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.

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

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

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

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

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

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

Upper and lower incisors show signs of  attrition.

7 PANORAMICAInitial panoramic radiograph of the patient before treatment.

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

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

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

The procedures would only be performed after joint decompression.

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

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

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

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

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

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

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

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

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

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

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

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

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

10A C7 COMPARATIVASComparison of lateral radiographs and cervical spine of the patient: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

46 DEPOIMENTO 1Patient testimony

Dear Lidia,

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

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

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

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

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

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

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

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

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

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

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

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

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

although prolonged, has improved my quality of life.

TMJ Study and Investigation Page. Three years of publication.

Dear friends,

At December 2014 I started the project TMJ Study and Investigation Page. At first, all its content was offered in three languages: Portuguese, English and Spanish. Due to the analysis of the webpage access statistics, at March 2015 I decided to offer the content solely in Portuguese and English.

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

Three years of publication

Nowadays, the medicine based on evidence is hierarchically stratified from top to bottom, where in the base of the pyramid we find the clinic cases, which are rarely seen as evidence.

The TMJ Study and Investigation Page had in its conception, the purpose of posting the clinic cases, which were carefully published with the documentation related to each of the patients treated at Clinica MY with pain complaints, dysfunction and TMJ pathology.

The proposition was of presenting these clinic cases and concepts in order share them, offering free access to the content along images, surface electromyographies, computerized kinesiography, scanned before and after the therapeutic process. Cases of tridimentional orthodontics and neuromuscular phisiologic reabilitation of the second phase of treatment, after the TMJ treatment, were also included.

FINAL

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

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

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

I want to celebrate these three years with you.

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

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

MARCUS LAZARI frontal E SAGITAL

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

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

3 ANOS DE PUBLICAÇÕES 2

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

Thank you!

Lidia Yavich

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

33 FINAL

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

24

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

27 CEF COMPARATIVAS ingles

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

FRONTAL COMPARATIVAS ESQUERDA 2016

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

10 abre e fecha inicial

FINALE FINALE

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

ITACIR COMBINADA

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

1 FOTOS FRENTE

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

HELLA

TMJ Study and Investigation Page. One year of publication

INITIAL

2

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

Thank you!

Lidia Yavich

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.

35-lamino-final

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

36-tele-final

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

38-frontal-final

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

38-dentes-comparativos-finais

Comparative patient occlusions before and after neurophysiological treatment.

39-oclusais-comparativas

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

34-a-panoramicas-comparativas

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.

41-comparativa-frontal

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

42-comparativa-perfil-1

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

43-teleradiog-comparativas-inicial-e-final

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

44-depoimento-1

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.