Med Oral Patol Oral Cir Bucal. 2019 Sep 1;24 (5):e562-70.

Incidence and histopathology of temporomandibular arthropathies

Journal section: Oral Medicine and Pathology doi:10.4317/medoral.22739

Publication Types: Research http://dx.doi.org/doi:10.4317/medoral.22739

Temporomandibular arthropathies:
A retrospective study with histopathological characteristics

Tamires-Aparecida S. Rennó 1, Amy-Chwen-Jing Chung 2 , Hans-Albrecht Gitt 3, Luciana Corrêa 2 ,

João-Gualberto C. Luz 1

1
Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo, Brazil
2
Department of General Pathology, School of Dentistry, University of São Paulo, Brazil
3
International College for Maxillo-Facial Surgery, Leipzig, Germany

Correspondence:
Av. Prof. Lineu Prestes, 2227
Cidade Universitária 05508–900
São Paulo – SP, Brazil
jgcluz@usp.br

Received: 30/08/2018 Rennó TAS, Chung ACJ, Gitt HA, Corrêa L, Luz JGC. Temporoman-
Accepted: 29/05/2019 dibular arthropathies: A retrospective study with histopathological char-
acteristics. Med Oral Patol Oral Cir Bucal. 2019 Sep 1;24 (5):e562-70.
http://www.medicinaoral.com/medoralfree01/v24i5/medoralv24i5p562.pdf

Article Number: 22739 http://www.medicinaoral.com/

© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: medicina@medicinaoral.com
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Abstract
Background: To investigate the incidence of temporomandibular arthropathies diagnosed in a university center
and to describe their histopathological characteristics.
Material and Methods: Temporomandibular arthropathy cases with corresponding slides were selected from an
oral and maxillofacial surgical pathology service. Cases of exclusively articular disc disease were not included.
Results: The mean age was 31.3 years with a predominance of females (69.7%). Of these diagnoses, 53.6% were
unilateral condylar hyperplasia, 17.8% were bony ankylosis, 14.3% were degenerative joint disease, 10.7% were
osteochondroma, and 3.6% were synovial chondromatosis. Condylar hyperplasia presented as thick fibrocartilage
and cartilage nests in the cancellous bone. Bony ankylosis exhibited lamellar bone and nests of chondrocytes.
Degenerative joint disease presented as an irregular layer of fibrocartilage with areas of clustered chondrocytes
and calcified cartilage. Osteochondroma of the condyle exhibited hyaline cartilage and areas of new bone forma-
tion. Synovial chondromatosis presented as immature cartilaginous tissue and randomly arranged chondrocytes.
Conclusions: The pathological alterations verified in these arthropathies involved diseases that were predomi-
nantly proliferative, i.e., unilateral condylar hyperplasia, osteochondroma and synovial chondromatosis of the
tumor or pseudotumor type and bony ankylosis associated with callus formation of the reparative type, and less
frequent degenerative changes for which the disease is so named.

Key words: Temporomandibular joint, pathology, ankylosis, pathology, arthritis, degenerative, osteochondroma,
chondromatosis, synovial.

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Introduction sis and synovial chondrosis are used synonymously to

Temporomandibular joint (TMJ) arthropathies occur in describe this entity (14).
the population but are not frequent pathological changes. The purpose of this study was to investigate the inci-
Arthropathy is a collective term for any disease of the dence of temporomandibular arthropathies diagnosed
joints. Case series studies of specific arthritis of the TMJ in a university center and provide descriptions of the
are found in the literature, but there are no reports of the associated histopathological characteristics.
incidence of TMJ arthropathies combined with histo-
pathological characteristics of various arthropathies. Material and Methods
Unilateral condylar hyperplasia is a relatively rare con- The cases were selected from histopathological reports
dition that is characterized by a slow-developing, pro- from the Oral and Maxillofacial Surgical Pathology
gressive enlargement of the condyle that affects facial Service of the University of São Paulo - USP from 2000
symmetry and occlusion (1,2). This disorder is self- to 2010. Clinical data were collected from stored biop-
limiting. However, while the condition remains active, sy reports. This study received approval from the lo-
the asymmetry progresses together with the associated cal human research ethics committee (Process CAAE:
occlusal disturbances (3). 01464212.0.0000.0075).
TMJ bony ankylosis is a severe disease that destroys the The inclusion criteria included cases, regardless of age,
joint itself, causes hypomobility of the jaw, and affects race or gender, who presented with a history of tem-
the functions of speech, mastication and oral hygiene (4). poromandibular joint surgery due to arthropathies and
The primary cause of TMJ bony ankylosis is trauma, but had corresponding specimens that had been sent for his-
this condition can also result from infection (5,6). While topathological analysis. Only cases with available he-
there are many publications regarding the treatment of matoxylin and eosin (H & E) - stained slides that were
TMJ bony ankylosis, its pathogenesis remains poorly well preserved were accepted. The exclusion criteria
described (7), and protein-energy malnutrition should were cases with incomplete data or histological slides
be considered as a predisposing cause of this entity (8). that were inadequate for microscopic evaluation. Cases
TMJ bony ankylosis frequently begins during the active exclusively involving articular disc displacement or
growth stage of childhood and results in facial deformity, disc tissues were not included. Regarding the Research
malocclusion and sleep apnea syndrome (4,7). Diagnostic Criteria for Temporomandibular Disorders
A study of the distribution of diagnoses in a popula- (RDC/TMD), only cases that were considered to in-
tion of patients with temporomandibular disorders re- volve temporomandibular disorders comprising arthral-
vealed that 22.3% of cases involved osteoarthritis and gia, arthritis and arthrosis (Group III) were included
osteoarthrosis, which are degenerative joint diseases (10). The slides were evaluated under light microscopy,
(9). According to the Research Diagnostic Criteria for and findings regarding the phenomena that occurred
Temporomandibular Disorders (RDC/TMD), muscle within the temporomandibular joint or the condyles
disorders (Group I) are more frequent, whereas disc were recorded.
displacements (Group II) and arthralgia, arthritis and Age, gender, ethnic group and unilateral or bilateral oc-
arthrosis (Group III) are less prevalent. These findings currence were recorded. Regarding histopathological
may explain the relative scarcity of studies involving evaluations of the specimens, the following criteria that
these latter disorders (10). The absolute indication for have been described in other studies were used according
surgical treatment of osteoarthritis of the TMJ is the to the type of arthropathy: unilateral condylar hyperpla-
presence of focal joint pain that affects the quality of sia (15-17), bony ankyloses (7,18,19), degenerative joint
life and a definite pathologic lesion on imaging (11). disease (20-23), osteochondroma (13,24), and synovial
Tumors of the temporomandibular joint are infrequent chondromatosis (25). For cases of condylar hyperplasia,
but occur in young adults. Given the limited specific- the lesions were classified based on the system of Sloot-
ity of the symptoms, i.e., pain, swelling and limited weg and Müller (15). This classification identifies four
joint movements, many tumors are initially diagnosed histologic types, which are described in detail in Villan-
as temporomandibular disorders (12). When a patient ueva-Alcojol et al. (26). Two experienced pathologists
presents with progressive facial asymmetry, a clinical and two research fellows conducted the slide review.
evaluation and imaging techniques are indicated, and The data were collected and entered into a Microsoft
the clinical hypothesis regarding the diagnosis includes Excel spreadsheet (Microsoft Corporation, Redmond,
condylar hyperplasia, osteochondroma, chondroblasto- WA, USA). Once the data were tabulated, descriptive
ma, osteoma, osteoblastoma and chondrosarcoma (13). statistics were performed.
Synovial chondromatosis is classified as a tumorous le-
sion of the tendofascial tissues that belongs to the group Results
of extraskeletal and chondrogenic neoplasms. The There were 53 cases of temporomandibular arthropa-
terms synovial chondrometaplasia, osteochondromato- thies among these files. Twenty-eight cases of temporo-

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mandibular arthropathies with the corresponding slides of chondrocytes, quite compact bone tissue with mini-
were included in this study according to the aforemen- mal bone marrow, and thick layers of fibrous connective
tioned criteria. After review of the slides, the diagnoses tissue (Table 2) (Fig. 2).
of four cases (cases No. 22, 23, 30 and 31; 12.1%) were The following characteristics were found among the
changed. Interestingly, all of these cases had clinical cases of degenerative joint disease: an articular surface
diagnoses of bony ankyloses, received histopathologi- with fibrous connective tissue of variable thickness, in-
cal diagnosis of articular tissue fragment (two cases) or tense osteoclastic activity with areas of bone neoforma-
condyle without cartilage (two cases) that was partially tion and osteoid deposition, dense connective tissue that
confirmed. The new diagnoses were bony ankyloses was richly hyaline and slightly vascularized, an irregu-
(two cases), unilateral condylar hyperplasia (one case) lar layer of fibrocartilage with chondrocyte clustering
and degenerative joint disease (one case). areas, and cartilage that was separated from the sub-
According to the histopathological diagnoses, unilateral chondral bone by a calcified layer (Table 3) (Fig. 3 A-D).
condylar hyperplasia was predominant (n=15; 53.6%) The following characteristics were observed among the
followed by bony ankylosis (n=5; 17.8%), degenera- cases of osteochondroma of the condyle: mononuclear
tive joint disease (n=4; 14.3%), osteochondroma (n=3; chondrocytes that defined the transition area between
10.7%) and synovial chondromatosis (n=1; 3.6%). The the bone tissue and the cartilage, and areas of new bone
unilateral condylar hyperplasia cases involved eight ju- formation (Table 4) (Fig. 3 E-H).
venile cases and seven adult cases. Of the five cases of Finally, the following characteristics were observed in
bony ankylosis, four were unilateral, and one was bi- the case of synovial chondromatosis: immature carti-
lateral. laginous tissue that occasionally exhibited a myxoid
The mean age was 31.3 years. Among the numerous pa- appearance, disordered cellularity, and randomly ar-
tients with arthropathies, the interval of 11-20 years of ranged chondrocytes.
age was predominant followed by the intervals of 21-
30 years and 31-40 years. Female patients were more Discussion
frequent (69.7%) among the patients with all arthropa- Temporomandibular joint arthropathies constitute a
thies. Regarding ethnicity, 26 (78.8%) of the patients challenge to oral and maxillofacial surgeons both with
were Caucasian, and seven (21.2%) were Afro-Ameri- regard to diagnosis and surgical treatment. Due to the
can. Among the patients with condylar hyperplasia, 11 low frequency of these conditions, population studies
(73.3%) were Caucasian, and four (26.7%) were Afro- are scarce. The present study assessed the incidence of
American. Among the patients with other arthropathies temporomandibular arthropathies that were diagnosed
of the TMJ, Caucasians predominated. in a university center and provided descriptions of the
In the review of the microscope slides, the following associated histopathological characteristics to contrib-
specific histopathologic findings that are characteristic ute to improved knowledge of these pathological chang-
of the main arthropathy were identified. es, which could subsequently contribute to better treat-
Among the cases of condylar hyperplasia, characteris- ment being offered to patients with such changes. The
tics of the juvenile and adult forms were found. Among study was based on samples from the archives of an oral
the juvenile form cases, the following histopathologic and maxillofacial surgical pathology service. The pos-
features predominated: a hyaline cartilage layer with sibility that not all of the cases that underwent surgery
hypertrophic chondrocytes, a well cellularized prolifer- included surgical specimens that were sent for exami-
ative zone, a continuity of the cartilage with the interior nation should be considered. However, the incidence of
of the trabecular bone, and a thick layer of fibrocartilage temporomandibular arthropathies was described.
(Fig. 1 A-D). In the adult form, the following charac- The demographic features of the study sample includ-
teristics were observed: clustering of the chondrocytes, ed a mean age within the fourth decade of life, a pre-
cartilage foci within the trabecular bone, a thick layer dominance of females and a predominance of Cauca-
of fibrocartilage or a layer of varying thickness, and the sians. The mean age was 31.3 years, and many of the
presence of clefts in the fibrocartilage (Table 1) (Fig. arthropathies were verified to occur predominantly in
1 E-J). The condylar hyperplasia cases were classified adolescents and young adults. However, the diagnoses
based on the histologic types established by Slootweg were age dependent, and different frequencies were
and Müller (15), and the most predominant type was observed according to the pathological alteration. Uni-
type I. lateral condylar hyperplasia predominated in adoles-
All cases of TMJ ankylosis involved bony ankylosis, cents and young adults, bony ankyloses predominated
and the following characteristics were observed: bone in adolescents and adults, and other arthropathies were
remodeling areas, mature lamellar and cellularized frequently noted in the adult population. Unilateral con-
bone tissue, cartilaginous tissue formed by chondro- dylar hyperplasia is generally observed at a mean age
cytes with proliferative activity with presence of nests that falls into the third decade of life but the range of

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Fig. 1: Representative histological sections for juvenile (A–D) and adult (E–J) condylar hyperplasia (hematoxylin and eosin, 100X
and 400X original magnification). Juvenile - A: Hyaline cartilage exhibiting a predominant pattern of hypertrophic zone. B: Detail of
previous case showing large chondrocytes surrounded by basophilic matrix adjacent to the bone. C: Hyperplasia of growth cartilage
with thick and irregular proliferative and resting zones. D: Detail of trabecular zone of the previous case showing high frequency of
osteoclasts. Adult - E: Hyperplasia of hyaline cartilage tissue on condylar surface showing a great amount of intercellular matrix and
isogenous group of chondrocytes with an irregular pattern scattered in the tissue. F: Detail of the previous case exhibiting osteoid foci
in the trabecular bone. G: Thick and hypercellularized fibrocartilage with eosinophilic matrix covering the entire condylar surface.
H: Detail of the previous case showing foci of cartilage in the trabecular bone. I: Irregular condylar surface covered by a hyperplastic
hyaline cartilage. J: Detail of the previous case focusing an area of few chondrocytes and great amount of intercellular matrix originat-
ing a discontinuous layer.

ages is wide and includes early adolescents and aged fourth decade of life (12,24). Synovial chondromatosis
patients (3,26). Bony ankylosis is frequent in children, is most frequent in the fifth decade of life (12,14).
but young adulthood is the most frequent time of pre- For most of the arthropathies reported in this study,
sentation (4,6,7,27). Degenerative joint disease has been females predominated. The predominance of females
reported to be frequent in patients with mean age of 34 among unilateral condylar hyperplasia cases is known,
years (22), whereas advanced stages of temporoman- and females represent approximately 70 - 75% of cases
dibular joint degeneration are frequently observed in el- (3,26). It has been suggested that this condition may be a
derly or aged individuals (9,11,23,28). Osteochondroma predominantly female condition; however, the possibil-
has been reported to occur most frequently within the ity that treatment might be more commonly sought by
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Table 1: Frequency of the main histopathological findings observed in juvenile (n = 8) and adult (n = 7) condylar hyperplasia cases (n=15).
Histopathological characteristics Juvenile (n=8) Adult (n=7) Total
n % n % N %

Thick articular surface with perpendicular layers 1 6.7 - - 1 6.7

Clefts in fibrocartilage - - 6 40.0 6 40.0
Well cellularized proliferative zone 3 20 - - 3 20.0
Chondrocyte clustering - - 4 26.7 4 26.7
Thick layer of fibrocartilage 2 13.3 3 20.0 5 33.3
Fibrocartilage of variable thickness 1 6.7 4 26.7 5 33.3
Thin layer of fibrocartilage 1 6.7 - - 1 6.7
Calcified cartilage areas 1 6.7 1 6.7 2 13.3
Presence of mitosis in fibrocartilage 1 6.7 - - 1 6.7
Hyaline cartilage layer with hypertrophic chondro- 6 40.0 1 6.7 7 46.7
cytes
Cartilage continuity to the interior of the trabecular 7 46.7 - - 7 46.7
bone
Foci of cartilage within bone trabeculae 5 33.3 6 40.0 11 73.3

Lamellar bone with areas of resorption and reverse - - 1 6.7 1 6.7

apposition

Table 2: Frequency of the main histopathological findings observed in cases of bony ankylosis.
Histopathological characteristics n %
Mature and well-cellularized lamellar bone tissue 4 80
Bone trabeculae within fibrocartilage areas 1 20
Areas of bone remodeling 5 100
Cartilaginous tissue formed by chondrocytes in proliferative activity 2 40
Dense connective tissue low cellularized 1 20
Compact bone tissue with little bone marrow tissue 2 40
Thick fibrous connective tissue and cartilaginous tissue with chondrocyte nests 2 40

females than males should be considered (1). Moreover, lous bone. These observations characterize the activity
degenerative joint disease is more frequent in females of the articular cartilage layers and indicate surgical
(11,22,28), and hormonal differences could account for management (1,16,26). A non-uniform picture of the
this incidence (29). Osteochondroma has been reported histopathological findings associated with condylar hy-
to be more frequent in females (12,24). Synovial chon- perplasia has been described and includes variations in
dromatosis is also more frequent in females (12,14). the depth of the cartilage islands and the thickness of
However, there is no consensus in the literature con- the fibrous layer of the articular surface (2). However,
cerning bony ankyloses; some studies have reported a the presence of an interrupted layer of undifferentiated
male predominance (4,30), and others have observed a mesenchymal cells, a hypertrophic cartilage layer, and
female predominance (6). Similar to condylar fractures, cartilage rests in the subchondral spongiosa are char-
the possibility that bony ankylosis is actually more fre- acteristic of condylar hyperplasia (26). A comparative
quent in males should be considered because trauma is study of normal and hyperplastic condyles revealed
the main cause of this condition (30). that the thickness of the hyperplastic cartilage layer
The main findings regarding the cases of condylar is significantly increased in condylar hyperplasia (31).
hyperplasia were the presence of a proliferative zone, Associations between histologic appearances and joint
hypertrophic chondrocytes, a subchondral bone plate symptoms have been described, e.g., frequent pain and
that was not closed, and cartilage rests in the cancel- joint sounds are associated with the presence of a patchy

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Fig. 2: Representative histological sections for bony ankylosis (hematoxylin and eosin, 100X and
400X original magnification). A: Presence of cartilage in the middle of the trabecular bone, which
is covered by thick and cellularized connective tissue. B: Detail of the cartilage described in the
previous case, which is cell poor and formed by a pale eosinophilic matrix without typical charac-
teristics of cartilaginous matrix. C: Trabecular bone covered by a large layer of hyaline connective
tissue. D: Detail of the connective tissue in which some chondrocyte-like cells are seen scattered
on the hyaline matrix.

Table 3: Frequency of the main histopathological findings observed in cases of degenerative joint disease.

Histopathological characteristics n %
Articular surface with dense connective tissue low cellularized 1 25
Articular surface with fibrous connective tissue of variable thickness 3 75
Richly hyalinized and poorly vascularized dense connective tissue 2 50
Irregular fibrocartilage layer with chondrocyte clustering areas 2 50
Cartilage layer separated from the subchondral bone by a calcified layer 2 50
Intense osteoclastic activity and areas of bone neoformation with osteoid 3 75

distribution of cartilage layers in which cell-rich areas cytes, a well-cellularized proliferative zone, continuity
alternate with nonproliferative cell-poor zones (26). of the cartilage with the interior of the bone trabeculae,
In our study, the cases included both the juvenile and and a thick layer of fibrocartilage, predominated, and
adult forms as initially classified according to the age these findings are characteristic of this form of condy-
of onset, and the histopathological findings confirmed lar hyperplasia (15,17). In the adult form, clustering of
this classification (15). In the juvenile form, findings the chondrocytes, cartilage foci within the trabecular
of a hyaline cartilage layer with hypertrophic chondro- bone, a thick layer of fibrocartilage or a layer of varying

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Fig. 3: Representative histological sections for degenerative joint disease (A–D) and osteochondroma (E–H)
(Hematoxylin and eosin, 50X and 400X original magnification). Degenerative joint disease - A: Presence of
irregular layer of cartilage on the articular surface of condyle. B: Detail of the cartilage, showing nonhomo-
geneous distribution of chondrocytes and islands of cartilage-like tissue in the bone. C: Fibrous connective
tissue in the region of articular capsule, exhibiting dense collagen matrix and large blood vessels. D: Few
cells were seen in the connective tissue, which showed a hyaline pattern. Osteochondroma - E: Condylar
surface showing a mixture of cartilage, bone, connective and necrotic tissue, rich of cells with an irregular
distribution. F: Detail of previous case showing cells with a varied phenotype, resembling or chondrocytes
or osteoblasts, with hyperchromatic nuclei and evident nucleoli, scattered in fibrous, bone and cartilage-like
matrices. G: Condylar surface covered by a thick cartilage rich of large chondrocytes, invading the trabecu-
lar bone. H: Detail of the previous case showing cartilage tissue composed of hypertrophic chondrocytes
localized in the middle of bone matrix.

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Table 4: Frequency of the main histopathological findings observed in the cases of osteochondroma of the condyle.
Histopathological characteristics n %
Mononuclear chondrocytes setting the transition area between bone and cartilage 2 66.7
Foci of calcification in the areas of cartilage 1 33.3
Areas of neoformed bone 2 66.7
Focal areas of necrosis 1 33.3
Mature bone tissue exhibiting focal areas of cartilaginous tissue 1 33.3
Dense connective tissue surrounding bone tissue 1 33.3

thickness, and the presence of clefts in the fibrocartilage calcified layer. These findings comprise most histologi-
were observed, and these findings are characteristic of cal parameters for osteoarthrosis or degenerative joint
this form of condylar hyperplasia (15,17). disease (20-22). A correlation between degenerative
The main findings from the ankylosis cases were bone changes in the temporomandibular joint and aging has
remodeling areas, mature lamellar and cellularized bone been described and could reflect an accumulation of tis-
tissues, cartilaginous tissue formed by chondrocytes un- sue damage due to a decline in the cellular capacities for
dergoing proliferative activity with the presence of nests adaptation (23,29).
of chondrocytes, quite compact bone tissue with reduced The main findings related to osteochondroma of the
amounts of bone marrow, and thick layers of fibrous con- condyle were mononuclear chondrocytes that defined
nective tissue. These findings are characteristic of bony the transition area between bone tissue and cartilage
ankyloses, and there were no cases of fibrous ankylosis. and areas of new bone formation. These findings are
Bony ankylosis is the most frequent form of temporo- characteristic of osteochondroma (13,33). The man-
mandibular ankyloses (4,6). Many of the cases of bony agement of osteochondroma is surgical excision of the
ankylosis in our series were unilateral, which confirms tumor, and the diagnosis is based only on clinical and
the reports in the literature (4,6). There are few reports of tomographic findings, but the diagnosis has been con-
the histopathological findings associated with temporo- firmed by histopathologic examination (12,13).
mandibular ankylosis, and most of these studies were The main findings regarding synovial chondromatosis
morphological and based on radiological or tomographic were immature cartilaginous tissue with an occasion-
descriptions. The concept of an ankylotic mass involves ally myxoid appearance, disordered cellularity, and ran-
abnormal bone that replaces the articulation and results domly arranged chondrocytes. These findings are char-
in a restriction of mandibular movement (18). This bone acteristic of synovial chondromatosis (14,25). Synovial
is capable of continued growth that is associated with a chondromatosis has been reported to correspond to the
reparative process that is similar to that observed in exu- metaplastic transformation of the synovial tissue into
berant calluses that occur in fractures in children (18,32). chondroid tissue (12).
The presence of bone remodeling areas and mature la- The main histopathological characteristics of the ana-
mellar and cellularized bone tissue could confirm this lyzed arthropathies were confirmed. Moreover, some
hypothesis. Cartilaginous tissue was present in a portion tendencies regarding the frequencies of temporoman-
of our cases. Remnants of fibrocartilage, presumably dibular joint arthropathies, excluding pathologic altera-
of discal origin, have been reported in many ankylosed tions of the articular disc, were demonstrated in this
temporomandibular joints (27). Thick layers of fibrous study. Thus, in our experience, it can be affirmed that
connective tissue were verified in a portion of our cases. the verified pathological alterations associated with the
Previous studies of bony ankylosis have reported that the TMJ arthropathies were predominantly proliferative,
joint is surrounded by dense fibrous tissue, mainly in the i.e., unilateral condylar hyperplasia, osteochondroma
medial aspect (18). and synovial chondromathosis comprised the tumor
The main findings from the cases of degenerative joint or pseudotumor type, and bony ankylosis comprised
disease were an articular surface with fibrous connec- the reparative type, which was associated with callus
tive tissue of variable thickness, intense osteoclastic formation. Degenerative changes were less frequently
activity and areas of bone neoformation with osteoid associated with temporomandibular arthropathies.
deposition, dense connective tissue richly hyaline and Therefore, oral and maxillofacial surgeons must con-
slightly vascularized, an irregular layer of fibrocarti- sider these findings during the diagnostic evaluation
lage with areas of chondrocytes clustering, and carti- and surgical planning of pathologic temporomandibular
lage that is separated from the subchondral bone by a joint alterations.

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