Tmj disorders/prosthodontic courses

TMJ
DISORDERS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

INTRODUCTION
T.M.J is a synovial ginglyoarthrodial joint
Ginglymus – a hinge (rotation)
Arthrodial – sliding movement

NORMAL ANATOMY
• Located anterior to the tragus of the ear
• Considered an articulation between the base of the skull
and the condyle of the mandible
• The articular surface is the squamous part of the
temporal bone

• Consists of
– Articular Fossa (Glenoid Fossa) - Concave
– Articular Tubercle or (Eminence) - Convex
– Condyle of the mandible
– Articular Disc
– Joint capsule
– Ligaments

DIAGNOSTIC CLASSIFICATION OF
TEMPEROMANDIBULAR DISORDERS
DIAGNOSTIC
CATEGORY
DIAGNOSES
Cranial bones
including the mandible
Congenital and developmental
disorders
Aplasia hypoplasia, hyperplasia,
dysplasia (eg, I st and 2nd
bronchial arch anomalies,
hemifacial microsomia, Pierre
Robin syndrome, Treacher Collins
syndrome, condylar hyperplasia,
prognathism, fibrous dysplasia)
Acquired disorders
(neoplasia, fracture

Temporomandibular joint
disorders
Deviation in form
Disk displacement (with
reduction; without
reduction)
Dislocation
Inflammatory conditions
(synovitis, capsulitis)
Arthritides (osteoarthritis,
osteoarthrosis,polyarthriti
des)
Ankylosis (fibrous, bony)
Neoplasia

Masticatory-muscle
disorders
Myofascial pain
Myositis
Spasm
Protective splinting
Contracture

Myofascial Pain Dysfunction Syndrome

• Myofascial pain is pain referred from a localised tender
area, a trigger point in a taut band of skeletal muscle.
• It can occur in any skeletal muscle including the muscles
of mastication
• The head, neck, shoulders and lower back are the areas
most frequently involved.

• Initially called as TMJ Pain Dysfunction syndrome
• Laskin renamed it as Myofascial pain Dysfunction
syndrome

ETIOLOGY
• Acute trauma
• Occlusal irregularities- such as occlusal interferences,
posterior bite collapse, deep overbite-jet relation
• Overuse of selected muscles of mastication results in
muscle fatigue
• Nocturnal parafunctional habits
• Psychological disorder- Shwartz hypothesized that
stress was a significant cause of clenching and grinding
habits, which resulted in spasm of muscles of
mastication. Based on this Laskin presented the
“psychophsiologic theory” of MPDS, which stated
that stress can cause clenching and grinding which in
turn can lead to muscle fatigue and finally spasm.

PAINPAIN
MUSCLE
SPASM
MUSCLE
SPASM
CLENCHIN
BRUXISM
CLENCHIN
BRUXISM
STRESSSTRESS

CLINICAL FEATURES
• FOUR CARDINAL SIGNS AND SYMPTOMS GIVEN
BY LASKIN
1. Unilateral dull pain in the ear or preauricular region
that is commonly worse on awakening
2. Tenderness of one or more muscle of mastication
3. Limitation or deviation of the mandible on opening
4. Clicking or popping in the TMJ.

• Referred pain in distant parts of the face arises from
trigger points in the involved muscles
• Features of bruxism

DIAGNOSIS
• History
• Examination of TMJ
• Examination of muscles of mastication and associated
cervical musculature
• Examination of the dentition and oral tissues

• These patients have two typical negative
characteristics
1. Absence of clinical, radiological or biochemical
evidence of organic changes in the joint itself
2. Lack of tenderness in the joint when palpated through
the external auditory meatus.

TREATMENT
• Treatment should be relatively accessible,
inexpensive, safe and reversible
• These include
1. Education
2. Self care and habit reversal
3. Physiotherapy
4. Intra oral appliances
5. Pharmacotherapy
6. Behavioral therapy and relaxation techniques
7. Trigger point therapy

Education
• Most patients have a fear of life threatening illness
• It is very important that the physician build up a rapport
with the patient and explain to him the origin of the pain
and the varied nature of the symptoms
• This is very effective in reducing the patients anxiety.

Self care and habit reversal
• The patient must be made aware of habits that are
causing the disorder
• Those habits must be replaced with restful jaw postures
and he must also be given a set of instructions that help
focus his attention on these habits
• E.g. avoid tooth contact except during chewing or
swallowing
• Check for clenching during routine daily activities
• Place the tip of the tongue behind the max teeth and
keep the teeth slightly apart
• Have a soft diet

• SELF CARE
• Application of moist heat compresses for 15 to 20 mins
daily
• controlled mouth opening exercises
• Use of cold compress for 10 mins every 2 hours during
an acute episode.

Physiotherapy
• Various modalities used are ultrasound, laser, TENS,
excercies
• TENS (TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION)
• uses low voltage current of varied frequency and is
designed for sensory counter stimulation for control of
pain
• It blocks the pain signals carried by the unmyelineated C
fibers by forcing the large myelineated A fibers to carry
light touch sensation.
• It is also involved in the stimulated release of
endorphins, which are endogenous morphine like
substances www.indiandentalacademy.com

• ULTRASOUND- high frequency oscillations are
produced and converted to heat waves as they are
transmitted through tissue, it produces deep heat more
effectively than surface warming
• Mobilisation techniques – done under the guidance of
the physiotherapist, includes distraction and combination
of lateral and protrusive gliding movements

Intra oral appliances
• The splint most commonly used is the maxillary, full
coverage, flat plane nightguard
• Can be made of hard or soft material
• Provides joint stabilization, redistributes forces, protects
the teeth and relaxes the elevator muscles
• Not worn for prolonged periods of time.

FLAT PLANE MAXILLARY STABILIZATION

Pharmacotherapy
• Drug therapy for MPDS should be used on a fixed dose
schedule rather than as needed for pain
• NSAIDS
• Antianxiety drugs e.g. Alprazolam 0.25mg at bed time
• Muscle relaxants e.g. Chloroxazone, Tizanidine
• Tricyclic antidepressants. – Amitriptyline 10 mg gradually
increase to 75 to 100 mg

Behavioral therapy and relaxation
techniques
• Relaxation techniques include deep breathing, paced
breathing, meditation, hypnosis
• Hypnosis produces a state of diffuse or selective focus to
produce relaxation. Individuals vary greatly in their
susceptibility to hypnosis
• Behavioral therapy includes relaxation techniques and it
also changes the pattern of negative thoughts

• Biofeedback
• It is helpful when the failure of other treatment modalities
is due to the inability to control stress and anxiety
• It provides the patient information about bodily functions
that are usually uncontrollable
• It monitors the electrical impulses of the muscles or the
peripheral temperature
• The patient then aims at either lowering the electrical
activity of the muscle or raising the temperature
• Repetitive use of this instrument provides training for the
patient to achieve a more relaxed state and also greater
sensitivity to activities that have adverse effects.

Trigger point therapy
1. Spray and stretch therapy – first cool the skin with
fluromethane (refrigerant) and then gently stretch the
involved muscle
• The cooling is done to allow stretching to take place
without the pain leading to reactive contraction
• Can be performed at home using ice for 10 mins,
stretching, then placing a hot compress over the area.
Repeat 3 times a day.

2. Injection of trigger point
• Intramuscular inj using LA without adrenaline, saline,
sterile water, or by dry needling without deposition of a
drug or solution
• Sterile water was associated with greater pain than
saline and so was discontinued
• Dry needling caused soreness 48 hours after the
procedure so was discontinued

Other methods
• Botulinum toxin injection- exerts a paralytic effect on the
muscle, but effect last only for 5 months and inj have to
be repeated
• Acupuncture
• Placebo effect -This effect can be powerful, accounting
for 30% to 60% of the effectiveness of various
treatments for MPDS

TMJ ARTHRITIS

CLASSIFICATION
• A) INFLAMMATORY ARTHRITIS
1. RHEUMATOID ARTHRITIS
2. JUVINILE RHEUMATOID ARTHRITIS
3. ANKYLOSING SPONDILYTIS
4. PSORIATIC SPONDYLITIS
5. REITER’S SYNDROME
• B) NON INFLAMMATORY
1. OSTEOARTHRITISwww.indiandentalacademy.com

• C) INFECTIOUS ARTHRITIS
• D) METABOLIC ARTHRITIS
1. GOUT
2. PSEUDO GOUT
• E) TRAUMATIC ARTHRITIS

RHEUMATOID ARTHRITIS
• Rheumatoid Arthritis is a chronic syndrome
characterized by non specific, usually symmetric
inflammation of the peripheral joints, particularly resulting
in progressive destruction of articular and periarticular
structures, with or without generalized manifestations

• Type 1--- the less common form, lasts a few months at
most and leaves no permanent disability.
• Type 2--- is chronic and lasts for years, sometimes for
life.
CLASSIFICATION

ETIOLOGY
• Genetic
• Environmental factors
• Abnormal immune response

Pathology
• The earliest change is the swelling and congestion of the
synovial membrane and underlying connective tissue
which becomes infiltrated with lymphocytes, plasma cells
and macrophages
• This villous synovitis, leads to the formation of
granulation tissue (pannus)
• This grows into the fibrocartilage and bone releasing
enzymes that destroy the articulating surfaces and
underlying bone

CRITERIA FOR DIAGNOSIS OF RHEUMATOID ARTHRITIS
(AMERICAN RHEUMATISM ASSOCIATION 1988 REVISION)
1.Morning stiffness(>1hour)*
2.Arthritis of 3 or more joints*
3.Arthritis of hand joints*
4.Symetrical arthritis*
5.Rheumatoid nodules
6.Rheumatoid factor
7.Radiological changes
• Duration of 6 weeks or more
DIAGNOSIS OF RA IS MADE WITH 4 OR MORE
CRITERIA www.indiandentalacademy.com

• Age: 40-60 years
• 1% of all population affected
• Women : Men 3:1
• Prevalence 2.5% - 2 %
• 50 – 75 % people have TMJ involvement
• Involves peripheral joints first then central skeleton
• Thoracic and lumbosacral rarely involved
CLINICAL FEATURES

SIGNS AND SYMPTOMS
• Joint pain
• Stiffness (greater than 30
min)
• Tenderness
• Swelling
• Warmth
• Erythema
• Limitation of movement
• severe in morning
decreases in night
• Systemic signs and
symptoms
• Fatigue
• Fever
• Weight loss
• Anemia

• TMJ bilaterally involved
• Limitation of mandibular opening
• Joint pain, especially in early acute phase of disease but
not later
• Morning stiffness, crepitus, tenderness, swelling over
joint area
• Symptoms usually transient in nature

Radiographic features
• Initially there is generalised osteopenia of the condyles
and temporal bone
• Bone erosion by pannus usually involves the articular
eminence and anterior aspect of the condylar head
• Severe erosion completely destroys the head of the
condyle with only the neck remaining as the articulating
surface
• Articular eminence totally destroyed such that the
normal convexity is replaced by concavity
• Subchondral sclerosis and flattening of the articular
surfaces may occur with subchondral cyst and
osteophyte formation.

Erosion of anterosup condylar head and temporal
component including articular eminence

BLOOD TEST :
• Normocytic Normochromic Anaemia in 80% cases
• ESR elevated in 90% of cases
• Rose Waaler Sheep cell Agglutination test : Antibodies to
altered globulin, so called Rheumatoid Factor (RF)
(1:1280)positive in 70% of cases
• Antinuclear antibody test : positive in 30% of cases
LABORATORY FINDINGS

SYNOVIAL FLUID:
• Abnormal during active joint inflammation, is cloudy but
sterile, with reduced viscosity and usually 3,000-50,000
WBCs/µl
• PMNs cells are typically predominant, but more than
50% may be lymphocytes and other mononuclear cells

TREATMENT
• PHYSICAL REST
• ANTI-INFLAMMATORY DRUG THERAPY
• MAINTAINENCE EXCERCISES
• SLOW ACTING ANTI RHEUMATIC DRUG THERAPY
• INTRAARTICULAR CORTICOSTEROID INJECTION

1.(NSAIDs);
• Salicylates (such as aspirin)- 2.6 gm/day
• Indomethacine-25-200mg/day,
• Propionic acid group-Naproxen-250-1000mg/day,
• Ibuprofen-900-2400mg/day
• Piroxicam-20mg/day etc
PHARMACOLOGIC AGENTS

Remission-inducing or disease modifying drugs
• Gold Compounds-AUROTHIOGLUCOSE or sodium
thiomalate salt
• Side effects of treatment with gold compounds include
hematologic toxicity, skin rash, and mouth ulcers.

• Antimalarial Drugs-Hydroxychloroquine (Plaquenil)-
200mg/daily
• Penicillamines-Sulfhydryl-reducing agent that lowers
serum rheumatoid factor
• Intra-articular (triamcinolone hexacetonide or
prednisolone tebutate) and/or
• systemic corticosteroids; used as an adjunct to any of
the other classes of drugs
• Immunosuppressive agents such as methotrexate are
also effective
• ORAL PHYSIOTHERAPY

JUVENILE RHEUMATOID ARTHRITIS

• Juvenile Rheumatoid Arthritis (JRA) is chronic
inflammation of the joint lining with an onset before the
patient reaches an age of 16 years.
• JRA is an autoimmune disorder
• The overall prevalence of JRA is uncertain, but
estimates of the number children affected in the United
States range from 30,000 to 250,000.
• Occurs predominantly in girls, 1:2 to 3
• Two peaks of onset
- Patients ages of 1 and 3 years
- Patients ages of 8 to 12 yearswww.indiandentalacademy.com

JRA is classified into three major onset sub types
- SYSTEMIC JRA
- POLYARTICULAR JRA
- PAUCIARTICULAR JRA

SYSTEMIC JRA :Called as STILL’S DISEASE
- occurs mostly in boys aged younger than 5 years
- can affects any joints
- usually accompany by several systemic signs like
high fever, rheumatoid rash, cardiopulmonary involvement,
lymphadenopathy, Hepato/spleenomegaly
- major complications are cardiac failure,
- patients generally are seronegative for both RF and ANA

POLYARTICULAR JRA
• Involves more than 4 joints
• Has fewer systemic signs
• Can be seropositive for RF and ANA
• Major complication is the long term possibility of
deformity and disability from poly arthritis

PAUCIARTICULAR JRA
• Affects girls more than boys
• Involves four joints or less
• Has fewer systemic signs
• Affects usually a large joints such as knee, hip, and
sarcoiliac, but patients rarely experience severe arthritis
• Patients generally are seronegative for RF but ANA is
present in 60% - 80% cases
• Major hazards of this subtype are idiocyclitis and
blindness www.indiandentalacademy.com

• Although, TMJ can be involved in any of these sub
types, it is mostly affected by POLYARTICULAR SUB
TYPE
• The clinical features of JRA TMJ include
– Pain
– Joint tenderness
– Crepitations
– Clicking
– Stiffness
– Decreased range of movements
– Unilateral onset is commonwww.indiandentalacademy.com

• Patients may have micrognathia and posterio inferior
chin rotation
• The degree of micrognathia is proportional to the
severity of the joint involvement and the early onset of
the disease
• If only one joint is involved then the patient may have
facial asymmetry, with the chin deviated to the affected
side

TREATMENT OF JRA
• Combination of active home exercises and proper use of
anti-inflammatory drugs that can suppress both the
articular and systemic manifestations of the disease is
necessary
• Pharmacologic management – two classes
-IMMEDIATE-ACTING: Action with in days to weeks
1.SALICYLATEs-ASPIRIN-80mg/Kg body weight
2.NSAIDS- NAPROXEN-10 mg/ kg to 15 mg/kg
3.CORTICOSTEROIDS

SLOW-ACTING, OR REMITTIVE: Action in months
Gold compounds, Antimalarial Drugs
(Hydroxychloroquine and Chloroquine) and D-
penicillamine. Because of their delayed onset of action,
these drugs are frequently given in conjunction with one
of the immediate-acting group.

OSTEOARTHRITIS
• Also known as Degenerative Joint Disease,
Osteoarthrosis, Degenerative Arthritis
• It is a non inflammatory disorder of the joints
characterized by joint deterioration and proliferation
• It is a localized joint disease without systemic
manifestations
• It primarily involves the articular cartilage and
subchondral bone with secondary inflammation of the
synovial membrane

• Joint deterioration is charecterised by loss of articular
cartilage and bone erosion
• The proliferative component is charecterised by new
bone formation at the articular surface and in the
subchondral region

CLINICAL FEATURES
• Occurs in any age , but incidence increases with age
• F>M
• Generally OA is unilateral, although bilateral involvement
does occur, with one side usually showing greater
severity of involvement .
• Gradual onset and runs a chronic course with clinical
features predominantly in the large weight-bearing joints

• When the disease involves the hands, the most
frequently affected joints are the distal inter-phalangeal
joints (DIP), producing the characteristic enlarge-ment
known as HEBERDEN'S NODES.
• When the proximal inter-phalangeal joints (PIP) are
affected, the nodes are called BOUCHARD'S NODES

HEBERDEN'S NODES AND BOUCHARD'S NODESwww.indiandentalacademy.com

Classification
PRIMARY OSTEOARTHRITIS
• As a result of wear and tear of the joint components
that occur with aging.
• PO usually begins in the fifth decade of life, with a slow
onset, and runs a course of mild symptoms.
SECONDARY OSTEOARTHRITIS
• This form affects patients 20 to 40 years old and
produces more symptoms than the primary form.
• Underlying cause such as trauma, congenital
dysplasia or metabolic disease present

• Pain and tenderness in the joint
• Tenderness in Masticatory Muscles
• Jaw muscle fatigue, stiffness and tiredness, difficulty
opening the mouth, reduced range of motion, and
crepitation and grating during mandibular movements
• Osteoarthritis is usually characterized by a lack of
morning jaw stiffness but, if present, lasts no more than
30 minute www.indiandentalacademy.com

RADIOGRAPHIC FEATURES
• Radiographic studies of OA of the TMJ reveal an
incidence of
- 40% in patients over 40 years of age
- 100% in patients over 80 years of age
- Approximately 50% of the population has
radiographic changes, but only 30% of these cases are
symptomatic

• Narrowing of joint space
• Irregular joint space
• Flattening of articular spaces
• Osteophyte formation occurs in the late stage at the ant-
sup surface of condyle, lateral aspect of temporal
component. In severe cases the osteophyte formation
originating in the glenoid fossa extend from the articular
eminence to encase the condylar head.
• In severe cases the glenoid fossa appears grossly
enlarged due to destruction of post slope of articular
eminence and the erosion of condylar head

Osteophyte on anterior surface of condyle

• Presence of Ely’s cyst– small, round, radiolucent areas
with irregular margins surrounded by varying area of
increased density are visible deep to the articular
surfaces. They are not true cysts but are areas of
degeneration that contain fibrous tissue, granulation
tissue and osteoid

Ely’s cyst

TREATMENT
• Reassurance and education of the patient
• Symptomatic management:
• Use of drug therapy
- NSAIDS, Indomethacin, Muscle relaxants etc
• Occlusal appliance therapy: Mandibular repositioning
appliances

Physical therapy:
• Application of Heat
-The use of ultrasound
-High-voltage electro-galvanic stimulation
-Massage
-Gentle mobilization exercises
• Individually or in combination
• In those instances when the disease progresses,
becomes more severe, and is refractory to these
treatment modalities, SURGERY may be indicated

INTERNAL DISK DERANGEMENT
• INTERNAL DISK DERANGEMENT of TMJ is defined
as an abnormal relationship of the articular disk to
the mandibular condyle, fossa and articular
eminence
• Disc mostly displaced in anterior direction
• Lateral and posterior displacements are rare.

ETIOLOGY
• LATERAL PTERYGOID MUSCLE SPASM
• DIRECT TRAUMA TO JOINT FROM BLOW TO
MANDIBLE
• INDIRECT TRAUMA FROM CERVICAL FLEXION
EXTENSI0ON INJURIES
• CHRONIC FUNCTIONAL OVERLOAD (CLENCHING)
• DEGENERATIVE JOINT DISEASESwww.indiandentalacademy.com

CLASSIFICATION
• Based on signs and symptoms
1. Anterior disc displacement with reduction (clicking
joint)
2. Anterior disc displacement with intermittent locking
3. Anterior disc displacement without reduction. (closed
lock)

Anterior disc displacement with reduction
• Due to a disc that has loosened because of elongation or
tearing of restraining ligaments and has moved from it’s
normal position to the top of the condyle
•

CLINICAL FEATURES
• Most cases without significant joint dysfunction or pain
• Abnormal joint sounds
• Limitation in mandibular range of motion
• Pain during mandibular motion
• Clicking sounds during both opening and closingwww.indiandentalacademy.com

Anterior disc displacement without
reduction. (closed lock)
• May be the first sign of TMD after severe trauma or long
term bruxism
• History of longstanding TMJ click that disappears with
sudden restriction in mandibular opening
• Patent also has pain over the joint during opening and
limited lateral movement since the joint is displaced
medially as well as anteriorly

TREATMENT MODALITIES
• NON SURGICAL
• EDUCATION
• PHYSICAL THERAPY
• PHARMACOLOGICAL THERAPY
• OCCLUSAL THERAPY

EDUCATION
• Each patients should understand the mechanism
that is causing symptoms
• Patient should be instructed to
- Decrease loading of joint as much as possible
- Soft food diet
- Slower chewing
- Smaller bites
- Not to allow joint to click
- Not to open his mouth forcefully
Patient should be told that condition is self
limiting

PHYSICAL THERAPY FOR
PAIN REDUCTION
• MOIST HEAT
Thermotherapy utilizes heat,heat increases
circulation to the applied area
- Hot water bottle or hot moist towel and
Electric heating pad are applied for
10 – 15 minutes

• COOLANT THERAPY
• Ice should be applied directly to the symptomatic joint /
muscles and moved in a circular motion without pressure
to the tissues.
• Continuous icing will result in mild aching and numbness
, when numbness begins , ice should be removed
• It should not be left on the tissues for not longer that 5 –
7 min
• After a period of warming, second application is advised
Ethlychloride and Fluoromethane spray applied to
desired area for 5 seconds

PHYSICAL THERAPY TO
IMPROVE FUNCTION
• Pain restricts the jaw movements which can lead to
chronic hypo mobility and muscle atrophy. Therefore
must be instructed
- to gently open the mouth to resistance and close
- jaw should be moved eccentrically
• If the disk is displaced without reduction then passive
distraction of the joint can increase the mobility

INTERNAL DISK DERANGEMENT
WITHOUT REDUCTION
• INITIAL THERAPY : Attempt to reduce or recapture
the disk displacement by manual manipulation
• This is successful in patients experiencing the first
episode of locking as the tissue are healthy &
morphological not changed
• In patients with longer history of dislocation, the
success rate decreases

• Patient is asked to move the mandible as far as
possible to the contralateral side, From this
eccentric position mouth is opened maximally
• If fails , then ASSISTANCE MANIPULATION is
needed
• The thumb is placed intra-orally on the 2nd
molar on
the affected side and fingers placed on the inferior
border of the mandible anterior to the thumb

PHARMACOLOGICAL THERAPY
– ANALGESICS :
NSAIDS like Ibuprofen, Diclofenac Sodium, Piroxicam,
ketolorac Tromethamine, Indomethacine are used
• ANTI – INFLAMMATORIES :
- Can be administered orally or by injection

OCCLUSAL THERAPY
• DISK DISPLACEMENT WITH REDUCTION :
ANTERIOR MANDIBULAR REPOSITIONING
APPLIANCE
- To be worn 24 hours a day for 3 – 6 months
- To position condyle back on the disk
DISADVANTAGE
Patient may develop POSTERIOR OPEN BITE
due to the reversible, myostatic contracture of
inferior lateral pterygoid muscleswww.indiandentalacademy.com

Appliance of choice since the risk of altering the
occlusion is minimized
- It should be noted that both appliances should
provide full arch coverage so as to avoid tooth
eruption
- as soon as patient becomes symptom free, the
appliance should be gradually reduced
- If the patient is suspected to have BRUXISM, a
muscle relaxation or flat plane appliance is
indicated www.indiandentalacademy.com

INDICATIONS FOR SURGERY
• PATIENTS WITH PAIN AND CLICKING WHOSE PAIN DOES NOT
RESPOND SATISFACTORICALLY TO NON SURGICAL THERAPY
OVER A PERIOD OF 2 – 3 MONTHS
• CHRONIC CLOSED LOCK JAW
• ARTICULAR DISC PERFORATIONS

STAGE OF CONDITION PROCEDURE
DISK DISPLACEMENT WITH REDUCTION
MECHANICAL INTERFERENCE ARTHROTOMY
SMOOTH MOVEMENT ARTHROTOMY
MODIFIED CONDYLECTOMY
DISK DISPLACEMENT WITHOUT REDUCTION
ACUTE ARTHROCENTESIS, LAVAGE AND
MANIPULATION, ARTHROSCOPY WITH
LAVAGE, LYSIS
CHRONIC ARTHROTOMY OR RTHROSCOPY WITH
LAVAGE, LYSIS
DISK DISPLACEMENT WITH PERFORATION
ARTHROTOMY

THANK YOU

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