Posteriorization of the Mandibular Condyle, Compression of the Retrodiscal Tissue and Anteriorization of the Articular Disc as a cause of Neurologic Pain. Recovery of the Physiological Relationship of the Head of the Mandible with the Articular Disc. Series of clinical cases.

In this page we present some of the physiological neuromuscular foundations for the treatment of temporomandibular joint pathologies, it was also presented the importance of differential diagnosis and also the use of bioinstrumentation as surface electromyography and computerized kinesiography.

Images of patients related to their symptoms were also presented. Several etiological factors such as trauma in early childhood, especially green stick fracture, recapture of the intra-articular discs in reducible displacements, and interrelation between craniomandibular disorders and the vertebral column.

When we talk about the treatment of TMJ pathologies we have to understand that there are different approaches. The proposal for a palliative treatment is the symptomatic treatment, that is, a treatment that seeks to block the symptoms. It is given through the administration of drugs, such as analgesics, anti-inflammatory and myo relaxing drugs. The restorative approach is the treatment that seeks when possible to correct or heal what is damaged. To know what is wrong, a differential diagnosis is necessary. This diagnosis must always be made prior to the treatment proposal.

1 FOTO INIC FRONTALA 19-year-old female patient presents at the clinic with complaints of constant headache, neck pain and swelling in the face, back of the head pain and migraines.

According to the anamnesis filled out by the patient herself, in the initial consultation she reports clicks in the jaw, dizziness, ear pain and low back pain.

The patient also reports bruxism and nighttime clenching.

2 FOTO INICIAL PERFILThe patient also refers to retro-ocular pain on the right side, pain in both shoulders, and pain in the TMJ (right temporomandibular joint).

The patient reports cracks in the TMJ on the right side, sensation of ear covering, strange sounds and non-specific facial pain.

The patient claims difficulty in opening the mouth and difficulty in chewing.

Summary report written by the patient

In the middle of the year 2014, I had a routine consultation at a dentist to clean my teeth and I reported cracking and pain in the jaw, she did not pay attention, she said it was normal and it would soon pass.

Since then I started with severe headaches, dizziness, ear pain, back pain, my feet (more in  my heel), pain in my eye as well, and in days of painful crises, my right eye would hardly open and the right side of the my face all swollen (mumps type).

After this worsening we looked for an TMJ specialist who gave me an acrylic plate, thin and only for my upper teeth.

I used the splint for six months and after that all the symptoms worsened.

We looked for another specialist, who made the same acrylic plate for the upper teeth, but in a very different size, it was a thick plate.

In the beginning it helped, after six months, all the symptoms started to appear stronger.

We consulted a new specialist, who made a new type of appliance, with the wires and the blue acrylic on the side (I took it to show to you), it was what had helped me the most, using it for 24 hours, improved pain, even dizziness , but after a year of use everything returned and with all the pain still stronger, however during that one year of treatment, despite the improvements I could not make any kind of physical effort even not strong  my jaw swelled (gym, climbing stairs, picking up weight …)

In March 2017, a year and four months of use of the appliance, the professional said it was time to start “weaning”, start leaving the device and use only to sleep because I should already be good, I commented that it had gotten worse and she insisted that it was the time to be well…

It was then that we looked for another specialist, this one said that the plate in use was not suitable for the problem and made a new plate of acrylic that judged the correct one for the presented problem, was thin and of acrylic, equal to the first one I already used, only for the upper teeth, I immediately told to my mother and to him that this plate would not solve, since I had already used identical plate in previous treatment, he insisted saying yes, that was the correct one.

With the use of the device I also did  hot compresses and shocks of physiotherapy and also needles, which helped a lot in the neck muscles that hurt a lot, but this device from the beginning did not help, the headaches that felt every day were even worse, I’ve had more dizziness.

3 DENTES INIC PROT FRONTALHabitual occlusion of the patient on the day of the consultation.

6 OCLUSAIS INIC SEM PROTUpper and lower occlusal views of the patient on the day of the consultation.

7 PANORAMICA INICIALInitial panoramic radiograph of the patient before treatment.

8 LAMINOGRAFIA INCIAL

TMJ laminography in habitual occlusion and in open mouth.

The laminography of the temporomandibular joints shows a modification of the axis of growth of the mandibular condyles caused by a trauma in the early childhood, (green stick fracture).

Important retro position of the jaw mandibular heads especially on the left side causing an important retrodiscal compression.

9 TELE PERFIL INICIALLateral radiograph of the patient in habitual occlusion before treatment.

10 C7 INICIALLateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis, rectification of the cervical spine.

11 FRONTAL INICIALFrontal radiography of the patient in habitual occlusion before treatment.

12 eletromiog dinamica inicial

Dynamic electromyographic record of the patient in habitual occlusion.

It is important to understand that surface electromyography is an additional tool in diagnosis, and not the only determinant, is a very interesting tool to be able to control the evolution in our own patient during the course of treatment.

13 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the left TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

The magnetic nuclear resonance of the patient in habitual occlusion demonstrates the anterior dislocation of both articular discs, retroposition of the mandibular heads and modification of the axis of growth caused by traumatism in the early childhood (Structural modifications of the mandibular condylar process as one of the sequels of traumatism. in infancy). Dislocation is reducible (open mouth resonance not included in this post).

14 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the left TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

15 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the right TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

16 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the right TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

17 RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

MRI: T1 frontal slices of right and left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right and left temporomandibular joint evidences a severe loss of joint space.

20 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Right and left sagittal slices in habitual occlusion prior to treatment.

21 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – left  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – right  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22a REGISTRO CINECIOGRAFICO INICIAL

When our proposal is a restorative treatment, we have a FIRST PHASE where the goal when possible is to heal the joint. Sometimes we can only improve it or prevent it from getting worse. Knowing what we can treat and what we cannot treat and the limitations of each individual case is very important.

To correctly evaluate the maxillomandibular relationship we should begin to consider the physiological position of mandibular rest.

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

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were electronically deprogrammed and a new resting neuromuscular physiological position was recorded.

The patient has a pathological free space of 7.7 mm.

The patient also had a 0.6 mm mandibular retroposition.

23 oclusao DIO

Occlusion of the patient with the DIO (intraoral device)

With the record obtained with the jaw tracker an intraoral device (DIO) was made to three dimensionally reposition the mandible.

The NEUROMUSCULAR PHYSIOLOGICAL position was recorded in the form of an occlusal bite record, which was later used to make a DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

24 COMPARATIVAS FRONTAIS POSTURAIS

Comparative frontal postural images.

The patient was derived along with TMJ pathology treatment for a physiotherapy team in the city where she resides. Along with mandibular repositioning the conditioning of all postural chains is necessary.

Each patient needs a specific derivation according to the particular case.

25 eletromiog dinamica com DIO

Dynamic electromyographic record of the patient with the DIO (intraoral device) in physiological neuromuscular occlusion.

26 CONTROLE DA ORTESE

28 RNM Comparativas esquerda 1 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

29 RNM Comparativas esquerda 2 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

30 RNM Comparativas esquerda 2 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

31 RNM Comparativas esquerda 2 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

32 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

33 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

34 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

35 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

36 RNM Comparativas esquerda frontal

RNM: Comparison of FRONTAL SLICE  T1, left TMJ, closed mouth, before the physiological neuromuscular treatment, and the same left TMJ, FRONTAL SLICE T1, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

37 RNM Comparativas direita frontal

RNM: Comparison of FRONTAL SLICE  T1, right TMJ, closed mouth, before the physiological neuromuscular treatment, and the same right TMJ, FRONTAL SLICE T1, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

38 panoramicas comparativas

Comparative panoramic radiographs of the patient before starting the treatment and at the beginning of the second phase of the treatment. At this time the removal of the third molars included can also be done.

39 laminografias comparativas

Comparative laminographies of the patient before starting the treatment and at the beginning of the second phase of the treatment. The joint decompression can be observed.

Laminographs and or COMPUTERIZED TOMOGRAPHS, even showing decompression DO NOT SHOW the position of the articular disc. The position of the articular disc and the presence or not of osseous edema of the mandibular condyle can only be evaluated with nuclear magnetic resonance. The result or not of the recovery of the Physiological Relationship of the Jaw Head to the Articular Disc can be evaluated by comparing the MRI after the first phase and the comparison with the initial MRI.

40 frontais comparativas

Comparative frontal radiographs of the patient before starting the treatment and at the beginning of the second phase of the treatment.

When the first phase is completed, we verify if the subsequent control images correspond to our goals set in the initial diagnosis. We know that there are cases where we can improve the case, and others where we can prevent it from worsening, and others where we can only treat the pain.

The patient did not report any symptoms from the temporomandibular joint. The comparative MRI showed the recovery of the physiological relation of the head of the mandible with the articular disc.

The electromyographic and kinesiographic records objectively showed improvement of the neuromuscular function.

In the case of positive results from the first phase we can start a second phase of treatment to remove the device that is used permanently during the first phase of the treatment. For this we can perform a three-dimensional orthodontic, a physiological neuromuscular rehabilitation or the combination of both. Always maintaining the mandibular location in balance with the muscular planes, temporomandibular joint and dental planes.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the physiological neuromuscular occlusion.

In this case we will move to a three-dimensional orthodontic, where the teeth are erupted to the new physiological neuromuscular position.

A three-dimensional orthodontics needs to maintain the three-dimensional position of the mandible in balance with its bone and muscle planes achieved in the FIRST PHASE, and whenever possible maintain the Physiological Relationship of the Jaw Head with the Articular Disc.
It is fundamental to understand, that this passage has to be made keeping the DIO (intraoral device, together with the different devices to be used for the dental eruption)

47 DEPOIMENTO 3

Patient’s statement:

After long three years of failure looking for a treatment for my problem in my city, I found Dr. Lidia in a simple Google search.

I went to her and with a proposal completely different from the others, we started the new treatment immediately.

I was in an advanced stage, where I had  headache all day, pain in the ear, swollen eye (often unable to open), right side of the swollen face too (like a mumps), pain in the neck, pain in my back and also on foot.

I had no quality of life, because I was in pain all the time. When I started the treatment in the first two days I did not feel any more headaches. With the monthly follow up, adjusting as my body asked, I no longer felt any pain in anything and I returned to a normal life.

Today I am in the middle of the second phase, super anxious to go to the end and every month that passes I feel better and better.

Recapturing the Articular Disc or Repositioning the Mandibular Condyle? What about Rethinking the Concept as the Recovery of the Physiological Relationship of the Head of the Mandible with the Articular Disc. Patients with a long history of pain. Case series. First Section.

Recapture the articular disc, repositioning the mandibular condyle?

What about rethinking the concept as the recovery of the physiological relationship of the mandible head with the articular disc ,WHEN IT IS POSSIBLE.

And when is it not possible? What is the differential diagnosis? WHAT CAN WE OFFER TO OUR PATIENTS?

What type of orthotic or intraoral device to use? What is the purpose of an orthotic  in a TMJ Pathology treatment? Repositioning the jaw, recapturing the articular discs? Is this always possible? DEPEND ON THE DIFFERENTIAL DIAGNOSIS!

Does it have changes in the articular structures of the temporomandibular joint?

Does it have distortions in the horizontal, vertical and transverse posture of the craniomandibular complex?

How are the bones?

How’s the cartilage?

How’s the articular disk?

How are the muscles in this system?

How is the cervical spine in relation to the whole system?

How is the relation of the vertebral column with the other parts of the system?

The teeth, the two temporomandibular joints and the postural musculature are parts of the same bone, the mandible. They are deeply interrelated and interdependent in growth, form, and function. An abnormality in one, profoundly affects the others.

1 frente

A 30-year-old female patient presents at the clinic with a history of headache, pain in the forehead, pain and stiffness in the nape of the neck, left eyebrow pain, pain behind the right eye, and pain in the right shoulder. The patient reports TMJ pain (temporomandibular joint) on the right side.

The patient reports bilateral crackling, non-specific facial pain, and muscle tremor, difficulty opening the mouth, difficulty in chewing and mandibular locking.

Summary report written by the patient:

I do not remember a sudden drop where there might have been some kind of injury.
At 6 years of age I was a gymnast. I always had falls, front, back and head. But there were protections on the floor.

Near 8 years old, I extract a molar from the lower left side. I think that from this I have always forced more chewing on the right side.

At approximately 13/14 years of age, I remember starting the cracks on the right side. On this side I had a cross bite and a deciduous canine that “bit” behind the lower tooth.

At this stage, the crackling became more frequent, causing a bit of difficulty to fully open the mouth.  When trying to open the mouth without the snap, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

In 2004 I had the first “lockup”. I remember being in winter and cold. I tried to do the “game” of the jaw and I could not open the mouth. Then I forced myself to open my mouth and I felt a strong crack, followed by pain in the ear / nose. The impression was that it had displaced some bone / nerve.

From this episode, whenever I force more the region, the locking happens. Ex: when I eat meats, candy, peanuts. Things that I need to force when chewing.

In 2008 I put orthodontic appliance to make the corrections. In the treatment, I made a process of spacing the teeth, with a device in the roof of the mouth to open the arch. I kept my teeth apart for a while.

After finishing the treatment, corrected the teeth, the clicks returned lighter. Approximately 1 year later, the locking returned as well. I started with headaches and cervical pain. I felt slight tingling in the head.

In 2015 I started to hear some kind of “sand” on the left side. Then I got pregnant and in this period began the crackling also on the left side. In February 2017 I had the first “lock” on the left side.

Now when I feel the locking, I try to relax the muscles well, leaving the jaw loose for a few minutes. Sometimes it returns to normal anyway, other times I have to force it with the opening of the mouth, causing a strong crack.

2 foto inicial perfil

Current information:

When I close my mouth, I feel my jaw line back slightly, to “marry” the bite. To keep my mouth “loose” and comfortable, I have to snap both sides, and let the jaw loose.

When I try to open my mouth without the snaps, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

Crashes usually occur:

– Yawning;

– In the morning (awake with the jaw locked);

– Eating meats.

2 tomo

CT: Part of the initial study of the patient sent before the consultation requested by another professional.

Anamnesis and clinical examination are a key part in the diagnosis of patients with TMJ pathology.

Computed tomography is an excellent image, but when we treat a synovial joint in a patient with TMJ pathologies, CT does NOT PROVIDE THE INFORMATION OF THE SOFT TISSUES.

Magnetic Nuclear Resonance (NMR) can give a lot of information and not just the position of the disk. It is essential to have the knowledge to KNOW WHAT TO DO WITH THIS INFORMATION.

We cannot treat a patient with mandible head necrosis or with medullary edema or arthrosis or rheumatoid arthritis or lupus in the same way that we treat another patient with only a wrong position of the jaw.

The temporomandibular joints of all these patients need to be decompressed, but that is only part of the problem.

3 dentes inicHabitual occlusion of the patient on the day of the consultation.

4 oclusaisUpper and lower occlusal views of the patient prior to treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

5 panoramica

Initial panoramic radiograph of the patient before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

6 laminografia

The laminography of the temporomandibular joints shows a modification of the growth axis of the mandibular condyles in both the left and right caused by a traumatism in the early childhood, (fracture in green stick).

Retro position of both mandibular heads in the articular fossae.

TMJ laminography in habitual occlusion and open mouth.

cicatriz do queixoThree-dimensional asymmetries in the head of the condyle may have been caused by different etiologies and cause morphofunctional pathologies.

Changes in the orientation of the mandible head occur in patients who have suffered blows in the chin region, either anteroposterior, vertical or lateral. We can observe in these cases a deformation of the head of the mandible in the form of curvature, with an anterior concavity, which in some cases may be so important which produces a compression of the retrodiscal region, causing severe symptoms.

7 frontal

Frontal radiography of the patient in habitual occlusion before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

8 teleperfil

Lateral radiograph of the patient in habitual occlusion before treatment.

9 c 7Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis and rectification of the cervical spine.

16 rnm inicial 1

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

17 rnm inicial 2

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

19 rnm inicial4

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

20 rnm dir inicial5

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

21 rnm inicial 6

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

22 frontal rnm inicial 7MRI: frontal slices of the right and the left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right and left temporomandibular joint evidences a severe loss of joint space.

24 atm aberta24a eletromiografia dinãmica habitual rolos de algodão

Dynamic electromyography record of the patient in habitual occlusion and with cotton rolls on the right side (second column), left side (third column) and both right and left sides (fourth column).

Note the improvement in recruitment of motor units in the fourth column.

25 registro cineciografico inicial

Patient’s initial record for the construction of the DIO ( intraoral device)

To correctly evaluate the Maxilomandibular relationship we should begin to consider the physiological rest mandible position.

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

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were deprogrammed electronically and a new physiological neuromuscular position at rest was recorded.

The patient has in this first record a pathological free space of 6,4 mm. 

The patient also presented a 0.4 mm  of mandibular retro position.

26 recalibraÇÃo da orteseRecalibration of the physiological neuromuscular position of the DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

28 ortoseOcclusion of the patient with the DIO (intraoral device)

With the record obtained with the jaw tracker an intraoral device (DIO) was made to reposition the mandible three-dimensionally.

The PHYSIOLOGICAL NEUROMUSCULAR position was recorded in the form of an occlusal bite record, which was later used to make a DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

29 controle da orteseAnother cinecigraphic record to control the DIO (intraoral device) in a physiological neuromuscular position as the device is changed or recalibrated.

The patient did not report any more symptomatology. The electromyography and kinesiography records objectively showed improvement of the neuromuscular function.

I asked for the second MRI (nuclear magnetic resonance) to objectively evaluate the physiological relationship between the mandibular condyles and the articular disc.

35 rnm comparativas 1RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

35b rnm comparativas 1RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

36 rnm comparativas 2RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

38 rnm comparativas 4RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

39 rnm comparativas 5

RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

40 rnm comparativas 6RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

41 rnm comparativas7RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

42 rnm comparativas 8RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ,  closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

43 frontal rnm comparativas 8

RNM: Comparison of the frontal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

44 frontal rnm comparativas 8

RNM: Comparison of the frontal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

45 imagens

The patient did not report any more symptomatology. The comparative MRI showed the recovery of the physiological relationship of the mandible head with the articular disc.

The electromyographic and kinesiographic records objectively showed improvement of the neuromuscular function.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the neuromuscular physiological occlusion.

For this we use a three-dimensional orthodontic, where the teeth are erupted to the new physiological neuromuscular position.

46 depoimento 1Patient Testimony:

My first memory of locking joints was at age 15 or so.

I looked for orthodontic specialists; I made the necessary “adjustments”, but the locking and the pain still continued.

I looked for Dr. Lidia now at the age of 30, since other experts told me that only surgery would be possible in my case. And yet, without knowing exactly whether we would succeed.

After starting the first phase of treatment with the device, the pain ceased and never again I had the jaw locking that so frighten me.

47 depoimento 2

I adapted very easily to the treatment, I was and I am being much disciplined with the use of the device.

Now, as Dr. Lidia explained to me, with the discs already in the right place, we will pass for the second phase, for withdrawal of the device.

Today I’m having a routine without worry that I can “lock” at any time.

I’m very grateful to Dr. Lidia.

TMJ Pathology in Professional Musicians: A look beyond the risk factors. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

Several articles and studies cite the prevalence of TMJ dysfunction in violinists and violists, especially by prolonged flexion of the head and shoulder, posture necessary to keep the violin in position. Studies also report that the incidence of TMJ dysfunction in musicians is similar to the general population.

Professional musicians require many hours of training and improvement that involve complicated movements, fast and repetitive actions with over use of the hands, fingers, arms and head.

Most articles report anxiety about professional performance and increased muscle tension, but few do a particular study of the state of the anatomical structures of the cases studied.

1 postura inicial frontalA 45-year-old female patient referred by her physiotherapist consults with complaints of headache, pain in the cervical and scapular region, muscular contractures in the mandible.

The patient also reports mandibular displacement when playing the violin and pain in both temporomandibular joints.

2 postura inicial lateralThe patient also reports clicks in both temporomandibular joints and occasionally the sensation of clogged ears.

Frequent pain in the spine and both shoulders.

At that time the patient had already consulted physiotherapists, rheumatologists, psychiatrists and psychologists.

2 bpontos de dorMarking chart of pain points.

3 OCLUSÃO INICIALImage of the patient’s habitual occlusion on the day of the appointment.

4 OCLUSAIS INICIAISUpper and lower occlusal views of the patient on the day of the consultation.

5 PANORAMICA 1Initial panoramic radiograph of the patient before treatment.

Teeth 18, 28 included.

Wear on the incisal and occlusal faces of the teeth present.

Prosthetic device 25 to 27 (26 pontic)

Horizontal resorption of alveolar ridges.

6 LAMINOGRAFIA INICIALPatient’s TMJ initial laminography before treatment

In the maximum opening position, observe the anterior angulation of the articular processes. Structural modification of the mandibular condylar process as one of the sequels of traumatism in infancy.

The patient reports a trauma in early childhood, a knock on the head while playing on a slide.

7 TELEPERFILLateral radiograph and patient profile before treatment. Patient in habitual occlusion.

8 FRONTALFrontal radiography of the patient in habitual occlusion before treatment.

9 C7Lateral and cervical radiograph of the patient in habitual occlusion before treatment.

At this time, the patient performed a CT scan of the cervical spine

In the report there is rectification of cervical lordosis.

Degenerative discopathy in C5-C6, observing reduction of the height of the disc space and osteophytic proliferations reactional. At this level the disc-osteophyte bar is identified that touches and distorts the ventral face of the dural sac.

There is no stenosis of the central vertebral canal.

Neural foramina with amplitude within the limits of normality.

Mild signs of uncovertebral arthrosis C5 and C6.

Relationship C1-C2 maintained.

Symmetric paravertebral regions.

10 eletromiog dinamica inicialDynamic electromyographic record in patient’s habitual occlusion before treatment. Note the minimal activation of the right and left masseter muscles in maximal intercuspation and the high activation of the right and left temporal muscles.

The masseter muscles are the most powerful muscles of the stomatognathic system, the temporal muscles even being elevating muscles have to have an equal and preferably smaller activation than the masseter muscles.

11 cineciog 1Initial cineciographic record of the patient.

Three-dimensional view of the mandibular displacement.

The record shows mandible opening, closing and speed when the patient makes these movements. The patient shows a 47 mm opening and a right deflection of 3.9 mm

Note a significant  loss of velocity in the middle of the mandibular closure.

13 ress esq fechMRI: sagittal slice of the left TMJ, closed mouth, anteversion of the mandibular condyle can be observed.

14 ress esq fechMRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

15 ress esq fechMRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

16 ress esq fechMRI: internal sagittal slice of the left TMJ, closed mouth.

17ress dir fechMRI: internal sagittal slice of the right TMJ, closed mouth.

18ress dir fechMRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

19 ress dir fechMRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

20 ress dir fech

MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Note the posterior compression in this section.

Primary objective has to be the three-dimensional decompression of the mandibular condyle.

21 FRONT DIR E ESQMRI: frontal slice of right and left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right temporomandibular joint shows a loss of joint space, especially in the region of the external lateral pole of the joint. Both frontal images show a decrease in joint space.

Slight medial disc deviation.

21A registro inicial para o DIOTo correctly evaluate the maxillomandibular relationship we should begin to consider the physiological rest mandible position.

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

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were deprogrammed electronically and a new physiological neuromuscular position at rest was recorded.

The patient has a pathological free space of 5.8 mm, already discounting the two physiological mm of a healthy free space.

The patient also presented a 2.1 mm mandibular retroposition

22 oclussao com o DIOWith these data we constructed a DIO (intraoral device), to maintain the three-dimensional recorded position. This device must be electromyographically tested to objectively measure the patient.

It is logical that the report of the patient’s symptomatology is important, but the surface electromyography shows in an objective way if the muscular function improved, worsened or did not modify.

22A eletromiografia com o DIOElectromyographic record with DIO (intraoral device) in physiological neuromuscular position.

Note the higher recruitment of motor units in the masseter muscles that previously showed very little activity.

22A Registro cinesiográfico para controlar o DIO em posição neurofisiológicaCineciographic record for the DIO (intraoral device) control in physiological neuromuscular position as the device is changed or recalibrated.

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

Each case IS UNIQUE. There are cases where the TMJ structures are so damaged that the objectives outlined will have limitations dictated by the initial diagnosis.

These limitations refer not only to the structures of the temporomandibular joint, but also to the patient’s systemic condition.

22B 2 Registro cinesiográfico para controlar o DIO em posição neurofisiológicaAnother cineciographical record to control the Dio in a physiological neuromuscular position as the device is changed or recalibrated.

23 laminografias comparativas com dioComparison of left and right temporomandibular joint laminography, closed and open mouth: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

24 ct comparativas com dioComparison of lateral radiographs and cervical spine of the patient: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

With the jaw in a physiological neuromuscular position the physiotherapist colleague worked the rest of the muscle chains, using global manual techniques, always taking into account the individuality of the patient. This work in a patient with degenerative discopathies should be maintained

25 rad lateral e perfilComparison of lateral radiographs of the patient: in habitual occlusion before the treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

Improvement of the profile and recovery of the vertical dimension.

26TELEFRONTAIS COMPARATIVASComparative frontal radiographs of the patient: at the beginning of treatment in habitual occlusion, during treatment with DIO (intraoral device) in physiological neuromuscular occlusion.

27 PANORAMICA com o DIOPanoramic radiograph of the patient with the DIO constructed in a physiological neuromuscular position.

47 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

48 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

49 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

50 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

51 ress direita comparativa 1MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

51a ress direita comparativa 1MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

52 ress direita comparativa 1MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

53 ress esquerda frontal comparativa 1

MRI: Comparison of the frontal slice of the LEFT TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same LEFT TMJ after the FIRST PHASE.

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

54 ress direita frontal comparativa 1

MRI: Comparison of the frontal slice of the RIGHT TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same RIGHT TMJ after the FIRST PHASE.

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

The patient did not report any more symptomatology related to the TMJ. Bioinstrumentation also objectively showed an improvement in neuromuscular function.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the physiological neuromuscular occlusion.

For this we used a three-dimensional orthodontic, where the teeth are erupted to the new neurophysiological position.

55 ORTO 1In the second phase, in this case the three-dimensional orthodontics the patient is monitored and deprogrammed electronically, and often the device is recalibrated, to maintain the position obtained in the first phase.

Part of the sequence of the second phase (in this specific clinical case).

56 PANORAMICA COM O IMPLANTEPatient’s panoramic radiograph after the installation of the implant and the removal of the retained upper third molars.

57 ORTO 2Part of the sequence of the second phase (in this specific clinical case).

58 ORTO 3Part of the sequence of the second phase (in this specific clinical case).

59 ORTO 4Part of the sequence of the second phase (in this specific clinical case).

60 ORTO 5

Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.

61 ORTO 6Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.

62 ORTO 7Part of the sequence of the second phase (in this specific clinical case).

63 ORTO 8Part of the sequence of the second phase (in this specific clinical case).

64 ORTO 9Part of the sequence of the second phase (in this specific clinical case).

65 ORTO10Part of the sequence of the second phase (in this specific clinical case).

66 ORTO101Part of the sequence of the second phase (in this specific clinical case).

67 ORTO102Part of the sequence of the second phase (in this specific clinical case).

68 ORTO103Part of the sequence of the second phase (in this specific clinical case).

68 RETIRADA DO DIORemoval of the DIO (intraoral device)

69 ORTO104Part of the sequence of the second phase (in this specific clinical case).

70 ORTO105Finalization of the second phase.

71 OCLUSAL FINALPatient’s upper and lower occlusal view after the finalization of the second phase.

72 b panoramicas comparativasPatient’s comparative panoramic radiographs before and after the end of the second phase of the treatment using a three-dimensional orthodontics.

72 comparação OCLUSAIS FINAISPatient’s comparative superior and inferior occlusal view, before and after, the end of the second phase of the treatment by a three-dimensional orthodontic.

72 OCLUSÃO IcomparativasComparative occlusion of the patient before and after the end of the second phase of the treatment using a three-dimensional orthodontics.

77 registro controle após a ortodontiaKinesiographic control record after the completion of the three-dimensional orthodontics in a physiological neuromuscular position.

Coincident neuromuscular trajectories.

73 laminografias finalLaminography of the patient in physiological neuromuscular occlusion after the finalization of the second phase of the treatment.

74 3 laminografias comparativasComparative laminography of the patient: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

75 TELEFRONTAIS COMPARATIVASPatient’s comparative frontal radiographs: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

76 rad lateral e perfil comparativas 3Patient’s comparative lateral radiograph and profile: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

78 DEPOIMENTO 1

Patient testimony:

What made me look for the treatment were recurrent headaches, frequent

(weekly) and intense, which lasted, on average, 2 days, affecting my productivity

at work as well as leisure hours.

The pain did not subside with common analgesics, requiring strong medication, which, in turn, only softened the pain a little.

Today, after the treatment, I can say that only very rarely do I suffer from these pains, greatly improving the quality of life, besides the posture.

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

14 ressonancia

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

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

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

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

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

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

15 ressonancia

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

Other slice of the same MRI:

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

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

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

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

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

16 ressonancia

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

Other slice of the same MRI:

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

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

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

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

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

17 ressonancia

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

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

Superior flattening, anterior marginal osteofhyte.

Anterior dislocation of the articular disc.

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

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

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

20 ressonancia

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

Other slice of the same MRI:

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

Superior flattening, anterior marginal osteofhyte.

Anterior dislocation of the articular disc.

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

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

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

21

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

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

Remember ANATOMY IS THE PLATFORM WHERE PHYSIOLOGY PERFORMS.

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

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

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

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

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

This record is three-dimensional.

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

Trunk antepulsion position improved;

Improvement of the shoulder anterior rotation;

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

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

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

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

Improvement  of the cervical spine physiological curve.

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

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

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

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

14 ressonancia

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

Comparative MRI images after the first phase of the treatment.

36 RNM AFTER TREATMENT

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

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

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

15 ressonancia

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

Comparative MRI images after the first phase of the treatment.

39 RNM AFTER TREATMENT 2

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

Comparative MRI images after the first phase of the treatment

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

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

16 ressonancia

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

Comparative MRI images after the first phase of the treatment.

40 RNM AFTER TREATMENT

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

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

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

17 ressonancia

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

42 RNM AFTER TREATMENT

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

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

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

20 ressonancia

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

Comparative MRI images after the first phase of the treatment.

44 RNM AFTER TREATMENT

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

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

Observe the positive remodeling of the cortical bone.

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

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

The structures continue to improve.

46 3 RIGHT TMJ

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

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

47 LEFT TMJ

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

The structures continue to improve.

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

We need to know:

Has the TMJ  a pathologic condition?

If positive, which structures are damaged?

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

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

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

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

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

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