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

Recapture the articular disc, repositioning the mandibular condyle?

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

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

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

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

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

How are the bones?

How’s the cartilage?

How’s the articular disk?

How are the muscles in this system?

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

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

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

1 frente

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

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

Summary report written by the patient:

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

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

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

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

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

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

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

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

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

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

2 foto inicial perfil

Current information:

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

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

Crashes usually occur:

– Yawning;

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

– Eating meats.

2 tomo

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

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

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

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

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

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

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

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

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

5 panoramica

Initial panoramic radiograph of the patient before treatment.

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

6 laminografia

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

Retro position of both mandibular heads in the articular fossae.

TMJ laminography in habitual occlusion and open mouth.

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

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

7 frontal

Frontal radiography of the patient in habitual occlusion before treatment.

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

8 teleperfil

Lateral radiograph of the patient in habitual occlusion before treatment.

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

16 rnm inicial 1

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

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

Important retrodiscal compression.

17 rnm inicial 2

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

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

Important retrodiscal compression.

19 rnm inicial4

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

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

Important retrodiscal compression.

20 rnm dir inicial5

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

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

Important retrodiscal compression.

21 rnm inicial 6

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

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

Important retrodiscal compression.

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

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

24 atm aberta24a eletromiografia dinãmica habitual rolos de algodão

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

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

25 registro cineciografico inicial

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

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

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

The stomatognathic musculature is no exception.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

39 rnm comparativas 5

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

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

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

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

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

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

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

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

43 frontal rnm comparativas 8

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

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

44 frontal rnm comparativas 8

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

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

45 imagens

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

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

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

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

46 depoimento 1Patient Testimony:

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

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

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

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

47 depoimento 2

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

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

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

I’m very grateful to Dr. Lidia.

TMJ Study and Investigation Page. Three years 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.

Anyway, access to the contents of the page is still available to other researchers, professionals in the field and to those interested in the research that I develop.

Three years of publication

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 Clinica MY with pain complaints, dysfunction and TMJ pathology.

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 neuromuscular phisiologic reabilitation of the second phase of treatment, after the TMJ treatment, were also included.

FINAL

The TMJ Study and Investigation Page completed in the month of December, three years of life.

I remembered to celebrate on the first anniversary of the Page.

In the middle of the work with patients, teaching and publications I did not remember to celebrate the second year.

I want to celebrate these three years with you.

With this project, we have a place in the Internet that presents a line of work known as neuromuscular physiologic dentistry, which takes into account the whole body system. It is an area which acts on posture, mandibular functioning and considers the entire body system.

In order to do that, the neuromuscular physiologic dentistry aims to establish, in the patient, a position that is based on a harmonious relation between the muscles, the teeth, and the temporomandibular joints.

MARCUS LAZARI frontal E SAGITAL

In the publication of this year’s end I have chosen the most significant images of all these years of publications, with direct links to each of the original publications.

At the end of this publication I placed the links of the publications of the first year of this page.

3 ANOS DE PUBLICAÇÕES 2

The TMJ Study and Investigation Page  has grown tremendously and continues to receive visitors from all over the world.

Thank you!

Lidia Yavich

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

33 FINAL

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

24

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

27 CEF COMPARATIVAS ingles

Reestablishment of the Bone Marrow Signal in a case of Avascular Necrosis of the Mandibular Head. Monitoring two years after treatment.

FRONTAL COMPARATIVAS ESQUERDA 2016

Neuromuscular Physiological Treatment in a Patient with Headache and Pain in the Temporomandibular Joints. Case report without possibility of Disc Recapture: first and second phase.

10 abre e fecha inicial

FINALE FINALE

TMJ Pathologies Treatment: Patient with Pain in the Back of the Head, Bilateral Tinnitus and Constant Teeth and Prosthesis Fracture. First and second phase. Case Report.

ITACIR COMBINADA

TMJ Pathologies Treatment: Patient with headache for 30 years. Neuromuscular Physiological Rehabilitation. First and second phase. Case Report.

1 FOTOS FRENTE

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

HELLA

TMJ Study and Investigation Page. One year of publication

INITIAL

2

The TMJ Study and Investigation Page  has grown tremendously and continues to receive visitors from all over the world.

Thank you!

Lidia Yavich

Child with Otalgia (earache) and Conductive Hearing Loss: when measuring makes the difference. Normalization of hearing thresholds. First and second phase. Case report.

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment.

The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY  TEMPOROMANDIBULAR DISORDERS  is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

There are two general types of hearing loss, conductive and sensorineural.

Conductive hearing loss results from disruption in the passage of sound from the external ear to the oval window.

Anatomically, this pathway includes the ear canal, tympanic membrane, and ossicles. Such loss may be due to cerumen impaction, tympanic membrane perforation, otitis media, osteosclerosis , intraaural muscle dysfunction, or displacement of the ossicles by the malleolar ligament.

Sensorineural hearing loss results from otology abnormalities beyond the oval window. Such abnormalities may affect the sensory cells of the cochlea or the neural fibers of the 8th cranial nerve. Hearing loss with age (presbycusis) is an example. Eight cranial nerve tumors may also lead to such hearing loss.

1

Male patient, eleven years old,  arrived to the clinic for consultation referring headache, pain on the  back of the head, shoulder pain, neck pain, hand numbness and tingling  in hands and LIMITATION OF MOUTH OPENING.

1A

The patient reports pain in the left ear and sensation of ear blockage especially on the left side. He also has tinnitus in both ears and DECREASE OF HEARING IN BOTH EARS.

Any hearing loss reported by the patient, must be evidenced by an audiometry.

2

Patient’s medical history: is relevant to this case the antecedent trauma on the chin at early childhood. It is also important to consider his recurrent infections of  ear and throat and that when he was eight months old he had a severe pneumonia that required hospitalization.

3

Images of the patient’s habitual occlusion. Upper and lower oclusal view. Patient’s photos:  frontal, profile and smiling on the day of consultation.

4

Patient’s initial panoramic radiograph

5

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

In the maximum opening position, we can observe the anterior angulation of the left articular processes.

6

Patient’s habitual image occlusion before treatment, in the consultation day.We may observe here an important overbite.

It is evident the lack of space for the correct positioning of the  left maxillary canine.

7

Superior and lower oclusal view of the patient before treatment. It is evident the lack of space for the correct positioning of the left maxillary canine.

8

Patient’s lateral radiograph together with the profile image before treatment.

Retrognathic profile and rectification of the cervical spine.

9 res fechada

MRI T1: Sagittal slice, left and right TMJ closed mouth before treatment.

We can observe anterior facets on the right and left mandibular heads.

In the right TMJ the disk is slightly anteriorly dislocated. The anterior dislocation is more evident on the left TMJ, with the head of the mandible backed on the retrodiscal  zone.

10 res aberta

MRI T1: Sagittal slice, left and right TMJ open mouth before treatment.

We can observe anterior facets on both mandibular heads.

Both mandibular condyles cannot translate, reducing mouth opening.

12 cineciog 1

Initial kinesiographic record: 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 of the record. Limited mouth opening as the patient can open only 32.9 mm.

11 ELET INICIAL

Surface electromyography of the patient in habitual occlusion in which are measured:

Anterior right and left temporalis

Right and left masseter

Right and left digastrics

Right and left superior trapezius

Activation of the digastrics in closure, these muscles should only must be in activity along the opening movement

During the examination there was an activation of the right and left upper trapezius even when the patient was instructed to lower his shoulders.He had activated both trapezius throughout the examination.

13

The patient reports pain in the left ear and sensation of ear blockage, especially on the left side. He also has tinnitus and DECREASE OF HEARING IN BOTH EARS.

ANY HEARING LOSS REPORTED BY THE PATIENT MUST BE EVIDENCED BY AN AUDIOMETRY.

15 AUDIOMETRIA INICIAL

An audiogram is produced by using a relative measure of the patient hearing as compared with an established “normal “value. It is a graphic representation of auditory threshold responses that are obtained from testing a patient’s hearing with pure-tone stimuli. The parameters of the audiogram are frequency, as measured in cycles per second (HZ) and intensity, as measured in dB­­­­.

The first audiometry of the patient revealed a mild hearing loss in the left ear and a moderate hearing loss in his right ear.

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Hearing loss is classified as mild, in which the ear is unable to detect sounds below 40 decibels which makes it  difficult to understand human speech.

In moderate loss, the sounds below 70 decibels are not heard.

17

We recorded the mandibular rest position after electronic deprogramming, together with the information of the MRI (magnetic resonance imaging) to orient our decisions of the bite registration, for the three-dimensional construction of the DIO (intraoral device).

The patient has a pathological free space of 8.6 mm and 8 mm of mandibular retro position.

The degree of compression determinates de reaction of the patient.

The retrusion of the mandible, whether it is iatrogenically induced, or a result of malocclusion, often results in otalgia due to excessive compression of the neurovascular retrodiscal tissues. The patient’s impression is ear pain.

18

I informed the parents of the patient, that at this stage, I was only worried about the health of the patient, and focused on  improving the functions, the symptoms and controlling the conductive hearing loss.

Hearing loss resulting from Eustachian tube dysfunction, initiated by craniomandibular disorders is usually subjective.

For this reason there is a need for an objective control by audiometry.

 I explained that I would not make any orthodontic intervention at this stage to include in the arcade the canine that was misaligned and out of space. I told them  that I would take care of it later and in this case I would not have the need to extract teeth.

19

The installed device is controlled through surface electromyography to evaluate the function.

20 AUDIOMETRIA 2

Patient’s second audiometry  shows normal thresholds in the left ear and a mild hearing loss in his right ear.

21 AUDIOMETRIA 1 e  2

Comparing the first and second audiometry of the patient during treatment.

Thresholds normalization of the right ear and thresholds improvement of the left ear.

23

Structural lesions may produce functional changes which in turn increases the structural changes.

24

Structural and functional changes.

25

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but  OTHERS CANNOT.

25A

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but OTHERS CANNOT.

26

It takes time to stabilize the muscles during treatment, different patients, different ages and different pathologies.

27 AUDIOMETRIA 3

Patient’s third audiometry shows NORMAL thresholds in the left ear and NORMAL thresholds in his right ear.

28 AUDIOMETRIA 1 e  2 e 3

Comparing the first, second and third audiometry of the patient during treatment.
Thresholds normalization in the right and left ear.

At this time with the normalization of the conductive hearing loss, the remission of symptoms and improvement of the images from the exams, we began the second phase through a three-dimensional orthodontics.

29 SERIES DE ORTO 1

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

30 SERIES DE ORTO 2

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

30 A PERFIL E RAD LATERAL ORTO

Patient’s lateral radiograph together with the profile image during treatment.

Aesthetic and not retrognathic profile as at the beginning of treatment.

There was not a recovery of the physiological lordosis, but there surely was an improvement of the cervical spine.

31 SERIES DE ORTO 3

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

32  SERIES DE ORTO4

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

33 RETIRADA DO DIO

Removal of the DIO (intra oral device) at the current stage of the three-dimensional orthodontics.

34 SERIES DE ORTO4

Images without the DIO (intraoral device) and completion of the treatment of the three-dimensional orthodontic in neurophysiological occlusion.

OCLUSAIS FINAIS

Comparative images of the upper and lower oclusal views from the patient before and after completion of the first and the second phase of the neurophysiologic treatment.

35 AUDIOMETRIA 4

The fourth audiometry of the patient after completion of the two phases of treatment maintains the normal thresholds in both the left ear and the right ear.

SERIES DE ORTO

Part of the sequence of the three-dimensional orthodontics in the second stage of the treatment of TMJ disorders in this particular patient.

panoramicas comparativas

Comparative panoramic radiographs: before treatment and after completion of the three-dimensional orthodontics.

CEF COMPARATIVOS

Comparative of lateral radiographs of the patient: at the beginning of the treatment in habitual occlusion, after the  completion of the three-dimensional orthodontic in neurophysiological occlusion and six years after the completion of treatment control.

37 CINESIO comparativoS

Patient’s kinesiographic records comparison: before and after treatment.

The mouth opening  of the patient improved from 32.9 mm to 38.9 mm and it also reached an excellent speed regarding  mouth opening and closing.

37 eletro comparativo

Patient’s electromyography records comparison: before, during and after treatment.

39 jaw trackwe  comparativoa

Patient’s kinesiographic records after electronically mandibular deprogramming comparison: before treatment the habitual trajectory is not coincident with the neuromuscular trajectory.

After treatment the habitual trajectory is tridimensional coincident with the neuromuscular trajectory.

40 todas as audiometrias

Comparing the first, second, third and forth  audiometry of the patient.
Thresholds normalization of right and left ear.

FINALE FINALE

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment. The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY  TEMPOROMANDIBULAR DISORDERS  is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

42 DEPOIMENTO 1

When the patient ended all the treatment, and being still a teenager, he left the following testament:

My dentist referred me to the orthodontist because I had a crooked canine. So, after a panoramic radiograph she suspected that I could have a TMJ problem. Then she referred me to Porto Alegre to do a MRI, and from that exam it was found something that indicated a TMJ problem. So then I started the tratment with Dr. Lidia Yavich, that also investigated the tinnitus and my hearing problem.

When I was little I felt and hit the chin but my parents didn’t know that it could affect my TMJ.

I suffered a lot from an earache and sore throat. I had even scheduled an ear surgery but after six months of treatment it was no longer necessary to do it. Today I am doing well. I have a good hearing and I don’t have any more the tinnitus and the throat pain. I am happy with this treatment, thanks to God and to Dra. Lidia Yavich.

42 DEPOIMENTO

Here follows the testimony of the same patient seven years after the completion of the treatment:

Today, more than seven years after the end of the TMJ treatment with Dr. Lidia, and thanks to the God-given gifts to her, I haven’t been suffering any more with the earaches nor with the throat pain or the hearing loss. I had had, before the treatment, the indication to make an ear operation since I was loosing my hearing and that was not necessary with the TMJ treatment because during the treatment I was monitorated by exams that had proven that my hearing improved. Today I live a normal life, without having problems with those things from the past. I thanks the treatment done by Dr. Lidia which has healed me and improved my life.

 

Neuromuscular Physiological Treatment in a Patient with Headache and Pain in the Temporomandibular Joints. Case report without possibility of Disc Recapture: first and second phase.

 

I often observe the debate on etiology and therapeutics, especially in TMJ dysfunction discussions groups, which are integrated by patients and professionals. These groups are active not only in Brazil but in several countries and communities from around the world.

I hope this space will add, strengthen or clarify those discussions.

The professional who treats patients with TMJ pathology has to take into account, at the moment of studying the clinical case, the patient’s particularities and the anatomical structures that are involved and provoking pain and affliction to our patient.

Even if the professional is scrupulous, evolutions can be different from patient to patient. That is why the professional has to investigate carefully which are the structures that can improve or even heal and which are the ones that cannot improve or still which ones we do not know if can be improved in the process of treatment.

Recognizing what we do not know is perhaps more important than recognizing  what we do know: and the communication of this understanding to the patient is essential.

When we start a treatment we must be certain of the structures we can meliorate, or even prevent of getting worse  and we also must know which structures  we DO NOT HAVE THE CONDITION TO MELIORATE and we certainly must communicate that to the patient. Within this framework, the most important thing is to investigate if  we can improve the quality of life of the patient.

1 FOTO FRONTAL

Female patient with 45 years old arrives to the clinic for consultation suffering from headache every day, also suffering from neck pain and pain in the back of the neck, pain in both temporomandibular joints and severe pain on the shoulders.

Pain is more intense on the left side.

2 FOTO PERFIL - Copia

The patient reports a sensation of plugged ears and hearing decrease which was confirmed by an audiometry that refers normal hearing at  4KHZ and a severe sensorineural hearing loss at 6 KHZ and moderate at 8 KHz in the right ear.

The left ear has normal hearing thresholds.

The patient presents a buzzing in the left ear, and peculiar noises.

3 DENTES INICIAIS - Copia

Patient’s habitual occlusion in the consultation day. Note patient’s overbite.

The patient reports that she wakes up with pain in the teeth, because of clenching.

4 OCLUSAIS INICIAIS - Copia

Patient’s upper and lower oclusal view before treatment. Note the wear of the lower anterior teeth. The patient states that have made maxillary anterior teeth reconstruction with resin due to attrition caused by bruxism.

5 PANORAMICA INICIAL - Copia

Patient’s panoramic radiograph before treatment. Absence of teeth 18,28,48.

Tooth 38 in a horizontal position, impacted

Reabsorption of the alveolar ridges.

6 LAMINOGRAFIA INICIAL - Copia

Radiographic image of the right and left temporomandibular joints in closed and open mouth. Flattening of the anterior superior and posterior superior surface of the left articular process.

7 TELEPERFIL

Patient’s lateral radiograph in habitual occlusion before treatment. Rectification of the cervical spine.

8 FRONTAL

Patient’s frontal radiograph in habitual occlusion before treatment.

9 C7

Patient’s lateral radiograph and cervical spine in habitual occlusion before treatment. Rectification of the cervical spine.

10 abre e fecha inicial

Patient’s computerized kinesiographic record before treatment. Patient without mouth opening restriction. Decreased closing speed, typical graph of an incisal guide that interferes with the closing trajectory.

11 RNM INICIAL DIREITA FECH

Sagittal slices of the right closed TMJ. The mandible heads presents irregularities and cortical and subcortical sclerosis. Degenerative process.

The right articular disc shows small size, change in signal intensity and degenerative morphostructural aspect. It is anteriorly displaced.

11B RNM INICIAL aberta dir

Sagittal slices of the right open TMJ. The articular disc shows small size, is anteriorly displaced WITHOUT REDUCTION WHEN THE MOUTH OPENS.

12 RNM INICIAL DIR FECH

Another sagittal internal slice of the right closed TMJ showing cortical bone irregularities. Degenerative aspect.

The articular disc shows small size, change in signal intensity and degenerative morphostructural aspect. It is anteriorly displaced, WITHOUT REDUCTION WHEN THE MOUTH OPENS.

12B RNM INICIAL aberta dir

Another sagittal slice of the right open TMJ. The articular disc shows small size, is anteriorly displaced WITHOUT REDUCTION WHEN THE MOUTH OPENS.

13 RNM INICIAL esquerda FEC

Sagittal slices of the left closed TMJ. Mild contours irregularity with rectification of the superior aspect of the mandibular condyle. The articular disc presents reduced dimensions.Alteration in orientation of the mandibular condilar axis because of traumatism in infancy. The disc is anteriorly displaced, WITH REDUCTION WHEN THE MOUTH OPENS.

14B RNM INICIAL esquerda aberta

Sagittal slice of the left open TMJ. THE DISC REDUCES WHEN THE MOUTH OPENS.

15 frontais iniciais

Frontal slice of the right and left temporomandibular joints, closed mouth. Note the cortical discontinuity on the right side already registered in the sagittal sections of the same side. The left side shows a medial disc deviation.

16 REGISTRO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and a 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 pathological free space of the patient is almost 7, 4 mm

16A ortese inicial so frontal

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

One year after the beginning of neurophysiological treatment, the patient had to interrupt the treatment to undergo a spine surgery.

The patient returned 10 months after the interval, recovered from the intervention. The patient was  then again documented to assess any changes that might have happened during the interruption and the spine surgery.

17 FOTO frontal reinicio de tratamento 1

Patient’s postural comparative frontal images: before treatment and restarting therapeutic after the spine surgery.

18 FOTO PERFIL reinicio de tratamento 2

Patient’s postural profil comparative images: before treatment and restarting therapeutic after the spine surgery.

19 ORTESE REINICIO DE TRATAMENTO

The masticatory muscles of the patient were AGAIN electronically deprogrammed and NEW DIO (intraoral device) was built in neurophysiological position.

20 PANORAMICA COM ORTESE

Patient’s panoramic radiograph with the DIO (intraoral device) built in neurophysiological position.

21 LAMINOGRAFIA COM ORTESE

Patient’s right and left temporomandibular joints laminography  in closed and open mouth  with the DIO built in neurophysiological position.

22 TELEPERFIL COM ORTESE

Patient’s lateral radiograph with the DIO built in neurophysiological position.

23 C7 COM ORTESE

Patient’s lateral and cervical spine radiograph with the DIO built in neurophysiological position.

PATIENT’S ANALYSIS AT THIS STAGE OF THE TREATMENT.

Patient with degenerative processes not only in the temporomandibular  joints but also in the cervical spine and lumbar spine which led her to surgery.

Inability to recapture of the right TMJ disk. Whereby this was an objective that was not taken into account.

Remission of symptoms and improvement of  life quality.

Physiological mandibular posture, recovery of free space interocclusal through the DIO (Intraoral device).

In this particular case even WITHOUT DISC RECAPTURE (CONDITION THAT WAS EXPLAINED IN THE DIAGNOSIS)  the patient can pass into the second phase, always taking into account that we should protect the joint during the night and during physical activity.

Each case is unique and the decision to move to a second phase also needs an individualized study.

It was decided to begin the SECOND PHASE of treatment to remove the DIO (intraoral device), keeping the neurophysiological occlusion.

26 orto 1

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

27 orto 2

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

28 orto 3

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

In this sequence the patient is still with the DIO (intraoral device)  in the mouth.

29 retirada da ortese

Removal of the DIO (intra oral device)

30 orto final

Completion of the second phase of the neurophysiological treatment in this case with a three-dimensional orthodontics. 

The second phase is here understood as the three- dimensional orthodontics, restorative, prosthetic procedures in accordance with each clinical case in order to remove the DIO, while maintaining the neurophysiological position obtained in the first phase.

31 oclusais finais

Patient’s upper and lower oclusal views after completion of the three-dimensional orthodontics.

32 LAMINOGRAFIA final

Patient’s right and left temporomandibular joints laminography in closed and open mouth  in neurophysiological position after finalization of the treatment.

33 panoramica  final

Patient’s panoramic radiograph in neurophysiological occlusion in the completion of treatment. The tooth 38 that was in a horizontal and impacted position was extracted since the patient had no more symptoms of joint pain.

34 TELEPERFIL final

Patient’s lateral radiograph in neurophysiological occlusion in the completion of the second phase of neurophysiological treatment.

NOVA RESSONANCIAS FINAIS

Temporomandibular joints MRI after de finalization of the second phase.

We must remember that this is a patient with degenerative processes and impossibility of recapture of the right TMJ disc, the left disk is so damaged that it does not fulfill its function.

The patient no longer has symptoms.

The final MRI shows no worsening of the situation and in the frontal slice it shows a better three-dimensional location of the mandibular condyle and cortical improvement.

36 B radiog laterais comparativas menor

Patient’s lateral comparative radiographs: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

35 registro COMPARATIVOS

Comparative records of mandibular rest position at the beginning of the treatment to build the DIO (intraoral device), and at the end of the second phase of the treatment (tridimensional orthodontics) to build a DIO (intraoral device) for night use.

Notice that in the beginning of the treatment the patient had a pathological interocclusal space of 7.4mm, and in the record at the end of the second phase for the nocturne DIO the patient has 3.3mm of free interocclusal space.

We have to take into account that  the free interocclusal space IS A THREE-DIMENSIONAL SPACE, AND WHEN WE HAVE STRUCTURAL DIFFERENCES IN THE JOINTS, THE SPACE IS NOT EQUAL ON THE RIGHT AND THE LEFT SIDE.

35 iimagens comparativas de perfil

Patient’s  comparative profil postural images: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery and treatment interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

36 iimagens comparativas frontais

Patient’s frontal comparative postural images: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery and treatment interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

37 DEPOIMENTO

I had made several appointments with specialists, such as otorhinolaryngologist, dentists and maxilo-facial surgeons. However, all of them were without success and that is when I looked for Dr. Lidia to whom I reported the following symptoms.

I used to wake up every day with a lot of pain on the left side, both in the head and neck and I used to feel a rigidity on the neck and shoulder. In that time I used to take painkillers every single day in the morning. I also used to suffer of a serious problem of bruxism and because of that I wore out my front teeth, both the upper and lower teeth, and I had to restore them. I used to feel a lot of pain from the tremendous pressure that I used to make between the lower and upper part of my mouth. Another symptom was the high sensitivity on the teeth when I drank cold liquids. I felt as my ears were always blocked in such a way that my hearing decreased. I also used to hear a noise, especially on the left side, which sounded like a continuous whistle.

38 DEPOIMENTO

I also told the doctor that when I was a child I was hit with a brick, in the middle of a child’s play.

After reporting all that she asked me to make many exams and many of them were made in the MY Clinic and finally she told me that I had a problem in the TMJ. I started a treatment with her in 2011. I started to use an acrylic splint on my lower teeth day and night, all the time, taking it of only for its hygiene.

The pain that I used to feel so much decreased and in short time I did not feel it any more. Doctor Lidia had to adjust the orthotic monthly, making exams in her clinic until it reached the optimal height. On the next year from when I started the treatment I had to interrupt it for 8 or 10 months because I had to make a column surgery but I returned to the treatment as soon as I was well enough. I kept on treatment for one more year and after that I started the second part of the treatment with braces.

39 DEPOIMENTO

At the time that the treatment ended I did not need to use any more braces nor the full time orthotic. Today I need to use the orthotic only when I do physical activities and to sleep. I never again felt the horrible pain that I used to feel. I also never felt again the sensation of having blocked ears and happily the noise reduced. Today I am very happy that I do not have to take daily painkillers and that I do not have any pain. I am very grateful to doctor Lidia because she discovered and solved my problem.

evento setembro2

For the interested coleagues in this training: the course starts at the September 1st.
Please write to the email for more informations:  lidiayavich@gmail   ou  lidiayavich@clinicamy.com.br
+55 5130612237    +55 5133322124       This course will be given in Portuguese

Reestablishment of the Bone Marrow Signal in a case of Avascular Necrosis of the Mandibular Head. Monitoring two years after treatment.

Preparing a new publication of the TMJ (temporomandibular joint) study and investigation page, I received the new MRI (magnetic resonance imaging) that I requested for the patient presented in the last clinical case published.

I decided that it was high priority to publish this follow up before the next clinical case.

Recapitulating the clinical situation and the images of the patient after treatment:

The patient had remission of symptoms.

The patient had improved function and recovered the vertical dimension.

The patient had improved aesthetics (recovering the vertical dimension).

The patient had recovered the mouth opening, without presenting limitation as observed before treatment.

The patient had improved her posture.

Is important to highlight that in this case, with discs of reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opened, the goal was to decompress, to recover the vertical dimension, and to wait for the medullary signal recovery by decompression, remembering that all bacteriological and rheumatologic research was negative.

At the end of treatment the MRI (magnetic resonance imaging) of the patient showed a MEDULAR SIGNAL IMPROVEMENT, yet still far from satisfactory recovery in terms of image, EVEN TAKING INTO ACCOUNT the improvement of symptomatology.

I will post some of the most remarkable initial MRI images before the treatment, to review the clinical case in detail enter in this link.

This publication will emphasis the images, a fundamental tool for understanding what we really can achieve beyond the patient’s clinical improvement.

Understanding the positive or negative changes in the structures affected in TMJ pathologies is critical in the comprehension of the etiology that led to the deterioration of the patient’s structures and consequently triggered the symptoms that affected the quality of life of our patients.

REMEMBERING THAT THIS IMPLIES A DIFFERENTIAL AND UNIQUE DIAGNOSIS FOR EACH CASE.

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, 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 when the mouth opens.

CAN BE SEEN AN IMPORTANT HIPOSSINAL COMPATIBLE WITH AVASCULAR NECROSIS.

Osteonecrosis of the mandible head corresponds to the death of bone tissue also called avascular necrosis.

The alteration in the bone marrow of the mandibular condyle is a possible source of TMJ pain.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

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.

Osteonecrosis of the mandible head corresponds to the death of bone tissue also called avascular necrosis.

The alteration in the bone marrow of the mandibular condyle is a possible source of TMJ pain.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

16A  ESQ boca fechada 2013 T2

MRI:same previous sagittal slice of the left TMJ, closed mouth in T2

MRI in T2 clearly shows the ARTICULAR 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.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

CORTE FRONTAL DA ATM ESQ INICIAL ANTES DO TRATAMENTO 2

MRI, frontal section of the left TMJ, closed mouth.

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.

Osteonecrosis of the condylar head corresponds to the death of bone tissue, also called avascular necrosis.

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

CORTE FRONTAL DA ATM DIR INICIAL ANTES DO TRATAMENTO

MRI, frontal section of the right 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.

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

In the last publication WERE POSTED THE INITIAL IMAGES BEFORE TREATMENT AND THE IMAGES AFTER TREATMENT.

IN THIS PUBLICATION I POSTED THE IMAGES COMPARING: before treatment, after treatment and TWO-YEARS FOLLOW-UP AFTER neurophysiological treatment.

FRONTAL COMPARATIVAS DIREITA 2016

T1-weighted right frontal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement in the medullary signal of the left condyle and the improvement of the superior cortical bone. THE THIRD IMAGE HAS NO TRACES OF THE SUBCORTICAL LESION .

FRONTAL COMPARATIVAS ESQUERDA 2016

T1-weighted left frontal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement in medullary signal of the left condyle in the central image and THE  BONE MEDULLARY RECOVERY IN THE THIRD IMAGE.

THE MANDIBULAR CONDYLE HAS A HELTHY BONE MARROW SIGNAL.

RESS COMP DIREITAS SAGITAL 2016

T1-weighted right sagittal images closed mouth comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement of the medullary signal and cortical bone. ABSENCE OF SUBCORTICAL BONE CYSTS in the anterior superior aspect of the mandibular condyle OBSERVED IN THE FIRST IMAGE before treatment. Improvement in the cortical bone of the mandibular head.

sagitais comparativas T2

T2-weighted right sagittal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

It is clear in the first image the inflammatory signal. In the central image we can notice the improvement of the intramedullary signal and the remission of posterior effusion.

IN THE THIRD IMAGE WE CAN SEE THE TOTAL REMISSION OF THE INFLAMMATORY SIGNAL.

The patient DID NOT USE ANY ANTI-INFLAMMATORY DRUG.

RESS COMP SAGITAL ESQ 2016

T1-weighted left sagittal images comparison: before treatment, after treatment and two years of follow-up after neurophysiological treatment.

We can see the improvement in medullary signal of the left condyle in the central image and THE  BONE MARROW RECOVERY IN THE THIRD IMAGE.

THE MANDIBULAR CONDYLE HAS A HELTHY BONE MARROW SIGNAL.

FINAL 1

All relevant images were posted, nevertheless I think it is important to highlight THIS FRONTAL RIGHT TMJ comparative image because of the MEDULLARY SIGNAL OBVIOUSNESS.

The first image before treatment and the second two years of follow-up after treatment. MEDULLARY BONE WITH AVASCULAR NECROSIS RECOVERED IN A HEALTHY MEDULLARY SIGNAL.

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 differential diagnosis of the alteration in signal intensity of the mandibular condyle begins with the knowledge of the normal characteristics of medullary signal.

FINAL menor

Right and left TMJ sagittal and frontal comparative slices. Before treatment and two years of follow-up after neurophysiological treatment.

finale finale

To  remember and follow in detail all the images and description of the case report, the reader should return to the previous post.

In the previous publication the control images after two years of treatment were NOT posted.

With the application of advanced diagnostic techniques like MRI the alterations of the medullary signal from the mandibular condyle can be detected, similar to those seen in the femoral head with osteonecrosis.

The detection of effusion and bone marrow alterations is important information before the treatment.

 The information of what really we achieve after our treatments in the image beyond the clinical improvement of our patient is also substantial information.

In this case showing the improvement and recuperation of the medullar signal with the correct mandibular reposition and decompression.

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.”

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

 

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

Nowadays dentistry has new resources for prosthetic resolution of patients with extensive loss of their dental pieces.

New technologies allow protocols to build prostheses where before, they would have no support solution.

Out of aesthetic recovery, essential for the patient IT IS NECESSARY to have an initial point of mandibular rest position, as these complex cases make rehabilitation more challenging.

1 frontal INICIALMale patient 54 years of age arrived to the clinic for consultation referring pain and sensation of plugged ear, especially on the left side. Also refers pain on top of the head and pain in the left shoulder.

2 PERFIL INICIALThe patient reports stiffness and pain in the back of the neck, a different sensation on the left side of the head as tingling and loss of sensibility and “blocked ear”

Refers an uncomfortable sensation in the left eye, in his words says that “the eye is sensitive”.

Refers hand tremor.

3 protese inicialThe image of the patient’s habitual occlusion shows a Class III or mandibular prognathism.

The  patient reports the prognathism  condition even before the dental loss.

When we study occlusion most of the time we do not consider if the inter-occlusal space is healthy or pathologic.

4 oclusaisPatient’s superior and inferior oclusal view.

4A questionarioWhat most encourages the patient to seek treatment was the sensation of blocked ear and his desire to resolve the issue.

The patient also relates noises when chewing and fatigue of the masticatory muscles. The patient also reported a numbness sensation near the left ear.

The patient had been medicated by another professional with muscle relaxant, but he did not feel any symptoms change.

5 PANORAMICA INICIALPatient’s initial panoramic radiograph before neurophysiological  treatment.

The patient has this protocol for more than 18 years.

The patient reported a periimplantitis history, and had no image prior to implant placement.

6 LAMINOGRAFIA INICIALPatient’s TMJ right and left laminography, closed and open mouth before neurophysiological  treatment.

7 TELERRADIOG INICIALPatient’s lateral radiograph in habitual occlusion before treatment.  Marked prognathic profile.

7A TELERRADIOG INICIAL LINHAMarking the aesthetic plane of  Ricketts in the lateral radiograph with the profile of the patient.

8 FRONTAL INICIALPatient’s frontal radiograph before treatment.

9 ELETROMIOGRAFIA INICIALPatient’s dynamic electromyography record in habitual occlusion before treatment.

In this dynamic record we registered the anterior right and left temporal muscles, the right and left masseter muscles, the right and left digastric muscles and the right and left upper trapezius muscles.

The right masseter muscle ALMOST CAN NOT RECRUIT MOTOR UNITS during maximum sustained  intercuspation, it can only generate 21 microvolts in the selected band.

Important asymmetry between the two masseter muscles, right and left.

10 ABERTURA E FECH INICIALPatient’s initial kinesiographic record: we can see a good speed when the mouth opens and a reduction of speed when the mouth closes.

There is no coincidence between the opening and closing trajectories in the sagittal view.

The opening movement has a propulsive closing and a lateralization in the frontal plane to the right of 8.2 mm.

11 CICLOS MASTIGATORIOS HABITUAL ANTES DO TRATThe patient’s masticatory cycles are registered with a jaw tracker. In the record of the masticatory cycles we used almonds to register chewing activity.

This post will not make a detailed analysis of this record. But it is important to note that: on the left side of the graph, even if the patient is chewing almonds on the left, THE GRAPHIC APPEARS ON THE RIGHT SIDE. This is due to mandibular torque that the patient needs to perform to chew.

11ARNMMRI: left and right TMJ closed mouth.  I chose this slice to show important asymmetry between the right and left side.

The left side shows a posterior dislocation of the articular disc. There is NO ARTICULAR DISC on the right side, is IMPORTANT TO MARK THIS, since in several posts I emphasized the importance of recapturing the disks when possible, (IN THIS CASE I CAN NOT RECAPTURE A STRUCTURE THAT DOES NOT EXIST).

In this particular case the request of resonance is part of the protocol to obtain fundamental information in the formulation of diagnosis.

Different slice and parameters do not show bone edema or other information requiring different interventions within the treatment.

The goal in this particularly case  will be the three-dimensional repositioning of the jaw, TO RECOVER the neurophysiological function, which should be widely understood, so that the muscles, temporomandibular joints and teeth and prostheses could work in balance.

12 JAW TRACKER BIOPACKTo determine the neurophysiological three-dimensional position of the jaw, even in cases of extensive rehabilitations we have to consider the physiological position of the mandibular rest.

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

The patient has a PATHOLOGICAL FREE WAY SPACE OF 7.2 mm. Maintaining the physiological 2 mm we still have more than five mm discrepancy, to be recovered tridimensionally.

The jaw also presents a retro position of almost two mm and a deflection at closing of 0.5 to the left side.

13 DENTES COM ORTESEWith this data and ALWAYS WITH THE IMAGES INFORMATION, we constructed a DIO (intraoral device) to keep the three-dimensionally recorded position.

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

13BTELERRADIOG COM DIOPatient’s lateral radiograph with the DIO in neurophysiological position.

13CTELERRADIOG COM DIO LINHAMarking the aesthetic plane of  Ricketts in the lateral radiograph with the DIO in neurophysiological position.

The DIO is an orthopedic device, recorded and controlled electromyographically. The DIO (intraoral device) is used to support, align and ameliorate deformities in order to improve the functions of the jaw, temporomandibular joints and the muscles.

14 ELETROMIOGRAFIAS COM o DIOPatient SEMG record with the DIO (intraoral device) in neurophysiological position built above the patient’s prosthesis.

We can note the improvement of the right masseter muscle activity. Before the treatment the right masseter muscle could not recruit motor units.

15 ELETROMIOGRAFIAS COMPARATIVASComparison of the SEMG records: before the treatment in habitual occlusion and with the DIO (intraoral device) in neurophysiological position built above the patient’s denture.

WE MUST CONSIDER that years of muscle accommodation and the central nervous system engrams cannot be modified with a first orthotic or DIO

That’s why the DIO should be adapted, changed, and recalibrated to follow dimensional changes that will happen when muscles are aligned.

16 ABERTURA E FECH COM O DIOPatient’s kinesiographic record after neurophysiological treatment.

Significant improvement in the opening and closing trajectories.

The closure no longer has a propulsive trajectory.

The lateralization which was 8.2 mm was reduced to 2 mm.

17 ABERTURA E FECH COMPARATIVOSPatient’s kinesiographic records comparison:  before treatment in the habitual occlusion and with the DIO (intraoral device) in neurophysiological position constructed above the patient’s prosthesis.

18 CICLOS MASTIGATORIOS COM DIOPatient’s masticatory cycles after the neurophysiological treatment.

In this graph the left side chewing appears on the left side as it corresponds.

In the previous graph before treatment in habitual occlusion, the left side chewing graphic appeared on the right side due to mandibular torque.

19 CICLOS MASTIGATORIOS SEM E COM DIOComparative chewing cycles of the patient: before treatment and after neurophysiological treatment.

20 LAMINOGRAFIA COM O DIOPatient’s TMJ right and left lamiography, closed and open mouth in neurophysiological occlusion after treatment.

21 LAMINOGRAFIAS COMPARATIVASPatient’s TMJ right and left lamiography, closed and open mouth comparison: in habitual occlusion before treatment and with the DIO (intraoral device) in neurophysiological position.

22 PANORAMICA COM ORTESEPatient’s panoramic radiograph after the neurophysiological treatment.

23 PANORAMICAS COMPARATIVASPatient’s panoramic radiograph comparison: before treatment and after the neurophysiological treatment.

24 frontal comparativosPatient’s frontal comparative images: before and after neurophysiological treatment.

25 perfis comparativosPatient’s lateral comparative images: before and after neurophysiological treatment.

26B LATERAIS COMPARATIVAS LINHA  Comparing the profile radiographs and the aesthetic profiles

And here, the words of Confucius: A picture is worth a thousand words.

27 Patient testimonyI lived for a long time with discomfort that sometimes manifested itself by a feeling of numbness and sometimes by headaches.

I could not identify the cause; although I repeatedly searched for expert help.

On the recommendation of my sister and my sister in law who were being treated by Dr. Lidia I consulted her and started a treatment which lasted a long period, getting excellent results and today I feel good without the symptoms that hindered me so much.

I appreciate the commitment and dedication of Dr. Lidia and her team.

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

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

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

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

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

1B HELENA DE MATTOS

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

1C

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

Patient’s testimony

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

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

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

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

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

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

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

4 PANORAMICA

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

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

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

Extensive restoration in the 13, 24 e44 dental elements.

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

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

Elongation of the left styloid process.

5 LAMINOGRAFIA

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

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

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

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

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

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

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

5D ressonancia boca fechada

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

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

Patient’s testimony

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

6 TELE PERFIL

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

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

7 C7

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

Patient’s testimony:

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

7B C7 2

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

7D FRONTAL 8 A DENTES ORTOSE

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

8 B eletromiografia em oc. habitual

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

8C fotos comparativas frontais

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

10B PANORAMICA implantes 1

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

10C panoramicas comparativas

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

9 dentes cavidades

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

10 dentes prov e inicio da ortodontia

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

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

11 preparo ortodontico setor anterior

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

12 preparo protese-1

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

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

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

16 terminado

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

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

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

16B oclusal final 17 laminografia final

Laminography showing the tridimensional decompression of the mandibular heads.

18 laminografias comparativas

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

19 PANORAMICA final

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

20 panoramicas comparativas

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

21 comparativas frontais

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

23

Intraoral photographs before and after treatment.

21 comparativas laterais

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

22 postura comparativa

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

dEPOIMENTO 1

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

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

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

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

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

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

dEPOIMENTO 2

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

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

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

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

FINAL

TMJ Articular Discs Recapture: Mandibular Neurophysiological Repositioning in a Patient with total Upper Denture and Lower partial Denture.

1

Female patient 54 years old consults in the clinic with complaints of many years of head ache, ache in the temples and in the back of the head. Shoulder ache, blocked ears sensation, popping in both temporomandibular joints. She presented limitation of mouth opening and difficult for mastication. She used pain killers and anti inflammatory that did not alleviated her symptoms.

2

Postural frontal images show de misalignment of the patient shoulders and the forward head position.

3

The patient had a complete superior prosthesis, she related that many professionals constructed different removable inferior prosthesis, but they increased her symptomatology.

4

Occlusal view show the wear of the anterior lower teeth.

5

Patient panoramic radiograph.

General alveolar horizontal resorption.

Asymmetrical condilar heads and suggestion of osteophytes in both mandibular heads.

Stylomandibular ligament calcification.

Periapical lesion in the endodontically treated element.

6

TMJ laminography before treatment. Important retro position of the mandibular condyles. Arrows in the zone of compression.

7

Surface electromyography of the patient in habitual occlusion.

Anterior right and left temporalis.

Right and left masseter.

Right and left digastrics.

Right and left superior trapezius.

Important asymmetry between the masseter muscles.

Activation of the digastrics in closure, these muscles only must be activated in opening movement.

8

MRI: sagittal slice of the right TMJ closed mouth, before treatment

Articular disk dislocation and retro position of the mandibular condyle.

9 MRI: sagittal slice of the right TMJ open  mouth before treatment.

Limitation of mouth opening.10 MRI: sagittal slice of the left TMJ closed  mouth before treatment.

Articular disk dislocation and retroposition of the mandibular condyle.
11

MRI: sagittal slice of the left TMJ open  mouth before treatment.

 

12

Favorable case for disks repositioning in a neurophysiological position promoting disk recapture

We consider not only the jaw tracker information after the electronic deprogramming but fundamentally the information of the MRI for the decision of the bite record for the tridimensional construction of the intraoral device.

The patient presents a pathological free way space of 10 mm and a mandibular retro position of 6 mm.

13

 

The device is electromiographically controlled to check the improvement of the muscular function.

14

The comparative laminography, demonstrate the decompression of the retrodiscal zone.

It is important to know that any laminography cannot demonstrate the recapture of the articular disc. This is only possible with the MRI

15

MRI: sagittal slice of the right TMJ closed mouth before and after treatment demonstrates the articular disc recapture and the repositioning of the mandibular condyle.

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MRI: sagittal slice of the right TMJ open mouth before and after treatment. The MRI after treatment demonstrates the right TMJ optimal translation without the limitation of the initial MRI

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MRI: sagittal slice of the left TMJ closed mouth before and after treatment. The MRI after treatment demonstrates the left TMJ articular disc recapture and the repositioning of the mandibular condyle.
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MRI: sagittal slice of the left TMJ open mouth. The MRI after treatment demonstrates the left TMJ optimal translation.


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Shoulders and head posture improvement.
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Head position improvement, comparison with the forward head posture of the image before treatment

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The lip has no more the inclination, of the initial image before the treatment.

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Improvement of the aesthetic facial plane

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Finishing the TMJ pathology treatment I recommended the patient to the colleague that carried   the neurophysiological rehabilitation, maintaining the tridimentional position.

The implants  more than five years after insertion.

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Patient testimony

I felt a lot of pain, during many years. Ear ache, pain behind the eyes, strong head ache that got stronger after chewing. I changed to eat only soft food and stop eating meat and raw vegetables. This food when I chewed provoked and increased my ear pain and head ache. I felt ashamed when I chewed because of the noises that came from my TMJ.

When I complained from the pain in the neck and shoulder pain, they told me that was because of my work, I am a seamstress. Today I continue with my job but I don´t feel more pain, neither in the shoulders, nor in the neck or behind my eyes.

I don´t feel the noises I had when I chewed before the treatment

I feel that I also, rejuvenate, looking to my pictures before and after the treatment, I see my mouth is not twisted like it was before.

final