-

1. MPDS
Asok kumar RS OMFS

2. SYNOPSIS
 Introduction
 History
 Incidence
 Etiology
 Pathophysiology
 Signs and symptoms
 Clinical examination
 Diagostic criteria
 Investigation
 Management
 Conclusion
 References
Asok kumar RS OMFS

3.  MYOFASCIAL – Muscular & connective tissue origin
 PAIN – An unpleasant sensational & emotional experience
 DYSFUNCTION – Deviated from normal function
 SYNDROME – Collection of various symptoms
 Psychophysiologic disease primarily involves the muscles of mastication.
 Functional disease related to the masticatory muscles, neural structures and
temporomandibular joint.
INTRODUCTION
Asok kumar RS OMFS

4.  Most common temporomandibular disorder.
 Non inflammatory disorder of musculoskeletal origin
 Characterized by the presence of pain, joint sounds and alterations in
mandibular movement.
 Originates from hyperirritable spots located within taut bands of skeletal
muscle known as myofascial trigger points
 Referred from the trigger points in myofascial structures to the muscles of the
head and neck.
introduction
Asok kumar RS OMFS

5. History
 1934- COSTEN described an abnormality associated with ear and maxillary sinus
 1952- TRAVELL AND RINZLER pointed out the existence of syndrome
associated with trigger areas in muscles coupled with pain, spasm, tenderness and
dysfunction.
 1956-SCHWARTZ coined the term “TMJ pain dysfunction syndrome”
 1960-TRAVEL through the use of injection of isotonic saline solution intramuscularly
demonstrated the transfer of pain from one area to another. Located the trigger points in
preauricular area and concluded trigger zone leads to referred pain
 1969- LASKIN proposed a theory for TMJ pain dysfunction syndrome and
suggested the term “Myofascial pain dysfunction syndrome “
Asok kumar RS OMFS

6.  Affects 3 to 30% of individuals.
 GENDER: Women are affected more frequently than men, with the ratio
ranging from 5:l to 3:l.
 AGE: 20 to 40 years of age.
 Increases with age
incidence
Asok kumar RS OMFS

7.  Facial arthromyalgia
 Temporomandibular joint dysarthrosis
 Costen’s syndrome
 Myelogelosen interstitial myofibrositis
 Non-articular rheumatism
 TMJ dysfunction myalgia
SYNOnyms
Asok kumar RS OMFS

8. etiology
 Multifactorial origin
1. Psychologic or central etiology
2. Occlusal or peripheral etiology
3. Intrinsic joint disorder etiology
 According to Okeson -Direct or indirect trauma to the muscle
I. Direct blow to the jaw
II. Opening the mouth too wide or for
too long a period
I. Whiplash-type
II. Local infection and trauma leading to
myositis
III. Occupational and repetitive strain injury
IV. Sleep disturbance and nocturnal habits
V. Oral parafunctional muscle tension
Direct trauma Indirect trauma
Nilima Budhraja; Shenoi SR; Anurag Choudhary et al. Overview of Myofascial Pain Dysfunction Syndrome
Asok kumar RS OMFS

9.  Tension, fatigue or spasm in the masticatory
muscles
 Bruxism, Habitual chewing or fingernail biting
 Malocclusion
 Trauma to the jaws
 Yawning
 Occlusal disturbances
 Intracapsular disorders
 Emotional turmoil
etiology
Asok kumar RS OMFS

10. Predisposing Factors Precipitating Factors
 Structural discrepancy of masticatory system.
 Physiologic disorders such as neurologic,
vascular and nutritional.
 Systemic diseases and infections, neoplasia,
and orthopedic imbalances.
 Noxious habits such as bruxism and tooth
clenching.
 Trauma.
 Stress.
 Iatrogenic and idiopathic
factors
etiology
Asok kumar RS OMFS

11. PERPETUATING FACTORS :
 Muscle fatigue due to parafunctional habits.
 Micro- or macro-muscular trauma.
 Class 2 skeletal discrepancies.
 Antihypertensives such as calcium channel blockers.
 Increased emotional tension.
 Endocrine problems.
 Sleep disorders.
 Nutritional deficiencies.
 Viral infections.
etiology
Gupta DS. Myofascial pain dysfunction syndrome an overview. Heal Talk 2013;5:12-6.
Asok kumar RS OMFS

12. Muscle fatigue &
accumulation of
metabolic byproducts like
lactic acid,
prostaglandin,
bradykinin,
histamin which
lowers pH
Involves a
psychogenic
component
which modifies
pain &
complicates the
treatment
Micro/ macro
trauma to
muscles
Increased
tone of
musculature
pathophysiology
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and occlusion (5th ed.)
Asok kumar RS OMFS

13.  Stress-related disorder.
 Increases in muscle tension combined with
the presence of parafunctional habits
[clenching /grinding] result in muscle
fatigue and spasm that produce the pain and
dysfunction.
 Occasionally can also result from muscular
over-extension, muscle over-contraction
or trauma
pathophysiology
Laskin DM: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969
Asok kumar RS OMFS

14. James Fricton. Myogenous Temporomandibular Disorders: Diagnostic and Management Considerations. Dent Clin N Am. 2007; 51: 61–83
REPETITIVE STRAIN HYPOTHESIS
Overactivity of muscles
Anaerobic muscle environment
Activation of muscle nociceptor
Muscle tenderness and pain
Muscle fatigue and decreased level of ATP and energy
Micro or macro traumatic events or continued muscle contractions
Accumulation of noxious metabolic end product [Lactic acid]
Muscle tone becomes sore and spastic
Asok kumar RS OMFS

15. Psychologically unbalanced individual
Hyperactivity of muscle
Under emotional stress
Due to persistent Parafunctional habits and Occlusal
disharmony
Muscle fatigue and muscle spasm
pathophysiology
PSCHYOGENIC CAUSE
Asok kumar RS OMFS

16. Trigger Points
 Presence of trigger points (TrP’s) in a specific group of
muscles is significant signs of myofascial pain syndrome.
 TRIGGER POINTS: Small exquisitely tender areas which
cause pain referred to a distant region, [Referred Pain Zone].
 Activated by change of barometric pressure and tension
[physical or emotional]
 TAUT BAND: Group of tense muscle fibres extending from
a trigger point to the muscle attachments.
 Tensions are caused by contraction knots that are located in
trigger point complex
Asok kumar RS OMFS

17. Signs and symptoms
 Unilateral pain in preauricular region [may be referred]
 Pain- Dull and constant in nature
 Associated with muscle tenderness
 Clicking sound over the affected TMJ (66%)
 Alteration or limitation of jaw function.
 Tinnitus
 Preauricular pain.
 Jaw tenderness on function
 No tenderness in temporomandibular joint (TMJ)
Asok kumar RS OMFS

18. Associated symptoms
NEUROLOGIC GASTRO
INTESTINAL
MUSCULO
SKELETAL
OTOLOGIC
 Headache
 Tingling
 Numbness
 Blurred
vision
 Twitches
 Trembling
 Lacrimation
Nausea
Vomitting
Diarrhoea
Constipation
Indigestion
Dry mouth
Fatigue
Tension
Shift joint pains
Tiredness
Weakness
Tinnitus
Ear pain
Dizziness
Vertigo
Dimished
hearing
Asok kumar RS OMFS

19. Diagnostic criteria
 LASKIN:FOUR CARDINAL SIGNS
1. Unilateral pain
2. Muscle tenderness
3. Clicking
4. Limitation of jaw function
 NEGATIVE CHARACTERISTICS:-
1. Absence of clinical, radiographic or biochemical evidence of changes in TMJ.
2. Lack of tenderness in TMJ area when palpated via external auditory meatus.
Asok kumar RS OMFS

20. History
 DESCRIPTION OF PAIN: Site, Mode of onset,
duration, frequency, type of pain, reference point,
aggravating or any relieving factor, and time of the
day at which pain is most prominent.
 HABITS : Sleeping and Parafunctional (bruxism,
cheek or lip biting. )
 History of traumatic injury
 Emotional Disturbance
 Occupation
Asok kumar RS OMFS

21. clinical examination
EXTRA-ORAL EXAMINATION:
PALPATION OF TMJ:
 Tenderness
 Synchronization of bilateral TMJ movement and clicking
sound.
 Range of movement
 Deviation of mandible while opening of mouth.
Asok kumar RS OMFS

22. Clinical examination
 Diagnosis – Made mainly by palpation.
PALPATION OF MUSCLE OF MASTICATION AND NECK MUSCLES
 Location of muscle pathology
 Evaluation of muscle tone
 Location of trigger points
 Evaluation of temperature change
 Location of swelling
 Identification of anatomic landmarks.
Asok kumar RS OMFS

23. Trigger points and their referred pain area
Trapezius muscle
Occipito frontalis muscle Sternocleido mastoid muscle
Simons DG, Travell JG: Myofascial pain and dysfunction: a trigger point manual, ed 2, Baltimore, MD, 1999,
Williams & Wilkins
Asok kumar RS OMFS

24. Referral of Myofascial trigger point to tooth
Travel JG, Simon DG; Myofascial pain and dysfunction. The trigger point manual, Baltimore MD,1983,Wiliams &
Wilkins
Temporalis muscle refers to maxillary teeth
Asok kumar RS OMFS

25. Masseter refers to posterior teeth
Anterior belly of digastric refers to mandibular
anterior teeth
Travel JG, Simon DG; Myofascial pain and dysfunction. The trigger point manual, Baltimore MD,1983,Wiliams & Wilkins
Asok kumar RS OMFS

26. Temporalis muscle palpation
Intra oral palpation
EXTRA ORAL PALPATION
Anterior region Middle region Posterior region
Asok kumar RS OMFS

27. masseter muscle palpation
Near lower border of mandible
Near Zygomatic arch
Asok kumar RS OMFS

28. sternocleido mastoid muscle palpation
Near Clavicle
Near mastoid process
Asok kumar RS OMFS

29. Trapezius
Splenius capitis
posterior cervical muscle palpation
Asok kumar RS OMFS

30. Superior lateral pterygoid Inferior lateral pterygoid
Lateral pterygoid muscle palpation
Asok kumar RS OMFS

31. Asok kumar RS OMFS

32.  OCCLUSION: Occlusal contacts, Anterior open bite,
cross bite, reduced vertical dimension observed.
 High points or premature contact of prosthesis or
restoration
 Gross occlusal discrepancies
 Attrition, wear facets, Mobile teeth, Missing teeth
 Type of malocclusion, skeletal, dentofacial deformities
Intra oral examination
Deviation
Deflection
Asok kumar RS OMFS

33. radiological investigation
 Helpful in diagnosis of
1. Intra articular pathologies
2. Osseous pathologies
3. Soft tissue pathologies
1. Panoramic radiograph
2. Transcranial projection
3. Transpharyngeal
projection
Conventional Radiograph Recent advances
1. CT
2. MRI
3. CBCT
4. Bone scaning
Asok kumar RS OMFS

34. Other investigation
 ELECTROMYOGRAPHY – Used to diagnose and monitor treatment of
MPDS. Increased EMG activity would be recorded from the involved
muscle.[Garlos AG, Gervios RO 1989]
 SONOGRAPHY -Technique of recording and graphically demonstrating joint
sounds.
 Presently, sonography does not provide the clinician with any additional
diagnostic information over manual palpation or stethoscopic evaluation.
 VIBRATION ANALYSIS- Aids in diagnosing intracapsular disorders, internal
derangements in particular.
 Measures the minute vibrations made by the condyle as it translates
Asok kumar RS OMFS

35.  THERMOGRAPHY - Technique that records and graphically illustrates
surface skin temperatures.
 Various temperatures are recorded by different colors producing a map that
depicts the surface being studied. [Feldman 1984]
 MANDIBULAR TRACKING DEVICE -Alterations in the normal
movements of the mandible. Used to diagnose and monitor treatment.
 No evidence to suggest that jaw tracking devices are reliable enough to be used
for diagnosis and management [Widmer 1990,Mohl 1990]
Other investigation
Asok kumar RS OMFS

36.  Treating the underlying etiology is currently the most widely accepted
definitive strategy for MPDS therapy.
 If the root cause is not properly treated, TrPs may reactivate and MPDS may
persist
 GOALS:
 Restore the muscle to normal length and posture
 Allow full joint range of motion through exercises and Trp therapy
 Reducing tenderness
 Eliminating contributing factors.
Management
Asok kumar RS OMFS

37. Treatment of MPDS can be done
Surgical management
Non surgical management :
1. Counseling and reassurance
2. Stress management and
relaxation therapy.
3. Pharmacological
4. Non- Pharmacological
5. Injections at Myofascial trigger
points
6. Physiotherapeutic Occlusal
splints
7. Intra-articular injections.
Management
Asok kumar RS OMFS

38. Phases in management of MPDS
Laskin DM: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969
Asok kumar RS OMFS

39. COUNSELLING AND REASSURANCE
 Counselling regarding prognosis, modification of lifestyle, daily activity, diet, exercises,
stress reduction aids in management of MPDS.
 Explain the nature and prognosis of the disorder to reassure the patient about the
treatment.
DIET
 Plays a very major role in the management of MPDS.
 Hard and sticky food should be eliminated to prevent the stress or stain over the
masticatory muscles.
Non surgical management
Asok kumar RS OMFS

40.  Daily exercises, yoga and deep breathing
relaxation therapy is considered to be
helpful in relieving stress.
 Biofeedback device is also useful to relax
as it allows patient to observe their
increased muscle activity and then relax.
Fonseca. Oral and Maxillofacial surgery. Volume(2)3E.p968
Non surgical management
STRESS MANAGEMENT AND RELAXATION THERAPY
Asok kumar RS OMFS

41.  Self-hypnosis, meditation and yoga all
promote relaxation
 Reduce levels of emotional stress as well as
the symptoms associated with muscle
hyperactivity
 Hypnosis provided by a trained therapist has
also proven to be helpful in reducing TMD
pain.
Audio recording relaxation technique
Non surgical management
Asok kumar RS OMFS

42. BIOFEEDBACK
 Technique that assists patient in regulating bodily functions that are
generally controlled unconsciously.
 Alter blood pressure, blood flow, and brainwave activity as well as
muscle relaxation.
 Electro myographically monitoring the state of contraction or
relaxation of the muscles through electrodes placed over the
muscles.
 EMG sensors attached to masseter muscle.
 Finger sensor –Monitors temperature/galvanic skin response
Non surgical management
Asok kumar RS OMFS

43.  Intraoral appliance reposition the mandible in centric
position, increasing the space within the joint which aids
in the free movement of the inflamed meniscus reducing its
inflammation and also reduces spasm as well as hyperactivity
of the muscle.
GOALS:
 To create balanced joint - tooth relationship.
 To reduce spasm, contracture, hyperactivity of musculature.
 To improve vertical dimension and prevent the over rotation
of the condyle during the closure so as to prevent stretching
of the fibres of bilamellar zone
 Allows free mandibular movement
 Decreased muscular activity
Non surgical management
OCCLUSAL SPLINT
Asok kumar RS OMFS

44. pharmacological management
Asok kumar RS OMFS

45. pharmacological management
Asok kumar RS OMFS

46. pharmacological management
Asok kumar RS OMFS

47. pharmacological management
Asok kumar RS OMFS

48.  Represents a group of supportive activities that is usually instituted in conjunction with
definitive treatment.
 Important part of the successful management
 PHYSICAL THERAPY MODALITIES:
1. Thermotherapy
2. Coolant therapy
3. Ultrasound
4. Phonophoresis
5. Iontophoresis
6. Electrogalvanic stimulation therapy
7. Transcutaneous electrical nerve stimulation and
8. Laser
physical therapy
Asok kumar RS OMFS

49.  Utilizes heat as a prime mechanism
MECHANISM:
 Decreased blood flow to the tissues is responsible for myalgia associated
with local myalgia.
 Counteracts by creating vasodilation in the compromised tissues,
leading to reduction of the symptoms
 Heat provides a cutaneous peripheral input carried by a-beta fibers that
can mask out nociceptive input carried by the c-fiber
 Surface heat is applied by laying a hot moist towel over the symptomatic
area
 Hot water bottle over the towel will help to maintain the heat.
TIME:10 to 15 minutes [not to exceed 30 minutes].
thermotherapy
Asok kumar RS OMFS

50.  Simple and often effective method of reducing pain
 Encourages the relaxation of muscles that are in spasm,
and thus relieves the associated pain.
 Ice should be applied directly to the affected area and
moved in a circular motion without pressure to the
tissues.
 APPLICATION: Styroform cup filled with water
 TIME: 5 to 7 minutes
 VASOCOOLANT SPRAY- Ethyl chloride and
fluoromethane for 5 minutes
coolant therapy
Asok kumar RS OMFS

51.  Ultrasound is a method of producing an increase in
temperature at the interface of the tissues and affects deeper
tissues than does surface heat
 Improves the flexibility and extensibility of connective
tissues
 Khan [1980] and Phero [1978] suggested that surface heat
and ultrasound be used together
 APPLICATION:0.7–1.0 watt/cm2 for 10 minutes
ultra sound therapy
Esposito CJ, Veal SJ, Farman AG: Alleviation of myofascial pain with ultrasonic therapy, J Prosthet Dent
51(1):106–108, 1984.
Asok kumar RS OMFS

52.  PHONOPHORESIS - Ultrasound has also been used to administer drugs through
the skin, by a process known as phonophoresis.
 10% hydrocortisone cream is applied to an inflamed joint and the ultrasound
transducer is then directed at the joint.
 Effect of salicylates and other topical anesthetics can also be enhanced in this
manner.
 IONTOPHORESIS – Technique similar to phonophoresis by which certain
medications can be introduced into the tissues without affecting any other organs.
 Local anesthetics and anti-inflammatories are common medications used with
iontophoresis.
Phonophersis and ionotophersis
1. Silveira PC, Victor EG, Schefer D, et al.: Effects of therapeutic pulsed ultrasound and dimethylsulfoxide (DMSO) phonophoresis on parameters of oxidative stress in traumatized muscle,
Ultrasound Med Biol 36(1):44–50, 2010.
2. Banta CA: A prospective, nonrandomized study of iontophoresis, wrist splinting, and antiinflammatory medication in the treatment of early-mild carpal tunnel syndrome, J Occup Med 36(2):166–
168, 1994.
Asok kumar RS OMFS

53.  TENS uses a low voltage, low amperage, biphasic current of varied
frequency .
 Designed primarily for sensory counterstimulation in painful
disorders.
 CONCEPT :Stimulation of the cutaneous branches creates an
inhibitory effect and reduces awareness of pain but also helps
indirectly to induce muscle relaxation.
 Portable TENS unit- Effective for long-term use by patients with
chronic pain.
 APPLICATION: Sessions last 30 minutes and repeated daily.
Transcutaneous electric nerve stimulation
Asok kumar RS OMFS

54.  Utilizes the principle that electrical stimulation of a muscle causes it to contract.
 EGS uses a high voltage, low amperage, monophasic current of varied frequency.
 A rhythmic electrical impulse is applied to the muscle, creating repeated involuntary contractions and
relaxations.
 Reduces myospasms as well as increase blood flow to the muscles.
 Leading to a reduction of pain in compromised muscle tissues.
 APPLICATION: Pulse at 80 cycles/ second for 10 minutes followed by exercise for 5 minutes is used.
 LASER: A cold laser is thought to accelerate collagen synthesis, increase vascularity of healing tissues,
decrease the number of microorganisms, and decrease pain.
ELECTROGALVANIC STIMULATION (EGS)
Murphy GJ: Electrical physical therapy in treating TMJ patients, J Craniomandib Pract 1(2):67–73, 1983.
Asok kumar RS OMFS

55.  Important aspect of Non-surgical management of
MPDS and provide stretching to the hypertonic
muscles.
 Exercises for MPDS can be divided into:
1. Active jaw exercises
2. Passive jaw exercises
3. Isometric exercises.
exercises
Active jaw exercise Passive jaw exercise
Isometric exercise
Asok kumar RS OMFS

56.  Gentle massage of the tissues overlying a painful area can often
reduce pain perception
 Deep massage can be more helpful than gentle massage in
reestablishing normal muscle function.
 Assist in mobilizing tissues, increasing blood flow to the area
and eliminating trigger points.
 APPLICATION:10 to 15 minutes of moist heat before beginning
the massage.
Massage therapy
Asok kumar RS OMFS

57.  According to the structures targeted :
1. Muscle injection
2. Nerve block injection and
3. Intracapsular injection.
 MUSCLE INJECTION: Injection of local anesthetic into a
myofascial trigger point can result in significant pain reduction
Steps in muscular injection
injections
Asok kumar RS OMFS

58. Masseter Temporalis Splenius capitis
Posterior occipital Trapezius Sternocleidomastoid
trigger point muscular injections
Asok kumar RS OMFS

59.  INDICATION: Acute pain and inflammation in relation to
the joint.
 Intra-articular injection steroids help in reducing the
inflammation within the joint and reduce the pain
 Superior joint space is the target for an intra-capsular
injection [Largest joint space and simple to locate]
 Steroids should not be injected very frequently and there
should be a gap of about 5 to 6 months between the two
injections
Intra capsular injections
Asok kumar RS OMFS

60. AURICULO TEMPORAL NERVE BLOCK
INDICATION: When TMJ is a source of pain
 Less traumatic method to anesthetize the joint structures
by blocking the auriculotemporal nerve before its fibers
reach the joint
Auriculo temporal nerve block
Nerve block injections
Asok kumar RS OMFS

61.  Another technique of modulating pain
 Stimulation of certain areas appears to cause the release of endogenous opioids
(endorphins and enkephalins)
 It reduce painful sensations by effectively block the transmission of noxious
impulses and thus reduce the sensations of pain.
 APPLICATION:
 Intermittent stimulation of about two pulses per second seems to be most
effective
 Needles are maintained in place for approximately 30 minutes and stimulated for
every 5 to 10 minutes
Acupuncture
Fernandes AC, Duarte Moura DM, Da Silva LGD, De Almeida EO, Barbosa GAS: Acupuncture in temporomandibular disorder myofascial pain
treatment: a systematic review, J Oral Facial Pain Headache 31(3):225–232, 2017.
Asok kumar RS OMFS

62.  Invasive and expensive method
 INDICATION: Excessive muscle activity or dystonia is the
major factor.
 BoNT-A is a potent neurotoxin that prevents muscle contraction
 Injection of BTX-A in the masseter and temporalis muscle fibers
extraorally under electromyography guidance proven effective
 SIDE EFFECTS: Muscle weakness and paralysis are mostly
local and reversible
Botulinum toxin injections
Asok kumar RS OMFS

63. Application of the low-level laser therapy:
 Promote healing
 Reduce inflammation.
 Accelerates collagen synthesis
 Increases vascularity
 Reduces cell membrane permeability for Na+ and K+ and
causes neuronal hyperpolarization resulting in increased pain
threshold.
 Removes metabolites
Low level laser therapy
Chitnis AV, Mistry GS, Puppala P, Swarup NA. Laser therapy for myofascial pain dysfunction syndrome. J Interdiscip Dentistry
2020;10:35-8.
Marking of trigger points
Asok kumar RS OMFS

64.  Considered as a last resort
 INDICATION: When conservative measures fail
 Condylotomy
 Condylectomy
 Mensicetomy
 Myotomy
 Arthroscopy and arthrocentesis
surgical management
Asok kumar RS OMFS

65. Asok kumar RS OMFS

66.  Successful management of patients with MPDS is dependent on
establishing an accurate diagnosis
 MPDS is self-limiting if etiological factors are removed.
 Management is mainly conservative
 Initially therapy should be directed at reducing stress and relaxing
muscles.
 Surgical management should be considered only after reasonable non-
surgical efforts have been tried
conclusion
Asok kumar RS OMFS

67.  Okeson JP. Management of temporomandibular disorders and occlusion. 8 th ed.
 Travel JG, Simon DG; Myofascial pain and dysfunction. The trigger point manual, Baltimore
MD,1983,Wiliams & Wilkins
 Peterson’s.Principles in oral and maxillofacial surgery.3E
 Fonseca. Oral and Maxillofacial surgery. Volume(2)3E.
 Laskin DM: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969
 JEWEKA OM, OGUNDANA OM, AGBELUSI GA.Temporomandibular pain dysfunction syndrome in
patients attending lagos university teaching hospital, lagos, nigeria. Journal of the west african college
of surgeons volume 6 number 1, january-march 2016.
 Chitnis AV, Mistry GS, Puppala P, Swarup NA. Laser therapy for myofascial pain dysfunction
syndrome. J Interdiscip Dentistry 2020;10:35-8.
 James Fricton. Myogenous Temporomandibular Disorders: Diagnostic and Management
Considerations. Dent Clin N Am. 2007; 51: 61–83. Murphy GJ: Electrical physical therapy in treating
TMJ patients, J Craniomandib Pract 1(2):67–73, 1983.
 James Fricton. Myogenous Temporomandibular Disorders: Diagnostic and Management
Considerations. Dent Clin N Am. 2007; 51: 61–83.
references
Asok kumar RS OMFS

68. Asok kumar RS OMFS