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.

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.

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

1 frontal inicial rosto

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

2 lateral inicial rosto

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

3 OCLUSÃO 1

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

4 OCLUSAIS

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

5 PANORAMICA INICIALInitial panoramic radiograph of the patient before treatment.

Absence of teeth 18, 28, 38, 48.

Horizontal resorption of alveolar ridges.

6 P6 INICIAL

Patient TMJ laminography in habitual occlusion before treatment.

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

7 TELE PERFIL INICIAL

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

8 C7 INICIAL

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

9 FRONTAL INICIAL

Frontal radiography of the patient in habitual occlusion before treatment.

10 ress1

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

11 ress3

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

12 b ress

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

13 ress4

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

13 cineciog 1

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

13 eletromiografia inicial

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

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

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

13 REGISTRO

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

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

The stomatognathic musculature is no exception.

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

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

The patient also presented a 2 mm mandibular retro position

13C PRIMEIRA ORTESE LUIS

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

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

13A FRONTAL DIO

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

13B LATERAL COM DIO

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

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

14 ress comp 1

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

15 ress comp 2

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

16 ress comp 3

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

17 ress comp DIR

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

18 ress comp DIR

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

19 ress comp DIR

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

20 PRIMEIRA ORTESE DA 2 FASE

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

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

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

21 ORTO 1

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

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

22 ORTO 2

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

23 ORTO 3

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

24 ORTO 4

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

25 ORTO 5

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

26 orto 6

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

27 orto 7

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

28 ORTO 8

Finalization of the second phase.

29 OCLUSAIS FINAIS

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

43 oclusoes comparativas

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

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

44 oclusoes comparativas

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

eletromiografia final

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

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

30 FRONTAL FINAL

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

31 TELEPERFIL FINAL

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

32 C7 FINAL

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

33 PANORAMICA FINAL

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

34 LAMINOGRAFIA FINAL

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

35 comparativas panoramicas

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

36 comparativas laminografias

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

40 COMPARAÇÃO TELE PERFIL

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

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

41 COMPARAÇÃO FRONTAIS

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

42 C7 COMPARATIVAS

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

46 DEPOIMENTO 1

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

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

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

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

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

day, which I have always identified as bruxism.

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

47 DEPOIMENTO 2

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

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

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

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

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

48 DEPOIMENTO 3

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

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

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

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

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

 

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

1 FOTOS FRENTE

A 54- year old female patient arrives to the clinic for consultation, referred by her rheumatologist with complaints of daily headache since her 23 years of age. The patient associates the beginning of the headache with the installation of a definitive crown on the right upper central incisor. When she was 12 years old the suffered a traumatism that provoked the fracture of the tooth. The patient also reports bruxism.

2 FOTOS PERFIL 2

The patient reports that in consultation with a neurologist, a nuclear magnetic resonance of the skull was requested, in which a change in white matter was detected.

At the same time the patient consults with a cardiologist. A FOP (Patent Oval Form) is detected, with no need for a surgical approach.

2A

After years and years of consultations and treatments for daily headaches, the patient also has a diagnosis of fibromyalgia.

The patient makes use of marevan, 5mg daily as indicated by the Cardiologist.

Sandomigran 1 time per day per Neurologist indication.

Nexium 40 mg once daily indication of Gastroenterologist.

Marevan works in the prevention of venous thromboembolism, systemic embolism in patients with prosthetic heart valves or atrial fibrillation, stroke, acute myocardial infarction and recurrence of myocardial infarction. Oral anticoagulants are also indicated in the prevention of systemic embolism in patients with cardiac valve disease.

Sandomigran, pizotifen is an antaminic characterized by its polyvalent inhibitory effect on biogenic amines, such as serotonin, histamine and tryptamine. It is suitable for the prophylactic treatment of migraine, reducing the frequency of seizures. Pizotifen also has appetite-stimulating properties and is mildly antidepressant.

Nexium: Expected action of medication, disappearance of symptoms of heartburn, epigastric pain and acid regurgitation. Healing of peptic ulcers.

3 dentes

Habitual occlusion of the patient on the day of the consultation. Note the persistence of a lower deciduous tooth on the left side.

4 OCLUSAIS

Upper and lower occlusal views of the patient on the day of the consultation. Note the persistence of a lower deciduous tooth on the left side.

Presence of bilateral torus mandibularis.

The lower incisors show signs of wear.

5 PANORAMICA 1

Absence of dental elements 18, 28, 38 and 48. Maintenance of element  75  in the dental arch. The element 11 is endodontically treated. Presence of fixed prosthesis with intracanal pin in element 11.

6 LAMINOGRAFIA INICIAL

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

7 TELEPERFIL

Lateral radiograph of the patient in habitual occlusion before treatment.

8 FRONTAL

Frontal radiography of the patient in habitual occlusion before treatment.

9 C7

Lateral and cervical radiograph of the patient in habitual occlusion prior to treatment. Note the loss of space between the cervical vertebrae, especially between C5 and C6, where osteophytes are also observed.

10

MRI: Sagittal slice of the left TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Facet on the superior surface and posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

Notice the posterior compression in this slice.

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

11

MRI: another sagittal slice of the left TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

12

MRI: Sagittal slice of the right TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Facet on the superior surface and posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

13

MRI: another sagittal slice of the right TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

Notice the posterior compression in this slice.

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

14

MRI: another sagittal  slice of the left TMJ in the closed mouth.

Notice the posterior compression in this slice.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

17 registro inicial para o DIO

The patient’s masticatory muscles were electronically deprogrammed and the mandible rest position was recorded with a computerized kinesiograph.

An intraoral device (DIO) was made to for three- dimensional mandible repositioning.

The patient presented a pathological free interocclusal space of 4,4 mm, a mandibular retroposition of 1, 6 mm, also a right deviation of 1 mm.

20 OCLUSAO DIO

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

21 Registro cinesiográfico para controlar o DIO em posição neurofisiológica

Control of the intraoral device registration (DIO). These controls are frequently performed during the first phase of the treatment, also monitored by surface electromyography. On average this first phase lasts one year. Modifying and improving PHYSIOLOGICAL NEUROMUSCULAR POSITION.

22 RC1

MRI: comparative sagittal sections of the left TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

23RC2

MRI: another comparative sagittal sections of the left TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

25 B RC5

MRI: comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

25 ARC4

MRI: another comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

24RC3

MRI: another comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

After the completion of the first phase of the treatment of TMJ pathologies and the patient WITHOUT HEADACHE, we began the second phase of TMJ pathology treatment.

In this specific case: three-dimensional orthodontics together with the rehabilitation of the necessary dental pieces and aesthetic improvement of the patient’s anterior teeth.

25 PANORAMICA ANTES DA ORTO

At this point I had to make a decision regarding the permanence of the deciduous tooth, firm and without mobility.

I did not think I should extract it for the placement of the implant, but to maintain it.

I clarified to the patient that during orthodontics we could lose it. I understood that this would have a compromise in the patient’s occlusion, but this fact did not concerned me, with the TMJ being decompressed and the patient functioning well, both electromyographically and in the computerized kinesiograph tests.

25 ORTO 1

The second phase with three-dimensional orthodontics is started in the second phase of the treatment of TMJ pathologies in this specific patient.

26 ORTO 2

The second phase with three-dimensional orthodontics is started in the second phase of the treatment of TMJ pathologies in this specific patient.

27 ORTO 3

The second phase with three-dimensional orthodontics is started in the second phase of the treatment of TMJ pathologies in this specific patient.

28 ORTO 4

The second phase with three-dimensional orthodontics is started in the second phase of the treatment of TMJ pathologies in this specific patient.

29 reconst do dente desiduo

Direct composite resin reconstruction of  the 75 and 37 elements maintaining patient’s  Neuromuscular Physiological position.

30 ORTO 6

Sequence of three-dimensional orthodontics in the second phase of TMJ pathologies treatment in this specific patient. Direct composite resin reconstruction of  the 75 and 37 elements maintaining patient’s  Neuromuscular Physiological position.

31 ORTO 8

Sequence of three-dimensional orthodontics in the second phase of TMJ pathologies treatment in this specific patient. Preparation for the reconstruction of elements 33, 32, 31, 41, 42 and 43 maintaining the patient’s Neuromuscular Physiological position.

32 ORTO 9

Direct composite resin reconstruction of  33,32,31,41,42 and 43 elements maintaining the patient’s Neuromuscular Physiological position, with three-dimensional orthodontics.

33 lentes de contato

After the resolution of the strong headache (reason why the patient consulted the clinic) and the finalization of the tridimensional orthodontics, it was decided to make laminated facets from canine to canine for aesthetic reasons.

34 Finalizaçaoo da primeira e segunda fase

Completion of the First and Second Phases in the treatment of TMJ Pathologies. Physiological Neuromuscular Rehabilitation.

36 LPANORAMICA FINAL

Patient’s panoramic radiograph after the end of the treatment in the Neuromuscular Physiological Dentistry.

37 LAMINOGRAFIA FINAL

Patient’s temporomandibular joints laminography  in physiological neuromuscular occlusion after treatment completion.

38 FRONTAL final

Patient’s frontal radiograph  in physiological neuromuscular occlusion after treatment completion.

39 LATERAIS COMPARATIVAS

Patient’s comparative lateral radiographs  before and after treatment. The first  in habitual occlusion and the second in physiological neuromuscular occlusion.

45 DEPOIMENTO 1

At age 11, I had a fall and broke the upper incisor tooth. At the time, I sought a dentist and he said that I should wait for the adult stage to make the porcelain definitive crown.

In 1986, when I was 23, I went to another dentist to make the crown. After the root canal treatment, the crown was placed.

In that moment I felt that there was an elevation that touched the lower tooth. The next day I woke up with an endless headache. Day by day the pain intensified.

I returned to the dentist and reported the fact, he said that in time it would settle. For 25 years I investigated the reason for my headache with several doctors.

In 2006 a rheumatologist asked me for an MRI of the skull, changes were identified in the gray matter. During this period, I was admitted to HMV for an investigation, and the diagnosis was SAF, topiramate 50 mg was introduced as a preventive of migraine and anticoagulant.These drugs were used from 2006 to 2011.

45 DEPOIMENTO 2

In 2007, I underwent systemic chemotherapy with METOTREXATE for 1 year. In 2011 another pain site showed up, this time in the hip, so I underwent corticoid in the vein for 6 months.

I decided to abandon the treatment, because it was no use. I looked for a respected neurologist who switched all my medication for an anti-allergy for headache prevention and an antiplatelet.

The diagnosis was leukoencephalopathy in a small degree. I also gave up treatment, because it did not work, either.

This neurologist referred me to another rheumatologist who examined me and identified a problem in my TMJ and a bursitis in the hip.

The same rheumatologist sent me to Dr. Lidia Yavich and to an orthopedist. In a short time I did not feel the same headache when I woke up. After all this, I continue to do MRI, and the changes have stabilized.

45 DEPOIMENTO 3

 

I sought an opinion from a second neurologist, and he thinks that all the changes I have are due to the intensity of the headache that I felt daily.

He did not agree with any diagnosis made so far.

I also believe that, because after the treatment with Dr. Lidia, I regained my quality of life.

The medication I use today: antiplatelet due to the existing changes and because I have a patent foramen ovale.

I thanks also to Dr. Luis Daniel for the conjunct treatment restoring function and aesthetics.

 

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.

1-itacir-inicial-frontal-copia

A 57-year-old male patient presented at the clinic, referred by a colleague with complaints of: back of the head pain mainly on the right side, ringing in both ears and perception of strange sounds.

2-itacir-inicial-lateral-copia

The patient complains of daytime and nighttime clenching.

Refers to dental losses very early, and installation of prostheses that are subsequently fractured, as well as dental fillings fracture.

3-dentes

Habitual occlusion of the patient on the day of the appointment, the patient had made a removable prosthesis, but felt neither stability nor comfort with it.

4-oclusais

Upper and lower occlusal views of the patient without the lower removable prosthesis before treatment

5-panoramica-1

Patient’s initial panoramic radiograph before treatment

Radiographic examination shows absence of dental elements 17, 15, 14, 24, 27, 28, 38, 37 and 36.

Alveolar bone loss in the maxilla and mandible. Impairment of the bone support of element 18. Impairment of the furcation region of element 46.

Alveolar extension of the maxillary sinus in the region of premolars and molars

Endodontically treated 13 and 12 elements.

6-laminografia-1

The laminography of the temporomandibular joints shows superior and posterior positioning of the right articular process in the articular cavity and inferior and anterior positioning of the left articular process in the articular cavity when the mandible is in the position of maximum intercuspation.

In the maximum opening position, observe anterior angulation of the articular processes. Significant flattening of the posterior and superior surfaces of the right joint process.

7-a-perfil-e-tele

Lateral radiography in conjunction with the patient profile image before treatment.

7-frontal-1

Frontal radiography in conjunction with the patient profile image before treatment.

8-c7-e-perfil

Lateral and cervical spine radiographs together with the lateral image of the patient before treatment.

9-comparativos-emg-basal

Patient’s comparative electromyographic records at rest,  before and after the electronic deprogramming with the TENS.

Note the relaxation of the muscles especially of the right masseter which after relaxation showed symmetrical values with the left masseter.

10-dinamico-1

Patient’s dynamic electromyographic record in habitual occlusion before treatment. Note the activation of trapezius and digastric muscles at the moment of maximum occlusion.

10-a-1-corte-ressonancia

One slice of the patient’s MRI (magnetic resonance imaging): we can observe anterior angulation of the articular processes, flattening of the superior and posterior surface of the articular process of the right side and the posterior surface of the left side. Information we had on laminography.

The articular discs are displaced anteriorly and are also very thin which imply a disc that structurally may not always fulfill the function for which a disc is drawn. However it is imperative in this case even if a recapture of the discs is not achieved, to promote joint decompression.

11-jaw-tracker-1

The patient’s masticatory muscles were electronically deprogrammed and the mandible rest position was recorded with a jaw tracker.

A device for the three-dimensional repositioning of the mandible was constructed.

The patient presented a very large pathological interocclusal free space 13 mm, and a mandible retro position of two mm.

A healthy free interocclusal space of two mm was left in the DIO construction.

The records change as the system improves, and the devices are changed and recalibrated.

14-ortese-1

The three-dimensional mandibular rest position was recorded as an occlusal bite record, which was later used to make a DIO (intraoral device).

16-laminografia-comparativa

Patient’s comparative laminographies:  the superior in habitual occlusion before the treatment and the lower in the neurophysiological position wearing the DIO (intraoral device).

17-a-perfil-comparativos

Patient comparative images: before the treatment and during treatment with the  DIO (intraoral device)

18-teleradiog-comparativas

Lateral radiographs of the patient: in habitualocclusion and with the use of the DIO (intraoral device)

19-comparativa-frontal

Patient’s comparative frontal images before and during the treatment with the DIO (intraoral device)

20-telefrontais-comparativas

Patient’s comparative frontalradiographs:  before and during the treatment with the DIO (intraoral device)

21-comparativa-perfil-1

Patient’s comparative postural images: before and during the treatment with the DIO (intraoral device)

22-comparativo-sorriso-1

Patient’s comparative frontal postural images smiling: before and during the treatment with the DIO (intraoral device)

24-radiografia-implante-1

Wearing  the orthotic, the first phase of implant placement begins.

Panoramic radiograph of the patient in neurophysiological occlusion with the DIO (intraoral device), after the installation of the first implants.

26-implantes-2

For the superior implants it was necessary to perform bone graft, 120 days after the bone graft the superior implants were placed.

Panoramic radiograph of the patient in neurophysiological occlusion with the DIO (intraoral device), after the installation of the remaining implants.

25-preparo-implante-1

Intraoral device constructed in neurophysiological position with the implants installed.

jaw-tracker-2

Controlling the record of the intraoral device, the records change as the system improves, and the devices are changed and recalibrated.

27-orto-1

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

29-orto-3

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

30-orto-4

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

31-orto-5

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

32-orto-6

Alignment and recovery of the lower sector with resins.

 The patient is tested with bioinstrumentation maintaining an aesthetic and functional result within the specific case.

jaw-tracker-3

Control of the neuromuscular trajectory in the rehabilitated patient.

eletro-apos-orto

Dynamic electromyographic record after completion of the patient’s second phase  treatment. Orthodontics and rehabilitation.

33-finalizacao-1

Completion of the TMJ pathology treatment, orthodontic and rehabilitative (in this specific clinical case).Neurophysiological rehabilitation was performed by Dr. João Sousa.

Subsequent rehabilitation was done keeping the vertical dimension with the device, but having to yield a little at the ideal height due to the patient’s bone conditions, rehabilitation possibilities and orthodontic limitations. The rehabilitation was done with metal ceramic crowns, and in the upper implants zirconia crowns in elements 14 and 15.

34-a-oclusais-finais-1

Patient’s upper and lower occlusal view after completion of the neurophysiological treatment.34-panoramica-final

Patient’s panoramic radiograph after completion of the neurophysiological treatment.

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Patient’s laminography in neurophysiological occlusion after completion of the neurophysiological treatment.

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Patient’s lateral radiograph after completion of the neurophysiological treatment.

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Patient’s frontal radiograph after completion of the neurophysiological treatment.

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Comparative patient occlusions before and after neurophysiological treatment.

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Comparative occlusal views of the patient: before and after the neurophysiological treatment

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Comparative panoramic radiographs of the patient: before during and after the neurophysiological treatment.

Subsequent rehabilitation was done keeping the vertical dimension with the device, but having to yield a little at the ideal height due to the patient’s bone conditions, rehabilitation possibilities and orthodontic limitations. The rehabilitation was done with metal ceramic crowns, and in the upper implants zirconia crowns in elements 14 and 15.

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Patient’s postural comparative frontal images: before, during and after the  neurophysiological treatment.

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Patient’s postural comparative profile images: before, during and after the  neurophysiological treatment.

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Patient’s lateral comparative lateral radiographs: before and after the  neurophysiological treatment.

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Main Symptoms:

1) Bilateral Tinnitus- This symptom bothered me greatly, especially in the silence of the night it was almost torture, today I do not feel anything else, so much that I have forgotten if I ever had tinnitus.

2) Strange sounds in both ears: I had difficulties to identify, I confused on which side came the sounds and voices.

3) Clenching and constant breaking of prostheses and restorations – I remember that this was the main reason why Dr. João told me to seek treatment.Today I use a orthotic to sleep and I never had any problems.

4) I had a great gift, which I did not expect and I was not looking for it either. Facial rejuvenation, to the point that some people do not recognize me as they pass me by. Others noticed the change and asked what I had done and more recently a friend asked me, what is the secret of growing young. I’m very happy, I’m much younger. Thank you Dr. Lídia, thank you Dr. João.

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

1

Female patient 31 years old comes to consultation reporting severe headache, severe pain in the temporal, especially on the left side, pain on the left ear and pressure on the left eye.

She also states strong neck pain, dizziness, and reports that she feels a burning sensation on the cheek and also pain.

2

She also reports allergic rhinitis and sinusitis, for which she had already made several treatments. But the rhinitis or the sinusitis where never acompannied by the pain she was reporting. This was something new.

She reports having bruxism.

3 OCLUSAO INICIAL

The patient states that she used removable and also fixed orthodontics appliances from her 15 years old until her 18 years old.

She refers to a traumatism in the anterior sector in which the incisor fractured the incisal edge when she was a child.(see publication Structural Modifications of the Mandibular Condylar Process as one of the sequels of traumatism in infancy)4 OCLUSAIS

We can see the wear on the upper and lower incisors.

Regarding the beginning of the pain, the patient reported that she frequently felt fatigue in her facial muscles; she was a teacher and talked a lot during the classes.

But then she felt just fatigue, she never had the pain she was feeling now.

The episode that the patient reported as triggering the pain was when she broke a tooth when she was chewing.4 retrato

Patient testimony

When I broke my tooth while chewing, I went to an emergency clinic where they made a curative and headed me for a root canal.

When the root canal was finished, I left the dental office with A LOT OF PAIN.

But it was not toothache; it was a lot of pain in the face, especially in the masseter muscle.

 Days after  I started to feel an hallucinating pain in the neck, pain in the left ear and headache;

At the time I was derived to a professional who did occlusal adjustments and installed a splint.

I threw away the splint, since I complained that the device did not ease the pain but increased the pain I was feeling.

From that moment I started to consult a lot of professionals.

When she ended the latter sentence, the patient looked into my eyes and while crying she asked: Dr, do you believe in the things I´m telling you?

I said YES, and I answered, I BELIEVE IN YOUR REPORT.

The patient increased her crying and told me that many of the professionals she visited said that she had nothing and the pain was a thing of her head. Just stress!

4A PANORAMICA INICIAL

The panoramic radiograph of the patient shows the root canals endodontically treated (maxillary first molar on the left, 26). This is the tooth that the patient reported having fractured and treated)

We can see that the third molar on the left (48) is angled and impacted on the distal of the second lower molar on the right.

4B LAMINOGRAFIA INICIAL

In the temporomandibular joint laminography of the patient, we can see an anterior angulation of the articular processes. We can also observe a flattening of the upper and posterior surface of both articular processes; it is more significant on the right side.

4C RADIOGRAFIA LATERAL INICIAL

Patient’s lateral radiograph before treatment4D LARGO DE PERNASAt a certain moment a scanning of the lower limbs was asked to the patient, as a difference in length of the lower limbs was suspected. It revealed to be just a muscle shortening, since structurally her lower limbs presented the same measure.5 abre e fecha 1

Computerized kinesiology analyzes the graphic movements that the jaw performs in the three directions of space. The patient has an opening of 30 mm which is already considered a limitation.

The patient does not have good speed in opening and  closing the mouth. This can be an indicator of muscle disorders, intra-articular injuries or discrepancies between the teeth and the muscles.

6 BASAL ANTES E APOS O DEM

In this basal electromyography the masticatory muscles are in hyperactivity, after electronic deprogramming the muscles down their values.

An electromyography with a lower value, after the electronic relaxation, for a particular muscle, is more important than the absolute value before being pulsed.

7 MORDE FORTE ABRE ENGOLE

In this dynamic electromyography, the patient clench hard twice, opens her mouth, closes her mouth and swallows. Masseter muscles, which are the most potent muscles of the stomatognathic system generate very little activity in maximum occlusion.

The anterior temporalis are recruiting more motor units than the masseters, which is not physiological in a system that works in a balanced manner.

8 HABITUAL E ROLOS

In this dynamic electromyography (A) the patient bites into habitual maximum intercuspation, (B) the patient bites with cotton rolls on the right and the  left between her occlusal surfaces, the activity improves considerably.

Every modification of the joint position leads to muscle length change, and consequently it change its strength.The muscles that are shortened or lengthened by approximately 20% exhibit the so-called mechanical failure and a decreased intrinsic potency (Macintosh, Valencia et al., 1986).9 ressonancias iniciais

MRI of the patient: we can see an anterior angulation of the articular processes, flattening of the upper and posterior surface of both articular processes, information that we already have in the laminography.

The joint articular discs are very thinned which structurally implies an articular disc that can not always fulfill the function for which an articular disk is designed. It is imperative to promote joint decompression.

Remember the electromyography improvement that we had with the placement of cotton rolls between the occlusal surfaces.

11A TOMA DE MORDIDA

The masticatory muscles of the patient were deprogrammed electronically and the rest position was registered with a computerized jaw tracker.

This record was very difficult to achieve.  It was very difficult to deprogram the patient.  Even so a very thin DIO (intraoral device) was constructed in neurophysiological position  to promote the jaw reposition that was in a slight posterior position.

We left an inter-occlusal free space of 1 mm which  normally is very little (remember that the jaw tracker enables this type of measurement)

In the screen we may read a comment  that says (this is the record that I managed to take). I wanted to register this in the original record, as many times we don´t get a good record in the first time and this was the case. Logically records will modify as the system improves.11B RECALIn this other record where we are recalibrating the patient’s device , we can see the coincidence of the habitual trajectory with the neuromuscular trajectory. The patient is now deprogramming better so we could build  a better intra-oral device.

12 ABRE FECHA ORTESE

In this kinesiographic record with the DIO (intraoral device) in neurophysiological position, we can see the improvement of the trajectory in mandibular opening, closing and speed. Remember that the patient did not have a good speed in mandibular opening and closing, and she had a more vertical opening trajectory.

13 ABRE FECHA comparativas

Kinesiographic comparative records of opening, closing and speed: in habitual position before treatment and with the DIO (intraoral device).

13A TOMA DE MORDIDA E RECAL

Comparative rest position records: before treatment and recalibrating the DIO (intraoral device). In the recalibration record we can observe the coincidence of the habitual trajectory with the neuromuscular trajectory.

14 PANORAMICA ANTES DA ORTO

The first phase was carried out ( treatment of the TMJ)  with the controls and recalibrations required to enhance the mandibular position, in this case together with physical therapy to balance the postural chains.

At the request of the panoramic radiograph before moving on to the second phase of this case (three-dimensional orthodontics) it can be observed the third right lower molar eruption. This molar was impacted in the distal of the second right  lower molar. (31-year-old patient).

At this step it was only released the acrylic of the DIO in the region of the third impacted molar, returning the vertical dimension of the patient and allowing the eruption of the third molar.

15 PANORAMICAS COMPARATIVAS

Comparison of pre-treatment panoramic radiograph and after the first phase with the DIO (intraoral device) installed in neurophysiological position.

At this point a three-dimensional orthodontics is initiated to remove the DIO.

This orthodontic treatment as was explained in previous publications (see the publication Tridimensional Orthodontics in the Second Phase  of TMJ pathologies) must maintain the mandibular location  in balance with the muscular planes, with the temporomandibular joints and the dental plans, obtained in the first phase.

For this we have tools such as surface electromyography and electronic jaw deprogramming, that helps us to control how the system is functioning.

Few sequences will be shown until the full withdrawal of the DIO (intraoral device)

16 orto 0 1

Active eruption of lateral segments, already in a more advanced stage. The teeth are filling the space formerly occupied by the DIO.18 PANORAMICA CONTROLE  ORTO

Patient´s panoramic x-ray: control of the active eruption. It corresponds to the sequence shown in the previous image.

19 orto 0 1B

Three-dimensional orthodontics treatment continuation: Image with and without the device, the lateral sectors have already erupted.20 orto 2Three-dimensional orthodontics treatment continuation.21 oclusao final

The alignment of the upper and lower incisors sector was achieved just as the restoration with resin of the fractured part of the incisor.

Conclusion of the three-dimensional orthodontics after TMJ treatment.22 OCLUSAIS FINALConclusion of the three-dimensional orthodontics after TMJ treatment.22A eletromiografia final 22APatient’s dynamic electromyographic record after treatment.22B eletromiografia COMPARATIVAPatient’s SEMG records: before and after treatment. We can analyze the balance and functioning of the masseter, which did not happen in the initial registration.23 ABRE FECHA APOS O TRATAMENTO 2Kineciographic record: opening, closing and speed after treatment conclusion.23 B abertura e fechamento comparativasKinesiographic comparative records of opening, closing and speed: in habitual position before treatment, with the DIO (intraoral device) and after treatment conclusion.24 LAMINOGRAFIAfinal LPatient’s laminography in neurophysiological occlusion after treatment conclusion.25 LAMINOGRAFIAS COMPARATIVAS

Patient’s comparative laminographies: in habitual occlusion before treatment and neurophysiological occlusion after treatment conclusion.

It should be understood that the chosen mandibular position is the one where the joints are decompressed and muscles are able to recruit more motor units, for that we use electronic mandibular deprogramming. Registration also depends on the information obtained in the images.25B res. comparativasMRI (magnetic resonance imaging) comparative images of the patient: in habitual occlusion before treatment and in neurophysiological occlusion in the conclusion of treatment.

It should be understood that the chosen mandibular position is the one where the joints are decompressed and muscles are able to recruit more motor units, for that we use electronic mandibular deprogramming.

Registration ALSO DEPENDS on the information obtained in the images. MRI also provides information that should be taken into account when we decide the mandibular position, enhancing the data provided by the computerized jaw tracker: which and the type of disc, disk positioning, whether or not recapture among other data.

26 panoramica final LPatient’s panoramic radiography after conclusion of the second phase, in this case the three-dimensional orthodontics.26B panoramica COMPARATIVAS

Patient’s comparative panoramic radiographs: 1 before treatment, 2 during the first phase, 3 during the three-dimensional orthodontics, 4 after conclusion of the three-dimensional orthodontics.

27 fase frontalPatient’s comparative frontal image before and after treatment.28 fase perfilPatient’s comparative profile image before and after treatment.29Patient testimony

Dear Doctor,

I clearly remember when everything began.

First I used to feel a huge fatigue in the muscles of the face and mouth. I was very stressed then, I was teaching and I used to speak a lot.

Then I broke a tooth. And (ouch!) what to do? I looked for an emergency doctor and he made me a curative. He advised me to go to a dentist and I had to make a root canal there. I left the clinic in pain.(an incredible, allucinating headache,and ear pain)

I began to loos weight… I felt a malaise, a lack ou courage. My face muscle, the masseter seemed to be making weightlifting. Felt as strong and stout, but it hurt so much! It looked as if I had 200 Kg on my face and my neck seemed not to be part of my body. What an unbearable pain! I felt a general rejection, a lack of will of living.) My whole body started to ache. Even fibromyalgia some would say I had, others said I had one leg which was smaller that the other other would say… To sum up, I was a time bomb of all the problems professionals said I had… (I felt like that…)

From there I visited a lot of professionals.

Michigan splint, intensive physiotherapy, chiropractic terapy , shiatsu, do-in… So desperate I was! I even searched for an afro-brazilian religious priest (mãe de santo)….. But nothing relief me from my pain.

I was then that I went to see a very SPECIAL person in my CRAZY life! Dr. Lidia!!

It got better… but NOOOO the strife started to increase!!! Exams, resonances, what an affliction!

From that day five years had passed until my life got back in track… Back to normal with or without pain. But actually it came back on track WITHOUT ANY PAIN!!!

But for that a lot of water had flowed under the bridge!

The result was that after many appointments at the clinic, I remember the attendance on a Sunday of World Cup when Brazil was Champion and that compassionate soul (hahaha) helped me.

So much pain! So much despair! Even so that doctor had so much will and patience to cure me!

It was a hard path. But… We made it and we found that one of my wisdom teeth were totally ignorant (they had no wisdom at all) and it decided to sprout after my thirties.

I used to say that my teeth were like two soccer fan crowds that did not fit, as Palmeiras e Corintians (something like Chelsea and Manchester). They were in ethernal fight!

But after the storm…. My problems started to be solved.

Today I have a big smile thanks to Dr. t Lidia, hahaha. I pray everyday to her.