Articular Disc Recapture: patient with significant mandibular heads asymmetry and unilateral reducible luxation. Case report

Different etiologic factors like trauma, local and systemic diseases, autoimmune disease and occlusion make create condition of discal displacement.

The importance and validity to recapture dislocated discs when the clinic case aloud, was commented in the publication of day February 22, 2015 entitled Recapture of articular disc displacement with reduction. Recapture or not recapture, that is the question.

We need to understand that treturn the anatomical joint elements to a healthy and physiological position is ALWAYS VALUABLE. Remember anatomy is the platform where physiology functions.

1 ERALDOMale patient 33 years old arrived to the clinic referring strong ache on the temporalis muscles, pain on the back of the head, unspecific facial pain, pain on the shoulders, buzzing and he also reports that he has been feeling numbness and tingling in his hands.

The patient also complains about clicking on  the left temporomandibular joint.

He also reported feeling of hearing loss, even if the audiometry is within the normal range.

2 ERALDO   He also reports about muscular tremors in the cheek region, and constant difficulty to open the mouth.

The patient does not present limitation to open the mouth, but to open the mouth he shifts the jaw to the left side.

He feels pain to chew hard foods, and he complains that he only can eat soft food

He tells that any meal is an effort and not a nice activity, even with food that he appreciate.

Refers bruxism and clenching

He  also finds difficulty to swallowing

3 ERALDO  The patient presents a retrusive profile, but this WAS NOT THE MOTIVE FOR CONSULTATION, the patient was not concerned about aesthetics, but with the PAIN.

Patient testimony:

When I was in the formation in the graduation of the Military Police ( with the order of not moving nor speaking) I was somewhat nervous, and suddenly everything went dark and I fell forward as a trunk, with all my weight and hit the chin (I was 18 years old).

My  teeth were closed, the pain from that episode was almost unbearable, I couldn´t eat or open the mouth, so was more or less for two weeks,  then start a tingling in the TMJ region and muscles, and a kind of sensitivity that remains to this day.

In the anamnesis the patient reported several injuries as a child, but nothing special to remember.

4 ERALDO Patient’s habitual occlusion.4B ERALDO  Wear in the upper and lower incisor sector

5 PANORAMICAS ERALDO  Patient’s panoramic radiograph before the treatment.6 PANORAMICAS ERALDOMandibular heads asymmetry7 LAMINO TMJ laminography in habitual occlusion.  Close and open mouth. Can be analyzed the asymmetry between the patient’s right and left mandibular head.

Superior flattening of both mandibular heads and change in the growth axis of both mandibular condyles.7A LAMINOThe color image highlights the structural differences between the right and left condyles.7B LAMINO   1- Normal growth axis

   2- Fracture location

  3-  Pathological growth axis

The website of the Clinica MY www.clinicamy.com.br  has the links for the article. Alterações na Orientação do Côndilo Mandibular Devido a Traumatismos na Primeira Infância (Portuguese). Clinic case presented in the 4th edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

5B LAMINOGRAFIA  The website of the Clinica MY  www.clinicamy.com.br  has the link for the article. 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.

5C LAMINOGRAFIA Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy8 CERVICAL  The cervical spine of the patient shows a rectification and a light curvature inversion

The patient’s cervical spine image reminded me similar images from many patients that suffered a whyplash traumatism.

I questioned the patient again, asking if out of trauma reported at graduation that had hit the chin, could not remember another accident.

INITIALLY THE PATIENT DID NOT REMEMBER. But in the next consultation he gave the following narration:

Patient’s testimony:

I was stopped at a traffic light driving my car when another vehicle hit behind the car in which I was.

The HIT WAS SO STRONG that the bank fully reclined back, I was lucky that I had a  headrest on the seat.

Evidently the whiplash suspicion was confirmed

9B FRONTAL  Mandible asymmetry is notorious on the patient’s frontal radiograph. IS SIMPLE TO UNDERSTAND IF WE THINK ON THE STRUCTURAL DIFFERENCE OF BOTH mandibular condyles. It’s like thinking in a patient with a structural difference in the length of legs. These structural alterations provoke morfofunctional alterations.

The muscles have to adapt and shorten three-dimensionally to compensate the system.

10 LATERAL  Many studies are based on a preconception, considering that the condyles are in a correct position and the patient does not present any pathology on the temporomandibular joints.

These structural alterations provoke morfofunctional alterations.

The muscles have to adapt and shorten three-dimensionally to compensate the system.

13

In this kinesiographic record   is registered the opening and closing mouth of the patient in sagital and frontal view and the velocity graphic.

The patient opens the mouth 40 mm, and frontally he needs to shift the mandible to the left side in order to open his mouth.

The opening and closing speed is poor, the patient has bradykinesia

12  In this electromyographic record of the patient in habitual occlusion is impressive the difference between the right and left anterior temporal.

There is nearly 70 percent difference between the left and right temporalis in habitual maximum occlusion. The right anterior temporalis can generate 105 microvolts in the window already analyzed, the left anterior temporalis can generate only 36 microvolts in the same range.

14 RNM

MRI: Magnetic Resonance Image of the patient. Selected slice.

1- Left TMJ closed mouth, sagital slice before treatment

Anterior displacement of the articular disc.

2- The Same image with color enhancement

3-  Left TMJ open mouth, sagital slice before treatment

4- The Same image with color enhancement

15B RNM

MRI: Magnetic Resonance Image of the patient. Selected slice.

Right TMJ closed mouth, sagital slice before treatment

Articular disc in habitual position.

Right TMJ open mouth, sagital slice before treatment

16 mordida The patient has a free way pathological space of 9,4 mm and a retrusion of 4,8 mm17 ORTESE  With the data obtained after mandibular electronic deprogramming and ALWAYS WITH THE INFORMATION OBTAINED IN THE IMAGES WE CONSTRUCT A DIO ( Intraoral Device) in neurophysiological position.18 eletro dio  Patient’s electromyographic record in neurophysiological occlusion with the intraoral device in mouth. The right and left temporalis are balanced.

There was nearly 70 percent difference between the left and right  temporalis in habitual maximum occlusion, before the intraoral device instalation.

19 eletro comparativas  Comparative EMG records on the top in habitual occlusion and on the bottom in neurophysiological occlusion with the DIO (intraoral device) in mouth.

21 cinecio comparativas e fotos  This image shows a patient’s profile sequence together with the sequence of kinesiographic records.. These records have to be related to EMG recordings previously posted.

All is correlated, joint decompression, masticatory muscles function and the three-dimensional location of the jaw.

The DIO (intraoral device) is planned not only by the electronic deprogramming, but also by the images and other auxiliary diagnosis tools. It is controlled, changed and recalibrated as part of a treatment.

It should be measured electromyographically. Logically the improvement of the patient’s symptoms must go along with the improvement of records.

22 frontal comparativas  Patient’s frontal radiographs comparison: the first in habitual occlusion and the second with the intraoral device in neurophysiological position.

Three-dimensional jaw alignment improvement, we can not fix the structural differences of the mandibular condyles, but we can balance the muscles.

22A frontal comparativas dellinhadas   Patient’s frontal radiographs comparison: tracing of the jaw to highlight the tridimensional alignment of the jaw in neurophysiological position.

24 FOTOS LATERAL comparativas Patient’s comparative profile: in habitual occlusion and in neurophysiological occlusion with the intraoral device. Improvement of the head position.24 foto LATERAL comparativas

.Patient’s lateral radiographs and cervical spine comparison: before treatment and completion of the first phase, correlation with the profile photos.

Although rectification of the cervical spine continues, it has a mild improvement in curvature inversion observed in the first radiography.

25 RNM COMP 2

MRI: Left TMJ sagital lateral slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

Control of the second comparative magnetic resonance imaging after the second treatment phase.

The images of the left TMJ which presented the displacement of the articular disc will be posted.

The right TMJ did not presented displacement of the articular disc, only the structural differences between the mandibular heads.

26 RNM COMP 3

MRI: Left TMJ Sagital lateral slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

27 RNM COMP 4

MRI: Left TMJ Sagital medial slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

28 RNM COMP 5

MRI: Left TMJ Sagital medial slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

32 depoimento  When I arrived at the Clinic My, I was suffering a lot, I felt a strong pain, migraine, and I could not open my mouth without pain.

I was really in need of treatment; it was then that Dr. Lidia offered me to take care of my problem.

Since my articular disc was displaced and the joint was compromised, we started immediately and from there I got better, the pain stopped, I began to eat better and everything got better.

Today I can say that I´m very well, I feel normal, my disc and all the system is working okay!

I´m very grateful to Dr. Lidia Yavich, she is a great professional that knows what she does.

A big hug,

33

1 thought on “Articular Disc Recapture: patient with significant mandibular heads asymmetry and unilateral reducible luxation. Case report

  1. Pingback: TMJ Study and Investigation Page. One year of publication | Page of Studies and Investigation – TMJ

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