- Email: [email protected]
The temporomandibular joint syndrome and occlusion
Ternporomandibularjoint disease
The temporomcmdibular Ulf Posselt,
L.D.S., D.&D.,
joint
syndrome
and
occlusion*
Odont.D.1
D
I revious investigations 1- I5 have shown that about 80 per cent of patients suffering from the temporomandibular joint syndrome are women, mostly in the third decade of life (Fig. 1). Most investigations have included many age groups and both sexes. The main purposes of this investigation were to ( 1) report the frequency of symptoms found in a group of subjects and compare it with that of other studies, (2) relate the temporomandibular syndrome to various features of the occlusion, (3) test the efficiency of occlusal adjustment, and (4) follow up changes in previously examined and treated individuals. SELECTION
OF SUBJECTS
Each term 38 to 39 nursing students start their training at the Royal Dental School, Malm6, Sweden. The average age of the girls at the beginning of their education is 19 to 22 years. These individuals constituted suitable material for research of the temporomandibular syndrome because a preliminary test indicated that a fairly large percentage exhibited symptoms related to the muscles of mastication and the temporomandibular joints. As expected, their dentitions were fairly complete. Examinations were undertaken for seven terms and involved 269 subjects. Each group exhibiting symptoms, and those who were symptom-free, were analyzed every term. EXAMINATION
PROCEDURE
The subjects were classified under the heading of bruxism when facets from attrition that presumably did not make contact during chewing were visible and when fatigue and tenderness of the muscle of mastication or soreness of the periodontal membranes were present. Also, information was obtained about clenching and other habits, such as tongue thrusting, when subjective symptoms were found. Patients *Project supported by a grant from the Educational dontics. Condensed by Dr. David J. Goodfriend. +Deceased.
432
and
Research
Foundation
of Prostho-
Volume Number
Temporomandibular
25 4 TENDERNESS CLICKING MOVEMENT PAIN
syndrome
and
occlusion
433
ON PALPATION OF THE JOINT
ON
ON MOVEMENT
EXCESSIVE LIMITED
MOVEMENT MOVEMENT
(INCLUPING TINNITUS
LOCK-JAW)
STOPPING OR STUFFY IN THE EARS
PAIN
joint
SENSATION
IN OR ABOUT THE EARS
PAIN OVER VERTEX, OCCIPUT, OR POSTAURICULAR AREAS MAND. AND NECK NEURALGIA MAX. BURNING OR PRICKING IN THE 'TONGUE
SENSATION
Fig. 1. Relative distribution of the symptoms from pooling five patient (total 73 1 patients). Crepitations have been included only if other present.16
materialsa, symptoms
11, 16, 2’3 2:: were also
exhibiting only facets of wear but without subjective symptoms were not included in the bruxism group. The relationship of contacts of opposing teeth was examined especially in regard to cuspal contacts on the balancing (nonworking) side during the total habitual lateral gliding movement to an edge-to-edge position of the cuspids on the working ride. Casting wax (28 gauge) or thin cellophane strips were used to test for contact on the balancing side. No differentiation was made between contacts on the balancing side with or without simultaneous contact on the working side. CLASSIFICATION
OF SYMPTOMS
The symptoms are grouped into four major divisions (Fig. 2) : Local temporomandibular joint symptoms. This category included symptoms of :pain and fatigue in the temporomandibular joints, clicking or crepitation, decreased :mobility, trismus, or hypermobility. Peripheral symptoms. This grouping included symptoms of headache, vertigo,
434
J. Pro&h: Dent.
Posselt
Apd,
\O%
20%
1971
25% 40.9
CLICKING MOVEMENT PAIN
OF
THE
JOINT
ON
ON MOVEMENT
EXCESSIVE LIMITED
MOVEMENT MOVEMENT
'VERTIGO
2 g a% SE
STOPPING OR STUFFY SENSATION IN THE EARS; TIi$W,'US: MILD CATARRHAL DEAFNESS: PAIN IN OR ABOUT THE EARS
NEURALGIA
SIMILAR
"AX.
MANO.
SENSATION
AND NECK
IN THE Y
Fig. 2. Relative distribution
of symptoms in the present material.
fitted into two or more of the groupings of symptoms. A corresponding number of individuals with no symptoms was selected at random from the remainder of the group to serve as the control. STATISTICAL ANALYSIS Statistical analysis was carried out at the Statistical Institute, University of Uppsala, Sweden (Docent G. Eklund) . The analysis included the following occlusal features : (1) tooth-to-tooth contacts in the retruded contact position (centric relation), (2) the sagittal and lateral mandibular shift between the retruded (centric relation) and intercuspal (centric occlusion) positions, and (3) contacts on the balancing side during lateral gliding movements. Of the total group, 8.5 subjects (30 per cent) exhibited a combination of two or more of the previous groups of symptoms. Fifty-six subjects (21 per cent) had symptomsof a magnitude that required treatment. A number of occlusal factors such as number of teeth, the amount of vertical and horizontal overlap, and Angle’s classification were included in the analysis. FREQUENCY OF SYMPTOMS AND COMBINATIONS OF SYMPTOMS Clicking and crepitations from the temporomandibular joint were found in 25 per cent of the subjects, whereas41 per cent had audible crepitations of the temporomandibular joint. Bruxism was noted in 65 per cent of the group. The six most frequent symptoms of the temporomandibular joint syndrome in order of occurrence as reported earlierI were (Figs. 3 and 4) : ( 1) clicking of the temporomandibular joint in connection with one or more other symptoms, (2) decreased joint mobility, (3) pain in or around the ears, (4) pain especially during mandibular movement, (5) headache, (6) tendernessof the joint to palpation. The most frequent symptoms in this study in order of occurrence were: (1) clicking,
Vo’lume Number
25 4
Temporomandibular
LIMITED
MOVEMENT
(INCLUDING
LOCK-JAW)
joint
syndrome
and occlusion
435
HEADACNE TENDERNESS
ON PALPATION
TINNITUS EXCESSIVE
MOVEMENT
MILD
CATRRRHAI.
PRIN
OVER
DEAFNESS
VERTEX,
PosTAVRICULAR
OCCIPUT.
OR
AREAS
Fig. 3. Same columns as in Fig. 1 but arranged according to frequency of symptoms. Symptoms appearing in less than 2 per cent not included. After crepitation, decreased mobility is the most common symptom.1G
LIMITED
MOVEMENT
(INCLUDING
LOCK-JAW
NEURALGIA
MAX.
EXCESSIVE
MOVEMENT
TENDERNESS
NAND.
&
NECK
ON PALPATION
Fig. 4. The symptoms of the present material arranged
according
to their frequency.
(2) headache, (3) vertigo, (4) nasopharyngeal symptoms, (5) pain on mandibular movement, and (6) limited movement. A high comparative incidence of vertigo ‘Yvaspresent in the most recent study. ‘TYPE AND FREQUENCY OF CUSPAL INTERFERENCES Eighty-one per cent of the subjects exhibited cuspal interferences in the terminal hinge closure. This cuspal interference was present in 35 of 36 subjects with symptoms. In the control group of an equal size, the cuspal interference was absent in three subjects. No statistically significant differences were seen in tooth-to-tooth contacts in the retruded position between these two groups. However, 55 per cent of the group with symptoms had unilateral interferences as compared with 33.5 per cent of the control group, while 45 per cent of the group with symptoms had bilateral contacts as compared with 55.5 per cent in the control group.
436
J. Prosth. Dent. April, 1971
Posselt
Table I. Results of selective grinding in 20 patients Result Cured Considerably improved Improved Slightly improved No improvement
No. 10 4 2 3 1
Percentape 50 20 10 15 5
The number of tooth-to-tooth contacts in the retruded position among 192 subjects was most frequent between first and second molars, even though these teeth were missing more often than the premolars. The teeth that made contact in the retruded position the next most frequently were the premolar-s, with little difference in occurrence between the first and secondpremolars. Statistical analysis did not indicate significant differences in the vertical and horizontal overlap or unilateral and bilateral tooth contacts in the retruded position of subjects with severe symptoms as compared with the corresponding control group. Neither was any difference found in the direction and degree of mandibular shift from the retruded position (centric relation) into the intercuspal position (centric occlusion). In the group with symptoms, the mean value of all scoresper subject was 3.3 as compared with 1.6 in the control group. When the factor of crowding of lower anterior teeth was included, the mean value per subject in the control group was 49 per cent lower than in the group with symptoms. When the same factor was eliminated, the mean score of the control group was 57 per cent lower than in the group with symptoms. This finding indicates an increased degree of significance in the difference between the two groups for this factor. RESULTSOF SELECTIVE GRINDING A relatively small group of the subjects has been under observation for more than one year. Therefore, only this group is recorded in Table I. The sequenceof treatment was carried out with an observation time of at least two weeks after each procedure and included: (1) adjustment of the occlusion to remove interfering tooth contacts in the retruded position, (2) elimination of tooth contacts on the balancing side, and (3) adjustment of contacts on the working sides to increase distribution of the occlusal load. Adjustment of the occlusion for the retruded contact position usually reduced or eliminated tendernessof the musclesof mastication to palpation and clicking of the joints. LONG-TERM OBSERVATION OF SYMPTOMS A questionnaire was mailed to 192 subjects examined during the first two years to obtain information about possible changes of symptoms. Those who had been treated were asked whether the symptoms were decreased, unchanged, or aggravated. Of the 158 subjects who responded, 116 (74 per cent) had no symptoms, and
b olume Number
25 4
had no change of condition, 13 reported total or considerable improvement after treatment, and 7 reported considerable improvement of symptoms in spite of the fact that no treatment had been carried out. Twenty subjects reported commencement or increase of symptoms, and one reported an increase of symptoms after treatment had been completed. DISCUSSION
The temporomandibular joint syndrome is widely believed to be of predominantly muscular origin rather than a joint disease proper.” The typical patients referred for treatment are women with a fairly large number of natural teeth. ‘This condition may differ in other geographic regions.” The population was selected to a certain extent as compared with a random sample of the population. Since only 56 subjects had severe symptoms, both the small for statistical groups with symptoms and the control group wfrr relatively analysis. In contrast to other studies? the range in age was small and there were no sex differences. Further, the dentitions were fairly complete. However, this may havp been a disadvantage since occlusal disharmonies had little time to exert their effect. Also, the growth of the joints may not have been totally concluded. Although the connection between cuspal interferences and functional derangements of the muscles of mastication and the temporomandibular joints was insufficiently documented, the results of treatment seemed to indicate a relationship or confirmed the results of other authors.lF. 21 SUMMARY
An investigation was conducted to determine the occurrence the temporomandibular joint syndrome, to relate the syndrome the occlusion, and to test the efficacy of occlusal adjustment. grouped into four categories. Of 269 subjects, 56 had such severe werf’ regarded to be in need of treatment. ‘The subjects exhibiting severe symptorns were treated by occlusion. The majority of symptoms were eliminated by means inq-.
and frequency of to characteristics of Symptoms were symptoms that they adjustment of selective
of the grind-
References 1.
Boman, K.: Temporomandibular Joint Arthrosis and Its Treatment by Extirpation of the Disc, Acta Chir. Stand. 95(Suppl. 118): 1947. 2. Ekensten, B.: Om det icke fysiologiska better som orsak till neuralgiska smartor i huvedet, och dess ortopedisk-proteriska behandling, Finska tandl. sallsk. forhandl. 45: 63-80, 1949. 3. Foged, J.: Operativ Behandling of Kaebeledsarthrose, Uskr. Laeger 103: 1445-1453, 1941. 4. Foged, J.: Temporomandibular Arthrosis, Lancet 259: 1209-1215, 1949. 5. Hankey, G. T.: Temporomandibular Arthrosis, Brit. Dent. J. 97: 249-270, 1954. 6. Hankey, G. T.: Discussion: Affections of the Temporomandibular Joint, Proc. Roy, Sot. Med. 49: 983-994, 1956. 7. Krogsgaard, C.: Kaebeledsarthrosen og dens ortopaediske Behandling, Tandlaegehl. 48: 733-752, 1944. II. Lindblom, G.: Disorders of the Temporomandibular Joint , Acta Odont. Sand. 11: 61-g-1, 1953.
438
Posselt
9. Kelly, H. T., and Goodfriend, D. J.: Vertigo Attributable to Dental and Temporomandibular Joint Causes, J. PROSTH. DENT. 14: 159-173, 1964. 10. Lovdal, A.: Lokale og perifere symptomer ved kjeveleddarthrose for og etter funsjonell behandling, Finska tandl. sallsk. forhandl. 45: 69-75, 1949. 11. Norgaard, F.: Temporomandibular Arthrography, Copenhagen, 1947. 12. Schwartz, L. L., and Cobin, H. P.: Symptoms Associated With the Temporomandibular Joint, Oral Surg. 10: 339-344, 1957. 13. Soderberg, F.: Malokklusion-Arthrose-Otalgie, Acta Otolaryng. Suppl. 95, pp. 85-96, 1950. 14. Posselt, U.: Kaebeledsarthrosen og dens funktionelle Behandling, Tandlaegebladet 49: 443-476, 1945. 15. Walsh, J. P.: Temporomandibular Arthritis, Mandibular Displacement and Facial Pain, N. Zealand Dent. J. 45: 233-239, 1949. 16. Posselt, U.: Physiology of Occlusion, Oxford, 1964. 17. Smith, J. P.: Personal communication. 18. Goodfriend, D. J., and Kelly, H. T.: A Technique for Balancing Occlusion for the Prevention and Treatment of Temporomandibular Joint and Ear Disorders, J. PROSTH. DENT. 13: 1130-1146, 1963.
The temporomcmdibular Ulf Posselt,
L.D.S., D.&D.,
joint
syndrome
and
occlusion*
Odont.D.1
D
I revious investigations 1- I5 have shown that about 80 per cent of patients suffering from the temporomandibular joint syndrome are women, mostly in the third decade of life (Fig. 1). Most investigations have included many age groups and both sexes. The main purposes of this investigation were to ( 1) report the frequency of symptoms found in a group of subjects and compare it with that of other studies, (2) relate the temporomandibular syndrome to various features of the occlusion, (3) test the efficiency of occlusal adjustment, and (4) follow up changes in previously examined and treated individuals. SELECTION
OF SUBJECTS
Each term 38 to 39 nursing students start their training at the Royal Dental School, Malm6, Sweden. The average age of the girls at the beginning of their education is 19 to 22 years. These individuals constituted suitable material for research of the temporomandibular syndrome because a preliminary test indicated that a fairly large percentage exhibited symptoms related to the muscles of mastication and the temporomandibular joints. As expected, their dentitions were fairly complete. Examinations were undertaken for seven terms and involved 269 subjects. Each group exhibiting symptoms, and those who were symptom-free, were analyzed every term. EXAMINATION
PROCEDURE
The subjects were classified under the heading of bruxism when facets from attrition that presumably did not make contact during chewing were visible and when fatigue and tenderness of the muscle of mastication or soreness of the periodontal membranes were present. Also, information was obtained about clenching and other habits, such as tongue thrusting, when subjective symptoms were found. Patients *Project supported by a grant from the Educational dontics. Condensed by Dr. David J. Goodfriend. +Deceased.
432
and
Research
Foundation
of Prostho-
Volume Number
Temporomandibular
25 4 TENDERNESS CLICKING MOVEMENT PAIN
syndrome
and
occlusion
433
ON PALPATION OF THE JOINT
ON
ON MOVEMENT
EXCESSIVE LIMITED
MOVEMENT MOVEMENT
(INCLUPING TINNITUS
LOCK-JAW)
STOPPING OR STUFFY IN THE EARS
PAIN
joint
SENSATION
IN OR ABOUT THE EARS
PAIN OVER VERTEX, OCCIPUT, OR POSTAURICULAR AREAS MAND. AND NECK NEURALGIA MAX. BURNING OR PRICKING IN THE 'TONGUE
SENSATION
Fig. 1. Relative distribution of the symptoms from pooling five patient (total 73 1 patients). Crepitations have been included only if other present.16
materialsa, symptoms
11, 16, 2’3 2:: were also
exhibiting only facets of wear but without subjective symptoms were not included in the bruxism group. The relationship of contacts of opposing teeth was examined especially in regard to cuspal contacts on the balancing (nonworking) side during the total habitual lateral gliding movement to an edge-to-edge position of the cuspids on the working ride. Casting wax (28 gauge) or thin cellophane strips were used to test for contact on the balancing side. No differentiation was made between contacts on the balancing side with or without simultaneous contact on the working side. CLASSIFICATION
OF SYMPTOMS
The symptoms are grouped into four major divisions (Fig. 2) : Local temporomandibular joint symptoms. This category included symptoms of :pain and fatigue in the temporomandibular joints, clicking or crepitation, decreased :mobility, trismus, or hypermobility. Peripheral symptoms. This grouping included symptoms of headache, vertigo,
434
J. Pro&h: Dent.
Posselt
Apd,
\O%
20%
1971
25% 40.9
CLICKING MOVEMENT PAIN
OF
THE
JOINT
ON
ON MOVEMENT
EXCESSIVE LIMITED
MOVEMENT MOVEMENT
'VERTIGO
2 g a% SE
STOPPING OR STUFFY SENSATION IN THE EARS; TIi$W,'US: MILD CATARRHAL DEAFNESS: PAIN IN OR ABOUT THE EARS
NEURALGIA
SIMILAR
"AX.
MANO.
SENSATION
AND NECK
IN THE Y
Fig. 2. Relative distribution
of symptoms in the present material.
fitted into two or more of the groupings of symptoms. A corresponding number of individuals with no symptoms was selected at random from the remainder of the group to serve as the control. STATISTICAL ANALYSIS Statistical analysis was carried out at the Statistical Institute, University of Uppsala, Sweden (Docent G. Eklund) . The analysis included the following occlusal features : (1) tooth-to-tooth contacts in the retruded contact position (centric relation), (2) the sagittal and lateral mandibular shift between the retruded (centric relation) and intercuspal (centric occlusion) positions, and (3) contacts on the balancing side during lateral gliding movements. Of the total group, 8.5 subjects (30 per cent) exhibited a combination of two or more of the previous groups of symptoms. Fifty-six subjects (21 per cent) had symptomsof a magnitude that required treatment. A number of occlusal factors such as number of teeth, the amount of vertical and horizontal overlap, and Angle’s classification were included in the analysis. FREQUENCY OF SYMPTOMS AND COMBINATIONS OF SYMPTOMS Clicking and crepitations from the temporomandibular joint were found in 25 per cent of the subjects, whereas41 per cent had audible crepitations of the temporomandibular joint. Bruxism was noted in 65 per cent of the group. The six most frequent symptoms of the temporomandibular joint syndrome in order of occurrence as reported earlierI were (Figs. 3 and 4) : ( 1) clicking of the temporomandibular joint in connection with one or more other symptoms, (2) decreased joint mobility, (3) pain in or around the ears, (4) pain especially during mandibular movement, (5) headache, (6) tendernessof the joint to palpation. The most frequent symptoms in this study in order of occurrence were: (1) clicking,
Vo’lume Number
25 4
Temporomandibular
LIMITED
MOVEMENT
(INCLUDING
LOCK-JAW)
joint
syndrome
and occlusion
435
HEADACNE TENDERNESS
ON PALPATION
TINNITUS EXCESSIVE
MOVEMENT
MILD
CATRRRHAI.
PRIN
OVER
DEAFNESS
VERTEX,
PosTAVRICULAR
OCCIPUT.
OR
AREAS
Fig. 3. Same columns as in Fig. 1 but arranged according to frequency of symptoms. Symptoms appearing in less than 2 per cent not included. After crepitation, decreased mobility is the most common symptom.1G
LIMITED
MOVEMENT
(INCLUDING
LOCK-JAW
NEURALGIA
MAX.
EXCESSIVE
MOVEMENT
TENDERNESS
NAND.
&
NECK
ON PALPATION
Fig. 4. The symptoms of the present material arranged
according
to their frequency.
(2) headache, (3) vertigo, (4) nasopharyngeal symptoms, (5) pain on mandibular movement, and (6) limited movement. A high comparative incidence of vertigo ‘Yvaspresent in the most recent study. ‘TYPE AND FREQUENCY OF CUSPAL INTERFERENCES Eighty-one per cent of the subjects exhibited cuspal interferences in the terminal hinge closure. This cuspal interference was present in 35 of 36 subjects with symptoms. In the control group of an equal size, the cuspal interference was absent in three subjects. No statistically significant differences were seen in tooth-to-tooth contacts in the retruded position between these two groups. However, 55 per cent of the group with symptoms had unilateral interferences as compared with 33.5 per cent of the control group, while 45 per cent of the group with symptoms had bilateral contacts as compared with 55.5 per cent in the control group.
436
J. Prosth. Dent. April, 1971
Posselt
Table I. Results of selective grinding in 20 patients Result Cured Considerably improved Improved Slightly improved No improvement
No. 10 4 2 3 1
Percentape 50 20 10 15 5
The number of tooth-to-tooth contacts in the retruded position among 192 subjects was most frequent between first and second molars, even though these teeth were missing more often than the premolars. The teeth that made contact in the retruded position the next most frequently were the premolar-s, with little difference in occurrence between the first and secondpremolars. Statistical analysis did not indicate significant differences in the vertical and horizontal overlap or unilateral and bilateral tooth contacts in the retruded position of subjects with severe symptoms as compared with the corresponding control group. Neither was any difference found in the direction and degree of mandibular shift from the retruded position (centric relation) into the intercuspal position (centric occlusion). In the group with symptoms, the mean value of all scoresper subject was 3.3 as compared with 1.6 in the control group. When the factor of crowding of lower anterior teeth was included, the mean value per subject in the control group was 49 per cent lower than in the group with symptoms. When the same factor was eliminated, the mean score of the control group was 57 per cent lower than in the group with symptoms. This finding indicates an increased degree of significance in the difference between the two groups for this factor. RESULTSOF SELECTIVE GRINDING A relatively small group of the subjects has been under observation for more than one year. Therefore, only this group is recorded in Table I. The sequenceof treatment was carried out with an observation time of at least two weeks after each procedure and included: (1) adjustment of the occlusion to remove interfering tooth contacts in the retruded position, (2) elimination of tooth contacts on the balancing side, and (3) adjustment of contacts on the working sides to increase distribution of the occlusal load. Adjustment of the occlusion for the retruded contact position usually reduced or eliminated tendernessof the musclesof mastication to palpation and clicking of the joints. LONG-TERM OBSERVATION OF SYMPTOMS A questionnaire was mailed to 192 subjects examined during the first two years to obtain information about possible changes of symptoms. Those who had been treated were asked whether the symptoms were decreased, unchanged, or aggravated. Of the 158 subjects who responded, 116 (74 per cent) had no symptoms, and
b olume Number
25 4
had no change of condition, 13 reported total or considerable improvement after treatment, and 7 reported considerable improvement of symptoms in spite of the fact that no treatment had been carried out. Twenty subjects reported commencement or increase of symptoms, and one reported an increase of symptoms after treatment had been completed. DISCUSSION
The temporomandibular joint syndrome is widely believed to be of predominantly muscular origin rather than a joint disease proper.” The typical patients referred for treatment are women with a fairly large number of natural teeth. ‘This condition may differ in other geographic regions.” The population was selected to a certain extent as compared with a random sample of the population. Since only 56 subjects had severe symptoms, both the small for statistical groups with symptoms and the control group wfrr relatively analysis. In contrast to other studies? the range in age was small and there were no sex differences. Further, the dentitions were fairly complete. However, this may havp been a disadvantage since occlusal disharmonies had little time to exert their effect. Also, the growth of the joints may not have been totally concluded. Although the connection between cuspal interferences and functional derangements of the muscles of mastication and the temporomandibular joints was insufficiently documented, the results of treatment seemed to indicate a relationship or confirmed the results of other authors.lF. 21 SUMMARY
An investigation was conducted to determine the occurrence the temporomandibular joint syndrome, to relate the syndrome the occlusion, and to test the efficacy of occlusal adjustment. grouped into four categories. Of 269 subjects, 56 had such severe werf’ regarded to be in need of treatment. ‘The subjects exhibiting severe symptorns were treated by occlusion. The majority of symptoms were eliminated by means inq-.
and frequency of to characteristics of Symptoms were symptoms that they adjustment of selective
of the grind-
References 1.
Boman, K.: Temporomandibular Joint Arthrosis and Its Treatment by Extirpation of the Disc, Acta Chir. Stand. 95(Suppl. 118): 1947. 2. Ekensten, B.: Om det icke fysiologiska better som orsak till neuralgiska smartor i huvedet, och dess ortopedisk-proteriska behandling, Finska tandl. sallsk. forhandl. 45: 63-80, 1949. 3. Foged, J.: Operativ Behandling of Kaebeledsarthrose, Uskr. Laeger 103: 1445-1453, 1941. 4. Foged, J.: Temporomandibular Arthrosis, Lancet 259: 1209-1215, 1949. 5. Hankey, G. T.: Temporomandibular Arthrosis, Brit. Dent. J. 97: 249-270, 1954. 6. Hankey, G. T.: Discussion: Affections of the Temporomandibular Joint, Proc. Roy, Sot. Med. 49: 983-994, 1956. 7. Krogsgaard, C.: Kaebeledsarthrosen og dens ortopaediske Behandling, Tandlaegehl. 48: 733-752, 1944. II. Lindblom, G.: Disorders of the Temporomandibular Joint , Acta Odont. Sand. 11: 61-g-1, 1953.
438
Posselt
9. Kelly, H. T., and Goodfriend, D. J.: Vertigo Attributable to Dental and Temporomandibular Joint Causes, J. PROSTH. DENT. 14: 159-173, 1964. 10. Lovdal, A.: Lokale og perifere symptomer ved kjeveleddarthrose for og etter funsjonell behandling, Finska tandl. sallsk. forhandl. 45: 69-75, 1949. 11. Norgaard, F.: Temporomandibular Arthrography, Copenhagen, 1947. 12. Schwartz, L. L., and Cobin, H. P.: Symptoms Associated With the Temporomandibular Joint, Oral Surg. 10: 339-344, 1957. 13. Soderberg, F.: Malokklusion-Arthrose-Otalgie, Acta Otolaryng. Suppl. 95, pp. 85-96, 1950. 14. Posselt, U.: Kaebeledsarthrosen og dens funktionelle Behandling, Tandlaegebladet 49: 443-476, 1945. 15. Walsh, J. P.: Temporomandibular Arthritis, Mandibular Displacement and Facial Pain, N. Zealand Dent. J. 45: 233-239, 1949. 16. Posselt, U.: Physiology of Occlusion, Oxford, 1964. 17. Smith, J. P.: Personal communication. 18. Goodfriend, D. J., and Kelly, H. T.: A Technique for Balancing Occlusion for the Prevention and Treatment of Temporomandibular Joint and Ear Disorders, J. PROSTH. DENT. 13: 1130-1146, 1963.