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

Several articles and studies cite the prevalence of TMJ dysfunction in violinists and violists, especially by prolonged flexion of the head and shoulder, posture necessary to keep the violin in position. Studies also report that the incidence of TMJ dysfunction in musicians is similar to the general population.

Professional musicians require many hours of training and improvement that involve complicated movements, fast and repetitive actions with over use of the hands, fingers, arms and head.

Most articles report anxiety about professional performance and increased muscle tension, but few do a particular study of the state of the anatomical structures of the cases studied.

1 postura inicial frontalA 45-year-old female patient referred by her physiotherapist consults with complaints of headache, pain in the cervical and scapular region, muscular contractures in the mandible.

The patient also reports mandibular displacement when playing the violin and pain in both temporomandibular joints.

2 postura inicial lateralThe patient also reports clicks in both temporomandibular joints and occasionally the sensation of clogged ears.

Frequent pain in the spine and both shoulders.

At that time the patient had already consulted physiotherapists, rheumatologists, psychiatrists and psychologists.

2 bpontos de dorMarking chart of pain points.

3 OCLUSÃO INICIALImage of the patient’s habitual occlusion on the day of the appointment.

4 OCLUSAIS INICIAISUpper and lower occlusal views of the patient on the day of the consultation.

5 PANORAMICA 1Initial panoramic radiograph of the patient before treatment.

Teeth 18, 28 included.

Wear on the incisal and occlusal faces of the teeth present.

Prosthetic device 25 to 27 (26 pontic)

Horizontal resorption of alveolar ridges.

6 LAMINOGRAFIA INICIALPatient’s TMJ initial laminography before treatment

In the maximum opening position, observe the anterior angulation of the articular processes. Structural modification of the mandibular condylar process as one of the sequels of traumatism in infancy.

The patient reports a trauma in early childhood, a knock on the head while playing on a slide.

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

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

9 C7Lateral and cervical radiograph of the patient in habitual occlusion before treatment.

At this time, the patient performed a CT scan of the cervical spine

In the report there is rectification of cervical lordosis.

Degenerative discopathy in C5-C6, observing reduction of the height of the disc space and osteophytic proliferations reactional. At this level the disc-osteophyte bar is identified that touches and distorts the ventral face of the dural sac.

There is no stenosis of the central vertebral canal.

Neural foramina with amplitude within the limits of normality.

Mild signs of uncovertebral arthrosis C5 and C6.

Relationship C1-C2 maintained.

Symmetric paravertebral regions.

10 eletromiog dinamica inicialDynamic electromyographic record in patient’s habitual occlusion before treatment. Note the minimal activation of the right and left masseter muscles in maximal intercuspation and the high activation of the right and left temporal muscles.

The masseter muscles are the most powerful muscles of the stomatognathic system, the temporal muscles even being elevating muscles have to have an equal and preferably smaller activation than the masseter muscles.

11 cineciog 1Initial cineciographic record of the patient.

Three-dimensional view of the mandibular displacement.

The record shows mandible opening, closing and speed when the patient makes these movements. The patient shows a 47 mm opening and a right deflection of 3.9 mm

Note a significant  loss of velocity in the middle of the mandibular closure.

13 ress esq fechMRI: sagittal slice of the left TMJ, closed mouth, anteversion of the mandibular condyle can be observed.

14 ress esq fechMRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

15 ress esq fechMRI: Another sagittal slice of the left TMJ in the closed mouth, the anteversion of the mandibular condyle can be observed.

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

16 ress esq fechMRI: internal sagittal slice of the left TMJ, closed mouth.

17ress dir fechMRI: internal sagittal slice of the right TMJ, closed mouth.

18ress dir fechMRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

19 ress dir fechMRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Important area of retrodiscal compression at the level of mandibular condyle deflection. Primary objective has to be the three-dimensional decompression of the mandibular condyle.

20 ress dir fech

MRI: another sagittal slice of the right TMJ, closed mouth, the anteversion of the mandibular condyle can be observed.

The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (open mouth images not included in the post)

Note the posterior compression in this section.

Primary objective has to be the three-dimensional decompression of the mandibular condyle.

21 FRONT DIR E ESQMRI: frontal slice of right and left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right temporomandibular joint shows a loss of joint space, especially in the region of the external lateral pole of the joint. Both frontal images show a decrease in joint space.

Slight medial disc deviation.

21A registro inicial para o DIOTo correctly evaluate the maxillomandibular relationship we should begin to consider the physiological rest mandible position.

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

The stomatognathic musculature is no exception.

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

The patient has a pathological free space of 5.8 mm, already discounting the two physiological mm of a healthy free space.

The patient also presented a 2.1 mm mandibular retroposition

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

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

22A eletromiografia com o DIOElectromyographic record with DIO (intraoral device) in physiological neuromuscular position.

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

22A Registro cinesiográfico para controlar o DIO em posição neurofisiológicaCineciographic record for the DIO (intraoral device) control in physiological neuromuscular position as the device is changed or recalibrated.

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

Each case IS UNIQUE. There are cases where the TMJ structures are so damaged that the objectives outlined will have limitations dictated by the initial diagnosis.

These limitations refer not only to the structures of the temporomandibular joint, but also to the patient’s systemic condition.

22B 2 Registro cinesiográfico para controlar o DIO em posição neurofisiológicaAnother cineciographical record to control the Dio in a physiological neuromuscular position as the device is changed or recalibrated.

23 laminografias comparativas com dioComparison of left and right temporomandibular joint laminography, closed and open mouth: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

24 ct comparativas com dioComparison of lateral radiographs and cervical spine of the patient: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

With the jaw in a physiological neuromuscular position the physiotherapist colleague worked the rest of the muscle chains, using global manual techniques, always taking into account the individuality of the patient. This work in a patient with degenerative discopathies should be maintained

25 rad lateral e perfilComparison of lateral radiographs of the patient: in habitual occlusion before the treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

Improvement of the profile and recovery of the vertical dimension.

26TELEFRONTAIS COMPARATIVASComparative frontal radiographs of the patient: at the beginning of treatment in habitual occlusion, during treatment with DIO (intraoral device) in physiological neuromuscular occlusion.

27 PANORAMICA com o DIOPanoramic radiograph of the patient with the DIO constructed in a physiological neuromuscular position.

47 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

48 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

49 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

50 ress esqu comparativa 1MRI: comparative sagittal slices of the left TMJ, closed mouth, before and after the physiological neuromuscular treatment.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

51 ress direita comparativa 1MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

51a ress direita comparativa 1MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

52 ress direita comparativa 1MRI: comparative sagittal slices of the right TMJ, closed mouth, before and after the physiological neuromuscular treatment. In this section we can see the improvement in the discal condylar relationship obtained.

Three-dimensional joint decompression is noted. Primordial objective in this specific case.

53 ress esquerda frontal comparativa 1

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

Note the decompression of the temporomandibular joint, especially in the lateral pole.

54 ress direita frontal comparativa 1

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

Note the decompression of the temporomandibular joint, especially in the lateral pole.

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

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

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

55 ORTO 1In the second phase, in this case the three-dimensional orthodontics the patient is monitored and deprogrammed electronically, and often the device is recalibrated, to maintain the position obtained in the first phase.

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

56 PANORAMICA COM O IMPLANTEPatient’s panoramic radiograph after the installation of the implant and the removal of the retained upper third molars.

57 ORTO 2Part of the sequence of the second phase (in this specific clinical case).

58 ORTO 3Part of the sequence of the second phase (in this specific clinical case).

59 ORTO 4Part of the sequence of the second phase (in this specific clinical case).

60 ORTO 5

Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.

61 ORTO 6Part of the sequence of the second phase (in this specific clinical case). Photograph of orthodontic wire before cutting from the right side for didactic purposes.

62 ORTO 7Part of the sequence of the second phase (in this specific clinical case).

63 ORTO 8Part of the sequence of the second phase (in this specific clinical case).

64 ORTO 9Part of the sequence of the second phase (in this specific clinical case).

65 ORTO10Part of the sequence of the second phase (in this specific clinical case).

66 ORTO101Part of the sequence of the second phase (in this specific clinical case).

67 ORTO102Part of the sequence of the second phase (in this specific clinical case).

68 ORTO103Part of the sequence of the second phase (in this specific clinical case).

68 RETIRADA DO DIORemoval of the DIO (intraoral device)

69 ORTO104Part of the sequence of the second phase (in this specific clinical case).

70 ORTO105Finalization of the second phase.

71 OCLUSAL FINALPatient’s upper and lower occlusal view after the finalization of the second phase.

72 b panoramicas comparativasPatient’s comparative panoramic radiographs before and after the end of the second phase of the treatment using a three-dimensional orthodontics.

72 comparação OCLUSAIS FINAISPatient’s comparative superior and inferior occlusal view, before and after, the end of the second phase of the treatment by a three-dimensional orthodontic.

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

77 registro controle após a ortodontiaKinesiographic control record after the completion of the three-dimensional orthodontics in a physiological neuromuscular position.

Coincident neuromuscular trajectories.

73 laminografias finalLaminography of the patient in physiological neuromuscular occlusion after the finalization of the second phase of the treatment.

74 3 laminografias comparativasComparative laminography of the patient: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

75 TELEFRONTAIS COMPARATIVASPatient’s comparative frontal radiographs: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

76 rad lateral e perfil comparativas 3Patient’s comparative lateral radiograph and profile: before the treatment, during the first phase of the treatment and after the finalization by the three-dimensional orthodontics.

78 DEPOIMENTO 1

Patient testimony:

What made me look for the treatment were recurrent headaches, frequent

(weekly) and intense, which lasted, on average, 2 days, affecting my productivity

at work as well as leisure hours.

The pain did not subside with common analgesics, requiring strong medication, which, in turn, only softened the pain a little.

Today, after the treatment, I can say that only very rarely do I suffer from these pains, greatly improving the quality of life, besides the posture.

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

1-itacir-inicial-frontal-copia

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

2-itacir-inicial-lateral-copia

The patient complains of daytime and nighttime clenching.

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

3-dentes

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

4-oclusais

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

5-panoramica-1

Patient’s initial panoramic radiograph before treatment

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

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

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

Endodontically treated 13 and 12 elements.

6-laminografia-1

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

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

7-a-perfil-e-tele

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

7-frontal-1

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

8-c7-e-perfil

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

9-comparativos-emg-basal

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

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

10-dinamico-1

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

10-a-1-corte-ressonancia

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

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

11-jaw-tracker-1

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

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

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

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

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

14-ortese-1

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

16-laminografia-comparativa

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

17-a-perfil-comparativos

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

18-teleradiog-comparativas

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

19-comparativa-frontal

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

20-telefrontais-comparativas

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

21-comparativa-perfil-1

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

22-comparativo-sorriso-1

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

24-radiografia-implante-1

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

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

26-implantes-2

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

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

25-preparo-implante-1

Intraoral device constructed in neurophysiological position with the implants installed.

jaw-tracker-2

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

27-orto-1

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

29-orto-3

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

30-orto-4

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

31-orto-5

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

32-orto-6

Alignment and recovery of the lower sector with resins.

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

jaw-tracker-3

Control of the neuromuscular trajectory in the rehabilitated patient.

eletro-apos-orto

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

33-finalizacao-1

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

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

34-a-oclusais-finais-1

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

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

35-lamino-final

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

36-tele-final

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

38-frontal-final

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

38-dentes-comparativos-finais

Comparative patient occlusions before and after neurophysiological treatment.

39-oclusais-comparativas

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

34-a-panoramicas-comparativas

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

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

41-comparativa-frontal

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

42-comparativa-perfil-1

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

43-teleradiog-comparativas-inicial-e-final

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

44-depoimento-1

Main Symptoms:

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

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

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

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

TMJ 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