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Ankylosis of temperomandibular joint Presentation Transcript

  • 1. ANKYLOSIS OF TEMPEROMANDIBULAR JOINT INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. ANKYLOSIS: • Inability to open the mouth beyond 5mm of inter-incisal opening due to fusion of head of the condyle of the mandible with the articulating surface of the glenoid fossa is termed as “ Ankylosis of the TMJ”. • Inability to open the mouth on account of muscular spasm or trismus is called as ‘ false ankylosis ’ as the cause here is extra -articular. www.indiandentalacademy.com
  • 3. Ankylosis, or Anchylosis ( from Greek αγκυλος, bent, crooked ) Ankylosis is a stiffness of a joint, as a result of injury or disease and results in hypomobiliy or no mobility. 1.When the structures outside the joint are involved, it is termed "false ankylosis”. 1.in contrast when the disease involves the TMJ itself, it is called "true ankylosis”. 1.When inflammation causes the joint-ends of the bones to be fused together the ankylosis is termed “ osseous” or complete. www.indiandentalacademy.com
  • 4. CLASSIFICATION OF ANKYLOSIS: 1. False ankylosis or true ankylosis. 2. Extra - articular or intra - articular. 3. Fibrous or bony. 4. Unilateral or bilateral. 5. Partial or complete. www.indiandentalacademy.com
  • 5. ETIOPATHOLOGY OF THE ANKYLOSIS OF TMJ FALSE ANKYLOSIS False ankylosis results from pathological condition outside the joint and leads to limited mandibular mobility. CAUSES OF FALSE ANKYLOSIS 1. MUSCULAR TRISMUS • It can be established because of pericoronitis, infection adjoining the muscles of mastication involving submasseteric pterygomandibular, www.indiandentalacademy.com infra - temporal or submandibular spaces.
  • 6. 2. MUSCULAR FIBROSIS • Muscular fibrosis from any dysfunction of long standing like a arthritis and myositis etc. hampers the jaw movements. 3. MYOSITIS OSSIFICANS • When there is progressive ossification after injury and hematoma formation especially of the masseter muscle, inability to open the mouth develops. This can be confirmed radiologically as well. www.indiandentalacademy.com
  • 7. 4. TETANY • When there is hypocalcaemia, the spasms in the muscles are produced hampering the opening of the mouth. 5. TETANUS • Acute infectious disease caused by Clostridium tetani is represented by an early symptom of lock-jaw because of persistent tonic spasm of the muscles. www.indiandentalacademy.com
  • 8. 6. NEUROGENIC CAUSES • Neurogenic causes like epilepsy, brain tumour, bulbar paralysis and embolic hemorrhage in medulla oblongata are also represented by hypomobility of the jaw. 7. TRISMUS HYSTERICUS • It is disease of psychogenic origin. A typical example is frightening of the lady of the house causing spasm of the masticatory muscles when a thief breaks into the house through the window. 8. DRUG INDUCED SPASMS • Drug induced spasms like in strychnine poisoning. www.indiandentalacademy.com
  • 9. 9. MECHANICAL BLOCKADE • Mechanical blockade on account of osteoma or elongation of the coronoid process of the mandible there by reducing it's movement under the zygomatic arch. 10. FRACTURE OF THE ZYGOMATIC ARCH • Fracture of the zygomatic arch with inward buckling will cause mechanical obstruction to coronoid process and hence restricting the movements of the mandible. 11: FRACTURE OF THE MANDIBLE • Trauma causing fracture of the mandible leads to reflex spasm of the muscles and hence trismus. www.indiandentalacademy.com
  • 10. 12. SCARS AND BURNS OF THE FACE • Scars and burns of the face also, restrict the movements of the jaw. Post irradiation fibrosis lead to hypomobility of the mandible. 13. CLEFT PALATE OPERATIONS • can produce fibrosis of the pterygomandibular raphe and, consequently, limitation of mouth opening. Moderate degrees of fibrosis can be released or a coronoidectomy performed if the temporalis muscle is involved. 14. SUBMUCOUS FIBROSIS • Submucous fibrosis results in tense fibrous bands in the cheeks and pillars of the fauces which stretch from mandible to maxilla limiting movement of the mandible, www.indiandentalacademy.com tongue and soft palate..
  • 11. TRUE ANKYLOSIS • True ankylosis, is a condition that produces - fibrous adhesions or - bony union between the articulating surfaces of TM joint and may be classified as: - Fibrous, - Fibro - osseous and - Bony ankylosis. • Further, it may be unilateral or bilateral and partial or complete. www.indiandentalacademy.com
  • 12. Etiopathology www.indiandentalacademy.com
  • 13. 1. Birth Trauma • Birth trauma producing so-called congenital ankylosis and occurs in cases of difficult delivery, particularly forceps delivery. • At times, other bones are fractured as well. • The injury of the jaw caused by the use of forceps may not be discovered until later when it is noticed that the child could open his jaw only slightly. www.indiandentalacademy.com
  • 14. 2. Haemarthrosis • Haemarthrosis is another cause of ankylosis. It is generally, due to: - fracture of the base of skull extending through the mandibular fossa - may also be caused by an intracapsular injury. www.indiandentalacademy.com
  • 15. • Cortical bone in a child is very thin - as a result of intracapsular # of TMJ, bleeding takes place within the joint – known as hemarthrosis  there is fragmentation of the condyle  this has highly osteogenic potential  the hematoma within the joint organises slowly  which is then converted to fibrous tissue and then  bone  resulting in bony ankylosis www.indiandentalacademy.com
  • 16. 3. Suppurative arthritis • Suppurative arthritis, may be due to infection of the ear or mastoiditis or it may be of hematogenous origin  leading to ankylosis www.indiandentalacademy.com
  • 17. 4. Rheumatoid arthritis • Rheumatoid arthritis, may cause great limitation of motion or complete ankylosis • There is associated atrophy of the muscles generally accompaning ankylosis, if contracted early in life. www.indiandentalacademy.com
  • 18. 5. Osteomyelitis Osteomyelitis affecting the mandibular condyle without involving the joint itself frequently results in limitation of motion + muscular trismus + peri-articular swelling, and suppuration often results in fistula formation. www.indiandentalacademy.com
  • 19. 6. Fracture of the condyle Fracture of the condyle, especially comminuted fractures of the head of the condyle, may cause ankylosis. The cause may be intra-articular or periarticular hemorrhage or comminution of the condyle. Trauma to the condyle in children is more likely to cause ankylosis than adults. www.indiandentalacademy.com
  • 20. • This is because condylar structure of children is different than adults. In a child the neck of the condyle is short & stubby but in adults its longer & narrower. • Due to this trauma - in an adult is likely to # the condylar neck but in a child it is likely to cause intra-capsular # www.indiandentalacademy.com
  • 21. CLINICAL FEATURES www.indiandentalacademy.com
  • 22. • CLINICAL FEATURES: • • • • Clinical manifestations vary according to: (a) Severity of ankylosis, (b) Time of onset of ankylosis, (c) Duration. • 1. Early joint involvement - less than 15 years: Severe facial deformity and loss of function. • 2. Later joint involvement after the age of 15 years: Facial deformity marginal or nil. But, functional loss severe. • Those patients in whom the ankylosis develops after full growth completion have no facial deformity. www.indiandentalacademy.com
  • 23. The CLINICAL MANIFESTATIONS of ankylosis vary. • Pain is not an outstanding symptom, it is present only in the early stages of the disease. On inspection see: • Healed chin laceration in case of trauma as injury to the chin is usually associated with # of the condyle or hemarthrosis • Reduced interincisal mouth opening or NO mouth opening at all + neglected oral hygiene + impacted / malposed /carious teeth. • Inability to open the jaw and difficulty or inability to masticate food. www.indiandentalacademy.com
  • 24. • In cases in which the disease was contracted early in life, a so-called ‘bird face’ results. • This includes - a receding chin, - malocclusion,and - impaction of teeth. The maxilla may be narrow and protrude because of the use of dilators and exercisers to counteract the freezing of the joint. www.indiandentalacademy.com
  • 25. • There is underdevelopment of the mandible and is associated with a prominent angle of the jaw and curve of the inferior border called ‘ante - gonial notching’. • This ante-gonial notching or curve denotes an attempt at bending the bone by the powerful depressor muscles attached to the symphysis, which come into function when great force is needed to open the jaw www.indiandentalacademy.com
  • 26. In BILATERAL ANKYLOSIS you will observe the following: 1. Bird face deformity + micro gnathic mandible 2. Inability to open mouth + inability to masticate 3. Class II malocclusion 4. Deep ante - gonial notching 5. Poor oral hygiene 6. Severe malocclusion with crowding + protrusive upper anterior teeth + anterior open bite www.indiandentalacademy.com
  • 27. So in UNILATERAL ANKYLOSIS you will find : 1. Facial asymmetry with affected side appearing normal & the opposite side appearing flat. 2. Chin is deviated to the ankylosed side. 3. This is because the normal side continues to grow & pushes the mandible to the affected side giving appearance of fullness on the ankylosed side. 4. Ante-gonial notch on the affected side 5. Minimal condylar movements on palpation. 6. Class II malocclusion on affected side and cross bite may be seen www.indiandentalacademy.com
  • 28. PROBLEMS ASSOCIATED WITH ANKYLOSIS 1. Interferes with the mastication of food and with nutrition 2. Prevents oral hygiene and prophylactic care, and treatment of dental caries, 3. As a result, patients with this ailment generally suffer from extensive multiple caries and periapical infections www.indiandentalacademy.com
  • 29. If the disease is contracted early in life, 4. There is destruction of the growth center [situated in the condyle] and with absence of functional stimulation prevents normal development of the jaw  5. This, in turn prevents normal eruption of the teeth and causes micrognathia - a disfigurement which handicaps the patient in many ways. www.indiandentalacademy.com
  • 30. Diagnosis www.indiandentalacademy.com
  • 31. Diagnosis is based on: 1. History of infection or trauma (birth trauma + falls + previous infection of the ear) 2. Findings at clinical examination (reduced interincisal opening + diminished/no TMJ movements + scar on the chin due to trauma) 3. Radiological findings www.indiandentalacademy.com
  • 32. Radiographic Examination www.indiandentalacademy.com
  • 33. For proper evaluation several radiographic views are useful • Orthopantomograph: OPG will show both the joints for comparision – important in unilateral cases –will also reveal ante-gonial notching. • PA view will show the mediolateral extent of the bony mass – also reveal any mandibular asymmetry. • Lateral oblique – will demonstrate the anteroposterior extent of the bony mass and the elongation of the coronoid process www.indiandentalacademy.com
  • 34. • CT Scan/3D CT Scan – gives relationship to the middle cranial fossa and internal carotid artery (carotid canal) medially to the ankylotic mass – usually not seen in conventional radiographs. 3D CT SCAN showing Bony Ankylosis Coronal CT Scan showing Bilateral TM Joint Ankylosis www.indiandentalacademy.com
  • 35. CONE BEAM 3D CT SCAN –The cone beam CT provides multiple images with unprecedented imaging of the maxillofacial area with less radiation than traditional CT beam www.indiandentalacademy.com
  • 36. • Radiographic changes are of extreme value in diagnosis In fibrous ankylosis  1.there is evidence of destructive + proliferative changes seen in bony compartments of TMJ + 2.haziness or narrowing of joint space In bony ankylosis  1.overall obliteration of joint space. 2.It will also show antegonial notching anterior to the angle of mandible and 3.elongation of coronoid process. www.indiandentalacademy.com
  • 37. What happens if Ankylosis is left untreated ? 1. Normal growth & development of face is affected 2. There is Nutritional impairment 3. Speech impairment 4. Sleep apnoea ( tongue falls back in sleep) in Bilateral Ankylosis. 5. Malocclusion 6. Poor and neglected oral hygiene 7. Multiple carious and impacted teeth. www.indiandentalacademy.com
  • 38. KABAN’S PROTOCOL FOR MANAGEMENT OF TMJ ANKYLOSIS 1. Early surgical management 2. Aggressive total excision of the ankylotic mass 3. Coronoidectomy + myotomy on the affected side to eliminate temporalis muscle restriction. 4. Lining with temporalis muscle/fascia 5. If steps 1 + 2 + 3 do not create enough opening, opposite side coronoidectomy is done. 6. Reconstruction of ramal height with costochondral graft 7. Early post-operative mobilisation and aggressive physiotherapy for at least 6 -12 months 8. Regular long term follow-up 9. Esthetic /orthognathic surgery to be carried out as a secondary procedure, when growth has completed www.indiandentalacademy.com
  • 39. MANAGEMENT OF ANKYLOSIS www.indiandentalacademy.com
  • 40. Management of Ankylosis • Treatment of Ankylosis is Surgical & should be corrected at the earliest. • WHY ?  TO ENSURE EFFECTIVE FUNCTION AND GROWTH. • Surgical treatment options will depend on: 1. Age of on set of ankylosis 2. Whether unilateral or bilateral ankylosis 3. Extent of ankylosis and 4. Any associated facial deformity ? www.indiandentalacademy.com
  • 41. • Aims and Objectives of Surgery 1. Release of ankylosed mass and creation of a gap to mobilize the joint. 2. Creation of a functional joint. - To improve patient's nutrition. - To improve patient's oral hygiene. - To carry out necessary dental treatment. 3. To reconstruct the joint and restore the vertical height of the ramus. 4. To prevent recurrence. 5. To restore normal facial growth pattern (based on functional matrix theory). 6. To improve esthetics and rehabilitate the patient (cosmetic surgery may be carried out at a later date or at second phase). www.indiandentalacademy.com
  • 42. Surgical Approaches to the TMJ 1. Preauricular incision with modifications 2. Submandibular incision 3. Post auricular 4. Post ramal 5. Endaural incision 6. Coronal incision www.indiandentalacademy.com
  • 43. PREAURICULAR APPROACH: www.indiandentalacademy.com
  • 44. • ALKAYAT - BRAMLEY INCISION • Alkayat - Bramley incision is a modification of the preauricular incision where the upper part of the incision is extended in a question mark fashion over the temporal area to gain better access. www.indiandentalacademy.com
  • 45. SURGICAL PROCEDURES www.indiandentalacademy.com
  • 46. Pre – surgical operative considerations In addition to the operative procedure the following factors must be considered. 1. Intubating the patient for General anaesthesia may be a problem as the patient has minimal to no mouth opening. 1. Techniques such as blind nasal, fibre-optic or retrograde intubation may need to be employed. 1. Only when it is not possible to intubate with these procedures should a tracheostomy be considered. 1. Blood loss may be significant at the time of surgery especially in children & there should be plans for blood www.indiandentalacademy.com replacement.
  • 47. TIMING OF SURGERY Surgery for Ankylosis can be done in 2 stages: • In the first stage surgery, only release of ankylosis with costochondral graft in young patients is done to bring about jaw mobility and growth. • In the second stage surgery an orthognathic surgery can be planned to restore facial esthetics. • Some surgeons prefer to use a single stage procedure where release of ankylosis and esthetic correction are done in a single stage in adults or after cessation of growth spurts in children. www.indiandentalacademy.com
  • 48. Basically these are the VARIOUS types of Surgical procedures. 1. Condylectomy 2. Gap arthroplasty 3. Interpositional Arthroplasty. 4. Ramus Osteotomy 5. Angle’s Osteotomy www.indiandentalacademy.com
  • 49. Use of Brisement Force • The forced opening of the jaw with the patient under general anesthesia is the oldest method that has been employed. • The jaw is forced open by means of a mouth gag and mobilized as much as possible by forceful manipulation. • In FIBROUS ANKYLOSIS or immobility caused by muscle spasms or fibrosis, this method may yield good results. • After the jaw has been mobilized, the patient is further benefited, by exercises by various exercisers or with a rubber block / acrylic screw / jaw exerciser inserted between the teethwww.indiandentalacademy.com side. on the affected
  • 50. Condylectomy and Arthroplasty • Surgical procedures for mobilisation of an ankylosed joint were first described by * Esmarch in 1851 * Murphy 1913 * Blair 1928 They reported that Arthrolysis is unsatisfactory, and it is usually followed by recurrence, but that condylectomy and osteoarthrotomy are satisfactory www.indiandentalacademy.com
  • 51. • In both condylectomy and osteoarthrotomy the condyle is removed. • The two methods do not differ a great deal, except for the amount of bone excised. • In a condylectomy the condyle is detached and removed, whereas • an osteoarthrotomy includes the excision of the entire joint and / or an adequate amount of bone below the joint www.indiandentalacademy.com
  • 52. I. Condylectomy • Condylectomy consists of excision of the condyle. It is indicated in: 1.severe arthrosis, 2.various types of arthritis, 3.in malunited condylar fractures with limitation of motion and pain during mastication. 4.Condylectomy can also be performed in cases of fibrous ankylosis where the articular space has not been completely eliminated. www.indiandentalacademy.com
  • 53. Condylectomy www.indiandentalacademy.com
  • 54. Complications / Disadvantages of Condylectomy 1.Loss of vertical height of the ramus. 1.In case of bilateral condylectomy, it may create an anterior open bite. 1.In unilateral cases, there may be deviation of the jaw on opening. www.indiandentalacademy.com
  • 55. II. Osteoarthrotomy (Gap Arthoplasty) • In bony ankylosis - the condyle is completely fused to the base of the skull - the sigmoid notch is lost by broad enlargement of the condylar head and - the coronoid is small size, often elongated • Because the joint is completed eliminated by the disease, or bony mass - an osteoarthrotomy or a double osteotomy is performed to remove a slice of bone, which is known as ‘ gap arthroplasty ’. • In gap arthroplasty, a piece of bone about 1.5 to 2 cm in width is removed. • Since there is a tendency for ankylosis to recur, some www.indiandentalacademy.com autogenous / alloplastic material should be interposed
  • 56. • Care should be taken while removing bone from the medial aspect of the TM Joint so as not to injure structures in close proximity, such as the maxillary artery and the carotid canal. • The mouth is forced open with the help of a mouth gag to check the mouth opening -a gap of 1.5 - 2 cms is created & not interposed with any material. • Post-op, this gap is maintained by active physiotherapy to prevent re-ankylosis. • When adequate movement and mouth opening cannot be achieved, it may be necessary to osteotomise the coronoid process also. www.indiandentalacademy.com
  • 57. www.indiandentalacademy.com
  • 58. Left Preauricular Incision showing surgical exposure and the Ankylotic bony mass TMJ - left side Right Surgical exposure showing the condyle fused to the zygomatic arch forming a ankylotic mass www.indiandentalacademy.com
  • 59. Left Ostoetomy Cut Right After the osteotomy, a gap of at least 1.5 – 2 cms between the roof of the fossa and the mandible is made. www.indiandentalacademy.com
  • 60. III. Interpositional Arthroplasty • Interpositional arthoplasty is similar to the gap arthroplasty and can be performed via a preauricular + submandibular incision or both can be used, when costochondral grafting is done. • Placing a interpositional material between the two bony cut ends avoids contact between them and thus minimises chances of re-ankylosis. www.indiandentalacademy.com
  • 61. • Various interpositional materials have been used which can be either alloplastic materials or autogenous. • ALLOPLASTIC MATERIALS such as silastic, acrylic etc., have been used. Another excellent material is Teflon such as is used for vascular grafts. • AUTOGENOUS MATERIALS such as temporalis muscle, temporalis fascia, skin grafts, auricular cartilage, fascia lata etc; have been attempted. www.indiandentalacademy.com
  • 62. Left After the osteotomy, a gap of at least 1.5 – 2 cms between the roof of the fossa and the mandible is made. Interpositional material –either Autogenous or alloplastic can be inserted and secured Right Lining of the Glenoid fossa Finger flap of the temporalis muscle rotated anteriorly under the zygomatic arch into the glenoid fossa www.indiandentalacademy.com
  • 63. CORONOIDECTOMY Ipsilateral coronoidectomy and temporalis myotomy: • In most of these cases there is always an elongated coronoid process. • After carrying out gap arthroplasty, coronoidectomy on the same side should be carried out either separately or in combination with the gap arthroplasty from the same extra-oral incision. • The coronoid process is cut at the level of sigmoid notch till the anterior border of the ramus + the temporalis muscle attachments are severed by carrying out temporalis myotomy. www.indiandentalacademy.com
  • 64. • The oral opening is checked after arthoplasty, and if maximum interincisal opening greater than 35 mm is obtained, then there is no need to carry out contralateral coronoidectomy. • But, if maximum inter-incisal opening is less than 35 mm  Then coronoidectomy + temporalis myotomy on the uninvolved side, can be carried out through an intraoral incision. • Lining of the glenoid fossa is done with temporalis muscle / fascia. www.indiandentalacademy.com
  • 65. IV. RAMUS OSTEOTOMY: • An operation in which osteotomy of ramus is done and a pully like structure is inserted between the fragments. V. ANGLES OSTEOTOMY: • Angle osteotomy in which masseter and medial pterygoid muscle are interposed between the fragment to prevent relapse. www.indiandentalacademy.com
  • 66. USE OF COSTOCHONDRAL GRAFT • In children, after the release of the ankylosis. it is necessary to place a material that will allow growth to occur. • A costochondral graft is harvested from the 5th 6th or 7th rib. • A costo-chondral junction of about 1.5 cm is harvested and attached to the lateral surface of the ramus of the mandible to reconstruct the ramus. • Thereby a functional and anatomical joint is created. • Cosmetic surgery is carried out at the later date when the growth of the patient is completed. www.indiandentalacademy.com
  • 67. Costochondral Graft can be fixed with either miniplates or lag screws www.indiandentalacademy.com
  • 68. Complications of costochondral grafting procedure 1.Second surgical site 2.Donor site complications such as pleuritic pain, pneumothorax 3.Excessive growth of the graft beyond what is required. This can be minimised by taking not more than 1.5 cm of costochondral graft. www.indiandentalacademy.com
  • 69. Postoperative treatment 1. After surgery, a pressure dressing is applied The pressure is accomplished by means of a thick gauze pack which is held in place by a bandage. 1. The patient is kept on steroids + antibiotic therapy for 7 to 10 days. 1. After 24 hours the dressing is changed and the rubber drain removed. After 24 to 36 hours the bandage is omitted and the dressing held by Elastoplast. 1. Immobilization of the jaw by means of intermaxillary elastics is recommended for the first 7- 10 days and then the patient is givenwww.indiandentalacademy.com functional treatment.
  • 70. Aftercare 1. After arthroplasty, especially gap arthroplasty, patient requires a splint inserted at the time of operation to prevent scar contracture 1.  Scar formation has the tendency to pull the ramus up, which causes malocclusion and cross-bite 1. The use of a splint to raise the bite increases the gap between the bone edges so that after the healing is complete there is a slack which allows the patient to bring the teeth into occlusion when the splint is removed and permits free opening of the jaw. 1. In unilateral cases it is also important to guide the jaw into normal position by means of a guide plane www.indiandentalacademy.com
  • 71. Postoperative Physiotherapy • Physiotherapy is as important as the surgery itself. • The patient should be encouraged to start active exercises of the jaws as soon as it can be tolerated. • Pressure with finger or simple finger exercises to gently force the mouth open initially; ice cream sticks / tongue blades / acrylic screw / jaw exerciser. • A mouth gag can be used for forceful mouth opening at a later stage. • During physiotherapy, medications can be given to relieve pain and enable movement. • Heat application to the joint region prior to exercise permits easy movement by relieving muscle spasm. www.indiandentalacademy.com
  • 72. COMPLICATIONS DURING TM JOINT ANKYLOSIS SURGERY • DURING ANAESTHESIA 1.As the patient cannot open the mouth, awake blind intubation has to be done, especially where patients cooperation is required, which is very difficult to obtain from younger patients. 2.Because of small mandible and altered position of the larynx, intubation poses a problem 3.Aspiration of blood clot, tooth or foreign body during extubation as throat cannot be packed prior to surgery. 4.Danger of falling back of tongue and obstructing airway is always after extubation. www.indiandentalacademy.com
  • 73. • DURING SURGERY • Hemorrhage due to damage to any of the superficial temporal vessels, transverse facial artery, inferior alveolar vessel and internal maxillary vessels, pterygoid plexus of veins. • Damage to external auditory meatus. • Damage to zygomatic and temporal branch of facial nerve. • Damage to glenoid fossa and thus perforation into middle cranial fossa. • Damage to auriculotemporal nerve. • Damage to parotid gland. • Damage to the teeth during opening of the jaws with www.indiandentalacademy.com jaw stretcher / mouth gag.
  • 74. • DURING POSTOPERATIVE FOLLOW-UP 1.Infection 2.Open bite 3.Recurrence of ankylosis. www.indiandentalacademy.com
  • 75. • What are the most important deterrent to re-ankylosis ? Three factors, namely: 1.Creation of a gap of sufficient width ( 1.5 -2 cm) 2.Careful application & stabilization of suitable interpositional medium that completely covers the surfaces of sectioned bone 3.Jaw exercises done sincerely over a period of several years Of the above 3 factors, the use of exercises is probably most important. www.indiandentalacademy.com
  • 76. That’s it ……..Thank You www.indiandentalacademy.com