TMJ DISORDERS

Presented
By: Dr
Deepankar
1
Misra
• The TMJ is a complex, multiaxial, synovial, bicondylar and
gingymo-di-arthroidal type of joint.
• TMJ has a key role in the bio-cybernetic functional cycle of
the orofacial system
• Temporomandibular disorders (TMD) refers to
the pathologic conditions affecting the TMJ
• Definition:
TMD are characterized by a wide range of conditions
diversely affecting presented as pain in the face or jaw
joint area, limited mouth opening, closed or open lock of
the TMJ, abnormal occlusal wear, clicking or popping
sounds in the jaw joints, & other complaints.” 2
 Etiology
• The cause of TMD are complex and multifactorial.
• Numerous factors can contribute to TMD,
• Those that increase the risk of TMD are called
predisposing factors,
•Those that cause the onset of TMD are called initiating
factors and
•Those that interfere with healing or enhance the
progression of TMD are called perpetuating factors.

3
 Parafunctional habits (eg, nocturnal bruxing, tooth
clenching, lip or cheek biting).
 Emotional distress.
 Acute trauma from blows or impacts.
 Trauma from hyperextension
 Instability of maxillomandibular relationships.
 Laxity of the joint.
 Co-morbidity of other rheumatic or musculoskeletal
disorders
 Poor general health and an unhealthy lifestyle
 Stress
 Sleep disorders 4
• Occlusal factors

Joint

Teeth

5
 CLASSIFICATION
I. Masticatory muscle disorders
1. Protective co-contraction
2. Local muscle soreness
3. Myofacial pain
4. Myospasm
5. Centrally mediated myalgia

II. Temporomandibular joint disorders

1. Derangement of the condyle –disc complex
a. Disc displacements
b. Disc dislocation with reduction
c. Disc dislocation without reduction

6
2. Structural incompatibility of the articular surface
a. Deviation in form
i. Disc
ii. Condyle
iii.Fossa
b. Adhesions
iv.Disc to condyle
v. Disc to fossa
c. Subluxation (hypermobility)
d. Spontaneous dislocation
7
3. Inflammatory disorders of the temporomandibular joint
a. Synovitis/capsulitis
b.Retrodiscitis
c. Arthritides
i. Osteoarthritis
ii. Osteoarthrosis
iii.Polyarthritides
d. Inflammatory
disorders of associated
structures
iv.Temporal
tendonitis 8

v. Stylomandibular
ligament
III. Chronic mandibular hypomobility
1.Ankylosis
a.Fibrous
b. Bony
2. Muscle
conracture
a. Myosta
tic
b. myofib
rotic
3. Coronoid
impedanc
e
IV. Growth
Disorders
1. Congentia
l and
developm 9
ental bone
disorders
a. Agenes
 Developmental
disorders of TMJ
Condylar Hyperplasia
Definition
Condylar hyperplasia is a developmental abnormality that
results in enlargement and occasionally deformity of the
condylar head; this may have a secondary effect on the
mandibular fossa as it remodels to accommodate the
abnormal condyle.

10
Clinical Features
More common in males before the age of 20 years.
It is self-limiting and tends to arrest with termination of
skeletal growth.
Patients have a mandibular asymmetry that varies in
severity, depending on the degree of condylar
enlargement.

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 The chin may be deviated to the unaffected side, or it
may remain unchanged but with an increase in the
vertical dimension of the ramus, mandibular body, or
alveolar process of the affected side.
 Posterior open bite on the affected side.
 Limited or deviated mandibular opening or both caused
by restricted mobility of the enlarged condyle.

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Radiographic Features
The condyle may appear relatively normal, but altered in
shape or irregular in outline.
Increased radiodensity.
Condylar neck may be elongated and thickened and
may bend laterally when viewed in the coronal plane.
The cortical thickness and trabecular pattern of the
enlarged condyle usually are normal, which helps to
distinguish this condition from a condylar neoplasm.

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The glenoid fossa, ramus and mandibular body on the
affected side also may be enlarged, resulting in a
characteristic depression of the inferior mandibular border
at the midline.
The affected ramus may have increased vertical depth
and may be thicker in the anteroposterior dimension
Differential diagnosis
Osteochondroma
Osteoma
Osteophyte
Treatment
Treatment consisting of orthodontics combined with
orthognathic surgery

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CONDYLAR HYPOPLASIA
Definition
Condylar hypoplasia is failure of the condyle to attain
normal size because of congenital and developmental
abnormalities or acquired diseases that affect condylar
growth. The condyle is small, but condylar morphology
usually is normal.

Clinical Features
It is a component of a mandibular growth deficiency
and therefore often is associated with an
underdeveloped ramus and mandibular body.

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Mandibular asymmetry and may have
symptoms of TMJ dysfunction.
The chin commonly is deviated to the
affected side, and the mandible deviates to the
affected side during mandibular opening.

Radiographic Features
•The condyle may be normal in shapeand structure but is
diminished in size, and the mandibular fossa also is
proportionally small.
•The condylar neck and coronoid process usually are
slender or sharpened or elongated.

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•The posterior border of the ramus and condylar neck may
have a dorsal (posterior) inclination.
•The ramus and mandibular body on the affected side may
also be small, mandibular asymmetry and occasional dental
crowding
• The antegonial notch is deepened.

Differential diagnosis
Juvenile rheumatoid arthritis
Treatment
Orthognathic surgery, bone grafts, and orthodontic
therapy may be required.

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BIFID CONDYLE
Definition
A bifid condyle has a vertical depression, notch, or deep
cleft in the centre of the condylar head seen in the frontal or
sagittal plane or an actual duplication of the condyle,
resulting in the appearance of a "double" or "bifid"
condylar head.

Clinical Features
Incidental finding, asymptomatic.
Some patients have signs and symptoms of
temporomandibular dysfunction, including joint noises
and pain.
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Radiographic Features
A depression or notch is present on the superior
condylar surface, giving the anteroposterior silhouette a
heart shape.
The mandibular fossa may remodel to accommodate
the altered condylar morphology.

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Agenesis of Condyle

Clinical features
Rare, unilaterally or bilaterally Free
movements of the joints, with
anterior open bite, asymmetry of face,
altered occlusion and inability to
masticate.
Mandible shifts to the affected side in
unilateral involvement

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CORONOID HYPERPLASIA
Definition
Coronoid process hyperplasia may be acquired or
developmental, resulting in elongation of the coronoid
process. In the developmental variant, the condition
usually is bilateral. Acquired types may be unilateral or
bilateral and usually are a response to restricted
condylar movement caused by abnormalities such as
ankvlosis.

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Clinical Features
More common in males often during puberty. Painless,
but closed lock and inability to open mouth.

Radiographic Features
The coronoid processes are
elongated, and the tips extend at
least 1 cm above the inferior rim
of the zygomatic arch.
The radiographic appearance of
the TMJs usually is normal:

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JUVENILE ARTHROSIS

Definition
Juvenile arthrosis, a condylar growth disturbance,
manifests as hypoplasia and characteristic morphologic
abnormalities.

Juvenile arthrosis may be unilateral or bilateral, and it

predisposes the TMJ to secondary degenerative
changes.

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Clinical Features
Juvenile arthrosis affects children and adolescents
during the period of mandibular growth.
More common in females.
mandibular asymmetry, and sometimes shows signs and
symptoms of TMJ dysfunction or both.

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Radiographic Features
The condylar head develops a characteristic
"toadstool"
appearance, with marked flattening and apparent
elongation of the articulating condylar surface.
The condylar neck is shortened or even absent in some
cases.
The articulating surface of the temporal component
often is flattened.
Progressive shortening of the ramus occurs on the
affected side, and the antegonial notch may be
deepened,

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Differential diagnosis Developmental
condylar hypoplasia Treatment
Orthognathic surgery and orthodontic
therapy

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TMJ ARTHRITIS
 CLASSIFICATION
A) INFLAMMATORY ARTHRITIS

1. RHEUMATOID ARTHRITIS

2. JUVENILE RHEUMATOID
ARTHRITIS

3. ANKYLOSING SPONDILYTIS

4. PSORIATIC SPONDYLITIS

5. REITER’S SYNDROME

B) NON INFLAMMATORY

1. OSTEOARTHRITIS
• C) INFECTIOUS ARTHRITIS

• D) METABOLIC ARTHRITIS

1. GOUT

2. PSEUDO GOUT

• E) TRAUMATIC ARTHRITIS
 RHEUMATOID
ARTHRITIS
• Rheumatoid Arthritis is a chronic syndrome characterized
by non specific, usually symmetric inflammation of the
peripheral joints, particularly resulting in progressive
destruction of articular and periarticular structures, with or
without generalized manifestations.
Manifests mainly as synovial membrane inflammation in
several joints.
50% cases show TMJ involvement.
CRITERIA FOR DIAGNOSIS OF RHEUMATOID ARTHRITIS
(AMERICAN RHEUMATISM ASSOCIATION 1988 REVISION)

1.Morning stiffness(>1hour)
2.Arthritis of 3 or more joints
3.Arthritis of hand joints
4.Symetrical arthritis
5.Rheumatoid nodules
6.Rheumatoid factor
7.Radiological changes
• Duration of 6 weeks or
more
DIAGNOSIS OF RA IS MADE WITH 4 OR
MORE CRITERIA
CLINICAL FEATURES
• Age: 40-60 years

• 1% of all population affected

• Women : Men 3:1

• Prevalence 2.5% - 2 %

• 50 – 75 % people have TMJ involvement

• Involves peripheral joints first then central skeleton

• Thoracic and lumbosacral rarely involved

 SIGNS AND SYMPTOMS

• Joint pain
• Stiffness (greater than 30
• Systemic signs and
min)
symptoms
• Tenderness
• Fatigue
• Swelling
• Warmth • Fever

• Erythema • Weight loss

• Limitation of movement • Anemia

• severe in morning
decreases in night
• The chin appears receded and anterior open bite is a

common finding, because of bilateral destruction and

anterosuperior positioning of the condyles.
 Radiographic features
• Initially there is generalised osteopenia of the condyles and
temporal bone
• Bone erosion by pannus usually involves the articular
eminence and anterior aspect of the condylar head
• Articular eminence totally destroyed such that the normal
convexity is replaced by concavity
• Subchondral sclerosis and
flattening of the articular
surfaces may occur with
subchondral cyst and
osteophyte formation.
• Severe erosion completely
destroys the head of the
condyle with only the neck
remaining as the
articulating surface

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 LABORATORY FINDINGS
BLOOD TEST :

• Normocytic Normochromic Anaemia in 80% cases

• ESR elevated in 90% of cases

• Rose Waller Sheep cell Agglutination test : Antibodies to

altered globulin, so called Rheumatoid Factor (RF)

(1:1280)positive in 70% of cases

• Antinuclear antibody test : positive in 30% of cases

SYNOVIAL FLUID:

• Abnormal during active joint inflammation, is cloudy but

sterile, with reduced viscosity and usually 3,000-50,000

WBCs/µl

• PMNs cells are typically predominant, but more than

50% may be lymphocytes and other mononuclear cells

 TREATMENT
• PHYSICAL REST

• ANTI-INFLAMMATORY DRUG THERAPY

• MAINTAINENCE EXCERCISES

• SLOW ACTING ANTI RHEUMATIC DRUG

THERAPY

• INTRAARTICULAR CORTICOSTEROID INJECTION

 OSTEOARTHRITIS
• Also known as Degenerative Joint Disease,
Osteoarthrosis, Degenerative Arthritis
• It is a non inflammatory disorder of the joints
characterized by joint deterioration and proliferation
• It is a localized joint disease without systemic
manifestations
• It primarily involves the articular cartilage and
subchondral bone with secondary inflammation of the
synovial membrane
• Joint deterioration is characterized by loss of articular
cartilage and bone erosion
• The proliferative component is characterized by new bone
formation at the articular surface and in the subchondral region
CONTRIBUTING FACTORS
1. Acute trauma
2. Hyper mobility
3. Loading of joint
4. Internal derangement
 CLINICAL FEATURES
• Occurs in any age , but incidence increases with age

• F>M

• Generally OA is unilateral, although bilateral involvement does

occur, with one side usually showing greater severity of
involvement .
• The disease may be asymptomatic, or patients may complain of
signs and symptoms of TMJ dysfunction, including pain on
palpation and movement, joint noises (crepitus), limited range of
motion, and muscle spasm.
• The onset of symptoms may be sudden or gradual, and
symptoms may disappear spontaneously
• Pain and tenderness in the joint

• Tenderness in Masticatory Muscles

• Jaw muscle fatigue, stiffness and tiredness, difficulty

opening the mouth, reduced range of motion,
• Osteoarthritis is usually characterized by a lack of
morning jaw stiffness but, if present, lasts no more than
30 minute
 RADIOGRAPHIC FEATURES
• Radiographic studies of OA of the TMJ reveal an incidence of

- 40% in patients over 40 years of age

- 100% in patients over 80 years of age

- Approximately 50% of the population has radiographic

changes, but only 30% of these cases
are symptomatic
• Narrowing of joint space
• Irregular joint space
• Flattening of articular spaces
• Osteophyte formation occurs in
the late stage at the ant-sup
surface of condyle, lateral
aspect of temporal component.
In severe cases the osteophyte
formation originating in the
glenoid fossa extend from the
articular eminence to encase the
condylar head.
• In severe cases the glenoid
fossa appears grossly enlarged
due to destruction of post slope
of articular eminence and the
erosion of condylar head
Osteophyte on anterior
surface of condyle
• Presence of Ely’s cyst– small, round, radiolucent areas

with irregular margins surrounded by varying area of

increased density are visible deep to the articular

surfaces. They are not true cysts but are areas of

degeneration that contain fibrous tissue, granulation

tissue and osteoid

Ely’s cyst
 TREATMENT
• Reassurance and education of the patient

• Symptomatic management:

• Use of drug therapy

- NSAIDS, Indomethacin, Muscle relaxants etc

• Occlusal appliance therapy: Mandibular
repositioning appliances
 Physical therapy:
• Application of Heat
-The use of ultrasound
-High-voltage electro-galvanic stimulation
-Massage
-Gentle mobilization exercises
• Individually or in combination
• In those instances when the disease progresses,
becomes more severe, and is refractory to these
treatment modalities, SURGERY may be indicated
TMJ DISLOCATION
Definition
Dislocation is abnormal
positioning of the condyle
out of the mandibular fossa
but within the joint capsule.
It usually occurs bilaterally
and most commonly in an
anterior direction.
Dislocation may be caused
by a failure of muscular
coordination, subluxation, or
external trauma and may be
associated with a condylar
fracture.

51
• Clinical Features
• Patients are unable to close the mandible to maximal
intercuspation; some patients cannot reduce the dislocation,
whereas others may be able to reduce the mandible by
manipulation. In the former case associated pain and
muscle spasm often are present
• Radiographic Features In bilateral cases both condyles
are located anterior and superior to the summits of the
articular eminence.
• Clinical information is important because the normal range
of motion may extend anterior to the summit of the
articular eminence.

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• Treatment
• Treatment consists of manual manipulation of the
mandible to reduce the dislocation. Surgery occasionally is
necessary to reduce the condyle in the case of a fracture
dislocation, although treatment may not be indicated for
this type of dislocation if andibular
function is adequate.

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Subluxation (Hypermobility)
This is a unilateral or bilateral positioning of the condyle
anterior to the eminence, with repositioning to normal
accomplished physiological activity. It is a self reducing
incomplete dislocation, which generally follows stretching
of the capsule and ligaments
C/F: may be unilateral or bilateral
The condyle may get locked when the mouth is opened
wide and upon closing it will return with a jumping
motion, accompanied with a loud sharp sound,”thud”.
On palpation a click on the opening and sliding of the
condyle over the articular eminence is present.

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Pain may sometimes be associated during the end of
mouth opening.
R/G shows excessive translation of the condyle from the
rest position to the position when the jaw is wide open.

T/t- Unless symptomatic no surgical intervention is done. It

comprises of injecting sclerosing agent or shortening the
temporalis tendon.

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ANKYLOSIS
Definition
Ankylosis is a condition in which condylar movement is
limited by a mechanical problem in the joint ("true"
ankylosis) or by a mechanical cause not related to joint
components ("false" ankylosis).
Extra articular or intra articular
Fibrous or bony
Unilateral or bilateral
Partial or complete

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ETIOLOGY
Joint infection
Inflammation: otitis, parotitis, tonsilitis, osteomyelitis,
furuncle, septic arthritis
Trauma
Systemic disease: smallpox, scarlet fever, typhoid,
scleroderma, ankylosing spondylitis
Prolonged trismus, bifid condyle, prolonged
immobilization.

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UNILATERAL
Facial asymmetry
deviation of mandible and chin on
affected side
Hypoplastic mandible on affected
side
Cross bite class II malocclusion,
interincisal distance depends upon
fibrous or bony ankylosis, condylar
movements are absent on affected
side

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BILATERAL
Inability to open mouth
Micrognathia
“Bird face” deformity
Neck-chin angle may be reduced
Antegonial notch becomes prominent
Class II malocclusion
Protrusive upper incisors
Poor oral and periodontal health, crowding and
impacted teeth may be seen.

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 Neoplasia
The most common benign intrinsic tumors affecting the
TMJ are osteomas, osteochondromas, Langerhans
histiocytosis and osteoblastomas. Chondroblastomas,
fibromyxomas, benign giant cell lesions, and aneurysmal
bone cysts also occur. Benign tumors and cysts of
the mandible (e.g., ameloblastomas, odontogenic
keratocysts, simple bone cysts) may involve the entire
ramus and in rare cases the condyle.

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 INTERNAL DISC DERANGEMENT
• INTERNAL DISK DERANGEMENT of TMJ is defined as an
abnormal relationship of the articular disk to the
mandibular condyle, fossa and articular eminence
• Disc mostly displaced in anterior direction

• Lateral and posterior displacements are rare.

 ETIOLOGY
• LATERAL PTERYGOID MUSCLE SPASM

• DIRECT TRAUMA TO JOINT FROM BLOW

TO MANDIBLE

• INDIRECT TRAUMA FROM CERVICAL

FLEXION EXTENSI0ON INJURIES

• CHRONIC FUNCTIONAL OVERLOAD

(CLENCHING)

• DEGENERATIVE JOINT DISEASES

 CLASSIFICATION
• Based on signs and symptoms

1. Anterior disc displacement with reduction (clicking

joint)

2. Anterior disc displacement with intermittent locking

3. Anterior disc displacement without reduction. (closed

lock)
 Anterior disc displacement
with reduction
• Due to a disc that has loosened because of elongation or
tearing of restraining ligaments and has moved from it’s
normal position to the top of the condyle.

• The posterior border of the disc becomes thin with elongation

of retrodiscal lamina, thus displacing the disc anteriorly k/a
disc displacement, hence there is loss of contact between the
articular surface of the condyle & disc.
Anterior disc displacement without
reduction. (closed lock)
• May be the first sign of TMD after severe trauma or long
term bruxism.
• This condition occurs when the patient is unable to
return the dislocated disc to its normal position on the
condyle.
• The max. mouth opening cannot be achieved because the
disc does not allow full translation of the condyle
 TREATMENT MODALITIES
NON SURGICAL

• EDUCATION

• PHYSICAL THERAPY

• PHARMACOLOGICAL
THERAPY

• OCCLUSAL THERAPY
EDUCATION
• Patient should be instructed
to
- Decrease loading of joint as
much as possible
- Soft food diet
- Slower chewing
- Smaller bites
- Not to allow joint to click
- Not to open his
mouth forcefully
•Patient should be told
that condition is self
limiting
PHYSICAL THERAPY FOR PAIN
REDUCTION
• MOIST HEAT

Thermotherapy utilizes heat, It

increases circulation to the applied
area

- Hot water bottle or hot moist towel

and Electric heating pad are applied

for

10 – 15 minutes
• COOLANT
THERAPY

PHYSICAL THERAPY TO IMPROVE FUNCTION

Pain restricts the jaw movements which can lead to chronic
hypo mobility and muscle atrophy. Therefore must be
instructed
 - to gently open the mouth to

resistance and close

- jaw should be moved eccentrically

• If the disk is displaced without

reduction then passive distraction of

the joint can increase the mobility

 INTERNAL DISK DERANGEMENT WITHOUT REDUCTION

• INITIAL THERAPY : Attempt to reduce or recapture the

disk displacement by manual manipulation

• This is successful in patients experiencing the first episode of

locking as the tissue are healthy & morphological not

changed

• In patients with longer history of dislocation, the success rate

decreases
• Patient is asked to move the mandible as far as

possible to the contralateral side, From this

eccentric position mouth is opened maximally
• If fails , then ASSISTANCE MANIPULATION is

needed
• The thumb is placed intra-orally on the 2nd molar on

the affected side and fingers placed on the inferior

border of the mandible anterior to the thumb position
 PHARMACOLOGICAL THERAPY

• ANALGESICS :

NSAIDS like Ibuprofen, Diclofenac Sodium, Piroxicam,

ketolorac Tromethamine, Indomethacine are used

• ANTI – INFLAMMATORIES :

- Can be administered orally or by injection

 OCCLUSAL THERAPY

• DISK DISPLACEMENT WITH REDUCTION :

ANTERIOR MANDIBULAR
REPOSITIONING APPLIANCE
- To be worn 24 hours a day for 3 – 6 months
-To position condyle back on the disk
DISADVANTAGE

•Patient may develop POSTERIOR OPEN BITE

due to the reversible, myostatic contracture
Appliance of choice since the risk of
altering the occlusion is minimized
-It should be noted that both appliances
should provide full arch coverage so as to
avoid tooth eruption
-as soon as patient becomes symptom free,
the appliance should be gradually reduced
-If the patient is suspected to have
BRUXISM, a muscle relaxation or flat
plane appliance is indicated
 Myofascial Pain Dysfunction
Syndrome
• Myofascial pain is pain referred from a localised tender

area, a trigger point in a taut band of skeletal muscle.

• It can occur in any skeletal muscle including the muscles of

mastication

• The head, neck, shoulders and lower back are the areas

most frequently involved.

 ETIOLOGY
• Acute trauma
• Occlusal irregularities- such as occlusal interferences,
posterior bite collapse, deep overbite-jet relation: self
protective system modifies the path of closure and
prevents painful contacts
• Overuse of selected muscles of mastication results in
muscle fatigue
• Nocturnal parafunctional habits
• Psychological disorder associated with stress
• Faulty complete or partial dentures over a period of time
results in TMJ pain. This causes changes in myotactic
stretch reflex.
 CLINICAL FEATURES
• FOUR CARDINAL SIGNS AND SYMPTOMS
GIVEN

BY LASKIN

1. Unilateral dull pain in the ear or preauricular region

that is commonly worse on awakening

2. Tenderness of one or more muscle of mastication

3. Limitation or deviation of the mandible on opening

4. Clicking or popping in the TMJ.

• Referred pain in distant parts of the face arises from
trigger points in the involved muscles.
• Occurs in episodes of several times a day, at times with
extended symptom free interval. Usually these episodes
are seen during increased emotional tension resulting in
increased intraarticular tension.
• Features of bruxism, difficulty in chewing, mandibular
excursion, with a rubbing noise, clicking or popping and
snapping sounds may be present.
• Other Signs:
• Restriction of opening and protrusion may be
accomplished by deflection of the mandible.
• Muscle soreness when palpated, myofascial trigger zones
are stimulated by pressure and produce referred pain

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DIAGNOSIS
• History

• Examination of TMJ

• Examination of muscles of mastication and associated

cervical musculature

• Examination of the dentition and oral tissues

• These patients have two typical negative

characteristics

1. Absence of clinical, radiological or biochemical

evidence of organic changes in the joint itself

2. Lack of tenderness in the joint when palpated through

the external auditory meatus.

 TREATMENT OF TMD
• All the treatment methods used for TMDs can be
categorized as:
1. Definitive treatment
2. Supportive therapy
Definitive treatment refers to those methods that are directed
towards controlling or eliminating the causes of the
disorder.
Supportive therapy refers to treatment methods that are
directed towards altering the symptoms.

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• Definitive treatment of Occlusal factors
1. Reversible
2. Irreversible
Reversible occlusal therapy temporary alters the patients
occlusal condition. Such as with use of occlusal
appliance.
Irreversible occlusal therapy is any treatment which
permanently alters the occlusal condition. Such as
grinding, restorations.

•Definitive treatment of trauma

Macrotrauma
Microtrauma 84
Definitive treatment of
Parafunctional habits
 Supportive therapy
PHARMACOLOGICAL THERAPY
Analgesics: NSAIDs, antiinflammatory agents,
corticosteroids, anxiolytic agents, muscle relaxants,
antidepressants, local anesthetics

PHYSICAL THERAPY
Modalities and manual techniques
1. Physical therapy modalities
Thermotherapy
Coolant therapy
Ultrasound therapy
Phonophoresis
Iontophoresis
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• Joint mobilization.
• Muscle conditioning:.
• Passive muscle stretching
• Assisted muscle stretching
• Resistance exercises
• Postural training

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THANK
YOU

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