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

In several publications of this page I have presented patients of different ages, different gender and different pathologies of the temporomandibular joints.

This is the second case report about a patient with prosthetic protocols built on implants.

I call once again the importance of  the attention in the diagnosis of temporomandibular joints pathologies and mandibular position as a key part of any procedure in dentistry.

1 FOTO INIC FRONTAL

Female patient 54 years old arrived to the clinic for consultation with severe headache complaints, pain in the temporomandibular joints, pain in the cervical spine, sore shoulders, ear pain, feeling of clogged ears and crepitation in both temporomandibular joints.

2 FOTO INICIAL PERFIL

The patient was referred by her dentist who performed the treatment of implants and prosthetics, rehabilitating the patient, but without being able to relieve the pain that afflicted her.

2A MARCAÇÃO DA DOR

Part of the questionnaire completed by the patient.

The patient reports daily pain.

FUNCTIONS THAT AGGRAVATE HER PAIN:

Mastication

Opening the mouth

Laughing

Yawning

The patient also refers back pain and numbness and tingling in the arms and fingers.

Refers that she wakes up with body aches.

3 DENTES INIC PROT FRONTAL

Patient habitual occlusion on the day of consultation.

The patient had fixed prostheses supported on implants on the lower jaw and a removable upper protocol supported on implants on the maxilla.

4 OCLUSAIS INICIAL PROTPatient’s superior and inferior oclusal view of the prostheses supported on implants on the day of consultation.

5 DENTE INICIAL SEM PROT

Image of the oral cavity of the patient without the upper prosthesis.

6 OCLUSAIS INIC SEM PROT

Patient’s superior and inferior oclusal view without the superior prostheses.

7 PANORAMICA INICIAL

Patient’s initial panoramic radiograph before treatment with the prosthesis in the habitual occlusion before treatment.

Presence of 4 metallic implants in the maxilla 2 on the right side and 2 on the left side; and 5 implants in the anterior mandible region.

8 LAMINOGRAFIA INCIAL

Patient’s TMJ right and left laminography, closed and open mouth: posterior positioning of the articular processes in the joint cavities when the jaw is in maximum intercuspation position.

9 TELE PERFIL INICIAL

Patient’s lateral radiograph with prosthesis in habitual occlusion.

10 C7 INICIAL

Patient’s lateral radiograph and cervical spine with prosthesis in habitual occlusion before treatment.

Alterations of the cervical spine, loss of physiological lordosis and loss of intervertebral spaces especially between the vertebrae C4, C5 and C6.cefalometria 2013 ingles

Ricketts cephalometric analysis before treatment with prostheses in habitual occlusion.

FACTORES CEF ANTESSS

Values of point A convexity and lower facial height before treatment.

11 FRONTAL INICIAL

Frontal radiograph of the patient with the prosthesis in habitual occlusion.

12 RNM DIREITA INICIAL

MRI, sagittal slice of the right TMJ closed mouth: there is an irregularity of contour with reduction of the superior aspect of the mandibular condyle, the condyle is ante versioned. There is a small anterior osteophyte.

The articular disc is displaced anteriorly, WITHOUT REDUCTION when the mouth opens.

Presence of subcortical bone cysts in the anterior superior aspect of the mandibular condyle.

13 RNM  ESQ  INICIAL

MRI, sagittal slice of the left TMJ closed mouth: there is a substantial irregularity of contour of the upper portion of the mandibular condyle, with the formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

13A RNM  ESQ  INICIAL

MRI, another sagittal slice of the left TMJ closed mouth: there is an important  irregularity of contour of the superior aspect of the mandibular condyle and a formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

16A  ESQ boca fechada 2013 T2

MRI in T2 clearly shows the joint effusion.

The differential diagnosis of TMJ effusion has a broad spectrum as the effusions in other joints in other parts of the skeleton.

MRI (magnetic resonance imaging) can give us a lot of information, not just the disc position.

14  RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

MRI, frontal section of the right and left TMJ, closed mouth. Upper lesion in the right mandibular condyle, as described in the same sagittal slice of the same condyle as subcortical bone cysts.

In the slice of the mandibular head on the left side can be seen an important hipossinal compatible with avascular necrosis.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. It can be caused by various conditions, such as bone or joint damage, pressure inside the bone and other medical conditions.

The condyle affected by avascular necrosis has low signal on T1-weighted images as a result of edematous changes in trabecular bone.

14 SERIE DE RESS DIR FECHADA 2013

Sagittal sections of the right TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

14 SERIE DE RESS DIR ABERTA 2013

MRI,sagittal sections of the right TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

15  SERIE DE RESS ESQ FECH 2013

MRI, sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

15 SERIE DE RESS ESQ ABERTA 2013

MRI,sagittal sections of the left TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

16 series ESQ boca fechada 2013 T2

MRI, T2 sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the image I find most relevant, but also this series are registered.

Serial in T2 clearly showing the joint effusion.

Tests were done on the patient to investigate systemic inflammatory disease, which were all negative.

It was also investigated chlamydia trachomatis infections, mycoplasma pneumoniae infections and beta hemolytic streptococcus infections , results in this case were also negative.

It was also investigated the functioning of the thyroid.

17 REGISTRO CINECIOGRAFICO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and 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 free space of the pathological patient is almost 7 mm and a retro position 0 8 mm.

18 DIO SOBRE A PROTESES

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

This device must be tested electromyographically to objectively measure the patient.

19 CONTROLE DA ORTESE

It is essential to control the DIO (intra oral device) as the patient is treated and the mandible is repositioned.

In this case the control still shows us the need for recalibration of the DIO (intraoral device)

19 PANORAMICA COMPARATIVA

Comparative panoramic radiographs: before treatment and after neurophysiological treatment.

20 FRONTAIS COMPARATIVAS

Patient’s frontal radiographs comparison: with the prosthesis in habitual occlusion and the DIO intraoral device built on the prosthesis.

20 LAMINOGRAFIA COMPARATIVAS

Right and left temporomandibular joints laminographies, closed and open mouth comparison: with the prosthesis in habitual occlusion and with the DIO intraoral device built on the prosthesis.

cefalometria 2014 CORTADA ingles

Ricketts cephalometric analysis after treatment with the DIO constructed on the prostheses in neurophysiological occlusion.

FACTORES CEF APOSSS

Values of point A convexity and lower facial height after treatment.

21 PERFIS COMPARATIVOS

Patient’s lateral radiographs comparison: with the prosthesis in habitual occlusion and with the DIO built on the prosthesis in neurophysiological position.

The DIO (intra oral device) is used to support, align and correct deformities in order to improve the functions of the jaw, temporomandibular joints and the muscles that move both. This device should be checked and recalibrated as the records indicate the need for modification.

21A PERFIS COMPARATIVOS

Comparison of aesthetic Ricketts plane in lateral radiograph with prosthesis in habitual occlusion and the DIO constructed on the prosthesis in neurophysiological position.

21 RNM COMPARATIVAS ESQ SAGITAL

Comparison of T1-weighted images: before treatment and after treatment: we can see the improvement in medullary signal.

26 comparativas ESQ boca fechada 2013 e 2014T2

Comparison of T2-weighted images: before and after treatment. It is clear in the first image the inflammatory signal and in the other image the improvement of the intramedullary signal and the remission of posterior effusion.

22 RNM Comparativas direita sagital

Comparison of T1-weighted images: before treatment and after treatment, we can see the improvement in medullary signal and improvement of the cortical bone.

23 RNM Comparativas direita FRONTAL

Frontal T1-weighted images comparison, before and after treatment treatment: we can see the improvement of the upper lesion on the right mandibular condyle.

24 RNM Comparativas ESQUERDA FRONTAL

Frontal T1-weighted images comparison, before and after treatment: we can see the improvement in medullary signal and improvement of the cortical bone of the left mandibular condyle.

25 SERIE DE RESS DIR ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the right TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

25 A SERIE DE RESS ESQ ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the left TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

COMPARATIVAS FRONTAIS POSTURAIS

Patient’s postural frontal comparative images before and after treatment.

COMPARATIVAS POSTURAIS PERFIL

Patient’s  postural profile comparative images  before and after treatment.

27 CEF COMPARATIVAS ingles

Ricketts cephalometric analysis before and after neurophysiological treatment.

COMPARAÇAO DOS FATORES

Skeletal problems in Ricketts cephalometric analysis before and after treatment.

28 DEPOIMENTO

“Headache (already when waking up in the morning), tiredness sensation at the cheekbones, strong tensing at the shoulders and neck, “clicks” at the temporomandibular joint, ear pain… consequently I also felt irritation, indisposition, stress etc.

All of that is something I had to live with for a long time. The investigations made on me always resulted in palliative measures that mitigated the problem for a short time.

I passed through implants and placement of prostheses which even without having (those measurements) the aim of healing this malaise I still had the hope that it would: but the relief only worked for a short period of time. Finally, by indication of my dentist, I arrived at Clinic MY starting then the TMJ treatment. Shortly after the start of the treatment the symptoms started to fade.

I am very thankful for the professionalism and dedication that I found there. Today, feeling better, I go back there for periodic evaluations and also to have the opportunity of thanking  once more.”

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

  1. You are singing my tune!

    Example mid 30’s woman came with persistant whiplash pain after a fat woman fell on her. She had c/spine fusions (C2/3 and later C5/6).

    As the pain persisted the surgeon place LA into Levator Scapulae. This stopped much of the pain – so the shoulder muscle was sectioned – leading to loss of sholulder control – dropped shoulder and brachial plexus stretching – Carpal Tunnel problems and loss of fine motor control. Unable to brush her teeth she presented at my clinic.

    I made a corrective splint to enhance airway and decompress the TMJ’s.

    3 years of high level (9/10) pain was essentially gone (3/10) pain in the week.

    What you are saying is brilliant as it shows this stuff in action.

    Dr David Zimmerman

    Stanmore Bay Dental

    TMJ & Sleep Therapy Centre

    ph +64 9 428 1081

    Like

  2. Pingback: Reestablishment of the Bone Marrow Signal in a case of Avascular Necrosis of the Mandibular Head. Monitoring two years after treatment. | Page of Studies and Investigation – TMJ

  3. Pingback: TMJ Study and Investigation Page. Three years of publication. | Page of Studies and Investigation – TMJ

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