Several articles and studies cite the prevalence of TMJ dysfunction in violinists and violists, especially by prolonged flexion of the head and shoulder, posture necessary to keep the violin in position. Studies also report that the incidence of TMJ dysfunction in musicians is similar to the general population.
Professional musicians require many hours of training and improvement that involve complicated movements, fast and repetitive actions with over use of the hands, fingers, arms and head.
Most articles report anxiety about professional performance and increased muscle tension, but few do a particular study of the state of the anatomical structures of the cases studied.
A 45-year-old female patient referred by her physiotherapist consults with complaints of headache, pain in the cervical and scapular region, muscular contractures in the mandible.
The patient also reports mandibular displacement when playing the violin and pain in both temporomandibular joints.
The patient also reports clicks in both temporomandibular joints and occasionally the sensation of clogged ears.
Frequent pain in the spine and both shoulders.
At that time the patient had already consulted physiotherapists, rheumatologists, psychiatrists and psychologists.
Marking chart of pain points.
Image of the patient’s habitual occlusion on the day of the appointment.
Upper and lower occlusal views of the patient on the day of the consultation.
Initial panoramic radiograph of the patient before treatment.
Teeth 18, 28 included.
Wear on the incisal and occlusal faces of the teeth present.
Prosthetic device 25 to 27 (26 pontic)
Horizontal resorption of alveolar ridges.
Patient’s TMJ initial laminography before treatment
In the maximum opening position, observe the anterior angulation of the articular processes. Structural modification of the mandibular condylar process as one of the sequels of traumatism in infancy.
The patient reports a trauma in early childhood, a knock on the head while playing on a slide.
Lateral radiograph and patient profile before treatment. Patient in habitual occlusion.
Frontal radiography of the patient in habitual occlusion before treatment.
Lateral and cervical radiograph of the patient in habitual occlusion before treatment.
At this time, the patient performed a CT scan of the cervical spine
In the report there is rectification of cervical lordosis.
Degenerative discopathy in C5-C6, observing reduction of the height of the disc space and osteophytic proliferations reactional. At this level the disc-osteophyte bar is identified that touches and distorts the ventral face of the dural sac.
There is no stenosis of the central vertebral canal.
Neural foramina with amplitude within the limits of normality.
Mild signs of uncovertebral arthrosis C5 and C6.
Relationship C1-C2 maintained.
Symmetric paravertebral regions.
Dynamic electromyographic record in patient’s habitual occlusion before treatment. Note the minimal activation of the right and left masseter muscles in maximal intercuspation and the high activation of the right and left temporal muscles.
The masseter muscles are the most powerful muscles of the stomatognathic system, the temporal muscles even being elevating muscles have to have an equal and preferably smaller activation than the masseter muscles.
Initial cineciographic record of the patient.
Three-dimensional view of the mandibular displacement.
The record shows mandible opening, closing and speed when the patient makes these movements. The patient shows a 47 mm opening and a right deflection of 3.9 mm
Note a significant loss of velocity in the middle of the mandibular closure.
MRI: sagittal slice of the left TMJ, closed mouth, anteversion of the mandibular condyle can be observed.
MRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.
Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.
MRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.
Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.
MRI: internal sagittal slice of the left TMJ, closed mouth.
MRI: internal sagittal slice of the right TMJ, closed mouth.
MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.
The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)
Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.
MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.
The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)
Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.
MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.
The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)
Note the posterior compression in this section.
Primary objective has to be the three-dimensional decompression of the mandibular condyle.
MRI: frontal slice of right and left temporomandibular joints, closed mouth in habitual occlusion before treatment.
The frontal slice of the right temporomandibular joint shows a loss of joint space, especially in the region of the external lateral pole of the joint. Both frontal images show a decrease in joint space.
Slight medial disc deviation.
To correctly evaluate the maxillomandibular relationship we should begin to consider the physiological rest mandible position.
Physiological rest is a concept applicable to all the muscles of the body.
The stomatognathic musculature is no exception.
The patient’s masticatory muscles were deprogrammed electronically and a new physiological neuromuscular position at rest was recorded.
The patient has a pathological free space of 5.8 mm, already discounting the two physiological mm of a healthy free space.
The patient also presented a 2.1 mm mandibular retroposition
With these data we constructed a DIO (intraoral device), to maintain the three-dimensional recorded position. This device must be electromyographically tested to objectively measure the patient.
It is logical that the report of the patient’s symptomatology is important, but the surface electromyography shows in an objective way if the muscular function improved, worsened or did not modify.
Electromyographic record with DIO (intraoral device) in physiological neuromuscular position.
Note the higher recruitment of motor units in the masseter muscles that previously showed very little activity.
Cineciographic record for the DIO (intraoral device) control in physiological neuromuscular position as the device is changed or recalibrated.
In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.
Each case IS UNIQUE. There are cases where the TMJ structures are so damaged that the objectives outlined will have limitations dictated by the initial diagnosis.
These limitations refer not only to the structures of the temporomandibular joint, but also to the patient’s systemic condition.
Another cineciographical record to control the Dio in a physiological neuromuscular position as the device is changed or recalibrated.
Comparison of left and right temporomandibular joint laminography, closed and open mouth: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.
Comparison of lateral radiographs and cervical spine of the patient: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.
With the jaw in a physiological neuromuscular position the physiotherapist colleague worked the rest of the muscle chains, using global manual techniques, always taking into account the individuality of the patient. This work in a patient with degenerative discopathies should be maintained
Comparison of lateral radiographs of the patient: in habitual occlusion before the treatment and with the DIO (intraoral device), in a physiological neuromuscular position.
Improvement of the profile and recovery of the vertical dimension.
Comparative frontal radiographs of the patient: at the beginning of treatment in habitual occlusion, during treatment with DIO (intraoral device) in physiological neuromuscular occlusion.
Panoramic radiograph of the patient with the DIO constructed in a physiological neuromuscular position.
MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
MRI: Comparison of the frontal slice of the LEFT TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same LEFT TMJ after the FIRST PHASE.
Note the decompression of the temporomandibular joint, especially in the lateral pole.
MRI: Comparison of the frontal slice of the RIGHT TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same RIGHT TMJ after the FIRST PHASE.
Note the decompression of the temporomandibular joint, especially in the lateral pole.
The patient did not report any more symptomatology related to the TMJ. Bioinstrumentation also objectively showed an improvement in neuromuscular function.
It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the physiological neuromuscular occlusion.
For this we used a three-dimensional orthodontic, where the teeth are erupted to the new neurophysiological position.
In the second phase, in this case the three-dimensional orthodontics the patient is monitored and deprogrammed electronically, and often the device is recalibrated, to maintain the position obtained in the first phase.
Part of the sequence of the second phase (in this specific clinical case).
Patient’s panoramic radiograph after the installation of the implant and the removal of the retained upper third molars.
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.
Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Part of the sequence of the second phase (in this specific clinical case).
Removal of the DIO (intraoral device)
Part of the sequence of the second phase (in this specific clinical case).
Finalization of the second phase.
Patient’s upper and lower occlusal view after the finalization of the second phase.
Patient’s comparative panoramic radiographs before and after the end of the second phase of the treatment using a three-dimensional orthodontics.
Patient’s comparative superior and inferior occlusal view, before and after, the end of the second phase of the treatment by a three-dimensional orthodontic.
Comparative occlusion of the patient before and after the end of the second phase of the treatment using a three-dimensional orthodontics.
Kinesiographic control record after the completion of the three-dimensional orthodontics in a physiological neuromuscular position.
Coincident neuromuscular trajectories.
Laminography of the patient in physiological neuromuscular occlusion after the finalization of the second phase of the treatment.
Comparative laminography of the patient: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.
Patient’s comparative frontal radiographs: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.
Patient’s comparative lateral radiograph and profile: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.
Patient testimony:
What made me look for the treatment were recurrent headaches, frequent
(weekly) and intense, which lasted, on average, 2 days, affecting my productivity
at work as well as leisure hours.
The pain did not subside with common analgesics, requiring strong medication, which, in turn, only softened the pain a little.
Today, after the treatment, I can say that only very rarely do I suffer from these pains, greatly improving the quality of life, besides the posture.
Congratulations Lidia for enriching the professionals with your experience
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Thank you Prafulla!
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