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

 

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

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

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

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

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

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

1 FOTO FRONTAL

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

Pain is more intense on the left side.

2 FOTO PERFIL - Copia

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

The left ear has normal hearing thresholds.

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

3 DENTES INICIAIS - Copia

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

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

4 OCLUSAIS INICIAIS - Copia

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

5 PANORAMICA INICIAL - Copia

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

Tooth 38 in a horizontal position, impacted

Reabsorption of the alveolar ridges.

6 LAMINOGRAFIA INICIAL - Copia

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

7 TELEPERFIL

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

8 FRONTAL

Patient’s frontal radiograph in habitual occlusion before treatment.

9 C7

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

10 abre e fecha inicial

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

11 RNM INICIAL DIREITA FECH

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

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

11B RNM INICIAL aberta dir

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

12 RNM INICIAL DIR FECH

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

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

12B RNM INICIAL aberta dir

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

13 RNM INICIAL esquerda FEC

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

14B RNM INICIAL esquerda aberta

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

15 frontais iniciais

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

16 REGISTRO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and a DIO (intraoral device) was constructed in neurophysiological position. In other publications computerized kinesiographic methods were mentioned.

In occlusion most often the healthy or pathological condition of the inter-oclusal space is not objectively considered. In this case the pathological free space of the patient is almost 7, 4 mm

16A ortese inicial so frontal

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

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

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

17 FOTO frontal reinicio de tratamento 1

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

18 FOTO PERFIL reinicio de tratamento 2

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

19 ORTESE REINICIO DE TRATAMENTO

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

20 PANORAMICA COM ORTESE

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

21 LAMINOGRAFIA COM ORTESE

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

22 TELEPERFIL COM ORTESE

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

23 C7 COM ORTESE

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

PATIENT’S ANALYSIS AT THIS STAGE OF THE TREATMENT.

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

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

Remission of symptoms and improvement of  life quality.

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

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

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

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

26 orto 1

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

27 orto 2

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

28 orto 3

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

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

29 retirada da ortese

Removal of the DIO (intra oral device)

30 orto final

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

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

31 oclusais finais

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

32 LAMINOGRAFIA final

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

33 panoramica  final

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

34 TELEPERFIL final

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

NOVA RESSONANCIAS FINAIS

Temporomandibular joints MRI after de finalization of the second phase.

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

The patient no longer has symptoms.

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

36 B radiog laterais comparativas menor

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

35 registro COMPARATIVOS

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

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

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

35 iimagens comparativas de perfil

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

36 iimagens comparativas frontais

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

37 DEPOIMENTO

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

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

38 DEPOIMENTO

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

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

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

39 DEPOIMENTO

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

evento setembro2

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

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

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

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

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

The patient had remission of symptoms.

The patient had improved function and recovered the vertical dimension.

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

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

The patient had improved her posture.

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

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

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

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

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

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

12 RNM DIREITA INICIAL

MRI: sagittal slice of the right TMJ closed mouth.

There is an irregularity of contour with reduction of the superior aspect of the mandibular condyle, the condyle is ante versioned. There is a small anterior osteophyte.

The articular disc is displaced anteriorly, when the mouth opens.

Presence of subcortical bone cysts in the anterior superior aspect of the mandibular condyle.

13 RNM  ESQ  INICIAL

MRI: sagittal slice of the left TMJ closed mouth. There is a substantial irregularity of contour of the upper portion of the mandibular condyle, with the formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced when the mouth opens.

CAN BE SEEN AN IMPORTANT HIPOSSINAL COMPATIBLE WITH AVASCULAR NECROSIS.

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

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

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

13A RNM  ESQ  INICIAL

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

There is an important  irregularity of contour of the superior aspect of the mandibular condyle and a formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

CAN BE SEEN AN IMPORTANT HIPOSSINAL COMPATIBLE WITH AVASCULAR NECROSIS.

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

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

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

16A  ESQ boca fechada 2013 T2

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

MRI in T2 clearly shows the ARTICULAR EFFUSION.

The differential diagnosis of TMJ effusion has a broad spectrum as the effusions in other joints in other parts of the skeleton.

 MRI (magnetic resonance imaging) can give us a lot of information, not just the disc position.

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

CORTE FRONTAL DA ATM ESQ INICIAL ANTES DO TRATAMENTO 2

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

CAN BE SEEN AN IMPORTANT HIPOSSINAL COMPATIBLE WITH AVASCULAR NECROSIS.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. It can be caused by various conditions, such as bone or joint damage, PRESSURE INSIDE THE BONE and other medical conditions.

The condyle affected by avascular necrosis has low signal on T1-weighted images as a result of edematous changes in trabecular bone.

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

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

CORTE FRONTAL DA ATM DIR INICIAL ANTES DO TRATAMENTO

MRI, frontal section of the right TMJ closed mouth. Upper lesion in the right mandibular condyle, as described in the same sagittal slice of the same condyle as subcortical bone cysts.

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

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

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

FRONTAL COMPARATIVAS DIREITA 2016

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

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

FRONTAL COMPARATIVAS ESQUERDA 2016

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

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

THE MANDIBULAR CONDYLE HAS A HELTHY BONE MARROW SIGNAL.

RESS COMP DIREITAS SAGITAL 2016

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

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

sagitais comparativas T2

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

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

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

The patient DID NOT USE ANY ANTI-INFLAMMATORY DRUG.

RESS COMP SAGITAL ESQ 2016

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

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

THE MANDIBULAR CONDYLE HAS A HELTHY BONE MARROW SIGNAL.

FINAL 1

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

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

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. It can be caused by various conditions, such as bone or joint damage, PRESSURE INSIDE THE BONE and other medical conditions.

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

FINAL menor

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

finale finale

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

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

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

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

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

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

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

In several publications of this page I have presented patients of different ages, different gender and different pathologies of the temporomandibular joints.

This is the second case report about a patient with prosthetic protocols built on implants.

I call once again the importance of  the attention in the diagnosis of temporomandibular joints pathologies and mandibular position as a key part of any procedure in dentistry.

1 FOTO INIC FRONTAL

Female patient 54 years old arrived to the clinic for consultation with severe headache complaints, pain in the temporomandibular joints, pain in the cervical spine, sore shoulders, ear pain, feeling of clogged ears and crepitation in both temporomandibular joints.

2 FOTO INICIAL PERFIL

The patient was referred by her dentist who performed the treatment of implants and prosthetics, rehabilitating the patient, but without being able to relieve the pain that afflicted her.

2A MARCAÇÃO DA DOR

Part of the questionnaire completed by the patient.

The patient reports daily pain.

FUNCTIONS THAT AGGRAVATE HER PAIN:

Mastication

Opening the mouth

Laughing

Yawning

The patient also refers back pain and numbness and tingling in the arms and fingers.

Refers that she wakes up with body aches.

3 DENTES INIC PROT FRONTAL

Patient habitual occlusion on the day of consultation.

The patient had fixed prostheses supported on implants on the lower jaw and a removable upper protocol supported on implants on the maxilla.

4 OCLUSAIS INICIAL PROTPatient’s superior and inferior oclusal view of the prostheses supported on implants on the day of consultation.

5 DENTE INICIAL SEM PROT

Image of the oral cavity of the patient without the upper prosthesis.

6 OCLUSAIS INIC SEM PROT

Patient’s superior and inferior oclusal view without the superior prostheses.

7 PANORAMICA INICIAL

Patient’s initial panoramic radiograph before treatment with the prosthesis in the habitual occlusion before treatment.

Presence of 4 metallic implants in the maxilla 2 on the right side and 2 on the left side; and 5 implants in the anterior mandible region.

8 LAMINOGRAFIA INCIAL

Patient’s TMJ right and left laminography, closed and open mouth: posterior positioning of the articular processes in the joint cavities when the jaw is in maximum intercuspation position.

9 TELE PERFIL INICIAL

Patient’s lateral radiograph with prosthesis in habitual occlusion.

10 C7 INICIAL

Patient’s lateral radiograph and cervical spine with prosthesis in habitual occlusion before treatment.

Alterations of the cervical spine, loss of physiological lordosis and loss of intervertebral spaces especially between the vertebrae C4, C5 and C6.cefalometria 2013 ingles

Ricketts cephalometric analysis before treatment with prostheses in habitual occlusion.

FACTORES CEF ANTESSS

Values of point A convexity and lower facial height before treatment.

11 FRONTAL INICIAL

Frontal radiograph of the patient with the prosthesis in habitual occlusion.

12 RNM DIREITA INICIAL

MRI, sagittal slice of the right TMJ closed mouth: there is an irregularity of contour with reduction of the superior aspect of the mandibular condyle, the condyle is ante versioned. There is a small anterior osteophyte.

The articular disc is displaced anteriorly, WITHOUT REDUCTION when the mouth opens.

Presence of subcortical bone cysts in the anterior superior aspect of the mandibular condyle.

13 RNM  ESQ  INICIAL

MRI, sagittal slice of the left TMJ closed mouth: there is a substantial irregularity of contour of the upper portion of the mandibular condyle, with the formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

13A RNM  ESQ  INICIAL

MRI, another sagittal slice of the left TMJ closed mouth: there is an important  irregularity of contour of the superior aspect of the mandibular condyle and a formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

16A  ESQ boca fechada 2013 T2

MRI in T2 clearly shows the joint effusion.

The differential diagnosis of TMJ effusion has a broad spectrum as the effusions in other joints in other parts of the skeleton.

MRI (magnetic resonance imaging) can give us a lot of information, not just the disc position.

14  RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

MRI, frontal section of the right and left TMJ, closed mouth. Upper lesion in the right mandibular condyle, as described in the same sagittal slice of the same condyle as subcortical bone cysts.

In the slice of the mandibular head on the left side can be seen an important hipossinal compatible with avascular necrosis.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. It can be caused by various conditions, such as bone or joint damage, pressure inside the bone and other medical conditions.

The condyle affected by avascular necrosis has low signal on T1-weighted images as a result of edematous changes in trabecular bone.

14 SERIE DE RESS DIR FECHADA 2013

Sagittal sections of the right TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

14 SERIE DE RESS DIR ABERTA 2013

MRI,sagittal sections of the right TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

15  SERIE DE RESS ESQ FECH 2013

MRI, sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

15 SERIE DE RESS ESQ ABERTA 2013

MRI,sagittal sections of the left TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

16 series ESQ boca fechada 2013 T2

MRI, T2 sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the image I find most relevant, but also this series are registered.

Serial in T2 clearly showing the joint effusion.

Tests were done on the patient to investigate systemic inflammatory disease, which were all negative.

It was also investigated chlamydia trachomatis infections, mycoplasma pneumoniae infections and beta hemolytic streptococcus infections , results in this case were also negative.

It was also investigated the functioning of the thyroid.

17 REGISTRO CINECIOGRAFICO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and DIO (intraoral device) was constructed in neurophysiological position. In other publications computerized kinesiographic methods were mentioned.

In occlusion most often the healthy or pathological condition of the inter-oclusal space is not objectively considered. In this case the free space of the pathological patient is almost 7 mm and a retro position 0 8 mm.

18 DIO SOBRE A PROTESES

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

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

19 CONTROLE DA ORTESE

It is essential to control the DIO (intra oral device) as the patient is treated and the mandible is repositioned.

In this case the control still shows us the need for recalibration of the DIO (intraoral device)

19 PANORAMICA COMPARATIVA

Comparative panoramic radiographs: before treatment and after neurophysiological treatment.

20 FRONTAIS COMPARATIVAS

Patient’s frontal radiographs comparison: with the prosthesis in habitual occlusion and the DIO intraoral device built on the prosthesis.

20 LAMINOGRAFIA COMPARATIVAS

Right and left temporomandibular joints laminographies, closed and open mouth comparison: with the prosthesis in habitual occlusion and with the DIO intraoral device built on the prosthesis.

cefalometria 2014 CORTADA ingles

Ricketts cephalometric analysis after treatment with the DIO constructed on the prostheses in neurophysiological occlusion.

FACTORES CEF APOSSS

Values of point A convexity and lower facial height after treatment.

21 PERFIS COMPARATIVOS

Patient’s lateral radiographs comparison: with the prosthesis in habitual occlusion and with the DIO built on the prosthesis in neurophysiological position.

The DIO (intra oral device) is used to support, align and correct deformities in order to improve the functions of the jaw, temporomandibular joints and the muscles that move both. This device should be checked and recalibrated as the records indicate the need for modification.

21A PERFIS COMPARATIVOS

Comparison of aesthetic Ricketts plane in lateral radiograph with prosthesis in habitual occlusion and the DIO constructed on the prosthesis in neurophysiological position.

21 RNM COMPARATIVAS ESQ SAGITAL

Comparison of T1-weighted images: before treatment and after treatment: we can see the improvement in medullary signal.

26 comparativas ESQ boca fechada 2013 e 2014T2

Comparison of T2-weighted images: before and after treatment. It is clear in the first image the inflammatory signal and in the other image the improvement of the intramedullary signal and the remission of posterior effusion.

22 RNM Comparativas direita sagital

Comparison of T1-weighted images: before treatment and after treatment, we can see the improvement in medullary signal and improvement of the cortical bone.

23 RNM Comparativas direita FRONTAL

Frontal T1-weighted images comparison, before and after treatment treatment: we can see the improvement of the upper lesion on the right mandibular condyle.

24 RNM Comparativas ESQUERDA FRONTAL

Frontal T1-weighted images comparison, before and after treatment: we can see the improvement in medullary signal and improvement of the cortical bone of the left mandibular condyle.

25 SERIE DE RESS DIR ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the right TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

25 A SERIE DE RESS ESQ ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the left TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

COMPARATIVAS FRONTAIS POSTURAIS

Patient’s postural frontal comparative images before and after treatment.

COMPARATIVAS POSTURAIS PERFIL

Patient’s  postural profile comparative images  before and after treatment.

27 CEF COMPARATIVAS ingles

Ricketts cephalometric analysis before and after neurophysiological treatment.

COMPARAÇAO DOS FATORES

Skeletal problems in Ricketts cephalometric analysis before and after treatment.

28 DEPOIMENTO

“Headache (already when waking up in the morning), tiredness sensation at the cheekbones, strong tensing at the shoulders and neck, “clicks” at the temporomandibular joint, ear pain… consequently I also felt irritation, indisposition, stress etc.

All of that is something I had to live with for a long time. The investigations made on me always resulted in palliative measures that mitigated the problem for a short time.

I passed through implants and placement of prostheses which even without having (those measurements) the aim of healing this malaise I still had the hope that it would: but the relief only worked for a short period of time. Finally, by indication of my dentist, I arrived at Clinic MY starting then the TMJ treatment. Shortly after the start of the treatment the symptoms started to fade.

I am very thankful for the professionalism and dedication that I found there. Today, feeling better, I go back there for periodic evaluations and also to have the opportunity of thanking  once more.”

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

The interrelationship between mandibular posture, occlusion and body posture is a topic covered by different health professionals.

When we speak of occlusion we do not mean only the relationship between the dental arches but we are also referring to the balance between teeth, muscles and temporomandibular joint in connection with all the postural scheme. In that way we can see and analyze patient as a whole.

This clinical case report describes a patient who came to the clinic for consultation after a scoliosis surgery, with craniomandibular symptoms and loss of vertical dimension.

Scoliosis is a three-dimensional structural deformation of the spine.

Idiopathic scoliosis is probably multi aetiological

The prevalence of the association between scoliosis and craniofacial anomalies should stimulate multidisciplinary collaboration on treating these patients, especially when we have an early diagnosis.

1 a

Patient narrative: brief history of the surgery:

When I was 14 years old I was diagnosed with scoliosis, after being noticed with a deformation on the back. Several medical experts were consulted and they stated the same diagnosis, however none of them could tell the causes, and they added that it could be related  to a malformation, some `trauma` in the growth phase, maybe being a hereditary problem.

“My mother noticed that the left side of my back was higher than the right side. In this period I also had frequently faints. Therefore, tests were performed, such as blood tests, electrocardiogram and electroencephalogram. They did not present any alteration”

“Concerned about the situation we consulted an orthopedic surgeon who ordered the realization of a panoramic X-ray of the spine. That test  showed a lumbar scoliosis of 25 degrees, for which the doctor recommended physical therapy.”

1 B JANELA

Panoramic radiographs of the spine were photographed on a glass of the window on day light, that’s why we can observe elements of the landscape.

22- 10 -2004  1

Cervicothoracic  Scoliosis. Left convexity, Cobb angle of 25 degrees. No significant pelvic difference.

“Initially, with about 25 degrees of curvature, I did physical therapy sessions and follow-up for a month.”

“I also used an insole ( which I stopped using it  because I did not perceive results and I felt no need) at the time I was also treating a cross bite.”

25-08-2004   2

Thoracic-lumbar scoliosis, left convexity, C0bb angle of 44 degrees. Accentuation of lumbar lordosis difference of the femoral heads of 3 mm.

“Clinical tests revealed that the curvature had evolved progressively to more than the double in size, reaching approximately 45 degrees. At the time, the proposed solution was the use of a neck vest in order to curb this trend.”

4-11-2004  3

X-rays taken for scoliosis treatment control with orthopedic brace.

“The vest was being used 22 hours per day, and it was also recommended swimming lessons for greater flexibility and aid in respiration in case of surgery.”

“During this period, there was a monitoring and vest readjustment in every month.”

“Finally, this alternative was not efficient enough, as the bending progressed to 64 degrees.”

15-02-2005  4

X-rays taken for scoliosis treatment control with orthopedic brace.

todas juntas

“Thus, according to doctors, we reached the surgical case.”

At my 16 years old, I had the surgery on my spine. The recovery was gradual, nonetheless restfull. The pains, which were always absent, were felt not often in the hip area and legs. The bend in my spine regressed to 19 degrees.”

CONTROL REPORT OF COLUMN XR PANORAMIC SPINAL AFTER SURGERY:

Radiographic examination performed for surgical treatment control of Thoracic-lumbar scoliosis, left convexity fixed by metal screws and rods.

“After a year, I was released to engage in any sport mode, which until then I was forbidden to practice.”

REASON FOR THE CONSULTATION AT CLINIC MY:

“After dental treatment (crossbite) with another professional, mainly due to a shift in the cervical spine that I had tried to fix at the same time – but I did not had  another solution unless the surgery, which had already been completed – I was guided to proceed with Dra. Lidia, also to investigate the relationship between the two cases, so far no connection, the dental arch and the cervical spine. ”

“Following the derivation, I met Dr. Lidia to whom I presented my case, including the surgery of the spine, which led her to investigate the links that could be  cause and consequence of the whole problematic. After many conversations and clarifications I surrendered to the treatment.”

1The patient arrived to the clinic for consultation after a spine surgery, complaining of headache, frequent fatigue, pain behind the eyes, pain in the shoulders and clenching.

2 perfil direito e esquerdo

Patient’s postural photographs of right and left profile after the spine surgery before the neurophysiological treatment.

3 frente e costas

Patient’s frontal and back postural photographs after the spine surgery before the neurophysiological treatment.

4d locais da dor

Part of the medical record where the patient marks the points where feels pain.

5 DENTES INICIAISPatient’s habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment before the neurophysiological mandibular repositioning.

6 oclusais iniciaisPatient’s superior and lower oclusal view on the day of consultation after spine surgery and the completion of orthodontic treatment before the neurophysiological mandibular repositioning.

7 panoramica inicial

Patient’s panoramic radiograph on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Remodeling apical teeth 11,21,22,33,43 compatible with orthodontic movement.

8 laminografia inicial

Patient’s temporomandibular joint laminography in habitual occlusion, closed and open mouth, both sides on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Asymmetrical head of the mandible: the left one with a facet in the posterior surface and a change of orientation in the vertical axis.

9 teleperfil inicial

Patient’s lateral radiograph in habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Note the beginning of the cervical curvature inversion at C4 level.

10 FRONTAL

Patient’s frontal radiograph in habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Note the loss of vertical dimension.

11 C7

Patient’s lateral radiograph and cervical spine in habitual occlusion on the day of consultation after spine surgery and the completion of orthodontic treatment, before the neurophysiological mandibular repositioning.

Note the the cervical curvature inversion at C4 level.

11 RESS DIR 1 BOCA FECHADA

MRI of the right TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

11 RESS DIR 2 BOCA FECHADA

MRI of the right TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

Mild cortical irregularity of the anterior-posterior edge of the condyle.

11 RESS ESQ  1 BOCA FECHADA

MRI of the left TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

11 RESS ESQ  2 BOCA FECHADA

MRI of the left TMJ:

Sagittal section, closed mouth; there is an anteversion of the mandibular condyle, discrete rectification of its anterosuperior portion.

Traumatism history reported by the patient

1 – Fall off a wall of approximately 1.50m tall. She fell on her back hitting the back of the head on the ground.

2- Sudden braking in the car. She was pushed against the windshield, but was held by her father.

3 – Bicycle fall. The pacient was taking a ride on the rack of a friend bycicle when she fell and and hits the mouth on the floor.

11A eletromiografia dinãmica habitualPatient’s electromyography record in habitual occlusion. Asymmetry between the right and left temporal muscles and asymmetry between the masseter muscles.

The most important thing in this case is the greater activity of the temporalis  muscles in relation to the masseter muscles. Remember that the muscles that must recruit more motor units in maximum intercuspation are the masseters and not the temporalis muscles.

12 registro neurofisiológico

Mandibular rest neurophysiological position record.

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

The patient had a pathological free way space of 5 mm and a shift to the right of 1,5 mm.

With the data obtained after the mandibular electronic deprogramming and ALWAYS WITH THE INFORMATION OBTAINED FROM THE IMAGES, a DIO (Intraoral device) in neurophysiological position was constructed.

13 DENTES ORTESE

DIO: Intraoral Device constructed in neurophysiological position.

14 ELETROMIOGRAFIA  controle da ortese

Electromyography dynamic record of the patient with the DIO built in neurophysiological position.

In the first selection we can already observe a symmetry between the anterior temporalis muscles.

In the last selection with cotton rolls on both sides it can be observed an improvement in the recruitment of motor units in the masseters muscles and even lower recruitment in the anterior temporalis muscles. Remember that the DIO (Intraoral Device) is tested and calibrated  with Bioinstrumentation.

14A controle da ortese

Kinesiographic control of the DIO. Freeway interocclusal space of 2.6 mm and shows no deviation on the frontal record.

15 FRONTAIS COMPARATIVASFrontal radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position. Improvement on the three-dimensional jaw alignment.

We cannot fix the structural differences of the mandibular condyles, but we can balance the muscles.

16RX  laterais COMPARATIVASLateral radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

17 C7 COMPARATIVAS

Lateral and cervical spine radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

18 LAMINOGRAFIAS COMPARATIVAS

Patient’s TMJ laminographies comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

19 RADIOGRAFIAS PANORAMICAS COMPARATIVAS

Patient’s panoramic radiographs comparison: the first in habitual occlusion and the second with the DIO (Intraoral device) in neurophysiological position.

20 ress COMP dir  1 e 2Right TMJ sagittal section, closed mouth comparison: before treatment in habitual occlusion and with the DIO (Intraoral device) in neurophysiological position.

21 ress COMP ESQ  1 e 2

Left TMJ sagittal section, closed mouth comparison: before treatment in habitual occlusion and with the DIO (Intraoral device) in neurophysiological position.

22D Comparativas de perfil com e sem ortese

Patient’s postural profile comparative images in habitual occlusion before the treatment, in the beginning of the treatment wearing the DIO (Intraoral Device) and as we can see in the third photograph) in the stage that alouds us to perform the second phase of the treatment with a tridimensional orthodontics.

23 DComparativas de frente com e sem ortese e inicio de orto

Patient’s postural frontal comparative images in habitual occlusion before the treatment, in the beginning of the treatment wearing the DIO (Intraoral Device) and ( as we can see in the third photograph) in the stage that alouds us to perform the second phase of the treatment with a tridimensional orthodontics.

After treatment:

PATIENT TESTIMONY:

Especially the headaches (frontal) and the tension in the trapezius, along with the other listed symptoms, which hindered my work and productivity, were easily controlled with the treatment.

I am grateful to Dr. Lidia Yavich and the Clinica MY team for the profissionalism and which always had great care and attention, in the connection of the teeth, face and temporomandibular joint with the spine and posture.

For reasons of study and work opportunities, I chose to take a break in treatment, before starting a three-dimensional orthodontics.

I kept on inued with the continuous  use of the DIO – the pain is still being controlled – until I had the conditions to finalize the treatment.

Description of habitual orthostatic position in the sagittal and frontal planes

24

Sagittal plane:

The evaluation is described according to the plumb line test. This test takes into account the anatomical points that must be aligned with the vertical axis (plumb line) that is perpendicular to the horizontal axis (foot rest surface). The points are the lateral malleolus (specifically in calcanocuboidea joint), the joint center of the knee, the hip center (located in the femoral head), the lumbar vertebrae (L3 – L4), the center of the shoulder joint (acromion) and the external auditory meatus (ear ).

Picture 1 – patient in habitual occlusion before treatment:                     

 

It is observed that the patient is with the body in front of the plumb line. This shift of the reference points is observed from the knee joint in direct side view.

Picture 2: Patient using the intraoral device at the beginning of the treatment

Note that in this situation the patient is with the joint reference points ahead of the plumb line, but there was an approximation of the body segments shoulder and external auditory canal in the direction of the plumb line.

Image 3: patient using the intraoral device ready to move to a three-dimensional orthodontics

It is observed in this image that the patient is more aligned in upright posture, where all the reference points are aligned or closer to the vertical axis. The lower back and ear still remained ahead of the regency axis.

According to the three images it can be seen an improvement in the alignment of the orthostatic position in the sagittal plane throughout the treatment. Initially the patient was possibly with the muscles of the posterior chain overloaded from the soles of the feet to the suboccipital region.

Probably the use of intraoral device relieved such overloading .

25

Frontal plane

In the frontal view, the description of the usual orthostatic position is made in relation to the plumb (vertical axis) and two horizontal axes: horizontal axis of surface supporting feet and horizontal axis that passes just above the shoulders. The reference points in the frontal plane are: midpoint between the two feet, pubic symphysis, xiphoid process (sternum center) center of the cervical vertebrae (spinous processes) and the midpoint between the eyes.

Picture 1: Patient in habitual occlusion before treatment

It is observed the following displacements in relation to the vertical axis: slight displacement of the pubis point to the right side of the patient, followed by a displacement of the rib cage (xiphoid process) to the left side. The neck and head region are displaced to the left side of the vertical axis.

In relation to the horizontal axis of the bearing surface and from above the shoulders, it is observed that the right shoulder is lower than the right one. According to this image it can be said that she has escolise or that she is in a postural attitute presenting scoliosis.

Picture 2: Patient using the intraoral device at the beginning of treatment

In image 2 it is possible to observe that the position of the pelvis remained slightly shifted to the right side of the vertical axis. However there was an approximation of the xiphoid process (the center of the sternum) in relation to the vertical axis, as well as to the cervical vertebrae and head. These segments still kept themselves to the right side of the reference point.

In relation to the horizontal reference axis, there is a better alignment of the shoulders. The left shoulder remains in a lower position than the left one. In this image it can be said that the patient has a scoliotic attitude whith the lower spine angles of lateral flexing smallers, in other words there is a change in the support, right where  the scoliotic attitude is milder.

Image 3: patient using the intraoral device ready to move to a three-dimensional orthodontics

From this photo it can be seen that there has been an alignment of reference points of the pubis and the xiphoid process in relation to the vertical axis. In addition, there was a repositioning of the cervical vertebrae and head, where the  reference points are closer to the reference axis. In relation to the horizontal axis the image shows a balanced alignment of the shoulders.

From the three images of the frontal plane it can be observed that there was an improvement in the usual orthostatic posture, however there is still a displacement of the cervical and head reference points to the left side of the vertical axis.

It can be suggested that before treatment the patient showed a distribution of a possibly assimetric body weight between the right and left feet. The pelvis shifted to the right, generates such imbalance. In the  high thoracic and cervical region, probably there was a shortening of the muscles of the left side chain and an overload of the right side chain. With the DIO probably these imbalances  were mitigated  in the habitual orthostatic posture.

This evaluation in orthostatic position is not a dynamic evaluation of the patient.

I appreciate this assessment to Cintia Brino Baril, Master in Science of Human Movement UFRGS.

TMJ Study and Investigation Page. One year of publication

Dear friends,

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

Nowadays, the medicine based on evidence is hierarchically stratified from top to bottom where in the base of the pyramid we find the clinic cases, which are rarely seen as evidence. The TMJ Study and Investigation Page had, in its conception, the purpose of posting the clinic cases, which were carefully published with the documentation related to each of the patients treated at Clínica MY with pain complaints, dysfunction and TMJ pathology.

INITIAL

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

site em portugues nova ingles

The TMJ Study and Investigation Page is completing, in this month of December, one year since it started, and I want to celebrate its anniversary with you. With this project, we have a place in the Internet that presents a line of work known as neurophysiologic dentistry, which takes into account the whole body system. It is an area that also operates regarding the posture and the mandibular functioning. In order to do that, the physiologic dentistry aims to establish, in the patient, a position that is based on a harmonious relation between the muscles, the teeth, and the temporolandibular joints.

site em ingles novaIn the publication of the end of this year I have chosen the most significant images of the whole year of publications, with their direct links to each one of the originals publications.

31

Joint Decompression in a Neurophysiological Mandibular Rest Position Promotes a Positive Remodeling in a Degenerative Process of a Teenager Temporomandibular Joint

english 1-1

Anatomy is the platform on which physiology functions

Sem Título-1

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

26

Articular discs recapture with mandibular neurophysiological repositioning

26

Cervical Dystonia or Spasmodic Torticollis: Positive evolution after Neurophysiological Treatment

2

Recapture of articular disc displacement with reduction. Recapture or not recapture that is the question.

17 COLUNA E PERFIL COMP

Inter relation of Craniomandibular disorders and vertebral spine. Case report

24

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

FINAL

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

FINAL

TMJ Pathologies Treatment: first and second phase (tridimensional orthodontics) in a hypermobile joint patient with low signal in the head of the mandible bone marrow. Case report.

33

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

Sem Título-1

Osteonecrosis of the Mandibular Head: recovery of condylar bone marrow alteration

6 BASAL ANTES E APOS O DEM

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

18 comparativas

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

15 3D comparativas

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

37 poster

The importance of Mandibular Rest Position by Electronic Deprogramming in the Treatment of Temporomandibular Joint Pathologies, Orthodontic Diagnosis and Oral Rehabilitation. Case report.

41 RNM AFTER TREATMENT cor

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

evento 4

Training in Diagnosis and Treatment of TMJ Pathologies

31

The Postural Position of the Mandible and its Complexity in the Maxillomandibular Tridimensional Relation: first and second phase in a patient with severe symptoms with subtle information on the images.

e images.

26B LATERAIS COMPARATIVAS LINHA

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

I want to thank my family that is always at my side in each one of the projects, I also want to thank my friends, that from Brazil and from many places of the world, supported and support this project. Last, but not least, I want to thank my colleagues and patients that often write, encouraging and thanking the existence of this virtual place.

By closing, in this moment, the annual analysis and the perspective for the year that follows, I therefore thank the readers of all places in the world that follow the TMJ Study and Investigation Page. It is a privilege to count with your visits.

With the best votes for 2016, and wishing for a year of peace, health, love and happiness for all.

Dr. Lidia Yavich

 

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

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

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

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

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

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

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

Refers hand tremor.

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

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

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

4 oclusaisPatient’s superior and inferior oclusal view.

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

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

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

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

The patient has this protocol for more than 18 years.

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

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

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

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

8 FRONTAL INICIALPatient’s frontal radiograph before treatment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Significant improvement in the opening and closing trajectories.

The closure no longer has a propulsive trajectory.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

Female patient, 40 years old comes to consultation referred by her rheumatologist WITH STRONG PAIN IN the TMJ (temporomandibular joint), TWINGES IN THE HEAD AND MOUTH OPENING LIMITATION.

The patient had a diagnosis of seronegative spondyloarthropathy until then nonspecific.Later diagnosed as Ankylosing Spondylitis

Seronegative spondyloarthropathies refers to a group of diseases that share common characteristics, including the occurrence of inflammation in the spine, peripheral joints and in various peri-articular tissues, in particular entheses.

Seronegative spondyloarthropathies laboratory outstanding feature is the absence of rheumatoid factor and auto antibodies. They have strong association with human leukocyte antigen HLA-B27.

1  The patient reports clicking on the right TMJ, difficulty to open the mouth, difficulty and paint in chewing. She also reports bruxism.2She reports feeling headache, neck pain, pain in the right eyebrow, pain behind the eyes, pain in the right shoulder. She also reports pain in both temporomandibular joints which is stronger  in the right joint.

Points where the patient reports pain

The patient marks on the record the most important points of pain.3  In the first consultation, during the anamnesis the patient reported that she had initiated a treatment for the bruxism problem, and that at one point with the device change she  began to feel a very strong pain and her mouth locked.

4The occlusal view shows the superior anterior sector wear and the anterior lower sector wear.5Patient’s panoramic radiograph.6The joints radiographic image shows the superior and posterior positioning of the articular process on the left side in the joint cavity when the jaw is in maximal intercuspal position.

In the maximum opening position, there is flattening of the posterior and anterior surface of the left mandibular condyle process and a flattening of the superior and anterior surface of the right mandibular condyle process. The right side also presents an alteration of the growth axis of the mandibular condyle.

6BPatient’s lateral and profile radiograph before treatment.7Patient’s lateral radiograph and cervical spine before treatment.7BPatient’s frontal radiograph in habitual occlusion before treatment.8 abre e fecha inicOpening and closing computerized kinesiographic record, the patient can open only 32 mm feeling strong pain, which shows an important limitation.

The patient also has a deflection of 2.7 mm to the right.8 B COMP abre e fecha inic Note in the skull graph, the left condyle moves more than the right condyle where the deviation is.

9The surface electromyography exam evaluates the superior anterior temporal right and left, the right and left masseter, the right and left digastrics and the right and left upper trapezius.

In this electromyography record the patient could not generate a good activity when we asked to bite hard (keeping the teeth in maximum intercuspation) and clench.

At the beginning of the record when we asked the patient to open the mouth it is important to note the different activity between right and left digastrics.

The left digastric activates double than the right digastric.

9

Image enlargement showing the difference in translation of the mandibular condyles. Patient in maximum mouth opening.

It is important to be able to understand and connect all the information, the surface electromyography and the computerized kinesiograph. These data still does NOT PROVIDE A DIAGNOSIS, However they are tools to help us in the diagnosis.

I asked the patient for an MRI-(magnetic resonance imaging) of the temporomandibular joints.

When the patient filled out the clinical record for the MRI she reported that she did a tattoo a month before, that prevented the realization of the MRI until completing the time of three months after the realization of the tattoo.

Remember that the resonator is a large magnet and tattoos have pigments which may contain metal and could heat up and cause burns.

We kept the patient with a temporary splint until we had the MRI information, as explained in previous posts; WE MUST NOT TREAT A PATIENT WITHOUT  A DEFINED DIAGNOSIS.

We could easily assume that as the patient had a systemic nonspecific inflammatory arthritis attacking various joints of her body also the TMJ could be involved.

It is fundamental to rethink something which SOMETIMES could be ONLY A CONJECTURE, even if the patient is a carrier of an inflammatory autoimmune disease.

In the systemic part it is the rheumatologist who will decide the therapy.

Our part is to promote a non-compressive position of the TMJ where the masticatory muscles may perform without loading the joint, and where the patient can fulfill all the functions of the stomatognathic system.

9APatient’s inflamed elbow after synovectomy with the disease still not controlled

9A  MRI: sagittal sections selected. Left TMJ closed mouth: articular disc anteriorly displaced. Change in the growth axis of the mandibular condyle.

Left TMJ open mouth: limitation in mouth opening.

The images here are in T1, all images analyzed including T2 and STIR DOES NOT SHOW inflammatory signs.

It is relevant to remember that in the first consultation, during the anamnesis the patient reported that she had initiated a treatment for the bruxism problem, and that at one point with the device change she began to feel a very strong pain and the mouth locked.

The patient remembers that the device change aimed to align the median line of the upper incisors to the median line of the lower incisors.

This has to be a warning to all of us in dentistry which were taught to carry out all our treatments without knowing the condition of the TMJ.  

9B  MRI: sagittal sections selected. Right TMJ closed mouth: articular disc anteriorly displaced. Change in the growth axis of the mandibular condyle.

Right TMJ open mouth: limitation in mouth opening.

After conducting the analysis of the MRI images, studying all the slices and all required parameters (not included in the post), we can proceed to carry out a neurophysiologic record.
10The masticatory muscles of the patient were electronically deprogrammed and the rest position was recorded with a computerized kinesiograph.

This record has been difficult to achieve. The patient was limited and in great pain. A very low DIO was made, leaving an interocclusal free space of one mm which would normally be too little.

11DIO (intraoral device constructed in neurophysiologic position)11A  Patient’s frontal image on the same day, before and after installing the intraoral device in neurophysiologic position.

11B  Patient’s lateral image on the same Day, before and after installing the intraoral device in neurophysiologic position.

11cPatient’s electromyography record in neurophysiologic occlusion wearing the device (DIO), even the muscles activation is low the difference with the initial record is remarkable.11DComparative EMG records: the upper in habitual occlusion and lower in neurophysiological occlusion with the DIO (intraoral device).12 abre e fecha com DIO  Patient’s kinesiographic record with the DIO (intraoral device) constructed in neurophysiological position.Improvement in mouth opening. 13 recalibração  DIO recalibration to improve the patient’s neurophysiological position. The condition of the patient now allows best records because the significant decrease in pain.14Control of the intraoral device, habitual and neuromuscular trajectory are coincident.15 REGISTROS DE AB COMPARATIVOSPatient’s comparative kinesiographic records before and during treatment. Improvement of the patient mandibular opening.16 abre e fecha inicNote on the skull graphic, both condyles right and left move symmetrically.16 A abre e fecha inicImage enlargement showing both condyles right and left moving symmetrically. Patient in maximum mouth opening.17 comparativosPatient’s kinesiographic records comparison with the skull 3D model before and after treatment.

17B comparativosSkull models in 3 D, graphic animation from patient’s kinesiographic record before and after treatment comparison. Patient in maximum mouth opening.

17A 2008MRI: Right TMJ, closed and open mouth before and after treatment. Articular disc in habitual position,(the disc was dislocated before treatment) Resolution of the opening limitation.

17B 2008MRI: Leftt TMJ, closed and open mouth before and after treatment. Articular disc in habitual position. Resolution of the opening limitation.

18 comparativasMRI: TMJ sagittal comparative images, open and closed mouth before and after treatment.

19 bThe patient without pain, decided to continue with the DIO and not perform the phase 2 to eliminate de DIO, with a tridimensional orthodontics. She decided only to restore the teeth that were worn. Restorations made by Dr. Luis Daniel Yavich Mattos.

20

When I was 39 years old I was diagnosed by my rheumatologist with arthritis.

All major joints of my left side were suddenly and without warning, very swollen, such as knee and elbow, preventing me from performing my simplier movements such as standing and stretching my arm.

I had swelling, redness and intense pain. Then I started to feel pain in the TMJ. I ended up in the clinic of an orthodontist and facial orthopedist  who told me that I had ‘bruxism’ and that I needed to use a device to place the tongue in the right position.

I wore the appliance for a month or two, my TMJ locked, I could not open my mouth and I felt an absurd pain in my entire head, I no longer knew what hurted more, if it were the joints of the body or my head and mouth.

My rheumatologist, apprehensive that I could have arthritis also in the TMJ immediately referred me to Dr. Lidia Yavich, who received me in the office and managed to relieve my pain completely .

I HAVE TO STRESS THAT, THERE WAS NO MEDICATION THAT COULD CEASE THE PAIN that I felt in the TMJ and in the cervical spine, NOTHING!

After the imaging studies performed by indication of Dr. Lidia, we came to the conclusion that I was not suffering from arthritis in both TMJ, but from a dislocation  of my right condyle  after using for a short time a mistaken device to place my bite and tongue in the ” RIGHT POSITION”

That treatment did not considered important assumptions as the asymmetry of my condyles, or their position, or the disc status in relation to the condyles, causing much suffering.

It took me a long time to understand what was happening to me in my TMJ; I suffered from absurd pain in the head in the middle of a very difficult treatment for arthritis. I was disfigured, terrified and unsure after using the first device with the previous professional because he did not know how to end the pain and even seemed, not to know what was actually happening with me.

I had panic to imagine that I had arthritis in my TMJ, but only after the MRI and the Dr. Lidia interpretation it was possible to exclude the possibility of rheumatic disease in the TMJ in that moment, and from then on to make an efficient treatment.

In a few weeks Dr. Lidia not only took out ALL THE PAIN of the TMJ, but also led me to a treatment that repositioned my disc and  stopped the pain, even being a carrier of a severe autoimmune disease.

I have been using the DIO for seven years without any pain, I have full understanding of the meaning of bruxism in my case and correct approach to the problem, including the options that I could have for a more permanent solution instead the use of the DIO.

I am very grateful to my rheumatologist  today for indicating me a treatment that saved me, because I certainly would have gone crazy with those TMJ pains.

I am very grateful to Dr. Lidia who took me from the rock bottom in which I found myself, ignorant from all  that was happening in a joint so unknown from most of us:.the TMJ.

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.

Osteonecrosis of the Mandibular Head: recovery of condylar bone marrow alteration

I had been showing clinical cases in the page lidiayavich.com  and in several groups. Some of them with rehabilitation and with tridimensional orthodontics, always after treating the TMJ.

In this post I’m not going to show all the sequence of the patient. I have  the intention to show the improvement of the signal of the MEDULLAR OF THE CONDYLE that had presented osteonecrosis.

Anamnesis and clinical inspection are a fundamental part in the  diagnosis of the patient that presents TMJ pathology.

Images are primordial when we study any sinovial joint, unfortunately I see patients with valuable information in their images that were told that those are just occasional findings.

MRI (magnetic resonance imaging) can give a lot of information and not only the disk position information. Logically is necessary to know what to do with that information.

Osteonecrosis of the mandibular head corresponds to a death of the osseous tissue, also called avascular necrosis.

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

01

MRI: T 1 closed sagittal rightTMJ before treatment.

Avascular necrosis in the acute phase can be diagnosed only through MRI imaging or biopsy.

The differential diagnosis of altered signal intensity in the mandibular condyle starts with an awareness of its normal signal characteristics.

This condyle has also a severe irregularity on the superior pole, with loss of substance, but in this post I want to analyze the bone marrow signal. Of course, in a diagnosis we need to consider all the information.

-1

MRI: T1 closed sagittal rightTMJ before treatment.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced, which may be caused by several conditions, like joint or bone injury, pressure inside the bone, medical conditions, among others.

A condyle affected by avascular necrosis displays low signal intensity on T1 weighted images as a result of edematous changes in the cancellous bone.

2

MRI: T2 closed sagital rightTMJ before treatment.

The differential diagnosis of effusions in the TMJ has a broad-spectrum as of joint effusions in other skeletal regions.

A MRI (magnetic resonance imaging) can give a lot of information and not only the disk position. In this case THE PATIENT HAS NO DISK.

2AA

The same sagittal slice of the condyle in T1 and T2. Image A shows osteonecrosis of the head of the mandible and image C shows the articular effusion.

The patient complained from severe pain in the TMJ, headache, and pain on the back of the neck.

The patient had a major trauma history in the jaw in adolescence. She had rheumatic fever in childhood.

 We referred her to a rheumatologist, and in that moment she did not present positive results for inflammatory systemic disease.

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

2A

Comparing T1  images: A (before the treatment) and B (after the treatment): we can see the improvement and recovery of the the medullar signal. Improvement of the superior cortical of the mandibular head. 

The differential diagnosis and the systemic condition of the patient must be taken in account for the prognosis of the case.

2B Comparing T2  images: C (before the treatment) and D (after the treatment).It is clear in the first one (C) the inflammatory signal and in the other (D) the remission of the effusion.

Sem Título-1

Comparing T1 images (A and B) we can see the improvement and recovery of the  medullar signal and the superior cortical of the mandibular head. In T2 weightened images (C and D) it  is clear (in C) the inflammatory signal and in the other (in D) the remission of the effusion.

Sem Título-6

One year after the second image, a new control was solicited, and the results were even better.

In this case  I decided  NOT TO GO forward to a second phase.  Diagnosis is essential for each case.  Dentistry need to understand like Medicine do, that we have limitations and if a patient needs to live with an orthotic  it is not the end of the world.

We have patients that are going to live with insulin all their life, or with other medicines that are saving their lives or just improving their life quality.
Therefore, diagnosis is essential and for that all the tools that can help to get there are welcome.

TMJ Pathologies Treatment: first and second phase (tridimensional orthodontics) in a hypermobile joint patient with low signal in the head of the mandible bone marrow. Case report.

1

Female patient 22 years old comes to the clinic with a strong headache principally on the top, pain on both temporalis, pain on the back of the head and on the shoulders.

Difficulty in chewing hard food, crepitations on both temporomandibular joints.

She reports bruxism since childhood.

Patient´s testimony

Since I was very little my parents reported that I had bruxism at night

1B

Patient with joint hipermobility. Patients with ligament hipermobilty present more risk to develop articular pathology.

2 DENTES Initial occlusion of the patient before treatment.3 OCLUSALSuperior and inferior occlusal view of the patient before treatment.

Wear in the upper and lower anterior sector
3b dinamico habitual

Surface electromyography, dynamic record in habitual occlusion. We ask to the patient to open the mouth, to close the mouth, to bite strong and to swallow. In this patient’s electromyography record we observe little activity in the masseters and anterior temporalis. We can also observe asymmetry between the right and left temporalis. It is obvious that the masseters have a loss of activity in the middle of the maximal occlusion.

4 PANORAMICA Patient’s initial panoramic radiograph before treatment.5LAMINOGRAFIA INICIAL

TMJ laminography of the patient before treatment in habitual occlusion and opening. Asymmetry of the mandibular heads. Superior and posterior position of the articular process of the right side in the joint cavity, provoking a retrodiscal compression.

We observe asymmetry between the left and right mandibular heads.

Alteration of the axis of the right mandibular condyle.

Patient´s testimony:

When I was 5 years old, while I was playing in the  pre school class interval  I had a traumatism.

A seesaw hit my chin when I was playing with another girl. They put ice on my chin to reduce the swelling. There was no much pain or apparent fracture.

I did not perform medical tests.

I remember another traumatism I had when I was 13 years old, I slipped on the sidewalk and felt hitting my chin on the ground, I FRACTURED THE UPPER INCISORS,  (they have resin)

Sometimes I wake up and I feel that I´m biting and moving my mandible.

If I don´t use the bruxism splint to sleep I brake the resin of my teeth.

The splint protects the resin, BUT DOESN´T ALLIVIATE THE PAIN.

The website of the Clinica MY  www.clinicamy.com.br  has the links for both articles. . Alterações na Orientação do Côndilo Mandibular Devido a Traumatismos na Primeira Infância (Portuguese). Clinic case presented in the 4th edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

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

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

6 RNM INICIAL MRI: left TMJ closed mouth  lateral slice. 7 RNM INICIAL MRI: left TMJ closed mouth  slice. MILD IRREGULARITY OF THE CORTICAL BONE OF THE MANDIBULAR HEAD.

When we analyze a MRI we have to take into account a lot of information beside disk position

8 RNM INICIAL

MRI :left TMJ closed mouth . Medial slice. Low signal in the head of the mandible bone marrow. The patient had a history of tonsillitis and otitis repetition.

When we requested for an ASO the exam showed high values, for which because of that she was medicated.

9 RNM INICIAL  MRI :right TMJ closed mouth medial  slice.
10 RNM INICIAL

MRI: right TMJ closed mouth  slice. Superior facet of the mandible head. Mild dislocation of the articular disc and retro position of the condyle.

11 rad. lateral Lateral radiograph and patient’s profile12 cervicalThe lateral radiograph including the cervical spine shows it´s rectification (loss of the physiological lordosis). Mild curvature inversion at C4.

13 Registro jaw tracker-3

Patient’s masticatory muscles were electronically deprogrammed and a bite in a neurophysiological position was registered using a jaw tracker.For the bite registration record we always use the information of the images obtained and the planned goals for each individual case.

The patient presented a free way pathological space of 6 mm and a retro-position of 2,8mm

A DIO (Intraoral Device)  was constructed in a neurophysiological position.

The website of the Clinica MY www.clinicamy.com.br  has the link for the article Neuromuscular Principles in Dentistry, Habitual Trajectory coincident with the Neuromuscular Trajectory.

Princípios Neuromusculares na Odontologia, Trajetória de Fechamento Habitual Coincidente com a Trajetória de Fechamento Neuromuscular (Portuguese) Brazilian Journal of TMJ, occlusion and Orofacial Pain, April/ June 2002.

14 dinamico com dio  Patient’s electromyography record with the DIO ( intraoral device) constructed in neurophysiological position). Observe the excellent muscle activity with the device.

15 registro eletromiografico comparativo  Patient’s electromyography records comparison: the first in habitual occlusion and the second with the intraoral device in neurophysiological position.  In the lower record the masseters present excellent activity with the device, even more if we compare the initial record where  the masseters lose  activity in the middle of the maximal occlusion.

Some MRI selected slices : before treatment and after de FIRST PHASE.

We need to be aware of the planned goals for this patient with joint hypermobility and a sequel of traumatism in infancy where we can see low signal in the head of the mandible bone marrow.

  • Better tridimensional placement of the mandibular condyle.
  • Closing dental trajectory coincident with the muscular closing trajectory.
  • Temporomandibular joints decompression.

 Image 1: improvement of the left condyle upper pole cortical bone in this lateral slice.

 Image 2: improvement of the left condyle superior pole cortical bone, bone marrow  signal improvement, positive remodeling of the condylar posterior surface.

Image 3: Improvement of the bone marrow signal and positive remodeling of the condylar posterior surface.

Image 4 : Positive remodeling of the superior pole and posterior surface of the head of the mandible.

16 A panoramica INICIO 2 FASEWe began assembling the upper and lower braces for a tridimensional orthodontics, maintaining the DIO (intraoral device)

A tridimensional orthodontics needs to maintain the tridimensional mandible position in balance with its osseous and muscular planes obtained in the FIRST PHASE, and always when possible it has the purpose to maintain the temporomandibular joint in a harmonious relation with the mandibular fossa as well as the disk in a correct position.

16B LATERAL INICIO 2 FASEPatient’s lateral radiograph and cervical spine  in the beginning of the 2 PHASE.17 comparativas coluna 1  Comparative lateral radiograph an cervical spine of the patient: before the FIRST PHASE and in the beginning of  the SECOND PHASE

In this image there is no recovery of the lordosis but yes, an improvement of the mild curvature inversion at C4.

18 orto 1

Tridimensional orthodontics sequence in the second phase of TMJ pathologies treatment, in this specific patient.

REMEMBER THAT NOT EVERY CASE WILL ALLOW YOU TO ADVANCE TO A SECOND PHASE.

19 orto 2 20 orto 3  Active eruption in the tridimensional orthodontics.21 orto 4   Active eruption in the tridimensional orthodontics.22 orto 5  Continuation of the tridimensional orthodontics with sequence of intraoral devices23 orto 6  New DIO (intraoral device) for the continuation of the tridimensional orthodontics.24 orto 7 25 orto 8 26 orto 9 27 orto 10 27B paciente retirando el dispositivo  Removal of the DIO ( intraoral device)28 orto 11 Image without the intraoral device.29 finaliz trat orto Tridimensional orthodontics treatment finalization in neurophysiological occlusion.30 comparação oclusao inical e final  Patient’s occlusion image in neurphysiological occlusion after treatment finalization. Comparison with the initial occlusion image.31 ELETRO FINAL  Patient’s electromyography records comparison: the first in habitual occlusion before the FIRST PHASE and the second AFTER THE TRIDIMENSIONAL ORTHODONTICS TREATMENT FINALIZATION. The masseters present excellent activity comparing with the initial record where the masseters lose activity in the middle of the maximal occlusion. Also the masseters present better potency than the temporalis.32 final CERVICO COMPARATIVAS  Patient’s lateral and cervical spine comparative radiograph: before the FIRST PHASE and in the TRIDIMENSIONAL ORTHODONTICS FINALIZATION.

Notice the cervical lordosis improvement.

33 lamino comparativas  Patient’s comparative laminography: initial in habitual occlusion where we can observe the retro position of the mandible heads, and the tridimensional orthodontics finalization laminography.

34 PANO FINAL (1) Patient’s panoramic control radiograph after the TRIDIMENSIONAL ORTHODONTICS finalization.35 RNM FINAL Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.36 RNM FINAL  Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.37 RNM FINAL  Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.38 RNM FINALRight TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.39 RNM FINAL  Right TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.40 RNM FINAL

Right TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.

DEPOIMENTOTMJ Pathologies Treatment: first and second phase (tridimensional orthodontics) in a hypermobile joint patient with low signal in the head of the mandible bone marrow. Case report.

FINAL