TMJ Pathologies Treatment: Patient with Severe Headaches and Temporomandibular Joint Pain with Significant Contour Irregularities in the Mandibular Condyle and Mouth Opening Limitation.

In several publications of this page I have presented patients of different ages, different gender and different pathologies of the temporomandibular joints.

This is the second case report about a patient with prosthetic protocols built on implants.

I call once again the importance of  the attention in the diagnosis of temporomandibular joints pathologies and mandibular position as a key part of any procedure in dentistry.

1 FOTO INIC FRONTAL

Female patient 54 years old arrived to the clinic for consultation with severe headache complaints, pain in the temporomandibular joints, pain in the cervical spine, sore shoulders, ear pain, feeling of clogged ears and crepitation in both temporomandibular joints.

2 FOTO INICIAL PERFIL

The patient was referred by her dentist who performed the treatment of implants and prosthetics, rehabilitating the patient, but without being able to relieve the pain that afflicted her.

2A MARCAÇÃO DA DOR

Part of the questionnaire completed by the patient.

The patient reports daily pain.

FUNCTIONS THAT AGGRAVATE HER PAIN:

Mastication

Opening the mouth

Laughing

Yawning

The patient also refers back pain and numbness and tingling in the arms and fingers.

Refers that she wakes up with body aches.

3 DENTES INIC PROT FRONTAL

Patient habitual occlusion on the day of consultation.

The patient had fixed prostheses supported on implants on the lower jaw and a removable upper protocol supported on implants on the maxilla.

4 OCLUSAIS INICIAL PROTPatient’s superior and inferior oclusal view of the prostheses supported on implants on the day of consultation.

5 DENTE INICIAL SEM PROT

Image of the oral cavity of the patient without the upper prosthesis.

6 OCLUSAIS INIC SEM PROT

Patient’s superior and inferior oclusal view without the superior prostheses.

7 PANORAMICA INICIAL

Patient’s initial panoramic radiograph before treatment with the prosthesis in the habitual occlusion before treatment.

Presence of 4 metallic implants in the maxilla 2 on the right side and 2 on the left side; and 5 implants in the anterior mandible region.

8 LAMINOGRAFIA INCIAL

Patient’s TMJ right and left laminography, closed and open mouth: posterior positioning of the articular processes in the joint cavities when the jaw is in maximum intercuspation position.

9 TELE PERFIL INICIAL

Patient’s lateral radiograph with prosthesis in habitual occlusion.

10 C7 INICIAL

Patient’s lateral radiograph and cervical spine with prosthesis in habitual occlusion before treatment.

Alterations of the cervical spine, loss of physiological lordosis and loss of intervertebral spaces especially between the vertebrae C4, C5 and C6.cefalometria 2013 ingles

Ricketts cephalometric analysis before treatment with prostheses in habitual occlusion.

FACTORES CEF ANTESSS

Values of point A convexity and lower facial height before treatment.

11 FRONTAL INICIAL

Frontal radiograph of the patient with the prosthesis in habitual occlusion.

12 RNM DIREITA INICIAL

MRI, sagittal slice of the right TMJ closed mouth: there is an irregularity of contour with reduction of the superior aspect of the mandibular condyle, the condyle is ante versioned. There is a small anterior osteophyte.

The articular disc is displaced anteriorly, WITHOUT REDUCTION when the mouth opens.

Presence of subcortical bone cysts in the anterior superior aspect of the mandibular condyle.

13 RNM  ESQ  INICIAL

MRI, sagittal slice of the left TMJ closed mouth: there is a substantial irregularity of contour of the upper portion of the mandibular condyle, with the formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

13A RNM  ESQ  INICIAL

MRI, another sagittal slice of the left TMJ closed mouth: there is an important  irregularity of contour of the superior aspect of the mandibular condyle and a formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

16A  ESQ boca fechada 2013 T2

MRI in T2 clearly shows the joint effusion.

The differential diagnosis of TMJ effusion has a broad spectrum as the effusions in other joints in other parts of the skeleton.

MRI (magnetic resonance imaging) can give us a lot of information, not just the disc position.

14  RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

MRI, frontal section of the right and left TMJ, closed mouth. Upper lesion in the right mandibular condyle, as described in the same sagittal slice of the same condyle as subcortical bone cysts.

In the slice of the mandibular head on the left side can be seen an important hipossinal compatible with avascular necrosis.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. It can be caused by various conditions, such as bone or joint damage, pressure inside the bone and other medical conditions.

The condyle affected by avascular necrosis has low signal on T1-weighted images as a result of edematous changes in trabecular bone.

14 SERIE DE RESS DIR FECHADA 2013

Sagittal sections of the right TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

14 SERIE DE RESS DIR ABERTA 2013

MRI,sagittal sections of the right TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

15  SERIE DE RESS ESQ FECH 2013

MRI, sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

15 SERIE DE RESS ESQ ABERTA 2013

MRI,sagittal sections of the left TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

16 series ESQ boca fechada 2013 T2

MRI, T2 sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the image I find most relevant, but also this series are registered.

Serial in T2 clearly showing the joint effusion.

Tests were done on the patient to investigate systemic inflammatory disease, which were all negative.

It was also investigated chlamydia trachomatis infections, mycoplasma pneumoniae infections and beta hemolytic streptococcus infections , results in this case were also negative.

It was also investigated the functioning of the thyroid.

17 REGISTRO CINECIOGRAFICO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and DIO (intraoral device) was constructed in neurophysiological position. In other publications computerized kinesiographic methods were mentioned.

In occlusion most often the healthy or pathological condition of the inter-oclusal space is not objectively considered. In this case the free space of the pathological patient is almost 7 mm and a retro position 0 8 mm.

18 DIO SOBRE A PROTESES

With this data and ALWAYS WITH THE INFORMATION OF IMAGES, we built a DIO (intraoral device) to keep the three-dimensionally recorded position.

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

19 CONTROLE DA ORTESE

It is essential to control the DIO (intra oral device) as the patient is treated and the mandible is repositioned.

In this case the control still shows us the need for recalibration of the DIO (intraoral device)

19 PANORAMICA COMPARATIVA

Comparative panoramic radiographs: before treatment and after neurophysiological treatment.

20 FRONTAIS COMPARATIVAS

Patient’s frontal radiographs comparison: with the prosthesis in habitual occlusion and the DIO intraoral device built on the prosthesis.

20 LAMINOGRAFIA COMPARATIVAS

Right and left temporomandibular joints laminographies, closed and open mouth comparison: with the prosthesis in habitual occlusion and with the DIO intraoral device built on the prosthesis.

cefalometria 2014 CORTADA ingles

Ricketts cephalometric analysis after treatment with the DIO constructed on the prostheses in neurophysiological occlusion.

FACTORES CEF APOSSS

Values of point A convexity and lower facial height after treatment.

21 PERFIS COMPARATIVOS

Patient’s lateral radiographs comparison: with the prosthesis in habitual occlusion and with the DIO built on the prosthesis in neurophysiological position.

The DIO (intra oral device) is used to support, align and correct deformities in order to improve the functions of the jaw, temporomandibular joints and the muscles that move both. This device should be checked and recalibrated as the records indicate the need for modification.

21A PERFIS COMPARATIVOS

Comparison of aesthetic Ricketts plane in lateral radiograph with prosthesis in habitual occlusion and the DIO constructed on the prosthesis in neurophysiological position.

21 RNM COMPARATIVAS ESQ SAGITAL

Comparison of T1-weighted images: before treatment and after treatment: we can see the improvement in medullary signal.

26 comparativas ESQ boca fechada 2013 e 2014T2

Comparison of T2-weighted images: before and after treatment. It is clear in the first image the inflammatory signal and in the other image the improvement of the intramedullary signal and the remission of posterior effusion.

22 RNM Comparativas direita sagital

Comparison of T1-weighted images: before treatment and after treatment, we can see the improvement in medullary signal and improvement of the cortical bone.

23 RNM Comparativas direita FRONTAL

Frontal T1-weighted images comparison, before and after treatment treatment: we can see the improvement of the upper lesion on the right mandibular condyle.

24 RNM Comparativas ESQUERDA FRONTAL

Frontal T1-weighted images comparison, before and after treatment: we can see the improvement in medullary signal and improvement of the cortical bone of the left mandibular condyle.

25 SERIE DE RESS DIR ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the right TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

25 A SERIE DE RESS ESQ ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the left TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

COMPARATIVAS FRONTAIS POSTURAIS

Patient’s postural frontal comparative images before and after treatment.

COMPARATIVAS POSTURAIS PERFIL

Patient’s  postural profile comparative images  before and after treatment.

27 CEF COMPARATIVAS ingles

Ricketts cephalometric analysis before and after neurophysiological treatment.

COMPARAÇAO DOS FATORES

Skeletal problems in Ricketts cephalometric analysis before and after treatment.

28 DEPOIMENTO

“Headache (already when waking up in the morning), tiredness sensation at the cheekbones, strong tensing at the shoulders and neck, “clicks” at the temporomandibular joint, ear pain… consequently I also felt irritation, indisposition, stress etc.

All of that is something I had to live with for a long time. The investigations made on me always resulted in palliative measures that mitigated the problem for a short time.

I passed through implants and placement of prostheses which even without having (those measurements) the aim of healing this malaise I still had the hope that it would: but the relief only worked for a short period of time. Finally, by indication of my dentist, I arrived at Clinic MY starting then the TMJ treatment. Shortly after the start of the treatment the symptoms started to fade.

I am very thankful for the professionalism and dedication that I found there. Today, feeling better, I go back there for periodic evaluations and also to have the opportunity of thanking  once more.”

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

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

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

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

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

Idiopathic scoliosis is probably multi aetiological

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

1 a

Patient narrative: brief history of the surgery:

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

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

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

1 B JANELA

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

22- 10 -2004  1

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

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

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

25-08-2004   2

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

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

4-11-2004  3

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

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

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

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

15-02-2005  4

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

todas juntas

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

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

CONTROL REPORT OF COLUMN XR PANORAMIC SPINAL AFTER SURGERY:

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

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

REASON FOR THE CONSULTATION AT CLINIC MY:

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

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

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

2 perfil direito e esquerdo

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

3 frente e costas

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

4d locais da dor

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

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

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

7 panoramica inicial

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

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

8 laminografia inicial

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

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

9 teleperfil inicial

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

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

10 FRONTAL

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

Note the loss of vertical dimension.

11 C7

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

Note the the cervical curvature inversion at C4 level.

11 RESS DIR 1 BOCA FECHADA

MRI of the right TMJ:

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

11 RESS DIR 2 BOCA FECHADA

MRI of the right TMJ:

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

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

11 RESS ESQ  1 BOCA FECHADA

MRI of the left TMJ:

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

11 RESS ESQ  2 BOCA FECHADA

MRI of the left TMJ:

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

Traumatism history reported by the patient

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

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

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

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

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

12 registro neurofisiológico

Mandibular rest neurophysiological position record.

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

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

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

13 DENTES ORTESE

DIO: Intraoral Device constructed in neurophysiological position.

14 ELETROMIOGRAFIA  controle da ortese

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

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

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

14A controle da ortese

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

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

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

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

17 C7 COMPARATIVAS

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

18 LAMINOGRAFIAS COMPARATIVAS

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

19 RADIOGRAFIAS PANORAMICAS COMPARATIVAS

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

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

21 ress COMP ESQ  1 e 2

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

22D Comparativas de perfil com e sem ortese

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

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

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

After treatment:

PATIENT TESTIMONY:

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

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

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

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

Description of habitual orthostatic position in the sagittal and frontal planes

24

Sagittal plane:

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

Picture 1 – patient in habitual occlusion before treatment:                     

 

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

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

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

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

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

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

Probably the use of intraoral device relieved such overloading .

25

Frontal plane

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

Picture 1: Patient in habitual occlusion before treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They may also produce an abnormal curvature of the spine.

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

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

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

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

Relates pain in both shoulders.

1B FOTO FRENTE

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

He refers a sensation of blocked ears and bilateral tinnitus.

2 FOTO PERFIL

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They may also produce an abnormal curvature of the spine.

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

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

9A 1 RNM 2

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

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

9A 2 RNM 1

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

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

9A 2 RNM 2

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

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

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

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

9A 4 RNM

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

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

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

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

The stomathognatic muscles are not the exception.

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

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

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

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

12 DENTES ORTESE

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

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

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

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

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

9A 1 RNM

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

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

9A 2 RNM

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

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

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

Habitual occlusion of the patient before treatment.

Patient’s occlusion  with the DIO ( intraoral device)

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

Installation of an upper removable expander.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

32 COMPARAÇAO PERFIL

 

 

 

 

 

 

 

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

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

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

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

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

32  FINAL DEPOIMENTO ingles

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

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

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

33 FINAL

 

 

TMJ Study and Investigation Page. One year of publication

Dear friends,

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

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

INITIAL

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

site em portugues nova ingles

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

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

31

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

english 1-1

Anatomy is the platform on which physiology functions

Sem Título-1

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

26

Articular discs recapture with mandibular neurophysiological repositioning

26

Cervical Dystonia or Spasmodic Torticollis: Positive evolution after Neurophysiological Treatment

2

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

17 COLUNA E PERFIL COMP

Inter relation of Craniomandibular disorders and vertebral spine. Case report

24

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

FINAL

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

FINAL

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

33

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

Sem Título-1

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

6 BASAL ANTES E APOS O DEM

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

18 comparativas

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

15 3D comparativas

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

37 poster

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

41 RNM AFTER TREATMENT cor

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

evento 4

Training in Diagnosis and Treatment of TMJ Pathologies

31

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

e images.

26B LATERAIS COMPARATIVAS LINHA

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

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

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

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

Dr. Lidia Yavich

 

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.

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