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

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

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

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

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

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

The patient also reports bruxism and nighttime clenching.

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

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

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

Summary report written by the patient

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

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

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

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

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

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

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

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

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

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

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

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

7 PANORAMICA INICIALInitial panoramic radiograph of the patient before treatment.

8 LAMINOGRAFIA INCIAL

TMJ laminography in habitual occlusion and in open mouth.

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

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

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

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

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

12 eletromiog dinamica inicial

Dynamic electromyographic record of the patient in habitual occlusion.

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

13 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

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

14 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

15 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

16 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

17 RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

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

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

20 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

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

21 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – left  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – right  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22a REGISTRO CINECIOGRAFICO INICIAL

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

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

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

The stomatognathic musculature is no exception.

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

The patient has a pathological free space of 7.7 mm.

The patient also had a 0.6 mm mandibular retroposition.

23 oclusao DIO

Occlusion of the patient with the DIO (intraoral device)

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

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

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

24 COMPARATIVAS FRONTAIS POSTURAIS

Comparative frontal postural images.

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

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

25 eletromiog dinamica com DIO

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

26 CONTROLE DA ORTESE

28 RNM Comparativas esquerda 1 sagital

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

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

29 RNM Comparativas esquerda 2 sagital

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

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

30 RNM Comparativas esquerda 2 sagital

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

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

31 RNM Comparativas esquerda 2 sagital

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

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

32 RNM Comparativas direia 2 sagital

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

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

33 RNM Comparativas direia 2 sagital

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

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

34 RNM Comparativas direia 2 sagital

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

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

35 RNM Comparativas direia 2 sagital

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

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

36 RNM Comparativas esquerda frontal

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

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

37 RNM Comparativas direita frontal

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

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

38 panoramicas comparativas

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

39 laminografias comparativas

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

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

40 frontais comparativas

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

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

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

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

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

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

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

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

47 DEPOIMENTO 3

Patient’s statement:

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

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

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

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

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

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

Different etiologic factors like trauma, local and systemic diseases, autoimmune disease and occlusion make create condition of discal displacement.

The importance and validity to recapture dislocated discs when the clinic case aloud, was commented in the publication of day February 22, 2015 entitled Recapture of articular disc displacement with reduction. Recapture or not recapture, that is the question.

We need to understand that treturn the anatomical joint elements to a healthy and physiological position is ALWAYS VALUABLE. Remember anatomy is the platform where physiology functions.

1 ERALDOMale patient 33 years old arrived to the clinic referring strong ache on the temporalis muscles, pain on the back of the head, unspecific facial pain, pain on the shoulders, buzzing and he also reports that he has been feeling numbness and tingling in his hands.

The patient also complains about clicking on  the left temporomandibular joint.

He also reported feeling of hearing loss, even if the audiometry is within the normal range.

2 ERALDO   He also reports about muscular tremors in the cheek region, and constant difficulty to open the mouth.

The patient does not present limitation to open the mouth, but to open the mouth he shifts the jaw to the left side.

He feels pain to chew hard foods, and he complains that he only can eat soft food

He tells that any meal is an effort and not a nice activity, even with food that he appreciate.

Refers bruxism and clenching

He  also finds difficulty to swallowing

3 ERALDO  The patient presents a retrusive profile, but this WAS NOT THE MOTIVE FOR CONSULTATION, the patient was not concerned about aesthetics, but with the PAIN.

Patient testimony:

When I was in the formation in the graduation of the Military Police ( with the order of not moving nor speaking) I was somewhat nervous, and suddenly everything went dark and I fell forward as a trunk, with all my weight and hit the chin (I was 18 years old).

My  teeth were closed, the pain from that episode was almost unbearable, I couldn´t eat or open the mouth, so was more or less for two weeks,  then start a tingling in the TMJ region and muscles, and a kind of sensitivity that remains to this day.

In the anamnesis the patient reported several injuries as a child, but nothing special to remember.

4 ERALDO Patient’s habitual occlusion.4B ERALDO  Wear in the upper and lower incisor sector

5 PANORAMICAS ERALDO  Patient’s panoramic radiograph before the treatment.6 PANORAMICAS ERALDOMandibular heads asymmetry7 LAMINO TMJ laminography in habitual occlusion.  Close and open mouth. Can be analyzed the asymmetry between the patient’s right and left mandibular head.

Superior flattening of both mandibular heads and change in the growth axis of both mandibular condyles.7A LAMINOThe color image highlights the structural differences between the right and left condyles.7B LAMINO   1- Normal growth axis

   2- Fracture location

  3-  Pathological growth axis

The website of the Clinica MY www.clinicamy.com.br  has the links for the article. 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.

5B LAMINOGRAFIA  The website of the Clinica MY  www.clinicamy.com.br  has the link for the article. 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.

5C LAMINOGRAFIA Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy8 CERVICAL  The cervical spine of the patient shows a rectification and a light curvature inversion

The patient’s cervical spine image reminded me similar images from many patients that suffered a whyplash traumatism.

I questioned the patient again, asking if out of trauma reported at graduation that had hit the chin, could not remember another accident.

INITIALLY THE PATIENT DID NOT REMEMBER. But in the next consultation he gave the following narration:

Patient’s testimony:

I was stopped at a traffic light driving my car when another vehicle hit behind the car in which I was.

The HIT WAS SO STRONG that the bank fully reclined back, I was lucky that I had a  headrest on the seat.

Evidently the whiplash suspicion was confirmed

9B FRONTAL  Mandible asymmetry is notorious on the patient’s frontal radiograph. IS SIMPLE TO UNDERSTAND IF WE THINK ON THE STRUCTURAL DIFFERENCE OF BOTH mandibular condyles. It’s like thinking in a patient with a structural difference in the length of legs. These structural alterations provoke morfofunctional alterations.

The muscles have to adapt and shorten three-dimensionally to compensate the system.

10 LATERAL  Many studies are based on a preconception, considering that the condyles are in a correct position and the patient does not present any pathology on the temporomandibular joints.

These structural alterations provoke morfofunctional alterations.

The muscles have to adapt and shorten three-dimensionally to compensate the system.

13

In this kinesiographic record   is registered the opening and closing mouth of the patient in sagital and frontal view and the velocity graphic.

The patient opens the mouth 40 mm, and frontally he needs to shift the mandible to the left side in order to open his mouth.

The opening and closing speed is poor, the patient has bradykinesia

12  In this electromyographic record of the patient in habitual occlusion is impressive the difference between the right and left anterior temporal.

There is nearly 70 percent difference between the left and right temporalis in habitual maximum occlusion. The right anterior temporalis can generate 105 microvolts in the window already analyzed, the left anterior temporalis can generate only 36 microvolts in the same range.

14 RNM

MRI: Magnetic Resonance Image of the patient. Selected slice.

1- Left TMJ closed mouth, sagital slice before treatment

Anterior displacement of the articular disc.

2- The Same image with color enhancement

3-  Left TMJ open mouth, sagital slice before treatment

4- The Same image with color enhancement

15B RNM

MRI: Magnetic Resonance Image of the patient. Selected slice.

Right TMJ closed mouth, sagital slice before treatment

Articular disc in habitual position.

Right TMJ open mouth, sagital slice before treatment

16 mordida The patient has a free way pathological space of 9,4 mm and a retrusion of 4,8 mm17 ORTESE  With the data obtained after mandibular electronic deprogramming and ALWAYS WITH THE INFORMATION OBTAINED IN THE IMAGES WE CONSTRUCT A DIO ( Intraoral Device) in neurophysiological position.18 eletro dio  Patient’s electromyographic record in neurophysiological occlusion with the intraoral device in mouth. The right and left temporalis are balanced.

There was nearly 70 percent difference between the left and right  temporalis in habitual maximum occlusion, before the intraoral device instalation.

19 eletro comparativas  Comparative EMG records on the top in habitual occlusion and on the bottom in neurophysiological occlusion with the DIO (intraoral device) in mouth.

21 cinecio comparativas e fotos  This image shows a patient’s profile sequence together with the sequence of kinesiographic records.. These records have to be related to EMG recordings previously posted.

All is correlated, joint decompression, masticatory muscles function and the three-dimensional location of the jaw.

The DIO (intraoral device) is planned not only by the electronic deprogramming, but also by the images and other auxiliary diagnosis tools. It is controlled, changed and recalibrated as part of a treatment.

It should be measured electromyographically. Logically the improvement of the patient’s symptoms must go along with the improvement of records.

22 frontal comparativas  Patient’s frontal radiographs comparison: the first in habitual occlusion and the second with the intraoral device in neurophysiological position.

Three-dimensional jaw alignment improvement, we can not fix the structural differences of the mandibular condyles, but we can balance the muscles.

22A frontal comparativas dellinhadas   Patient’s frontal radiographs comparison: tracing of the jaw to highlight the tridimensional alignment of the jaw in neurophysiological position.

24 FOTOS LATERAL comparativas Patient’s comparative profile: in habitual occlusion and in neurophysiological occlusion with the intraoral device. Improvement of the head position.24 foto LATERAL comparativas

.Patient’s lateral radiographs and cervical spine comparison: before treatment and completion of the first phase, correlation with the profile photos.

Although rectification of the cervical spine continues, it has a mild improvement in curvature inversion observed in the first radiography.

25 RNM COMP 2

MRI: Left TMJ sagital lateral slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

Control of the second comparative magnetic resonance imaging after the second treatment phase.

The images of the left TMJ which presented the displacement of the articular disc will be posted.

The right TMJ did not presented displacement of the articular disc, only the structural differences between the mandibular heads.

26 RNM COMP 3

MRI: Left TMJ Sagital lateral slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

27 RNM COMP 4

MRI: Left TMJ Sagital medial slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

28 RNM COMP 5

MRI: Left TMJ Sagital medial slice, closed mouth, before the treatment showing THE ARTICULAR DISC ANTERIORLY DISPLACED and the RECAPTURE OF THE ARTICULAR DISC after the treatment.

32 depoimento  When I arrived at the Clinic My, I was suffering a lot, I felt a strong pain, migraine, and I could not open my mouth without pain.

I was really in need of treatment; it was then that Dr. Lidia offered me to take care of my problem.

Since my articular disc was displaced and the joint was compromised, we started immediately and from there I got better, the pain stopped, I began to eat better and everything got better.

Today I can say that I´m very well, I feel normal, my disc and all the system is working okay!

I´m very grateful to Dr. Lidia Yavich, she is a great professional that knows what she does.

A big hug,

33