Patient presenting Oromandibular Dystonia two years after the first consultation, when she presented temporomandibular disorder without dystonia. Oromandibular dystonia and the connection with cranio-cervico-mandibular disorders.

Posted on 15 de March de 2020 by lidiayavich

57-year-old female patient attended the consultation in 2017 complaining of pain in the temporomandibular joints and limited mouth opening. According to the anamnesis completed by the patient herself at the initial consultation, she reports occasional headache, tinnitus, nonspecific facial pain, strange sounds in both ears, difficulty in opening her mouth and pain in both TMJs (temporomandibular joints).

The patient reports that her symptoms started in 2011 after a procedure to replace all old amalgam fillings with resins.

Brief report written by the patient

Dear Dr. Lidia,

Here is the succinct account of what happened to my maxilar or jaw.

In 2011 I went to the dentist at the recommendation of a friend to remove the old fillings (amalgams).

The work was long during this year and I was satisfied with the result.

Months later the right side of my mouth started to bother me because I felt as if a gap was occurring when I closed my mouth. I returned to the professional and he again aligned the height of the teeth and improved a little.

I started to feel pain and in 2012 I was recommended to have a consultation with a professional specialist in TMD who prescribed Mioflex for pain.

I used a bruxism splint because I couldn’t open my mouth wide, it opened a little (it hurt the right side of my face)

Postural front and back photographs of the patient at the first consultation in 2017.

Shoulder misalignment and forward head posture.

Postural photographs of the patient’s right and left profile at the first consultation in 2017.

Important postural anteriorization of the head. Note the prognata profile.

The patient’s habitual occlusion at the first consultation in 2017.

Upper and lower occlusal view of the patient at the first consultation in 2017.

Small crowding in the lower incisor sector.

Continuation of the summary report written by the patient

After using the bruxism splint, the TMD specialist suggested physiotherapy with an excellent professional physiotherapist specialized in facial trauma with car accidents, etc.

With her consultations, the mouth returned to the place and the pain diminished a lot, but with the cold it pulled to the right again.

I took Mioflex boxes because it hurt me in the right TMJ region and gave me a headache.

I consulted more other orthodontists and recommended splints.

To relieve the pain I did more than a year of acupuncture with another physiotherapist. It was great because because the pain relieved a lot. The physiotherapist left to live outside Brazil and I didn’t do acupuncture anymore

One day in 2017 having a lot of pain I found your name on the internet and read a wonderful testimony.

I went to see you, but I was unable to do the treatment.

Panoramic radiograph of the patient at the first consultation in 2017.

Laminography of the patient at the first consultation in 2017.

Frontal radiography of the patient at the first consultation in 2017. Mandibular deviation to the right. Midline deviation to the right. Cervical spine and odontoid process are centralized.

Frontal radiography of the patient at the first consultation in 2017. Mandibular deviation to the right. Midline deviation to the right. Cervical spine and odontoid process are centralized. Ilustration to facilitate the recognition of structures.

Lateral radiography of the patient at the first consultation in 2017.

The profile with mandibular protrusion is observed.

Important forward head posture.

Lateral and cervical spine radiography of the patient at the first consultation in 2017.

Important forward head posture.

The profile with mandibular protrusion is observed.

Initial dynamic electromyography of the patient in habitual occlusion at the first consultation in 2017.

This electromyography recorded in the consultation of the year 2017 shows significant asymmetry of the right and left temporal muscles between each other also asymmetry between the right and the left masseter. Right masseter spasm with very little activation at maximum intercuspation. The digastric muscle on the left side in constant activation during all functions.

In this electromyography, the patient is asked to open and close her mouth. Clench the teeth tightly at maximum intercuspation and swallow.

MRI: DP sagittal and T1 frontal view of the closed right TMJ in 2017.

Deflection of the mandibular condyle due to trauma in early childhoodand rectification of the upper aspect of the mandibular condyle.

MRI: DP sagittal and T1 frontal view of the closed left TMJ in 2017.

The image is not good due to the patient’s nervousness inside the resonator. The mandibular condyle on the left side is anteriorized even with the mouth closed.

MRI: T1 sagittal section of both right and left TMJs open mouth in 2017.

The limitation of opening of the right condyle can be observed, coinciding with the clinical complaint. In this image, we can observe the sequela of a green fracture in the right condyle due to trauma in early childhood.

The same 59-year-old female patient returns to consult to start the treatment in 2019, two years after the first consultation. According to the anamnesis, again filled out by the patient herself at the consultation, she reports: occasional headache, tinnitus, difficulty in chewing, stiff neck, pain in the left shoulder, pain in the right TMJ. Involuntary movements of the mandible, Oromandibular Dystonia.

Dystonia and oromandibular dystonia

Dystonia can be defined as involuntary and prolonged contractions, resulting in twisting movements and the adoption of abnormal positions. Involuntary rhythmic and oscillatory movements, due to alternating or synchronous contraction of antagonistic muscles with reciprocal innervation.

Dystonia can occur practically in all muscle groups. Various names are used to describe the different locations of dystonia.

Oromandibular dystonia is called when it is located in the lower part of the face, lips and jaw, the patient presenting involuntary closing of the mouth opening, retraction or pursing of the lips and may present repeated contractions of the platysma.

Summary report written by the patient on return for treatment in 2019, continuation of the report in 2017 at the first consultation.

After consulting with you in 2017, I was appointed at the time to another professional and soon put on the first functional device. The pain disappeared and the mouth started to return to its normal position (it pulled a lot to the right).

I used two more devices with her always mobile, the last one showing improvement in the symmetry of my face.

She did what she can up to here and now I’m following you, because I want my smile back and also the tinnitus to disappear.

When I take Frontal night (alprazolam) my facial muscle relaxes and the jaw returns to its normal position, but when the effect passes the jaw starts to shift again.

I also use this last device at night that the professional that was treating me made.

It is important to say that I have been to two neurologists and the observation was for me to always control vitamin B12 Since the first consultation I have been taking Citoneurin.

Trauma history:

In 1996 I don’t remember the year well, I fell off a stair and I hit my back until I hit the floor. I was seen at the hospital and had no fractures.

In 2003 I had an accident at an amusement park when a stroller that came behind mine, without brakes hit my back violently.

I was treated at the hospital, there were no fractures, I wore a vest around my neck for a while and I took Tramal.

I suffered two more car accidents where they hit me in the back and I suffered what is called “whiplash” I was driving.

I work weight training twice a week since two years ago, before I did Pilates.

As far as I know I have one leg shorter than the other.

Documentation of the patient when she returned in 2019, to start treatment

Postural front and back photographs of the patient when she returned to start treatment in 2019. It is noteworthy the mandibular deviation to the right in comparison with the postural photographs of the year 2017, which will be compared later on.

Postural photographs of the patient’s right and left profile when she returned to start treatment in 2019. It is noteworthy that the jaw that had a protruded position in the first photographs shows a more straight position compared to the postural photographs of the year 2017, which will be compared further ahead.

Video of the patient at the consultation in 2019 when she returns using a functional device, which relieved certain pains, but already with OROMANDIBULAR DYSTONIA.
Note the patient’s difficulty in closing her mouth. A filter was placed in the eyes to not identify the patient . The patient tries to close her eyes tightly to control the mandibular movement (sensory trick), but fails.

Patient’s habitual occlusion when she returned to start treatment in 2019. It is noteworthy a modification of the median line in comparison with the postural photographs of the year 2017, which will be compared later

Upper and lower occlusal view of the patient when she returned to start the treatment in 2019. Draws attention, the alignment of the lower crowding in comparison with the occlusal photographs of the year 2017, which will be compared later.

Panoramic radiograph of the patient when she returned to start treatment in 2019.

Laminography of the patient when she returned to start treatment in 2019.

Frontal radiography of the patient when she returned to start treatment in 2019. Important lateralization of the cervical spine to the right and sliding of the odontoid process of the axis to the right compared to the frontal radiography of the year 2017, which will be compared later on.

Frontal radiography of the patient when she returned to start treatment in 2019. Important lateralization of the cervical spine to the right and sliding of the odontoid process of the axis to the right compared to the frontal radiography of the year 2017, which will be compared later on. Design to facilitate recognition of structures.

Lateral radiograph of the patient when she returned to start treatment in 2019.

It is noteworthy that the jaw that had a protruded position on the first radiographs presents a more straight position compared to postural photographs from the year 2017, which will be compared later on.

Lateral and cervical spine radiography of the patient when she returned to start treatment in 2019.

It is noteworthy that the jaw that had a protruded position on the first radiographs presents a more straight position compared to postural photographs from the year 2017, which will be compared later on.

Increased upper thoracic kyphosis and anteriorization of the sixth cervical vertebra compared to the X-rays of the year 2017, which will be compared later.

This dynamic electromyography recorded in the consultation of the year 2019 shows greater asymmetry of the right and left masseter pairs muscles between them and the right and left temporal muscles between them, compared to the electromyography recorded in the year 2017.

The right masseter muscle is in spasm with very low activation at maximum intercuspation. In this electromyography, the right and left sternocleidomastoids were measured. The sternocleidomastoid muscle on the left side is activated during all functions.

MRI: T1 sagittal section of both right and left open TMJs when the patient returned to start the treatment in 2019.

The right condyle improved the opening but is still limited. The right mandibular head has a deflection and gives an appearance that comes to eminence. The opening in cases with deflection should be evaluated with reference to the continuation of the body and mandibular neck. In this image, the sequela of a green stick fracture due to trauma in early childhood can be observed very well in the right condyle.

MRI: Sagittal and frontal slice of the right TMJ closed mouth when the patient returned to start treatment in 2019.
Slight retroposition of the condyle in the sagittal section compared to the 2017 image.

MRI: Sagittal and frontal view of the left TMJ closed mouth when the patient returned to start treatment in 2019.

Retroposition of the condyle in the sagittal section compared to the 2017 image where it was in more forward position.

Comparison of the patient’s documentation of the first consultation in 2017 and when she returned to start treatment in 2019.

Comparative frontal images of the patient at the first consultation in 2017 and when she returned to start treatment in 2019.

Note the greater mandibular deviation to the right compared to the postural photographs of 2017.

Greater forward-rotation of both shoulders.

Comparative right and left profile images of the patient at the first consultation in 2017 and when she returned to start treatment in 2019.

Greater forward-rotation of both shoulders in 2019 images

Increased forward posture of the head in the 2019 images even more displacing the center of gravity.

The jaw is more retro positioned in the images of 2019 compared to the images in 2017.

Comparative images of the patient’s habitual occlusion when she returned to start treatment in 2019.

Modification of the median line compared to postural photographs from the year 2017.

Comparative images of the patient’s upper and lower occlusal view when she returned to start treatment in 2019. The alignment of the lower crowding in comparison with the occlusal photographs of the year 2017 is noteworthy.

Comparative frontal radiographs of the patient at the first consultation in 2017 and when she returned to start treatment in 2019.

Important lateralization of the cervical spine to the right and sliding of the odontoid process of the axis to the right compared to the frontal radiography of the year 2017.

Comparative frontal radiographs of the patient at the first consultation in 2017 and when she returned to start treatment in 2019.

Important lateralization of the cervical spine to the right and sliding of the odontoid process of the axis to the right compared to the frontal radiography of the year 2017. Design for easy viewing.

Comparative lateral radiographs of the patient at the first consultation in 2017 and when she returned to start treatment in 2019.

The jaw that had a protruded position on the first radiographs shows a straighter position compared to postural photographs from the year 2017. A more compressed position.

Greater forward posture of the head on the 2019 radiography compared to the 2017 radiography.

Comparative lateral and cervical spine radiographs of the patient at the first consultation in 2017 and when she returned to start treatment in 2019.

The jaw that had a protruded position on the first radiographs shows a straighter position compared to postural photographs from the year 2017. A more compressed position.

Greater forward posture of the head on the 2019 radiography compared to the 2017 radiography.

Increased high thoracic kyphosis on the 2019 radiography compared to the 2017 radiography.

Video of the patient when she returned for treatment BEFORE placing the orthotic on her.

You can notice the involuntary movement of the jaw and the patient trying to press her lips to control the movement.

A filter has been placed and the audio is removed.

Video Content: Good morning, what you have is an oromandibular dystonia, did you know that?

The Dr. who was treating me took my case to São Paulo, at a congress and commented on oromandibular dystonia. Then I consulted with a neurologist who said it was dyskinesia. He claimed that MRI showed nothing that neurologically I had nothing. He said he could continue with the functional device and prescribed an anxiolytic and Citoneurin.

Initiation of the treatment:

In this specific case of oromandibular dystonia, IT WAS NOT POSSIBLE to use a computerized jaw tracker to record the bite, due to lateral mandibular movements.

It was not possible to record the neuromuscular physiological rest position of the mandible with the jaw tracker, invalidated due to the involuntary movements of the patient’s jaw.

Example of a record with the jaw tracker in a physiological neuromuscular rest position of a patient with TMJ pathology, but WITHOUT OROMANDIBULAR DYSTONIA. We can observe the symmetrical and repetitive pulse that corresponds to the elevation of the mandible by the action of TENS.

The bite registration for the construction of the orthotic was performed using information from the surface electromyography (record already posted) and Tens, without using the jaw tracker due to mandibular movements. Taking into account joint decompression and manual muscle tests of arms and legs strength in coordination with the orthotic.

Together with the installation of the orthotic for continuous use, the patient was referred for osteopathic treatment with Dr. Kaciane Boschetti to adjust the biomechanics and body alignment.

Video with the patient wearing the mandibular orthotic.

Video Content:

Hi, how are you?

Hi Dr. Good morning on this wonderful day full of the warmest spring sun, I am here very happy doing my review.

My mouth, the jaw is getting back to normal, this rush that the jaw was doing, it is passing , I’m feeling very positive about the treatment, I know this is a walk I’ve been here for a while and I’m at least having my face back. I hope to be totally cured, I believe in miracles, but it doesn’t depend on me anymore. I’m doing what I have to do.

Video with the patient without the mandibular orthotic.

Video Content:

I am recording this video for you to tell you that I am going out to dinner now, I put on makeup, put on lipstick and I am hoping to be successful tonight.

I want to thank you for the affection and dedication with me. A big kiss dear. I have no device now.

Considerations of movement disorders and their connection to the TMJ.

Dystonia is a term that defines a group of diseases characterized by involuntary muscle spasms that generate abnormal movements and postures of a certain part or the whole body.

Oromandibular dystonia: is characterized by spasms in the lower region of the face, such as the lips, mouth, tongue and jaws. The most frequent symptoms are difficulty in chewing, opening the mouth, swallowing food and articulating words.

The prevalence of temporomandibular disorders in oromandibular dystonia is very high. It is important that health professionals are familiar with oromandibular dystonia and temporomandibular disorders.

The dental nerve that innervates the jaw muscles and the TMJ also mixes with the nerves in the neck. Therefore, dysfunction in the cervical structures usually leads to problems in the jaw and vice versa.

Neuritis of the auriculotemporal branch of the trigeminal nerve, which has a direct entry into the reticular formation (RF) can activate the cells in the pontine region of RF known for the control and deviation of the head posture.

Precision orthotics can help by modifying the nociceptive reflexes in the region of the temporomandibular joint. It is essential to work on biomechanical adjustments and body alignment carried out by specialized professionals with experience in dystonic patients.

Each patient is UNIQUE, the time and the result are also unique for each patient. In general, those patients where focal dystonia has been installed for a shorter time have a faster and more favorable response.

There are patients who take years to improve and others where the improvement is faster. You can’t predict this at the beginning.

In this specific case, the patient feels very well nowadays without the use of the orthotic this fact is unusual, my recommendations: always to take the orthosis with her and continue with all the indications given by the osteopath.

I asked the patient for radiographs to assess changes in both the mandible and the upper cervical.

I am deeply grateful to Dr. Anthony B. Sims for his teachings in the area of movement disorders and its relationship with the TMJ.

This knowledge is essential due to the large number of patients who can be helped.

Testimony of the patient:

Good night Dr. Lidia

Follow my testimony.

These past few months have been wonderful in my life.

In 2011, when changing the old amalgam of my teeth, I entered a year later in a journey of intense pain on the right side of my face, in addition to having a very strong drawing of my jaw in this same direction.

Even using a functional appliance, my condition worsened until I received a diagnosis of oromandibular dystonia.

There were many dentists and doctors that I consulted but the improvement started to happen with the treatment suggested by Dr. Lidia with the use of a splint totally different from the ones I had used previously.

During the first consultations I was fully evaluated considering my movements and posture.

Thanks to God through this new protocol that I tried I started to feel relevant improvements the pain started to decrease a lot.

During this period I totally changed my physical exercises and started dancing and walking a lot too (advice from the osteopath Dr. Kaciane Boschetti indicated by Dr. Lidia).

I started to have more health and also looked for a more nutritious diet because I had a low immunity during this period.

Today I take supplements including higher doses of vitamin D, magnesium chloride for anxiety control. I also have permanent control of the B and C complex vitamins as well as type 2 collagen which had a direct effect on pain relief.

With the continued use of the orthotic the jaw started to return to the place and this was a real miracle!

The movement on the right side of the face no longer exists.

I believe that the neurological system has absorbed the new position of the face and the alignment of the face has improved.

It was just a few months and the result was surprising.

I have no more pain. I can chew any food without difficulty and speak normally without the jaw pulling.

After the entire period of treatment I find that I learned new principles of healthy health. Small initial jaw disorders if not treated properly can lead to dystonia!

My smile came back and I currently don’t use the orthotic anymore.

First of all, I thank God for life and for inspiring Dr. Lidia to study movement disorders in the face because it was through her knowledge that today I am cured.

A hug God bless

High technology in the diagnosis and treatment of TMJ pathologies and the optimized bite for enhance the highest performance in Sports Dentistry

Posted on 24 de June de 2019 by lidiayavich

The advances in biotechnology have allowed a deeper understanding of the pathologies that affect the temporomandibular joint.
Nuclear magnetic resonance images and biotechnology were transferred to the realm of clinicians, no longer being exclusive to the realm of researchers.
These advances play a key role in conjunction with clinical examination, carefully integrated with the patient’s history and pathophysiology.
Controlling pain is a fundamental goal, but it is also possible today, in certain cases, to regenerate structures.

Cephalometry presupposes that the mandibular heads are in a physiological position and patients do not present any pathology in the temporomandibular joint.
Many of our patients looking for correction of a malocclusion, or a prosthetic rehabilitation, present noises in their TMJ, facets and erosions in their images and pain in the retrodiscal palpation.
Hard tissue injuries as a result of early childhood trauma can lead to injuries to the disc and ligaments.
Infections and autoimmune diseases should be considered, since they affect not only the temporomandibular joint but also all the fascial and muscular chains of the human body.
The evaluation of TMJ and the diagnosis of its pathologies should be an inseparable part of our procedures, not only in orthodontics and orthopedics but in all fields of dentistry.

Dr. Lidia Graciela Yavich

Specialist in Temporomandibular Dysfunction and Orofacial Pain. Specialist in Orthodontics and Facial Orthopedics. Co-author of the Compendium of Diagnosis of TMJ Pathologies. Medical Arts. Edition in Portuguese and Spanish. Author of the Atlas book of healthy and pathological images of the temporomandibular joint. Medical Arts, Trilingual edition- EnglishSpanish and Portuguese. Invited speaker in National and International Institutions.

Dr. Luis Daniel Yavich

Specialist in Temporomandibular Dysfunction and Orofacial Pain. Specialist in Sports Dentistry Specialist in Radiology and Imaginology Dentist of the Botafogo F. R. CEO of Diosport Co-funder of the Brazilian Academy for Sports Dentistry Invited speaker in Brazil, Uruguay, Argentina, Chile, USA, Portugal, Germany

DAY 1 | TMJ PATHOLOGIES AND NEUROMUSCULAR PHYSIOLOGY

Images in diagnosis and treatment. Form and function. Lesions in TMJ pathologies.
TMJ pathologies in children and adolescents.
Autoimmune diseases and pathologies of TMJ.
Nuclear Magnetic Resonance (MRI). Method of choice in the diagnosis and treatment plan.
Tomography and its correlation with MRI. Comparison of data obtained in both studies, done to the same patient.
Introduction to surface electromyography.
Determination of the vertical dimension by electronic mandibular deprogramming.

DAY 2 | DIOSPORT: DENTAL PROTECTORS WITH PERFORMANCE

Sports Medicine: a new promising market.
Oral protectors and their classification. Types, personalization and characterization.
Mouth guard optimized for the increase of the sport performance accomplished with the physiological neuromuscular technique.
Intra-oral devices optimized for non-contact sports.
Relationship between these devices with TMJ, posture and better sports performance.
Reality of a Dental Department inserted in a soccer club.

High Tech Denta BJ Jeanne Barret, Parc Valmy Dijon

25-26 October 2019

fb.com/HighTechDenta
contact@hightechdenta.fr
http://www.hightechdenta.fr

In October 25 and 26 we will met in the beautiful city of Dijon where I will have the pleasure to share with you about TMJ pathologies and their impact on the whole body system and in sport dentistry.
• We will speak on images of the temporomandibular joint from the gold standard that is MRI, but also I want to mark the signs in everyday radiographs.
• We will also analyze posture and occlusion since dentistry is pure neurology and the interventions that we perform in our patients are present in the whole body. Degenerative processes that affect the head of the mandible, disk dislocations, changes in the growing axis of the condyle, impair the joints. The masticatory system represents the highest link of the postural chain and deeply influences the lower links. This relation is fundamental not only in pathology but also in sports dentistry.
• See you in Dijon.
À bientôt

Hello my friends from Europe: on the 25 and 26 of October I will be in Dijon, France at the High Tech Denta explaining and teaching how we can adjust, using the biometric tools, the mouth guards and splints that we construct to enhance the performance in Sports Dentistry. See in Dijon!

Posteriorization of the Mandibular Condyle, Compression of the Retrodiscal Tissue and Anteriorization of the Articular Disc as a cause of Neurologic Pain. Recovery of the Physiological Relationship of the Head of the Mandible with the Articular Disc. Series of clinical cases.

Posted on 3 de April de 2019 by lidiayavich

In this page we present some of the physiological neuromuscular foundations for the treatment of temporomandibular joint pathologies, it was also presented the importance of differential diagnosis and also the use of bioinstrumentation as surface electromyography and computerized kinesiography.

Images of patients related to their symptoms were also presented. Several etiological factors such as trauma in early childhood, especially green stick fracture, recapture of the intra-articular discs in reducible displacements, and interrelation between craniomandibular disorders and the vertebral column.

When we talk about the treatment of TMJ pathologies we have to understand that there are different approaches. The proposal for a palliative treatment is the symptomatic treatment, that is, a treatment that seeks to block the symptoms. It is given through the administration of drugs, such as analgesics, anti-inflammatory and myo relaxing drugs. The restorative approach is the treatment that seeks when possible to correct or heal what is damaged. To know what is wrong, a differential diagnosis is necessary. This diagnosis must always be made prior to the treatment proposal.

A 19-year-old female patient presents at the clinic with complaints of constant headache, neck pain and swelling in the face, back of the head pain and migraines.

According to the anamnesis filled out by the patient herself, in the initial consultation she reports clicks in the jaw, dizziness, ear pain and low back pain.

The patient also reports bruxism and nighttime clenching.

The patient also refers to retro-ocular pain on the right side, pain in both shoulders, and pain in the TMJ (right temporomandibular joint).

The patient reports cracks in the TMJ on the right side, sensation of ear covering, strange sounds and non-specific facial pain.

The patient claims difficulty in opening the mouth and difficulty in chewing.

Summary report written by the patient

In the middle of the year 2014, I had a routine consultation at a dentist to clean my teeth and I reported cracking and pain in the jaw, she did not pay attention, she said it was normal and it would soon pass.

Since then I started with severe headaches, dizziness, ear pain, back pain, my feet (more in my heel), pain in my eye as well, and in days of painful crises, my right eye would hardly open and the right side of the my face all swollen (mumps type).

After this worsening we looked for an TMJ specialist who gave me an acrylic plate, thin and only for my upper teeth.

I used the splint for six months and after that all the symptoms worsened.

We looked for another specialist, who made the same acrylic plate for the upper teeth, but in a very different size, it was a thick plate.

In the beginning it helped, after six months, all the symptoms started to appear stronger.

We consulted a new specialist, who made a new type of appliance, with the wires and the blue acrylic on the side (I took it to show to you), it was what had helped me the most, using it for 24 hours, improved pain, even dizziness , but after a year of use everything returned and with all the pain still stronger, however during that one year of treatment, despite the improvements I could not make any kind of physical effort even not strong my jaw swelled (gym, climbing stairs, picking up weight …)

In March 2017, a year and four months of use of the appliance, the professional said it was time to start “weaning”, start leaving the device and use only to sleep because I should already be good, I commented that it had gotten worse and she insisted that it was the time to be well…

It was then that we looked for another specialist, this one said that the plate in use was not suitable for the problem and made a new plate of acrylic that judged the correct one for the presented problem, was thin and of acrylic, equal to the first one I already used, only for the upper teeth, I immediately told to my mother and to him that this plate would not solve, since I had already used identical plate in previous treatment, he insisted saying yes, that was the correct one.

With the use of the device I also did hot compresses and shocks of physiotherapy and also needles, which helped a lot in the neck muscles that hurt a lot, but this device from the beginning did not help, the headaches that felt every day were even worse, I’ve had more dizziness.

Habitual occlusion of the patient on the day of the consultation.

Upper and lower occlusal views of the patient on the day of the consultation.

Initial panoramic radiograph of the patient before treatment.

TMJ laminography in habitual occlusion and in open mouth.

The laminography of the temporomandibular joints shows a modification of the axis of growth of the mandibular condyles caused by a trauma in the early childhood, (green stick fracture).

Important retro position of the jaw mandibular heads especially on the left side causing an important retrodiscal compression.

Lateral radiograph of the patient in habitual occlusion before treatment.

Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis, rectification of the cervical spine.

Frontal radiography of the patient in habitual occlusion before treatment.

Dynamic electromyographic record of the patient in habitual occlusion.

It is important to understand that surface electromyography is an additional tool in diagnosis, and not the only determinant, is a very interesting tool to be able to control the evolution in our own patient during the course of treatment.

MRI: sagittal T1 slices of the left TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

The magnetic nuclear resonance of the patient in habitual occlusion demonstrates the anterior dislocation of both articular discs, retroposition of the mandibular heads and modification of the axis of growth caused by traumatism in the early childhood (Structural modifications of the mandibular condylar process as one of the sequels of traumatism. in infancy). Dislocation is reducible (open mouth resonance not included in this post).

MRI: sagittal T1 slices of the left TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: sagittal T1 slices of the right TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: sagittal T1 slices of the right TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: T1 frontal slices of right and left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right and left temporomandibular joint evidences a severe loss of joint space.

Tomographic examination of temporo-mandibular joints.

Right and left sagittal slices in habitual occlusion prior to treatment.

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – left TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – right TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

When our proposal is a restorative treatment, we have a FIRST PHASE where the goal when possible is to heal the joint. Sometimes we can only improve it or prevent it from getting worse. Knowing what we can treat and what we cannot treat and the limitations of each individual case is very important.

To correctly evaluate the maxillomandibular relationship we should begin to consider the physiological position of mandibular rest.

Physiological rest is a concept applicable to all the muscles of the body.

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were electronically deprogrammed and a new resting neuromuscular physiological position was recorded.

The patient has a pathological free space of 7.7 mm.

The patient also had a 0.6 mm mandibular retroposition.

Occlusion of the patient with the DIO (intraoral device)

With the record obtained with the jaw tracker an intraoral device (DIO) was made to three dimensionally reposition the mandible.

The NEUROMUSCULAR PHYSIOLOGICAL position was recorded in the form of an occlusal bite record, which was later used to make a DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

Comparative frontal postural images.

The patient was derived along with TMJ pathology treatment for a physiotherapy team in the city where she resides. Along with mandibular repositioning the conditioning of all postural chains is necessary.

Each patient needs a specific derivation according to the particular case.

Dynamic electromyographic record of the patient with the DIO (intraoral device) in physiological neuromuscular occlusion.

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

RNM: Comparison of FRONTAL SLICE T1, left TMJ, closed mouth, before the physiological neuromuscular treatment, and the same left TMJ, FRONTAL SLICE T1, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

RNM: Comparison of FRONTAL SLICE T1, right TMJ, closed mouth, before the physiological neuromuscular treatment, and the same right TMJ, FRONTAL SLICE T1, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

Comparative panoramic radiographs of the patient before starting the treatment and at the beginning of the second phase of the treatment. At this time the removal of the third molars included can also be done.

Comparative laminographies of the patient before starting the treatment and at the beginning of the second phase of the treatment. The joint decompression can be observed.

Laminographs and or COMPUTERIZED TOMOGRAPHS, even showing decompression DO NOT SHOW the position of the articular disc. The position of the articular disc and the presence or not of osseous edema of the mandibular condyle can only be evaluated with nuclear magnetic resonance. The result or not of the recovery of the Physiological Relationship of the Jaw Head to the Articular Disc can be evaluated by comparing the MRI after the first phase and the comparison with the initial MRI.

Comparative frontal radiographs of the patient before starting the treatment and at the beginning of the second phase of the treatment.

When the first phase is completed, we verify if the subsequent control images correspond to our goals set in the initial diagnosis. We know that there are cases where we can improve the case, and others where we can prevent it from worsening, and others where we can only treat the pain.

The patient did not report any symptoms from the temporomandibular joint. The comparative MRI showed the recovery of the physiological relation of the head of the mandible with the articular disc.

The electromyographic and kinesiographic records objectively showed improvement of the neuromuscular function.

In the case of positive results from the first phase we can start a second phase of treatment to remove the device that is used permanently during the first phase of the treatment. For this we can perform a three-dimensional orthodontic, a physiological neuromuscular rehabilitation or the combination of both. Always maintaining the mandibular location in balance with the muscular planes, temporomandibular joint and dental planes.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the physiological neuromuscular occlusion.

In this case we will move to a three-dimensional orthodontic, where the teeth are erupted to the new physiological neuromuscular position.

A three-dimensional orthodontics needs to maintain the three-dimensional position of the mandible in balance with its bone and muscle planes achieved in the FIRST PHASE, and whenever possible maintain the Physiological Relationship of the Jaw Head with the Articular Disc.
It is fundamental to understand, that this passage has to be made keeping the DIO (intraoral device, together with the different devices to be used for the dental eruption)

Patient’s statement:

After long three years of failure looking for a treatment for my problem in my city, I found Dr. Lidia in a simple Google search.

I went to her and with a proposal completely different from the others, we started the new treatment immediately.

I was in an advanced stage, where I had headache all day, pain in the ear, swollen eye (often unable to open), right side of the swollen face too (like a mumps), pain in the neck, pain in my back and also on foot.

I had no quality of life, because I was in pain all the time. When I started the treatment in the first two days I did not feel any more headaches. With the monthly follow up, adjusting as my body asked, I no longer felt any pain in anything and I returned to a normal life.

Today I am in the middle of the second phase, super anxious to go to the end and every month that passes I feel better and better.

Recapturing the Articular Disc or Repositioning the Mandibular Condyle? What about Rethinking the Concept as the Recovery of the Physiological Relationship of the Head of the Mandible with the Articular Disc. Patients with a long history of pain. Case series. First Section.

Posted on 9 de January de 2019 by lidiayavich

Recapture the articular disc, repositioning the mandibular condyle?

What about rethinking the concept as the recovery of the physiological relationship of the mandible head with the articular disc ,WHEN IT IS POSSIBLE.

And when is it not possible? What is the differential diagnosis? WHAT CAN WE OFFER TO OUR PATIENTS?

What type of orthotic or intraoral device to use? What is the purpose of an orthotic in a TMJ Pathology treatment? Repositioning the jaw, recapturing the articular discs? Is this always possible? DEPEND ON THE DIFFERENTIAL DIAGNOSIS!

Does it have changes in the articular structures of the temporomandibular joint?

Does it have distortions in the horizontal, vertical and transverse posture of the craniomandibular complex?

How are the bones?

How’s the cartilage?

How’s the articular disk?

How are the muscles in this system?

How is the cervical spine in relation to the whole system?

How is the relation of the vertebral column with the other parts of the system?

The teeth, the two temporomandibular joints and the postural musculature are parts of the same bone, the mandible. They are deeply interrelated and interdependent in growth, form, and function. An abnormality in one, profoundly affects the others.

A 30-year-old female patient presents at the clinic with a history of headache, pain in the forehead, pain and stiffness in the nape of the neck, left eyebrow pain, pain behind the right eye, and pain in the right shoulder. The patient reports TMJ pain (temporomandibular joint) on the right side.

The patient reports bilateral crackling, non-specific facial pain, and muscle tremor, difficulty opening the mouth, difficulty in chewing and mandibular locking.

Summary report written by the patient:

I do not remember a sudden drop where there might have been some kind of injury.
At 6 years of age I was a gymnast. I always had falls, front, back and head. But there were protections on the floor.

Near 8 years old, I extract a molar from the lower left side. I think that from this I have always forced more chewing on the right side.

At approximately 13/14 years of age, I remember starting the cracks on the right side. On this side I had a cross bite and a deciduous canine that “bit” behind the lower tooth.

At this stage, the crackling became more frequent, causing a bit of difficulty to fully open the mouth. When trying to open the mouth without the snap, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

In 2004 I had the first “lockup”. I remember being in winter and cold. I tried to do the “game” of the jaw and I could not open the mouth. Then I forced myself to open my mouth and I felt a strong crack, followed by pain in the ear / nose. The impression was that it had displaced some bone / nerve.

From this episode, whenever I force more the region, the locking happens. Ex: when I eat meats, candy, peanuts. Things that I need to force when chewing.

In 2008 I put orthodontic appliance to make the corrections. In the treatment, I made a process of spacing the teeth, with a device in the roof of the mouth to open the arch. I kept my teeth apart for a while.

After finishing the treatment, corrected the teeth, the clicks returned lighter. Approximately 1 year later, the locking returned as well. I started with headaches and cervical pain. I felt slight tingling in the head.

In 2015 I started to hear some kind of “sand” on the left side. Then I got pregnant and in this period began the crackling also on the left side. In February 2017 I had the first “lock” on the left side.

Now when I feel the locking, I try to relax the muscles well, leaving the jaw loose for a few minutes. Sometimes it returns to normal anyway, other times I have to force it with the opening of the mouth, causing a strong crack.

Current information:

When I close my mouth, I feel my jaw line back slightly, to “marry” the bite. To keep my mouth “loose” and comfortable, I have to snap both sides, and let the jaw loose.

When I try to open my mouth without the snaps, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

Crashes usually occur:

– Yawning;

– In the morning (awake with the jaw locked);

– Eating meats.

CT: Part of the initial study of the patient sent before the consultation requested by another professional.

Anamnesis and clinical examination are a key part in the diagnosis of patients with TMJ pathology.

Computed tomography is an excellent image, but when we treat a synovial joint in a patient with TMJ pathologies, CT does NOT PROVIDE THE INFORMATION OF THE SOFT TISSUES.

Magnetic Nuclear Resonance (NMR) can give a lot of information and not just the position of the disk. It is essential to have the knowledge to KNOW WHAT TO DO WITH THIS INFORMATION.

We cannot treat a patient with mandible head necrosis or with medullary edema or arthrosis or rheumatoid arthritis or lupus in the same way that we treat another patient with only a wrong position of the jaw.

The temporomandibular joints of all these patients need to be decompressed, but that is only part of the problem.

Habitual occlusion of the patient on the day of the consultation.

Upper and lower occlusal views of the patient prior to treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

Initial panoramic radiograph of the patient before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

The laminography of the temporomandibular joints shows a modification of the growth axis of the mandibular condyles in both the left and right caused by a traumatism in the early childhood, (fracture in green stick).

Retro position of both mandibular heads in the articular fossae.

TMJ laminography in habitual occlusion and open mouth.

Three-dimensional asymmetries in the head of the condyle may have been caused by different etiologies and cause morphofunctional pathologies.

Changes in the orientation of the mandible head occur in patients who have suffered blows in the chin region, either anteroposterior, vertical or lateral. We can observe in these cases a deformation of the head of the mandible in the form of curvature, with an anterior concavity, which in some cases may be so important which produces a compression of the retrodiscal region, causing severe symptoms.

Frontal radiography of the patient in habitual occlusion before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

Lateral radiograph of the patient in habitual occlusion before treatment.

Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis and rectification of the cervical spine.

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

MRI: frontal slices of the right and the left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right and left temporomandibular joint evidences a severe loss of joint space.

Dynamic electromyography record of the patient in habitual occlusion and with cotton rolls on the right side (second column), left side (third column) and both right and left sides (fourth column).

Note the improvement in recruitment of motor units in the fourth column.

Patient’s initial record for the construction of the DIO ( intraoral device)

To correctly evaluate the Maxilomandibular relationship we should begin to consider the physiological rest mandible position.

Physiological rest is a concept applicable to all the muscles of the body.

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were deprogrammed electronically and a new physiological neuromuscular position at rest was recorded.

The patient has in this first record a pathological free space of 6,4 mm.

The patient also presented a 0.4 mm of mandibular retro position.

Recalibration of the physiological neuromuscular position of the DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

Occlusion of the patient with the DIO (intraoral device)

With the record obtained with the jaw tracker an intraoral device (DIO) was made to reposition the mandible three-dimensionally.

The PHYSIOLOGICAL NEUROMUSCULAR position was recorded in the form of an occlusal bite record, which was later used to make a DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

Another cinecigraphic record to control the DIO (intraoral device) in a physiological neuromuscular position as the device is changed or recalibrated.

The patient did not report any more symptomatology. The electromyography and kinesiography records objectively showed improvement of the neuromuscular function.

I asked for the second MRI (nuclear magnetic resonance) to objectively evaluate the physiological relationship between the mandibular condyles and the articular disc.

RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

RNM: Comparison of the frontal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

RNM: Comparison of the frontal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

The patient did not report any more symptomatology. The comparative MRI showed the recovery of the physiological relationship of the mandible head with the articular disc.

The electromyographic and kinesiographic records objectively showed improvement of the neuromuscular function.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the neuromuscular physiological occlusion.

For this we use a three-dimensional orthodontic, where the teeth are erupted to the new physiological neuromuscular position.

Patient Testimony:

My first memory of locking joints was at age 15 or so.

I looked for orthodontic specialists; I made the necessary “adjustments”, but the locking and the pain still continued.

I looked for Dr. Lidia now at the age of 30, since other experts told me that only surgery would be possible in my case. And yet, without knowing exactly whether we would succeed.

After starting the first phase of treatment with the device, the pain ceased and never again I had the jaw locking that so frighten me.

I adapted very easily to the treatment, I was and I am being much disciplined with the use of the device.

Now, as Dr. Lidia explained to me, with the discs already in the right place, we will pass for the second phase, for withdrawal of the device.

Today I’m having a routine without worry that I can “lock” at any time.

I’m very grateful to Dr. Lidia.

Treatment of TMJ Pathologies: Patient with headache and excessive clenching. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

Posted on 2 de August de 2018 by lidiayavich

A 32-year-old male patient presents at the clinic with complaints of constant headaches, pain in the jaw and daily pressure on the teeth.
The patient also reports pain in the temporomandibular joints and pain to open the mouth.

The patient also reports bilateral clicks and the sensation of clogged ears.
It also states in its clinical history difficulty in chewing and opening the mouth and inability to control teeth tightening.
The patient reported that he sought various dentists and treatments and that he had previously used “miorelaxant” splints that did not alleviate the referred symptoms.

Habitual occlusion of the patient on the day of the consultation.
The patient had a deep bite and significant wear on the upper and lower incisors.

Upper and lower occlusal views of the patient prior to treatment. Wear on lower and upper incisors.

Initial panoramic radiograph of the patient before treatment.

Absence of teeth 18, 28, 38, 48.

Horizontal resorption of alveolar ridges.

Patient TMJ laminography in habitual occlusion before treatment.

The laminography of the temporomandibular joint shows retroposition of the articular processes in the articular cavities when the mandible is in position of maximum intercuspation
In the mandibular aperture, the presence of osteophytes was observed in both condyles.Flattening of the superior anterior surface of the articular processes and superior posterior of the right articular process.

Lateral radiograph and patient profile in habitual occlusion before treatment. Rectification of the cervical spine.

Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Rectification of the cervical spine.

Frontal radiography of the patient in habitual occlusion before treatment.

MRI: sagittal slices of the left closed TMJ before treatment. The mandibular head is in retro position. The joint disc is slightly dislocated.
The articular disc has a reduction in open-mouth maneuvers. Open mouth images not included in this post.

MRI: sagittal slices of the left closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

MRI: sagittal slices of the right closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

Patient’s initial cineciographic record
Three-dimensional view of the mandibular movement.
The record shows opening and closing and speed when making these moves. The patient shows an opening of more than 50 mm
Note a significant loss of speed in the mandibular closure.

Dynamic electromyographic record in patient’s habitual occlusion before treatment.

Note very little activation of the right and left masseter muscles in maximal intercuspation, indicating to the patient to bite hard without opening his mouth.

The masseter muscles are the most powerful muscles of the stomatognathic system, even more considering a brachyfacial biotype patient as in this case.

To correctly evaluate the Maxilomandibular relationship we should begin to consider the physiological rest mandible position.

Physiological rest is a concept applicable to all the muscles of the body.

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were deprogrammed electronically and a new physiological neuromuscular position at rest was recorded.

The patient has a pathological free space of 8,2 mm, already discounting the two physiological mm of a healthy free space.

The patient also presented a 2 mm mandibular retro position

With these data we constructed a DIO (intraoral device), to maintain the three-dimensional recorded position. This device must be electromyographically tested to objectively measure the patient.

It is logical that the report of the patient’s symptomatology is important, but the surface electromyography shows in an objective way if the muscular function improved, worsened or did not modify.

Frontal radiography of the patient with the DIO (intraoral device) constructed in a physiological neuromuscular position.

Lateral and cervical radiograph of the patient with the DIO (intraoral device) constructed in a physiological neuromuscular position.

The second MRI is requested after one year on average of the first phase treatment, also during the second phase of the treatment, the patient is monitored, and the device recalibrated or changed according to the controlled data throughout this step.

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc.

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

The patient did not report any more symptomatology related to the TMJ. Bioinstrumentation also objectively showed an improvement in neuromuscular function.

We decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the physiological neuromuscular occlusion.

For this we used a three-dimensional orthodontics, where the teeth are erupted to the new neurophysiological position.

In the second phase, in this case the three-dimensional orthodontics,the patient is monitored and deprogrammed electronically, and often the device is recalibrated or changed, to maintain the position obtained in the first phase.

Part of the sequence of the second phase (in this specific clinical case).

Finalization of the second phase.

Patient’s upper and lower occlusal view after the finalization of the second phase.

Comparative occlusion of the patient before and after the end of the second phase of the treatment using a three-dimensional orthodontics.

The non-coincidence of the median dental lines may be noted.
The patient’s fundamental alignment is muscle alignment that does not always coincide with tooth alignment. In this case the muscular alignment is respected.

Patient’s comparative superior and inferior occlusal view, before and after, the end of the second phase of the treatment by a three-dimensional orthodontics.

Electromyographic record of the patient in physiological neuromuscular position after the completion of three-dimensional orthodontics.

Note the higher recruitment of motor units in the masseter muscles that previously showed little activity.

Frontal radiography of the patient after the end of the second phase of the treatment.
Patient in physiological neuromuscular occlusion.

Lateral radiograph and patient profile after completion of the second phase of treatment.
Patient in physiological neuromuscular occlusion.

Lateral and cervical radiography of the patient after the end of the second phase of the treatment.
Patient in physiological neuromuscular occlusion.

Panoramic radiograph of the patient after the end of the second phase of the treatment with three-dimensional orthodontics.

Patient TMJ laminography after the completion of three-dimensional orthodontics.
Patient in physiological neuromuscular occlusion.

Comparative panoramic radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

Patient comparative TMJ laminography: before treatment and after completion with three-dimensional orthodontics.

Comparative lateral and profile radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

Take into account that the result corresponds more to a three-dimensional recovery of the vertical dimension and not simply to an anteroposterior modification.
Even a retroposition of the mandibular head is the product of a three-dimensional alteration.

Comparative frontal radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

Comparative patient lateral and cervical radiographs: before treatment and after completion with three-dimensional orthodontics.

At the end of 2012, I attended the Life and Health program on RBS TV and saw a report with Dr. Luis Daniel Yavich Mattos, on the treatment of problems related to TMJ.

Living with constant headaches, jaw pain and daily pressure on the teeth,

I decided to bet on the treatment and I do not regret it.

Since I was 18 years old, I had been suffering from pain in the TMJ region, and what

bothered me was a pressure that made me want to grind my teeth even

day, which I have always identified as bruxism.

I had already sought out various dentists and treatments, with the use of the famous splints to sleep. The diagnosis was always the same: emotional stress was the cause of my teeth and constant pains, although the pains started only after I have extracted my first wisdom.

I used to use the plates to sleep during the 24 hours of the day, so the will of biting and grinding teeth. The use of the splints prevented wear, but the pressure I felt to bite and grind my teeth caused me TMJ fatigue and headaches.

And when I had no more hope emerged, the possibility of doing the treatment with Dr. Luis Daniel and Dr. Lidia Yavich, when I was 32 years old.

With Dr. Luis Daniel they were approximately 1 year and 2 months using a very high plate, 24 hours a day, including to make meals, which I only took to do the oral hygiene.

The device was called the “big monster,” because of the height. In the end, no longer pain and without the will of grinding and biting my teeth.

I went on to the second stage of treatment, now with Dr. Lidia Yavich.

With Dr. Lidia were approximately 3 years, in which I used fixed dental appliance, with brackets, steel wires, etc., in order to be able to stop using the board 24 hours a day, and improve the aesthetics of my dental arch.

As the treatment progressed, the device was diminished and new splints were used in order of erupting my teeth respecting the TMJ position.

At the end of the treatment, I now use one sleeping device and another one for aesthetic reasons.

I no longer have the willingness to bite and grind teeth, or pain in the TMJ or headaches. I can yawn without worrying about hurting my jaw.

Finally, it was an individualized, artisanal treatment that required time and dedication, and brought excellent results, which is why I am eternally grateful to Dr. Luis Daniel and to Dr. Lidia.

The temporomandibular joint (TMJ) as a peripheral trigger in the headache. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

Posted on 13 de June de 2018 by lidiayavich

A 36-year-old female patient with a major complaint of headache consults at the clinic, referred by a co-worker who had been treated at the clinic for the same reason.

The patient’s main complaint was a high frequency headache. The patient reports that she has investigated the cause of the pain and even had at the request of the neurologist a nuclear magnetic resonance of the skull that did not accuse any abnormality.

The patient had already consulted with Neurologist, Otorhinolaryngologist, Orthopedist and with the general practitioner.
The patient also refers back pain.

Habitual occlusion of the patient on the day of the consultation.

Upper and lower occlusal views of the patient on the day of the consultation.

Upper and lower incisors show signs of attrition.

Initial panoramic radiograph of the patient before treatment.

Absence of the second right upper premolar and the lower third molars.

The patient reports that the upper premolar was extracted in adolescence due to lack of space for the eruption of the canine.

The first maxillary molar on the left side and the first lower molar on the left side presented endodontic treatment with extensive restorations and risk of fracture, was informed of the need to extract the third molar retained.

The procedures would only be performed after joint decompression.

Laminography of the temporomandibular joints shows a modification of the axis of growth of the mandibular condyle on the left side caused by a trauma in the early childhood, (green stick fracture).

Lateral radiograph and patient profile before treatment. Patient in habitual occlusion.

Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis, rectification of the cervical spine.

Frontal radiography of the patient in habitual occlusion before treatment.

MRI: sagittal slices of the left TMJ, the closed mouth.

The facet on the upper surface and posterior flattening of the mandibular condyle can be observed.

Note the important posterior compression of the left condyle.
Primary objective has to be the three-dimensional decompression of the mandibular condyle.

The patient’s masticatory muscles were deprogrammed electronically and the resting position was recorded with a computerized kinesiograph.
The patient had a pathological interocclusal free space of 6.3 mm and a mandibular retroposition of 0.5 mm.

With the record obtained with the computerized jaw tracker an intraoral device (DIO) was made to achieve the three dimensionally reposition of the mandible.

The PHYSIOLOGICAL NEUROMUSCULAR position was recorded in the form of an occlusal bite record, which was later used to make a DIO (intraoral device)

Panoramic radiograph of the patient during treatment with the DIO (intraoral device).

Comparison of lateral radiographs and patient profile: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

Comparative frontal radiographs of the patient: at the beginning of treatment in habitual occlusion, during treatment with DIO (intraoral device) in physiological neuromuscular occlusion.

Comparison of lateral radiographs and cervical spine of the patient: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

Control of intraoral device (DIO). THESE CONTROLS ARE FREQUENTLY MADE during the first and second phases of the treatment modifying and improving the PHYSIOLOGICAL NEUROMUSCULAR POSITION.

The patient did not report any TMJ-related symptomatology. Bioinstrumentation also objectively showed an improvement in neuromuscular function.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the physiological neuromuscular occlusion.

For this we use a three-dimensional orthodontic, where the teeth are erupted to the new neurophysiological position.

Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

During three-dimensional orthodontics the DIO (intraoral device) is recalibrated and changed to maintain the position obtained in FIRST PHASE

Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

Preparation to increase the width of the upper incisors respecting the patient’s Neuromuscular Physiological position.

Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

Preparation to increase the width of the upper incisors respecting the patient’s Neuromuscular Physiological position.

Completion of the First and Second Phases in the treatment of TMJ Pathologies. Physiological Neuromuscular Rehabilitation.

In this specific sequence, another possibility was proposed for the patient with an important improvement of aesthetics for the increase of the clinical crowns of the upper incisors, due to the limitation in this case of the composite resins.

The patient alleged: that she did not work on television, that even knowing the aesthetic limitation of the procedure with resins, she was satisfied.

For her the goal of the treatment was the resolution of the PAIN, and that had been reached.

Upper and lower occlusal views of the patient after the end of the second phase.

Panoramic radiograph of the patient after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

The extraction of the first maxillary molar and the placement of an implant after bone grafting was necessary. The third left retained molar exodontia was also performed.

TMJ laminography of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

Lateral radiograph and profile of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

Lateral radiograph and cervical spine of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

Frontal radiography of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

Comparative frontal radiographs of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

Comparative lateral radiographs and cervical spine of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

Comparative lateral radiographs and profile of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

Comparative occlusion of the patient before and after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

Comparative upper and lower occlusal view of the patient before and after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

Cineciographic record after completion of the first and second phases of physiological neuromuscular treatment. The neuromuscular trajectories are coincident. We would have liked to have an interocclusal space of 2.5 to 3 mm, we obtained 4.1 mm

Patient testimony

Dear Lidia,

You know, I really realized how much the treatment I’ve undergone improved my quality of life when I was in the clinic this year (2018) and I looked at my file with the information I had recorded when I started treatment.

To be honest I did not even remember that before the treatment I had pains in the jaw joints !! And how strong they were.

I always had headaches and migraines, besides the pains in the joint of the mandible. I always record it because I remember when I was a child I already felt them. I felt very ill and indisposed when I had crises.

In a certain phase of my life due to the increase in the frequency of pain headache and the constant vomiting I went to many doctors because I thought I was with stomach problem. I thought my headaches and migraines were consequence.

But based on the examinations I made at the time, my general practice told me that the question of the stomach was actually a consequence of severe headaches and migraines.

So she told me to go to a neurologist for evaluation and treatment. I went to the neurologist, did tests, treatment, tried to avoid the huge list of foods he I was informed as probable triggers of migraine. Everything I did reduced the headaches, but it did not solve the problem that plagued me.

And it was during one of my “crises” of headache that a coworker commented the possibility that I would make an evaluation with a dentist who had treated him when had problems with the TMJ. To be honest, I had no idea what it was, but when if you have pain, every attempt is valid.

I made the appointment, made available the exams I had already done in the region of the head and remember that in my first conversation with Lidia she commented that the exams indicated that in my infancy I had probably suffered a fall that caused a growth modification of my jaw.

Exactly the side where I had the headaches and the migraine.

I stress that at no time did the treatment for an aesthetic question, but rather seeking, if it is not possible to avoid the pains, but minimizes them.

I spent several years attending the clinic. I remember that my splint in one of the stages of the treatment was a “big monster” (kkk) considering its height.

Gradually throughout the treatment I was noticing the reduction of headaches and of frequency between migraine attacks.

Today, thinking about before and after treatment, I realize how much the treatment,

although prolonged, has improved my quality of life.

TMJ Study and Investigation Page. Three years of publication.

Posted on 15 de January de 2018 by lidiayavich

Dear friends,

At December 2014 I started the project TMJ Study and Investigation Page. At first, all its content was offered in three languages: Portuguese, English and Spanish. Due to the analysis of the webpage access statistics, at March 2015 I decided to offer the content solely in Portuguese and English.

Anyway, access to the contents of the page is still available to other researchers, professionals in the field and to those interested in the research that I develop.

Nowadays, the medicine based on evidence is hierarchically stratified from top to bottom, where in the base of the pyramid we find the clinic cases, which are rarely seen as evidence.

The TMJ Study and Investigation Page had in its conception, the purpose of posting the clinic cases, which were carefully published with the documentation related to each of the patients treated at Clinica MY with pain complaints, dysfunction and TMJ pathology.

The proposition was of presenting these clinic cases and concepts in order share them, offering free access to the content along images, surface electromyographies, computerized kinesiography, scanned before and after the therapeutic process. Cases of tridimentional orthodontics and neuromuscular phisiologic reabilitation of the second phase of treatment, after the TMJ treatment, were also included.

The TMJ Study and Investigation Page completed in the month of December, three years of life.

I remembered to celebrate on the first anniversary of the Page.

In the middle of the work with patients, teaching and publications I did not remember to celebrate the second year.

I want to celebrate these three years with you.

With this project, we have a place in the Internet that presents a line of work known as neuromuscular physiologic dentistry, which takes into account the whole body system. It is an area which acts on posture, mandibular functioning and considers the entire body system.

In order to do that, the neuromuscular physiologic dentistry aims to establish, in the patient, a position that is based on a harmonious relation between the muscles, the teeth, and the temporomandibular joints.

In the publication of this year’s end I have chosen the most significant images of all these years of publications, with direct links to each of the original publications.

At the end of this publication I placed the links of the publications of the first year of this page.

The TMJ Study and Investigation Page has grown tremendously and continues to receive visitors from all over the world.

Thank you!

Lidia Yavich

Temporomandibular Joint Pathology in a Patient with Congenital Fusion of two Cervical Vertebrae. First and Second Phase. Case Report.

Postural Improvement in a Patient after Neuromuscular Physiological Mandible Repositioning Treatment. Patient with Scoliosis Surgery and Craniomandibular Symptomatology.

TMJ Pathologies Treatment: Patient with Severe Headaches and Temporomandibular Joint Pain with Significant Contour Irregularities in the Mandibular Condyle and Mouth Opening Limitation.

Reestablishment of the Bone Marrow Signal in a case of Avascular Necrosis of the Mandibular Head. Monitoring two years after treatment.

Neuromuscular Physiological Treatment in a Patient with Headache and Pain in the Temporomandibular Joints. Case report without possibility of Disc Recapture: first and second phase.

Child with Otalgia (earache) and Conductive Hearing Loss: when measuring makes the difference. Normalization of hearing thresholds. First and second phase. Case report.

TMJ Pathologies Treatment: Patient with Pain in the Back of the Head, Bilateral Tinnitus and Constant Teeth and Prosthesis Fracture. First and second phase. Case Report.

TMJ Pathologies Treatment: Patient with headache for 30 years. Neuromuscular Physiological Rehabilitation. First and second phase. Case Report.

TMJ Pathology in Professional Musicians: A look beyond the risk factors. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

TMJ Study and Investigation Page. One year of publication

The TMJ Study and Investigation Page has grown tremendously and continues to receive visitors from all over the world.

Thank you!

Lidia Yavich

TMJ Pathology in Professional Musicians: A look beyond the risk factors. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

Posted on 4 de October de 2017 by lidiayavich

Several articles and studies cite the prevalence of TMJ dysfunction in violinists and violists, especially by prolonged flexion of the head and shoulder, posture necessary to keep the violin in position. Studies also report that the incidence of TMJ dysfunction in musicians is similar to the general population.

Professional musicians require many hours of training and improvement that involve complicated movements, fast and repetitive actions with over use of the hands, fingers, arms and head.

Most articles report anxiety about professional performance and increased muscle tension, but few do a particular study of the state of the anatomical structures of the cases studied.

A 45-year-old female patient referred by her physiotherapist consults with complaints of headache, pain in the cervical and scapular region, muscular contractures in the mandible.

The patient also reports mandibular displacement when playing the violin and pain in both temporomandibular joints.

The patient also reports clicks in both temporomandibular joints and occasionally the sensation of clogged ears.

Frequent pain in the spine and both shoulders.

At that time the patient had already consulted physiotherapists, rheumatologists, psychiatrists and psychologists.

Marking chart of pain points.

Image of the patient’s habitual occlusion on the day of the appointment.

Upper and lower occlusal views of the patient on the day of the consultation.

Initial panoramic radiograph of the patient before treatment.

Teeth 18, 28 included.

Wear on the incisal and occlusal faces of the teeth present.

Prosthetic device 25 to 27 (26 pontic)

Horizontal resorption of alveolar ridges.

Patient’s TMJ initial laminography before treatment

In the maximum opening position, observe the anterior angulation of the articular processes. Structural modification of the mandibular condylar process as one of the sequels of traumatism in infancy.

The patient reports a trauma in early childhood, a knock on the head while playing on a slide.

Lateral radiograph and patient profile before treatment. Patient in habitual occlusion.

Frontal radiography of the patient in habitual occlusion before treatment.

Lateral and cervical radiograph of the patient in habitual occlusion before treatment.

At this time, the patient performed a CT scan of the cervical spine

In the report there is rectification of cervical lordosis.

Degenerative discopathy in C5-C6, observing reduction of the height of the disc space and osteophytic proliferations reactional. At this level the disc-osteophyte bar is identified that touches and distorts the ventral face of the dural sac.

There is no stenosis of the central vertebral canal.

Neural foramina with amplitude within the limits of normality.

Mild signs of uncovertebral arthrosis C5 and C6.

Relationship C1-C2 maintained.

Symmetric paravertebral regions.

Dynamic electromyographic record in patient’s habitual occlusion before treatment. Note the minimal activation of the right and left masseter muscles in maximal intercuspation and the high activation of the right and left temporal muscles.

The masseter muscles are the most powerful muscles of the stomatognathic system, the temporal muscles even being elevating muscles have to have an equal and preferably smaller activation than the masseter muscles.

Initial cineciographic record of the patient.

Three-dimensional view of the mandibular displacement.

The record shows mandible opening, closing and speed when the patient makes these movements. The patient shows a 47 mm opening and a right deflection of 3.9 mm

Note a significant loss of velocity in the middle of the mandibular closure.

MRI: sagittal slice of the left TMJ, closed mouth, anteversion of the mandibular condyle can be observed.

MRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

MRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

MRI: internal sagittal slice of the left TMJ, closed mouth.

MRI: internal sagittal slice of the right TMJ, closed mouth.

MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Note the posterior compression in this section.

Primary objective has to be the three-dimensional decompression of the mandibular condyle.

MRI: frontal slice of right and left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right temporomandibular joint shows a loss of joint space, especially in the region of the external lateral pole of the joint. Both frontal images show a decrease in joint space.

Slight medial disc deviation.

To correctly evaluate the maxillomandibular relationship we should begin to consider the physiological rest mandible position.

Physiological rest is a concept applicable to all the muscles of the body.

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were deprogrammed electronically and a new physiological neuromuscular position at rest was recorded.

The patient has a pathological free space of 5.8 mm, already discounting the two physiological mm of a healthy free space.

The patient also presented a 2.1 mm mandibular retroposition

With these data we constructed a DIO (intraoral device), to maintain the three-dimensional recorded position. This device must be electromyographically tested to objectively measure the patient.

It is logical that the report of the patient’s symptomatology is important, but the surface electromyography shows in an objective way if the muscular function improved, worsened or did not modify.

Electromyographic record with DIO (intraoral device) in physiological neuromuscular position.

Note the higher recruitment of motor units in the masseter muscles that previously showed very little activity.

Cineciographic record for the DIO (intraoral device) control in physiological neuromuscular position as the device is changed or recalibrated.

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

Each case IS UNIQUE. There are cases where the TMJ structures are so damaged that the objectives outlined will have limitations dictated by the initial diagnosis.

These limitations refer not only to the structures of the temporomandibular joint, but also to the patient’s systemic condition.

Another cineciographical record to control the Dio in a physiological neuromuscular position as the device is changed or recalibrated.

Comparison of left and right temporomandibular joint laminography, closed and open mouth: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

Comparison of lateral radiographs and cervical spine of the patient: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

With the jaw in a physiological neuromuscular position the physiotherapist colleague worked the rest of the muscle chains, using global manual techniques, always taking into account the individuality of the patient. This work in a patient with degenerative discopathies should be maintained

Comparison of lateral radiographs of the patient: in habitual occlusion before the treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

Improvement of the profile and recovery of the vertical dimension.

Comparative frontal radiographs of the patient: at the beginning of treatment in habitual occlusion, during treatment with DIO (intraoral device) in physiological neuromuscular occlusion.

Panoramic radiograph of the patient with the DIO constructed in a physiological neuromuscular position.

MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

MRI: Comparison of the frontal slice of the LEFT TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same LEFT TMJ after the FIRST PHASE.

Note the decompression of the temporomandibular joint, especially in the lateral pole.

MRI: Comparison of the frontal slice of the RIGHT TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same RIGHT TMJ after the FIRST PHASE.

Note the decompression of the temporomandibular joint, especially in the lateral pole.

The patient did not report any more symptomatology related to the TMJ. Bioinstrumentation also objectively showed an improvement in neuromuscular function.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the physiological neuromuscular occlusion.

For this we used a three-dimensional orthodontic, where the teeth are erupted to the new neurophysiological position.

In the second phase, in this case the three-dimensional orthodontics the patient is monitored and deprogrammed electronically, and often the device is recalibrated, to maintain the position obtained in the first phase.

Part of the sequence of the second phase (in this specific clinical case).

Patient’s panoramic radiograph after the installation of the implant and the removal of the retained upper third molars.

Part of the sequence of the second phase (in this specific clinical case).

Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.

Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.

Part of the sequence of the second phase (in this specific clinical case).

Removal of the DIO (intraoral device)

Part of the sequence of the second phase (in this specific clinical case).

Finalization of the second phase.

Patient’s upper and lower occlusal view after the finalization of the second phase.

Patient’s comparative panoramic radiographs before and after the end of the second phase of the treatment using a three-dimensional orthodontics.

Patient’s comparative superior and inferior occlusal view, before and after, the end of the second phase of the treatment by a three-dimensional orthodontic.

Comparative occlusion of the patient before and after the end of the second phase of the treatment using a three-dimensional orthodontics.

Kinesiographic control record after the completion of the three-dimensional orthodontics in a physiological neuromuscular position.

Coincident neuromuscular trajectories.

Laminography of the patient in physiological neuromuscular occlusion after the finalization of the second phase of the treatment.

Comparative laminography of the patient: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

Patient’s comparative frontal radiographs: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

Patient’s comparative lateral radiograph and profile: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

Patient testimony:

What made me look for the treatment were recurrent headaches, frequent

(weekly) and intense, which lasted, on average, 2 days, affecting my productivity

at work as well as leisure hours.

The pain did not subside with common analgesics, requiring strong medication, which, in turn, only softened the pain a little.

Today, after the treatment, I can say that only very rarely do I suffer from these pains, greatly improving the quality of life, besides the posture.

TMJ Pathologies Treatment: Patient with headache for 30 years. Neuromuscular Physiological Rehabilitation. First and second phase. Case Report.

Posted on 2 de May de 2017 by lidiayavich

A 54- year old female patient arrives to the clinic for consultation, referred by her rheumatologist with complaints of daily headache since her 23 years of age. The patient associates the beginning of the headache with the installation of a definitive crown on the right upper central incisor. When she was 12 years old the suffered a traumatism that provoked the fracture of the tooth. The patient also reports bruxism.

The patient reports that in consultation with a neurologist, a nuclear magnetic resonance of the skull was requested, in which a change in white matter was detected.

At the same time the patient consults with a cardiologist. A FOP (Patent Oval Form) is detected, with no need for a surgical approach.

After years and years of consultations and treatments for daily headaches, the patient also has a diagnosis of fibromyalgia.

The patient makes use of marevan, 5mg daily as indicated by the Cardiologist.

Sandomigran 1 time per day per Neurologist indication.

Nexium 40 mg once daily indication of Gastroenterologist.

Marevan works in the prevention of venous thromboembolism, systemic embolism in patients with prosthetic heart valves or atrial fibrillation, stroke, acute myocardial infarction and recurrence of myocardial infarction. Oral anticoagulants are also indicated in the prevention of systemic embolism in patients with cardiac valve disease.

Sandomigran, pizotifen is an antaminic characterized by its polyvalent inhibitory effect on biogenic amines, such as serotonin, histamine and tryptamine. It is suitable for the prophylactic treatment of migraine, reducing the frequency of seizures. Pizotifen also has appetite-stimulating properties and is mildly antidepressant.

Nexium: Expected action of medication, disappearance of symptoms of heartburn, epigastric pain and acid regurgitation. Healing of peptic ulcers.

Habitual occlusion of the patient on the day of the consultation. Note the persistence of a lower deciduous tooth on the left side.

Upper and lower occlusal views of the patient on the day of the consultation. Note the persistence of a lower deciduous tooth on the left side.

Presence of bilateral torus mandibularis.

The lower incisors show signs of wear.

Absence of dental elements 18, 28, 38 and 48. Maintenance of element 75 in the dental arch. The element 11 is endodontically treated. Presence of fixed prosthesis with intracanal pin in element 11.

The laminography of the temporomandibular joints shows a modification of the growth axis of both mandibular condyles caused by a trauma in the early childhood, (greenstick fracture).

Lateral radiograph of the patient in habitual occlusion before treatment.

Frontal radiography of the patient in habitual occlusion before treatment.

Lateral and cervical radiograph of the patient in habitual occlusion prior to treatment. Note the loss of space between the cervical vertebrae, especially between C5 and C6, where osteophytes are also observed.

MRI: Sagittal slice of the left TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Facet on the superior surface and posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

Notice the posterior compression in this slice.

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

MRI: another sagittal slice of the left TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc besides the position of the disc.

MRI: Sagittal slice of the right TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Facet on the superior surface and posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc besides the position of the disc.

MRI: another sagittal slice of the right TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

Notice the posterior compression in this slice.

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc besides the position of the disc.

MRI: another sagittal slice of the left TMJ in the closed mouth.

Notice the posterior compression in this slice.

The patient’s masticatory muscles were electronically deprogrammed and the mandible rest position was recorded with a computerized kinesiograph.

An intraoral device (DIO) was made to for three- dimensional mandible repositioning.

The patient presented a pathological free interocclusal space of 4,4 mm, a mandibular retroposition of 1, 6 mm, also a right deviation of 1 mm.

The PHYSIOLOGICAL NEUROMUSCULAR position was recorded in the form of an occlusal bite record, which was later used to make a DIO (intraoral device)

Control of the intraoral device registration (DIO). These controls are frequently performed during the first phase of the treatment, also monitored by surface electromyography. On average this first phase lasts one year. Modifying and improving PHYSIOLOGICAL NEUROMUSCULAR POSITION.

MRI: comparative sagittal sections of the left TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

MRI: another comparative sagittal sections of the left TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

MRI: comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

MRI: another comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

After the completion of the first phase of the treatment of TMJ pathologies and the patient WITHOUT HEADACHE, we began the second phase of TMJ pathology treatment.

In this specific case: three-dimensional orthodontics together with the rehabilitation of the necessary dental pieces and aesthetic improvement of the patient’s anterior teeth.

At this point I had to make a decision regarding the permanence of the deciduous tooth, firm and without mobility.

I did not think I should extract it for the placement of the implant, but to maintain it.

I clarified to the patient that during orthodontics we could lose it. I understood that this would have a compromise in the patient’s occlusion, but this fact did not concerned me, with the TMJ being decompressed and the patient functioning well, both electromyographically and in the computerized kinesiograph tests.

The second phase with three-dimensional orthodontics is started in the second phase of the treatment of TMJ pathologies in this specific patient.

Direct composite resin reconstruction of the 75 and 37 elements maintaining patient’s Neuromuscular Physiological position.

Sequence of three-dimensional orthodontics in the second phase of TMJ pathologies treatment in this specific patient. Direct composite resin reconstruction of the 75 and 37 elements maintaining patient’s Neuromuscular Physiological position.

Sequence of three-dimensional orthodontics in the second phase of TMJ pathologies treatment in this specific patient. Preparation for the reconstruction of elements 33, 32, 31, 41, 42 and 43 maintaining the patient’s Neuromuscular Physiological position.

Direct composite resin reconstruction of 33,32,31,41,42 and 43 elements maintaining the patient’s Neuromuscular Physiological position, with three-dimensional orthodontics.

After the resolution of the strong headache (reason why the patient consulted the clinic) and the finalization of the tridimensional orthodontics, it was decided to make laminated facets from canine to canine for aesthetic reasons.

Completion of the First and Second Phases in the treatment of TMJ Pathologies. Physiological Neuromuscular Rehabilitation.

Patient’s panoramic radiograph after the end of the treatment in the Neuromuscular Physiological Dentistry.

Patient’s temporomandibular joints laminography in physiological neuromuscular occlusion after treatment completion.

Patient’s frontal radiograph in physiological neuromuscular occlusion after treatment completion.

Patient’s comparative lateral radiographs before and after treatment. The first in habitual occlusion and the second in physiological neuromuscular occlusion.

At age 11, I had a fall and broke the upper incisor tooth. At the time, I sought a dentist and he said that I should wait for the adult stage to make the porcelain definitive crown.

In 1986, when I was 23, I went to another dentist to make the crown. After the root canal treatment, the crown was placed.

In that moment I felt that there was an elevation that touched the lower tooth. The next day I woke up with an endless headache. Day by day the pain intensified.

I returned to the dentist and reported the fact, he said that in time it would settle. For 25 years I investigated the reason for my headache with several doctors.

In 2006 a rheumatologist asked me for an MRI of the skull, changes were identified in the gray matter. During this period, I was admitted to HMV for an investigation, and the diagnosis was SAF, topiramate 50 mg was introduced as a preventive of migraine and anticoagulant.These drugs were used from 2006 to 2011.

In 2007, I underwent systemic chemotherapy with METOTREXATE for 1 year. In 2011 another pain site showed up, this time in the hip, so I underwent corticoid in the vein for 6 months.

I decided to abandon the treatment, because it was no use. I looked for a respected neurologist who switched all my medication for an anti-allergy for headache prevention and an antiplatelet.

The diagnosis was leukoencephalopathy in a small degree. I also gave up treatment, because it did not work, either.

This neurologist referred me to another rheumatologist who examined me and identified a problem in my TMJ and a bursitis in the hip.

The same rheumatologist sent me to Dr. Lidia Yavich and to an orthopedist. In a short time I did not feel the same headache when I woke up. After all this, I continue to do MRI, and the changes have stabilized.

I sought an opinion from a second neurologist, and he thinks that all the changes I have are due to the intensity of the headache that I felt daily.

He did not agree with any diagnosis made so far.

I also believe that, because after the treatment with Dr. Lidia, I regained my quality of life.

The medication I use today: antiplatelet due to the existing changes and because I have a patent foramen ovale.

I thanks also to Dr. Luis Daniel for the conjunct treatment restoring function and aesthetics.

TMJ Pathologies Treatment: Patient with Pain in the Back of the Head, Bilateral Tinnitus and Constant Teeth and Prosthesis Fracture. First and second phase. Case Report.

Posted on 28 de December de 2016 by lidiayavich

A 57-year-old male patient presented at the clinic, referred by a colleague with complaints of: back of the head pain mainly on the right side, ringing in both ears and perception of strange sounds.

The patient complains of daytime and nighttime clenching.

Refers to dental losses very early, and installation of prostheses that are subsequently fractured, as well as dental fillings fracture.

Habitual occlusion of the patient on the day of the appointment, the patient had made a removable prosthesis, but felt neither stability nor comfort with it.

Upper and lower occlusal views of the patient without the lower removable prosthesis before treatment

Patient’s initial panoramic radiograph before treatment

Radiographic examination shows absence of dental elements 17, 15, 14, 24, 27, 28, 38, 37 and 36.

Alveolar bone loss in the maxilla and mandible. Impairment of the bone support of element 18. Impairment of the furcation region of element 46.

Alveolar extension of the maxillary sinus in the region of premolars and molars

Endodontically treated 13 and 12 elements.

The laminography of the temporomandibular joints shows superior and posterior positioning of the right articular process in the articular cavity and inferior and anterior positioning of the left articular process in the articular cavity when the mandible is in the position of maximum intercuspation.

In the maximum opening position, observe anterior angulation of the articular processes. Significant flattening of the posterior and superior surfaces of the right joint process.

Lateral radiography in conjunction with the patient profile image before treatment.

Frontal radiography in conjunction with the patient profile image before treatment.

Lateral and cervical spine radiographs together with the lateral image of the patient before treatment.

Patient’s comparative electromyographic records at rest, before and after the electronic deprogramming with the TENS.

Note the relaxation of the muscles especially of the right masseter which after relaxation showed symmetrical values with the left masseter.

Patient’s dynamic electromyographic record in habitual occlusion before treatment. Note the activation of trapezius and digastric muscles at the moment of maximum occlusion.

One slice of the patient’s MRI (magnetic resonance imaging): we can observe anterior angulation of the articular processes, flattening of the superior and posterior surface of the articular process of the right side and the posterior surface of the left side. Information we had on laminography.

The articular discs are displaced anteriorly and are also very thin which imply a disc that structurally may not always fulfill the function for which a disc is drawn. However it is imperative in this case even if a recapture of the discs is not achieved, to promote joint decompression.

The patient’s masticatory muscles were electronically deprogrammed and the mandible rest position was recorded with a jaw tracker.

A device for the three-dimensional repositioning of the mandible was constructed.

The patient presented a very large pathological interocclusal free space 13 mm, and a mandible retro position of two mm.

A healthy free interocclusal space of two mm was left in the DIO construction.

The records change as the system improves, and the devices are changed and recalibrated.

The three-dimensional mandibular rest position was recorded as an occlusal bite record, which was later used to make a DIO (intraoral device).

Patient’s comparative laminographies: the superior in habitual occlusion before the treatment and the lower in the neurophysiological position wearing the DIO (intraoral device).

Patient comparative images: before the treatment and during treatment with the DIO (intraoral device)

Lateral radiographs of the patient: in habitualocclusion and with the use of the DIO (intraoral device)

Patient’s comparative frontal images before and during the treatment with the DIO (intraoral device)

Patient’s comparative frontalradiographs: before and during the treatment with the DIO (intraoral device)

Patient’s comparative postural images: before and during the treatment with the DIO (intraoral device)

Patient’s comparative frontal postural images smiling: before and during the treatment with the DIO (intraoral device)

Wearing the orthotic, the first phase of implant placement begins.

Panoramic radiograph of the patient in neurophysiological occlusion with the DIO (intraoral device), after the installation of the first implants.

For the superior implants it was necessary to perform bone graft, 120 days after the bone graft the superior implants were placed.

Panoramic radiograph of the patient in neurophysiological occlusion with the DIO (intraoral device), after the installation of the remaining implants.

Intraoral device constructed in neurophysiological position with the implants installed.

Controlling the record of the intraoral device, the records change as the system improves, and the devices are changed and recalibrated.

The second phase with the three-dimensional orthodontics is started. Sequence of the three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

Sequence of the three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

Alignment and recovery of the lower sector with resins.

The patient is tested with bioinstrumentation maintaining an aesthetic and functional result within the specific case.

Control of the neuromuscular trajectory in the rehabilitated patient.

Dynamic electromyographic record after completion of the patient’s second phase treatment. Orthodontics and rehabilitation.

Completion of the TMJ pathology treatment, orthodontic and rehabilitative (in this specific clinical case).Neurophysiological rehabilitation was performed by Dr. João Sousa.

Subsequent rehabilitation was done keeping the vertical dimension with the device, but having to yield a little at the ideal height due to the patient’s bone conditions, rehabilitation possibilities and orthodontic limitations. The rehabilitation was done with metal ceramic crowns, and in the upper implants zirconia crowns in elements 14 and 15.

Patient’s upper and lower occlusal view after completion of the neurophysiological treatment.

Patient’s panoramic radiograph after completion of the neurophysiological treatment.

Patient’s laminography in neurophysiological occlusion after completion of the neurophysiological treatment.

Patient’s lateral radiograph after completion of the neurophysiological treatment.

Patient’s frontal radiograph after completion of the neurophysiological treatment.

Comparative patient occlusions before and after neurophysiological treatment.

Comparative occlusal views of the patient: before and after the neurophysiological treatment

Comparative panoramic radiographs of the patient: before during and after the neurophysiological treatment.

Patient’s postural comparative frontal images: before, during and after the neurophysiological treatment.

Patient’s postural comparative profile images: before, during and after the neurophysiological treatment.

Patient’s lateral comparative lateral radiographs: before and after the neurophysiological treatment.

Main Symptoms:

1) Bilateral Tinnitus- This symptom bothered me greatly, especially in the silence of the night it was almost torture, today I do not feel anything else, so much that I have forgotten if I ever had tinnitus.

2) Strange sounds in both ears: I had difficulties to identify, I confused on which side came the sounds and voices.

3) Clenching and constant breaking of prostheses and restorations – I remember that this was the main reason why Dr. João told me to seek treatment.Today I use a orthotic to sleep and I never had any problems.

4) I had a great gift, which I did not expect and I was not looking for it either. Facial rejuvenation, to the point that some people do not recognize me as they pass me by. Others noticed the change and asked what I had done and more recently a friend asked me, what is the secret of growing young. I’m very happy, I’m much younger. Thank you Dr. Lídia, thank you Dr. João.

High Tech Denta BJ Jeanne Barret, Parc Valmy Dijon

25-26 October 2019

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