The former publication worked on  the neuromuscular physiological approach of the first and second phase in the treatment of TMJ pathologies.

The patient of the last publication, entitled “Tridimensional Orthodontics in the Second Phase of TMJ Pathologies” has her complete dentition in mouth and a good periodontal health, condition that permited us by a tridimensional orthodontics to restore and balance the system after the First Phase, with the REMOVAL OF THE INTRAORAL DEVICE.

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.

In this publication we will report a case where a good quality of life was returned to the patient and we could offer a neuromuscular physiological rehabilitation combined with a tridimensional orthodontics, always keeping the mandibular localization in equilibrium with the muscular planes, temporomandibular joint and dental planes, achieved in the first Phase.

In this case, due to several degenerative processes active throughout the body, we decided to protect the patient, to maintain the orthosis.

1 HELENA DE MATTOS Female patient 54 years old came to the consultation with strong pain in the superior part of the head, in both temporalis, in the back of the head and in the cervical spine.


The pain was so strong that SHE REFERRED THE WILL to extract all the teeth, believing that they were the origin of the pain. She reported a lot of pain in the face, and strong twinges in the ears.


In this graphic the patient marked the pain areas in the head and neck, but she referred pain in several joints of the body, registered in the anamnesis.

Patient’s testimony:

Long time ago I began to feel ear pain. I consulted   many otorhinolaringologist that told me I didn’ t had anything wrong in my ear.

Then I consulted  a neurologist that medicated me with carbamezepine and told me that I had a GLOSSOFHARYNGEAL NEURALGIA.

I felt very uncomfortable with the medication. I experienced dizziness and lack of concentration.

I consulted  Dr. Valdai Souza, a physician , who removed the medication, improved my general health and checking my TMJ referred me to Clinica My.



The patient had tried too many dentistry treatments; even so she continued grinding and breaking teeth. She had lost teeth.

She had prostheses installed, but the patient gave up to search a better aesthetics because  the pain in the joint and  headache didn’t allow her a normal life.

3 DENTES Patient’s  occlusal view is marked by the wear of the anterior teeth, both superior and inferior

She had consulted  several specialists until she was derived by her physician to Clinica My.


In the radiographic exam we observe the absence of the 18,16,28,28,36, 46 4 48 dental elements.

The 15, 14, 22, 24, 26, 35,44 e 45 elements are endodontically treated.

Fixed prosthesis with support in the 16/15 elements. Presence of unitary fixed with metallic intracanal pin in the 14, 22, 26, 35, 34 e 45 dental elements.

Extensive restoration in the 13, 24 e44 dental elements.

Restorative material in the 11, 21, 23, 27, 32 and 47 elements.

Maxillary and mandibular bone loss more pronounced in the edentulous areas.

Elongation of the left styloid process.


Patient’s laminography in habitual occlusion shows de retro position of the mandibular condyles and a sequel of traumatism in infancy (left side).

We can observe in this image the alteration of the axis of the mandibular condyle.Changes in mandibular condyle orientation due to early childhood trauma (portuguese).

Clinic case presented in the 4th edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2,  July/December de 2014.

5B LAMINOGRAFIA Alterations in the Orientation of the Mandibular Condyle Because of Traumatism in Infancy

Clinic case presented in the number 4 edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

5C LAMINOGRAFIA Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy.

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2,  July/December de 2014.

In the trauma history, the patient reported that her mother had reported that she had fallen from tree when she was very young and hit the head.

5D ressonancia boca fechada

One of the slices of the MRI showing the asymmetry of the mandibular heads and the alteration of the condyle axis in the left side.

The articular discs are anteriorly dislocated with reduction in the slices of the MRI in open mouth (not included in this publication).

The principal objective in this case is the TMJ decompression and the tridimensional balance of the masticatory muscles. The structural asymmetries provoked by traumatism cannot be modified. But yes we can balance the muscles!

Patient’s testimony

My mother told me that when I was very little I felt from a tree and hit my head.


The profile radiograph shows the patient’s occlusion collapse.

In a simple view we could attribute this collapse to the teeth loss, BUT IS NOT SO SIMPLE. The patient presents also a dimensional loss provoked by the alteration of de axis of the mandibular condyle.

This dimensional loss is many times observed in patients with all THE DENTAL ELEMENTS IN MOUTH, but they also present an alteration of the mandibular condylar axis, because of traumatism in infancy or others etiologic conditions that affected one or both mandibular heads.

7 C7

The lateral radiograph including the cervical spine shows the vertebral misalignment, the degenerative condition and the loss of space between the vertebrae.

Patient’s testimony:

I had a car accident, a truck crossed in front of my vehicle, I hit  my face on the car’s front glass  and I needed an intervention  in my face.

7B C7 2

Osteophytes especially in C4, C5 and C6. The patient also has the cervical MRI showing  vertebral discs protrusions.  


Her muscles were electronically deprogrammed and a DIO (Intraoral Device) or orthotic ese was constructed in a neuromuscular physiological position. In other publications we mentioned the kinesiographic methods wich were used.

8 B eletromiografia em oc. habitual

Surface electromyography in habitual occlusion shows an important asymmetry between the right and left temporalis muscles, also asymmetries between right and left masseters.

8C fotos comparativas frontais

Aesthetic modifications with the intraoral device in neuromuscular physiological position in mouth.

10B PANORAMICA implantes 1

The installation of two implants on the inferior left side were planned and also two implants on the superior right side where the patient had an old prosthesis.

All these procedures were ALWAYS WITH THE DIO (intraoral device) constructed in neuromuscular physiological position in mouth 24 hours in a day.

10C panoramicas comparativas

Comparative panoramic radiographs: initial panoramic radiograph in habitual occusion before the treatment and the panoramic radiograph with the implants installed, always with the DIO, Intraoral Device in neuromuscular physiological position.

9 dentes cavidades

The cavity preparation had only a provisional aesthetic goal that permitted us to begin the anterior sector orthodontics movement. That will be posted later.

10 dentes prov e inicio da ortodontia

The teeth were rehabilitated PROVISIONALLY WITH RESINES to improve patient´s aesthetics and self-esteem.

The patient had no symptomatology, that condition permitted us to work in the recuperation of her stomatognathic system health and aesthetics.

Orthodontics movement wearing THE INTRAORAL DEVICE WAS INITIATED.  The first objective was the molar uprighting on the inferior right side in order to recuperate the  space to install the implant.

11 preparo ortodontico setor anterior

The second objective continuing the neuromuscular physiological rehabilitation combined with the tridimensional orthodontics was the vestibularization of the superior anterior sector to aloud the proper anatomical reconstruction of the teeth.

12 preparo protese-1

Some of the teeth presented pulp degeneration, needing endodontic and a reinforcement of the dental nuclei with metallic pins.

13 cimentação de coroas provisoriasImplant on the place of the 46, after space recuperation

14 cimentação definitiva dos provisórios 15 cimentação coroas definitivas

In this view, without the DIO (Intraoral Device), with the metal-ceramic crowns already cemented, we can see the wear of the inferior anterior sector, which needs to be rehabilitated with resins.

16 terminado

In this case, the initial planning was to maintain the intraoral device after rehabilitation, because the dimensional loss was very large.

The patient presented bone loss and degenerative conditions in several body joints.

The patient had already undergone procedures such as INSTALLING A PROSTHESIS IN THE BASIN.

The patient had an IMPORTANT misalignment in the CERVICAL with OSTEOPHYTES and LOSS OF INTERVERTEBRAL SPACE.

The 35 element had a 10 years fractured old pin with important overload (remember that this was the last tooth in mouth in the left inferior sector before the implants installation) .

The extraction of this element was decided.The patient  is WITHOUT PAIN, AND WITH THE SPACE PRESERVED BY THE DIO, will decide later the implant installation.

16B oclusal final 17 laminografia final

Laminography showing the tridimensional decompression of the mandibular heads.

18 laminografias comparativas

Laminography comparison before in habitual occlusion and after the neuromuscular physiological rehabilitation combined with the tridimensional orthodontics.


Panoramic radiograph with the finalization of the rehabilitation and the space of the 35 element preserved for the future implant.

20 panoramicas comparativas

Panoramic radiographs comparison: intial panoramic before treatment in habitual occlusion, panoramic during the treatment and panoramic after the neuromuscular physiological rehabilitation combined with the tridimensional orthodontics.

21 comparativas frontais

Frontal radiographs comparison before and after the neuromuscular physiological rehabilitation combined with the tridimensional orthodontics.


Intraoral photographs before and after treatment.

21 comparativas laterais

Patient’s lateral and cervical spine radiographs comparison before and after the neuromuscullar physiological rehabilitation combined with the tridimensional orthodontics.

Remember that one of the reasons to maintain the intraoral device was because the degenerative conditions of the cervical spine and in other joints.

22 postura comparativa

Patient’s postural and aesthetics modifications before treatment and after the neuromuscular physiological rehabilitation.

dEPOIMENTO 1I arrived in the clinic with a strong  pain in the face, headache and pain in my ear. I wanted to extract all my teeth because of the pain and twinges in the ear.

In a quiet environment I felt the buzz on my left ear and the pain rose to the head. Sometimes I spent the night walking to be able to endure…

I began to treat the TMJ (temporomandibular joint) pathology. And I got a relief of my pain.

After two years I initiated the rehabilitation. In the middle of the rehabilitation I had a pelvis surgery; the physicians needed to install a hip prosthesis.

I had also a tumor in my kidney and the physicians needed to remove it.

These situations delayed the pace of rehabilitation.

Without pain and with aesthetic improvement Dr. Lidia and Dr. Luis Daniel explained to me that they couldn’t totally remove the device, because the dimensional loss  was too large and also because of my degenerative active condition, which meant loss of stability not only in the TMJ, but also in other joints.


Nowadays I wear a small intraoral device.This device  will be changed for one aesthetics DIO, instead of the transparent  one.

My life quality improved 100 percent, I sleep very  well and I even  don´t feel the buzz any more, neither the twinges.

THE AESTHETICS ACHIEVEMENT ALSO IMPROVED MY SELF-ESTEEM, even if that was not the motive for my treatment. The reason was to alleviate my pain. NOW  WITHOUT PAIN, EVEN THE AESTHETICS IS IMPORTANT.

A big hug and my gratitude to my Drs. Lidia and Dr. Luis Daniel for my life quality change!