscle carcinomas have been reported The publisher sincerely regrets the errors. rapid advances in our knowl- to extend to the TMJ region edge regarding pain mecha- resulting in pain and alteration nisms and pathways, classifi- of normal function.11,12 Dys- cation systems must be ever “Presently an ideal system function is not usually caused Syndrome is an example of in- evolving, not rigid. Presently by neoplasm.13 complete development.20 Con- an ideal system related to related to masticatory dylar hypoplasia can occur sec- masticatory system disorders Primary tumors known to ondary to trauma, resulting does not exist. have involved the condyle in- from incomplete or underde- system disorders clude osteoma, benign os- velopment of the mandibular One set of diagnostic criteria teoblastoma14, chondroma and condyle. will not satisfy all circum- chondrosarcoma, benign giant stances to which it might be ap- does not exist.” cell tumor, ossifying fibroma, fi- Hyperplasia is the overde- plied. More importantly, many brous dysphasia and myxoma.15 velopment of the cranial bones classifications systems were may complain of muscle stiff- scarring. It is a chronic resist- Malignant neoplasm have been or the mandible. This can be developed for the purpose of ness, acute malocclusion, ear ance to a passive stretch as a re- reported originating from the developmental or acquired. enhancing the formation of symptoms, tinnitus, vertigo, sult of fibrosis of the supporting temporomandibular joint space Hyperplasia can occur as a study populations for clinical toothache, tension-type head- tendons, ligaments or muscle (fibrosarcoma, synovial sar- localized enlargement, such as research endeavors and are not ache and masticatory muscles fibers themselves. The patient coma).16,17,18 in condylar hyperplasia or co- absolutely applicable to every involvement. The most com- usually does not complain of ronoid hyperplasia, or as an clinical case presentation. mon differential diagnoses to pain unless the muscle is ex- Congenital or developmen- overdevelopment of the entire consider includes osteoarthri- tended beyond its functional tal disorders of the cranial mandible or side of the face. For example, the inclusion tis, myositis, myalgia, neoplasia length. There are two basic bones and mandible includes Fibrous dysplasia is a form of criteria for a clinical trial might and fibromyalgia. subcategories: myostatic (re- aplasia (agenesis), hypoplasia, hyperplasia due to a benign, require the presence of all crite- versible condition) and myofi- hyperplasia and neoplasia. Le- slow growing swelling of the ria for a specific disease, while Myositis is inflammation of brotic (irreversible condition). sions and disorders of the jaws mandible and/or maxilla. It is a clinical diagnosis might re- a muscle due to local causes Clinical characteristics include can be either odontogenic or characterized by the presence quire the presence of only a few. such as infection or injury. Pain a limited range of motion, un- non-odontogenic in origin and of fibrous connective tissue. These criteria are meant only is usually acute and in a local- yielding firmness on passive generalized or metastatic in na- to provide clinical guidance for ized area with localized tender- The disease occurs in chil- diagnosis. Final diagnostic de- ness over the entire region of dren and young adults and be- cisions must be based on the the muscle. The inflammation “two basic categories comes inactive when they reach clinical judgment of the health can occur also in the tendinous skeletal maturity. Radiographi- care professional. This article attachment of the muscle, cally the lesion may appear will provide the reader with “tendonitis or tendomyositis”. of TMD exist, extracapsular from an opaque ground-glass to a review of the most accepted Increased pain with mandibu- a lucent appearance, depend- diagnostic classification system lar activity with alteration in (myogenous) and intracapsular ing on the ratio of fibrous tissue related to temporomandibular function due to inflammation to bone. Clinically, usually there disorder (TMD). or pain. Swelling, tissue red- (arthrogenous)” is no displacement of teeth and dening and an increase in tem- the cortical bone and occlusion It is generally recognized perature over the entire muscle remain intact. that two basic categories of can be noticed. The most com- stretch and a history of trauma ture. Most congenital or devel- TMD exist, extracapsular (myo- mon differential diagnoses to or infection is usually reported opmental disorders primarily Disc derangement disorders genous) and intracapsular consider includes myositis, lo- by the patient. The most com- cause problems with esthetics are an abnormal arrangement (arthrogenous). The majority cal myalgia-unclassified and mon differential diagnoses to or function and are rarely accom- of intra-capsular joint parts of TMDs are extracapsular in myofascial pain. consider includes TMJ ankylo- panied by orofacial pain unless causing interference with the nature; however, it is not un- sis and coronoid hypertrophy. associated with Neoplasia (eg, structural relation during common for these two basic Myospasm is an involuntary, osteomyelitis, multiple myeloma, mandibular condyle translation categories to co-exist. sudden, continuous (fascicula- Masticatory muscle neopla- Paget’s disease). Complete age- with mouth opening and clos- tion) tonic contraction of the sia can be benign or malignant nesis is extremely rare.19 ing. In the TM joint this alter- Masticatory muscle-related muscle. Previously used terms and may be associated with pain ation can relate to the elon- conditions are found to be the are trismus, “cramp”. A muscle or not. Neoplasia is defined as Aplasia is a faulty or incom- gation, tear or rupture of the most common subgroup of in spasm is acutely shortened. a new, abnormal or uncon- plete development of the cra- capsule or ligaments causing TMD.1,2 The patient experiences acute trolled growth of muscle tissue nial bones or mandible. Most of a disruption in the disc position pain, a limited range of motion (eg, myxoma). Confirmation the aplasias conditions of the or morphology. The subclassi- The current understanding and often acute malocclusion. must be obtained by biopsy and mandible are categorized un- fication of disc displacement of the complexity and the dy- EMG studies verify sustained imaging. der hemifacial microsomia represents a disc-condyle mis- namic relationship between muscle contraction even at syndromes. The auditory sys- alignment and is subdivided the masticatory and cervical rest.5 The most common dif- Congenital or developmen- tem is frequently affected in into disc displacement with musculature enables the practi- ferential diagnoses to consider tal disorders Most congenital or these syndromes reduction or disc displacement tioner to better assess the condi- includes myositis, local myal- developmental disorders are without reduction.21–23 tion(s) possible etiology(ies). gia-unclassified and neoplasia. not associated with orofacial Hypoplasia is the incom- The individual variations and pain. They can be categorized plete development or underde- Disc displacement with re- demands placed on the system, Local Myalgia-Unclassified as agenesis, hypoplasia, hyper- velopment of cranial bones or duction is characterized by the as well as normal function This category includes muscle plasia and neoplasia. the mandible that is congenital “temporary” alteration or inter- pain secondary to ischemia6, or acquired. The growth is con- i Part 1 appeared in Dental Tribune Asia Pacific, bruxism7, fatigue, metabolic al- Neoplasia, a new, often un- sidered normal but proportion- No. 9 Vol. 5, September 2007. terations, delayed onset muscle controlled growth of abnormal ately reduced. Treacher-Collins DT page 16 DTAP1007_14_16-17_GuzmanGremillion 30.10.2007 15:15 Uhr Seite 2

16 Trends & Applications DENTAL TRIBUNE Asia Pacific Edition

DT page 14 It has been theorized that or that arthritic changes must de- tated by joint movement and soft-tissue imaging reveals disc the momentary misalignment velop25,26, probably demonstrat- deviation during movement displaced without reduction of the disc is due to articular ing a normal physiological coinciding with a click. and hard-tissue imaging re- ference of the disc-condyle surface irregularities, disc-ar- response.27,28,29 veals no extensive osteo- structural relationship during ticular surface adherence, Disc displacement without arthritic changes. mandibular translation result- synovial fluid degradation and Diagnostic criteria include: reduction, or “closed-lock”, is ing in an opening joint sound, disc/condyle incoordination as reproducible joint noise usually described as an altered or mis- Patient may experience pain for example clicking or pop- a result of abnormal muscle at variable position (opening, aligned disc-condyle structural precipitated by forced mouth ping. A reciprocal closing noise activity or disc deformation. closing), soft-tissue imaging relationship that is maintained opening. A history of clicking is usually of less magnitude and Although the concept of natural confirms a displaced disk that during mandibular translation. that ceased with the occurrence is thought to be produced by progression has been sug- improves its position during jaw It is characterized by a lack of locking, ipsilateral hyper- the displacement once again of gested, there is currently no opening and hard tissue imag- of joint noise and limited jaw occlusion (during acute stage) the disc (to its original position) convincing evidence that TMJ ing will demonstrate absence motion (opening <35 mm), and occasionally hard-tissue in usually an anterior or antero- clicking typically progresses of extensive degenerative bone mandibular deflection to the imaging can reveal moderate medial position.24 to locking and degeneration changes. Pain may be precipi- affected side (if not bilateral), osteoarthritic changes. Studies on the progression of the disease have demonstrated very AD few reducing displaced disc cases progressing to a non- www.idem-singapore.com reducing stage, but almost all the non-reducing displaced disc cases developed structural bone changes.30

Joint dislocation, or “open- lock”, is characterized by the condyle and usually the disc position anterior to the articular h 2007 eminence and unable to return Visit us at Dentec to a closed position without Q32, 2nd floor a specific manipulation. Ele- Booth # vator muscles activity and/or a true hyperextension of the disc-condyle complex may be responsible for the patient’s dif- ficulty in returning to a normal position. A temporary dislocation that can be reduced by the patient is referred to as sublux- ation. Patient usually reports a history of excessive range of motion (hypermobility) that is not painful, but pain can occur at the time of dislocation with mild residual pain after the episode. Radiographic evidence reveals the condyle well beyond the eminence. The most common differential diagnosis to consider is fracture.

Inflammatory conditions can occur as localized synovitis, capsulitis or retrodiscal tissues of the temporomandibular joint that can be due to infection, an immunologic condition secondary to articular degenera- Putting new ideas into practices tion or trauma. Clinically it is difficult and may be impossible to differentiate between these. Diagnostic criteria must in- Exhibition: Conference: clude localized TM joint pain exacerbated by function, espe- With new product groups in 2008! Theme: Scientific Basis of Clinical Practice! cially with superior or posterior joint loading on palpation. Now 10,000 sqm exhibition space! Speakers include: No evidence of extensive osteoarthritic changes with hard- • Steven Offenbacher (Periodontology) tissue imaging. Additional clin- • Edward J. Swift (Restorative Dentistry) “Many exhibitors chose IDEM to launch new products ical findings may exist, such as • Stephen Chen /Lisa Heitz-Mayfield localized pain at rest, limited to the Asia Pacific region and the show accurately (Guided Tissue Regeneration) range of motion secondary to reflected the state of the art in dentistry in 2006.” pain, fluctuating swelling (due Infodent International, issue 2/2006 • Daniel Buser/Hans-Peter Weber (Modern Implant Dentistry) to effusion) causing a decrease • Shimon Friedman /Patrick Tseng (Endodontics) in the ability to occlude on ipsi- • Gregory King (Orthodontics) lateral posterior side and ear “As always, the IDEM provides a common ground for pain. • Michael Martin (Infection Control) dealers, manufacturers and dentists to come together and push the dental market forward in Asia.” Additional hands-on courses available! The most common differ- eNewsletter report, US-Pavilion ential diagnoses include: os- Click on “Conference Program” at www.idem-singapore.com! teoarthritis, polyarthritis, ear infection, neoplasia, general- Endorsed By: Supported By: Held In: ized systemic polyarthritic condition, rheumatoid arthritis, juvenile rheumatoid arthritis (Still’s disease), spondyloarthro- pathies (ankylosing spondylitis, In Cooperation With: Organizers: Ms. Sharon Ng psoriatic arthritis, infectious Koelnmesse Pte. Ltd. · 152 Beach Road arthritis, Reiter’s syndrome), #25-05 Gateway East · Singapore 189721 crystal-induced disease (gout, Tel +65 6500 6722 · Fax +65 6296 2771 hyperuricemia), and autoim- mune disease and other mixed [email protected] Singapore Dental Association connective tissue diseases (lupus erythematous, sclero- DTAP1007_14_16-17_GuzmanGremillion 30.10.2007 15:16 Uhr Seite 3

DENTAL TRIBUNE Asia Pacific Edition Trends & Applications 17

derma, Sjögren’s Syndrome). deviation to the affected side on the mandible. Analysis of nine ies. Part II. J Craniomand Disord Polyarthritides are character- opening and is usually not cases and review of the literature. Facial Oral Pain 1991;5:155–166. Contact Info ized by pain during acute and associated with pain.40 Fibrous J Oral Maxillofac Surg 1990;48: 29. Scapino RP. Histopathology as- 246–251. sociated with malposition of the subacute stages, possible crepi- adhesions occur mainly in the 10. Bavitz JB, Chewning LC. Malig- human temporomandibular joint Ulises A. Guzman, tus, limited range of motion sec- superior compartment of the nant disease as temporoman- disc. Oral Surg Oral Med Oral D.D.S., FAGD ondary to pain and/or degener- TM joint, affecting the transla- dibular joint dysfunction: Review Pathol 1983;55:382–397. ation and bilateral radiographic tion movement of the affected of the literature and report of case. 30. de Leeuw R, Boering G, Stegenga Dr. Ulises A. Guzman is a Fel- evidence of structural bony condyle. Adhesions can occur J Am Dent Assoc 1990;120: B, de Bont LG. Clinical signs of low in Craniofacial Pain pro- changes.31 The complexity of secondary to joint inflamma- 163–166. TMJ, Osteoarthrosis and Internal gram in the Parker E. Mahan the disease mandates serology tion resulting from trauma 11. Sharav Y, Feinsod M. Nasopharyn- derangement 30 years after non Facial Pain Center at the Uni- geal tumor initially manifested as surgical treatment. J Orofacial studies and management by or systemic conditions such versity of Florida College of Myofascial pain dysfunction syn- Pain 1994;8:18–24. a rheumatologist. Bilateral re- as polyarthrotic disease. Bony Dentistry. He graduated from drome. Oral Surg Oral Med Oral 31. Altman RD. Criteria for classifi- Marquette University School sorption of condylar structures ankylosis can lead to a complete Pathol 1977;44:54–77. cation of clinical osteoarthritis. of Dentistry. He served as a can result in an anterior open immobilization of the TM joint. 12. Malins TJ, Farrow A. Facial pain J Rheumatol 1991;18(suppl27): Captain in the United States Air bite. Clinically, evidence of bone due to occult parotid adenoid cys- 10–12. Force Dental Corps. He main- proliferation is appreciated ra- tic carcinoma. J Oral Maxillofac 32. Holmlund AB, Gynther G, Rein- tained a private general dental Osteoarthritis is considered diographically. Patient demon- Surg 1991;49:1127–1129. holt FP. Rheumatoid arthritis and 13. Trumpy IG, Lyberg T. Temporo- disc derangement of the temporo- practice in Cooper City, Florida a non-inflammatory arthritic strates deviation to the affected mandibular joint dysfunction and mandibular joint: a comparison for 12 years where his clinical condition that is commonly side and significant limited facial pain caused by neoplasms: study. Oral Surg Oral Med Oral interests included restorative found in synovial joints. Os- movement to the contralateral Report of three cases. Oral Surg Pathol 1993;73:273–277. dentistry, orthodontics, and teoarthritis is classified accord- side. Oral Med Oral Pathol 1993;76: 33. De Bont LGM, Boering G, Liem temporomandibular disorders. ing to the etiology of the condi- 149–152. RSB, et al. Osteoarthritis of the tion. It is divided into a primary Fracture is direct trauma to 14. Svensson D, Isacsson G. Benign temporomandibular joint: A light osteoblastoma associated with You may contact him at: and secondary non-inflam- the mandible and may result microscopic and scanning elec- an aneurysmal bone cyst of the [email protected]. 32 tron microscopic study of the ar- matory arthritic condition. in fracture to the condylar mandibular ramus and condyle. ticular cartilage of the mandibu- The recognition of secondary process. All related components Oral Surg Oral Med Oral Pathol lar condyle. J Oral Maxillofac osteoarthritis is clinically sig- of the masticatory system—soft 1993;76:433–436. Surg 1985;43:481–488. Henry A. Gremillion, nificant because it may repre- tissue, disc, capsule, synovium, 15. Nitzan DW, Marmary Y, Hasson O, 34. Kopp S. Clinical findings in D.D.S., MAGD sent the first stage of treatment. retrodiscal tissue, ligaments, et al. Chondrosarcoma arising temporomandibular joint osteo- Dr. Henry A Gremillion is and/or articular surface—may in the temporomandibular joint: A arthrosis. Scand J Dent Res 1977; Professor in the Department of case report and literature review. Osteoarthritis (primary) is also be affected. Condylar frac- 85:434–443 Orthodontics at the University J Oral Maxillofac Surg 1993; 35. Bland JH, Stulberg SD. Os- a degenerative non-inflammatory tures are usually unilateral and of Florida College of Dentistry. 51:312–315. teoarthritis:Pathologt and clinical He holds an affiliate appoint- condition of the joint character- may occur in the condylar neck 16. White RD, Makar J, Steckler RM. patterns. In: Keeley WM, et al ment in the Department of ized by deterioration and abrasion or in the capsule (intra- or ex- Synovial sarcoma of the temporo- (eds). Textbook of Rheumatology, of the articular tissue and con- tracapsular) with or without mandibular joint. J Oral Maxillo- 2nd ed. Philadelphia:Saunders, Prosthodontics at UFCD. He is comitant remodeling of the under- displacement. Location of the fac Surg 1992;50:1227–1230. 1985. the Director of the Parker E. lying subchondral bone due to fracture and degree of the 17. Mendoca-Caridad JJ, Schwartz 36. Stegenga B, de Bont LGM, Boer- Mahan Facial Pain Center and HC. Synovial chondromatosis of ing G, et al. Tissue responses directs a Fellowship in Cranio- overload on the remodeling mech- fracture will determine the di- the temporomandibular joint: to degenerative changes in the facial Pain program. He has anism.33–36 Osteoarthritis is cate- rection of displacement. A dis- Arthroscopic diagnosis and treat- temporomandibular joint: A re- expertise in the diagnosis and gorized as primary on the absence placement anterior-medial-in- ment of a case. J Oral Maxillofac view. J Oral Maxillofac Surg 1991; management of orofacial pain. of identifiable etiologic factors.37 ferior usually results due to the Surg 1994;56:624–625. 49:1079–1088. He has authored or co-au- action of the lateral pterygoid 18. Quinn PD, Stanton DC, Foote JW. 37. Brandt KD, Slemenda CW. Os- thored numerous scientific Clinical characteristics in- muscle. Clinical characteristics Synovial chondromatosis with teoarthritis: Epidemiology, path- cranial extension. Oral Surg Oral articles, abstracts, and book clude: pain with function, point include: associated trauma, ology and pathogenesis. In: Schu- Med Oral Pathol 1992;73:398–402. macher HR (ed). Primer on the chapters. He lectures inter- tenderness with palpation, limited preauricular pain and swelling 19. Brecht K, Johnson CM. Complete rheumatic diseases, 10th ed. nationally in the field of tem- range of motion with deviation to (synovitis, capsulitis), limited mandibular agenesis. Report of Atlanta: Arthritis Foundation, poromandibular disorders and the affected side on opening and opening, and if the condylar a case. Arch Otolaryngol 1985; 1993:184–188. orofacial pain. crepitus or multiple joint noises. fragment is displaced, occlusal 111:132–134. 38. Rasmussen OC. Clinical findings 20. Behrents RG, Mc Namara JA, during the course of temporo- Radiographically, evidence of changes and deviation to the af- You may contact him at: structural bony changes (sub- fected side. The development of Avery JK. Prenatal mandibulofa- mandibular arthropathy. Scand cial dysostosis (Treacher-Collins Parker E. Mahan Facial chondral sclerosis, osteophytic adhesions and osteoarthrosis J Dent Res 1981;89:283–288. syndrome). Cleft Palate J 1977;14: 39. Block MS, Provenzano J, Neary JP. Pain Center formation, erosion). Pain and dys- are common findings implicated 13–34. Complications of mandibular P.O. Box 100437 39, 40 DT function can vary depending on in condylar fractures. 21. Farrar WB. Differentiation of tem- fractures. Oral Maxillofac Surg University of Florida College the degree of inflammation and poromandibular joint dysfunc- Clin North Am 1990;2:525–550 of Dentistry Gainesville, Literature morphologic changes. Studies tion to simplify treatment. 40. Bell WE. Temporomandibular FL 32610-0437 suggest that the course of the dis- 1. Dworkin, S.F., Huggins, K.H., Le J Prosthet Dent1972;28:629–36. Disorders. Classification, Diag- Resche, L., et al. Epidemiology E-mail: ease usually progresses favorably; 22. Dolwick MF. Diagnosis and etiol- nosis, Management, 3rd ed. of signs and symptoms in temporo- ogy of internal derangements [email protected] allowing remodeling and adapta- Chicago: Year Book, 1990:166– mandibular disorders: clinical of the temporomandibular joint. 176. tion. Treatment must be rendered signs in cases and control. JADA, In Laskin D, Greenfield W, Gale E, on a case specific basis depending 1990, 120:273–81. et al, editors. The President’s AD upon the degree of pain and dys- 2. Schiffman, E., Fricton, J.R., Haley, Conference on the examination, function.38 The most common dif- D., et al. The prevalence and treat- diagnosis and management of ment needs of subjects with tem- ferential diagnoses to consider: temporomandibular joint disor- poromandibular disorders. JADA, ders. Chicago: Am Dent Assoc inflammation, polyarthritis, neo- 1990, 120:295–304. 1983:112–7. plasia. 3. Fricton, J.R., Myofascial pain syn- 23. Hansson TL. Temporomandibu- drome: Characteristics and epi- lar joint anatomical findings rele- Osteoarthritis (secondary) demiology. In: Fricton, J.R, Awad vant to the clinician. In Clark GT, is a degenerative condition of EA (eds). Advances in Pain Re- Solberg WK, editors. Perspectives the joint characterized by dete- search and Therapies, vol 17. in temporomandibular disorders. Myofascial pain and Fibromyalgia. rioration and abrasion of the ar- Chicago:Quintessence Publish- New York: Raven, 1990:107–127. ing Co, 1987:45–57. ticular tissue and the concomi- 4. Fricton, J, Kroening R, Haley D, 24. Isberg-Holm AM, Westesson P. Medesy is the result of tant remodeling of the underly- et al. Myofascial Pain syndrome of Movement of th disc and condyle know-how spread ing subchondral bone due to the head and neck: A review of clin- in temporomandibular joints with over 6 centuries of the a prior event or disease that ical characteristics of 168 patients. clicking: An arthrographic and Maniago smith’s art, overload the remodeling mech- Oral Surg Oral Med Oral Pathol cineradiographic study on au- from the Renaissance to today and the expression anism. Clinical characteristics 1982;60:615–23. topsy specimens. Acta Odontol 5. Layzer RB. Diagnostic implication of a culture of ingenious include: a clearly documented Scand 1982;40:151–164. of clinical fasciculations and 25. Nikerson JW, Boering G. Natural and industrious craftsmen, disease or event associated with cramps. In. Rowland LP (ed). Hu- course of osteoarthrosis as it dedicated to their profession as if it were an art. osteoarthritis, pain with func- man Motor Diseases. New York: relates to internal derangement tion, point tenderness on palpa- Raven, 1982:23–27. of the temporomandibular joint. Make a test! tion, limited range of mandib- 6. Sahlin K, Eldstrom L, Sigholm H, et Oral Maxillofac Surg Clin North www.medesy.it ular motion with deviation to al. Effectsof lactic acid accumula- Am 1989;1:1–19. the affected side on opening tion and ATP decrease on muscle 26. de Bont, LF, Dijkgraaf LC, Stenga tension and relaxation. Am J Phys- and crepitus or multiple joint B. Epidemiology and natural iol 1981;240:C121–C126. progression of articular temporo- sounds. Potential etiological 7. Dao TTT, Lund JP, Lavinge GJ. mandibular disorders. Oral Surg factors include direct trauma to Comparison of pain and quality of Oral Med Oral Pathol Oral Radiol the TM joint (traumatic arthri- life in bruxers and patients with Endod 1997;83(1):72–76. tis), local TMJ infection or his- Myofascial pain of the masticatory 27. Scapino RP. The posterior attach- tory of active systemic arthritis muscles. J Orofacial Pain 1994; ment: Its structure, function and (eg, rheumatoid arthritis). 8:350–356. appearance in TMJ imaging stud- 8. Tveteras K, Kristensen S. The etiol- ies. Part I. J Craniomand Disord ogy and pathogenesis of trismus. Facial Oral Pain 1991;5:83–95. Ankylosis is clinically char- Clin Otolaryngol 1986;11:383–7. 28. Scapino RP. The posterior attach- acterized by the restriction of 9. Aniceto GS, Penin AG, de la Meta ment: Its structure, function and HIGH QUALITY SURGICAL INSTRUMENTS a mandibular movement with Pages R, et al. Tumors metastatic to appearance in TMJ imaging stud-