The temporomandibular joint (TMJ) as a peripheral trigger in the headache. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

1 FRENTEA 36-year-old female patient with a major complaint of headache consults at the clinic, referred by a co-worker who had been treated at the clinic for the same reason.

The patient’s main complaint was a high frequency headache. The patient reports that she has investigated the cause of the pain and even had at the request of the neurologist a nuclear magnetic resonance of the skull that did not accuse any abnormality.

1 PERFILThe patient had already consulted with Neurologist, Otorhinolaryngologist, Orthopedist and with the general practitioner.
The patient also refers back pain.

2 DENTES INICIAISHabitual occlusion of the patient on the day of the consultation.

3 OCLUSAISUpper and lower occlusal views of the patient on the day of the consultation.

Upper and lower incisors show signs of  attrition.

7 PANORAMICAInitial panoramic radiograph of the patient before treatment.

Absence of the second right upper premolar and the lower third molars.

The patient reports that the upper premolar was extracted in adolescence due to lack of space for the eruption of the canine.

The first maxillary molar on the left side and the first lower molar on the left side presented endodontic treatment with extensive restorations and risk of fracture, was informed of the need to extract the third molar retained.

The procedures would only be performed after joint decompression.

8A LAMINOGRAFIALaminography of the temporomandibular joints shows a modification of the axis of growth of the mandibular condyle on the left side caused by a trauma in the early childhood, (green stick fracture).

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

5 C7Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis, rectification of the cervical spine.

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

8b ressonancias sagitaisMRI: sagittal slices of the left TMJ, the closed mouth.

The facet on the upper surface and posterior flattening of the mandibular condyle can be observed.

8Dressonancias sagitais CORTES SUPERIORESNote the important posterior compression of the left condyle.
Primary objective has to be the three-dimensional decompression of the mandibular condyle.

8B CINECIOGRAFIA 1BThe patient’s masticatory muscles were deprogrammed electronically and the resting position was recorded with a computerized kinesiograph.
The patient had a pathological interocclusal free space of 6.3 mm and a mandibular retroposition of 0.5 mm.

9 ORTESEWith the record obtained with the computerized jaw tracker an intraoral device (DIO) was made to achieve the three dimensionally reposition of the mandible.

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

9D PANORAMICA COM ORTESEPanoramic radiograph of the patient during treatment with the DIO (intraoral device).

9C COMPARATIVAS DE TELEPERFIL 1Comparison of lateral radiographs and patient profile: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

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

10A C7 COMPARATIVASComparison 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.

10B CONTROLE ORTESEControl of intraoral device  (DIO). THESE CONTROLS ARE FREQUENTLY MADE during the first and second phases of the treatment modifying and improving the PHYSIOLOGICAL NEUROMUSCULAR POSITION.

The patient did not report any TMJ-related symptomatology. 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 use a three-dimensional orthodontic, where the teeth are erupted to the new neurophysiological position.

19 ORTO 0Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

20 ORTO 1Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

21 ORTO 2Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

22 ORTO 3Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

23 ORTO 4Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

24 ORTO 5Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

25 ORTO 6During three-dimensional orthodontics the DIO (intraoral device) is recalibrated and changed to maintain the position obtained in FIRST PHASE

Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

26 ORTO 7Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

27 ORTO 8Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

29 ORTO 9Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

30 ORTOSequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

Preparation to increase the width of the upper incisors respecting the patient’s Neuromuscular Physiological position.

31 ORTOSequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

Preparation to increase the width of the upper incisors respecting the patient’s Neuromuscular Physiological position.

32 orto finalCompletion of the First and Second Phases in the treatment of TMJ Pathologies. Physiological Neuromuscular Rehabilitation.

In this specific sequence, another possibility was proposed for the patient with an important improvement of aesthetics for the increase of the clinical crowns of the upper incisors, due to the limitation in this case of the composite resins.

The patient alleged: that she did not work on television, that even knowing the aesthetic limitation of the procedure with resins, she was satisfied.

For her the goal of the treatment was the resolution of the PAIN, and that had been reached.

33 OCLUSAIS FINAISUpper and lower occlusal views of the patient after the end of the second phase.

34 PANORAMICA FINALPanoramic radiograph of the patient after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

The extraction of the first maxillary molar and the placement of an implant after bone grafting was necessary. The third left retained molar exodontia was also performed.

35 LAMINOGRAFIA FINALTMJ laminography of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

36 PERFIL FINALLateral radiograph and profile of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

37 C7 FINALLateral radiograph and cervical spine of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

38 FRONTAL FINALFrontal radiography of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

39 FRONTAIS COMPARATIVASComparative frontal radiographs of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

40 C7 COMPARATIVASComparative lateral radiographs and cervical spine of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

41 PERFIL 3 COMPARATIVASComparative lateral radiographs and profile of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

43 DENTES COMPARATIVASComparative occlusion of the patient before and after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

44 OCLUSAIS comparativasComparative upper and lower occlusal view of the patient before and after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

45 CINECIOGRAFIA final.jpgCineciographic record after completion of the first and second phases of physiological neuromuscular treatment. The neuromuscular trajectories are coincident. We would have liked to have an interocclusal space of 2.5 to 3 mm, we obtained 4.1 mm

46 DEPOIMENTO 1Patient testimony

Dear Lidia,

You know, I really realized how much the treatment I’ve undergone improved my quality of life when I was in the clinic this year (2018) and I looked at my file with the information I had recorded when I started treatment.

To be honest I did not even remember that before the treatment I had pains in the jaw joints !! And how strong they were.

I always had headaches and migraines, besides the pains in the joint of the mandible. I always record it because I remember when I was a child I already felt them. I felt very ill and indisposed when I had crises.

In a certain phase of my life due to the increase in the frequency of pain headache and the constant vomiting I went to many doctors because I thought I was with stomach problem. I thought my headaches and migraines were consequence.

47 DEPOIMENTO 2But based on the examinations I made at the time, my general practice told me that the question of the stomach was actually a consequence of severe headaches and migraines.

So she told me to go to a neurologist for evaluation and treatment. I went to the neurologist, did tests, treatment, tried to avoid the huge list of foods he I was informed as probable triggers of migraine. Everything I did reduced the headaches, but it did not solve the problem that plagued me.

And it was during one of my “crises” of headache that a coworker commented the possibility that I would make an evaluation with a dentist who had treated him when had problems with the TMJ. To be honest, I had no idea what it was, but when if you have pain, every attempt is valid.

47 DEPOIMENTO 3I made the appointment, made available the exams I had already done in the region of the head and remember that in my first conversation with Lidia she commented that the exams indicated that in my infancy I had probably suffered a fall that caused a growth modification of my jaw.

Exactly the side where I had the headaches and the migraine.

I stress that at no time did the treatment for an aesthetic question, but rather seeking, if it is not possible to avoid the pains, but minimizes them.

I spent several years attending the clinic. I remember that my splint in one of the stages of the treatment was a “big monster” (kkk) considering its height.

Gradually throughout the treatment I was noticing the reduction of headaches and of frequency between migraine attacks.

Today, thinking about before and after treatment, I realize how much the treatment,

although prolonged, has improved my quality of life.

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