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.

cartaz1 modificado cartazII modificado

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

Female patient, 40 years old comes to consultation referred by her rheumatologist WITH STRONG PAIN IN the TMJ (temporomandibular joint), TWINGES IN THE HEAD AND MOUTH OPENING LIMITATION.

The patient had a diagnosis of seronegative spondyloarthropathy until then nonspecific.Later diagnosed as Ankylosing Spondylitis

Seronegative spondyloarthropathies refers to a group of diseases that share common characteristics, including the occurrence of inflammation in the spine, peripheral joints and in various peri-articular tissues, in particular entheses.

Seronegative spondyloarthropathies laboratory outstanding feature is the absence of rheumatoid factor and auto antibodies. They have strong association with human leukocyte antigen HLA-B27.

1  The patient reports clicking on the right TMJ, difficulty to open the mouth, difficulty and paint in chewing. She also reports bruxism.2She reports feeling headache, neck pain, pain in the right eyebrow, pain behind the eyes, pain in the right shoulder. She also reports pain in both temporomandibular joints which is stronger  in the right joint.

Points where the patient reports pain

The patient marks on the record the most important points of pain.3  In the first consultation, during the anamnesis the patient reported that she had initiated a treatment for the bruxism problem, and that at one point with the device change she  began to feel a very strong pain and her mouth locked.

4The occlusal view shows the superior anterior sector wear and the anterior lower sector wear.5Patient’s panoramic radiograph.6The joints radiographic image shows the superior and posterior positioning of the articular process on the left side in the joint cavity when the jaw is in maximal intercuspal position.

In the maximum opening position, there is flattening of the posterior and anterior surface of the left mandibular condyle process and a flattening of the superior and anterior surface of the right mandibular condyle process. The right side also presents an alteration of the growth axis of the mandibular condyle.

6BPatient’s lateral and profile radiograph before treatment.7Patient’s lateral radiograph and cervical spine before treatment.7BPatient’s frontal radiograph in habitual occlusion before treatment.8 abre e fecha inicOpening and closing computerized kinesiographic record, the patient can open only 32 mm feeling strong pain, which shows an important limitation.

The patient also has a deflection of 2.7 mm to the right.8 B COMP abre e fecha inic Note in the skull graph, the left condyle moves more than the right condyle where the deviation is.

9The surface electromyography exam evaluates the superior anterior temporal right and left, the right and left masseter, the right and left digastrics and the right and left upper trapezius.

In this electromyography record the patient could not generate a good activity when we asked to bite hard (keeping the teeth in maximum intercuspation) and clench.

At the beginning of the record when we asked the patient to open the mouth it is important to note the different activity between right and left digastrics.

The left digastric activates double than the right digastric.

9

Image enlargement showing the difference in translation of the mandibular condyles. Patient in maximum mouth opening.

It is important to be able to understand and connect all the information, the surface electromyography and the computerized kinesiograph. These data still does NOT PROVIDE A DIAGNOSIS, However they are tools to help us in the diagnosis.

I asked the patient for an MRI-(magnetic resonance imaging) of the temporomandibular joints.

When the patient filled out the clinical record for the MRI she reported that she did a tattoo a month before, that prevented the realization of the MRI until completing the time of three months after the realization of the tattoo.

Remember that the resonator is a large magnet and tattoos have pigments which may contain metal and could heat up and cause burns.

We kept the patient with a temporary splint until we had the MRI information, as explained in previous posts; WE MUST NOT TREAT A PATIENT WITHOUT  A DEFINED DIAGNOSIS.

We could easily assume that as the patient had a systemic nonspecific inflammatory arthritis attacking various joints of her body also the TMJ could be involved.

It is fundamental to rethink something which SOMETIMES could be ONLY A CONJECTURE, even if the patient is a carrier of an inflammatory autoimmune disease.

In the systemic part it is the rheumatologist who will decide the therapy.

Our part is to promote a non-compressive position of the TMJ where the masticatory muscles may perform without loading the joint, and where the patient can fulfill all the functions of the stomatognathic system.

9APatient’s inflamed elbow after synovectomy with the disease still not controlled

9A  MRI: sagittal sections selected. Left TMJ closed mouth: articular disc anteriorly displaced. Change in the growth axis of the mandibular condyle.

Left TMJ open mouth: limitation in mouth opening.

The images here are in T1, all images analyzed including T2 and STIR DOES NOT SHOW inflammatory signs.

It is relevant to remember that in the first consultation, during the anamnesis the patient reported that she had initiated a treatment for the bruxism problem, and that at one point with the device change she began to feel a very strong pain and the mouth locked.

The patient remembers that the device change aimed to align the median line of the upper incisors to the median line of the lower incisors.

This has to be a warning to all of us in dentistry which were taught to carry out all our treatments without knowing the condition of the TMJ.  

9B  MRI: sagittal sections selected. Right TMJ closed mouth: articular disc anteriorly displaced. Change in the growth axis of the mandibular condyle.

Right TMJ open mouth: limitation in mouth opening.

After conducting the analysis of the MRI images, studying all the slices and all required parameters (not included in the post), we can proceed to carry out a neurophysiologic record.
10The masticatory muscles of the patient were electronically deprogrammed and the rest position was recorded with a computerized kinesiograph.

This record has been difficult to achieve. The patient was limited and in great pain. A very low DIO was made, leaving an interocclusal free space of one mm which would normally be too little.

11DIO (intraoral device constructed in neurophysiologic position)11A  Patient’s frontal image on the same day, before and after installing the intraoral device in neurophysiologic position.

11B  Patient’s lateral image on the same Day, before and after installing the intraoral device in neurophysiologic position.

11cPatient’s electromyography record in neurophysiologic occlusion wearing the device (DIO), even the muscles activation is low the difference with the initial record is remarkable.11DComparative EMG records: the upper in habitual occlusion and lower in neurophysiological occlusion with the DIO (intraoral device).12 abre e fecha com DIO  Patient’s kinesiographic record with the DIO (intraoral device) constructed in neurophysiological position.Improvement in mouth opening. 13 recalibração  DIO recalibration to improve the patient’s neurophysiological position. The condition of the patient now allows best records because the significant decrease in pain.14Control of the intraoral device, habitual and neuromuscular trajectory are coincident.15 REGISTROS DE AB COMPARATIVOSPatient’s comparative kinesiographic records before and during treatment. Improvement of the patient mandibular opening.16 abre e fecha inicNote on the skull graphic, both condyles right and left move symmetrically.16 A abre e fecha inicImage enlargement showing both condyles right and left moving symmetrically. Patient in maximum mouth opening.17 comparativosPatient’s kinesiographic records comparison with the skull 3D model before and after treatment.

17B comparativosSkull models in 3 D, graphic animation from patient’s kinesiographic record before and after treatment comparison. Patient in maximum mouth opening.

17A 2008MRI: Right TMJ, closed and open mouth before and after treatment. Articular disc in habitual position,(the disc was dislocated before treatment) Resolution of the opening limitation.

17B 2008MRI: Leftt TMJ, closed and open mouth before and after treatment. Articular disc in habitual position. Resolution of the opening limitation.

18 comparativasMRI: TMJ sagittal comparative images, open and closed mouth before and after treatment.

19 bThe patient without pain, decided to continue with the DIO and not perform the phase 2 to eliminate de DIO, with a tridimensional orthodontics. She decided only to restore the teeth that were worn. Restorations made by Dr. Luis Daniel Yavich Mattos.

20

When I was 39 years old I was diagnosed by my rheumatologist with arthritis.

All major joints of my left side were suddenly and without warning, very swollen, such as knee and elbow, preventing me from performing my simplier movements such as standing and stretching my arm.

I had swelling, redness and intense pain. Then I started to feel pain in the TMJ. I ended up in the clinic of an orthodontist and facial orthopedist  who told me that I had ‘bruxism’ and that I needed to use a device to place the tongue in the right position.

I wore the appliance for a month or two, my TMJ locked, I could not open my mouth and I felt an absurd pain in my entire head, I no longer knew what hurted more, if it were the joints of the body or my head and mouth.

My rheumatologist, apprehensive that I could have arthritis also in the TMJ immediately referred me to Dr. Lidia Yavich, who received me in the office and managed to relieve my pain completely .

I HAVE TO STRESS THAT, THERE WAS NO MEDICATION THAT COULD CEASE THE PAIN that I felt in the TMJ and in the cervical spine, NOTHING!

After the imaging studies performed by indication of Dr. Lidia, we came to the conclusion that I was not suffering from arthritis in both TMJ, but from a dislocation  of my right condyle  after using for a short time a mistaken device to place my bite and tongue in the ” RIGHT POSITION”

That treatment did not considered important assumptions as the asymmetry of my condyles, or their position, or the disc status in relation to the condyles, causing much suffering.

It took me a long time to understand what was happening to me in my TMJ; I suffered from absurd pain in the head in the middle of a very difficult treatment for arthritis. I was disfigured, terrified and unsure after using the first device with the previous professional because he did not know how to end the pain and even seemed, not to know what was actually happening with me.

I had panic to imagine that I had arthritis in my TMJ, but only after the MRI and the Dr. Lidia interpretation it was possible to exclude the possibility of rheumatic disease in the TMJ in that moment, and from then on to make an efficient treatment.

In a few weeks Dr. Lidia not only took out ALL THE PAIN of the TMJ, but also led me to a treatment that repositioned my disc and  stopped the pain, even being a carrier of a severe autoimmune disease.

I have been using the DIO for seven years without any pain, I have full understanding of the meaning of bruxism in my case and correct approach to the problem, including the options that I could have for a more permanent solution instead the use of the DIO.

I am very grateful to my rheumatologist  today for indicating me a treatment that saved me, because I certainly would have gone crazy with those TMJ pains.

I am very grateful to Dr. Lidia who took me from the rock bottom in which I found myself, ignorant from all  that was happening in a joint so unknown from most of us:.the TMJ.

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

1

Female patient 31 years old comes to consultation reporting severe headache, severe pain in the temporal, especially on the left side, pain on the left ear and pressure on the left eye.

She also states strong neck pain, dizziness, and reports that she feels a burning sensation on the cheek and also pain.

2

She also reports allergic rhinitis and sinusitis, for which she had already made several treatments. But the rhinitis or the sinusitis where never acompannied by the pain she was reporting. This was something new.

She reports having bruxism.

3 OCLUSAO INICIAL

The patient states that she used removable and also fixed orthodontics appliances from her 15 years old until her 18 years old.

She refers to a traumatism in the anterior sector in which the incisor fractured the incisal edge when she was a child.(see publication Structural Modifications of the Mandibular Condylar Process as one of the sequels of traumatism in infancy)4 OCLUSAIS

We can see the wear on the upper and lower incisors.

Regarding the beginning of the pain, the patient reported that she frequently felt fatigue in her facial muscles; she was a teacher and talked a lot during the classes.

But then she felt just fatigue, she never had the pain she was feeling now.

The episode that the patient reported as triggering the pain was when she broke a tooth when she was chewing.4 retrato

Patient testimony

When I broke my tooth while chewing, I went to an emergency clinic where they made a curative and headed me for a root canal.

When the root canal was finished, I left the dental office with A LOT OF PAIN.

But it was not toothache; it was a lot of pain in the face, especially in the masseter muscle.

 Days after  I started to feel an hallucinating pain in the neck, pain in the left ear and headache;

At the time I was derived to a professional who did occlusal adjustments and installed a splint.

I threw away the splint, since I complained that the device did not ease the pain but increased the pain I was feeling.

From that moment I started to consult a lot of professionals.

When she ended the latter sentence, the patient looked into my eyes and while crying she asked: Dr, do you believe in the things I´m telling you?

I said YES, and I answered, I BELIEVE IN YOUR REPORT.

The patient increased her crying and told me that many of the professionals she visited said that she had nothing and the pain was a thing of her head. Just stress!

4A PANORAMICA INICIAL

The panoramic radiograph of the patient shows the root canals endodontically treated (maxillary first molar on the left, 26). This is the tooth that the patient reported having fractured and treated)

We can see that the third molar on the left (48) is angled and impacted on the distal of the second lower molar on the right.

4B LAMINOGRAFIA INICIAL

In the temporomandibular joint laminography of the patient, we can see an anterior angulation of the articular processes. We can also observe a flattening of the upper and posterior surface of both articular processes; it is more significant on the right side.

4C RADIOGRAFIA LATERAL INICIAL

Patient’s lateral radiograph before treatment4D LARGO DE PERNASAt a certain moment a scanning of the lower limbs was asked to the patient, as a difference in length of the lower limbs was suspected. It revealed to be just a muscle shortening, since structurally her lower limbs presented the same measure.5 abre e fecha 1

Computerized kinesiology analyzes the graphic movements that the jaw performs in the three directions of space. The patient has an opening of 30 mm which is already considered a limitation.

The patient does not have good speed in opening and  closing the mouth. This can be an indicator of muscle disorders, intra-articular injuries or discrepancies between the teeth and the muscles.

6 BASAL ANTES E APOS O DEM

In this basal electromyography the masticatory muscles are in hyperactivity, after electronic deprogramming the muscles down their values.

An electromyography with a lower value, after the electronic relaxation, for a particular muscle, is more important than the absolute value before being pulsed.

7 MORDE FORTE ABRE ENGOLE

In this dynamic electromyography, the patient clench hard twice, opens her mouth, closes her mouth and swallows. Masseter muscles, which are the most potent muscles of the stomatognathic system generate very little activity in maximum occlusion.

The anterior temporalis are recruiting more motor units than the masseters, which is not physiological in a system that works in a balanced manner.

8 HABITUAL E ROLOS

In this dynamic electromyography (A) the patient bites into habitual maximum intercuspation, (B) the patient bites with cotton rolls on the right and the  left between her occlusal surfaces, the activity improves considerably.

Every modification of the joint position leads to muscle length change, and consequently it change its strength.The muscles that are shortened or lengthened by approximately 20% exhibit the so-called mechanical failure and a decreased intrinsic potency (Macintosh, Valencia et al., 1986).9 ressonancias iniciais

MRI of the patient: we can see an anterior angulation of the articular processes, flattening of the upper and posterior surface of both articular processes, information that we already have in the laminography.

The joint articular discs are very thinned which structurally implies an articular disc that can not always fulfill the function for which an articular disk is designed. It is imperative to promote joint decompression.

Remember the electromyography improvement that we had with the placement of cotton rolls between the occlusal surfaces.

11A TOMA DE MORDIDA

The masticatory muscles of the patient were deprogrammed electronically and the rest position was registered with a computerized jaw tracker.

This record was very difficult to achieve.  It was very difficult to deprogram the patient.  Even so a very thin DIO (intraoral device) was constructed in neurophysiological position  to promote the jaw reposition that was in a slight posterior position.

We left an inter-occlusal free space of 1 mm which  normally is very little (remember that the jaw tracker enables this type of measurement)

In the screen we may read a comment  that says (this is the record that I managed to take). I wanted to register this in the original record, as many times we don´t get a good record in the first time and this was the case. Logically records will modify as the system improves.11B RECALIn this other record where we are recalibrating the patient’s device , we can see the coincidence of the habitual trajectory with the neuromuscular trajectory. The patient is now deprogramming better so we could build  a better intra-oral device.

12 ABRE FECHA ORTESE

In this kinesiographic record with the DIO (intraoral device) in neurophysiological position, we can see the improvement of the trajectory in mandibular opening, closing and speed. Remember that the patient did not have a good speed in mandibular opening and closing, and she had a more vertical opening trajectory.

13 ABRE FECHA comparativas

Kinesiographic comparative records of opening, closing and speed: in habitual position before treatment and with the DIO (intraoral device).

13A TOMA DE MORDIDA E RECAL

Comparative rest position records: before treatment and recalibrating the DIO (intraoral device). In the recalibration record we can observe the coincidence of the habitual trajectory with the neuromuscular trajectory.

14 PANORAMICA ANTES DA ORTO

The first phase was carried out ( treatment of the TMJ)  with the controls and recalibrations required to enhance the mandibular position, in this case together with physical therapy to balance the postural chains.

At the request of the panoramic radiograph before moving on to the second phase of this case (three-dimensional orthodontics) it can be observed the third right lower molar eruption. This molar was impacted in the distal of the second right  lower molar. (31-year-old patient).

At this step it was only released the acrylic of the DIO in the region of the third impacted molar, returning the vertical dimension of the patient and allowing the eruption of the third molar.

15 PANORAMICAS COMPARATIVAS

Comparison of pre-treatment panoramic radiograph and after the first phase with the DIO (intraoral device) installed in neurophysiological position.

At this point a three-dimensional orthodontics is initiated to remove the DIO.

This orthodontic treatment as was explained in previous publications (see the publication Tridimensional Orthodontics in the Second Phase  of TMJ pathologies) must maintain the mandibular location  in balance with the muscular planes, with the temporomandibular joints and the dental plans, obtained in the first phase.

For this we have tools such as surface electromyography and electronic jaw deprogramming, that helps us to control how the system is functioning.

Few sequences will be shown until the full withdrawal of the DIO (intraoral device)

16 orto 0 1

Active eruption of lateral segments, already in a more advanced stage. The teeth are filling the space formerly occupied by the DIO.18 PANORAMICA CONTROLE  ORTO

Patient´s panoramic x-ray: control of the active eruption. It corresponds to the sequence shown in the previous image.

19 orto 0 1B

Three-dimensional orthodontics treatment continuation: Image with and without the device, the lateral sectors have already erupted.20 orto 2Three-dimensional orthodontics treatment continuation.21 oclusao final

The alignment of the upper and lower incisors sector was achieved just as the restoration with resin of the fractured part of the incisor.

Conclusion of the three-dimensional orthodontics after TMJ treatment.22 OCLUSAIS FINALConclusion of the three-dimensional orthodontics after TMJ treatment.22A eletromiografia final 22APatient’s dynamic electromyographic record after treatment.22B eletromiografia COMPARATIVAPatient’s SEMG records: before and after treatment. We can analyze the balance and functioning of the masseter, which did not happen in the initial registration.23 ABRE FECHA APOS O TRATAMENTO 2Kineciographic record: opening, closing and speed after treatment conclusion.23 B abertura e fechamento comparativasKinesiographic comparative records of opening, closing and speed: in habitual position before treatment, with the DIO (intraoral device) and after treatment conclusion.24 LAMINOGRAFIAfinal LPatient’s laminography in neurophysiological occlusion after treatment conclusion.25 LAMINOGRAFIAS COMPARATIVAS

Patient’s comparative laminographies: in habitual occlusion before treatment and neurophysiological occlusion after treatment conclusion.

It should be understood that the chosen mandibular position is the one where the joints are decompressed and muscles are able to recruit more motor units, for that we use electronic mandibular deprogramming. Registration also depends on the information obtained in the images.25B res. comparativasMRI (magnetic resonance imaging) comparative images of the patient: in habitual occlusion before treatment and in neurophysiological occlusion in the conclusion of treatment.

It should be understood that the chosen mandibular position is the one where the joints are decompressed and muscles are able to recruit more motor units, for that we use electronic mandibular deprogramming.

Registration ALSO DEPENDS on the information obtained in the images. MRI also provides information that should be taken into account when we decide the mandibular position, enhancing the data provided by the computerized jaw tracker: which and the type of disc, disk positioning, whether or not recapture among other data.

26 panoramica final LPatient’s panoramic radiography after conclusion of the second phase, in this case the three-dimensional orthodontics.26B panoramica COMPARATIVAS

Patient’s comparative panoramic radiographs: 1 before treatment, 2 during the first phase, 3 during the three-dimensional orthodontics, 4 after conclusion of the three-dimensional orthodontics.

27 fase frontalPatient’s comparative frontal image before and after treatment.28 fase perfilPatient’s comparative profile image before and after treatment.29Patient testimony

Dear Doctor,

I clearly remember when everything began.

First I used to feel a huge fatigue in the muscles of the face and mouth. I was very stressed then, I was teaching and I used to speak a lot.

Then I broke a tooth. And (ouch!) what to do? I looked for an emergency doctor and he made me a curative. He advised me to go to a dentist and I had to make a root canal there. I left the clinic in pain.(an incredible, allucinating headache,and ear pain)

I began to loos weight… I felt a malaise, a lack ou courage. My face muscle, the masseter seemed to be making weightlifting. Felt as strong and stout, but it hurt so much! It looked as if I had 200 Kg on my face and my neck seemed not to be part of my body. What an unbearable pain! I felt a general rejection, a lack of will of living.) My whole body started to ache. Even fibromyalgia some would say I had, others said I had one leg which was smaller that the other other would say… To sum up, I was a time bomb of all the problems professionals said I had… (I felt like that…)

From there I visited a lot of professionals.

Michigan splint, intensive physiotherapy, chiropractic terapy , shiatsu, do-in… So desperate I was! I even searched for an afro-brazilian religious priest (mãe de santo)….. But nothing relief me from my pain.

I was then that I went to see a very SPECIAL person in my CRAZY life! Dr. Lidia!!

It got better… but NOOOO the strife started to increase!!! Exams, resonances, what an affliction!

From that day five years had passed until my life got back in track… Back to normal with or without pain. But actually it came back on track WITHOUT ANY PAIN!!!

But for that a lot of water had flowed under the bridge!

The result was that after many appointments at the clinic, I remember the attendance on a Sunday of World Cup when Brazil was Champion and that compassionate soul (hahaha) helped me.

So much pain! So much despair! Even so that doctor had so much will and patience to cure me!

It was a hard path. But… We made it and we found that one of my wisdom teeth were totally ignorant (they had no wisdom at all) and it decided to sprout after my thirties.

I used to say that my teeth were like two soccer fan crowds that did not fit, as Palmeiras e Corintians (something like Chelsea and Manchester). They were in ethernal fight!

But after the storm…. My problems started to be solved.

Today I have a big smile thanks to Dr. t Lidia, hahaha. I pray everyday to her.

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

I had been showing clinical cases in the page lidiayavich.com  and in several groups. Some of them with rehabilitation and with tridimensional orthodontics, always after treating the TMJ.

In this post I’m not going to show all the sequence of the patient. I have  the intention to show the improvement of the signal of the MEDULLAR OF THE CONDYLE that had presented osteonecrosis.

Anamnesis and clinical inspection are a fundamental part in the  diagnosis of the patient that presents TMJ pathology.

Images are primordial when we study any sinovial joint, unfortunately I see patients with valuable information in their images that were told that those are just occasional findings.

MRI (magnetic resonance imaging) can give a lot of information and not only the disk position information. Logically is necessary to know what to do with that information.

Osteonecrosis of the mandibular head corresponds to a death of the osseous tissue, also called avascular necrosis.

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

01

MRI: T 1 closed sagittal rightTMJ before treatment.

Avascular necrosis in the acute phase can be diagnosed only through MRI imaging or biopsy.

The differential diagnosis of altered signal intensity in the mandibular condyle starts with an awareness of its normal signal characteristics.

This condyle has also a severe irregularity on the superior pole, with loss of substance, but in this post I want to analyze the bone marrow signal. Of course, in a diagnosis we need to consider all the information.

-1

MRI: T1 closed sagittal rightTMJ before treatment.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced, which may be caused by several conditions, like joint or bone injury, pressure inside the bone, medical conditions, among others.

A condyle affected by avascular necrosis displays low signal intensity on T1 weighted images as a result of edematous changes in the cancellous bone.

2

MRI: T2 closed sagital rightTMJ before treatment.

The differential diagnosis of effusions in the TMJ has a broad-spectrum as of joint effusions in other skeletal regions.

A MRI (magnetic resonance imaging) can give a lot of information and not only the disk position. In this case THE PATIENT HAS NO DISK.

2AA

The same sagittal slice of the condyle in T1 and T2. Image A shows osteonecrosis of the head of the mandible and image C shows the articular effusion.

The patient complained from severe pain in the TMJ, headache, and pain on the back of the neck.

The patient had a major trauma history in the jaw in adolescence. She had rheumatic fever in childhood.

 We referred her to a rheumatologist, and in that moment she did not present positive results for inflammatory systemic disease.

Her muscles were electronically deprogrammed and a DIO (Intraoral Device) was constructed in a neurophysiological position. In other publications we mentioned the computarized kinesiographic used methods.

2A

Comparing T1  images: A (before the treatment) and B (after the treatment): we can see the improvement and recovery of the the medullar signal. Improvement of the superior cortical of the mandibular head. 

The differential diagnosis and the systemic condition of the patient must be taken in account for the prognosis of the case.

2B Comparing T2  images: C (before the treatment) and D (after the treatment).It is clear in the first one (C) the inflammatory signal and in the other (D) the remission of the effusion.

Sem Título-1

Comparing T1 images (A and B) we can see the improvement and recovery of the  medullar signal and the superior cortical of the mandibular head. In T2 weightened images (C and D) it  is clear (in C) the inflammatory signal and in the other (in D) the remission of the effusion.

Sem Título-6

One year after the second image, a new control was solicited, and the results were even better.

In this case  I decided  NOT TO GO forward to a second phase.  Diagnosis is essential for each case.  Dentistry need to understand like Medicine do, that we have limitations and if a patient needs to live with an orthotic  it is not the end of the world.

We have patients that are going to live with insulin all their life, or with other medicines that are saving their lives or just improving their life quality.
Therefore, diagnosis is essential and for that all the tools that can help to get there are welcome.

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

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

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

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

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

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

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

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

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

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

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

Refers bruxism and clenching

He  also finds difficulty to swallowing

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

Patient testimony:

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

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

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

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

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

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

   2- Fracture location

  3-  Pathological growth axis

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

5B LAMINOGRAFIA  The website of the Clinica MY  www.clinicamy.com.br  has the link for the article. Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2, July/December de 2014.

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

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

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

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

Patient’s testimony:

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

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

Evidently the whiplash suspicion was confirmed

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

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

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

These structural alterations provoke morfofunctional alterations.

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

13

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

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

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

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

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

14 RNM

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

1- Left TMJ closed mouth, sagital slice before treatment

Anterior displacement of the articular disc.

2- The Same image with color enhancement

3-  Left TMJ open mouth, sagital slice before treatment

4- The Same image with color enhancement

15B RNM

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

Right TMJ closed mouth, sagital slice before treatment

Articular disc in habitual position.

Right TMJ open mouth, sagital slice before treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

25 RNM COMP 2

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

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

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

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

26 RNM COMP 3

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

27 RNM COMP 4

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

28 RNM COMP 5

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

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

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

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

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

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

A big hug,

33

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.

1

Female patient 22 years old comes to the clinic with a strong headache principally on the top, pain on both temporalis, pain on the back of the head and on the shoulders.

Difficulty in chewing hard food, crepitations on both temporomandibular joints.

She reports bruxism since childhood.

Patient´s testimony

Since I was very little my parents reported that I had bruxism at night

1B

Patient with joint hipermobility. Patients with ligament hipermobilty present more risk to develop articular pathology.

2 DENTES Initial occlusion of the patient before treatment.3 OCLUSALSuperior and inferior occlusal view of the patient before treatment.

Wear in the upper and lower anterior sector
3b dinamico habitual

Surface electromyography, dynamic record in habitual occlusion. We ask to the patient to open the mouth, to close the mouth, to bite strong and to swallow. In this patient’s electromyography record we observe little activity in the masseters and anterior temporalis. We can also observe asymmetry between the right and left temporalis. It is obvious that the masseters have a loss of activity in the middle of the maximal occlusion.

4 PANORAMICA Patient’s initial panoramic radiograph before treatment.5LAMINOGRAFIA INICIAL

TMJ laminography of the patient before treatment in habitual occlusion and opening. Asymmetry of the mandibular heads. Superior and posterior position of the articular process of the right side in the joint cavity, provoking a retrodiscal compression.

We observe asymmetry between the left and right mandibular heads.

Alteration of the axis of the right mandibular condyle.

Patient´s testimony:

When I was 5 years old, while I was playing in the  pre school class interval  I had a traumatism.

A seesaw hit my chin when I was playing with another girl. They put ice on my chin to reduce the swelling. There was no much pain or apparent fracture.

I did not perform medical tests.

I remember another traumatism I had when I was 13 years old, I slipped on the sidewalk and felt hitting my chin on the ground, I FRACTURED THE UPPER INCISORS,  (they have resin)

Sometimes I wake up and I feel that I´m biting and moving my mandible.

If I don´t use the bruxism splint to sleep I brake the resin of my teeth.

The splint protects the resin, BUT DOESN´T ALLIVIATE THE PAIN.

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

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

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2, July/December de 2014.

6 RNM INICIAL MRI: left TMJ closed mouth  lateral slice. 7 RNM INICIAL MRI: left TMJ closed mouth  slice. MILD IRREGULARITY OF THE CORTICAL BONE OF THE MANDIBULAR HEAD.

When we analyze a MRI we have to take into account a lot of information beside disk position

8 RNM INICIAL

MRI :left TMJ closed mouth . Medial slice. Low signal in the head of the mandible bone marrow. The patient had a history of tonsillitis and otitis repetition.

When we requested for an ASO the exam showed high values, for which because of that she was medicated.

9 RNM INICIAL  MRI :right TMJ closed mouth medial  slice.
10 RNM INICIAL

MRI: right TMJ closed mouth  slice. Superior facet of the mandible head. Mild dislocation of the articular disc and retro position of the condyle.

11 rad. lateral Lateral radiograph and patient’s profile12 cervicalThe lateral radiograph including the cervical spine shows it´s rectification (loss of the physiological lordosis). Mild curvature inversion at C4.

13 Registro jaw tracker-3

Patient’s masticatory muscles were electronically deprogrammed and a bite in a neurophysiological position was registered using a jaw tracker.For the bite registration record we always use the information of the images obtained and the planned goals for each individual case.

The patient presented a free way pathological space of 6 mm and a retro-position of 2,8mm

A DIO (Intraoral Device)  was constructed in a neurophysiological position.

The website of the Clinica MY www.clinicamy.com.br  has the link for the article Neuromuscular Principles in Dentistry, Habitual Trajectory coincident with the Neuromuscular Trajectory.

Princípios Neuromusculares na Odontologia, Trajetória de Fechamento Habitual Coincidente com a Trajetória de Fechamento Neuromuscular (Portuguese) Brazilian Journal of TMJ, occlusion and Orofacial Pain, April/ June 2002.

14 dinamico com dio  Patient’s electromyography record with the DIO ( intraoral device) constructed in neurophysiological position). Observe the excellent muscle activity with the device.

15 registro eletromiografico comparativo  Patient’s electromyography records comparison: the first in habitual occlusion and the second with the intraoral device in neurophysiological position.  In the lower record the masseters present excellent activity with the device, even more if we compare the initial record where  the masseters lose  activity in the middle of the maximal occlusion.

Some MRI selected slices : before treatment and after de FIRST PHASE.

We need to be aware of the planned goals for this patient with joint hypermobility and a sequel of traumatism in infancy where we can see low signal in the head of the mandible bone marrow.

  • Better tridimensional placement of the mandibular condyle.
  • Closing dental trajectory coincident with the muscular closing trajectory.
  • Temporomandibular joints decompression.

 Image 1: improvement of the left condyle upper pole cortical bone in this lateral slice.

 Image 2: improvement of the left condyle superior pole cortical bone, bone marrow  signal improvement, positive remodeling of the condylar posterior surface.

Image 3: Improvement of the bone marrow signal and positive remodeling of the condylar posterior surface.

Image 4 : Positive remodeling of the superior pole and posterior surface of the head of the mandible.

16 A panoramica INICIO 2 FASEWe began assembling the upper and lower braces for a tridimensional orthodontics, maintaining the DIO (intraoral device)

A tridimensional orthodontics needs to maintain the tridimensional mandible position in balance with its osseous and muscular planes obtained in the FIRST PHASE, and always when possible it has the purpose to maintain the temporomandibular joint in a harmonious relation with the mandibular fossa as well as the disk in a correct position.

16B LATERAL INICIO 2 FASEPatient’s lateral radiograph and cervical spine  in the beginning of the 2 PHASE.17 comparativas coluna 1  Comparative lateral radiograph an cervical spine of the patient: before the FIRST PHASE and in the beginning of  the SECOND PHASE

In this image there is no recovery of the lordosis but yes, an improvement of the mild curvature inversion at C4.

18 orto 1

Tridimensional orthodontics sequence in the second phase of TMJ pathologies treatment, in this specific patient.

REMEMBER THAT NOT EVERY CASE WILL ALLOW YOU TO ADVANCE TO A SECOND PHASE.

19 orto 2 20 orto 3  Active eruption in the tridimensional orthodontics.21 orto 4   Active eruption in the tridimensional orthodontics.22 orto 5  Continuation of the tridimensional orthodontics with sequence of intraoral devices23 orto 6  New DIO (intraoral device) for the continuation of the tridimensional orthodontics.24 orto 7 25 orto 8 26 orto 9 27 orto 10 27B paciente retirando el dispositivo  Removal of the DIO ( intraoral device)28 orto 11 Image without the intraoral device.29 finaliz trat orto Tridimensional orthodontics treatment finalization in neurophysiological occlusion.30 comparação oclusao inical e final  Patient’s occlusion image in neurphysiological occlusion after treatment finalization. Comparison with the initial occlusion image.31 ELETRO FINAL  Patient’s electromyography records comparison: the first in habitual occlusion before the FIRST PHASE and the second AFTER THE TRIDIMENSIONAL ORTHODONTICS TREATMENT FINALIZATION. The masseters present excellent activity comparing with the initial record where the masseters lose activity in the middle of the maximal occlusion. Also the masseters present better potency than the temporalis.32 final CERVICO COMPARATIVAS  Patient’s lateral and cervical spine comparative radiograph: before the FIRST PHASE and in the TRIDIMENSIONAL ORTHODONTICS FINALIZATION.

Notice the cervical lordosis improvement.

33 lamino comparativas  Patient’s comparative laminography: initial in habitual occlusion where we can observe the retro position of the mandible heads, and the tridimensional orthodontics finalization laminography.

34 PANO FINAL (1) Patient’s panoramic control radiograph after the TRIDIMENSIONAL ORTHODONTICS finalization.35 RNM FINAL Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.36 RNM FINAL  Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.37 RNM FINAL  Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.38 RNM FINALRight TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.39 RNM FINAL  Right TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.40 RNM FINAL

Right TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.

DEPOIMENTOTMJ 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.

FINAL

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

The former publication worked on  the neurophysiological approach of the first and second phase in the treatment of TMJ pathologies. The patient of the last publication, entitled “Tridimensional Orthodontics in the Second Phase of TMJ Pathologies” has her complete dentition in mouth and a good periodontal health, condition that permited us by a tridimensional orthodontics to restore and balance the system after the First Phase, with the REMOVAL OF THE INTRAORAL DEVICE.

We know that there are cases that can meliorate, others that we can avoid its aggravation, and still others that we can only can relieve the pain.

In this publication we will report a case where a good quality of life was returned to the patient and we could offer a neurophysiological rehabilitation combined with a tridimensional orthodontics, always keeping the mandibular localization in equilibrium with the muscular planes, temporomandibular joint and dental planes, achieved in the first Phase.

1 HELENA DE MATTOS Female patient 54 years old came to the consultation with strong pain in the superior part of the head, in both temporalis, in the back of the head and in the cervical spine.

1B HELENA DE MATTOS

The pain was so strong that SHE REFERRED THE WILL to extract all the teeth, believing that they were the origin of the pain. She reported a lot of pain in the face, and strong twinges in the ears.

1C

The patient marked the pain areas in the head and neck, but she referred pain in several joints of the body.

Patient’s testimony

Long time ago I began to feel ear pain. I consulted   many otorhinolaringologist that told me I didn´t had anything wrong in my ear. Then I consulted  a neurologist that medicated me with carbamezepine and told me that I had a GLOSSOFHARYNGEAL NEURALGIA.

I felt very uncomfortable with the medication. I experienced dizziness and lack of concentration.

I consulted  Dr. Valdai Souza, a physician , who removed the medication, improved my general health and checking my TMJ referred me to Clinica My.

2 DENTES The patient presented a very deteriorated aesthetics, BUT THE MOTIVE OF HER CONSULTATION WAS PAIN IN THE TEMPOROMANDIBULAR JOINT, PAIN IN THE FACE, STRONG HEADACHE AND PAIN IN THE EAR.

The patient had tried too many dentistry treatments; even so she continued grinding and breaking teeth. She had lost teeth. She had prostheses installed, but the patient gave up to search a better aesthetics because  the pain in the joint and  headache didn´t allow her a normal life.

3 DENTES Patient’s  occlusal view is marked by the wear of the anterior teeth, both superior and inferior

She had consulted  several specialists until she was derived by her physician to Clinica My.

4 PANORAMICA

In the radiographic exam we observe the absence of the 18,16,28,28,36, 46 4 48 dental elements.

The 15, 14, 22, 24, 26, 35,44 e 45 elements are endodontically treated.

Fixed prosthesis with support in the 16/15 elements. Presence of unitary fixed with metallic intracanal pin in the 14, 22, 26, 35, 34 e 45 dental elements.

Extensive restoration in the 13, 24 e44 dental elements.

Restorative material in the 11, 21, 23, 27, 32 and 47 elements.

Maxillary and mandibular bone loss more pronounced in the edentulous areas.

Elongation of the left styloid process.

5 LAMINOGRAFIA

Patient’s laminography in habitual occlusion shows de retro position of the mandibular condyles and a sequel of traumatism in infancy (left side). We can observe in this image the alteration of the axis of the mandibular condyle. The website of the Clinica MY  www.clinicamy.com.br  has the links for both articles. . Alterações na Orientação do Côndilo Mandibular Devido a Traumatismos na Primeira Infância (portuguese). Clinic case presented in the 4th edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

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

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2,  July/December de 2014.

5B LAMINOGRAFIA Alterations in the Orientation of the Mandibular Condyle Because of Traumatism in Infancy

Clinic case presented in the number 4 edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

5C LAMINOGRAFIA Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy.

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2,  July/December de 2014.

5D ressonancia boca fechada

One of the slices of the MRI showing the asymmetry of the mandibular heads and the alteration of the condyle axis in the left side.

The articular discs are anteriorly dislocated with reduction in the slices of the MRI in open mouth (not included in this publication). The principal objective in this case is the TMJ decompression and the tridimensional balance of the masticatory muscles. The structural asymmetries provoked by traumatism cannot be modified. But yes we can balance the muscles!

Patient’s testimony

My mother told me that when I was very little I felt from a tree and hit my head.

6 TELE PERFIL

The profile radiograph shows the patient’s occlusion collapse. In a simple view we could attribute this collapse to the teeth loss, BUT IS NOT SO SIMPLE. The patient presents also a dimensional loss provoked by the alteration of de axis of the mandibular condyle.

This dimensional loss is many times observed in patients with all THE DENTAL ELEMENTS IN MOUTH, but they also present an alteration of the mandibular condylar axis, because of traumatism in infancy or others etiologic conditions that affected one or both mandibular heads.

7 C7

The lateral radiograph including the cervical spine shows the vertebral misalignment, the degenerative condition, the loss of space between the vertebrae.

Patient’s testimony:

I had a car accident, a truck crossed in front of my vehicle, I hit  my face on the car’s front glass  and I needed an intervention  in my face.

7B C7 2

Osteophytes especially in C4, C5 and C6. The patient also has the cervical MRI showing  vertebral discs protrusions.  

7D FRONTAL 8 A DENTES ORTOSE

Her muscles were electronically deprogrammed and a DIO (Intraoral Device) or ortese was constructed in a neurophysiological position. In other publications we mentioned the kinesiographic methods wich were used.

8 B eletromiografia em oc. habitual

Surface electromyography in habitual occlusion shows an important asymmetry between the right and left temporalis muscles, also asymmetries between right and left masseters.

8C fotos comparativas frontais

Aesthetic modifications with the intraoral device in neurophysiological position in mouth.

10B PANORAMICA implantes 1

The installation of two implants on the inferior left side were planned and also two implants on the superior right side where the patient had an old prosthesis. All these procedures were ALWAYS WITH THE DIO (intraoral device) constructed in neurophysiological position in mouth 24 hours in a day.

10C panoramicas comparativas

Comparative panoramic radiographs: initial panoramic radiograph before the treatment and the panoramic radiograph with the implants installed, always with the DIO, Intraoral Device in neurophysiological position.

9 dentes cavidades

The cavity preparation had only a provisional aesthetic goal that permitted us to begin the anterior sector orthodontics movement. That will be posted later.

10 dentes prov e inicio da ortodontia

The teeth were rehabilitated PROVISIONALLY WITH RESINES to improve patient´s aesthetics and self-esteem. The patient had no symptomatology, that condition permitted us to work in the recuperation of her stomatognathic system health and aesthetics.

Orthodontics movement wearing THE INTRAORAL DEVICE WAS INITIATED.  The first objective was the molar uprighting on the inferior right side in order to recuperate the  space to install the implant.

11 preparo ortodontico setor anterior

The second objective continuing the neurophysiological rehabilitation combined with the tridimensional orthodontics was the vestibularization of the superior anterior sector to aloud the proper anatomical reconstruction of the teeth.

12 preparo protese-1

Some of the teeth presented pulp degeneration, needing endodontic and a reinforcement of the dental nuclei with metallic pins.

13 cimentação de coroas provisorias Implant on the place of the 46, after space recuperation14 cimentação definitiva dos provisórios 15 cimentação coroas definitivas

In this view, without the DIO (Intraoral Device), with the metal-ceramic crowns already cemented, we can see the wear of the inferior anterior sector, which needs to be rehabilitated with resins.

16 terminado

In this case, the initial planning was to maintain the intraoral device after rehabilitation, because the dimensional loss was very large. The patient presented bone loss and degenerative conditions in several body joints: A PROSTHESES IN HER HIP, AN IMPORTAT MISALIGNEMENT OF THE CERVICAL SPINE WITH OSTEOPHYTES AND LOSS OF THE SPACE BETWEEN VERTEBRAE.

The 35 element had a 10 years fractured old pin with important overload (remember that this was the last tooth in mouth in the left inferior sector before the implants installation) .

The extraction of this element was decided.The patient  is WITHOUT PAIN, AND WITH THE SPACE PRESERVED BY THE DIO, will decide later the implant installation.

16B oclusal final 17 laminografia final

Laminography showing the tridimensional decompression of the mandibular heads.

18 laminografias comparativas

Laminography comparison before and after the neurophysiological rehabilitation combined with the tridimensional orthodontics.

19 PANORAMICA final

Panoramic radiograph with the finalization of the rehabilitation and the space of the 35 element preserved for the future implant.

20 panoramicas comparativas

Panoramic radiographs comparison: intial panoramic before treatment, panoramic during the treatment and panoramic after the neurophysiological rehabilitation combined with the tridimensional orthodontics.

21 comparativas frontais

Frontal radiographs comparison before and after the neurophysiological rehabilitation combined with the tridimensional orthodontics.

23

Intraoral photographs before and after treatment.

21 comparativas laterais

Patient’s lateral and cervical spine radiographs comparison before and after the neurophysiological rehabilitation combined with the tridimensional orthodontics. Remember that one of the reasons to maintain the intraoral device was because the degenerative conditions of the cervical spine and in other joints.

22 postura comparativa

Patient’s postural and aesthetics modifications before treatment and after the neurophysiological rehabilitation

dEPOIMENTO 1

I arrived in the clinic with a strong  pain in the face, headache and pain in my ear. I wanted to extract all my teeth because of the pain and twinges in the ear.

In a quiet environment I felt the buzz on my left ear and the pain rose to the head. Sometimes I spent the night walking to be able to endure…

I began to treat the TMJ (temporomandibular joint) pathology. And I got a relief of my pain.

After two years I initiated the rehabilitation. In the middle of the rehabilitation I had a pelvis surgery; the physicians needed to install a hip prosthesis.

I had also a tumor in my kidney and the physicians needed to remove it.

Without pain and with aesthetic improvement Dr. Lidia and Dr. Luis Daniel explained to me that they couldn´t totally remove the device, because the dimensional loss  was too large and also because of my degenerative active condition, which meant loss of stability not only in the TMJ, but also in other joints.

dEPOIMENTO 2

Nowadays I wear a small intraoral device.This device  will be changed for one aesthetics DIO, instead of the transparent  one.

My life quality improved 100 percent, I sleep very  well and I even  don´t feel the buzz any more, neither the twinges.

THE AESTHETICS ACHIEVEMENT ALSO IMPROVED MY SELF-ESTEEM, even if that was not the motive for my treatment. The reason was to alleviate my pain. NOW  WITHOUT PAIN, EVEN THE AESTHETICS IS IMPORTANT.

A big hug and my gratitude to my Drs. for my life quality change !

FINAL

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

1A

In the former publications of this study page some of the neurophysiological fundaments of the TMJ pathologies treatment were presented, the importance of the differential diagnosis and also the utilization of bioinstrumentation like surface electromyography and jaw tracker were also introduced.

Patients images relating their symptomatology were also shown, some of the diverse etiological factors as traumatisms in infancy, especially green stick fracture, intra articular discs recapture in reducible dislocations, interrelation between Craniomandibular disorders and vertebral spine, as well as a case of cervical dystonia and its relation with TMJ that can also be read in this page. From December 2014 there were seven publications.

1

When we talk about TMJ pathologies treatment we need to understand that there are different approaches. The proposal of a Palliative treatment is the Symptomatic treatment, which tries to block the symptoms. For that means, it uses analgesics administration, anti- inflammatory drugs and muscle relaxants.

The restorative approach is the treatment that aims, when possible to correct or to heal what is damaged. Recognition of what is wrong (differential diagnosis) must precede the question of how to fix it. To know what is wrong, it is necessary a differential diagnosis. This diagnosis must always be elaborated before we reach a treatment proposal.

2

When our proposal is a restorative treatment, we have a FIRST PHASE where the objective is to heal the joint when it is possible. Sometimes we can only improve the joint condition or to avoid its deterioration.

To know what we can treat and what we cannot deal with, and the limitations of every individual case.

3

When we finished the first phase, we compare if the control images of the case corresponds with the goals we intended to achieve in our initial diagnosis. We know that there are cases that can meliorate, others that we can avoid its aggravation, and still others that we can only can relieve the pain. If the case has positive results of the first phase we can initiate a second phase of the treatment in order to remove the device that is used in a permanent way during the first phase of the treatment.

For this we can perform a tridimensional orthodontics, a neurophysiological rehabilitation or the combination of both.

Always remember of keeping the mandibular localization in equilibrium with the muscular planes, temporomandibular joint and dental planes.

4

I will relate what happened at the current week with a teenager patient that had finished the first phase, in a case of  neurophysiologic decompression of the temporomandibular joint and where she was still wearing the DIO (intraoral device)

The patient had remission of her symptomatology (ear pain irradiated from the TMJ since childhood), and now she was preparing herself  to initiate the second phase with a tridimensional orthodontics. I wasn´t satisfied with her breathing so again I asked for an evaluation to meliorate her breathing and consequently her tongue position.

The professional that made this evaluation affirmed that the patient presented an open bite and that she needed to consult a buco maxillary surgeon to “close her bite” by surgery.

The anguish that was provoked on the patient and that consequently also affected me, resulted in my indignation on her conclusive opinion referring the patient to a surgical consultation without firs entering first in contact with the professional responsible for the treatment (me in this case)

In any way I demand complicity of any professional, since I consider ethics beyond everything. As much as respect for the patient.

This event encouraged me to publish a case on tridimentional orthodontics in the second phase of TMJ pathologies

Before the SECOND PHASE, let´s begin with the FIRST PHASE.

5

Female patient, 17 years old consults in the clinic complaining of headache, ear pain, shoulder pain and bilateral clicks.

In the clinical inspection she had strong ache when retrodiscal palpation was performed.

The patient showed an “ideal occlusion” and in the clinical tests she did not exhibits any kind of interferences neither in protrusion nor in lateral translation.

6

Patient’s initial laminography in habitual occlusion before treatment

Patient’s initial laminography in habitual occlusion,  retro position of the mandibular heads, especially on the left side provoking an important retrodiscal compression.

7

Patient’s MRI in habitual occlusion, both anterior reducible disc luxation, retro- position of the mandible heads and modification of the growth axis provoked by a traumatism in infancy (Structural modification of the mandibular condylar process as one of the sequels of traumatism in infancy). The luxation is reducible (MRI in open mouth not included in this post)

8

Patient’s initial electromyography record (4 channels) in habitual occlusion

In this record we measure both right and left anterior temporalis, and right and left masseters. Notice that the masseters that are the most potent muscles of the masticatory system cannot generate activity.

9 10

A static image doesn’t speak of muscular harmony, doesn’t show if there is coordination between the systems and does not show if the patient has local or distant pain.

11

Patient’s masticatory muscles were electronically deprogrammed. A bite was registered in a neurophysiological position with a jaw tracker.

The patient presents a pathological free way space of 6,2 mm and a retro mandibular position of 2,5 mm.

12

With this data we construct an intraoral device (DIO) tested electromiographically to support the neurophysiological occlusion.

13

Patient’s comparative laminographies

Patient’s initial laminography in habitual occlusion, retro position of the mandibular heads, especially on the left side provoking an important retrodiscal compression. The new laminography with the intraoral device in neurophysiological position shows the tridimensional decompression of the retrodiscal zone.

14

Comparison of the two electromyography records the first in habitual occlusion and the second with the intraoral device in neurophysiologic position. The masseters present excellent activity with the DIO, compare the first initial record where these muscles couldn’t activate.

15

Comparison of one of the slices of the MRI. Left closed TMJ before the treatment in habitual occlusion and in a neurophysiological occlusion with the DIO.

Disc in physiological position and tridimensional decompression of the mandibular head.

Correlation with the electromyography records in habitual occlusion and in neurophysiological occlusion with the DIO.

16

Comparison of one of the slices of the MRI. Right closed TMJ before the treatment in habitual occlusion and in a neurophysiological occlusion with the DIO.

Disc in physiological position and tridimensional decompression of the mandibular head.

Correlation with the electromyography records in habitual occlusion and in neurophysiological occlusion with the DIO.

17

Lateral radiograph of the patient for the initiation of the tridimensional orthodontics treatment. The patient is with the DIO (intraoral device constructed in neurophysiological position)

Patient’s masticatory muscles were electronically deprogrammed for the bite registration and the construction of the intraoral device.

Not all case can pass to a second phase, orthodontics, prosthodontics or rehabilitation.

There are patients with active autoimmune disease, where is not possible to eliminate de intraoral device, because these patient’s  anatomical structures ( temporomandibular joints, cervical spine…) are affected by the disease, what makes this structures unstable pillars, because of the active inflammatory process.

18

Neuromuscular diagnosis in orthodontics: effects of TENS on maxillo-mandibular relationship.

19

Atlas of Maxillary Orthopedics: diagnosis Thomas Irmtrud and Jonas Rakosi. Electronic rest mandibular registration in three spatial planes.

20

Starting the 2 phase of the treatment in this case with a tridimensional orthodontics. The device will be removed keeping the muscular planes in equilibrium with the osseous and dental plans.  INITIATING THE ACTIVE ERUPTION.

21

Image with and WITHOUT the intraoral device. The space between arches IS THE SPACE THAT WE NEED TO RESTORE (this space is filled with the DIO). The DIO operated as a tridimensional boot sole. IN THE SECOND PHASE THE ACTIVE ERUPTION OF THE TEETH will fulfill the objective

22

Continuing the treatment in the tridimensional orthodontics. Image with and without the device. Posterior sector already erupted.

23

Molar and pre-molar sector already erupted. Alignment of the lower incisors and finalization of the tridimensional orthodontics in the second phase of TMJ Pathologies.

The ultimate goal in an orthodontic treatment is to treat all three components of the stomatognathic system and create an environment for synergistic function of the teeth, temporomandibular joints and neuromuscular system.

24

A tridimensional orthodontic needs to maintain the tridimensional position of the mandible in balance with its osseous and muscular planes obtained in the first phase, and whenever possible it needs to keep the temporomandibular joint in an harmonic relation with the mandibular fossa as well with the articular disc in correct position.

gRUMMONS

The patient’s clinical history, clinical inspection, technology, bioinstrumentation and images, helped us to improve TMJ pathologies diagnosis and treatment.

When we arrive to a SECOND PHASE, many professionals and patients don´t know that the active eruption has been used from MANY, MANY years ago. Dr. Duane Grummons book edited in 1994 is only one of the several examples. Logically a TRIDIMENSIONAL ORTHODONTICS in the patient with TMJ Pathology needs a differential diagnosis and a restorative treatment in the FIRST PHASE.

25

If we don´t understand that teeth are the ending point of a joint…

If we don´t understand that this joint can be affected by systemic

and local pathologies…

If we don´t understand that it is the muscles that move the mandible

and propitiate the rest position…

If we don´t understand that structural differences determine tridimentional adaptations…

We may not understand treatments failure, in the cases where the patients present TMJ pathologies.

26

Inter relation of Craniomandibular disorders and vertebral spine. Case report

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

The patient consults in the clinic with strong complaints of: Ache in the top of the head, frontal ache, pain in the back of the head, scalp ache, pain in the eyebrow zone, ache behind the eyes, shoulder ache.

2 FOTO

Cervical pain, numbness and tingling in the hands and fingers. Pain in both TMJ (temporomandibular joints)

Dizziness, blocked ears sensation.

Ringing ears

3 FOTO

Constant difficult to open the mouth

Difficult for mastication

Bruxism.

When she was 4 years old she had a car accident and was thrown out of the vehicle.

SHE RELATES INTENSE HEADACHE SINCE INFANCY.

4 A DENTES

The patient relates that when she was fourteen years old she had “maxillary cists” and many teeth where extracted

She began to break frontal teeth when she was twenty years old. Prostheses where constructed but the sensation was that anything fixed.

5 DENTES

She continued with headache.

4 B ELECTRO HABITUAL 1 CORTADA

Surface electromyography, dynamic record in habitual occlusion. In this protocol we ask to the patient to open the mouth, to close, bite strong and swallow. In this electromyographic record we measure 8 muscles: Right and left anterior temporalis, right and left masseters, right and left superior trapezius and right and left digastrics. We observe very low activity of the superficial temporalis right and left and an almost absence of activity in both masseters. Both digastrics show activity when the patient is biting, what is not physiologic because the digastrics are muscles that work in mouth opening and NOT in mouth closing.

6 PANORAMICA

In the radiographic exam we observe the absence of dental elements 16, 15,22,26,27,38,36,46 and 47. Other dental permanent elements are present

The panoramic radiograph shows the asymmetry of the corps and the ramus of the mandible

7 LAMINOGRAFIA

TMJ laminography of the patient before treatment in habitual occlusion and opening. Asymmetry of the articular cavities. Important asymmetry of the mandibular heads.

7 LAMINOGRAFIA COR

Significant flattening of the anterior surface of the articular process in the left side. Anterior angulation of the articular process of the right side and flattening of the posterior and anterior surfaces.

Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy http://www.craniomaxillary.com

8 CERVICAL INICIAL CRISTIANE KELLY

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

The cervical spine gives sustainability to the cranium and guarantees the movement. Any dysfunction of this balance can provoke pain.

REMEMBER WHEN PATIENT WAS FOUR YEARS OLD SHE HAD A CAR ACCIDENT AND WAS THROWN OUT OF THE VEHICLE.

An often overlooked result of sudden hyperextension or hyperflexion of the cervical muscles is the trauma to the intra-articular structures of the temporomandibular joint. The damage is caused by force acting on connecting structures of different mass and weight. The difference in velocity between cranium and mandible which is in a muscle ligamentous sling during hyperflexion or hyperextension can cause stretching, tearing or overt detachment of the posterior and lateral ligaments of the temporomandibular joint. This factor, in itself, can cause anterior and medial displacement of the articular disc.

8 CERVICAL INICIAL CRISTIANE KELLY

Loss of the physiologic cervical lordoses of the patient, inter-vertebral spaces diminishing, increase of the space between the posterior arc of the atlas and the occipital

9 FRONTAL-1

Frontal radiograph of the patient in habitual occlusion. ROCABADO (1984) refers that the ideal position for the head in space depends on three planes: bipupilar plane, otic plane and occlusal transverse plane. These three planes keep a horizontal and parallel relation that assures postural stability for the cranium. Is evident that this premises are not present in this patient.

10 RESSONANCIA DIR E ESQU

One of the slices of the MRI in closed mouth shows a small disc with and anterior displacement on the right side. In the open slice of the RNM (not included in this post) the disc is not recaptured on the right side.

Significant flattening of the anterior surface of the articular process in the left side.

Anterior angulation of the articular process of the right side and flattening of the posterior and anterior surfaces. Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy www.craniomaxillary.com

11 BITE

Her masticatory muscles were electronically deprogrammed with an electronic mandibular deprogrammer.

A jaw tracker then registered a neurophysiologic position from where an intraoral appliance was constructed and tested with SEMG (Surface Electromyography)

We consider not only the jaw tracker information after the electronic deprogramming but fundamentally the information of the MRI for the decision of the bite record for the tridimensional construction of the intraoral device.  For this we use the neurophysiologic technique of Dr. Learreta.

The patient presents a pathological free way space of 9,2 mm and a mandibular retro position of 5,2 mm.

12  B DENTES-1ORTOSE

With this data we construct an intraoral device tested electromiographically to support the new neurophysiological occlusion

12 B ELECTRO com DIO 1 CORT

Dynamic Surface electromyography record wearing the DIO (Intra Oral Device) constructed in neurophysiologic position. In this protocol we ask to the patient to open the mouth, to close, to bite strong and swallow WITH THE DEVICE IN THE MOUTH

In this electromyographic record we measure 8 muscles: Right and left anterior temporalis, right and left masseters, right and left superior trapezius and right and left digastrics. We observe the activity in both superficial temporalis and in both masseters and the reduction of the digastrics activity when the patient is biting.

Even is not an ideal record when we compare with the initial record in habitual occlusion shows the progress of the treatment, in the first record the patient could not activate her masseters. This shows a strong tool in the control of the treatment.

13 A LAMINOGRAFIA COMPARATIVO CRISTIANE KELLY

Patient´s comparative laminographies: initial in habitual occlusion where we can observe the retro position of the mandibular heads and with the intraoral device in neurophysiological position with a tridimensional decompression of the retrodiscal space.

13 B electros comparativas

Patient’s electromyographic records comparison (A) in habitual occlusion and (B) with the device in neurophysiological position.

14 FOTO COMPARATIVA FRONTAL

Patient’s frontal postural image in habitual occlusion and with the device in neurophysiological position. Tridimensional recovery of the vertical dimension. Improvement of the head and shoulder posture.

15 CERVICAL COMPARATIVO CRISTIANE KELLY

As the occlusal vertical dimension is amended IN BALANCE WITH MASTICATORY MUSCLES AND TEMPOROMANDIBULAR JOINTS, a significant change in the cervical posture happens that need to be evaluated and follow by trained professionals in this area

16 FOTO COMPARATIVA PERFIL

Patient’s postural lateral imagesin habitual occlusion and with the device in neurophysiological position. Tridimensional recovery of the vertical dimension. Improvement of the head and shoulder posture.

17 COLUNA E PERFIL COMP

Postural lateral images and lateral radiographs and cervical spine in habitual occlusion comparison with the device in neurophysiological position. IMPROVEMENT OF THE CERVICAL SPINE.
 As the occlusal vertical dimension is amended in balance with masticatory muscles and temporomandibular joints, a significant change in the cervical posture happens that need to be evaluated and follow by trained professionals in this area.

DEPOIMENTO

I searched for the Clinicamy to calm down my pain. The headache began since childhood. Nothing was ever found, a lot of exams, medications and no results.

Approximately with 14 or 15 years old I had cists in the mouth and loose some teeth. Before that, with 4 years old I had a car accident and I was thrown out of the vehicle.

Probably then everything began. Because I grinded my teeth ( I didn´t perceive that) I began to lose other teeth.

DEPOIMENTO 2

Pain increased, pressure in the neck and head, spine, and knees. Misalignment of the spine with dehydration of the vertebral discs, arthrosis signals in C4-C5, C5-C6, e C6-C7. I was recommended by my dentist Dr João de Souza to search an alternative for my pain, at that time he was wearing a DIO for the treatment of a TMJ dysfunction with Dr. Lidia Yavich.

In that time he didn´t treat TMJ Pathologies, today he studied how to treat cases like mine.

That was the salvation for my pain. The treatment propitiated a better quality of life.

In this moment when muscles, temporomandibular joints and occlusion are in balance, the patient will initiate a neurophysiological rehabilitation treatment with implants and prostheses.

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

Figure 1. Anterior displacement of the articular disc in a female patient. 52 years old.

The temporomandibular joint (TMJ) is a synovial joint that unlike other joints in the body are capable of movement in all three dimensions.

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

The superior retrodiscal ligament is quite susceptible to injury. Permanent injury to this retrodiscal tissue makes difficult to the disc to return to the physiological position that is over the condyle.

This joint TMJ (Temporomandibular Joint) has a complex biomechanics.

Figure 2. Anterior displacement of the articular disc. Male patient 34 years old.

In a very simplify definition DISC DISPLACEMENT WITH REDUCTION means that the disc is anterior from normal to the condyle in the mandibular fossa, while the condyle can be or nots simultaneously positioned posteriorly from its normal position when the teeth are in habitual occlusion.

When the mouth opens the normal and healthy disc condyle relationship is restored.(I am not going to enter here in classifications that are widely published in literature).

When we face an articular disc displacement with reduction, the question is: RECAPTURE OR NOT RECAPTURE?

Is disc recapture one of the goals that I need to achieve?

When we treat this joint arthropathy we need to formulate some propositions.

Figure 3. Anterior displacement of the articular disc. Female patient 14 years old. Mild irregularity of bone cortical.

1) First of all to make a differential diagnosis: What lead to this disk to be displaced?

2) The goal always is to give to our patient a quality of life. And if exists inflammation to solve it. Today MRI has excellent parameters to see that.  But again to know what is causing that inflammation. Is it local it is systemic?

3) WHEN WE CAN recapture the disc, and that is DIAGNOSIS, we need to understand that to return the anatomical joint elements to a healthy and physiological position is ALWAYS VALUABLE. Remember anatomy is the platform where physiology functions.

4) To PROVE THAT WE RECAPTURE THE DISC, we need the comparison of the MRI before and after treatment.

The aim of this post is images comparison, for that I choose  expressive images.

Is just to compare the changes in the soft tissues and also in the hard tissues.

Figure 4. Comparative images of disc recapture and positive remodeling of bone cortical in a teenager.

One of the MRI slices before and after treatment, in cases of TMJ Pathologies in children and teenagers. The most important in this slice is not only the disc recapture but the positive remodeling of the mandibular head where was visible the osseous irregularity.Female patient 14 years old.

April 2012 – TMJ Pathologies in children the overlooked diagnosis 2012 IAO (International Association for Orthodontics Annual Meeting 3th Place Award-Table Clinics- San Juan, Puerto Rico

The teenager didn’t has pain in the joint, only pain in the shoulders and clicks!

Joint decompression. Mandible reinstatement with the neurophysiologic technique. Allow disc recapture.

Logically differential diagnosis permits the favorable prognostic, not all arthropathy will permit this result, but this is a part of the initial diagnosis.

Figure 5. Anterior displacement of the articular disc. Female patient 52 years old. Disc recapture.

Female patient 52 years old consults in the clinic with complaints of many years of head ache, ache in the temples, and in the back of the head. Shoulder ache, blocked ears sensation, popping in both temporomandibular joints. She presented limitation of mouth opening and difficult for mastication. She used pain killers and anti inflammatory that didn´t alleviated her symptoms.

Joint decompression. Mandible reinstatement with the neurophysiologic technique. Allow disc recapture. Today asymptomatic.

Figure 6 . Lateral disc displacement in a female child ( 9 years old) Disc recapture. Realignment of the condyle.

Direct traumatism, provoking a distention of the medial ligament. External disc luxation.

TMJ pathologies, differential diagnosis and treatment in children and teenagers.

9 years old female patient

Main complaints: Pain in the right ear, headache principally on the right side. Pain in the back of the neck, principally on the right side. Pain in the shoulders principally on the right side. TMJ pain, more in the right side. Pain when chewing. Blocked right ear sensation, Pain when opening and closing the mouth. She fell in the swimming pool and hurt her chin. She begun to have symptomatology only four months later; initially the pain was at the beginning of the night . Afterwards the pain was continuous .Before coming to the consultation she was medicated by various colleagues with: Anti –inflammatory and pain killers that didn´t work. The images that were solicited by the colleagues, like panorex and CT didn´t showed relevant information. Even in the MRI the sagital slices, didn´t determinate a proper information for the symptomatology ONLY IN THIS CASE THE FRONTAL SLICE
Mandible reinstatement with the neurophysiologic technique.Allow disc recapture.
Patient today asymptomatic

Figure 7 . anterior disc displacement in a male patient 34 years old. Recapture of the disc and positive remodeling of the cortical bone.

One of the  slices of the MRI before and after treatment, in a male patient 34 years old. The patient presented frontal head ache, pain in the back of the neck, pain in the back of the eyes, pain in temporal muscles, and difficulty for hard food mastication. Is very important to consider not only the recuperation of the relation of the disc with the mandibular head but also the positive remodeling of the mandibular head .Joint decompression. Mandible reinstatement with the neurophysiologic technique. Allow disc recapture. Today asymptomatic. 30