1A

In the previous publications of this page, some of the physiological neuromuscular foundations of the treatment of pathologies of temporomandibular joints were presented.

The importance of differential diagnosis was also emphasized, together with the use of bioinstrumentation such as surface electromyography and kinesiography.

Images of patients reporting their symptoms were presented and several etiological factors were also exposed, such as trauma in early childhood, especially the green stick fracture.

The page has posts dealing with the recapture of intra-articular discs in reducible displacements and the interrelationship between craniomandibular disorders and the spine.

A case of cervical dystonia was also exposed and its relationship with TMJ was exposed.

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When we talk about TMJ pathologies treatment we need to understand that there are different approaches.

The proposal of a Palliative treatment is the Symptomatic treatment, which tries to block the symptoms. For that means, it uses analgesics administration, anti- inflammatory drugs and muscle relaxants.

The restorative approach is the treatment that aims, when possible to correct or to heal what is damaged. Recognition of what is wrong (differential diagnosis) must precede the question of how to fix it.

To know what is wrong, it is necessary a differential diagnosis. This diagnosis must always be elaborated before we reach a treatment proposal.

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When our proposal is a restorative treatment, we have a FIRST PHASE where the objective is to heal the joint when it is possible. Sometimes we can only improve the joint condition or to avoid its deterioration.

To know what we can treat and what we cannot deal with, and the limitations of every individual case.

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When we finished the first phase, we compare if the control images of the case corresponds with the goals we intended to achieve in our initial diagnosis.

We know that there are cases that can meliorate, others that we can avoid its aggravation, and still others that we can only can relieve the pain.

If the case has positive results of the first phase we can initiate a second phase of the treatment in order to remove the device that is used in a permanent way during the first phase of the treatment.

For this we can perform a tridimensional orthodontics, a neuromuscular physiological rehabilitation or the combination of both.

Always remember of keeping the mandibular localization in equilibrium with the muscular planes, temporomandibular joint and dental planes.

4

I will relate what happened at the current week with a teenager patient that had finished the first phase, in a case of  neuromuscular physiologic decompression of the temporomandibular joint and where she was still wearing the DIO (intraoral device)

The patient had remission of her symptomatology (ear pain irradiated from the TMJ since childhood), and now she was preparing herself  to initiate the second phase with a tridimensional orthodontics.

I wasn’t satisfied with her breathing so again I asked for a new evaluation to meliorate her breathing and consequently her tongue position.

The professional that made this evaluation affirmed that the patient presented an open bite and that she needed to consult a buco maxillary surgeon to “close her bite” by surgery.

The anguish that was provoked on the patient and that consequently also affected me, resulted in my indignation on her conclusive opinion referring the patient to a surgical consultation without  entering first in contact with the professional responsible for the treatment (me in this case)

In any way I demand complicity of any professional, since I consider ethics beyond everything. As much as respect for the patient.

The patient’s own father, grateful for the result of the daughter’s treatment, who had already consulted many professionals and had received only the stress diagnosis, without considering any structural failure, made the following comment: I have seen several publications on his page of the first phase of treatment, but none of the second phase.

This event encouraged me to publish a case on tridimentional orthodontics in the second phase of TMJ pathologies

Before the SECOND PHASE, let’s begin with the FIRST PHASE.

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The patient’s usual occlusion, who presents with complaints of pain.

Female patient, 17 years old consults in the clinic complaining of headache, ear pain, shoulder pain and bilateral clicks.

In the clinical inspection she had strong ache when retrodiscal palpation was performed.

The patient showed an “ideal occlusion” and in the clinical tests she did not exhibits any kind of interferences neither in protrusion nor in lateral translation.

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Patient’s initial laminography in habitual occlusion before treatment

Patient’s initial laminography in habitual occlusion,  retro position of the mandibular heads, especially on the left side provoking an important retrodiscal compression.

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Patient’s MRI in habitual occlusion, both anterior reducible disc luxation, retro- position of the mandible heads and modification of the growth axis provoked by a traumatism in infancy (Structural modification of the mandibular condylar process as one of the sequels of traumatism in infancy).

The luxation is reducible (MRI in open mouth not included in this post)

8

  Initial electromyographic record of the patient in habitual occlusion.

In this record we measure both right and left anterior temporalis, and right and left masseters.

Notice that the masseters that are the most potent muscles of the masticatory system cannot generate activity.

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An ideal occlusion is noted, but the muscles are unable to recruit motor units.

A static image doesn’t speak of muscular harmony, doesn’t show if there is coordination between the systems and does not show if the patient has local or distant pain.

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Patient’s masticatory muscles were electronically deprogrammed. A bite was registered in a neuromuscular physiological position with a jaw tracker.

The patient presents a pathological free way space of 6,2 mm and a retro mandibular position of 2,5 mm.

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With this data we construct an intraoral device (DIO) tested electromiographically to support the neurophysiological occlusion.

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Comparison of the patient’s laminography: the superior patient’s initial laminography in habitual occlusion, retro position of the mandibular heads, especially on the left side provoking an important retrodiscal compression.

The inferior laminography with the intraoral device in neuromuscular physiological position shows the tridimensional decompression of the retrodiscal zone.

13bWe will measure the device electronically in order to compare the function of the masticatory muscles in this three-dimensional mandibular position.

14

Comparison of the two electromyography records the first in habitual occlusion and the second with the intraoral device in neurophysiologic position.

The masseters present excellent activity with the DIO, compare the first initial record where these muscles couldn’t activate.

15

Comparison of one of the slices of the MRI. Left closed TMJ before the treatment in habitual occlusion and in a neurophysiological occlusion with the DIO.

Disc in physiological position and tridimensional decompression of the mandibular head.

Correlation with the electromyography records in habitual occlusion and in neurophysiological occlusion with the DIO.

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Comparison of one of the slices of the MRI. Left closed TMJ before the treatment in habitual occlusion and in a neurophysiological occlusion with the DIO.

Disc in physiological position and tridimensional decompression of the mandibular head.

Correlation with the electromyography records in habitual occlusion and in neurophysiological occlusion with the DIO.

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Comparison of one of the slices of the MRI. Right closed TMJ before the treatment in habitual occlusion and in a neurophysiological occlusion with the DIO.

Disc in physiological position and tridimensional decompression of the mandibular head.

Correlation with the electromyography records in habitual occlusion and in neurophysiological occlusion with the DIO.

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Lateral radiograph of the patient for the initiation of the tridimensional orthodontics treatment. The patient is with the DIO (intraoral device constructed in neuromuscular physiological position)

Patient’s masticatory muscles were electronically deprogrammed for the bite registration and the construction of the intraoral device.

Not all case can pass to a second phase, orthodontics, prosthodontics or rehabilitation.

There are patients with active autoimmune disease, this is one of the causes among other pathologies that does not allow us to remove the intraoral device.

The structures of these patients, such as the temporomandibular joints, cervical spine and others, may be affected by the disease itself with active inflammatory processes and frequent peaks of exacerbation of the disease.

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Neuromuscular diagnosis in orthodontics: effects of TENS on maxillo-mandibular relationship.

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Atlas of Maxillary Orthopedics: diagnosis Thomas Irmtrud and Jonas Rakosi. Electronic rest mandibular registration in three spatial planes.

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Starting the 2 phase of the treatment in this case with a tridimensional orthodontics. The device will be removed in stages keeping the muscular planes in equilibrium with the osseous and dental plans.  INITIATING THE ACTIVE ERUPTION.

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Image with and WITHOUT the intraoral device. The space between arches IS THE SPACE THAT WE NEED TO RESTORE (this space is filled with the DIO).

The DIO operated as a tridimensional boot sole. 

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Continuing the treatment in the tridimensional orthodontics. Image with and without the device. Posterior sector already erupted.

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Molar and pre-molar sector already erupted. Alignment of the lower incisors and finalization of the tridimensional orthodontics in the second phase of TMJ Pathologies.

The ultimate goal in an orthodontic treatment is to treat all three components of the stomatognathic system and create an environment for synergistic function of the teeth, temporomandibular joints and neuromuscular system.

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A tridimensional orthodontic needs to maintain the tridimensional position of the mandible in balance with its osseous and muscular planes obtained in the first phase, and whenever possible it needs to keep the temporomandibular joint in an harmonic relation with the mandibular fossa as well with the articular disc in correct position.

gRUMMONS

The patient’s clinical history, clinical inspection, technology, bioinstrumentation and images, helped us to improve TMJ pathologies diagnosis and treatment.

When we arrive to a SECOND PHASE, many professionals and patients don´t know that the active eruption has been used from MANY, MANY years ago. Dr. Duane Grummons book edited in 1994 is only one of the several examples.

TMJ pathologies always need a differential diagnosis.

THREE-DIMENSIONAL ORTHODONTICS always follows the restorative treatment in the FIRST PHASE.

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If we don´t understand that teeth are the ending point of a joint…

If we don´t understand that this joint can be affected by systemic

and local pathologies…

If we don´t understand that it is the muscles that move the mandible

and propitiate the rest position…

If we don´t understand that structural differences determine tridimentional adaptations…

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We may not understand treatments failure, in the cases where the patients present TMJ pathologies.

In this post specifically, themes such as posture, airways and connection with the spine were not specifically addressed, especially with the cervical one. 

There are several posts dealing with all this interconnection. The objective of this publication is more focused on the mechanical part of this active eruption in mandibular physiological neuromuscular posture.