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3. Embrylogy – TMJ
• TMJ develops between 7th & 12th week of
gestation from two separate
blastemas.(Temporal, Condyle)
• Superior to condylar blastema, a band of
mesenchymal cells defferentiate to form
articular disk.
• Temporal & Condylar blastemas
→Osteoblasts
→Membranous bone
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4. Embrylogy – TMJ…
• In the centre of the condyle, Cartilage
develops → Secondary Cartilage
Endochondral Ossification
Subchondral Bone Formation
Enlargement of the condyle in
adulthood in adaptation to
overloading
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5. Embrylogy – TMJ…
• The developing disk is highly cellular & vascular
• It continues anteriorly with Lat.pterygoid muscle &
posteriorly by a ligament with superior end of Meckel’s
cartilage that develops in to malleus of middle ear. –
Discomalleolar ligament / Pinto’s ligament *
• In post natal life pinto’s lig. Inserts most of its fibers into
squamo tympanic fissure & loses its attachment to the
malleus.
*- Viva Question
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6. Embrylogy – TMJ…
• Pinto’s ligament: / Discomalloelar ligament
• Described by Pinto -1962
• “Fibrous link between the poasteromedial aspect of articular
disk & anterior process of malleus of middle ear seen in
fetal tm joints”
• In adults the ligament is present, but looses its attachment to
malleus
• Loughner et al -1989: dissection 14 cadaveric heads, showed
that only one had anatomic continuity to malleus
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7. Anatomy - TMJ
• “Uniqueness” of the TMJ- Stegenga B, DeBont
LGM et al, JOMS 47:249-256 1989
• Bilateral articulation with the cranium
• Occlusion and articulation of teeth affect joint
movement and condylar positions
• Articular surfaces are fibrocartilage rather
than hyaline cartilage
• TMJ contains an articular disc
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12. Anatomy – TMJ…
CAPSULE:
TMJ is enclosed in a thick
fibrous capsule.
Capsule attachments:
• superiorly: articular
eminence & the
circumference of the
mandibular fossa.
• Inferiorly: neck of the
condyle.
• Laterally - thickened temporo-mandibular
ligament.
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15. Anatomy – TMJ…
•
•
•
•
•
Articular Disk – Functions:
Shock absorber of Joint
Prevents bone- bone contact
Viscoelastic property?
Keratan sulfate,
Glycosaminoglycans - -Chondroitin 4 sulfate,
-GAG
Hyaluronic acid & Link proteins
• GAG are distributed in load bearing areas
• GAG-absorb water-allows disk to absorb stresses by deforming &
leaking water.
• On relief from stress, water content restored & loaded tissue returns
to original shape
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26. Biomechanics of normal TMJ
• The condyle functions in both a hinge and a sliding
fashion. During full opening the condyle not only
rotates on a hinge axis but also translates forward to
a position near the most inferior portion of the
articular eminence.
• During function the biconcave disk remains
interpositioned between the condyle and fossa, with
the condyle remaining against the thin intermediate
zone during all phases of opening and closing.
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27. Biomechanics of normal TMJ
• Normal tmj – Postion
of disk
Posterior band --12 o’
clock
Intermediate zone—
1 o’clock
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28. Biomechanics of normal TMJ
Stretching of bilaminar zone & retrodiskal tissues
→ forward movement of disk
→ condylar translation
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29. But..
• Prolonged overloading of Joint
• Chronic Macro & Micro trauma – joint
• Dental &/ skeletal malocclusions
• Oromandibular dyskinesias… etc
↓
• Overstretching/laxity of retrodiskal tissues
↓ +/• Hyperactivity of Lateral pterygoid muscle
↓
• Malrelationship/ in-co-ordination of condyle-disc movement
↓
•
Internal derangement of TMJ
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30. Internal derangement of TMJ
• Hey & Davies (1814) – ― a localized
mechanical fault interfering with smooth
action of a joint‖
• Laskin (1994) -- ― A disturbance in the
normal antatomic relationship between the
disc & the condyle that interferes with
smooth movement of the joint & causes
momentary catching, clicking,popping or
locking ‖
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31. Internal derangements of TMJ…
Staging of internal derangement – Wilkes system:
Stage-I: Early reducing disk displacement
Stage-II: Late reducing disk displacement
Stage-III: Non reducing disk displacementAcute/subacute
Stage-IV: Chronic Non reducing disk
displacementStage-V: Stage-IV + Osteoarthrosis
**Wilkes CH,
Arch Otolaryngol Head Neck Surg 115:469-457 1989
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32. Internal derangement of TMJ…
• Clinical features & physical examination:
• Opening & reciprocal click(Stage-I or II)
• Joint Pain & tenderness to palpation, on
function
• Deviation to affected side until clicking
occurs
• Limitation of mouth opening /Deviation of
opening with lack of palpable translation
( stage-III – V)
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33. Internal derangement of TMJ…
• Clinical features & physical
examination:contd.
• Crepitus – Chronic disk displacement with
perforation, degenerative changes (StageV)
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35. Internal derangement of TMJ…
Disk displacement with reduction – (Wilkes stage-I/II)
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36. Internal derangement of TMJ…
Disk displacement with reduction – (Wilkes stage-I/II)
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37. Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings
• Stage- I
• Clincal:-no mechanical symptoms,
Reciprocal click +, no pain or limitation of ROM
• Imaging:normal tomograms, good disc contours
• Surgical: normal anatomic form, slight anterior
displacement, passive clicking
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38. Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings
Stage-II
• Clinical: Few episodes of pain
•
•
Imaging: Normal tomogram, slight forward
displacement & slight thickening of posterior
edge of disc
Surgical: Anterior displacement, early anatomic deformity
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39. Internal derangement of TMJ…
No Clicking
Disk displacement without reduction – (Wilkes stage-III/IV)
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40. Internal derangement of TMJ…
Disk displacement without reduction – (Wilkes stage-III/IV/V)
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41. • ―A clicking joint doesn’t lock & a locking
joint doesn’t click‖ - Farrar et al
Current advances in Oral Surgery Vol.III- William Irby
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42. Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings
• Stage-III:
• Clinical: Multiple episodes of pain, joint
tenderness, catching and locking, restriction of
motion, pain with function
• Imaging: Anterior displacement with moderate
to marked thickening of the posterior edge,
normal tomogram
• Surgical: Marked anatomic deformity,
displacement, adhesions, no hard tissue changes
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44. Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings
• Stage-IV:
• Clincal: Chronicity with variable and episodic pain
• Imaging:abnormal tomograms, early to moderate
degenerative changes
• Surgical: Hard tissue degenerative remodeling
changing of both bearing surfaces with
osteophytes, no perforation
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45. Staging Criteria for Internal Derangements of
the TMJ with Respect to Clinical, Radiologic
and Surgical Findings
• Stage-V:
• Clinical: Crepitus, variable and episodic pain,
restriction of motion, functional impairment
•
Imaging: Anterior displacement with
perforation, degerative arthritic changes
•
Surgical: Gross degenerative changes of hard
and soft tissue, perforation of posterior attachments,
osteophytes
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46. Pathophysiology Of Disk
displacements
• Disk displacements– Adaptive response
Pseudo disk Formation,
Remodelling of condyle..
• Chronic disk displacements
→DEGENERATIVE JOINT DISORDER
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47. Pathophysiology Of degenerative
joint disorders
• Mechanisms of Injury:
• 1.DIRECT MECHANICAL TRAUMA:
• Trauma (mechanical overloading) → generation of free
radicals →intracellular damage & reduction in the reparative
capacity
• 2.HYPOXIA - REPERFUSION INJURY
• Increased intracapsular hydrostatic pressure (clenching &
bruxing) ----- → hypoxia.
• When the pressure in the joint is decreased and perfusion is
reestablished, free radicals are formed leading to intracellular
damage.
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48. Pathophysiology Of degenerative
joint disorders
• 3.NEUROGENIC INFLAMMATION
• In cases of disk displacement the compression or
stretching of the nerve - rich retrodiscal tissue may
result in release of pro-inflammatory neuropeptides.
• The release of cytokines results in release and
activation of prostaglandins, leukotrienes, and
matrix-degrading enzymes.
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54. Evaluation of the patient with disc
displacement & investigations
•
•
•
•
•
•
•
•
•
•
•
1. Case history
2. Physical examination
3. Radiographic evaluation
a. Transcranial views
b. OPG
c. Tomograms
d. Arthrography
e. CT scans
f. MRI
g. Nuclear imaging
4. Psychologic evaluation
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55. Treatment – Internal
derangement
Treatment for all pts with disc displacement ???
Disc displacement ---35 % asymptomatic volunteers.
• 1. Katzberg RW, Westesson PL et al “ Anatomic disorders of
the temporomandibular joint disc in asymptomatic subjects.”
J Oral Maxillofac Surg 1996; 54:147-53.
• 2. Ribeiro RF, Tallents RH et al “ The prevalence of disc
displacement in symptomatic and asymptomatic volunteers
aged 6 to 25 years. ” J Orofac Pain 1997; 11:37-47.
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56. • Self remission of internal derangements??
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57. Treatment – disk displacement
disorders
• Sato S, Takahashi K, et al “The natural course of nonreducing
disc displacement of the TMJ : changes in condylar mobility
and radiographic alterations at one-year follow-up.”
Int J Oral Maxillofac Surg 1998; 27:173-7.
• 44 subjects who agreed to observation without treatment
• Successful resolution - 68% @ 18 months
• Mouth opening increased from 29.7 mm to 38 mm
• Conclusion: Self reduction of displaced disc-unlikely
• Stretching & remodelling of the retrodiscal tissues, enabling the
disc to be displaced more anteriorly by the translating condyle.
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58. Treatment – Disk displacement
disorders
•
•
•
•
•
Conservative Treatment:
AIMS:
Reducing pain and discomfort
Decreasing inflammation in muscles and joints
Improving jaw function
•
•
•
•
•
METHODS OF CONSERVATIVE TREATMENT:
1. Patient education
2. Medication
3. Physical therapy
4. Splints
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59. Treatment – Disk displacement
disorders
1. PATIENT EDUCATION
• Awareness about the pathology
• Discontinuation of parafunctional habits
• Biofeedback devices
• Psychologic counseling
• Modification of diet and home exercises
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61. Treatment – Disk displacement
disorders
• “Treatment of severe TMJ clicking with botulinum
toxin in the lateral pterygoid muscle in two cases of
anterior disc displacement .”
Merette Bakke, Eigild Moller et al
OOOE 2005;100:693-700
• EMG guided injection BTX-A & after 6
months.
• Assessment: clinical ex.,EMG, MRI
• Results:Permanent elimination of clicking
Small improvement in condyle - disc
relationship
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62. Treatment – Disk displacement
disorders
•
•
•
•
•
•
3.PHYSICAL THERAPY
1. Isometric jaw exercises
2. Ultrasound ( 0.7 to 1.0 watts per cm 2)
3. Spray and stretch
4. Pressure massage
5. Transcutaneous Electrical Nerve
Stimulation
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63. 4.Splint therapy – TMJ disk
displacement disorders
• RATIONALE FOR THE USE OF SPLINT
THERAPY
• “Unloading the joint” / ↑Joint space
• Reduce inflammation, increases free jaw
movement
• Decreases muscular activity
• Provides stable dental occlusion
• Possible effect in bruxism
• Placebo effect
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66. • “Orthodontic treatment of TMJ disc
displacement with pain: an 18 year
follow-up”
Ugo Capurso, Ida Marini
Progress in orthodontics 2007; 8(2):240-250
68 pts with wilkes II,III– splints– orthodontic Rx
Tmj pain & Function – 1,5,10,18 yrs post Rx
Significant % of pts.-- improvement of symptoms
(73 %)
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67. • “Temporomandibular joint dysfunction and
orthognathic surgery: a retrospective study”
Jean-Pascal Dujoncquoy, Joël Ferri et al
Head & Face Medicine 2010, 6:27
• High prevalence of TMJ disorders in dysgnathic patients.
• Patients with preoperative TMJ signs and symptoms can
improve TMJ dysfunction and pain levels be reduced by 80 %
• A percentage of dysgnathic patients who were preoperatively
asymptomatic developed TMJ disorders after surgery ---3.6 %
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74. ARTHROSCOPY
• Placement of cannula into superior joint
space
• Arthroscope with light source is inserted
• Video camera and monitor are connected
• Instrumentation forceps, scissors,
sutures, medication needles, cautery
probes, burs, shavers, and laser fibers
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78. Fridrich KL et al . “Prospective comparison of arthroscopy and
arthrocentesis for temporomandibular joint disorders.”
J Oral Maxillofac Surg 1996; 54:816-20.
•
•
•
•
•
•
•
19 patients
GroupI: Arthroscopic lysis and lavage under general
anesthesia,
GroupII: Aarthrocentesis, hydraulic distention and
lavage under intravenous sedation.
Subjective & Objective assesment of TMJ --- 26
months
Success rates : 82% - arthroscopy
75%Arthrocentesis.
Conclusion: Both modalities - decreasing TMJ pain
Increasing mandibular range of motion
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79. Murakami K, et al. “Short-term treatment outcome study for
the management of temporomandibular joint closed lock. A
comparison of arthrocentesis to nonsurgical therapy and
arthroscopic lysis and lavage.”
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;
80:253-7.
• 108 patients- Results of arthrocentesis, arthroscopic
surgery were comparable.
• Conclusion: Arthrocentesis was indicated for the
patient with acute TMJ closed lock who was
refractory to medication and mandibular
manipulation.
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82. 3. Arthrotomy + Disc Repair:
PLICATION:
• Chronic non reducing disc displacements
• A wedge of retrodiscal tissue is removed
• Disc is repositioned a posterior & lateral
plane
• The remaining retrodiscal tissue sutured
directly to posterior ligament
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83. 3. Arthrotomy + Disc Repair:
• DISK PLICATION:
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84. 4.Arthrotomy+ Disk repositioning
• Condylar Diskopexy:
• In Wilke’s stage –III,IV disk displacements
• Displaced disk freed in both joint spacesadhesions released
• Small hole drilled in Lat.pole of condyle
• A 2.0/3.0 non resorbable suture passed
through the hole & disk @ junction of ant.
& intermediate bands
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86. Arthrotomy+ Disk repositioning
• Temporal diskopexy:
• In Wilke’s stage IV cases with too
deformed disks
• Bur holes drilled in postero-lateral lip of
glenoid fossa
• Disk secured to roof of fossa
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87. Diskopexy- bone anchors
―Temporomandibular joint disc
repositioning using
bone anchors: an immediate
post surgical evaluation by
MRI‖
ShanYong Zhang, XiuMing Liu
et al
BMC Musculoskeletal
Disorders 2010, 11:262
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88. 5.Arthrotomy+diskectomy
• Wilkes stage IV & V , disks with
perforations & severe degenerative
changes
• Cases with relapse of symptoms after disk
repair surgeries
• Fibrocartilagenous disk removed totally
• Condylar / fossa irregularities smoothened
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89. 6.Arthrotomy+diskectomy+autogenous
graft
• ―There is little evidence to suggest that
autogenous graft disk raplacement is
superior to no replacement at all‖
• But hypothesized rationale favouring
grafting:
a)graft provides scaffold for ingrowth of
tissue from synovium
b)May prevent degeneration that follows
diskectomy.
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92. 7.Condylotomy
• Popularized by Ward1952
• Creation of a
displaced condylar
neck #
• Condyle repositons
antero-inferiorly
• Unloads the posterior
attachment of disc
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93. Hall’s Modified Condylotomy
• Vertical subcondylar
osteotomy
• Open osteotomy
procedure
• More controlled
approach to condylar
repositioning
• Less risk of total
dislocation of
condylar head
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94. Recent advances – Rx of Internal
Recent articles on Mgmt of TMJ
Internal derangementRRecent
derangement
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95. • “Pterygoid Plate Disjunction: Minimally Invasive
Treatment for Internal Derangement of the
Temporomandibular Joint”
Varghese Mani, Antony George et al
Asian J Oral Maxillofac Surg. 2005;17:247-255
• Patients - internal derangement of TMJ, with pain and/or trismus
and/or joint noise, underwent pterygoid plate disjunction on the
affected side.
• Subjective & Objective Assesment Pre & 18 months post-op
• Results: Pain symptoms resolved in 26 of 29 joints and diminished in the
remaining 3 joints. Trismus resolved in 22 of 24 patients and diminished in the
remaining 2 patients. Joint noise disappeared in 23 of 30 joints
• Conclusion: : Pterygomaxillary disjunction appears to be an
effective treatment for painful internal derangement of the
temporomandibular joint that is worthy of further investigation
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96. “Pterygoid disjunction for internal derangement of
Temporomandibular joint”
Rohit Sharma.
J.Maxillofac.Oral surg.Apr-Jun2011;10(2):142-147
• As a 1* Rx modality in Wilkes I & II in 33 pts.
• Pts evaluated –Helkimo anamnestic, &
clinical dysfuntion indices, pre & post
opearively
• All the patients had improvement in Pre
operative pain & dysfunction
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97. Randomized Effectiveness Study of Four Therapeutic
Strategies for TMJ Closed Lock
E.L. Schiffman, J.O. Look et al
J Dent Res. 2007 January ; 86(1): 58–63.
Comaprison of medical, rehabilitative, arthroscopy, arthroplaty.
Assessment of TMJ pain & funtion @ 3,6,12,18,24,60 months
• Within-group improvement for all groups
• Conlusion: Primary treatment for individuals
with TMJ closed lock should consist of medical
management or rehabilitation.
• This approach will avoid unnecessary surgical
procedures.
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98. Chronic Recurrent dislocation of
Condyle
• Recurrent dislocation of
condyle out of the fossa
& anterior to eminece.
• Predisposing factors:
• Laxity of the ligaments
• Degenerative joint
disease
• Morphologic condition
of condyle & eminence
• Non synchronised
muscle function
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99. Chronic Recurrent dislocation of
Condyle- TREATMENT
•
•
•
•
•
•
Miller & Murphy (1976)*:
1.Capsular tightening procedures
2.Creation of a mechanical obstacle
3.Direct restraint of condyle
4. Creation of new muscle balance
5.Removal of mechanical obstacle
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*-Viva Q / Short Q/ Essay Q
100. Chronic Recurrent dislocation of
Condyle- TREATMENT contd…
• 1.Capsular tightening procedures:
• Chemical sclerosants: Sod.teradecyl
sulfate,etc
• Capsulorrhaphy:
• Placement of horizontal mattress sutures
• Placement of vertical incision, overlapping
edges & suturing
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107. Recent articles – TMJ
dislocation
―Evaluation of the mechanism and principles of
management of temporomandibular
jointdislocation. Systematic review of literature and
a proposed new classification of
temporomandibular joint dislocation‖
--- Babatunde O Akinbami
-Head & Face Medicine 2011, 7:10
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108. Key to success ---PG Exams
•
•
•
•
•
•
A
B
C
D
E
F
-
Articles / Authors
Books
Charts/flowcharts/algorithms..
Diagrams
Estimate time
Format Your answers
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109. Suggested Reading:
•
•
•
•
Peter.D.Quinn: Atlas of TMJ surgery
Irby:Volume -3 TMJ Disorders
Norman & Bramley- TMJ Disorders
Fonseca, Vol-4 of seven volume series: TMJ
disorders
• OMS clin. North america. –Modern surgical
management of the TMJ –Vol.18,No.3,aug.2006
• Okeson: Orofacial Pain
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