Treatment of TMJ Pathologies: Patient with headache and excessive clenching. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

1 frontal inicial rosto

A 32-year-old male patient presents at the clinic with complaints of constant headaches, pain in the jaw and daily pressure on the teeth.
The patient also reports pain in the temporomandibular joints and pain to open the mouth.

2 lateral inicial rosto

The patient also reports bilateral clicks and the sensation of clogged ears.
It also states in its clinical history difficulty in chewing and opening the mouth and inability to control teeth tightening.
The patient reported that he sought various dentists and treatments and that he had previously used “miorelaxant” splints that did not alleviate the referred symptoms.

3 OCLUSÃO 1

Habitual occlusion of the patient on the day of the consultation.
The patient had a deep bite and significant wear on the upper and lower incisors.

4 OCLUSAIS

Upper and lower occlusal views of the patient prior to treatment. Wear on lower and upper incisors.

5 PANORAMICA INICIALInitial panoramic radiograph of the patient before treatment.

Absence of teeth 18, 28, 38, 48.

Horizontal resorption of alveolar ridges.

6 P6 INICIAL

Patient TMJ laminography in habitual occlusion before treatment.

The laminography of the temporomandibular joint shows retroposition of the articular processes in the articular cavities when the mandible is in position of maximum intercuspation
In the mandibular aperture, the presence of osteophytes was observed in both condyles.Flattening of the superior anterior surface of the articular processes and superior posterior of the right articular process.

7 TELE PERFIL INICIAL

Lateral radiograph and patient profile in habitual occlusion before treatment. Rectification of the cervical spine.

8 C7 INICIAL

Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Rectification of the cervical spine.

9 FRONTAL INICIAL

Frontal radiography of the patient in habitual occlusion before treatment.

10 ress1

MRI: sagittal slices of the left closed TMJ before treatment. The mandibular head is in retro position. The joint disc is slightly dislocated.
The articular disc has a reduction in open-mouth maneuvers. Open mouth images not included in this post.

11 ress3

MRI: sagittal slices of the left closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

12 b ress

MRI: sagittal slices of the right closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

13 ress4

MRI: sagittal slices of the right closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

13 cineciog 1

Patient’s initial cineciographic record
Three-dimensional view of the mandibular movement.
The record shows opening and closing and speed when making these moves. The patient shows an opening of more than 50 mm
Note a significant loss of speed in the mandibular closure.

13 eletromiografia inicial

Dynamic electromyographic record in patient’s habitual occlusion before treatment.

Note very little activation of the right and left masseter muscles in maximal intercuspation, indicating to the patient to bite hard without opening his mouth.

The masseter muscles are the most powerful muscles of the stomatognathic system, even more considering a  brachyfacial biotype patient as in this case.

13 REGISTRO

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

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

The stomatognathic musculature is no exception.

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

The patient has a pathological free space of 8,2 mm, already discounting the two physiological mm of a healthy free space.

The patient also presented a 2 mm mandibular retro position

13C PRIMEIRA ORTESE LUIS

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

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

13A FRONTAL DIO

Frontal radiography of the patient with the DIO (intraoral device) constructed in a physiological neuromuscular position.

13B LATERAL COM DIO

Lateral and cervical radiograph of the patient with the DIO (intraoral device) constructed in a physiological neuromuscular position.

The second MRI is requested after one year on average of the first phase treatment, also during the second phase of the treatment, the patient is monitored, and the device recalibrated or changed according to the controlled data throughout this step.

14 ress comp 1

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc.

15 ress comp 2

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

16 ress comp 3

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

17 ress comp DIR

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

18 ress comp DIR

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

19 ress comp DIR

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

20 PRIMEIRA ORTESE DA 2 FASE

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

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

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

21 ORTO 1

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

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

22 ORTO 2

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

23 ORTO 3

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

24 ORTO 4

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

25 ORTO 5

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

26 orto 6

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

27 orto 7

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

28 ORTO 8

Finalization of the second phase.

29 OCLUSAIS FINAIS

Patient’s upper and lower occlusal view after the finalization of the second phase.

43 oclusoes comparativas

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

The non-coincidence of the median dental lines may be noted.
The patient’s fundamental alignment is muscle alignment that does not always coincide with tooth alignment. In this case the muscular alignment is respected.

44 oclusoes comparativas

Patient’s comparative superior and inferior occlusal view, before and after, the end of the second phase of the treatment by a three-dimensional orthodontics.

eletromiografia final

Electromyographic record of the patient in physiological neuromuscular position after the completion of three-dimensional orthodontics.

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

30 FRONTAL FINAL

Frontal radiography of the patient after the end of the second phase of the treatment.
Patient in physiological neuromuscular occlusion.

31 TELEPERFIL FINAL

Lateral radiograph and patient profile after completion of the second phase of treatment.
Patient in physiological neuromuscular occlusion.

32 C7 FINAL

Lateral and cervical radiography of the patient after the end of the second phase of the treatment.
Patient in physiological neuromuscular occlusion.

33 PANORAMICA FINAL

Panoramic radiograph of the patient after the end of the second phase of the treatment with three-dimensional orthodontics.

34 LAMINOGRAFIA FINAL

Patient TMJ laminography after the completion of three-dimensional orthodontics.
Patient in physiological neuromuscular occlusion.

35 comparativas panoramicas

Comparative panoramic radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

36 comparativas laminografias

Patient comparative TMJ laminography: before treatment and after completion with three-dimensional orthodontics.

40 COMPARAÇÃO TELE PERFIL

Comparative lateral and profile radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

Take into account that the result corresponds more to a three-dimensional recovery of the vertical dimension and not simply to an anteroposterior modification.
Even a retroposition of the mandibular head is the product of a three-dimensional alteration.

41 COMPARAÇÃO FRONTAIS

Comparative frontal radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

42 C7 COMPARATIVAS

Comparative patient lateral and cervical radiographs: before treatment and after completion with three-dimensional orthodontics.

46 DEPOIMENTO 1

At the end of 2012, I attended the Life and Health program on RBS TV and saw a report with Dr. Luis Daniel Yavich Mattos, on the treatment of problems related to TMJ.

Living with constant headaches, jaw pain and daily pressure on the teeth,

I decided to bet on the treatment and I do not regret it.

Since I was 18 years old, I had been suffering from pain in the TMJ region, and what

bothered me was a pressure that made me want to grind my teeth even

day, which I have always identified as bruxism.

I had already sought out various dentists and treatments, with the use of the famous splints to sleep. The diagnosis was always the same: emotional stress was the cause of my teeth and constant pains, although the pains started only after I have extracted my first wisdom.

47 DEPOIMENTO 2

I used to use the plates to sleep during the 24 hours of the day, so the will of biting and grinding teeth. The use of the splints  prevented wear, but the pressure I felt to bite and grind my teeth caused me TMJ fatigue and headaches.

And when I had no more hope emerged, the possibility of doing the treatment with Dr. Luis Daniel and Dr. Lidia Yavich, when I was 32 years old.

With Dr. Luis Daniel they were approximately 1 year and 2 months  using a very high plate, 24 hours a day, including to make meals, which I only took to do the oral hygiene.

The device was called the “big monster,” because of the height. In the end, no longer  pain and without the will of grinding and biting my teeth.

I went on to the second stage of treatment, now with Dr. Lidia Yavich.

48 DEPOIMENTO 3

With Dr. Lidia were approximately 3 years, in which I used fixed dental appliance, with brackets, steel wires, etc., in order to be able to stop using the board 24 hours a day, and improve the aesthetics of my dental arch.

As the treatment progressed, the device was diminished and new splints were used in order of erupting my teeth respecting the TMJ position.

At the end of the treatment, I now use one sleeping device and another one for aesthetic reasons.

I no longer have the willingness to bite and grind teeth, or pain in the TMJ or headaches. I can yawn without worrying about hurting my jaw.

Finally, it was an individualized, artisanal treatment that required time and dedication, and brought excellent results, which is why I am eternally grateful to Dr. Luis Daniel and to Dr. Lidia.

 

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

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

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

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

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

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

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

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

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

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

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

3 LAMINOGRAFIA INICIAL

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

A  CT was solicited to get a more accurate diagnosis.

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

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

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

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

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

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

THE PATIENT ABSOLUTELY REFUSED TO HAVE A NEW SURGERY

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

Analyzing the alternatives  he accepted the clinic’s proposal.

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

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

9 0clusão com o DIO

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

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

LOOK THE UPRIGHTING OF THE WIRE FROM THE SURGERY.

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

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

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

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

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

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

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

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