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

When two adjacent vertebrae are fused since birth, the whole vertebral unit is called congenital vertebral block.

Embryologically this fusion is the result of an error in the normal process of segmentation of somites (segmented structure, formed on both sides of the neural tube) during the differentiation in fetal weeks.

Due to the existence of a mobile segment, free joints  (non-fused), on top and underneath the vertebral block, suffer more stress.

They may also produce an abnormal curvature of the spine.

Understanding the complex inter relation of craniomandibular disorders require a wide comprehension, not only on anatomy and physiology of head and neck, but also of the vertebral spine.

The cervical spine is the flexible link between the head and the trunk.

1 FOTO FRENTEMale patient arrived to the clinic for consultation referring headache, pain behind the eyes mostly on the right side and pain on the right eyebrow.

States that, when he passes his fingertips on the left eyebrow toward the right side, reaching the center he feels pain.

Relates pain in both shoulders.

1B FOTO FRENTE

The patient reports pain and clicking in both temporomandibular joints. He also complaints from a crepitation sensation in both TMJ.

He refers a sensation of blocked ears and bilateral tinnitus.

2 FOTO PERFIL

The patient reports that he tightens the teeth all day, and also mentions nocturnal bruxism.

He also complaints of pain in the back of the neck and pain in the cervical spine.

In his clinical history he reported a car accident when he was 12 year old.

He also had a strong blow in his mouth and mandible. He underwent a surgery on  L3, L4 and L5 because of disk herniation.

3 DENTES Patient’s habitual occlusion image before the treatment in the consultation day.  We can notice the  fractured superior incisors   and the absence of the left superior canine.

4 OCLUSAL SUP E INFSuperior and lower oclusal view of the patient before treatment. In this image we can see the wear of the lower incisors and the fracture of the upper central incisors.

5 PANORAMICAPatient’s initial panoramic radiograph: we can observe the absence of the  18, 23, 28, 38 and 48 elements. We can also notice the maxillary sinus extension on the premolars and molars region.

6 p6Patient temporomandibular joint laminography before treatment: we can observe the superior and posterior position of the right condylar process in the articular cavity  and the lower posterior positioning of the left condylar process in the articular cavity when the jaw is in maximum intercuspidation position.

In the maximum open position, we can observe the anterior angulation of the articular processes. More significant on the left side. Flattening of  the posterior surface of the articular processes.

7 frontalPatient’s frontal radiograph in habitual occlusion before treatment.

8 perfilLateral radiograph in conjunction with the profile image of the patient before treatment.

9 C7Patient’s lateral radiograph and cervical spine before treatment.

The arrow marks the FUSION OF THE CERVICAL VERTEBRAE  C3 and C4.

When two adjacent vertebrae are fused since birth, the whole vertebral unit is called congenital vertebral block.

Embryologically, this fusion is the result of an error in the normal process of segmentation of somites (segmented structure, formed on both sides of the neural tube) during the differentiation in fetal weeks.

Due to the existence of a mobile segment, free joints (non-fused), on top and underneath the vertebral block, suffer more stress.

They may also produce an abnormal curvature of the spine.

9A 1 RNM 1MRI TI: Sagittal slice sequence of the left TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 1 RNM 2

MRI TI: Sagittal slice sequence of the left TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 2 RNM 1

MRI TI: Sagittal slice sequence of the right TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 2 RNM 2

MRI TI: Sagittal slice sequence of the right TMJ closed mouth.

We can see that despite the anterior angulation of the articular process (because of one of the sequels of traumatism in infancy) the disc is positioned at the head of the mandibular condyle.  Notice that the health of the soft elements had been preserved, even so there is a compression of the retrodiscal elements at the level of the  neck flexioned angle  of the mandibular condyle.

9A 3 RNMMRI TI: Sagittal slice  of the right and left TMJ, open mouth.

In the maximum open position, we can better observe the anterior angulation of the articular processes. More significant in the left side.

9A 4 RNM

MRI TI: Frontal slice  of the right and left TMJ, closed mouth.

10 AB E FECHInitial kinesiographic record: significant loss of speed when the patient opens and closes his mouth. There is no coincidence between the opening and closing trajectories in the sagittal view record. The record  in the sagittal view looks very vertical when the patient opens and closes the mouth, which is  typical of deep overbites.

11 REGISTRO DE MORDIDATo properly evaluate the maxillomandibular relationship we  should start considering the physiological mandibular rest position.

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

The stomathognatic muscles are not the exception.

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

The record showed a pathological free space of 11,8 mm and a retrusion of 2 mm.

Remember that the angulation of the mandibular condyle caused by trauma in early childhood led to a loss in the  vertical growth and a compression at the  level of the flexioned angle of the mandibular condyle neck.

   Click here To read more about traumatisms in childhood and the greenstick fractures of the mandibular process.

12 DENTES ORTESE

With the recorded data after the electronical mandibular deprogramming and the kinesiographic trace obtained with the jaw tracker, we constructed a  DIO (intraoral device), to mantain the tridimentional registered position.

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

13 CONTROLE ORTESEKinesiographic record control of the DIO  (intra oral device), constructed in neurophysiological position. Neuromuscular trajectories  are coincident and the  interocclusal free space is now 2.4mm.

These controls must be performed PERIODICALLY DURING THE FIRST PHASE OF TREATMENT and also during the SECOND PHASE OF TREATMENT.
In the clinical cases published in the  TMJ STUDY AND INVESTIGATION PAGE  I post a minimum selection of the sequenced records obtained during the treatment.

It is important to remember that during the neurophysiological treatment the patient is measured and controlled during all treatment.

9A 1 RNM

The patient presented problems in the three-dimensional localization of the mandibular condyle

Even that structurally the mandibular condyles had undergone changes in the growth axis due to trauma in early childhood, they did not presented lesions that prevented us (after the  improvement of the three-dimensional jaw location) to continue with the SECOND PHASE OF THE TREATMENT.

9A 2 RNM

In this specific clinical case I decided NOT  to request a second MRI, since I didn’t need to control the improvement of the condyle disc complex nor the bone marrow signal.

The patient had remission of symptoms, allowing us to move on to the SECOND STAGE OF THE NEUROPHYSIOLOGICAL TREATMENT.

15 sequencia 1In the upper image we can observe from top to bottom:

Habitual occlusion of the patient before treatment.

Patient’s occlusion  with the DIO ( intraoral device)

Initiation of the  three-dimensional orthodontics, ALWAYS WITH DIO (intraoral device) built in neurophysiological position.

Installation of an upper removable expander.

16 B sequenciaSequence in three-dimensional orthodontics with the expander and the movement of the first upper  premolar on the left side for the installation of a dental implant.

17 sequenciaSequence of the three-dimensional orthodontics in this specific clinical case.

17B sequenciaSequence of the three-dimensional orthodontics in this specific clinical case and installation of the dental implant, because of the absence of the upper left canine.

18 sequenciaThe upper incisors were rehabilitated with resins to recover the aesthetics and functionality of the patient.

19 PANORAMICA NO TRATPatient’s panoramic radiograph:  control with the implant installed  and three-dimensional orthodontics during the neurophysiological treatment.

The DIO, (intraoral device) in neurophysiological position installed in the mouth during the Second Phase.

20 RESINAS INFERIORESThe lower incisors were rehabilitated with resins to recover the aesthetics and functionality of the patient.

The active eruption in the posterior sector was completed until the finalization of the second phase.

In this particular clinic case the active eruption sequence was not documented in images. For those who want to remember this THREE- DIMENTIONAL ORTHODONTICS I suggest to click on this link

22 DENTES FINALThe patient’s occlusion after neurophysiological treatment. First and second phase finished.

23 DENTES FINAL COMPARATIVOSPatient’s comparative occlusion  images before and after the  neurophysiological treatment.

24 OCLUSAIS FINAISUpper and lower oclusal view of the patient after the neurophysiological treatment.

25 OCLUSAIS FINAIS COMPARATIVASPatient’s comparative images of the upper and lower oclusal view before and after the neurophysiological treatment.

26 PANORAMICAfinalPatient’s panoramic radiograph after the first and second phase of the neurophysiological treatment.

26A PANORAMICACOMPARATIVASComparative panoramic radiographs: before treatment, during treatment and after completion of the three-dimensional orthodontics and neurophysiological rehabilitation.

27 laminograpfia finalPatient’s laminography after the first and second phase of the neurophysiological treatment.

30 COMPARAÇAO PERFISPatient’s comparative lateral radiographs, before and after the neurophysiological treatment.

31 COMPARAÇAO C7Patient’s comparative lateral radiograph and cervical spine before the FIRST PHASE and fter the finalization of the THREE DIMENSIONAL ORTHODONTICS and the NEUROPHYSIOLOGICAL REABILITATION. 

In this case we cannot change a congenital fusion of the cervical vertebrae, but if we understand that there are myofascial chains that connect the TMJ to the body, we may then improve the three-dimensional location of the mandible and help the system. Naturally, the system is a whole and depending on each clinical case we will need the help help of professionals of different specialties.

32 COMPARAÇAO IMAGEM FRONTAL Comparative frontal images of the patient: before and after the neurophysiological treatment.

32 COMPARAÇAO PERFIL

 

 

 

 

 

 

 

Comparative profile images of the patient: before and after the neurophysiological treatment.

32  INICIAL DEPOIMENTO inglesSome time ago, while searching for an orthodontic treatment for my first child, I got to know Clinica MY.

At that time my priority was in fact to search for a solution to correct a teeth problem that my son had. After some consultations at the clinic I met Dr. Lidia, which already in our firsts and brief talks, and because of some complaints that I shared with her, she diagnosed that I, much more than my son, had problems related to dysfunctions in the TMJ.

She told me that I needed to search for a treatment.

In that occasion I had many teeth problems as inferior and superior teeth wear, broken tips, crackling when chewing.

32  FINAL DEPOIMENTO ingles

I had a lot of headaches, pain at the nape base and behind the eyes, and also pain on the back and shoulders. I also felt a pain sensation on my right eyebrow whenever I pass my hand on the forehead. It was something really strange and uncomfortable.

Happily this is something in the past. Thanks to the accurate diagnosis of Dr. Lidia and to the treatment that I followed strictly to the letter I am today free of those terrible symptoms.

I also would like to thank the careful work of Dr. Luis Daniel during all the treatment process and the attention and care that was given to me by all the Clinica MY team.

33 FINAL