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 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.
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.
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 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.
