journal of prosthodontic research 63 (2019) 202–209

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Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Original article

Efficacy of mandibular manipulation technique for

temporomandibular disorders patients with mouth opening
limitation: a randomized controlled trial for comparison with
improved multimodal therapy
Kazuhiro Nagata* , Satol Hori, Ryo Mizuhashi, Tomoko Yokoe, Yojiro Atsumi,
Wataru Nagai, Motoatu Goto
Temporomandibular Disorders and Bruxism Clinic, Niigata Hospital, The Nippon Dental University, Niigata, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: Manual therapy has been used for the treatment of patients with temporomandibular disorders
Received 28 March 2018 (TMD) with mouth-opening limitations. However, the curative effect of manipulation differs among
Received in revised form 16 November 2018 researchers, and its necessity remains controversial. The purpose of this study was to confirm the efficacy
Accepted 17 November 2018
of manipulation using a randomized controlled trial (RCT).
Available online 15 December 2018
Methods: A total of 61 TMD patients who had mouth-opening limitation (upper and lower middle incisor
distance 35 mm) were selected. They were divided into two treatment groups: conventional treatment
Keywords:
(n = 30) and conventional treatment plus manipulation (n = 31). The conventional treatment included
Temporomandibular joint disorders (TMD)
Exercise
two types of self-exercise: cognitive behavioral therapy for bruxism and education. Mouth-opening
Manipulation limitation, orofacial pain, and temporomandibular joint (TMJ) sounds were recorded from baseline to 18
Cognitive-behavioral therapy (CBT) weeks after baseline. These parameters were statistically compared between the two treatment groups
Randomized controlled trial (RCT) by using analysis of variance (ANOVA) and Scheffe’s test to assess mouth opening distance and pain; TMJ
sounds were compared using Mann–Whitney U test.
Results: No statistical difference was observed between the two treatment groups except for mouth-
opening limitation after treatment at the first visit. Subgroup analyses, stratified according to the
pathological type of TMD, indicated a similar trend.
Conclusions: The efficacy of manipulation seems to be limited, in contrast to our expectations, and
improved execution of therapeutic exercises has a similar effect to that of manipulation during long-term
observation. The advantage of manipulation was observed only during the first treatment session. The
RCT was registered in the University Hospital Medical Information Network in Japan (UMIN-CTR:
000010437).
© 2018 The Authors. Published by Elsevier Ltd on behalf of Japan Prosthodontic Society. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Exercise therapy, including manipulation, has been used to
improve pain and disability in patients with temporomandibular
disorders (TMD). Importantly, multiple papers have been pub-
lished from the viewpoint of evidence-based medicine (EBM);
several randomized controlled trials (RCTs) [1–10] have suggested
the validity of exercise therapy, combined with other treatments,
and have recommended it as a noninvasive and safe treatment. In
* Corresponding author at: TMD and Bruxism Clinic, Niigata Hospital, The Nippon
Dental University, 1-8 Hamaura-cho, Niigata, Niigata, 951-8580, Japan.
E-mail address: nagata@ngt.ndu.ac.jp (K. Nagata).
contrast, some RCTs [11–15] have shown that exercise therapy had
no significant effect for patients with TMD. According to these
results, most systematic reviews concluded that the exercise
therapy was promising, but its effect was unclear because the
quality of the evidence was limited.
On the basis of the results of these studies, we concluded that
exercise therapy for TMD is largely divided into two types:
therapeutic exercise, which the patient performs as self-care at
home, and manual therapy, which the specialist performs in the
clinic. Potentially, the two types of exercises could be used
depending on the pathological type and disability of TMD
(e.g., myogenous or arthrogenous disorders, disc displacement
or normal joint, restricted or not restricted temporomandibular
joint (TMJ) movement). Moreover, manual therapy involves several

https://doi.org/10.1016/j.jpor.2018.11.010
1883-1958/© 2018 The Authors. Published by Elsevier Ltd on behalf of Japan Prosthodontic Society. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 K. Nagata et al. / journal of prosthodontic research 63 (2019) 202–209
methods, including mandibular manipulation [16] and cervical
mobilization [17,18]. However, the selective criteria for these
exercises have not been clearly determined because an objective
comparison has not been performed. In particular, the use of
manual therapy for closed lock cases, which are mainly caused by
disc displacement without reduction, is controversial. Some
studies have supported its usage [19,20], whereas others have
not [11,12].
The purpose of this study was to confirm the efficacy and
necessity of manipulation therapy for TMD patients with mouth-
opening limitation, by performing an RCT to compare manual
therapy combined with therapeutic exercise (TE + MN) and
therapeutic exercise alone (TE).
2. Materials and methods
2.1. Participants
Participants were selected from among patients who were
admitted to our Hospital between May 2014 and June 2017. All
participants had been diagnosed with TMD with the Diagnostic
Criteria for Temporomandibular Disorders (DC/TMD) axis I [21,22].
They had myalgia or arthralgia or mixed, triggered by jaw opening
or palpation; all exhibited mouth-opening limitation, where the
maximum self-opening distance (with pain) between upper and
lower middle incisors was 35 mm. Therefore, all patients were
clinically diagnosed with “disc displacement without reduction,
with limited opening.” These participants provided written
informed consent for the study. The exclusion criteria were as
follows: (1) inability to visit our clinic during a specific 2-to-4-
week period; (2) patients wanted to have a particular treatment
(e.g., drug or occlusal treatment); and (3) any mental or physical
disorders that might disturb treatment. Sixty-six patients were
included in this study; ultimately, 61 patients (11 men, 50 women,
mean age 49.6  25) were statistically analyzed in the RCT (Table 1
and Fig. 1).
The p-values of normality omnibus test with D’Agostino
analysis at baseline were 0.0596 for mouth-opening limitation,
0.2507 for pain, and 0.0167 for sound. The p-values of homosce-
dasticity with Bartlett’s test were 0.3176 for mouth-opening
limitation, 0.4009 for pain, and 0.8557 for sound. The test of sound
did not show normality. Therefore, we selected two way-analysis
of variance (ANOVA) for mouth-opening limitation and pain, and
Mann–Whitney U test (with Bonferroni correction) for sound. The
sample size of this study was determined by using prior power
analysis with G*Power software [23]. Selected statistical analyses
of G*Power were F-test and ANOVA—repeated measures, within-
between interaction. The following parameters were used: input
effect size f = 0.1, α error = 0.05, power = 0.95, number of groups = 2,
number of measurements = 11. The total sample size calculated was
112; finally, 112/11 = 10.18. Considering subgroup analysis, 30
participants were selected for each group in this study. This study
was conducted under the approval of the Ethical Review Board of
our Hospital (ECNG-H-153) and under a petition to the University
Hospital Medical Information Network in Japan (UMIN-CTR:
000010437).
2.2. Study design
Participants were randomly assigned to TE + MN (n = 31) or TE
(n = 32) with block randomization to equalize the numbers of
participants in the two groups. The study was designed as a
single-blind RCT, in which participants in each group received
detailed explanations of their individual treatment, but further
information was not provided to them to avoid education bias.
The assignment of blocks was performed based on the random
203
Table 1. Subjects of this randomized controlled trial
TE + MN (SD) TE (SD) Comparison
Patients number 31 30
Mean age 48.2 (21.1) 50.7 (18.3) ns
Mouth-opening distance (mm) 28.32 (4.55) 27.02 (5.48) ns
Pain NRS 5.76 (2.26) 5.77 (2.79) ns
Sound NRS 2.32 (2.76) 2.10 (2.67) ns
TE + MN, standard therapy, including the self-exercise for temporomandibular
disorder (TMD), plus Jog-manipulation.
TE, standard therapy, including the self-exercise for TMD; ns, not significant in the
statistical analysis with Student’s t-test.
number table of a computer owned only by the administrator, to
ensure concealment.
2.3. Treatment groups
TE + MN patients also underwent jog-type jaw manipulation
(Jog-manipulation) [19] as a manual therapy by the predefined
dentist in charge of the patient (Fig. 2). Jog-manipulation,
developed at our treatment department, was a combination of
four different types of manipulations; a pivot made of gauze was
set on the last molar. The following four steps were executed
continuously: (1) closing type with fulcrums on both sides.
(2) side-to-side type. (3) opening type. (4) closing type with
fulcrums on the impaired side. If an insufficient opening, <40 mm,
of the mouth could be obtained, the same process was repeated
three times. The implementation of this technique was conducted
at the first visit and each subsequent visit of the patients until the
restoration of mouth-opening limitation <40 mm.
All TE + MN and TE patients received standard therapy,
including self-exercise, cognitive-behavioral therapy (CBT), and
education for TMD. Following our previous RCT regarding the
splint therapy, we did not use any type of splints in this study [24].
The self-exercise consisted of two types of exercise for the
mandibular jaw. One exercise pulled down on a patient’s bilateral
lower last molars with their secondary fingers, while opening the
jaw to the greatest possible extent (molar pulldown type) [24] with
10 repetitions, three or five times per day (Fig. 3). The other
exercise comprised simplified myo-functional therapy (S-MFT),
combined with (1) maximum mouth opening, (2) clenching, (3)
protrusion of the lip, (4) maximum mouth opening and maximum
tongue protrusion without use of the patient’s fingers; this
approach was advocated by Imai [25] (Fig. 4). Instructions were
to execute S-MFT every hour throughout the day. The patients were
guided to perform two types of self-exercise, to the extent that
weak pain was felt every time. If sufficient recovery of the mouth-
opening (<40 mm) had been achieved, patients were prescribed a
reduction of exercise strength.
Furthermore, CBT (e.g., guidance regarding clenching control
during waking hours, as well as coping with pain and stress) and
education regarding TMD self-management (i.e., a diet of soft foods,
avoiding gum chewing, and correcting bad posture) were provided.
Nine dentists were selected as the predefined practitioners from
among our clinic members in this study. Each practitioner had more
than 3 years of clinical experience with TMD treatment and
underwent standardization training for the treatment in this study.
2.4. Subgroup analysis
TMJ diagnosis via magnetic resonance imaging (MRI) was
performed at the second visit for patients who received approval
for this examination. These patients were categorized according to
their diagnostic results: normal TMJ (N), disc-displacement with
reduction (3a), and disc-displacement without reduction (3b).
Disc-displacement included anterior, lateral, or partial
204 K. Nagata et al. / journal of prosthodontic research 63 (2019) 202–209

Fig. 1. Flow diagram of the randomized controlled trial and subgroup analysis.
*
These patients’ last temporomandibular disorder values were extrapolated to fill in the post-assessment time points, according to the intention-to-treat concept.

Fig. 2. Jog-type jaw manipulation technique (for right side temporomandibular joint).
(a) A pivot made of gauze was set on the last molar. (b) The pivot closing type. (c) The side-to-side type. (d) The opening type. (e) The one-side pivot type. Each manipulation
was executed for 10–20 s, then performed continuously.

displacement of the disc. Osteo-change of the TMJ was not
considered in this diagnosis because no direct relationship to the
mouth-opening limitation was inferred in comparison with the
disc displacement. Each pathological group was compared to
investigate the influence of the treatment on each pathological
type of TMD. Fourteen participants declined or were not able to
undergo MRI examination; 23 participants in the TE + MT group
and 24 in the TE group underwent the examination.
2.5. Evaluation parameters
Three TMD signs/symptoms of mouth-opening distance,
orofacial pain, and TMJ sounds were recorded for all patients to
evaluate treatment efficacy. There were 11 measurement points in
the study: baseline, then after treatment at the first visit and every
2 weeks thereafter, from 2 to 18 weeks after baseline. The mouth-
opening distance between the upper and lower medial incisor was
measured with a caliper. Participants were instructed to open their
mouths as widely as possible, even if they felt pain. Orofacial pain
(i.e., TMJ or masticatory muscles), as well as TMJ sounds, were
estimated using a self-reported numerical rating scale (NRS) with
scores ranging from 0 to 10. If a drug therapy or manipulation other
than the pre-arranged protocol was provided to a participant when
an insufficient decrease in TMD signs/symptoms was achieved
after several treatments, or if a participant canceled treatment
before the completion of this study, the patient’s last values were
 K. Nagata et al. / journal of prosthodontic research 63 (2019) 202–209 205

Fig. 3. Self-exercise of the jaw for temporomandibular disorder patients.

This conservative exercise was performed three times daily. It promotes smooth condylar transfer by pulling down the rearmost molars.

Fig. 4. Simplified myo-functional therapy (S-MFT).

(1) maximum mouth opening, (2) clenching, (3) protrusion of the lip, (4) maximum mouth opening and maximum tongue protrusion. This developed exercise was performed
several times each day.

extrapolated to fill in the post-assessment time points, in

accordance with the intention-to-treat concept. 3. Results

2.6. Statistical analysis
For each parameter, changes invariables were not observed after 10
weeks. Therefore, statistical analyses were performed only from
baseline through the 10-week measurement point. A two-factor
repeated-measures ANOVA was used to evaluate the efficacy of the
two treatment modalities (TE + MN vs. TE); Scheffe’s multiple
comparison test was used to compare mouth-opening limitation
and pain during each treatment period, Mann–Whitney U test (with
Bonferroni correction) was used to compare sound during each
treatment period. The same analyses were performed in the subgroup
analysis to clarify the pathological specificity of the treatment. Excel
add-in software (SSRI Co., Ltd., Tokyo, Japan) was used for all analyses.
All three parameters significantly improved over time in both
treatment groups (Fig. 5). These improvements continued until the
sixth measurement point; however, most improvements were
observed by the third measurement point, with the exception of
the TMJ sound. In the overall comparison of the two treatment
groups, TE + MN tended to be superior to TE with regard to mouth-
opening limitation and TMJ sound. However, ANOVA from the
baseline up to the sixth measurement point (10 weeks) and
Mann–Whitney revealed no statistically significant differences
between treatment groups with respect to changes in the mouth-
opening limitation. There was no statistically significant
interaction between time and treatment group for any of the
outcome measurements (P > 0.05).
206 K. Nagata et al. / journal of prosthodontic research 63 (2019) 202–209

Fig. 5. Changes in mouth-opening distance (mm), pain score and sound score (NRS), comparing TE + MN and TE.
Data points indicate the mean and 95% confidence interval.
The results of ANOVA and Scheffe’s multiple comparisons of mouth-opening distance and pain and Mann–Whitney U test (with Bonferroni correction) of sound from baseline
through 10 weeks are shown with p-values. No statistical difference was revealed between TE + MN and TE other than after the first treatment in mouth-opening distance.
TE + MN, standard therapy, including the self-exercise for temporomandibular disorder (TMD), plus Jog-manipulation. TE, standard therapy, including the self-exercise for
TMD.

The results of Scheffe’s test showed statistical differences Table 2. Results of magnetic resonance examination of the temporomandibular
between treatment groups after the first treatment in terms of joint at the second visit in each treatment method

mouth-opening limitation; the mean average increment was n 3a 3b

6.86 mm (95% CI = 8.12–5.55). In contrast, no significant differences
were observed after the second visit. No complications or side
effects were observed in both treatment groups during the
evaluation period.
The results of subgroup analysis regarding MRI examination for
TMJ in each treatment group showed no differences in ratio of the
pathological type by Fisher’s exact test (P = 1.00) (Table 2). The
incidence ratios of disc recapture in centric occlusion were 9/23
(39.1%) in TE + MN and 11/24 (45.8%) in TE before the second visit.
There was no statistical difference between the two treatment
groups (P = 0.77).
In the results of subgroup analysis regarding pathological
differences, ANOVA revealed statistical differences between the
two treatment groups only in the mouth-opening limitation of
pathological group 3a (Fig. 6-3a). The pain and sound score did not
differ among all pathological groups (Figs. 7 and 8). The results of
Scheffe’s test showed statistical differences between treatment
groups after the treatment at the first visit with regard to mouth-
opening limitation (Fig. 6). Subgroup analysis indicated a trend
similar to that of the comprehensive comparison, which combined
all three pathological types. The characteristic findings, based on
pathological state of TMD, were not clear.
4. Discussion
Mouth-opening limitation of TMD arises from multiple
causes, such as masticatory muscle disorder, TMJ disorder, and
central nervous system disorder. Nonetheless, disc displace-
ment without reduction of TMJ has been presumed to be a
TE + MN 4 5 14
TE 5 6 13
N, normal; 3a, disc-displacement with reduction; 3b, disc-displacement without
reduction.
There was no statistical difference between the two treatment groups (P = 0.77).
major mechanism of mouth-opening limitation. Hence, it is
reasonable that recapturing the disc is considered necessary to
improve this type of TMD, and that TMJ manipulation has been
used to restore the disc [16].
However, some case-studies have revealed that even if
manipulation was used and mouth-opening limitation improved
in patients with anterior disc displacement without reduction
(ADDWo/R), the disc recapturing was limited [26,27]. Moreover,
even when the disc is recaptured, a considerable number of cases
will be re-dislocated without symptomatic recurrence [28].
Because of these observations, negative views have been shared
regarding the effectiveness and necessity of manipulation techni-
ques; thus, the efficacy and necessity of the manipulation remain
controversial. For these reasons, we conducted an RCT on TMD
patients with mouth-opening limitation; we compared combined
standard treatment and manipulation with standard treatment
alone to evaluate the clinical effect of manipulation.
In the current criteria for DC/TMD [21], the diagnosis of TMD is
based on one of the following situations: (1) muscular pain, (2) TMJ
pain, (3) disc displacement, and (4) degeneration of TMJ. These
pathological situations may influence treatment results. However,
manipulation was originally designed for closed lock patients with
disc displacement without reduction to recapture the disc.
 K. Nagata et al. / journal of prosthodontic research 63 (2019) 202–209 207

Fig. 6. Changes in mouth-opening distance (mm) of TE + MN and TE in each pathological type.

Data points indicate the mean and 95% confidence interval. The statistical difference between the two treatment groups, by ANOVA, was observed only in the pathological 3a
type. Scheffe’s multiple comparisons showed significant differences only after treatment in every pathological type. TE + MN, standard therapy, including the self-exercise for
temporomandibular disorder (TMD), plus Jog-manipulation. TE, standard therapy, including the self-exercise for TMD.

Fig. 7. Changes in pain score TE + MN and TE in each pathological type.

Data points indicate the mean and 95% confidence interval. No statistical differences were observed between the two treatment groups by ANOVA and Scheffe’s multiple
comparisons. TE + MN, standard therapy, including the self-exercise for temporomandibular disorder (TMD), plus Jog-manipulation. TE, standard therapy, including the self-
exercise for TMD.
208 K. Nagata et al. / journal of prosthodontic research 63 (2019) 202–209
Fig. 8. Changes in sound score TE + MN and TE in each pathological type.
Data points indicate the mean and 95% confidence interval. No statistical differences were observed between the two treatment groups by Mann–Whitney U test (with
Bonferroni correction). TE + MN, standard therapy, including the self-exercise for temporomandibular disorder (TMD), plus Jog-manipulation. TE, standard therapy, including
the self-exercise for TMD.
Moreover, our previous RCT revealed that the pain was sufficiently
alleviated in both treatment groups; manipulation did not affect
pain for closed lock patients [19]. Therefore, we considered that
there was little need for classifying patients according to pain; we
evaluated disc displacement only in subgroup analysis.
The results of this overall comparison of TE + MN and TE showed
statistical differences only in the mouth-opening limitation after
the treatment at the first visit. This indicates that the effect of the
manipulation appeared to be limited, in contrast to what we had
expected prior to this study; moreover, the developed therapeutic
exercise demonstrated an effect similar to that of manipulation in
the long term. This conclusion was different from that of our
previous RCT [19], which revealed clinical superiority of manipu-
lation as analyzed by ANOVA (P = 0.000008).
We considered that the inconsistency might be caused by
differences in the exercise therapies used in the two RCTs. In the
previous study, we used only the molar pulldown type as the
therapeutic exercise, whereas in the present study, we combined
two types of therapeutic exercises: the pulldown and S-MFT.
Consequently, additional S-MFT may have led to improvement in
the symptoms of the TE treatment group. S-MFT combined four
types of exercises without the assistance of a patient’s fingers. Each
exercise produced an extension and contraction of the masticatory
muscle, the perioral muscle, the opening muscle, and hyoid bone
muscle. As a result of this complex effect, S-MFT is presumed to
improve the disorder of TMD at an early stage. Notably, the
maximum opening, accompanied by protrusion of the tongue, can
assist the smooth sliding motion of the condylar and enable the
stretching movement of digastric or suprahyoid muscles, which is
difficult in other exercises. Moreover, S-MFT does not require a
patient’s hand or finger support, as in other exercise therapies
including the pulldown type. Thus, patients were able to easily
apply S-MFT at any place and any time, even at work or when their
hands were otherwise occupied. We presume that these character-
istics are extremely useful in mandibular exercises, and that this is
the reason that the difference between TE + MN and TE was
reduced in our present RCT.
As described above, the effect of the manipulation seems to be
limited, compared with our expectations. If so, does manipulation
have no superiority over therapeutic exercise? From our finding,
6.86 mm (95% CI = 8.12–5.55 mm) improvement of mouth opening
was observed after the initial implementation of manipulation,
without increasing pain. This is considered to be a salutary effect
for patients with mouth-opening limitation. Notably, manipula-
tion had no effect for the pain and the sound, such that the
treatment effect was limited to mouth-opening limitation.
Therefore, we recommend that practitioners implement manipu-
lation only once, at the first visit for patients with mouth-opening
limitation; we also recommend guiding the patients through the
relevant therapeutic exercise continually from the first visit, even
when patients exhibit acute symptoms.
The difference of the control group was assumed to affect the
results of RCT. If no-treatment, education, some splints, or conven-
tional exercise therapy without S-MFT were only used for the control
group, the statistical difference may be clarified. However, when a
practitioner selects multimodal therapy combined with improved
exercise and habit control, the validity of the RCT using the no-
treatment control or education control will be disturbed. Therefore,
we conclude that our RCT exhibited limited applicability—to practi-
tioners mainly using rehabilitation therapy. The control group of this
study used the improved therapeutic exercise, which was presumed to
be effective for mouth-opening limitation.
In subgroup analysis, the recapturing ratio of the disc in centric
occlusion was not statistically different between TE + MN and TE.
Both recapturing ratios, including normal and ADDW/R, were
approximately 40%. In previous reports, the recapturing ratios after
 K. Nagata et al. / journal of prosthodontic research 63 (2019) 202–209
successful treatment of TMD were 10% [27] with four different
treatments, 36.6% (not including partial DDW/R in maximum
opening) with manipulation [26], and 18% with mandibular
manipulation [29]. Since our data were not inferior compared
with these results, our manipulation technique was presumed to
be relevant. Incidentally, MRI was acquired only once, between the
first and second visit in our subgroup analyses. Some patients may
have had normal or ADDW/R before the treatment; thus, the actual
recapturing ratio for DDW/R should be estimated at several
percent lower than the value we have reported in this study.
The recapturing ratio of the disc showed no statistical
difference between TE + MT and TE. This indicated that the
manipulation did not improve the dynamic of the disc, compared
to the optimized therapeutic exercise. Moreover, the change of sign
and symptoms between two treatment groups was not signifi-
cantly different with the exception of the mouth-opening
limitation of DDW/R (Fig. 6-3a). This exception indicates that
continuous manipulation contributes to the improvement of
condylar movement. However, this effect is observed only in
DDW/R, and the difference was approximately 5 mm near the
40 mm in the two treatment groups. These results indicate that the
recapturing of the disc by manipulation is less important clinically
than we had recognized previously, and that the recovery of
mobility of the restricted disc and condyle is more important. We
conclude that the mobility of condylar components is the main
purpose of the exercise or manipulation for patients with mouth-
opening limitation. An appropriate exercise therapy, such as
S-MFT, is presumed to be effective for symptomatic relief in TMD
patients with mouth-opening limitations, even when the disc
reduction could not be obtained in many cases. Manipulation
should be supplementarily used for the early improvement of
mouth-opening during the initial treatment.
5. Conclusion
This RCT comparing the comprehensive standard treatment,
including therapeutic exercise, and comprehensive standard
treatment plus manipulation, showed no statistical difference in
terms of mouth-opening limitation, pain, or sound, except for
mouth-opening limitation after the initial treatment. Subgroup
analyses regarding the pathological type of TMD indicated similar
results. These results revealed that the effect of the manipulation
was limited, in contrast to what we have shown in a previous RCT;
the developed therapeutic exercise seemed to have a similar effect
to that of manipulation over long term. The advantage of
manipulation was observed only during initial treatment. There-
fore, we encourage immediate implementation during the first
visit for TMD patients with mouth-opening limitation, in the
context of continual optimized therapeutic exercise.
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