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.

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

Posted on 29 de July de 2016 by lidiayavich

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment.

The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY TEMPOROMANDIBULAR DISORDERS is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

There are two general types of hearing loss, conductive and sensorineural.

Conductive hearing loss results from disruption in the passage of sound from the external ear to the oval window.

Anatomically, this pathway includes the ear canal, tympanic membrane, and ossicles. Such loss may be due to cerumen impaction, tympanic membrane perforation, otitis media, osteosclerosis , intraaural muscle dysfunction, or displacement of the ossicles by the malleolar ligament.

Sensorineural hearing loss results from otology abnormalities beyond the oval window. Such abnormalities may affect the sensory cells of the cochlea or the neural fibers of the 8^th cranial nerve. Hearing loss with age (presbycusis) is an example. Eight cranial nerve tumors may also lead to such hearing loss.

Male patient, eleven years old, arrived to the clinic for consultation referring headache, pain on the back of the head, shoulder pain, neck pain, hand numbness and tingling in hands and LIMITATION OF MOUTH OPENING.

The patient reports pain in the left ear and sensation of ear blockage especially on the left side. He also has tinnitus in both ears and DECREASE OF HEARING IN BOTH EARS.

Any hearing loss reported by the patient, must be evidenced by an audiometry.

Patient’s medical history: is relevant to this case the antecedent trauma on the chin at early childhood. It is also important to consider his recurrent infections of ear and throat and that when he was eight months old he had a severe pneumonia that required hospitalization.

Images of the patient’s habitual occlusion. Upper and lower oclusal view. Patient’s photos: frontal, profile and smiling on the day of consultation.

Patient’s initial panoramic radiograph

Patient temporomandibular joint laminography before treatment: we can observe the superior and posterior position of the left condylar process in the articular cavity when the jaw is in the position of maximum intercuspidation.

In the maximum opening position, we can observe the anterior angulation of the left articular processes.

Patient’s habitual image occlusion before treatment, in the consultation day.We may observe here an important overbite.

It is evident the lack of space for the correct positioning of the left maxillary canine.

Superior and lower oclusal view of the patient before treatment. It is evident the lack of space for the correct positioning of the left maxillary canine.

Patient’s lateral radiograph together with the profile image before treatment.

Retrognathic profile and rectification of the cervical spine.

MRI T1: Sagittal slice, left and right TMJ closed mouth before treatment.

We can observe anterior facets on the right and left mandibular heads.

In the right TMJ the disk is slightly anteriorly dislocated. The anterior dislocation is more evident on the left TMJ, with the head of the mandible backed on the retrodiscal zone.

MRI T1: Sagittal slice, left and right TMJ open mouth before treatment.

We can observe anterior facets on both mandibular heads.

Both mandibular condyles cannot translate, reducing mouth opening.

Initial kinesiographic record: loss of speed when the patient opens and closes his mouth. There is no coincidence between the opening and closing trajectories in the sagittal view of the record. Limited mouth opening as the patient can open only 32.9 mm.

Surface electromyography of the patient in habitual occlusion in which are measured:

Anterior right and left temporalis

Right and left masseter

Right and left digastrics

Right and left superior trapezius

Activation of the digastrics in closure, these muscles should only must be in activity along the opening movement

During the examination there was an activation of the right and left upper trapezius even when the patient was instructed to lower his shoulders.He had activated both trapezius throughout the examination.

The patient reports pain in the left ear and sensation of ear blockage, especially on the left side. He also has tinnitus and DECREASE OF HEARING IN BOTH EARS.

ANY HEARING LOSS REPORTED BY THE PATIENT MUST BE EVIDENCED BY AN AUDIOMETRY.

An audiogram is produced by using a relative measure of the patient hearing as compared with an established “normal “value. It is a graphic representation of auditory threshold responses that are obtained from testing a patient’s hearing with pure-tone stimuli. The parameters of the audiogram are frequency, as measured in cycles per second (HZ) and intensity, as measured in dB.

The first audiometry of the patient revealed a mild hearing loss in the left ear and a moderate hearing loss in his right ear.

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Hearing loss is classified as mild, in which the ear is unable to detect sounds below 40 decibels which makes it difficult to understand human speech.

In moderate loss, the sounds below 70 decibels are not heard.

We recorded the mandibular rest position after electronic deprogramming, together with the information of the MRI (magnetic resonance imaging) to orient our decisions of the bite registration, for the three-dimensional construction of the DIO (intraoral device).

The patient has a pathological free space of 8.6 mm and 8 mm of mandibular retro position.

The degree of compression determinates de reaction of the patient.

The retrusion of the mandible, whether it is iatrogenically induced, or a result of malocclusion, often results in otalgia due to excessive compression of the neurovascular retrodiscal tissues. The patient’s impression is ear pain.

I informed the parents of the patient, that at this stage, I was only worried about the health of the patient, and focused on improving the functions, the symptoms and controlling the conductive hearing loss.

Hearing loss resulting from Eustachian tube dysfunction, initiated by craniomandibular disorders is usually subjective.

For this reason there is a need for an objective control by audiometry.

I explained that I would not make any orthodontic intervention at this stage to include in the arcade the canine that was misaligned and out of space. I told them that I would take care of it later and in this case I would not have the need to extract teeth.

The installed device is controlled through surface electromyography to evaluate the function.

Patient’s second audiometry shows normal thresholds in the left ear and a mild hearing loss in his right ear.

Comparing the first and second audiometry of the patient during treatment.

Thresholds normalization of the right ear and thresholds improvement of the left ear.

Structural lesions may produce functional changes which in turn increases the structural changes.

Structural and functional changes.

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but OTHERS CANNOT.

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but OTHERS CANNOT.

It takes time to stabilize the muscles during treatment, different patients, different ages and different pathologies.

Patient’s third audiometry shows NORMAL thresholds in the left ear and NORMAL thresholds in his right ear.

Comparing the first, second and third audiometry of the patient during treatment.
Thresholds normalization in the right and left ear.

At this time with the normalization of the conductive hearing loss, the remission of symptoms and improvement of the images from the exams, we began the second phase through a three-dimensional orthodontics.

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

Patient’s lateral radiograph together with the profile image during treatment.

Aesthetic and not retrognathic profile as at the beginning of treatment.

There was not a recovery of the physiological lordosis, but there surely was an improvement of the cervical spine.

Removal of the DIO (intra oral device) at the current stage of the three-dimensional orthodontics.

Images without the DIO (intraoral device) and completion of the treatment of the three-dimensional orthodontic in neurophysiological occlusion.

Comparative images of the upper and lower oclusal views from the patient before and after completion of the first and the second phase of the neurophysiologic treatment.

The fourth audiometry of the patient after completion of the two phases of treatment maintains the normal thresholds in both the left ear and the right ear.

Part of the sequence of the three-dimensional orthodontics in the second stage of the treatment of TMJ disorders in this particular patient.

Comparative panoramic radiographs: before treatment and after completion of the three-dimensional orthodontics.

Comparative of lateral radiographs of the patient: at the beginning of the treatment in habitual occlusion, after the completion of the three-dimensional orthodontic in neurophysiological occlusion and six years after the completion of treatment control.

Patient’s kinesiographic records comparison: before and after treatment.

The mouth opening of the patient improved from 32.9 mm to 38.9 mm and it also reached an excellent speed regarding mouth opening and closing.

Patient’s electromyography records comparison: before, during and after treatment.

Patient’s kinesiographic records after electronically mandibular deprogramming comparison: before treatment the habitual trajectory is not coincident with the neuromuscular trajectory.

After treatment the habitual trajectory is tridimensional coincident with the neuromuscular trajectory.

Comparing the first, second, third and forth audiometry of the patient.
Thresholds normalization of right and left ear.

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment. The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY TEMPOROMANDIBULAR DISORDERS is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

When the patient ended all the treatment, and being still a teenager, he left the following testament:

My dentist referred me to the orthodontist because I had a crooked canine. So, after a panoramic radiograph she suspected that I could have a TMJ problem. Then she referred me to Porto Alegre to do a MRI, and from that exam it was found something that indicated a TMJ problem. So then I started the tratment with Dr. Lidia Yavich, that also investigated the tinnitus and my hearing problem.

When I was little I felt and hit the chin but my parents didn’t know that it could affect my TMJ.

I suffered a lot from an earache and sore throat. I had even scheduled an ear surgery but after six months of treatment it was no longer necessary to do it. Today I am doing well. I have a good hearing and I don’t have any more the tinnitus and the throat pain. I am happy with this treatment, thanks to God and to Dra. Lidia Yavich.

Here follows the testimony of the same patient seven years after the completion of the treatment:

Today, more than seven years after the end of the TMJ treatment with Dr. Lidia, and thanks to the God-given gifts to her, I haven’t been suffering any more with the earaches nor with the throat pain or the hearing loss. I had had, before the treatment, the indication to make an ear operation since I was loosing my hearing and that was not necessary with the TMJ treatment because during the treatment I was monitorated by exams that had proven that my hearing improved. Today I live a normal life, without having problems with those things from the past. I thanks the treatment done by Dr. Lidia which has healed me and improved my life.

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.

Posted on 19 de June de 2016 by lidiayavich

I often observe the debate on etiology and therapeutics, especially in TMJ dysfunction discussions groups, which are integrated by patients and professionals. These groups are active not only in Brazil but in several countries and communities from around the world.

I hope this space will add, strengthen or clarify those discussions.

The professional who treats patients with TMJ pathology has to take into account, at the moment of studying the clinical case, the patient’s particularities and the anatomical structures that are involved and provoking pain and affliction to our patient.

Even if the professional is scrupulous, evolutions can be different from patient to patient. That is why the professional has to investigate carefully which are the structures that can improve or even heal and which are the ones that cannot improve or still which ones we do not know if can be improved in the process of treatment.

Recognizing what we do not know is perhaps more important than recognizing what we do know: and the communication of this understanding to the patient is essential.

When we start a treatment we must be certain of the structures we can meliorate, or even prevent of getting worse and we also must know which structures we DO NOT HAVE THE CONDITION TO MELIORATE and we certainly must communicate that to the patient. Within this framework, the most important thing is to investigate if we can improve the quality of life of the patient.

Female patient with 45 years old arrives to the clinic for consultation suffering from headache every day, also suffering from neck pain and pain in the back of the neck, pain in both temporomandibular joints and severe pain on the shoulders.

Pain is more intense on the left side.

The patient reports a sensation of plugged ears and hearing decrease which was confirmed by an audiometry that refers normal hearing at 4KHZ and a severe sensorineural hearing loss at 6 KHZ and moderate at 8 KHz in the right ear.

The left ear has normal hearing thresholds.

The patient presents a buzzing in the left ear, and peculiar noises.

Patient’s habitual occlusion in the consultation day. Note patient’s overbite.

The patient reports that she wakes up with pain in the teeth, because of clenching.

Patient’s upper and lower oclusal view before treatment. Note the wear of the lower anterior teeth. The patient states that have made maxillary anterior teeth reconstruction with resin due to attrition caused by bruxism.

Patient’s panoramic radiograph before treatment. Absence of teeth 18,28,48.

Tooth 38 in a horizontal position, impacted

Reabsorption of the alveolar ridges.

Radiographic image of the right and left temporomandibular joints in closed and open mouth. Flattening of the anterior superior and posterior superior surface of the left articular process.

Patient’s lateral radiograph in habitual occlusion before treatment. Rectification of the cervical spine.

Patient’s frontal radiograph in habitual occlusion before treatment.

Patient’s lateral radiograph and cervical spine in habitual occlusion before treatment. Rectification of the cervical spine.

Patient’s computerized kinesiographic record before treatment. Patient without mouth opening restriction. Decreased closing speed, typical graph of an incisal guide that interferes with the closing trajectory.

Sagittal slices of the right closed TMJ. The mandible heads presents irregularities and cortical and subcortical sclerosis. Degenerative process.

The right articular disc shows small size, change in signal intensity and degenerative morphostructural aspect. It is anteriorly displaced.

Sagittal slices of the right open TMJ. The articular disc shows small size, is anteriorly displaced WITHOUT REDUCTION WHEN THE MOUTH OPENS.

Another sagittal internal slice of the right closed TMJ showing cortical bone irregularities. Degenerative aspect.

The articular disc shows small size, change in signal intensity and degenerative morphostructural aspect. It is anteriorly displaced, WITHOUT REDUCTION WHEN THE MOUTH OPENS.

Another sagittal slice of the right open TMJ. The articular disc shows small size, is anteriorly displaced WITHOUT REDUCTION WHEN THE MOUTH OPENS.

Sagittal slices of the left closed TMJ. Mild contours irregularity with rectification of the superior aspect of the mandibular condyle. The articular disc presents reduced dimensions.Alteration in orientation of the mandibular condilar axis because of traumatism in infancy. The disc is anteriorly displaced, WITH REDUCTION WHEN THE MOUTH OPENS.

Sagittal slice of the left open TMJ. THE DISC REDUCES WHEN THE MOUTH OPENS.

Frontal slice of the right and left temporomandibular joints, closed mouth. Note the cortical discontinuity on the right side already registered in the sagittal sections of the same side. The left side shows a medial disc deviation.

The masticatory muscles of the patient were electronically deprogrammed and a DIO (intraoral device) was constructed in neurophysiological position. In other publications computerized kinesiographic methods were mentioned.

In occlusion most often the healthy or pathological condition of the inter-oclusal space is not objectively considered. In this case the pathological free space of the patient is almost 7, 4 mm

With this data and ALWAYS WITH THE INFORMATION OF THE IMAGES OBTAINED WITH THE MRI, we built a DIO (intraoral device) to keep the three-dimensionally recorded position.

One year after the beginning of neurophysiological treatment, the patient had to interrupt the treatment to undergo a spine surgery.

The patient returned 10 months after the interval, recovered from the intervention. The patient was then again documented to assess any changes that might have happened during the interruption and the spine surgery.

Patient’s postural comparative frontal images: before treatment and restarting therapeutic after the spine surgery.

Patient’s postural profil comparative images: before treatment and restarting therapeutic after the spine surgery.

The masticatory muscles of the patient were AGAIN electronically deprogrammed and NEW DIO (intraoral device) was built in neurophysiological position.

Patient’s panoramic radiograph with the DIO (intraoral device) built in neurophysiological position.

Patient’s right and left temporomandibular joints laminography in closed and open mouth with the DIO built in neurophysiological position.

Patient’s lateral radiograph with the DIO built in neurophysiological position.

Patient’s lateral and cervical spine radiograph with the DIO built in neurophysiological position.

PATIENT’S ANALYSIS AT THIS STAGE OF THE TREATMENT.

Patient with degenerative processes not only in the temporomandibular joints but also in the cervical spine and lumbar spine which led her to surgery.

Inability to recapture of the right TMJ disk. Whereby this was an objective that was not taken into account.

Remission of symptoms and improvement of life quality.

Physiological mandibular posture, recovery of free space interocclusal through the DIO (Intraoral device).

In this particular case even WITHOUT DISC RECAPTURE (CONDITION THAT WAS EXPLAINED IN THE DIAGNOSIS) the patient can pass into the second phase, always taking into account that we should protect the joint during the night and during physical activity.

Each case is unique and the decision to move to a second phase also needs an individualized study.

It was decided to begin the SECOND PHASE of treatment to remove the DIO (intraoral device), keeping the neurophysiological occlusion.

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

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

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

In this sequence the patient is still with the DIO (intraoral device) in the mouth.

Removal of the DIO (intra oral device)

Completion of the second phase of the neurophysiological treatment in this case with a three-dimensional orthodontics.

The second phase is here understood as the three- dimensional orthodontics, restorative, prosthetic procedures in accordance with each clinical case in order to remove the DIO, while maintaining the neurophysiological position obtained in the first phase.

Patient’s upper and lower oclusal views after completion of the three-dimensional orthodontics.

Patient’s right and left temporomandibular joints laminography in closed and open mouth in neurophysiological position after finalization of the treatment.

Patient’s panoramic radiograph in neurophysiological occlusion in the completion of treatment. The tooth 38 that was in a horizontal and impacted position was extracted since the patient had no more symptoms of joint pain.

Patient’s lateral radiograph in neurophysiological occlusion in the completion of the second phase of neurophysiological treatment.

Temporomandibular joints MRI after de finalization of the second phase.

We must remember that this is a patient with degenerative processes and impossibility of recapture of the right TMJ disc, the left disk is so damaged that it does not fulfill its function.

The patient no longer has symptoms.

The final MRI shows no worsening of the situation and in the frontal slice it shows a better three-dimensional location of the mandibular condyle and cortical improvement.

Patient’s lateral comparative radiographs: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

Comparative records of mandibular rest position at the beginning of the treatment to build the DIO (intraoral device), and at the end of the second phase of the treatment (tridimensional orthodontics) to build a DIO (intraoral device) for night use.

Notice that in the beginning of the treatment the patient had a pathological interocclusal space of 7.4mm, and in the record at the end of the second phase for the nocturne DIO the patient has 3.3mm of free interocclusal space.

We have to take into account that the free interocclusal space IS A THREE-DIMENSIONAL SPACE, AND WHEN WE HAVE STRUCTURAL DIFFERENCES IN THE JOINTS, THE SPACE IS NOT EQUAL ON THE RIGHT AND THE LEFT SIDE.

Patient’s comparative profil postural images: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery and treatment interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

Patient’s frontal comparative postural images: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery and treatment interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

I had made several appointments with specialists, such as otorhinolaryngologist, dentists and maxilo-facial surgeons. However, all of them were without success and that is when I looked for Dr. Lidia to whom I reported the following symptoms.

I used to wake up every day with a lot of pain on the left side, both in the head and neck and I used to feel a rigidity on the neck and shoulder. In that time I used to take painkillers every single day in the morning. I also used to suffer of a serious problem of bruxism and because of that I wore out my front teeth, both the upper and lower teeth, and I had to restore them. I used to feel a lot of pain from the tremendous pressure that I used to make between the lower and upper part of my mouth. Another symptom was the high sensitivity on the teeth when I drank cold liquids. I felt as my ears were always blocked in such a way that my hearing decreased. I also used to hear a noise, especially on the left side, which sounded like a continuous whistle.

I also told the doctor that when I was a child I was hit with a brick, in the middle of a child’s play.

After reporting all that she asked me to make many exams and many of them were made in the MY Clinic and finally she told me that I had a problem in the TMJ. I started a treatment with her in 2011. I started to use an acrylic splint on my lower teeth day and night, all the time, taking it of only for its hygiene.

The pain that I used to feel so much decreased and in short time I did not feel it any more. Doctor Lidia had to adjust the orthotic monthly, making exams in her clinic until it reached the optimal height. On the next year from when I started the treatment I had to interrupt it for 8 or 10 months because I had to make a column surgery but I returned to the treatment as soon as I was well enough. I kept on treatment for one more year and after that I started the second part of the treatment with braces.

At the time that the treatment ended I did not need to use any more braces nor the full time orthotic. Today I need to use the orthotic only when I do physical activities and to sleep. I never again felt the horrible pain that I used to feel. I also never felt again the sensation of having blocked ears and happily the noise reduced. Today I am very happy that I do not have to take daily painkillers and that I do not have any pain. I am very grateful to doctor Lidia because she discovered and solved my problem.

For the interested coleagues in this training: the course starts at the September 1st.
Please write to the email for more informations: lidiayavich@gmail ou lidiayavich@clinicamy.com.br
+55 5130612237 +55 5133322124 This course will be given in Portuguese