Amplitude de movimento articular cervical, postura e atividade eletromiográfica da musculatura mastigatória na disfunção temporomandibular

fm Fisioterapia em Movimento Fisioter. mov. 1980-5918 Pontifícia Universidade Católica do Paraná Resumo Introdução: A disfunção temporomandibular (DTM) compreende alterações clínicas e sintomas que envolvem a articulação temporomandibular (ATM) e estruturas associadas. A ATM possui conexões anatômicas com a região cervical, onde os movimentos das vértebras cervicais ocorrem simultaneamente com a ativação dos músculos mastigatórios e dos movimentos da mandíbula. Objetivo: O objetivo foi verificar a relação entre achados do Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) com a eletromiografia de superfície (EMGs) da musculatura mastigatória, postura e flexibilidade cervical em mulheres com DTM. Método: Cinquenta mulheres com DTM, pelo RDC/TMD, com idade média de 27,0 ± 6,37 anos foram avaliadas quanto à postura craniocervical, flexibilidade cervical e EMGs da musculatura mastigatória. Resultados: Não houve diferença quanto às limitações relacionadas à função mandibular (LRFM), depressão, grau de dor e interferência no trabalho e atividades diárias, postura e EMGs entre os diagnósticos de DTM e entre a classificação muscular (p > 0,05). O comprometimento biarticular apresentou maior depressão (p = 0,023). O grupo com bruxismo apresentou maior grau de dor no momento (p = 0,001), e maior comprometimento na capacidade de trabalhar (p = 0,039). A DTM muscular e mista tiveram menor rotação à direita em comparação ao diagnóstico articular. Conclusão: Os diagnósticos de DTM, os variados comprometimentos articulares e musculares e a presença de bruxismo não apresentaram diferença quanto à postura e a EMGs. O comprometimento muscular está associado a uma menor rotação cervical à direita. As LRFM não interferiram na postura e na EMGs. A depressão tem associação com a dor. Introduction Temporomandibular disorder (TMD) is an umbrella term that covers a set of clinical signs and symptoms involving the temporomandibular joint (TMJ), masticatory (chewing) muscles and associated structures 1)- (6. The prevalence of this disorder ranges between 5 and 12% in the general population and 65% of patients experience associated pain 6. Women aged between 20 and 40 years are 4 to 6 times more likely to be affected than men, also exhibiting more pain, muscle sensitivity and other symptoms than their male counterparts. Despite the scarce data on the economic impact of TMD, it is expected to have an impact given the set of symptoms and presence of pain 6), (7. The physiopathology of this disorder is unclear and its etiology multifactorial, including joint trauma, occlusal discrepancies, joint hypermobility, skeletal problems, bruxism (teeth grinding), internal TMJ disorders, parafunctional habits, psychosocial factors and emotional stress 4), (6. It often overlaps with other pain disorders 5 and, except for dental pain, is the most common cause of orofacial pain 1), (3. The Research Diagnostic Criteria for Temporomandibular Disorder (RDC/TMD) is considered the most comprehensive tool for diagnosing and classifying TMD in myofascial pain, joint disc alterations, arthralgia, arthritis and osteoarthritis 8), (9. Surface electromyography (sEMG) can contribute to knowledge of muscle physiology as a complementary instrument in TMD assessment, as well as differential diagnosis and TMD monitoring10. Body posture has been described as a causal or risk factor. Temporomandibular disorder is not only related to the position of the jaw and skull, but also involves the cervical spine, suprahyoid and infrahyoid muscles, shoulders and thoracolumbar spine. Several studies have described greater prevalence of TMD signs and symptoms in patients with poor body posture when compared with those with no postural impairments 11. Likewise, cervical flexibility and the electrical activity of chewing muscles may also affect or be influenced by the function of the stomatognathic system. Patients with TMD report areas significantly more tense on palpations of the neck and shoulder muscles 12. Given the complexity of TMD, its multifactorial etiology, repercussions, varied and complex associated factors and different clinical pictures, no single field is capable of developing comprehensive knowledge regarding TMD. Thus, interdisciplinary studies and shared knowledge are vital to ensure a better understanding of this phenomenon. Considering the aforementioned information and the scarce studies that address joint range of motion, posture and electromyographic activity, this study sought to determine if there is a relationship between the presence of RDC/TMD, surface electromyography of the masseter and anterior temporalis muscles, posture and cervical flexibility in women with TMD. Methods This is an observational cross-sectional prospective study with an applied quantitative approach whose objectives are based on explanatory research. The study was conducted at the Guairacá Integrated Clinic belonging to Faculdade Guairacá in Guarapuava, state of Paraná, Brazil. It was approved by the Research Ethics Committee of the State University of Ponta Grossa (UEPG) on August 17, 2016 under protocol number 1.682.504 and registered on the Brazilian Clinical Trials Registry database under RBR-5F6ZW4. Volunteers were selected by advertising the study at Faculdade Guairacá, Guairacá Integrated Clinic, and on printed and electronic media. Sixty-two participants accepted the established conditions and signed an informed consent form. Inclusion criteria were: women aged between 18 and 40 years, diagnosed with TMD according to RDC/TMD Axes I and II. Exclusion criteria were: history of trauma, neoplasms or facial surgery, cognitive and neurological alterations, use of mobility aids, the presence of rheumatic disease, physical disability and pregnancy. Participants were advised of study objectives and procedures in accordance with ordinance 466/2012 of the National Health Council, which regulates studies with human beings. Sample size was determined based on the number of individuals who agreed to participate between January and May 2017. The final sample consisted of 50 women aged between 18 and 40 years, diagnosed with TMD according to Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), translated into Brazilian Portuguese and considered the gold standard for diagnosing TMD 13. This version was selected because a new updated translation currently underway was not yet available when data were collected. The RDC/TMD is a dual-axis classification system covering the physical (Axis I) and psychosocial components (Axis II) of TMD 14. Axis I classifies muscle disorders (muscular TMD), disc displacement, arthralgia, osteoarthritis and osteoarthrosis (articular TMD) and a combination of both (mixed TMD) 15; and Axis II provides information on the psychosocial aspect of TMD such as chronic pain, depressive symptoms, nonspecific physical symptoms including and excluding pain items, and jaw functional limitations 16. Range of motion (ROM) of the cervical spine was assessed using a Sanny® pendulum fleximeter (American Medical do Brasil, São José dos Campos, state of São Paulo, Brazil). The fleximeter is a gravity-dependent goniometer that provides more reliable measurements because the angle is produced by the effect of gravity, minimizing errors in the interpretation of the corresponding longitudinal axis. Except for cervical rotations performed in dorsal decubitus, all movements were analyzed with participants seated on a chair with their back straight, head positioned according to the Frankfurt plane, knees flexed at 90° and feet flat on the floor 17. Movements were actively executed 18 with three repetitions each, considering the average of the three measurements. Biophotogrammetry is a safe, accurate, reliable and reproducible method that detects postural symmetry, asymmetry, deviations and/or abnormalities between body segments. For postural assessment, participants were photographed using a 14.1 mega pixel SONY® Cyber-Shot DCS- w350 digital camera with 4× optical zoom (SONY BRASIL, São Paulo, state of São Paulo, Brazil). Head and neck posture were evaluated in the orthostatic position, with anterior and left lateral views. The camera was positioned one meter from the participants, with the height adjusted to the level of their left tragus using a professional universal tripod with bubble level 19. A plumb bob was suspended from the ceiling running anteriorly to the lateral malleolus and defining the true vertical line in the digital images. Points were marked on the participant’s left side using 16 mm-wide Styrofoam spheres according to the following anatomical points: the spinous process of the seventh cervical vertebra [C7], outer corner of the left eye, tragus of the left and right ears, suprasternal notch, and center of the chin 19. Posture was assessed based on the position of the participant’s head and neck in relation to the plumb bob. The following angles were analyzed for the left lateral view: 1. craniovertebral angle, based on the intersection of a straight line passing through the C7 spinous process and a horizontal line intercepting C7 in the sagittal plane; 2. head position angle, defined as the angle between the tragus manubrium line and the line extending from the center of the chin to the tragus; 3. Forward head posture angle, formed between the line connecting the tragus of the ear to the canthus of the eye and the horizontal line passing through the tragus 19. Angles assessed for the anterior view were: 4. the forward head posture angle, defined by the intersection of the straight line formed by the two tragi (left and right) and the horizontal line, and 5. the cervical rotation angle formed by the line between the chin and manubrium and true vertical line. Posture was assessed using Corel DrawX8® software (Corel Corporation, Ottawa, Ontario, Canada). The different points were marked with a mouse to form the body planes and analyzed based on the true vertical line, to determine possible body inclination or asymmetry of body structures 20. Surface electromyography (sEMG) is a noninvasive technique that can be used to assess muscle behavior and hyperactivity in TMD 21. Participants remain seated on a chair with a backrest, their feet apart, shoulders relaxed, hands resting on their thighs and head positioned in the Frankfurt plane 22. The masseter and anterior temporalis muscles were assessed bilaterally 23. Prior to sEMG signal collection, the skin was cleaned with a soft sponge and cotton wool soaked in 70% alcohol 24. The electrodes were placed on the muscle belly of each muscle, according to the direction of the muscle fibers and palpation of the muscle mass during contraction 25. Disposable LH-ED4020 double trace bipolar electrodes (Shanghai Litu Medical Appliances Co. Ltd.) were used. These electrodes measure 44 mm long, 21 mm wide and 20 mm from center to center and are registered with ANVISA under 80351690008. A square (30 mm) Maxicor reference electrode (Shanghai Intco Electrode Manufacturing Co. Ltd.) was used to reduce noise during acquisition (ANVISA registration no. 10299800009). After a three-minute rest, sEMG activity was recorded for 15 seconds, three times consecutively under the following conditions: 1. resting position, 2. maximum voluntary clenching (MVC, isometric), with two strips of Parafilm M® (American National CanTM, Chicago, USA) folded into 4 parts and positioned bilaterally on the first and second lower molars 10), (23), (26, 3. while chewing two Parafilm strips positioned bilaterally in time with a metronome calibrated to 60 beats a minute 10. The rest interval between chewing and isometric clenching readings was three minutes and one minute in the resting position. Figure 1 Rotation angle. An eight-channel signal acquisition module was used (EMG 830C, EMG System do Brasil Ltda®, S. J. Campos, São Paulo state, Brazil), with a sampling frequency of 2 kHz per channel, 16-bit resolution, amplifier gain of 2000, common mode rejection ratio > 100 dB and 20-500 Hz filters. The system was connected via a USB port to a Lenovo B40-70 laptop computer (Lenovo Group LTD, Morrisville, North Carolina, USA), with a 1.7 GHz Intel Core i3 4005U processor, 3 MB cache, 4 GB DDR3 1600 MHz memory RAM and Microsoft Windows 8.1 operating system (64 bits) on which the data were saved for subsequent analysis in EMGLab 2.0 software. Ten seconds of the signal were used to estimate the root mean square (RMS) amplitude, with the first three and last two seconds of the 15-second reading disregarded for the recorded data. Signal amplitude in all three conditions was expressed as a percentage of the maximum potential RMS recorded in the three MVC readings (MVC%). The variables were estimated based on the MVC% for the resting position: MVC % rest = ( RMS rest × 100 ) / RMS MVC and chewing: %MVCchewing=(RMSchewing×100)/RMSMVC10. All the assessments (RDC/TMD, cervical range of motion, postural assessment and sEMG of the chewing muscles) were performed by a trained physical therapist. The results were analyzed using IBM SPSS 20 software. The mean, standard deviation, median, interquartile range, minimum and maximum value, frequency and percentages were used for descriptive results and nonparametric tests for inferential statistics, namely the Kruskal Wallis and Mann-Whitney test for comparisons and Spearman test for correlations. Significance was set at less than or equal to 0.05. Results The sample consisted of 50 women with an average age of 27.0 ± 6.37 years. Participants exhibited complete dentition, with 24 to 32 teeth, and most reported (76%) clenching and bruxism. The sample was divided into muscle disorders (muscular TMD), disc displacement, arthralgia, osteoarthritis and osteoarthrosis (articular TMD) and a combination of the two (mixed TMD), as well as muscle dysfunction and joint impairment, as shown in Table 1. Table 1 Participant characterization in terms of temporomandibular disorder diagnosis, side of the joint impairment and muscle dysfunction classification Oral condition / Diagnosis n - % General diagnosis Muscular 15 - 30 Articular 2 - 4 Mixed 33 - 66 Side of the joint impairment No joint dysfunction 15 - 30 Both joints 19 - 38 Right joint 7 - 14 Left joint 9 - 18 Muscle dysfunction classification No diagnosis 2 - 4 Muscular 16 - 32 Muscular with limited mouth opening 32 - 64 Jaw function limitations, depression and pain assessed by RDC/TMD Axis II showed no differences regarding TMD diagnoses and muscle dysfunction. Depression differed considering joint impairment and pain for the presence of bruxism, as shown in Table 2. Women with no joint impairment exhibited higher depression scores (0.90; 0.55 - 1.50) than those with monoarticular dysfunction (0.37; 0.15 - 0.83), (p = 0.008), while those with biarticular impairment (0.80; 0.45 - 1.60) had better scores than those with only one compromised joint (0.37; 0.15 - 0.83), (p = 0.023). The group with bruxism experienced more pain at assessment (3.0; 2.0 - 6.0) than those without the condition (0; 0 - 2.0), (p = 0.001), as well as reduced work ability due to pain (1.5; 0 - 3.0) when compared with the bruxism-free group (0; 0 - 0.75), (p = 0.039). Table 2 Comparison of limitation, depression and pain assessed by RDC/TMD Axis II between groups with TMD diagnoses, muscle and joint dysfunction and the presence of bruxism (Kruskal Wallis Test) A B C D p p p p Jaw function limitations 0.451 0.682 0.171 0.069 Depression 0.222 0.547 0.017* 0.440 Pain level at assessment 0.147 0.148 0.928 0.001* Worst pain level over the last six months 0.086 0.072 0.891 0.138 Average pain level over the last six months 0.120 0.123 0.639 0.076 Sick days taken due to pain in the last six months 0.479 0.824 0.121 0.510 Extent to which pain interfered in daily activities 0.209 0.191 0.604 0.452 Extent to which pain interfered in leisure, social and family activities 0.265 0.203 0.239 0.495 Extent to which pain affected work ability 0.307 0.390 0.359 0.039* Note: A: muscular, articular and mixed TMD; B: muscle dysfunction (no dysfunction, muscle dysfunction, muscle dysfunction with limited mouth opening); C: joint impairment (no impairment, monoarticular, biarticular); D: reported presence or not of bruxism/clenching. The muscular and mixed TMD groups showed reduced cervical ROM in right rotation (69.00; 64.5 - 79.3 and 78.60; 71.6 - 85.0, respectively) when compared with those with articular TMD (93.15; 91.3 - 95.0, p = 0.037 and p = 0.033), as shown in Table 3. Table 3 Comparison of postural angles, cervical flexibility and surface electromyography between groups with TMD diagnoses, muscle and joint dysfunction and the presence of bruxism (Kruskal- Wallis Test) A B C D Posture p p p p Craniovertebral 0.611 0.428 0.879 0.803 Head position 0.433 0.990 0.420 0.166 Head tilt 0.820 0.800 0.370 0.928 Forward head posture 0.980 0.237 0.865 0.937 Cervical rotation 0.473 0.393 0.742 0.084 Cervical ROM Cervical flexion 0.163 0.181 0.623 0.883 Cervical extension 0.290 0.538 0.058 0.510 Right lateral cervical inclination 0.283 0.107 0.258 0.964 Left lateral cervical inclination 0.490 0.825 0.260 0.847 Right cervical rotation 0.021* 0.047* 0.075 0.937 Left cervical rotation 0.948 0.732 0.184 0.023* Surface electromyography Isometric RMS Right masseter muscle 0.809 0.721 0.997 0.928 Left masseter muscle 0.828 0.584 0.630 0.666 Right temporalis muscle 0.408 0.154 0.848 0.733 Left temporalis muscle 0.692 0.266 0.382 0.683 Chewing RMS Right masseter muscle 0.819 0.785 0.926 0.617 Left masseter muscle 0.909 0.690 0.661 0.803 Right temporalis muscle 0.757 0.245 0.981 0.964 Left temporalis muscle 0.755 0.412 0.468 0.803 Resting RMS Right masseter muscle 0.706 0.201 0.482 0.076 Left masseter muscle 0.489 0.642 0.425 0.229 Right temporalis muscle 0.324 0.355 0.650 0.140 Left temporalis muscle 0.151 0.323 0.323 0.650 Chewing MVC% Right masseter muscle 0.257 0.995 0.199 0.134 Left masseter muscle 0.172 0.862 0.141 0.166 Right temporalis muscle 0.668 0.481 0.885 0.716 Left temporalis muscle 0.231 0.903 0.222 0.318 Resting MVC% Right masseter muscle 0.891 0.932 0.902 0.481 Left masseter muscle 0.975 0.775 0.937 0.097 Right temporalis muscle 0.682 0.562 0.857 0.066 Left temporalis muscle 0.499 0.119 0.329 0.146 Note: A: muscular, articular and mixed TDM; B: muscle dysfunction (no dysfunction, muscle dysfunction, muscle dysfunction with limited mouth opening); C: joint impairment (no impairment, monoarticular, biarticular); D: reported presence or not of bruxism/clenching. For the sample divided according to muscle dysfunction, the myofascial pain (82.95; 66.0 - 88.0) and myofascial pain with limited mouth opening groups (77.00; 67.8 - 79.6) exhibited less cervical ROM in right rotation when compared with the group with no muscle dysfunction (93.15; 91.3 - 95.0, p = 0.049 and p = 0.028, respectively), also shown in Table 3. Participants without bruxism had decreased ROM in left cervical rotation (75.95; 68.35 - 80.90) when compared with those without the condition (81.95; 77.22 - 87.15, p = 0.023), also shown in Table 3. The muscular and mixed TMD groups showed reduced cervical ROM in right rotation (69.00; 64.5 - 79.3 and 78.60; 71.6 - 85.0, respectively) when compared with those with articular TMD (93.15; 91.3 - 95.0, p = 0.037 and p = 0.033), as shown in Table 3. For the sample divided according to muscle dysfunction, the myofascial pain (82.95; 66.0 - 88.0) and myofascial pain with limited mouth opening groups (77.00; 67.8 - 79.6) exhibited less cervical ROM in right rotation when compared with the group with no muscle dysfunction (93.15; 91.3 - 95.0, p = 0.049 and p = 0.028, respectively), also shown in Table 3. Participants without bruxism had decreased ROM in left cervical rotation (75.95; 68.35 - 80.90) when compared with those without the condition (81.95; 77.22 - 87.15, p = 0.023), also shown in Table 3. For variables related to posture, sEMG showed no correlation with jaw function limitations. There was a weak negative correlation between the ROM of right lateral cervical inclination and jaw function limitations, as shown in Table 4. Table 4 Correlation between jaw function limitations and postural angles, cervical flexibility and surface electromyography (Spearman Test) Jaw function limitations Posture ρ Ρ Craniovertebral 0.170 0.237 Head position 0.104 0.472 Head tilt 0.127 0.379 Forward head posture −0.064 0.661 Cervical rotation 0.021 0.883 Cervical ROM Cervical flexion 0.205 0.153 Cervical extension −0.243 0.089 Right lateral cervical inclination −0.315 0.026* Left lateral cervical inclination −0.099 0.496 Right cervical rotation −0.266 0.062 Left cervical rotation −0.098 0.499 Surface electromyography Isometric RMS Right masseter muscle −0.115 0.427 Left masseter muscle −0.027 0.850 Right temporalis muscle −0.051 0.723 Left temporalis muscle 0.064 0.661 Chewing RMS Right masseter muscle 0.023 0.876 Left masseter muscle −0.154 0.285 Right temporalis muscle −0.215 0.134 Left temporalis muscle 0.128 0.376 Resting RMS Right masseter muscle −0.048 0.741 Left masseter muscle 0.060 0.681 Right temporalis muscle 0.065 0.653 Left temporalis muscle 0.082 0.569 Chewing MVC% Right masseter muscle −0.115 0.427 Left masseter muscle −0.027 0.850 Right temporalis muscle −0.051 0.723 Left temporalis muscle 0.064 0.661 Resting MVC% Right masseter muscle 0.023 0.876 Left masseter muscle −0.154 0.285 Right temporalis muscle −0.215 0.134 Left temporalis muscle 0.128 0.376 Note: ρ: Spearman’s correlation coefficient. There was a positive correlation between depression, pain interference in daily activities, leisure and work ability and jaw function limitations, as shown in Table 5. Table 5 Correlation between jaw function limitations, depression and pain assessed by RDC/DTM Axis II (Spearman test) Jaw function limitations ρ p Depression 0.343 0.015* Pain level at assessment 0.173 0.230 Worst pain level in the last six months 0.246 0.085 Average pain level over the last six months 0.187 0.193 Sick days taken due to pain in the last six months 0.252 0.077 Extent to which pain interfered in daily activities 0.298 0.036* Extent to which pain interfered in leisure, social and family activities 0.333 0.018* Extent to which pain affected work ability 0.341 0.015* Note: ρ: Spearman’s correlation coefficient. Discussion Almost 5% of the global population has some form of temporomandibular disorder (TMD) and one third exhibit at least one TMD symptom 27. Epidemiological studies suggest that TMD-related symptoms are more prevalent in 20 to 40-year-old women 5),(10),(28. This has been attributed to inflammatory responses to stress, sociocultural behavior in response to pain and effects related to hormonal characteristics. One hypothesis is that endogenous reproductive hormones play a role in TMD-related pain, but the exact mechanism of these hormonal effects remains unknown 28. Given the distribution of TMD in the population, our study opted for a sample consisting primarily of women aged 18 to 40 years. The average age of participants was 27.48 ± 6.37 years. According to Berger et al. 29 and Magalhães et al. 30, bruxism compromises the masticatory system and is considered a major etiological factor in TMD. A common condition in patients with TMD, it is predominantly associated with muscle disorders, but can also be attributed to temporomandibular joint (TMJ) dysfunction. Reissmann et al. 31 found that bruxism is associated with a greater incidence of painful TMD. Huhtela et al. 32 also related the presence of bruxism to pain and TMJ dysfunction, with women who reported bruxism experiencing a higher pain level and reduced work ability due to pain. Magalhães et al. 30 reported that 52% of individuals with TMD exhibited bruxism and those with bruxism were twice as likely to develop TMD. These studies corroborate our findings, in which 76% of women with TMD reported suffering from bruxism. Our study showed a correlation between jaw function limitations and high depression scores, interference of pain in daily and leisure activities and the extent to which pain affected work ability. Similarly, Graciola and Silveira 33 found a correlation between TMD and stress. Patients with high stress levels exhibited a greater incidence of mild and moderate TMD and were the only group to display severe TMD. Al-Khotani et al. 34 found that children with TMD and pain experienced greater anxiety, depression and somatic complaints than the group without TMD. In a study by Lei et al. 35, the muscular TMD group displayed significantly higher anxiety levels than the control group. By contrast, Martins et al. 36 found no association between TMD and stress. According to Rocha, Croci and Caria 37, several authors have reported that postural problems involving the cervical spine and skull can also cause TMD. The TMJ is connected to the neck region via muscles and ligaments, forming a functional complex, in which movements of the atlanto-occipital joint and cervical vertebrae occur simultaneously to activation of the chewing muscles and jaw movements 38. Although the association between TMD and craniocervical posture has been studied, questions remain. Several studies have shown that individuals with TMD exhibit cervical spine and head posture changes and that body posture is related to dysfunctions of the stomatognathic system 39)- (43; however, other investigations have not established this correlation 44)- (46. In our study, there was a significant difference in postural angles between muscular, articular and mixed TMD diagnoses. A similar result was reported by Faulin et al. 45 and Câmara-Souza et al. 46, who demonstrated a relation between cervical posture in the sagittal and frontal planes and TMD. Andrade 47 found no significant differences in head posture between patients with muscular TMD and Rocha et al. 44 studied the postural characteristics of individuals without pain exhibiting disc displacement compared with those without TMD and observed no significant intergroup differences. According to Rocha et al. 44 and Munhoz et al. 48, studies on the relationship between postural deviations and the functional health of the temporomandibular system are controversial and inconclusive. This is because authors use to consider TMD as a whole without considering the specific signs and symptoms of individuals. Azato 41 and Castillo et al. 42 reported that postural deviations can interfere in the function and organization of the TMJ. The authors observed a significant improvement in the vertical alignment of the head and less pain in the treatment group. This may be because the neck muscles and those of the stomatognathic system play an important role in maintaining head balance, and interventions at any level can result in changes in this complex. As such, manipulating the jaw muscles changes typical head posture 49. Despite this anatomical, muscular and neural proximity, there was no difference in postural angles among those with and without bruxism/clenching. According to Munhoz 50, age, gender and dental malocclusion are directly related to specific postural changes in the cervical spine and shoulders, as well as postural deviations in the anterior-interior chain of the hip. These factors can interfere in the results and conclusions of studies aimed at analyzing the correlation between body posture and TMD, which may be the reason for the lack of consensus between studies. The results obtained by Baldini et al. 51 combined with previous data indicated that jaw position does not influence active cervical mobility in healthy patients. In our study, the muscular and mixed TMD groups showed significantly less cervical rotation to the right than those with articular TMD. In the muscular TMD subgroups, the myofascial pain group with limited mouth opening exhibited less cervical rotation to the right, followed by the myofascial group, with no significant differences. The group with no muscular diagnosis displayed the greatest rotation, with significant differences when compared with the other groups, suggesting that masticatory muscle dysfunction most influenced cervical mobility. Similar findings were reported by Ballenberger, et al. 52, who reported reduced cervical mobility in subjects with mixed TMD, followed by muscular TMD. Extension mobility was most affected in the mixed and muscular TMD groups and flexion mobility the least compromised. In our study, those with bruxism/clenching had significantly larger angles in left cervical rotation, with no statistical difference for the remaining movements. The decline in cervical mobility may be due to changes in the TMJ. Costa 53 found that neck disability was significantly greater in patients with muscular TMD when compared with the control group without the disorder and observed a negative correlation between neck disability and the pressure pain threshold of stomatognathic structures. However, study results are still contradictory. Greenbaum et al. 54 observed a significant limitation in upper cervical rotation in patients with myogenic TMD. On the other hand, pure physiological cervical movements in these patients did not differ from those recorded in individuals without TMD. In contrast, in our study, the greater the jaw function limitations, the smaller the angle of right lateral cervical inclination. According to Von Piekartz et al. 38, the more severe the TMD, the greater the cervical musculoskeletal dysfunction and the greater the dysfunction and pain in the temporomandibular region, the higher the levels of cervical musculoskeletal impairment. Guarda-Nardini et al. 55, Grondin and Hall 56 and Walczyńska-Dragon et al. 57 showed that TMJ interventions improved cervical ROM and reduced cervical pain. However, there is no record in the literature on whether cervical mobility is influenced differently by the various types of TMD. In our study, comparison of cervical fleximetry values between the articular, monoarticular and biarticular involvement groups showed no intergroup differences. There is evidence that TMD influences cervical mobility. Masticatory muscle activity may be a risk indicator in TMD due to the association between hyperactivity of these muscles and pain-related diagnoses 58. Individuals with TMD were more susceptible to fatigue than healthy controls 59), (60. In a study by Woźniak et al. 61, masticatory muscle fatigue increased in direct proportion to the severity of TMD symptoms in the patients studied. In our study, RMS values in raw and normalized sEMG signals did not differ between women with and without bruxism/clenching. Several studies address the influence of TMD severity with surface electromyography of the chewing muscles. In TMD, especially with more severe symptoms, the masticatory muscles exhibited hyperactivity 22. De Paiva Tosato al. 9, Lauriti et al. 10 and Mazzetto et al. 62 showed that EMG activity of the chewing muscles was positively correlated with the severity of TMD. Regarding TMD severity, our study found no correlation between jaw function limitations and raw and normalized EMG values. In a study by Santana-Mora et al. 63, the RMS values of resting anterior temporal and masseter muscles and maximum voluntary clenching were greater in individuals with TMD when compared with the control group, with no significant differences. Dos Santos Berni et al. 23 obtained the same results, but with significant differences. In a study by Rodrigues et al. 64, the TMD group displayed significantly higher RMS in the masticatory muscles during chewing than the control group, who showed more symmetrical muscle activity than those with TMD. Li et al. 65 reported similar findings, with electrical activity differing between the TMD and control groups. Bortolazzo et al. corroborate these results 26. Upper cervical manipulation in women with muscular TDM stabilized the electrical activity of chewing muscles. The RMS of the anterior temporal and masseter muscles declined at rest but increased during isometric contraction (clenching). Strini et al. 66 and Chaves et al. 67 compared healthy individuals and patients with TMD and observed different results from those of other studies. Individuals with TMD obtained similar electrical activity values (raw and normalized RMS) for masticatory muscles when compared with the control group. There was no control group without TMD in our study, which may justify the results. The sample was divided into muscular, articular and mixed TMD, with no significant intergroup differences in RMS values for raw and normalized sEMG. The results obtained partially corroborate the findings of other studies. There is still no consensus or clear parameter regarding the influence of TMD on chewing muscle EMG activity, body posture and cervical mobility. This disparity may be due to the different TMD diagnoses, which go beyond the muscular, articular and mixed classifications, the various assessment methods for muscle electrical activity and body posture, multi-causality and the different aggravating factors of this complex group of functional alterations involved in TMD. Thus, the results of our study indicate the need for further studies regarding possible changes in electromyographic activity in the different types of TMD and if they are a cause or consequence of TMD. The limitations of our study are the different number of subjects in the muscular, articular and mixed TMD groups, as well as the complexity and diversity of signs and symptoms in the different forms of the disorder. Conclusion The predominant diagnosis was mixed TMD, with no difference in posture or masticatory muscle electrical activity between TMD diagnoses, the different types of muscle and joint dysfunction and the presence or not of bruxism. Cervical ROM in right rotation was smaller in the muscular and mixed TMD groups when compared with those with articular TMD. For the sample divided according to muscle dysfunction, the myofascial pain and myofascial pain with limited mouth opening groups exhibited smaller ROM for cervical rotation to the right when compared with the control group with no muscular diagnosis. Participants without bruxism had decreased ROM in left cervical rotation when compared with those without the condition. For variables related to posture, sEMG showed no correlation with jaw function limitations. High depression scores were accompanied by greater pain interference in daily activities, leisure and work ability, with jaw function limitations. References 1 1. Tomaz-Morais JF, Lucena LBS, Mota IA, Pereira AKFTC, Lucena BTL, Castro RD, et al. Temporomandibular disorder is more prevalent among patients with primary headaches in a tertiary outpatient clinic. Arq Neuro-Psiquiatria. 2015;73 (11):913-7. Tomaz-Morais JF Lucena LBS Mota IA Pereira AKFTC Lucena BTL Castro RD Temporomandibular disorder is more prevalent among patients with primary headaches in a tertiary outpatient clinic Arq Neuro-Psiquiatria 2015 73 11 913 917 2 2. Conti PC, Corrêa AS, Lauris JR, Stuginski-Barbosa J. Management of painful temporomandibular joint clicking with different intraoral devices and counseling: a controlled study. J Appl Oral Sci. 2015;23(5):529-35. Conti PC Corrêa AS Lauris JR Stuginski-Barbosa J Management of painful temporomandibular joint clicking with different intraoral devices and counseling: a controlled study J Appl Oral Sci 2015 23 5 529 535 3 3. Dantas AMX, Santos EJL, Vilela RM, Lucena LBS. Perfil epidemiológico de pacientes atendidos em um serviço de controle da dor orofacial. Rev Odontol Unesp. 2015;44(6):313-9. Dantas AMX Santos EJL Vilela RM Lucena LBS Perfil epidemiológico de pacientes atendidos em um serviço de controle da dor orofacial Rev Odontol Unesp 2015 44 6 313 319 4 4. Piccin CF, Pozzebon D, Chiodelli L, Boufleus J, Pasinato F, Corrêa ECR. Aspectos clínicos e psicossociais avaliados por critérios de diagnóstico para disfunção temporomandibular. Rev CEFAC. 2016;18(1):113-9. Piccin CF Pozzebon D Chiodelli L Boufleus J Pasinato F Corrêa ECR Aspectos clínicos e psicossociais avaliados por critérios de diagnóstico para disfunção temporomandibular Rev CEFAC 2016 18 1 113 119 5 5. Sanders AE, Jain D, Sofer T, Kerr KF, Laurie CC, Shaffer JR, et al. GWAS identifies new loci for painful temporomandibular disorder: Hispanic Community Health Study/Study of Latinos. J Dent Res. 2017;96(3):277-84. Sanders AE Jain D Sofer T Kerr KF Laurie CC Shaffer JR GWAS identifies new loci for painful temporomandibular disorder: Hispanic Community Health Study/Study of Latinos J Dent Res 2017 96 3 277 284 6 6. Celakil T, Muric A, Gokcen Roehlig B, Evlioglu G, Keskin H. Effect of high-frequency bio-oxidative ozone therapy for masticatory muscle pain: a double-blind randomised clinical trial. J Oral Rehabil. 2017;44(6):442-51. Celakil T Muric A Gokcen Roehlig B Evlioglu G Keskin H Effect of high-frequency bio-oxidative ozone therapy for masticatory muscle pain: a double-blind randomised clinical trial J Oral Rehabil 2017 44 6 442 451 7 7. Ferreira CLP, Silva MAMR, Felício CM. Sinais e sintomas de desordem temporomandibular em mulheres e homens. CoDAS. 2016;28(1):17-21. Ferreira CLP Silva MAMR Felício CM Sinais e sintomas de desordem temporomandibular em mulheres e homens CoDAS 2016 28 1 17 21 8 8. Ahrari F, Madani AS, Ghafouri ZS, Tunér J. The efficacy of low-level laser therapy for the treatment of myogenous temporomandibular joint disorder. Lasers Med Sci. 2014;29(2):551-7. Ahrari F Madani AS Ghafouri ZS Tunér J The efficacy of low-level laser therapy for the treatment of myogenous temporomandibular joint disorder Lasers Med Sci 2014 29 2 551 557 9 9. Tosato JP, Caria PH, Gomes CA, Berzin F, Politti F, Gonzalez TO, et al. Correlation of stress and muscle activity of patients with different degrees of temporomandibular disorder. J Phys Ther Sci. 2015;27(4):1227-31. Tosato JP Caria PH Gomes CA Berzin F Politti F Gonzalez TO Correlation of stress and muscle activity of patients with different degrees of temporomandibular disorder J Phys Ther Sci 2015 27 4 1227 1231 10 10. Lauriti L, Motta LJ, Godoy CHL, Biasotto-Gonzalez DA, Politti F, Mesquita-Ferrari RA, et al. Influence of temporomandibular disorder on temporal and masseter muscles and occlusal contacts in adolescents: an electromyographic study. BMC Musculoskelet Disord. 2014;15(1):123. Lauriti L Motta LJ Godoy CHL Biasotto-Gonzalez DA Politti F Mesquita-Ferrari RA Influence of temporomandibular disorder on temporal and masseter muscles and occlusal contacts in adolescentes: an electromyographic study BMC Musculoskelet Disord 2014 15 1 123 123 11 11. Fernández RF, Carter P, Muñoz S, Silva H, Venegas GHO, Cantin M, et al. Evaluation of validity and reliability of a methodology for measuring human postural attitude and its relation to temporomandibular joint disorders. Singapore Med J. 2016;57(4):204-8. Fernández RF Carter P Muñoz S Silva H Venegas GHO Cantin M Evaluation of validity and reliability of a methodology for measuring human postural attitude and its relation to temporomandibular joint disorders Singapore Med J 2016 57 4 204 208 12 12. Santander H, Zúñiga C, Miralles R, Valenzuela S, Santander MC, Gutiérrez MF, et al. The effect of a mandibular advancement appliance on cervical lordosis in patients with TMD and cervical pain. Cranio. 2014;32(4):275-82. Santander H Zúñiga C Miralles R Valenzuela S Santander MC Gutiérrez MF The effect of a mandibular advancement appliance on cervical lordosis in patients with TMD and cervical pain Cranio 2014 32 4 275 282 13 13. Pereira Júnior FJ, Favilla EE, Dworkin S, Huggins K. Critérios de diagnóstico para pesquisa das disfunções temporomandibulares (RDC/TMD): tradução oficial para a língua portuguesa. JBC J Bras Clin Odontol Integr. 2004;8(47):384-95. Pereira FJ Júnior Favilla EE Dworkin S Huggins K Critérios de diagnóstico para pesquisa das disfunções temporomandibulares (RDC/TMD): tradução oficial para a língua portuguesa JBC J Bras Clin Odontol Integr 2004 8 47 384 395 14 14. Bayat M, Abbasi AJ, Noorbala AA, Mohebbi SZ, Moharrami M, Yekaninejad MS. Oral health-related quality of life in patients with temporomandibular disorders: a case-control study considering psychological aspects. Int J Dent Hyg. 2018;16(1):165-70. Bayat M Abbasi AJ Noorbala AA Mohebbi SZ Moharrami M Yekaninejad MS Oral health-related quality of life in patients with temporomandibular disorders: a case-control study considering psychological aspects Int J Dent Hyg 2018 16 1 165 170 15 15. Cordeiro PC, Guimaraes JP, Souza VA, Dias IM, Silva JN, Devito KL, et al. Temporomandibular joint involvement in rheumatoid arthritis patients: association between clinical and tomographic data. Acta Odontol Latinoam. 2016;29(3):123-9. Cordeiro PC Guimaraes JP Souza VA Dias IM Silva JN Devito KL Temporomandibular joint involvement in rheumatoid arthritis patients: association between clinical and tomographic data Acta Odontol Latinoam 2016 29 3 123 129 16 16. Osiewicz MA, Lobbezoo F, Loster BW, Loster JE, Manfredini D. Frequency of temporomandibular disorders diagnoses based on RDC/TMD in a Polish patient population. Cranio. 2017;36(5):304-10. Osiewicz MA Lobbezoo F Loster BW Loster JE Manfredini D Frequency of temporomandibular disorders diagnoses based on RDC/TMD in a Polish patient population Cranio 2017 36 5 304 310 17 17. Aranha MF, Müller CEE, Gavião MBD. Pain intensity and cervical range of motion in women with myofascial pain treated with acupuncture and electroacupuncture: a double-blinded, randomized clinical trial. Braz J Phys Ther. 2015;19(1):34-43. Aranha MF Müller CEE Gavião MBD Pain intensity and cervical range of motion in women with myofascial pain treated with acupuncture and electroacupuncture: a double-blinded, randomized clinical trial Braz J Phys Ther 2015 19 1 34 43 18 18. Gurgel FFA. Amplitude dos movimentos craniomandibulares e cervicais e limiar de dor após manipulação osteopática da articulação atlanto-axial [dissertation]. Mossoró: Universidade do Estado do Rio Grande do Norte; 2015. Gurgel FFA Amplitude dos movimentos craniomandibulares e cervicais e limiar de dor após manipulação osteopática da articulação atlanto-axial 2015 dissertation Mossoró Universidade do Estado do Rio Grande do Norte 19 19. Salahzadeh Z, Maroufi N, Ahmadi A, Behtash H, Razmjoo A, Gohari M, et al. Assessment of forward head posture in females: observational and photogrammetry methods. J Back Musculoskelet Rehabil. 2014;27(2):131-9. Salahzadeh Z Maroufi N Ahmadi A Behtash H Razmjoo A Gohari M Assessment of forward head posture in females: observational and photogrammetry methods J Back Musculoskelet Rehabil 2014 27 2 131 139 20 20. Macedo RMB, Ricieri DV, Ulbricht L, Preis C, Duarte JM, Bertassoni Neto L. Análise cinemática 2D da postura ortostática de ciclistas lombálgicos. Rev Uniandrade. 2013;14(1):7-23. Macedo RMB Ricieri DV Ulbricht L Preis C Duarte JM Bertassoni L Neto Análise cinemática 2D da postura ortostática de ciclistas lombálgicos Rev Uniandrade 2013 14 1 7 23 21 21. Choi KH, Kwon OS, Jerng UM, Lee SM, Kim LH, Jung J. Development of electromyographic indicators for the diagnosis of temporomandibular disorders: a protocol for an assessor-blinded cross-sectional study. Integr Med Res. 2017;6(1):97-104. Choi KH Kwon OS Jerng UM Lee SM Kim LH Jung J Development of electromyographic indicators for the diagnosis of temporomandibular disorders: a protocol for an assessor-blinded cross-sectional study Integr Med Res 2017 6 1 97 104 22 22. Lauriti L, Silva PF, Politti F, Biasotto-Gonzalez DA, Fernandes KP, Mesquita-Ferrari RA, et al. Pattern of electromyographic activity in mastication muscles of adolescents with temporomandibular disorder. J Phys Ther Science. 2013;25(10):1303-7. Lauriti L Silva PF Politti F Biasotto-Gonzalez DA Fernandes KP Mesquita-Ferrari RA Pattern of electromyographic activity in mastication muscles of adolescents with temporomandibular disorder J Phys Ther Science 2013 25 10 1303 1307 23 23. Santos Berni KC, Dibai-Filho AV, Pires PF, Rodrigues-Bigaton D. Accuracy of the surface electromyography RMS processing for the diagnosis of myogenous temporomandibular disorder. J Electromyogr Kinesiol. 2015;25(4):596-602. Santos Berni KC Dibai-Filho AV Pires PF Rodrigues-Bigaton D Accuracy of the surface electromyography RMS processing for the diagnosis of myogenous temporomandibular disorder J Electromyogr Kinesiol 2015 25 4 596 602 24 24. Herpich CM, Leal-Junior ECP, Amaral AP, Tosato JP, Glória IP, Garcia MB et al. Effects of phototherapy on muscle activity and pain in individuals with temporomandibular disorder: a study protocol for a randomized controlled trial. Trials. 2014;15:491. Herpich CM Leal-Junior ECP Amaral AP Tosato JP Glória IP Garcia MB et al Effects of phototherapy on muscle activity and pain in individuals with temporomandibular disorder: a study protocol for a randomized controlled trial Trials 2014 15 491 491 25 25. Godoy CH, Silva PF, Araujo DS, Motta LJ, Biasotto-Gonzalez DA, Politti F, et al. Evaluation of effect of low-level laser therapy on adolescents with temporomandibular disorder: study protocol for a randomized controlled trial. Trials. 2013;14:229. Godoy CH Silva PF Araujo DS Motta LJ Biasotto-Gonzalez DA Politti F Evaluation of effect of low-level laser therapy on adolescents with temporomandibular disorder: study protocol for a randomized controlled trial Trials 2013 14 229 229 26 26. Bortolazzo GL, Pires PF, Dibai-Filho AV, Berni KCS, Rodrigues BM, Rodrigues-Bigaton D. Efeitos da manipulação cervical alta sobre a atividade eletromiográfica dos músculos mastigatórios e amplitude de movimento de abertura da boca em mulheres com disfunção temporomandibular: ensaio clínico randomizado e cego. Fisioter Pesqui. 2015;22(4):426-34. Bortolazzo GL Pires PF Dibai-Filho AV Berni KCS Rodrigues BM Rodrigues-Bigaton D Efeitos da manipulação cervical alta sobre a atividade eletromiográfica dos músculos mastigatórios e amplitude de movimento de abertura da boca em mulheres com disfunção temporomandibular: ensaio clínico randomizado e cego Fisioter Pesqui 2015 22 4 426 434 27 27. Aksakalli S, Temucin F, Pamukcu A, Ezirganli S, Kazancioglu HO, Malkoc MA. Effectiveness of two different splints to treat temporomandibular disorders. J Orofac Orthop. 2015;76(4):318-27. Aksakalli S Temucin F Pamukcu A Ezirganli S Kazancioglu HO Malkoc MA Effectiveness of two different splints to treat temporomandibular disorders J Orofac Orthop 2015 76 4 318 327 28 28. Lora VR, Canales GL, Gonçalves LM, Meloto CB, Barbosa CM. Prevalence of temporomandibular disorders in postmenopausal women and relationship with pain and HRT. Braz Oral Res. 2016;30(1):e100. Lora VR Canales GL Gonçalves LM Meloto CB Barbosa CM Prevalence of temporomandibular disorders in postmenopausal women and relationship with pain and HRT Braz Oral Res 2016 30 1 e100 29 29. Berger M, Szalewski L, Szkutnik J, Ginszt M, Ginszt A. Different association between specific manifestations of bruxism and temporomandibular disorder pain. Neurol Neurochir Pol. 2017;51(1):7-11. Berger M Szalewski L Szkutnik J Ginszt M Ginszt A Different association between specific manifestations of bruxism and temporomandibular disorder pain Neurol Neurochir Pol 2017 51 1 7 11 30 30. Magalhães BG, Freitas JLM, Barbosa ACS, Gueiros MCSN, Gomes SGF, Rosenblatt A, et al. Temporomandibular disorder: otologic implications and its relationship to sleep bruxism. Braz J Otorhinolaryngol. 2017;84(5):614-9. Magalhães BG Freitas JLM Barbosa ACS Gueiros MCSN Gomes SGF Rosenblatt A Temporomandibular disorder: otologic implications and its relationship to sleep bruxism Braz J Otorhinolaryngol 2017 84 5 614 619 31 31. Reissmann DR, John MT, Aigner A, Schön G, Sierwald I, Schiffman EL. Interaction between awake and sleep bruxism is associated with increased presence of painful temporomandibular disorder. J Oral Facial Pain Headache. 2017;31(4):299-305. Reissmann DR John MT Aigner A Schön G Sierwald I Schiffman EL Interaction between awake and sleep bruxism is associated with increased presence of painful temporomandibular disorder J Oral Facial Pain Headache 2017 31 4 299 305 32 32. Huhtela OS, Näpänkangas R, Joensuu T, Raustia A, Kunttu K, Sipilä K. Self-reported bruxism and symptoms of temporomandibular disorders in Finnish university students. J Oral Facial Pain Headache. 2016;30(4):311-7. Huhtela OS Näpänkangas R Joensuu T Raustia A Kunttu K Sipilä K Self-reported bruxism and symptoms of temporomandibular disorders in Finnish university students J Oral Facial Pain Headache 2016 30 4 311 317 33 33. Graciola J, Silveira AM. Avaliação da influência do estresse na prevalência de disfunções temporomandibulares em militares estaduais do Rio Grande do Sul. J Oral Investigations. 2015;2(1):32-7. Graciola J Silveira AM Avaliação da influência do estresse na prevalência de disfunções temporomandibulares em militares estaduais do Rio Grande do Sul J Oral Investigations 2015 2 1 32 37 34 34. Al-Khotani A, Naimi-Akbar A, Gjelset M, Albadawi E, Bello L, Hedenberg-Magnusson B, et al. The associations between psychosocial aspects and TMD-pain related aspects in children and adolescents. J Headache Pain. 2016;17:30. Al-Khotani A Naimi-Akbar A Gjelset M Albadawi E Bello L Hedenberg-Magnusson B The associations between psychosocial aspects and TMD-pain related aspects in children and adolescents J Headache Pain 2016 17 30 30 35 35. Lei J, Liu MQ, Yap AU, Fu KY. Sleep disturbance and psychologic distress: prevalence and risk indicators for temporomandibular disorders in a Chinese population. J Oral Facial Pain Headache. 2015;29(1):24-30. Lei J Liu MQ Yap AU Fu KY Sleep disturbance and psychologic distress: prevalence and risk indicators for temporomandibular disorders in a Chinese population J Oral Facial Pain Headache 2015 29 1 24 30 36 36. Martins RJ, Saliba-Garbin CA, Biage Cândido N, Ísper Garbin AJ, Saliba Rovida TA. Prevalence of temporomandibular disorders among industrial workers: association with stress and sleep disorder. Rev Salud Publica (Bogota). 2016;18(1):142-51. Martins RJ Saliba-Garbin CA Biage Cândido N Ísper Garbin AJ Saliba Rovida TA Prevalence of temporomandibular disorders among industrial workers: association with stress and sleep disorder Rev Salud Publica (Bogota) 2016 18 1 142 151 37 37. Rocha CP, Croci CS, Caria PH. Is there relationship between temporomandibular disorders and head and cervical posture? A systematic review. J Oral Rehabil. 2013;40(11):875-81. Rocha CP Croci CS Caria PH Is there relationship between temporomandibular disorders and head and cervical posture? A systematic review J Oral Rehabil 2013 40 11 875 881 38 38. von Piekartz H, Pudelko A, Danzeisen M, Hall T, Ballenberger N. Do subjects with acute/subacute temporomandibular disorder have associated cervical impairments: a cross-sectional study. Man Ther. 2016;26:208-15. von Piekartz H Pudelko A Danzeisen M Hall T Ballenberger N Do subjects with acute/subacute temporomandibular disorder have associated cervical impairments: a cross-sectional study Man Ther 2016 26 208 215 39 39. An JS, Jeon DM, Jung WS, Yang IH, Lim WH, Ahn SJ. Influence of temporomandibular joint disc displacement on craniocervical posture and hyoid bone position. Am J Orthod Dentofacial Orthop. 2015;147(1):72-9. An JS Jeon DM Jung WS Yang IH Lim WH Ahn SJ Influence of temporomandibular joint disc displacement on craniocervical posture and hyoid bone position Am J Orthod Dentofacial Orthop 2015 147 1 72 79 40 40. Milanesi JM, Weber P, Pasinato F, Corrêa ECR. Severidade da desordem temporomandibular e sua relação com medidas cefalométricas craniocervicais. Fisioter Mov. 2013;26(1):79-86. Milanesi JM Weber P Pasinato F Corrêa ECR Severidade da desordem temporomandibular e sua relação com medidas cefalométricas craniocervicais Fisioter Mov 2013 26 1 79 86 41 41. Azato FK. Influência do tratamento das desordens temporomandibulares na postura global dos pacientes [dissertation]. 2013. Campo Grande: Universidade Federal de Mato Grosso do Sul; 2013. Azato FK Influência do tratamento das desordens temporomandibulares na postura global dos pacientes 2013 dissertation Campo Grande Universidade Federal de Mato Grosso do Sul 42 42. Castillo DB, Azato FK, Coelho TK, Pereira PZ, Silva MG. Clinical study on head and jaw position of patients with muscle temporomandibular disorder. Rev Dor. 2016;17(2):88-92. Castillo DB Azato FK Coelho TK Pereira PZ Silva MG Clinical study on head and jaw position of patients with muscle temporomandibular disorder Rev Dor 2016 17 2 88 92 43 43. Saddu SC, Dyasanoor S, Valappila NJ, Ravi BV. The evaluation of head and craniocervical posture among patients with and without temporomandibular joint disorders: a comparative study. J Clin Diagn Res. 2015;9(8):55-8. Saddu SC Dyasanoor S Valappila NJ Ravi BV The evaluation of head and craniocervical posture among patients with and without temporomandibular joint disorders: a comparative study J Clin Diagn Res 2015 9 8 55 58 44 44. Rocha T, Castro MA, Guarda-Nardini L, Manfredini D. Subjects with temporomandibular joint disc displacement do not feature any peculiar changes in body posture. J Oral Rehabil. 2017;44(2):81-8. Rocha T Castro MA Guarda-Nardini L Manfredini D Subjects with temporomandibular joint disc displacement do not feature any peculiar changes in body posture J Oral Rehabil 2017 44 2 81 88 45 45. Faulin EF, Guedes CG, Feltrin PP, Joffiley CM. Association between temporomandibular disorders and abnormal head postures. Braz Oral Res. 2015;29(1):1-6. Faulin EF Guedes CG Feltrin PP Joffiley CM Association between temporomandibular disorders and abnormal head postures Braz Oral Res 2015 29 1 1 6 46 46. Câmara-Souza MB, Figueredo OMC, Maia PRL, Dantas IDS, Barbosa GAS. Cervical posture analysis in dental students and its correlation with temporomandibular disorder. Cranio. 2017;36(2):85-90. Câmara-Souza MB Figueredo OMC Maia PRL Dantas IDS Barbosa GAS Cervical posture analysis in dental students and its correlation with temporomandibular disorder Cranio 2017 36 2 85 90 47 47. Andrade RM. Avaliação do movimento da mandíbula por meio da fotogrametria em portadores de disfunção temporomandibular: dor, EMG e posicionamento da cabeça [dissertation]. São Paulo: Universidade de São Paulo; 2013. Andrade RM Avaliação do movimento da mandíbula por meio da fotogrametria em portadores de disfunção temporomandibular: dor, EMG e posicionamento da cabeça 2013 dissertation São Paulo Universidade de São Paulo 48 48. Munhoz WC, Hsing WT. Interrelations between orthostatic postural deviations and subjects' age, sex, malocclusion, and specific signs and symptoms of functional pathologies of the temporomandibular system: a preliminary correlation and regression study. Cranio. 2014;32(3):175-86. Munhoz WC Hsing WT Interrelations between orthostatic postural deviations and subjects' age, sex, malocclusion, and specific signs and symptoms of functional pathologies of the temporomandibular system: a preliminary correlation and regression study Cranio 2014 32 3 175 186 49 49. Khan MT, Verma SK, Maheshwari S, Zahid SN, Chaudhary PK. Neuromuscular dentistry: occlusal diseases and posture. J Oral Biol Craniofac Res. 2013;3(3):146-50. Khan MT Verma SK Maheshwari S Zahid SN Chaudhary PK Neuromuscular dentistry: occlusal diseases and posture J Oral Biol Craniofac Res 2013 3 3 146 150 50 50. Munhoz WC. Relação entre idade, gênero, características de maloclusão dental e sintomatologia de patologias funcionais do sistema temporomandibular com aspectos de postura corporal ortostática: implicações fisiopatológicas mútuas [master's thesis]. São Paulo: Universidade de São Paulo; 2016. Munhoz WC Relação entre idade, gênero, características de maloclusão dental e sintomatologia de patologias funcionais do sistema temporomandibular com aspectos de postura corporal ortostática: implicações fisiopatológicas mútuas 2016 master's thesis São Paulo Universidade de São Paulo 51 51. Baldini A, Nota A, Tecco S, Ballanti F, Cozza P. Influence of the mandibular position on the active cervical range of motion of healthy subjects analyzed using an accelerometer. Cranio. 2016;36(1):29-34. Baldini A Nota A Tecco S Ballanti F Cozza P Influence of the mandibular position on the active cervical range of motion of healthy subjects analyzed using an accelerometer Cranio 2016 36 1 29 34 52 52. Ballenberger N, von Piekartz H, Danzeisen M, Hall T. Patterns of cervical and masticatory impairment in subgroups of people with temporomandibular disorders: an explorative approach based on factor analysis. Cranio. 2018;36(2):74-84. Ballenberger N von Piekartz H Danzeisen M Hall T Patterns of cervical and masticatory impairment in subgroups of people with temporomandibular disorders an explorative approach based on factor analysis Cranio 2018 36 2 74 84 53 53. Costa DRA. Avaliação da incapacidade cervical e sua associação com dor miofascial mastigatória e hipersensibilidade mecânica generalizada em indivíduos com disfunção temporomandibular [dissertation]. Aracaju: Universidade Federal de Sergipe; 2014. Costa DRA Avaliação da incapacidade cervical e sua associação com dor miofascial mastigatória e hipersensibilidade mecânica generalizada em indivíduos com disfunção temporomandibular 2014 dissertation Aracaju Universidade Federal de Sergipe 54 54. Greenbaum T, Dvir Z, Reiter S, Winocur E. Cervical flexion-rotation test and physiological range of motion: a comparative study of patients with myogenic temporomandibular disorder versus healthy subjects. Musculoskelet Sci Pract. 2017;27:7-13. Greenbaum T Dvir Z Reiter S Winocur E Cervical flexion-rotation test and physiological range of motion: a comparative study of patients with myogenic temporomandibular disorder versus healthy subjects Musculoskelet Sci Pract 2017 27 7 13 55 55. Guarda-Nardini L, Cadorin C, Frizziero A, Masiero S, Manfredini D. Interrelationship between temporomandibular joint osteoarthritis (OA) and cervical spine pain: effects of intra-articular injection with hyaluronic acid. Cranio. 2017;35(5):276-82. Guarda-Nardini L Cadorin C Frizziero A Masiero S Manfredini D Interrelationship between temporomandibular joint osteoarthritis (OA) and cervical spine pain: effects of intra-articular injection with hyaluronic acid Cranio 2017 35 5 276 282 56 56. Grondin F, Hall T. Changes in cervical movement impairment and pain following orofacial treatment in patients with chronic arthralgic temporomandibular disorder with pain: a prospective case series. Physiother Theory Pract. 2017;33(1):52-61. Grondin F Hall T Changes in cervical movement impairment and pain following orofacial treatment in patients with chronic arthralgic temporomandibular disorder with pain: a prospective case series Physiother Theory Pract 2017 33 1 52 61 57 57. Walczynska-Dragon K, Baron S, Nitecka-Buchta A, Tkacz E. Correlation between TMD and cervical spine pain and mobility: is the whole body balance TMJ related? Biomed Res Int. 2014;2014:582414. Walczynska-Dragon K Baron S Nitecka-Buchta A Tkacz E Correlation between TMD and cervical spine pain and mobility is the whole body balance TMJ related? Biomed Res Int 2014 2014 582414 582414 58 58. Khawaja SN, McCall W Jr, Dunford R, Nickel JC, Iwasaki LR, Crow HC. Infield masticatory muscle activity in subjects with pain-related temporomandibular disorders diagnoses. Orthod Craniofac Res. 2015;Suppl 1:137-45. Khawaja SN McCall W Jr Dunford R Nickel JC Iwasaki LR Crow HC Infield masticatory muscle activity in subjects with pain-related temporomandibular disorders diagnoses Orthod Craniofac Res 2015 1 137 145 59 59. Pitta NC, Nitsch GS, Machado MB, Oliveira AS. Activation time analysis and electromyographic fatigue in patients with temporomandibular disorders during clenching. J Electromyogr Kinesiol. 2015;25(4):653-7. Pitta NC Nitsch GS Machado MB Oliveira AS Activation time analysis and electromyographic fatigue in patients with temporomandibular disorders during clenching J Electromyogr Kinesiol 2015 25 4 653 657 60 60. Ries LGK, Graciosa MD, Soares LP, Sperandio FF, Santos GM, Degan VV, et al. Efeito do tempo de contração e repouso na atividade dos músculos masseter e temporal anterior em indivíduos com DTM. CoDAS. 2016;28(2):155-62. Ries LGK Graciosa MD Soares LP Sperandio FF Santos GM Degan VV Efeito do tempo de contração e repouso na atividade dos músculos masseter e temporal anterior em indivíduos com DTM CoDAS 2016 28 2 155 162 61 61. Wozniak K, Lipski M, Lichota D, Szyszka-Sommerfeld L. Muscle fatigue in the temporal and masseter muscles in patients with temporomandibular dysfunction. Biomed Res Int. 2015;2015:269734. Wozniak K Lipski M Lichota D Szyszka-Sommerfeld L Muscle fatigue in the temporal and masseter muscles in patients with temporomandibular dysfunction Biomed Res Int 2015 2015 269734 269734 62 62. Mazzetto MO, Rodrigues CA, Magri LV, Melchior MO, Paiva G. Severity of TMD related to age, sex and electromyographic analysis. Braz Dent J. 2014;25(1):54-8. Mazzetto MO Rodrigues CA Magri LV Melchior MO Paiva G Severity of TMD related to age, sex and electromyographic analysis Braz Dent J 2014 25 1 54 58 63 63. Santana-Mora U, López-Ratón M, Mora MJ, Cadarso-Suárez C, López-Cedrún J, Santana-Penín U. Surface raw electromyography has a moderate discriminatory capacity for differentiating between healthy individuals and those with TMD: a diagnostic study. J Electromyogr Kinesiol. 2014;24(3):332-40. Santana-Mora U López-Ratón M Mora MJ Cadarso-Suárez C López-Cedrún J Santana-Penín U Surface raw electromyography has a moderate discriminatory capacity for differentiating between healthy individuals and those with TMD: a diagnostic study J Electromyogr Kinesiol 2014 24 3 332 340 64 64. Rodrigues CA, Melchior MO, Magri LV, Mestriner W Jr, Mazzetto MO. Is the masticatory function changed in patients with temporomandibular disorder? Braz Dent J. 2015;26(2):181-5. Rodrigues CA Melchior MO Magri LV Mestriner W Jr Mazzetto MO Is the masticatory function changed in patients with temporomandibular disorder? Braz Dent J 2015 26 2 181 185 65 65. Li BY, Zhou LJ, Guo SX, Zhang Y, Lu L, Wang MQ. An investigation on the simultaneously recorded occlusion contact and surface electromyographic activity for patients with unilateral temporomandibular disorders pain. J Electromyogr Kinesiol. 2016;28:199-207. Li BY Zhou LJ Guo SX Zhang Y Lu L Wang MQ An investigation on the simultaneously recorded occlusion contact and surface electromyographic activity for patients with unilateral temporomandibular disorders pain J Electromyogr Kinesiol 2016 28 199 207 66 66. Strini PJSA, De Souza Barbosa T, Gavião MBD. Assessment of thickness and function of masticatory and cervical muscles in adults with and without temporomandibular disorders. Arch Oral Biol. 2013;58(9):1100-8. Strini PJSA De Souza Barbosa T.Gavião MBD Assessment of thickness and function of masticatory and cervical muscles in adults with and without temporomandibular disorders Arch Oral Biol 2013 58 9 1100 1108 67 67. Chaves TC, Santos Aguiar A, Felicio LR, Greghi SM, Hallak Regalo SC, Bevilaqua-Grossi D. Electromyographic ratio of masseter and anterior temporalis muscles in children with and without temporomandibular disorders. Int J Pediatr Otorhinolaryngol. 2017;97:35-41. Chaves TC Santos Aguiar A Felicio LR Greghi SM Hallak Regalo SC Bevilaqua-Grossi D Electromyographic ratio of masseter and anterior temporalis muscles in children with and without temporomandibular disorders Int J Pediatr Otorhinolaryngol 2017 97 35 41