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 Table of Contents  
RESEARCH
Year : 2023  |  Volume : 23  |  Issue : 1  |  Page : 30-37

An evaluation of the effect of wearing complete dentures on temporomandibular joint vibrations over time using the joint vibration analyzer


Department of Prosthodontics and Implantology, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India

Date of Submission28-Apr-2022
Date of Decision14-Oct-2022
Date of Acceptance22-Oct-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Majji Vasavi
Vishnu Dental College, Vishnupur, Kovvada Village, West Godavari District, Bhimavaram - 534 202, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jips.jips_215_22

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  Abstract 


Aim: To evaluate the changes in temporomandibular joint (TMJ) vibrations after insertion of the complete denture in edentulous patients.
Settings and Design: An observational in vivo study conducted to evaluate the changes in maximum mouth opening, total integrals, peak amplitude, and peak frequency in TMJ vibrations on the day of complete denture insertion and 6 months of follow up.
Materials and Methods: Twenty patients (male: 12 and female: 8) were selected for the fabrication of balanced complete dentures following conventional procedure. Joint vibration analysis was recorded using the joint vibration analyzer. The patients were instructed to open as wide as possible and close to the intercuspal position with rhythmic speed following the metronome projected on the screen. The TMJ vibrations were amplified and displayed as waveforms in a graphical representation by system software.
Statistical Analysis Used: Wilcoxon test.
Results: A significant decrease in the total integral (P = 0.001) and peak amplitude (P = 0.044) for opening and closing movements of the left and right joints was observed. There was no significant change in maximum mouth opening (P = 0.624). A decrease in peak frequency was noted only at left opening movements between the day of insertion and at 6 months (P = 0.025).
Conclusion: The function of TMJ mechanics was improved till 6 months after insertion of complete denture with balanced articulation (BA).

Keywords: Complete denture, joint vibration analysis, temporomandibular joint, vertical dimension


How to cite this article:
Vasavi M, Ramaraju AV, Sajjan M C, Rao D B, Manikyamba YJ, Thorreti V S. An evaluation of the effect of wearing complete dentures on temporomandibular joint vibrations over time using the joint vibration analyzer. J Indian Prosthodont Soc 2023;23:30-7

How to cite this URL:
Vasavi M, Ramaraju AV, Sajjan M C, Rao D B, Manikyamba YJ, Thorreti V S. An evaluation of the effect of wearing complete dentures on temporomandibular joint vibrations over time using the joint vibration analyzer. J Indian Prosthodont Soc [serial online] 2023 [cited 2023 Jan 31];23:30-7. Available from: https://www.j-ips.org/text.asp?2023/23/1/30/365942




  Introduction Top


The temporomandibular joint (TMJ) is a ginglymoarthrodial joint with well-lubricated surfaces that glide over one another in function. Any change in the surface due to degeneration, perforation, or mechanical displacement creates friction between the articulating surfaces. The friction is often heard as crepitus.[1] The intensity and timing of vibrations differ due to different disorders.[2]

The vertical dimension of the lower third of the face is maintained by the posterior teeth in natural dentition.[3] This also limits the rotation of the condyle to locate on the anterior slope of the glenoid fossa. The loss of teeth eliminates the vertical stop during the closure of the mandible allowing the mandible to move excessively superior to bring the ridges into contact with the anterior region to mash the food. This excessive movement results in a backward rotation of the condyles, thus increasing the duration of friction between the articulating surfaces. The backward rotation may also compress the retrodiscal tissue and strain the articular disk. In the long run, this may induce changes in the TMJ.

The loss of vertical stop forces the elevator muscles to contract more for bringing the ridges together and TMJ structure and introduces a heavier burden during the function.[4] Any change in the position of the condyle would disturb the joint spaces bringing in friction between articulating surfaces and the disk.

The frictional sounds of the TMJ are conventionally evaluated by palpation and auscultation.[5] Palpation of the joint requires excellent tactile sensitivity. A stethoscope is used to listen for abnormal TMJ sounds like crepitus. The outcomes of the palpation and auscultation are subject to the operator's interpretation and are not measurable. Clinical detection of TMJ sounds is shown to provide inaccurate data.[6]

Complex objective methods to document TMJ sounds include Doppler ultrasound, thermography, and sonography. These examinations include the involvement of specially trained individuals and are also of high cost.

The joint vibration analyzer (JVA) provides a dynamic analysis of the joint. It is used in various fields of the stomatognathic system both dentulous and edentulous conditions. JVA objectively records all the vibrations from the TMJ during mandibular movement and distinguishes the side of the origin. JVA provides data on maximum mouth opening (mm), and the vibrations in the joint are recorded by transducers positioned on the joint and expressed in terms of total integrals, peak amplitude, and peak frequency by the software. The software also provides the signature waveforms to be correlated with the flowchart provided by the company to determine the condition of the TMJ.

Total integrals indicate the total amount of vibration energy in the TMJ joint. Peak amplitude indicates the point of highest vibration intensity, which was measured in Pascals. Peak Frequency indicates the point at which the highest intensity of energy of vibration occurred, which was measured in Hz. It is a noninvasive diagnostic method, supplementing essential clinical examination and elucidating the structural abnormalities of the TMJ.

Occlusal instability contributes to TMJ disorders among complete denture wearers.[7] A harmonious relationship can be established in complete dentures by establishing a balanced articulation (BA) to restore healthy conditions to the TMJs.

There is limited literature available regarding the effect of wearing complete dentures on changes in TMJ with time using JVA. The present study was formulated to evaluate the changes in the extent of maximum mouth opening (mm), total integrals, peak amplitude, and peak frequency of the TMJ with complete dentures with BA on the day of insertion till 6 months in asymptomatic individuals. The null hypothesis adapted was that there will not be any significant difference in the TMJ vibrations on the day of complete denture insertion and 6 months after postinsertion of complete denture.


  Materials and Methods Top


An observational study was planned to evaluate the changes in the joint vibrations from insertion up to 6 months. Approval for the study was obtained from the Institutional Review Board and Ethics Committee (VDC/IEC/2018/42). All patients were given detailed information about the investigation and written informed consent was obtained for their participation. A simple random sampling technique was employed to select the study population.

Twenty edentulous patients reported to the department of prosthodontics from December 2018 to November 2019 fulfilling the inclusion criteria and who consented to report for the follow-up were included in the study. The recruitment period was 1 year with the follow-up of 6 months.

Twenty (male: 12 and female: 8) volunteered edentulous participants of age between 40 and 70 years having moderately formed alveolar ridges (ACP class I and II) with an edentulous period of >3 months and first time denture wearers were included. Patients expressing signs and symptoms of TMJ disorder, orofacial myalgia, poor neuromuscular coordination, and compromised ridges (ACP class III and IV) were excluded.

The sample size was calculated using software program (G*Power 3.0.10; Heinrich Heine University Dusseldorf). The effect size was kept at 0.36, an alpha error probability of 5% and power was 80%. The final sample size was calculated as 20 with a dropout rate estimated as 20%.

To standardize the procedure and reduce the number of variables, patients with TMJ disorder were not included. Variables such as duration of denture wearing per day and tolerance threshold were not considered in our study. The duration of edentulous period and personality of the individual can be confounding factors. However, since evaluation in the present study was within the same patient for a period of 6 months, it would not be relevant. All the data acquisition was done by the single operator to minimize the interoperator bias.

Procedure

A detailed case history was recorded and conventional maxillary and mandibular removable complete dentures were fabricated in BA for each participant. Postfabrication, a laboratory remount procedure and selective grinding were followed to eliminate the processing errors and maintain the achieved BA. The dentures were verified clinically for bilateral simultaneous occlusal contact without any glide in centric relation and without any interferences during excursive movements. Clinical remount and occlusal adjustment was done to refine the occlusal balance before final insertion.

Each patient underwent JVA (BioResearch, Inc. Milwaukee, WI, USA) recording once at the time of denture insertion and at 6-month follow-up. All patients were instructed to remove their ear jewelry, spectacles, and hearing aids to avoid errors when recording JVA.

To record JVA, the participant was seated in an upright position, with the Frankfurt plane parallel to the floor. The skin in front of the tragus of the ear was wiped with an alcohol swab before mounting the headset carrying the transducer for good tissue contact and accurate recording. The transducers were positioned on the skin over TMJ. The transducers were connected to a signal amplifier and to the computer equipped with BIOPAK software program (BioResearch, Inc., Milwaukee, WI, USA) [Figure 1].
Figure 1: Patient mounted with BIO-JVA and amplifier. BIO-JVA: BIO-Joint vibration analyzer

Click here to view


The range of maximum mouth opening, deviation in excursive movements of the mandible were measured. These data were entered into the program as prompted by the software when registering the patient. The patient was trained to follow the metronome on the computer screen to do maximum unassisted wide opening and to tap the teeth while closure. These data were entered into the program as prompted by the software when registering the patient. The patients were instructed and trained to follow the metronome on the computer screen and do maximum unassisted wide opening and closing movements of the mandible, and to tap the teeth.

The patients were trained to synchronize with the metronome for uniform cycles of movement when recording. Six cycles of the mouth opening and closing were recorded.

Graphical recordings of the left and right TMJ vibrations were displayed in real time as acoustic waveform graphs, suggesting the relationship between time and vibration amplitude[7] at the selected point of the cycle. Graphical waveform is evaluated with JVA flowchart. Three uniform cycles were selected for evaluation in acoustic form window.

The sounds in the joint are displayed in the form of vibrations for both the condyles separately. Three vibrations corresponding to the similar timing were selected manually. The vibrations either at the time of opening or closing have to be considered individually. The center of opening of the selected three cycles was marked. The mean values at the selected points of the three waves were calculated and displayed by the software program [Figure 2]. The same procedure was followed for all the participants. These values were tabulated for further analysis. BioResearch, Inc., provides a JVA flowchart with signature wave patterns for the interpretation of the data.
Figure 2: Components of JVA. (a) JVA sweep indicates vibrations and the timing of the vibrations during opening and closing waveform has white color indicating teeth coming in occlusion. High-intensity vibrations indicate a tapping of teeth. (b) JVA summary indicate average values of three selected vibrations either at opening or closure of both right and left joints. (c) Average of vibrations. (d) Superimposed image of selected vibrations. (e) X-Y view indicating the cycle of movement and location of the selected vibration in the cycle. JVA: Joint vibration analyzer

Click here to view


All obtained mean values were tabulated and statistically analyzed using SPSS software (IBM SPSS, Version 21.0. Armonk, NY, USA: IBM Corp).

Due to the nonnormal distribution of mean values, the Wilcoxon test was used to compare the pairwise tests for maximum mouth opening, total integrals of the right and left TMJ, and peak amplitude and peak frequency. P < 0.05 was considered statistically significant, and the confidence interval was 95%.


  Results Top


All twenty cases presented vibrations during opening or closing. Twenty percent (n = 4) of the patients showed small vibrations and they remained the same for 6 months. Eighty percent of the patients showed medium vibrations. Forty percent (n = 8) remained the same at follow-up, while 40% (n = 8) of the patients showed a reduction in the vibrations, however remained within the range of medium intensity vibrations at the 6–month follow-up for total integrals and peak amplitude, suggesting an improvement in the health of their TMJs.

The range of mouth opening (min 44 mm–max 45 mm) did not show any significant change between denture insertion and after 6 months of follow-up (P = 0.624) [Table 1].
Table 1: Comparison between mean maximum mouth opening (mm) within the samples obtained at insertion and after 6 months of follow-up

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A comparison of the total integrals from insertion and follow-up showed a statistically significant reduction for the opening and closing movements of both left and right joints (P = 0.001*) [Table 2].
Table 2: Comparison of the total integrals peak amplitude (Hz) during opening and closing movements after complete dentures insertion and 6 months of follow-up

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A statistically significant decrease was observed in opening movements for both the left joint (P = 0.008*) and the right joint (P = 0.001*) and closing of the left joint (P = 0.008*), while the right joint's peak amplitude was also decreased (P = 0.044*) [Table 3].
Table 3: Comparison of the peak amplitude during opening and closing movements after complete dentures insertion and 6 months of follow-up

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A comparison of peak frequency showed a statistically significant decrease between insertion and 6 months only for opening movements of the left joint (P = 0.025*) [Table 4].
Table 4: Comparison of the peak frequency (Hz) during opening and closing movements after complete dentures insertion and 6 months of follow-up

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Based on the gender issues, it was observed that the difference in change of intensity between males and females was significant.


  Discussion Top


The loss of teeth usually brings in an essential change in the stomatognathic system, the bone structure, the oral mucosa, and the masticatory muscles. TMJ disorder symptoms are more common in conditions of multiple teeth lost than with a few teeth lost.[8] The TMJ is a complex joint with the condyle articulating with the glenoid fossa. A fibrocartilage articular disk is located between the condyle and the glenoid fossa.

Synovial fluid facilitates smooth gliding movement with no friction in a healthy joint. Any form of changes in the articular disk and synovial fluid would result in friction and experienced as sounds. Sounds are caused by conditions such as degeneration, perforation, or mechanical displacement of the articular disk. TMJ sounds may be described as clicking or cracking, by the patient.[5],[9]

TMJ dysfunction has been documented as a prevalent condition among complete denture wearers, with most estimates ranging between 15% and 25%.[10] Differences in prevalence by age and sex have been reported, and these associations remain equivocal. One of the potential risk factors for mandibular dysfunction among complete denture wearers was the existence of an unstable occlusion.[11]

Balanced articulation (BA) is the bilateral, simultaneous occlusal contact of the anterior and posterior teeth in excursive movements (GPT 9).

BA maintains the stability of the dentures when the mandible moves from centric to eccentric positions. An unbalanced articulation disturbs the stability of the denture during eccentric movement, resulting in malposition and change in TMJ conditions.[3]

JVA is a passive device that works on the simple principles of motion and friction. It includes a headset with transducers encompassing accelerometers on each side. The accelerometer consists of a piezoelectric crystal in a metal case connected to an amplifier. This crystal responds to acceleration by producing a minute electric charge directly proportional to the acceleration. The electric charge then passes through an amplifier of high input impedance before being recorded as a vibration signal. During opening and closing movements, the characteristic vibrations produced by the joint will be detected by the accelerometers and the data will be transferred to the computer.

The software program then interprets the data and displays it in graphical form. The highest amplitude consistently occurring in each joint recording either at opening or closing movements will be used to calculate the frequency spectrum computed by the fast Fourier transform algorithm. Three vibrations are marked for evaluation.

All the vibrations marked should be either during opening vibrations or closing movements. It can record inaudible sounds below 20 Hz, creates an image of the vibration patterns, distinguishes mild or moderate TMJ dysfunctions from severe disorders, precisely quantifies the frequency content, and provides a permanent record for future comparison.[12]

In the present study, no significant change was seen in the maximum mouth opening range with an average range of 45 mm [Figure 3]. Intrasubject comparison of mean maximum mouth opening values within the samples was not statistically significant between insertion and follow-up. In accordance with the study by Olivieri and Garcia, we obtained similar results that the vibratory energy without mandibular position change is minor and remains stable at the analyzed positions.[5],[13] After denture placement and re-establishment of vertical stop during masticatory function, the elevator muscles will be reconditioned. The vibrations (Hz) no longer occur, or their intensity would be diminished from insertion to follow-up. This could eliminate the inflammatory process and the TMJ vibrations due to stabilized occlusion, improving the occlusal force redistribution and improving the disk's lubrication mechanism.
Figure 3: JVA sweep showing closing cycles present in both the right and left joint on the day of insertion. JVA: Joint vibration analyzer

Click here to view


Comparison of total integral (PaHz) and peak amplitude (Pa) for the opening and closing movements of the left and right joints showed a significant reduction of total integrals between insertion of the dentures and 6-month follow-up. In the present experimental study, the total integrals of the vibrations analyzed using JVA showed that four patients (20%) had total integrals below 20 PaHz (small vibrations), and they remained the same after follow-up. Eight patients (40%) presented with large-intensity vibrations (120 PaHz) at insertion, and there was a reduction in the intensity of the vibrations (50 PaHz) after 6 months of follow-up [Figure 4].
Figure 4: JVA sweep showing in closing cycles present in both the right and left joint at six months of follow-up. JVA: Joint vibration analyzer

Click here to view


Eight patients (e.g., 40%) presented with medium vibrations (60 PaHz) during insertion, and there was a reduction in the intensity of the vibrations (30 PaHz) after 6 months of follow-up; however, they were still within the range of medium vibrations (20–80 PaHz).

The increase in the edentulous period in posterior teeth increases the burden on the TMJs to alter the smoothness of the joint tissue surface and can produce changes such as disk shifting and degenerative joint disorders.[10] The loss of teeth eliminates the vertical stop during the closure of the mandible allowing the mandible to move excessively superior to bring the ridges into contact with the anterior region to mash the food. The backward rotation of the condyles during excessive movement may induce changes in the TMJs. The loss of vertical support makes the elevator muscles contract more to bring the ridges together and introduces a heavier burden during the function.[4]

In the present study, after insertion of the dentures, the occlusal vertical dimension (OVD) was re-established, and the vibrations' intensity varied in TMJ. Significant diminished vibrations were found in most of the subjects (80%) with new dentures for opening and closing movements during the observation period. Patients with low intensity (20%) did not show any change in TMJ vibrations with new denture insertion.

Intragroup comparison of the total integrals' means during the opening and closing movements of both the left and right joint vibrations, with complete dentures on the day of insertion and after 6 months, demonstrated a significant reduction. Higher frequency vibrations indicate a more progressive degenerative condition.[14],[15] The authors[7] found improvement in TMD signs and also observed reduced vibrations after new dentures were put in place due to the correct re-establishment of OVD, in correlation with the present study. The frequency spectra view in the JVA software plots the amplitude (vertical axis) versus the frequency (horizontal axis) [Figure 2]. The height of the curve is directly proportional to the energy of the spectrum at each frequency. The thick line represents the average spectrum of all the marked vibration spectra. Two spectra are plotted for each side, the smaller of the two represents the absolute magnitude of the vibrations' spectra as recorded (N/m2), and the larger one has been scaled to the maximum range (at the recorded amplification) and is known as the relative plot.[16],[17],[18] The relative plot accentuates features that may not be visible in the absolute plot.

Intragroup comparison of mean peak amplitude during the opening and closing movements of both left and right joint vibrations, with complete dentures on the day of insertion and after 6 months, demonstrated marked reduction (statistically significant). A larger amplitude of 25 dB from symptomatic subjects was noted compared to asymptomatic subjects with 15 dB.[19]

The peak amplitude is the intensity or “loudness“ of the dominant frequency (values >6 Pa are usually audible TM joint noises). The significant change suggests that a decrease in the amplitude of the vibrations from denture insertion to follow-up suggests an improvement in the health of TMJ.

Intragroup comparison of mean peak frequency (Hz) did not show a statistically significant difference in opening of right joint and closing of left and right joint peak frequency except during opening movement of the left joint. The numeric values that are calculated and displayed in the JVA summary view are based on the absolute frequency spectra. The frequency spectrums showed similar patterns of joint vibrations before and after the 6 month recording suggesting that there were no changes in the degree of internal derangement and shape of the disk.[9],[15],[20]

The results inferred that the loss of posterior teeth causes anatomical, physiological, and biochemical changes in the TMJs.

Rehabilitation of lost vertical dimension with removable prostheses brought about significant changes to the TMJ structural vibrations [Table 2] and [Table 3].

The reduced vibrations were seen as smaller total integrals. Less energy below 300 Hz typically due to reduced disk hyper mobility, lowered peak amplitudes (loudness), and lower peak frequencies observed at the opening movement of the left joint, indicating that there was less aberrant disk movement. This is a indicative of a definitive improvement in disk function during mandibular motion.

Limitations

Use of electromyographical data to substantiate the muscular activity along with JVA analysis provide, would substantiate the effect of vertical jaw relations and effect on TMJ. Parameters did not include gender variation due to the smaller sample size.


  Conclusion Top


Within the limitations of the study, from the BIO-JVA evaluation of removable complete dentures, the following conclusions can be drawn:

  1. The fabrication of complete dentures with corrected vertical dimensions showed a decrease in the total integral of the vibrations and peak amplitude in opening and closing movements of the TM joints from the time of denture insertion to 6 months
  2. The values verified through analysis of the peak frequency showed a decrease in peak frequency only at left opening movements from the day of insertion and at 6 months
  3. The analysis of the maximum mouth opening did not show any statistically significant difference between the denture insertion and at 6 months.


The function of TMJ mechanics was improved till 6 months could be due to BA and maintenance of vertical dimension. The authors[7] found that vertical rotation of condyle is limited during the closure from edentulous to after wearing of complete denture due to the correct vertical dimension. The present study shows that Bio-JVA can be an effective tool for evaluating TMJ function in individuals.

Declaration of patient consent

The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.

Acknowledgment

I would like to acknowledge my special thanks of gratitude to Dr. John Radke for his able guidance and support for the study.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Okeson JP. Management of T.M.J. Disorder and Occlusion. 6th ed. U.S.A.: Elsevier; 2008. p. 7-9.  Back to cited text no. 1
    
2.
Rondeau B, Johnson D, Radke J. An introduction to joint vibration analysis (J.V.A.) Part I. Oral Health J 2005;6:1. Available from: https://www.oralhealthgroup.com/features/an-introduction-to-joint-vibration-analysis-jva-part-i/. [Link was accessed on 2019 Sep 18].  Back to cited text no. 2
    
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Dervis E. Changes in temporomandibular disorders after treatment with new complete dentures. J Oral Rehabil 2004;31:320-6.  Back to cited text no. 3
    
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Herdiyani I, Kurnikasari E, Damayanti L. The severity of temporomandibular joint disorder by teeth loss in the elderly. Padjadjaran J Dent 2011;23:85-8.  Back to cited text no. 4
    
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Baba K, Tsukiyama Y, Yamazaki M, Clark GT. A review of temporomandibular disorder diagnostic techniques. J Prosthet Dent 2001;86:184-94.  Back to cited text no. 5
    
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Goiato MC, Garcia AR, dos Santos DM, Pesqueira AA. TMJ vibrations in asymptomatic patients using old and new complete dentures. J Prosthodont 2010;19:438-42.  Back to cited text no. 7
    
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Hotta PT, Hotta TH, Bataglion C, Pavão RF, Siéssere S, Regalo SC. Bite force in temporomandibular dysfunction (TMD) and healthy complete denture wearers. Braz Dent J 2008;19:354-7.  Back to cited text no. 8
    
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Ishigaki S, Bessette RW, Maruyama T. Vibration analysis of the temporomandibular joints with degenerative joint disease. Cranio 1993;11:276-83.  Back to cited text no. 9
    
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Divaris K, Ntounis A, Marinis A, Polyzois G, Polychronopoulou A. Loss of natural dentition: Multi-level effects among a geriatric population. Gerodontology 2012;29:e192-9.  Back to cited text no. 10
    
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Agerberg G. Mandibular function and dysfunction in complete denture wearers – A literature review. J Oral Rehabil 1988;15:237-49.  Back to cited text no. 11
    
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Kondrat W, Sierpińska T, Gołębiewska M. Vibration analysis of temporomandibular joints – BioJVA device description and its clinical application in dental diagnostics – Review of the literature. J Stomatol 2012;65:207-15.  Back to cited text no. 12
    
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Olivieri KA, Garcia AR. Joint vibration analysis in mandibular movements in asymptomatic volunteers. Braz Dent Sci 2000;3:17-24.  Back to cited text no. 13
    
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Widmalm SE, Bae HE, Djurdjanovic D, McKay DC. Inaudible temporomandibular joint vibrations. Cranio 2006;24:207-12.  Back to cited text no. 14
    
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Radke JC, Kull RS. Distribution of temporomandibular joint vibration transfer to the opposite side. Cranio 2012;30:194-200.  Back to cited text no. 15
    
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Madhav VN. Application of joint vibration analysis in TMJ disorders and occlusion. Int J Curr Res 2016;8:37317-9.  Back to cited text no. 16
    
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Radke J, Ruiz-Velasco G. Joint vibration analysis (JVA) bridges the gap between clinical procedures and sophisticated TMJ imaging. Adv Dent Technol Tech 2020;3:1-20.  Back to cited text no. 17
    
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Vijaykumar B, Sai JS, Sameeullah S, Venkata S, Sai P, Nikita, et al. Joint vibration analysis is a functional tool in the diagnosis of temporomandibular disorders – Case reports. Int J Contemp Med Surg Radiol 2019;4:B127-31.  Back to cited text no. 18
    
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Sano T, Widmalm SE, Westesson PL, Takahashi K, Yoshida H, Michi K, et al. Amplitude and frequency spectrum of temporomandibular joint sounds from subjects with and without other signs/symptoms of temporomandibular disorders. J Oral Rehabil 1999;26:145-50.  Back to cited text no. 19
    
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Hwang IT, Jung DU, Lee JH, Kang DW. Evaluation of TMJ sound on the subject with TMJ disorder by Joint Vibration Analysis. J Adv Prosthodont 2009;1:26-30.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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