Reestablishment of the Bone Marrow Signal in a case of Avascular Necrosis of the Mandibular Head. Monitoring two years after treatment.

Preparing a new publication of the TMJ (temporomandibular joint) study and investigation page, I received the new MRI (magnetic resonance imaging) that I requested for the patient presented in the last clinical case published.

I decided that it was high priority to publish this follow up before the next clinical case.

Recapitulating the clinical situation and the images of the patient after treatment:

The patient had remission of symptoms.

The patient had improved function and recovered the vertical dimension.

The patient had improved aesthetics (recovering the vertical dimension).

The patient had recovered the mouth opening, without presenting limitation as observed before treatment.

The patient had improved her posture.

Is important to highlight that in this case, with discs of reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opened, the goal was to decompress, to recover the vertical dimension, and to wait for the medullary signal recovery by decompression, remembering that all bacteriological and rheumatologic research was negative.

At the end of treatment the MRI (magnetic resonance imaging) of the patient showed a MEDULAR SIGNAL IMPROVEMENT, yet still far from satisfactory recovery in terms of image, EVEN TAKING INTO ACCOUNT the improvement of symptomatology.

I will post some of the most remarkable initial MRI images before the treatment, to review the clinical case in detail enter in this link.

This publication will emphasis the images, a fundamental tool for understanding what we really can achieve beyond the patient’s clinical improvement.

Understanding the positive or negative changes in the structures affected in TMJ pathologies is critical in the comprehension of the etiology that led to the deterioration of the patient’s structures and consequently triggered the symptoms that affected the quality of life of our patients.

REMEMBERING THAT THIS IMPLIES A DIFFERENTIAL AND UNIQUE DIAGNOSIS FOR EACH CASE.

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, 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 when the mouth opens.

CAN BE SEEN AN IMPORTANT HIPOSSINAL COMPATIBLE WITH AVASCULAR NECROSIS.

Osteonecrosis of the mandible head corresponds to the death of bone tissue also called avascular necrosis.

The alteration in the bone marrow of the mandibular condyle is a possible source of TMJ pain.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

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.

Osteonecrosis of the mandible head corresponds to the death of bone tissue also called avascular necrosis.

The alteration in the bone marrow of the mandibular condyle is a possible source of TMJ pain.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

16A  ESQ boca fechada 2013 T2

MRI:same previous sagittal slice of the left TMJ, closed mouth in T2

MRI in T2 clearly shows the ARTICULAR 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.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

CORTE FRONTAL DA ATM ESQ INICIAL ANTES DO TRATAMENTO 2

MRI, frontal section of the left TMJ, closed mouth.

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.

Osteonecrosis of the condylar head corresponds to the death of bone tissue, also called avascular necrosis.

 Alteration in the bone marrow of the mandibular condyle is a possible source of TMJ pain.

CORTE FRONTAL DA ATM DIR INICIAL ANTES DO TRATAMENTO

MRI, frontal section of the right 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.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

In the last publication WERE POSTED THE INITIAL IMAGES BEFORE TREATMENT AND THE IMAGES AFTER TREATMENT.

IN THIS PUBLICATION I POSTED THE IMAGES COMPARING: before treatment, after treatment and TWO-YEARS FOLLOW-UP AFTER neurophysiological treatment.

FRONTAL COMPARATIVAS DIREITA 2016

T1-weighted right frontal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement in the medullary signal of the left condyle and the improvement of the superior cortical bone. THE THIRD IMAGE HAS NO TRACES OF THE SUBCORTICAL LESION .

FRONTAL COMPARATIVAS ESQUERDA 2016

T1-weighted left frontal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement in medullary signal of the left condyle in the central image and THE  BONE MEDULLARY RECOVERY IN THE THIRD IMAGE.

THE MANDIBULAR CONDYLE HAS A HELTHY BONE MARROW SIGNAL.

RESS COMP DIREITAS SAGITAL 2016

T1-weighted right sagittal images closed mouth comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement of the medullary signal and cortical bone. ABSENCE OF SUBCORTICAL BONE CYSTS in the anterior superior aspect of the mandibular condyle OBSERVED IN THE FIRST IMAGE before treatment. Improvement in the cortical bone of the mandibular head.

sagitais comparativas T2

T2-weighted right sagittal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

It is clear in the first image the inflammatory signal. In the central image we can notice the improvement of the intramedullary signal and the remission of posterior effusion.

IN THE THIRD IMAGE WE CAN SEE THE TOTAL REMISSION OF THE INFLAMMATORY SIGNAL.

The patient DID NOT USE ANY ANTI-INFLAMMATORY DRUG.

RESS COMP SAGITAL ESQ 2016

T1-weighted left sagittal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement in medullary signal of the left condyle in the central image and THE  BONE MARROW RECOVERY IN THE THIRD IMAGE.

THE MANDIBULAR CONDYLE HAS A HELTHY BONE MARROW SIGNAL.

FINAL 1

All relevant images were posted, nevertheless I think it is important to highlight THIS FRONTAL RIGHT TMJ comparative image because of the MEDULLARY SIGNAL OBVIOUSNESS.

The first image before treatment and the second two years of follow-up after treatment. MEDULLARY BONE WITH AVASCULAR NECROSIS RECOVERED IN A HEALTHY MEDULLARY SIGNAL.

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 differential diagnosis of the alteration in signal intensity of the mandibular condyle begins with the knowledge of the normal characteristics of medullary signal.

FINAL menor

Right and left TMJ sagittal and frontal comparative slices. Before treatment and two years of follow-up after neurophysiological treatment.

finale finale

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

In the previous publication the control images after two years of treatment were NOT posted.

With the application of advanced diagnostic techniques like MRI the alterations of the medullary signal from the mandibular condyle can be detected, similar to those seen in the femoral head with osteonecrosis.

The detection of effusion and bone marrow alterations is important information before the treatment.

 The information of what really we achieve after our treatments in the image beyond the clinical improvement of our patient is also substantial information.

In this case showing the improvement and recuperation of the medullar signal with the correct mandibular reposition and decompression.

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.”

Postural Improvement in a Patient after Neuromuscular Physiological Mandible Repositioning Treatment. Patient with Scoliosis Surgery and Craniomandibular Symptomatology

The interrelationship between mandibular posture, occlusion and body posture is a topic covered by different health professionals.

When we speak of occlusion we do not mean only the relationship between the dental arches but we are also referring to the balance between teeth, muscles and temporomandibular joint in connection with all the postural scheme. In that way we can see and analyze patient as a whole.

This clinical case report describes a patient who came to the clinic for consultation after a scoliosis surgery, with craniomandibular symptoms and loss of vertical dimension.

Scoliosis is a three-dimensional structural deformation of the spine.

Idiopathic scoliosis is probably multi aetiological

The prevalence of the association between scoliosis and craniofacial anomalies should stimulate multidisciplinary collaboration on treating these patients, especially when we have an early diagnosis.

1 a

Patient narrative: brief history of the surgery:

When I was 14 years old I was diagnosed with scoliosis, after being noticed with a deformation on the back. Several medical experts were consulted and they stated the same diagnosis, however none of them could tell the causes, and they added that it could be related  to a malformation, some `trauma` in the growth phase, maybe being a hereditary problem.

“My mother noticed that the left side of my back was higher than the right side. In this period I also had frequently faints. Therefore, tests were performed, such as blood tests, electrocardiogram and electroencephalogram. They did not present any alteration”

“Concerned about the situation we consulted an orthopedic surgeon who ordered the realization of a panoramic X-ray of the spine. That test  showed a lumbar scoliosis of 25 degrees, for which the doctor recommended physical therapy.”

1 B JANELA

Panoramic radiographs of the spine were photographed on a glass of the window on day light, that’s why we can observe elements of the landscape.

22- 10 -2004  1

Cervicothoracic  Scoliosis. Left convexity, Cobb angle of 25 degrees. No significant pelvic difference.

“Initially, with about 25 degrees of curvature, I did physical therapy sessions and follow-up for a month.”

“I also used an insole ( which I stopped using it  because I did not perceive results and I felt no need) at the time I was also treating a cross bite.”

25-08-2004   2

Thoracic-lumbar scoliosis, left convexity, C0bb angle of 44 degrees. Accentuation of lumbar lordosis difference of the femoral heads of 3 mm.

“Clinical tests revealed that the curvature had evolved progressively to more than the double in size, reaching approximately 45 degrees. At the time, the proposed solution was the use of a neck vest in order to curb this trend.”

4-11-2004  3

X-rays taken for scoliosis treatment control with orthopedic brace.

“The vest was being used 22 hours per day, and it was also recommended swimming lessons for greater flexibility and aid in respiration in case of surgery.”

“During this period, there was a monitoring and vest readjustment in every month.”

“Finally, this alternative was not efficient enough, as the bending progressed to 64 degrees.”

15-02-2005  4

X-rays taken for scoliosis treatment control with orthopedic brace.

todas juntas

“Thus, according to doctors, we reached the surgical case.”

At my 16 years old, I had the surgery on my spine. The recovery was gradual, nonetheless restfull. The pains, which were always absent, were felt not often in the hip area and legs. The bend in my spine regressed to 19 degrees.”

CONTROL REPORT OF COLUMN XR PANORAMIC SPINAL AFTER SURGERY:

Radiographic examination performed for surgical treatment control of Thoracic-lumbar scoliosis, left convexity fixed by metal screws and rods.

“After a year, I was released to engage in any sport mode, which until then I was forbidden to practice.”

REASON FOR THE CONSULTATION AT CLINIC MY:

“After dental treatment (crossbite) with another professional, mainly due to a shift in the cervical spine that I had tried to fix at the same time – but I did not had  another solution unless the surgery, which had already been completed – I was guided to proceed with Dra. Lidia, also to investigate the relationship between the two cases, so far no connection, the dental arch and the cervical spine. ”

“Following the derivation, I met Dr. Lidia to whom I presented my case, including the surgery of the spine, which led her to investigate the links that could be  cause and consequence of the whole problematic. After many conversations and clarifications I surrendered to the treatment.”

1The patient arrived to the clinic for consultation after a spine surgery, complaining of headache, frequent fatigue, pain behind the eyes, pain in the shoulders and clenching.

2 perfil direito e esquerdo

Patient’s postural photographs of right and left profile after the spine surgery before the neurophysiological treatment.

3 frente e costas

Patient’s frontal and back postural photographs after the spine surgery before the neurophysiological treatment.

4d locais da dor

Part of the medical record where the patient marks the points where feels pain.

5 DENTES INICIAISPatient’s habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment before the neurophysiological mandibular repositioning.

6 oclusais iniciaisPatient’s superior and lower oclusal view on the day of consultation after spine surgery and the completion of orthodontic treatment before the neurophysiological mandibular repositioning.

7 panoramica inicial

Patient’s panoramic radiograph on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Remodeling apical teeth 11,21,22,33,43 compatible with orthodontic movement.

8 laminografia inicial

Patient’s temporomandibular joint laminography in habitual occlusion, closed and open mouth, both sides on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Asymmetrical head of the mandible: the left one with a facet in the posterior surface and a change of orientation in the vertical axis.

9 teleperfil inicial

Patient’s lateral radiograph in habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Note the beginning of the cervical curvature inversion at C4 level.

10 FRONTAL

Patient’s frontal radiograph in habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Note the loss of vertical dimension.

11 C7

Patient’s lateral radiograph and cervical spine in habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Note the the cervical curvature inversion at C4 level.

11 RESS DIR 1 BOCA FECHADA

MRI of the right TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

11 RESS DIR 2 BOCA FECHADA

MRI of the right TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

Mild cortical irregularity of the anterior-posterior edge of the condyle.

11 RESS ESQ  1 BOCA FECHADA

MRI of the left TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

11 RESS ESQ  2 BOCA FECHADA

MRI of the left TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

Traumatism history reported by the patient

1 – Fall off a wall of approximately 1.50m tall. She fell on her back hitting the back of the head on the ground.

2- Sudden braking in the car. She was pushed against the windshield, but was held by her father.

3 – Bicycle fall. The pacient was taking a ride on the rack of a friend bycicle when she fell and and hits the mouth on the floor.

11A eletromiografia dinãmica habitualPatient’s electromyography record in habitual occlusion. Asymmetry between the right and left temporal muscles and asymmetry between the masseter muscles.

The most important thing in this case is the greater activity of the temporalis  muscles in relation to the masseter muscles. Remember that the muscles that must recruit more motor units in maximum intercuspation are the masseters and not the temporalis muscles.

12 registro neurofisiológico

Mandibular rest neurophysiological position record.

The masticatory muscles of the patient were electronically deprogrammed and a new neurophysiological rest position was recorded.

The patient had a pathological free way space of 5 mm and a shift to the right of 1,5 mm.

With the data obtained after the mandibular electronic deprogramming and ALWAYS WITH THE INFORMATION OBTAINED FROM THE IMAGES, a DIO (Intraoral device) in neurophysiological position was constructed.

13 DENTES ORTESE

DIO: Intraoral Device constructed in neurophysiological position.

14 ELETROMIOGRAFIA  controle da ortese

Electromyography dynamic record of the patient with the DIO built in neurophysiological position.

In the first selection we can already observe a symmetry between the anterior temporalis muscles.

In the last selection with cotton rolls on both sides it can be observed an improvement in the recruitment of motor units in the masseters muscles and even lower recruitment in the anterior temporalis muscles. Remember that the DIO (Intraoral Device) is tested and calibrated  with Bioinstrumentation.

14A controle da ortese

Kinesiographic control of the DIO. Freeway interocclusal space of 2.6 mm and shows no deviation on the frontal record.

15 FRONTAIS COMPARATIVASFrontal radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position. Improvement on the three-dimensional jaw alignment.

We cannot fix the structural differences of the mandibular condyles, but we can balance the muscles.

16RX  laterais COMPARATIVASLateral radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

17 C7 COMPARATIVAS

Lateral and cervical spine radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

18 LAMINOGRAFIAS COMPARATIVAS

Patient’s TMJ laminographies comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

19 RADIOGRAFIAS PANORAMICAS COMPARATIVAS

Patient’s panoramic radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

20 ress COMP dir  1 e 2Right TMJ sagittal section, closed mouth comparison: before treatment in habitual occlusion and with the DIO (Intraoral device) in neurophysiological position.

21 ress COMP ESQ  1 e 2

Left TMJ sagittal section, closed mouth comparison: before treatment in habitual occlusion and with the DIO (Intraoral device) in neurophysiological position.

22D Comparativas de perfil com e sem ortese

Patient’s postural profile comparative images in habitual occlusion before the treatment, in the beginning of the treatment wearing the DIO (Intraoral Device) and as we can see in the third photograph) in the stage that alouds us to perform the second phase of the treatment with a tridimensional orthodontics.

23 DComparativas de frente com e sem ortese e inicio de orto

Patient’s postural frontal comparative images in habitual occlusion before the treatment, in the beginning of the treatment wearing the DIO (Intraoral Device) and ( as we can see in the third photograph) in the stage that alouds us to perform the second phase of the treatment with a tridimensional orthodontics.

After treatment:

PATIENT TESTIMONY:

Especially the headaches (frontal) and the tension in the trapezius, along with the other listed symptoms, which hindered my work and productivity, were easily controlled with the treatment.

I am grateful to Dr. Lidia Yavich and the Clinica MY team for the profissionalism and which always had great care and attention, in the connection of the teeth, face and temporomandibular joint with the spine and posture.

For reasons of study and work opportunities, I chose to take a break in treatment, before starting a three-dimensional orthodontics.

I kept on inued with the continuous  use of the DIO – the pain is still being controlled – until I had the conditions to finalize the treatment.

Description of habitual orthostatic position in the sagittal and frontal planes

24

Sagittal plane:

The evaluation is described according to the plumb line test. This test takes into account the anatomical points that must be aligned with the vertical axis (plumb line) that is perpendicular to the horizontal axis (foot rest surface). The points are the lateral malleolus (specifically in calcanocuboidea joint), the joint center of the knee, the hip center (located in the femoral head), the lumbar vertebrae (L3 – L4), the center of the shoulder joint (acromion) and the external auditory meatus (ear ).

Picture 1 – patient in habitual occlusion before treatment:                     

 

It is observed that the patient is with the body in front of the plumb line. This shift of the reference points is observed from the knee joint in direct side view.

Picture 2: Patient using the intraoral device at the beginning of the treatment

Note that in this situation the patient is with the joint reference points ahead of the plumb line, but there was an approximation of the body segments shoulder and external auditory canal in the direction of the plumb line.

Image 3: patient using the intraoral device ready to move to a three-dimensional orthodontics

It is observed in this image that the patient is more aligned in upright posture, where all the reference points are aligned or closer to the vertical axis. The lower back and ear still remained ahead of the regency axis.

According to the three images it can be seen an improvement in the alignment of the orthostatic position in the sagittal plane throughout the treatment. Initially the patient was possibly with the muscles of the posterior chain overloaded from the soles of the feet to the suboccipital region.

Probably the use of intraoral device relieved such overloading .

25

Frontal plane

In the frontal view, the description of the usual orthostatic position is made in relation to the plumb (vertical axis) and two horizontal axes: horizontal axis of surface supporting feet and horizontal axis that passes just above the shoulders. The reference points in the frontal plane are: midpoint between the two feet, pubic symphysis, xiphoid process (sternum center) center of the cervical vertebrae (spinous processes) and the midpoint between the eyes.

Picture 1: Patient in habitual occlusion before treatment

It is observed the following displacements in relation to the vertical axis: slight displacement of the pubis point to the right side of the patient, followed by a displacement of the rib cage (xiphoid process) to the left side. The neck and head region are displaced to the left side of the vertical axis.

In relation to the horizontal axis of the bearing surface and from above the shoulders, it is observed that the right shoulder is lower than the right one. According to this image it can be said that she has escolise or that she is in a postural attitute presenting scoliosis.

Picture 2: Patient using the intraoral device at the beginning of treatment

In image 2 it is possible to observe that the position of the pelvis remained slightly shifted to the right side of the vertical axis. However there was an approximation of the xiphoid process (the center of the sternum) in relation to the vertical axis, as well as to the cervical vertebrae and head. These segments still kept themselves to the right side of the reference point.

In relation to the horizontal reference axis, there is a better alignment of the shoulders. The left shoulder remains in a lower position than the left one. In this image it can be said that the patient has a scoliotic attitude whith the lower spine angles of lateral flexing smallers, in other words there is a change in the support, right where  the scoliotic attitude is milder.

Image 3: patient using the intraoral device ready to move to a three-dimensional orthodontics

From this photo it can be seen that there has been an alignment of reference points of the pubis and the xiphoid process in relation to the vertical axis. In addition, there was a repositioning of the cervical vertebrae and head, where the  reference points are closer to the reference axis. In relation to the horizontal axis the image shows a balanced alignment of the shoulders.

From the three images of the frontal plane it can be observed that there was an improvement in the usual orthostatic posture, however there is still a displacement of the cervical and head reference points to the left side of the vertical axis.

It can be suggested that before treatment the patient showed a distribution of a possibly assimetric body weight between the right and left feet. The pelvis shifted to the right, generates such imbalance. In the  high thoracic and cervical region, probably there was a shortening of the muscles of the left side chain and an overload of the right side chain. With the DIO probably these imbalances  were mitigated  in the habitual orthostatic posture.

This evaluation in orthostatic position is not a dynamic evaluation of the patient.

I appreciate this assessment to Cintia Brino Baril, Master in Science of Human Movement UFRGS.

Temporomandibular Joint Pathology in a Patient with Congenital Fusion of two Cervical Vertebrae. First and Second Phase. Case Report.

When two adjacent vertebrae are fused since birth, the whole vertebral unit is called congenital vertebral block.

Embryologically this fusion is the result of an error in the normal process of segmentation of somites (segmented structure, formed on both sides of the neural tube) during the differentiation in fetal weeks.

Due to the existence of a mobile segment, free joints  (non-fused), on top and underneath the vertebral block, suffer more stress.

They may also produce an abnormal curvature of the spine.

Understanding the complex inter relation of craniomandibular disorders require a wide comprehension, not only on anatomy and physiology of head and neck, but also of the vertebral spine.

The cervical spine is the flexible link between the head and the trunk.

1 FOTO FRENTEMale patient arrived to the clinic for consultation referring headache, pain behind the eyes mostly on the right side and pain on the right eyebrow.

States that, when he passes his fingertips on the left eyebrow toward the right side, reaching the center he feels pain.

Relates pain in both shoulders.

1B FOTO FRENTE

The patient reports pain and clicking in both temporomandibular joints. He also complaints from a crepitation sensation in both TMJ.

He refers a sensation of blocked ears and bilateral tinnitus.

2 FOTO PERFIL

The patient reports that he tightens the teeth all day, and also mentions nocturnal bruxism.

He also complaints of pain in the back of the neck and pain in the cervical spine.

In his clinical history he reported a car accident when he was 12 year old.

He also had a strong blow in his mouth and mandible. He underwent a surgery on  L3, L4 and L5 because of disk herniation.

3 DENTES Patient’s habitual occlusion image before the treatment in the consultation day.  We can notice the  fractured superior incisors   and the absence of the left superior canine.

4 OCLUSAL SUP E INFSuperior and lower oclusal view of the patient before treatment. In this image we can see the wear of the lower incisors and the fracture of the upper central incisors.

5 PANORAMICAPatient’s initial panoramic radiograph: we can observe the absence of the  18, 23, 28, 38 and 48 elements. We can also notice the maxillary sinus extension on the premolars and molars region.

6 p6Patient temporomandibular joint laminography before treatment: we can observe the superior and posterior position of the right condylar process in the articular cavity  and the lower posterior positioning of the left condylar process in the articular cavity when the jaw is in maximum intercuspidation position.

In the maximum open position, we can observe the anterior angulation of the articular processes. More significant on the left side. Flattening of  the posterior surface of the articular processes.

7 frontalPatient’s frontal radiograph in habitual occlusion before treatment.

8 perfilLateral radiograph in conjunction with the profile image of the patient before treatment.

9 C7Patient’s lateral radiograph and cervical spine before treatment.

The arrow marks the FUSION OF THE CERVICAL VERTEBRAE  C3 and C4.

When two adjacent vertebrae are fused since birth, the whole vertebral unit is called congenital vertebral block.

Embryologically, this fusion is the result of an error in the normal process of segmentation of somites (segmented structure, formed on both sides of the neural tube) during the differentiation in fetal weeks.

Due to the existence of a mobile segment, free joints (non-fused), on top and underneath the vertebral block, suffer more stress.

They may also produce an abnormal curvature of the spine.

9A 1 RNM 1MRI TI: Sagittal slice sequence of the left TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 1 RNM 2

MRI TI: Sagittal slice sequence of the left TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 2 RNM 1

MRI TI: Sagittal slice sequence of the right TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 2 RNM 2

MRI TI: Sagittal slice sequence of the right TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 3 RNMMRI TI: Sagittal slice  of the right and left TMJ, open mouth.

In the maximum open position, we can better observe the anterior angulation of the articular processes. More significant in the left side.

9A 4 RNM

MRI TI: Frontal slice  of the right and left TMJ, closed mouth.

10 AB E FECHInitial kinesiographic record: significant loss of speed when the patient opens and closes his mouth. There is no coincidence between the opening and closing trajectories in the sagittal view record. The record  in the sagittal view looks very vertical when the patient opens and closes the mouth, which is  typical of deep overbites.

11 REGISTRO DE MORDIDATo properly evaluate the maxillomandibular relationship we  should start considering the physiological mandibular rest position.

Physiological rest is a concept, applicable to the rest of the body muscles.

The stomathognatic muscles are not the exception.

The masticatory muscles of the patient were  electronically deprogrammed and a new neurophysiological rest position was recorded.

The record showed a pathological free space of 11,8 mm and a retrusion of 2 mm.

Remember that the angulation of the mandibular condyle caused by trauma in early childhood led to a loss in the  vertical growth and a compression at the  level of the flexioned angle of the mandibular condyle neck.

   Click here To read more about traumatisms in childhood and the greenstick fractures of the mandibular process.

12 DENTES ORTESE

With the recorded data after the electronical mandibular deprogramming and the kinesiographic trace obtained with the jaw tracker, we constructed a  DIO (intraoral device), to mantain the tridimentional registered position.

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

13 CONTROLE ORTESEKinesiographic record control of the DIO  (intra oral device), constructed in neurophysiological position. Neuromuscular trajectories  are coincident and the  interocclusal free space is now 2.4mm.

These controls must be performed PERIODICALLY DURING THE FIRST PHASE OF TREATMENT and also during the SECOND PHASE OF TREATMENT.
In the clinical cases published in the  TMJ STUDY AND INVESTIGATION PAGE  I post a minimum selection of the sequenced records obtained during the treatment.

It is important to remember that during the neurophysiological treatment the patient is measured and controlled during all treatment.

9A 1 RNM

The patient presented problems in the three-dimensional localization of the mandibular condyle

Even that structurally the mandibular condyles had undergone changes in the growth axis due to trauma in early childhood, they did not presented lesions that prevented us (after the  improvement of the three-dimensional jaw location) to continue with the SECOND PHASE OF THE TREATMENT.

9A 2 RNM

In this specific clinical case I decided NOT  to request a second MRI, since I didn’t need to control the improvement of the condyle disc complex nor the bone marrow signal.

The patient had remission of symptoms, allowing us to move on to the SECOND STAGE OF THE NEUROPHYSIOLOGICAL TREATMENT.

15 sequencia 1In the upper image we can observe from top to bottom:

Habitual occlusion of the patient before treatment.

Patient’s occlusion  with the DIO ( intraoral device)

Initiation of the  three-dimensional orthodontics, ALWAYS WITH DIO (intraoral device) built in neurophysiological position.

Installation of an upper removable expander.

16 B sequenciaSequence in three-dimensional orthodontics with the expander and the movement of the first upper  premolar on the left side for the installation of a dental implant.

17 sequenciaSequence of the three-dimensional orthodontics in this specific clinical case.

17B sequenciaSequence of the three-dimensional orthodontics in this specific clinical case and installation of the dental implant, because of the absence of the upper left canine.

18 sequenciaThe upper incisors were rehabilitated with resins to recover the aesthetics and functionality of the patient.

19 PANORAMICA NO TRATPatient’s panoramic radiograph:  control with the implant installed  and three-dimensional orthodontics during the neurophysiological treatment.

The DIO, (intraoral device) in neurophysiological position installed in the mouth during the Second Phase.

20 RESINAS INFERIORESThe lower incisors were rehabilitated with resins to recover the aesthetics and functionality of the patient.

The active eruption in the posterior sector was completed until the finalization of the second phase.

In this particular clinic case the active eruption sequence was not documented in images. For those who want to remember this THREE- DIMENTIONAL ORTHODONTICS I suggest to click on this link

22 DENTES FINALThe patient’s occlusion after neurophysiological treatment. First and second phase finished.

23 DENTES FINAL COMPARATIVOSPatient’s comparative occlusion  images before and after the  neurophysiological treatment.

24 OCLUSAIS FINAISUpper and lower oclusal view of the patient after the neurophysiological treatment.

25 OCLUSAIS FINAIS COMPARATIVASPatient’s comparative images of the upper and lower oclusal view before and after the neurophysiological treatment.

26 PANORAMICAfinalPatient’s panoramic radiograph after the first and second phase of the neurophysiological treatment.

26A PANORAMICACOMPARATIVASComparative panoramic radiographs: before treatment, during treatment and after completion of the three-dimensional orthodontics and neurophysiological rehabilitation.

27 laminograpfia finalPatient’s laminography after the first and second phase of the neurophysiological treatment.

30 COMPARAÇAO PERFISPatient’s comparative lateral radiographs, before and after the neurophysiological treatment.

31 COMPARAÇAO C7Patient’s comparative lateral radiograph and cervical spine before the FIRST PHASE and fter the finalization of the THREE DIMENSIONAL ORTHODONTICS and the NEUROPHYSIOLOGICAL REABILITATION. 

In this case we cannot change a congenital fusion of the cervical vertebrae, but if we understand that there are myofascial chains that connect the TMJ to the body, we may then improve the three-dimensional location of the mandible and help the system. Naturally, the system is a whole and depending on each clinical case we will need the help help of professionals of different specialties.

32 COMPARAÇAO IMAGEM FRONTAL Comparative frontal images of the patient: before and after the neurophysiological treatment.

32 COMPARAÇAO PERFIL

 

 

 

 

 

 

 

Comparative profile images of the patient: before and after the neurophysiological treatment.

32  INICIAL DEPOIMENTO inglesSome time ago, while searching for an orthodontic treatment for my first child, I got to know Clinica MY.

At that time my priority was in fact to search for a solution to correct a teeth problem that my son had. After some consultations at the clinic I met Dr. Lidia, which already in our firsts and brief talks, and because of some complaints that I shared with her, she diagnosed that I, much more than my son, had problems related to dysfunctions in the TMJ.

She told me that I needed to search for a treatment.

In that occasion I had many teeth problems as inferior and superior teeth wear, broken tips, crackling when chewing.

32  FINAL DEPOIMENTO ingles

I had a lot of headaches, pain at the nape base and behind the eyes, and also pain on the back and shoulders. I also felt a pain sensation on my right eyebrow whenever I pass my hand on the forehead. It was something really strange and uncomfortable.

Happily this is something in the past. Thanks to the accurate diagnosis of Dr. Lidia and to the treatment that I followed strictly to the letter I am today free of those terrible symptoms.

I also would like to thank the careful work of Dr. Luis Daniel during all the treatment process and the attention and care that was given to me by all the Clinica MY team.

33 FINAL

 

 

TMJ Study and Investigation Page. One year of publication

Dear friends,

At December 2014 I started the Project TMJ Study and Investigation Page. At first, all its content was offered in three languages: Portuguese, English and Spanish. Due to the analysis of the webpage access statistics, at March 2015 I decided to offer the content solely in Portuguese and English.

Nowadays, the medicine based on evidence is hierarchically stratified from top to bottom where in the base of the pyramid we find the clinic cases, which are rarely seen as evidence. The TMJ Study and Investigation Page had, in its conception, the purpose of posting the clinic cases, which were carefully published with the documentation related to each of the patients treated at Clínica MY with pain complaints, dysfunction and TMJ pathology.

INITIAL

The proposition was of presenting these clinic cases and concepts in order share them, offering free access to the content along images, surface electromyographies, computerized kinesiography, scanned before and after the therapeutic process. Cases of tridimentional orthodontics and neurophisiologic reabilitation of the second phase of treatment, after the TMJ treatment, were also included.

site em portugues nova ingles

The TMJ Study and Investigation Page is completing, in this month of December, one year since it started, and I want to celebrate its anniversary with you. With this project, we have a place in the Internet that presents a line of work known as neurophysiologic dentistry, which takes into account the whole body system. It is an area that also operates regarding the posture and the mandibular functioning. In order to do that, the physiologic dentistry aims to establish, in the patient, a position that is based on a harmonious relation between the muscles, the teeth, and the temporolandibular joints.

site em ingles novaIn the publication of the end of this year I have chosen the most significant images of the whole year of publications, with their direct links to each one of the originals publications.

31

Joint Decompression in a Neurophysiological Mandibular Rest Position Promotes a Positive Remodeling in a Degenerative Process of a Teenager Temporomandibular Joint

english 1-1

Anatomy is the platform on which physiology functions

Sem Título-1

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

26

Articular discs recapture with mandibular neurophysiological repositioning

26

Cervical Dystonia or Spasmodic Torticollis: Positive evolution after Neurophysiological Treatment

2

Recapture of articular disc displacement with reduction. Recapture or not recapture that is the question.

17 COLUNA E PERFIL COMP

Inter relation of Craniomandibular disorders and vertebral spine. Case report

24

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

FINAL

Neurophysiological Combined Orthodontics and Rehabilitation: patient with degenerative conditions in several body joints

FINAL

TMJ Pathologies Treatment: first and second phase (tridimensional orthodontics) in a hypermobile joint patient with low signal in the head of the mandible bone marrow. Case report.

33

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

Sem Título-1

Osteonecrosis of the Mandibular Head: recovery of condylar bone marrow alteration

6 BASAL ANTES E APOS O DEM

TMJ ( temporomandibular joint) Pathologies: Patient with severe pain in the region of the face, neck and temporomandibular joint. First and second phase.

18 comparativas

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

15 3D comparativas

Mandible Condyle Fracture Consolidation by Neurophysiological Alignment of the Segments, Four Months after Unsuccessful Surgery. Case report

37 poster

The importance of Mandibular Rest Position by Electronic Deprogramming in the Treatment of Temporomandibular Joint Pathologies, Orthodontic Diagnosis and Oral Rehabilitation. Case report.

41 RNM AFTER TREATMENT cor

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

evento 4

Training in Diagnosis and Treatment of TMJ Pathologies

31

The Postural Position of the Mandible and its Complexity in the Maxillomandibular Tridimensional Relation: first and second phase in a patient with severe symptoms with subtle information on the images.

e images.

26B LATERAIS COMPARATIVAS LINHA

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

I want to thank my family that is always at my side in each one of the projects, I also want to thank my friends, that from Brazil and from many places of the world, supported and support this project. Last, but not least, I want to thank my colleagues and patients that often write, encouraging and thanking the existence of this virtual place.

By closing, in this moment, the annual analysis and the perspective for the year that follows, I therefore thank the readers of all places in the world that follow the TMJ Study and Investigation Page. It is a privilege to count with your visits.

With the best votes for 2016, and wishing for a year of peace, health, love and happiness for all.

Dr. Lidia Yavich

 

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

Nowadays dentistry has new resources for prosthetic resolution of patients with extensive loss of their dental pieces.

New technologies allow protocols to build prostheses where before, they would have no support solution.

Out of aesthetic recovery, essential for the patient IT IS NECESSARY to have an initial point of mandibular rest position, as these complex cases make rehabilitation more challenging.

1 frontal INICIALMale patient 54 years of age arrived to the clinic for consultation referring pain and sensation of plugged ear, especially on the left side. Also refers pain on top of the head and pain in the left shoulder.

2 PERFIL INICIALThe patient reports stiffness and pain in the back of the neck, a different sensation on the left side of the head as tingling and loss of sensibility and “blocked ear”

Refers an uncomfortable sensation in the left eye, in his words says that “the eye is sensitive”.

Refers hand tremor.

3 protese inicialThe image of the patient’s habitual occlusion shows a Class III or mandibular prognathism.

The  patient reports the prognathism  condition even before the dental loss.

When we study occlusion most of the time we do not consider if the inter-occlusal space is healthy or pathologic.

4 oclusaisPatient’s superior and inferior oclusal view.

4A questionarioWhat most encourages the patient to seek treatment was the sensation of blocked ear and his desire to resolve the issue.

The patient also relates noises when chewing and fatigue of the masticatory muscles. The patient also reported a numbness sensation near the left ear.

The patient had been medicated by another professional with muscle relaxant, but he did not feel any symptoms change.

5 PANORAMICA INICIALPatient’s initial panoramic radiograph before neurophysiological  treatment.

The patient has this protocol for more than 18 years.

The patient reported a periimplantitis history, and had no image prior to implant placement.

6 LAMINOGRAFIA INICIALPatient’s TMJ right and left laminography, closed and open mouth before neurophysiological  treatment.

7 TELERRADIOG INICIALPatient’s lateral radiograph in habitual occlusion before treatment.  Marked prognathic profile.

7A TELERRADIOG INICIAL LINHAMarking the aesthetic plane of  Ricketts in the lateral radiograph with the profile of the patient.

8 FRONTAL INICIALPatient’s frontal radiograph before treatment.

9 ELETROMIOGRAFIA INICIALPatient’s dynamic electromyography record in habitual occlusion before treatment.

In this dynamic record we registered the anterior right and left temporal muscles, the right and left masseter muscles, the right and left digastric muscles and the right and left upper trapezius muscles.

The right masseter muscle ALMOST CAN NOT RECRUIT MOTOR UNITS during maximum sustained  intercuspation, it can only generate 21 microvolts in the selected band.

Important asymmetry between the two masseter muscles, right and left.

10 ABERTURA E FECH INICIALPatient’s initial kinesiographic record: we can see a good speed when the mouth opens and a reduction of speed when the mouth closes.

There is no coincidence between the opening and closing trajectories in the sagittal view.

The opening movement has a propulsive closing and a lateralization in the frontal plane to the right of 8.2 mm.

11 CICLOS MASTIGATORIOS HABITUAL ANTES DO TRATThe patient’s masticatory cycles are registered with a jaw tracker. In the record of the masticatory cycles we used almonds to register chewing activity.

This post will not make a detailed analysis of this record. But it is important to note that: on the left side of the graph, even if the patient is chewing almonds on the left, THE GRAPHIC APPEARS ON THE RIGHT SIDE. This is due to mandibular torque that the patient needs to perform to chew.

11ARNMMRI: left and right TMJ closed mouth.  I chose this slice to show important asymmetry between the right and left side.

The left side shows a posterior dislocation of the articular disc. There is NO ARTICULAR DISC on the right side, is IMPORTANT TO MARK THIS, since in several posts I emphasized the importance of recapturing the disks when possible, (IN THIS CASE I CAN NOT RECAPTURE A STRUCTURE THAT DOES NOT EXIST).

In this particular case the request of resonance is part of the protocol to obtain fundamental information in the formulation of diagnosis.

Different slice and parameters do not show bone edema or other information requiring different interventions within the treatment.

The goal in this particularly case  will be the three-dimensional repositioning of the jaw, TO RECOVER the neurophysiological function, which should be widely understood, so that the muscles, temporomandibular joints and teeth and prostheses could work in balance.

12 JAW TRACKER BIOPACKTo determine the neurophysiological three-dimensional position of the jaw, even in cases of extensive rehabilitations we have to consider the physiological position of the mandibular rest.

The masticatory muscles of the patient were deprogrammed electronically and a resting neurophysiological position was recorded.

The patient has a PATHOLOGICAL FREE WAY SPACE OF 7.2 mm. Maintaining the physiological 2 mm we still have more than five mm discrepancy, to be recovered tridimensionally.

The jaw also presents a retro position of almost two mm and a deflection at closing of 0.5 to the left side.

13 DENTES COM ORTESEWith this data and ALWAYS WITH THE IMAGES INFORMATION, we constructed a DIO (intraoral device) to keep the three-dimensionally recorded position.

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

13BTELERRADIOG COM DIOPatient’s lateral radiograph with the DIO in neurophysiological position.

13CTELERRADIOG COM DIO LINHAMarking the aesthetic plane of  Ricketts in the lateral radiograph with the DIO in neurophysiological position.

The DIO is an orthopedic device, recorded and controlled electromyographically. The DIO (intraoral device) is used to support, align and ameliorate deformities in order to improve the functions of the jaw, temporomandibular joints and the muscles.

14 ELETROMIOGRAFIAS COM o DIOPatient SEMG record with the DIO (intraoral device) in neurophysiological position built above the patient’s prosthesis.

We can note the improvement of the right masseter muscle activity. Before the treatment the right masseter muscle could not recruit motor units.

15 ELETROMIOGRAFIAS COMPARATIVASComparison of the SEMG records: before the treatment in habitual occlusion and with the DIO (intraoral device) in neurophysiological position built above the patient’s denture.

WE MUST CONSIDER that years of muscle accommodation and the central nervous system engrams cannot be modified with a first orthotic or DIO

That’s why the DIO should be adapted, changed, and recalibrated to follow dimensional changes that will happen when muscles are aligned.

16 ABERTURA E FECH COM O DIOPatient’s kinesiographic record after neurophysiological treatment.

Significant improvement in the opening and closing trajectories.

The closure no longer has a propulsive trajectory.

The lateralization which was 8.2 mm was reduced to 2 mm.

17 ABERTURA E FECH COMPARATIVOSPatient’s kinesiographic records comparison:  before treatment in the habitual occlusion and with the DIO (intraoral device) in neurophysiological position constructed above the patient’s prosthesis.

18 CICLOS MASTIGATORIOS COM DIOPatient’s masticatory cycles after the neurophysiological treatment.

In this graph the left side chewing appears on the left side as it corresponds.

In the previous graph before treatment in habitual occlusion, the left side chewing graphic appeared on the right side due to mandibular torque.

19 CICLOS MASTIGATORIOS SEM E COM DIOComparative chewing cycles of the patient: before treatment and after neurophysiological treatment.

20 LAMINOGRAFIA COM O DIOPatient’s TMJ right and left lamiography, closed and open mouth in neurophysiological occlusion after treatment.

21 LAMINOGRAFIAS COMPARATIVASPatient’s TMJ right and left lamiography, closed and open mouth comparison: in habitual occlusion before treatment and with the DIO (intraoral device) in neurophysiological position.

22 PANORAMICA COM ORTESEPatient’s panoramic radiograph after the neurophysiological treatment.

23 PANORAMICAS COMPARATIVASPatient’s panoramic radiograph comparison: before treatment and after the neurophysiological treatment.

24 frontal comparativosPatient’s frontal comparative images: before and after neurophysiological treatment.

25 perfis comparativosPatient’s lateral comparative images: before and after neurophysiological treatment.

26B LATERAIS COMPARATIVAS LINHA  Comparing the profile radiographs and the aesthetic profiles

And here, the words of Confucius: A picture is worth a thousand words.

27 Patient testimonyI lived for a long time with discomfort that sometimes manifested itself by a feeling of numbness and sometimes by headaches.

I could not identify the cause; although I repeatedly searched for expert help.

On the recommendation of my sister and my sister in law who were being treated by Dr. Lidia I consulted her and started a treatment which lasted a long period, getting excellent results and today I feel good without the symptoms that hindered me so much.

I appreciate the commitment and dedication of Dr. Lidia and her team.

The Postural Position of the Mandible and its Complexity in the Maxillomandibular Tridimensional Relation: first and second phase in a patient with severe symptoms with subtle information on the images.

Understanding the complex inter relation of  craniomandibular disorders require a wide comprehension not only on anatomy and physiology of head and neck, but also of the vertebral spine. The cervical spine is the flexible link between the head and the trunk.

Only recently, dentistry began to think about the jaw and its association with the skull as a three-dimensional relationship, instead of considering it an isolated structure and evaluated in two dimensions as has been done traditionally.

To properly evaluate the maxillomandibular relationship we should start considering the physiological rest position.

Physiological rest is a concept, applicable to the rest of the body muscles

The stomathognatic muscles and not the exception

1 FRONTAL Male patient arrived to the clinic for consultation referring a strong pain behind the eyes, nonspecific facial pain, popping in the right temporomandibular joint and crackling on the same side.2 FRONTAL The patient reports tingling and numbness in the cervical spine, tingling sensation in his right shoulder. He also reports pain and stiffness in the back of the neck, shoulder pain and muscular tremor.

The patient had completed an orthodontic treatment and after the removal of the orthodontic device he began to feel the reported symptoms .3 PERFIL Due to the strong symptoms the patient consulted several professionals: clinical dentist, physiotherapist, general practitioner and a orthopedist for the  shoulder pain.

The orthodontist who treated him referred the patient to me, to see if I could help him.

4 MARCAÇÃO DA DOR

Section of the clinical record where the patient marks the pain points

 

Marking the pain points: headache, back of the neck stiffness, pain in the top of the head and in the forehead. Pain behind the eyes and in the back of the neck, popps, nonspecific facial pain, crepitus, dizziness and muscle tremor.

5 DENTESPatient’s habitual occlusion before treatment.

6 OCLUSALPatient’s occlusal superior and inferior view before treatment.

7 PANORAMICA INICIALPatient’s initial panoramic radiograph before treatment.

8 LAMINOGRAFIA INICIALPatient’s TMJ right and left laminography, closed and open mouth before treatment.

9 TELEPERFILPatient’s lateral radiograph before treatment.

10 FRONTALPatient’s frontal radiograph before treatment.

11 C7Patient’s lateral radiograph and cervical spine before treatment.

12 ELETROMIOGRAFIA INICIAL

Patient’s electromyography record in habitual occlusion before treatment.

In this dynamic record we registered the anterior right and left temporal muscles, the right and left masseter muscles, the right and left digastric muscles and the right and left upper trapezius muscles.

For this record we ask to the patient to open the mouth, close the mouth, clench strong and swallow.

Notice the asymmetry between the right masseter muscle and the left masseter muscle at maximal intercuspal sustained position. The digastric muscles during swallowing are activated before the masseter muscles which should not happen in a functional swallowing.

13 F CINECIO INICIAL

Patient’s initial kinesiographic record shows a significant loss of speed when the patient opens and closes the mouth. There is no coincidence between the neuromuscular trajectories in the sagittal view of the record.

The patient has hypermobile joints and has no limitation in opening the mouth.

13 A RES. ESQ 1 INICIAL MRI: sagittal slice left TMJ closed mouth. This image does not show significant alterations.

13 B RES. ESQ 2 INICIAL MRI: sagittal slice left TMJ closed mouth, this more medial slice shows the compression and the retroposition of the mandibular condyle. We can observe a facet on the top of the mandibular head.

REMEMBER THAT we are looking at a two-dimensional image and we have to understand that the COMPRESSION IS TRIDIMENSIONAL.

13 C RES. DIR 1 INICIAL  MRI: sagittal slice right TMJ closed mouth, this medial slice shows the compression and the retroposition of the mandibular condyle. We can observe a facet on the top of the mandibular head.

REMEMBER THAT we are looking at a two-dimensional image and we have to understand that the COMPRESSION IS TRIDIMENSIONAL.

13 D RES. DIR 2 INICIAL MRI: sagittal slice right TMJ closed mouth, in this medial slice is even more evident the compression and the retroposition of the mandibular condyle. We can observe a facet on the top of the mandibular head.

REMEMBER THAT we are looking at a two-dimensional image and we have to understand that the COMPRESSION IS TRIDIMENSIONAL.

13 E RESFRONTAIS INICIAIS

MRI: frontal slice from the right and left TMJ, closed mouth in habitual occlusion before treatment.

The right TMJ frontal slice makes clear a loss of joint space especially on the lateral pole.region  In both frontal images we can notice the reduction of the joint space.

13G REGISTRO NEUROFISIOLOGICOTo properly evaluate the maxillomandibular relationship we  should start considering the physiological mandibular rest position.

Physiological rest is a concept, applicable to the rest of the body muscles

The stomathognatic muscles and not the exception

The masticatory muscles of the patient were deprogrammed electronically and a new neurophysiological rest position was recorded.

14 ORTESE INICIAL With this data we constructed a DIO (intraoral device), to keep the three-dimensionally recorded position. This device must be tested electromyographically to objectively measure the patient.

Of course checking the patient’s symptoms is important, but the surface electromyography objectively shows if the muscular function improved, worst or did not change.

15 ELETROMIOGRAFIA COM O DIO Patient’s electromyographic record with the DIO (intraoral device), in neurophysiological position.

Note the symmetry of the masseter muscles. The digastric muscles DON’T ACTIVATE before the masseter muscles during swallowing. This implies that the patient closes the teeth and swallows and not the contrary as the first record in habitual occlusion.

16 CINCECIO COM DIO Patient’s kinesiographic record with the DIO (intraoral device): there has been an improvement in speed and COINCIDENCE in the trajectories when he opens and closes the mouth.17 FRONTAIS COMPARATIVAS Patient’s frontal radiographs comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

18 LAMINOGRAFIAS COMPARATIVAS Patient’s TMJ right and left closed and open mouth laminography comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

19 TELERADIOGRAFIAS COMPARATIVASPatient’s lateral radiographs comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

In the middle of the treatment I referred the patient to a physical terapist for a postural reprogramming.

With the jaw in a neurophysiological position the physiotherapist colleague worked on the rest of the muscular chains. The patient also presented an incipient discopathy at the level of C3 and C6.

20 PANORAMICAS COMPARATIVASPatient’s panoramic radiograph comparison: before treatment and during the neurophysiological treatment.20 A cinesiografias COMPARATIVAS Kinesiographic records comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

Note the improvement of the speed and the COINCIDENCE in the opening and closing trajectories.

20 A ELETROMIOGRAFIAS COMPARATIVAS Electromyography records comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

Note the symmetry of the masseter muscles, the digastric muscles DON’T ACTIVATE before the masseter muscles during swallowing. This implies that the patient closes the teeth and swallows and not the contrary as the first record in habitual occlusion before treatment.

21 ORTO The patient did not complained from pain and the other symptoms he had in the beginning of the treatment.The electromyography and kinesiographic records objectively showed the muscular function improvement.

We decided to start the SECOND PHASE of the treatment.

For this we used a three-dimensional orthodontics, where the teeth are erupted towards the new neurophysiological position. This procedure  will allow us, following the technical steps to remove the DIO.

22 ORTO 2  In the  second phase, in this case the three-dimentional orthodontics  the patient is monitored and electronically deprogrammed and many times the device is recalibrate to maintain the position obtained in the first phase.

23 ORTO Sequence of the second phase (in this specific clinical case).

24 ORTO Sequence of the second phase (in this specific clinical case).

25 ORTO Sequence of the second phase (in this specific clinical case).

26 ORTO Sequence of the second phase (in this specific clinical case).

27 ORTO Sequence of the second phase (in this specific clinical case).

28 ORTO2 Sequence of the second phase (in this specific clinical case).

29 ORTO

Second phase completed!

39 panoramica finalPatient’s panoramic radiograph after the finalization of the three-dimensional orthodontics.

30 ress comparativa frontal dir 1 MRI: Comparison of the frontal section of the RIGHT TMJ closed mouth  before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint, especially in the lateral pole.

30 ress comparativa frontal dir 1 flecha

MRI: Comparison of the frontal section of the RIGHT TMJ closed mouth  before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint, especially in the lateral pole. Note the arrows.

31 ress comparativa frontal esq 1 MRI: Comparison of the frontal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.31 ress comparativa frontal esq flecha 1MRI: Comparison of the frontal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint. Note the arrows.32 ressonancia comparativa 1 MRI: Comparison of the sagittal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.33 ressonancia comparativa 2

MRI: Comparison of the sagittal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.

34 ressonancia comparativadir 1 int

MRI: Comparison of the sagittal section of the RIGHT  TMJ closed mouth, before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.

Improvement in the relationship between the mandibular condyle and the articular disk.

35 ressonancia comparativadir 2int MRI: Comparison of the sagittal section of the RIGHT TMJ closed mouth, before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.

Improvement in the relationship between the mandibular condyle and the articular disk.36 eletromiografia final Patient’s electromyography record in neurophysiological occlusion AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.

Note the symmetry of the masseter muscles.

The digastric muscles DO NOT ACTIVATE before the masseter muscles during swallowing. This implies that the patient closes the teeth and swallows and not the contrary as the first record in habitual occlusion before treatment..

This means that the objectives achieved in the FIRST PHASE with the DIO in neurophysiological position were held after the finalization of the THREE DIMENSIONAL ORTHODONTICS.

37 eletromiografia comparativas Patient’s electromyography records comparison:

Before the treatment in habitual occlusion.

With the DIO (intraoral device), in neurophysiological position, during the FIRST PHASE of the treatment.

 AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.38 laterais comparativas

Patient’s lateral radiograph comparison:

Before the treatment in habitual occlusion.

With the DIO (intraoral device), in neurophysiological position, during the FIRST PHASE of the treatment.

 AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.

38 laterais comparativas 1

 Maxillomandibular values comparison: 

Before the treatment in habitual occlusion.

With the DIO (intraoral device), in neurophysiological position, during the FIRST PHASE of the treatment.

 AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.

41 OCLUSAO FINALIn a recent revision after two years of completion of the SECOND PHASE with the three dimensional, I registered the habitual patient’s occlusion.

The patient continues free of symptoms.

In the postural mandible position and its complex three-dimensional relationship with the maxilla little details are essentials, especially in a hypermobile joint patient.

It is not a case of deep bite, not a case where simply moving the incisive guide anteriorly could solve the problem.

In the  images the three-dimensional compression in this patient looks SUBTLE, but no less devastating.

Each case is different and every human being is a unique individual.

patient testimony

 In the first evaluation, Dr. Lidia was very helpful explaining to me all the method of the treatment and what was necessary to achieve the expected results.

 Along the way, I had neither more headaches nor joint pain, I was pain free.

Everyone in the team was very devoted to my treatment, and I had in the end an excellent result.

Today I am very grateful to Dr. Lidia and her team for all the attention.

Big huge to everyone from clinica my.

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

The work that is been presented in this publication won the third place in the clinical table presentation in the congress of the IAO (International Association for Orthodontics) April 2012, entitled – TMJ Pathologies in Children and Teenagers, the Overlooked Diagnosis.

At the same congress I presented a more extensive conference on the mentioned subject.

I presented this paper at a congress that bring together orthodontists and orthopedists from around the world. The intention was to make them aware about TMJ pathologies in children and teenagers even in cases apparently simples that we can see in our clinics, where the TMJ can be compromised.The evaluation of the TMJ and the diagnosis of its pathologies should be an inseparable part of our procedures, not only in orthodontics and orthopedics but in all areas of dentistry.

I had presented in this page several cases with the first and second phases completed.

In this publication I WILL PRESENT ONLY THE FIRS PHASEas it was presented in the clinical table and in the lecture.

Nowadays the patient is already in an advanced stage of the second phase.

THE IMPORTANT SUBJECT  IN THIS PUBLICATION IS THE STRUCTURAL IMPROVEMENTS ACHIEVED IN THIS FIRST PHASE.

1 Female patient, 14 years of age comes to consultation with complaints of pain in the lower teeth, shoulder pain and TMJ clicking on the left side.

Aesthetic correction is an important issue  for the patient, but she and her mother were also  concerned with the  pain in the lower teeth and the noise generated by the click. 

2 dentes The occlusion of the patient suggests a case without major difficulty, a simple case.

In this case could be very easy to evaluate and diagnose the need for superior expansion for the accommodation and advancement of the mandible, and afterwards the vertical deficiency.3 oclusais Often when we analyze a case for orthodontic correction, we can list the possible etiological factors that led the patient to this situation.

When evaluating a functional failure we must take into account ALL THE ETIOLOGIC FACTORS INVOLVED IN THIS DYSFUNCTION.4 panoramica Patient’s initial panoramic radiograph before treatment.5 lateral cervical Patient’s initial lateral and cervical spine radiograph before treatment.

Besides the rectification of the cervical spine we can notice the start of an inversion of the physiological curvature from C4.6 frontalPatient’s initial frontal radiograph before treatment.7 cefalometria Cephalometry is a very important part in the diagnosis and correction of clinical cases, both in orthodontics as in orthopedics, BUT it is not an exam to show pathology of temporomandibular joints.8 laminografiaThe laminography of the temporomandibular joints in closed and open mouth is considered as the panoramic radiograph for the temporomandibular joints.

It cannot be compared to a CT scan of the temporomandibular joints, but it is a basic examination for the first information on TMJ.8 laminografia corIn this same image with color highlight, we can appreciate the retroposition of the left TMJ, the change in the growth axis of this same side and the loss of joint space on both sides.

The patient reports a traumatism when she was child “I hit the neck, near to the chin, playing on the bedside table”.9 ampliação laminografiaLaminography image magnification with highlight color, closed mouth, right and left side.10 ampliação laminografiaThis image magnification from the temporomandibular joints in closed mouth; right and left sides, DOES NOT SHOW THE ARTICULAR DISC CONDITION NOR THE LIGAMENTS.12 ressonancia When the patient comes for consultation with some sort of dysfunction, the professional treatment should be directed to the restoration of normal function, when possible.

To know what normal function is, we must understand that ANATOMY IS THE PLATFORM WHERE PHYSIOLOGY PERFORMS.

13 ressonancia It is necessary to know the functional anatomy of any part of our body to understand the physiopathology of any part of our body.

14 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

MRI: patient’s left TMJ closed mouth before treatment:

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

15 ressonancia

MRI: patient’s left TMJ closed mouth before treatment;

Other slice of the same MRI:

MRI: patient’s left TMJ closed mouth before treatment:

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

16 ressonancia

MRI: patient’s left TMJ closed mouth before treatment:

Other slice of the same MRI:

MRI: patient’s left TMJ closed mouth before treatment:

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

17 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

MRI: patient’s right TMJ closed mouth before treatment.

Superior flattening, anterior marginal osteofhyte.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

20 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

Other slice of the same MRI:

MRI: patient’s right TMJ closed mouth before treatment.

Superior flattening, anterior marginal osteofhyte.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

21

When the patient comes to our clinic with some sort of dysfunction the treatment should be directed to the restoration of normal function.

How could this professional succeed if he  doesn not understand what is a normal function.

Remember ANATOMY IS THE PLATFORM WHERE PHYSIOLOGY PERFORMS.

When a patient like this, presents damage in the cortical bone and also in the articular disc and its ligaments, the question should be: CAN I IMPROVE THIS SITUATION?

If the answer is positive, it is important to document it in an objective way, in order to inform the colleagues that are always eager to learn and are not afraid to change paradigms. IF WE CAN NOT IMPROVE THIS SITUATION because of the sequels of different etiologies, we need to analise if we can improve our patient’s life quality and we also must inform the patient about the difficulties and limitations of each case.

22 Remember that systemic diseases, traumatism, infections, damage to the site of growth, muscle balance disruption, can have a profound influence on the craniofacial complex during this critical growth phase.23 eletromiografia inicial Initial dynamic electromyography record in habitual occlusion. We ask to the patient to open the mouth, clench strong and swallow. In this record we can observe that the patient cannot maintain the strength in clenching, even that she was instructed to close the mouth and not to open before we ask her to do that.24 registro magnetografico Her masticatory muscles where electronically deprogrammed and a bite record  in neurophysiological position was registered using a jaw tracker.

Remember that the information obtained from the images and that the  individualized objectives for each clinical case should always be taken into account in the bite registration.

The patient had a pathological free space of 4.3 mm and a retro position of 2.1 mm

This record is three-dimensional.

25 DIOWith this data we can construct a DIO (intraoral device). This device must be tested electromiographically to represent the ideal position of the muscles.26 eletromiografia DIO Dynamic electromyography record with the intraoral device in neurophysiological position. In this record we can see that the patient can maintain the strength of the bite, and that she increased the strenght of the masseters  and balanced  both digastric.27 ELETROS COMPARATIVAS Comparison of the SEMG records of the patient, the first in habitual occlusion and the second with the intraoral device in neurophysiological position.28 perfil comparativas Standing posture (orthostatic position) right side, sagittal plane:

Trunk antepulsion position improved;

Improvement of the shoulder anterior rotation;

It seems that the shoulder blades are flat, more neutral;

In the first photograph, in habitual occlusion, it can be observed a rectification of  the physiological curvature in the cervical spine. On the second photograph we can see an improvement of the physiological curvature.

The head position is more balanced, closer to the proper alignment of the center of gravity where the neck flexors seem to be less contracted.

30 c7 comparativasPatient’s lateral and cervical spine comparison: in habitual occlusion and in neurophysiological occlusion.

Improvement  of the cervical spine physiological curve.

Increase of the  intervertebral spaces.31 comparativas do perfil Patient’s lateral radiographs with the profile comparison: in habitual occlusion and in neurophysiological occlusion.

Recovery of the lower facial height.32 lamino comparativas TMJ laminographies comparison: in habitual occlusion and in neurophysiological occlusion. Observe the decompression of the  temporomandibular joints.33 lamino comparativas COR In the same image with color highlight, we can better observe the decompression of the temporomandibular joints and compare it with the laminography in habitual occlusion.34 lamino comparativas COR AMPLIADAS Comparative images of TMJ laminographies magnification: in habitual occlusion and neurophysiological occlusion. Right and left TMJ, closed mouth.35 lamino comparativas COR AMPLIADAS PROVISORIASLaminography image magnification with highlight color, closed mouth. Right  and left TMJ in neurophysiological position.

This image, EVEN THAT IT IS SHOWING THE JOINT DECOMPRESSION, DOES NOT PROVE THE ARTICULAR DISC RECAPTURE, NOR PROVES THE IMPROVEMENT OF THE IRREGULARITIES ON THE CORTICAL BONE OBSERVED IN THE INITIAL PATIENT’S MRI.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

14 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

36 RNM AFTER TREATMENT

Comparative MRI images, left TMJ closed mouth, after the first phase of the treatment

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

15 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

39 RNM AFTER TREATMENT 2

Comparative MRI images, left TMJ closed mouth, after the first phase of the treatment.

Comparative MRI images after the first phase of the treatment

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

16 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

40 RNM AFTER TREATMENT

Comparative MRI images, left TMJ closed mouth, after the first phase of the treatment.

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

17 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

42 RNM AFTER TREATMENT

Comparative MRI images, right TMJ closed mouth, after the first phase of the treatment.

Comparative MRI images after the first phase of the treatment.Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

20 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

44 RNM AFTER TREATMENT

Comparative MRI images, right TMJ closed mouth, after the first phase of the treatment.

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

Nowadays the patient is already in an advanced stage of the second phase.

In this image we have a third MRI that was not presented at the IAO Congress.

The structures continue to improve.

46 3 RIGHT TMJ

Right TMJ closed mouth sagittal slices comparison: initial, after the first phase of treatment and in the control of the second phase still not completed.

 In this image we have a third MRI that was not presented at the IAO Congress.

47 LEFT TMJ

Left TMJ closed mouth sagittal slices comparison: initial, after the first phase of treatment and in the control of the second phase still not completed.

The structures continue to improve.

The evaluation of the TMJ and the diagnosis of its pathologies should be an inseparable part of our procedures, not only in orthodontics and orthopedics but in all areas of dentistry.

We need to know:

Has the TMJ  a pathologic condition?

If positive, which structures are damaged?

How this condition can influence the joint  function and  the future of the patien’s joint?

Do I have the possibilty to give to the patient the condition to heal the damaged structures or to improve them?

The target is to bring this structures the closer we can to a healthy function, when possible.

Is this always possible? OF COURSE NOT, but when  it is possible, the structures must be repaired.

Logically, differential diagnosis allow us a prognosis: favorable or not. favorable.

NOT ALL THE ARTHROPATHIES WILL HAVE THE RESULT WE HAD IN THIS CASE, BUT PROGNOSIS IS ALSO A PIECE IN THE INITIAL DIAGNOSIS that must include all the systems involved.

The importance of Mandibular Rest Position by Electronic Deprogramming in the Treatment of Temporomandibular Joint Pathologies, Orthodontic Diagnosis and Oral Rehabilitation. Case report.

1 frontal  Male patient 42 years old arrived to the clinic referring a strong complaint because of  the wear in his upper and  lower arch teeth, frequent breakage of teeth, intense bruxism, shoulder pain and pain in the cervical spine.2 perfil The patient reports an aesthetic problem in his appearance in relation to his frontal  and  profile semblance, and emphasizes that his teeth “are almost over.”3 DENTES In the image of the patient’s habitual occlusion we can observe the intense wear of the upper and lower teeth, especially the anterior sector.

The patient had consulted a colleague to replace an adhesive fixed prosthesis. This colleague,  Dr. Joao Souza  was then attending the TMJ  Pathologies Megarresidency program in our clinic in Porto Alegre.

Dr. Joao Souza while looking at the profile, occlusion and wear condition of the teeth, suggested a consultation in our clinic for an evaluation of both the TMJ and also  the non-surgical possibilities within the neurophysiological philosophy.

The patient had already a scheduled orthognathic surgery, but still considered interesting to make another assessment of his clinic case.4 OCLUSAL Analizing the occlusal view we can better see the high degree of wear and tear of the anterior upper and lower teeth.5 PANORAMICA INICIAL We can observe in the panoramic radiograph the absence of the dental elements 17, 15, 26, 28, 37, 36 and 45.

The elements 38 and 47 are endodontically  treated.6 LAMINOGRAFIA Patient’s TMJ laminography in habitual occlusion: we can observe the inferior and posterior positioning of the articular process on the left side, in the articular fossa, when the jaw is in maximal intercuspal position.

In the maximum opening position we can observe the flattening of the anterior surface of the right articular process. We can also observe the anterior angulation of the articular process, on the left side, with the flattening of its posterior and upper anterior surface.7 PERFIL E ROSTO Lateral radiograph in conjunction with the profile image of the patient before the treatment. This images highlight the aesthetic problem that afflicts the patient.8 FRONTAL INICIAL Patient’s frontal radiograph before treatment.9 C7 INICIAL Patient’s lateral radiograph and cervical spine before treatment.10 ELETROMIOGRAFIA INICIAL ANTES DO DEM Electromyographic record before electronic deprogramming in the first consultation: slightly elevated activity of the left masseter muscle  and both digastrics muscles at rest.

All these masticatory muscles lowered their values after the electronic deprogramming.11 ELETROMIOGRAFIA INICIAL APÓS DEM In this record we can see a decrease in the activity of masticatory muscles at rest after the electronic deprogramming.12 ELETROMIOGRAFIA INICIAIS COMPARATIVASComparative electromyographic records before and after electronic deprogramming of the patient first consultation.7 PERFIL E ROSTOAfter the mandibular electronic deprogramming, it was verified the pathological increase of the interocclusal free space. This information, along all the auxiliary diagnostic tests, allowed us to propose a non-surgical neurophysiological treatment for the patient.

First we needed to locate the jaw in balance with the muscles with a DIO (intraoral device) built in neurophysiological position.

Subsequently we needed to perform a three-dimensional orthodontics to maintain the neurophysiological position in conjunction with a neurophysiological rehabilitation while maintaining the muscle equilibrium  initially obtained. For this it is essential to measure and control the patient in each and all of these phases.

In this patient specific clinic case  the recovery of the free interocclusal space would provide very good aesthetic and functional result!

IT IS NOT IN ALL CASES that surgery can be avoided (EACH CASE IS A CASE) and even similar cases require a personalized assessment and a unique study.

The patient was informed of all treatment stages and analyzing all the alternatives the patient accepted our clinical proposal.

An MRI, (Magnetic Resonance Imaging) to analyze the disk and ligaments  condition of the TMJ, (temporomandibular joint) was requested. The MRI revealed that the discs and ligaments were in good health.

13 a It was used neural transcutaneous electrical stimulation (TENS) in the mandibular division of the trigeminal nerve (V) to relax the masticatory muscles and record the rest position of the jaw.

The patient had a pathological free space of 8 mm and a retrusion of 3.8 mm.

This three-dimensional mandibular rest position had been recorded in the form of an occlusal bite registration, which was later used to construct a DIO (intraoral device).13 Registration for the recalibration of the DIO (intraoral device) during the first phase of the neurophysiological treatment.14 ORTESE RECALIBRADA The DIO (intraoral device) is a removable mandibular device which in this case must be used during the day and night by the patient, including in the meals. This oral appliance is tested electromyographically and magnetographically to support this neurophysiological position.15 PERFIS COMPARATIVOSPatient profile images in habitual occlusion and in neurophysiological occlusion with the DIO (intraoral device) in mouth. 16 FRONTAL COMPARATIVOSPatient frontal images in habitual occlusion and in neurophysiological occlusion with the DIO (intraoral device) in mouth.19 PANORAMICA PREPARO PARA IMPLANTES 1Patient’s panoramic radiograph shows the orthodontic preparation for the installation of dental implants.19b PANORAMICA IMPLANTES 1Patient’s panoramic radiograph after the placement of first dental implants.20 ORTO 1After the placement of the dental implants I began the orthodontic movement for reconstruction of the anterior teeth with composite resin.21 REABILITAÇÃO E ORTO E IMPLANTESAfter the anterior movement of the anterior teeth the braces were temporarily removed to allow the reconstruction of the teeth with composite resin.

This rehabilitation was performed by Dr. Joao Souza following all the neurophysiological protocols.22 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTESAfter the reconstruction with composite resin of the anterior sector, the orthodontic appliance was reinstalled and a new DIO (intraoral device) was constructed in neurophysiological position.

The adhesive prosthesis of the lower right sector was removed and an implant was installed.15b RADIOGRAFIAS LATERAIS COMPARATIVASPatient’s comparative lateral radiographs in habitual occlusion before treatment and in neurophysiological occlusion during treatment.16 bRADIOGRAFIAS FRONTAL COMPARATIVASPatient’s comparative frontal radiographs in habitual occlusion before treatment and in neurophysiological occlusion during treatment.17 LAMINOGRAFIAS CONTROLEThe TMJ laminography in neurophysiological occlusion shows the inferior and anterior positioning of the articular processes in the articular fossa when the jaw is in maximal intercuspal position.18 LAMINOGRAFIAS COMPARATIVASTMJ comparative laminographies: before and during neurophysiological treatment.24 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 2 Sequence of the orthodontic treatment: preparation for the installation of the lower prosthetic implant.25 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 3 Installation of the provisional element in the lower implant and the brace placement on the same element.26 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 4 Sequence of orthodontic treatment for the active eruption of the posterior sectors.27 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 5   Sequence of the orthodontic treatment for alignment and leveling of the lower anterior teeth for reconstruction with composite resin.28 ORTO 6 Sequence of the orthodontic treatment for alignment and leveling of the lower anterior teeth for reconstruction with composite resin.30  Finalization of all the phases of the neurophysiological treatment.30b Upper and lower occlusal view in the finalization of the neurophysiological treatment.31 COMP Comparative images of the patient’s occlusion before and after the neurophysiological treatment.31B Comparative images of the patient’s upper and lower occlusal views before and after the neurophysiological treatment.32 panoramicas comparativasComparative panoramic radiographs: before treatment and after the neurophysiological treatment, that included  the first phase, the three-dimensional orthodontics and the neurophysiological rehabilitation.

In the course of the treatment it was decided to install two posterior implants The lower due to an infectious process in the third molar, on the right, and the other implant, superior, on the same side, to better support the joint.33 laminografias comparativasPatient’s TMJ comparative laminographies: before, during and after neurophysiological treatment.34teles comparativasPatient’s lateral comparative radiographs: before, during and after neurophysiological treatment.35 frontais comparativos 22 Patient’s frontal comparative images: before, during and after neurophysiological treatment.36 perfis comparativos 2Patient’s profile comparative images: before, during and after neurophysiological treatment.37 posterThe importance of Mandibular Rest Position by Electronic Deprogramming in the Treatment of Temporomandibular Joint Pathologies, Orthodontic Diagnosis and Oral Rehabilitation. Case report.38 depoimento

I had already decided to have surgery for facial correction due to various problems such as wear of the teeth, bruxism, tingling, physical imbalance, pain and bad appearance.

In a consultation for a small dental procedure with Dr. Joao Souza, I was advised by him to get in contact with Dr. Lidia Yavich for a consultation in order to see if there was any chance, in my case, to avoid surgery and solve the problems I was having.

In the first consultation that I had with Dr. Lidia Yavich I was introduced to a facial and dental correction technique that gave me more security than surgery.

Dr. Lidia stated that THERE WERE CASES WHERE SURGERY WAS ABSOLUTELY NECESSARY, but that in my case there could be another alternative.

So, I started the treatment, and THAT really changed my daily life completely. Today I am very happy with the result achieved and the quality of life provided due to the disappearance of the above-reported symptoms.

I would like to place on record that in addition to the professionalism of the entire team of Clinica MY, especially Dr. Lidia, I had the privilege to make great friendships with special people, that will always be a part of my life. I also want to leave a special thanks to Dr.  Joao Souza, that with his recommendation made all this possible because he always strives for quality and the well-being of his patients.

Mandible Condyle Fracture Consolidation by Neurophysiological Alignment of the Segments, Four Months after Unsuccessful Surgery. Case report

Fractures of the mandibular condyle are one of the most commonly occurring mandibular fractures. Management of these fractures has always been a controversial issue. One of the complications of mandibular condyle fracture is nonunion.

This case report documents a 57-year-old male patient with a complication nonunion of the left mandibular condyle 4 months after surgery and the resolution of this case with a neurophysiological alignment of the segments, without a new surgery or internal fixation.

1 AA 57 year-old male patient was referred to the clinic by his dentist. His principal complaints were lack of strength when chewing, difficulty in opening the mouth, cervical pain, pain in the TMJs and ringing in the left ear.

Past history revealed that the patient fell in the bathroom 4 months before the consultation, hitting his jaw and fracturing his mandible. He was subsequently surgically treated for fracture of the symphysis and the left mandibular condyle.

Extra oral examination did not reveal any obvious swelling. 1 BAfter performing all the clinical evaluations a panoramic radiograph was solicited where the nonunion of the left condyle was noticed.

Dental abnormalities included missing 14, 36 and 46 and a posterior open bite on the left side.

Panoramic radiograph of the patient on the day of consultation showing a nonunion of the left condyle.

Asymmetric mandibular condyles. Radiopaque image compatible with osteosynthesis wire in the lower region of condylar apophysis on the left side with bone fragment displacement.

In the region of the chin on the right, horizontal radiopaque images compatible with osteosynthesis devices for contention of the fracture of the anterior mentonian symphysis.

2 condilo inicial Magnification of the left mandibular condyle on the panoramic radiograph.

3 LAMINOGRAFIA INICIAL

TMJ laminography of the patient on the day of consultation showing the nonunion fracture of the left mandibular condyle 4 months after surgery.

A  CT was solicited to get a more accurate diagnosis.

4 CORTES DE TOMOGRAFIA INICIAISCT sagital slices confirming the total nonunion of the mandibular condyle fracture four months after surgery.        

4AA CORTES DE TOMOGRAFIA INICIAIS   CT frontal slices confirming the total nonunion of the mandibular condyle fracture four months after surgery.               5 3D da fratura  3D reconstruction showing the total  nonunion of the mandibular condyle fracture four months after surgery .        6 3D transparencia da fraturaAnother 3D reconstruction showing the total  nonunion of the mandibular condyle fracture four months after surgery .        7 A ELETROMIOGRAFI inicial  Surface electromyographic record before electronic deprogramming on the first consultation: elevated activity of the right masseter, right trapezius and right digastric at rest. All this masticatory muscles lowered after electronic deprogramming.7 B ELETROMIOGRAFIA após demaDecreased masticatory muscle activity at rest after  electronic deprogramming.7 Cc ELETROMIOGRAFIA comparativas ante e apos desprogramação Comparative rest electromyography records before and after electronic deprogramming.

Based on the case history it´s clinical and radiographic features, this case was diagnosed as nonunion fracture of the left mandibular condyle . Nonunion is a complication in mandibular fractures. The causative factors include delay in treatment, infection, inadequate immobilization, and improper internal fixation; concomitant infection may be present.

Other suspected contributory factors include failure to provide antibiotics, delay in treatment, teeth in the fracture line, alcohol and drug abuse, inexperience of the surgeon, and lack of patient compliance.

Generally treatment of nonunion consists of standard techniques of debridement, antibiotic therapy and further immobilization.1 A

We referred the patient back to the surgeon where a new surgery was proposed.

THE PATIENT ABSOLUTELY REFUSED TO HAVE A NEW SURGERY

Considering the categorical decision of not performing a new surgery the patient returned to the clinic and a conservative approach to treatment was proposed. The patient was informed about possible limitations due to his age.

Analyzing the alternatives  he accepted the clinic’s proposal.

8 REGISTRO INICIALUltra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles to record the rest position of the mandible.

That tridimentional mandible rest position was recorded in the form of a bite occlusal registration, which was later used to fabricate a Intraoral device. This is a removable mandibular appliance that in this case must be worn during day and night by the patient. This intraoral appliance, tested electromiographically and magne­tographically, support this neurophysiological position.

9 0clusão com o DIO

The patient was asked to wear the intraoral appliance full time. The dynamic evaluations improved and the patient felt no more pain, and no difficulty to chew.

During the treatment  new intraoral device in neurophysiological position was constructed.10  0clusão com o 2 DIOA second panoramic radiograph was solicited after three months. The new panoramic radiograph showed the improvement of the condyle position and finally, four months after this control a third panoramic radiograph was solicited where we can see the union of the fracture. 11 comparação de panorâmicas Comparative image of the left mandibular condyle of the first panoramic radiograph of the patient on the day of consultation (4A), second panoramic radiograph three months after (4B) and third panoramic radiograph (4C) four months after the second control showing the improvement of condyle position and the union bone.

LOOK THE UPRIGHTING OF THE WIRE FROM THE SURGERY.

11Aa comparação de panorâmicas E OCLUSÃO Comparative image of the left mandibular condyle of the first panoramic radiograph of the patient on the day of consultation (4A), second panoramic radiograph three months after (4B) and third panoramic radiograph (4C) four months after the second control showing the improvement of condyle position and the union bone.

The frontal images of the habitual occlusion on the consultation day, four and seven months after initiating the treatment are also posted.

11AB comparação de panorâmicas com inversãoLOOK THE UPRIGHTING OF THE WIRE FROM THE SURGERY.

COLOR INVERSION of the comparative image of the left mandibular condyle of the first panoramic radiograph of the patient on the day of consultation (4A), second panoramic radiograph three months after (4B) and third panoramic radiograph (4C) four months after the second control showing the improvement of condyle position and the union bone.12 CORTES DE TOMOGRAFIA FINAIS A new CT was solicited and clearly showed the union of the fracture, without submitting the patient to a new surgery and   without using any maxillomandibular fixation (MMF)  15 3D comparativas3D reconstruction showing the nonunion of the left mandibular condyle after four months surgery and the later union of the mandibular condyle after neurophysiological treatment.

Fractures where the muscles tend to draw fragments together are more favorable than those fractures where the muscles tend to draw fragments apart.

The displacement of fracture fragments is observed in mandibular condyle fractures. The most commonly observed type is the displacement of the condyle head to the anteromedial side because of lateral pterygoid muscle action.

The ability to place the mandible in a spatial relationship by measuring the masticatory muscles at their rest length can be an important auxiliary tool to assist in the recuperation of condylar fractures.

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