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 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

 

Cervical Dystonia or Spasmodic Torticollis: Positive evolution after Neurophysiological Treatment

The patient of this post contacted me through a derivation from a colleague from abroad.

Soon after he sent an email where he explained the motif for his consultation on Cervical Dystonia or Spasmodic Torticollis, I answered that it was not my

knowledge  area, that I treated TMJ Pathologies , Orthodontics and Facial Orthopedics.

The patient insisted, commenting that the colleague that recommended me and knew me from the AACP meeting where I was invited as a lecturer explained to him that he didn´t know if I treated Distonia, but he thought that considering  what he had  watched  I could help him.

I began to study more on  published articles of this field. One of the articles that impacted me was: Spasmodic Torticollis: The Dental Connection. Anthony b. Sims, D.D.S.; Brendan C> Stack, D>D>S> ;MS.;Gary Demererjian, D.D.S.

1

Dystonia is a  neurological movement disorder, which sustained muscle contractions causing twisting and repetitive movements or abnormal postures. The movements may resemble a tremor. Dystonia is often initiated or worsened by voluntary movements, and symptoms may “overflow” into adjacent muscles.There are multiple types of dystonia, and numerous diseases and conditions may cause dystonia.

Focal   dystonia:  affects a muscle or group of muscles in a specific part of the body causing involuntary muscular contractions and abnormal postures, like eyes, neck or hands.The precise cause of primary dystonia is unknown .It is suspected to be caused by a pathology of the central nervous system, likely originating in those parts of the brain concerned with motor function, such as the basal ganglia.

2

Main common dystonia denomination are :

blepharospasm (from Greek: blepharon, eyelid, and spasm, an uncontrolled muscle contraction), is any abnormal contraction or twitch of the eyelid.

Oromandibular dystonia is a form of focal dystonia affecting the mouth, jaw and tongue, and in this disease it is hard to speak.

Cervical dystonia (spasmodic torticollis ) affects the muscles of the neck. Causes the head to rotate to one side, to pull down towards the chest, or back, or a combination of these postures.

Spasmodic dysphonia (or laryngeal dystonia) is a voice disorder characterized by involuntary movements or spasms of one or more muscles of the larynx(vocal folds or voice box) during speech.

2

Patient Testimony

Everything began approximately after the placement of the  lower implants.

One year after that, I began to feel uncomfortable.

I felt a back and neck stiffness, a strong weight in the back of the head and pain.

I began to make a lot of examination tests with neurologists, physical therapists, rheumatologists, orthopedists.
All of them followed the same line, saying that it could be a stress problem and fatigue.

Later I began to feel a twist movement in my neck towards the left. It was not so strong  but I felt I had no  control on my neck.

My neck always tried to rotate to the left, especially  when I walked and when I tried to hold an object.

After doing physical therapy, chiropractic’s, acupuncture and all those techniques I began to research and finally consulted another neurologist who told me that  I had CERVICAL DYSTONIA.

He asked for many exams to eliminate the possibility of being  a trauma or other problem related to Wilson disease. That hypothesis was soon discarded.

I consulted another neurologist that confirmed the same diagnosis: CERVICAL DYSTONIA.

The neurologist initiated a treatment with Botox, to alleviate, and to relax some muscles, trapeziums, sternocleidomastoids and splenius. I was also oriented to have three applications of miorelaxants.

I began to investigate more on the subject and I found some videos about TMJ and some treatments with dental appliances.

4

Habitual patient’s occlusion

Patient Testimony

The situation is very bad because doctors say: “is neurological”,  we don’t know the etiology and it has no cure until today.

I believe all of this must have a relation with the implants, because I passed more than 30 years without these teeth, maybe  the position of my mouth could have provoked some slow alteration that end up in this situation.

I’m not an specialist to affirm that this is the real situation, but I believe that it is worthy to investigate because there is the existence of written articles.

Moreover Dr. Anthony Sims, and other doctors in the dentistry field point for possible head and neck disturbance, motor coordination, Tourette disease or something like that, so many things connected with TMJ (temporomandibular joints) disorders.

3

Patient’s occlusal superior and inferior view

1

Patient report: Detail of principal symptoms

Impossibility of head stabilization

Ringing ears

Ear compression sensation

Muscle spasm when I want to move the head down and to the right.

Noises in the vertebras in the back of the neck region, may be C1 and C2, but I am not sure and noises in the spine.

Noises in the TMJ, specially when yawn.

5

Patient’s panoramic radiograph before treatment.

6

Patient’s frontal radiograph where it is clearly seen the impossibility for straight posture of the head.

7

Patient’s initial laminography, in habitual occlusion where we can observe the retro position of both mandibular heads.

9

Patient’s initial lateral radiograph in habitual occlusion before treatment.

10

We can observe in this lateral radiograph and cervical spine radiograph the total lack of space between the ATLAS posterior arc and the Occipital base. I suspected adherences so I solicited a lateral radiograph in flexion.

11

In the Cervical Spine radiograph in flexion we can observe a REDUCED space between the ATLAS posterior arc and the base of the occipital. THE SPACE IS REDUCED, BUT EXISTS.

12

The MRI in closed mouth shows a small disc, superior facets in both mandibular condyles and bilateral retro discal compression. The patient has no limitation in opening the mouth and the discs are well situated on the mandibular heads when opening. I didn´t judge important to include the image of open mouth for this clinic case.

tHE 13

The Semg dynamic record shows an important asymmetry between anterior right and left temporalis, low activity of both masseters muscles. The trapezius doesn’t show activity during mandibular closing, which is physiologically correct. Important activity from the digastrics muscles in closing movement, which is not physiologically correct.

14

The Semg dynamic record shows an important asymmetry between anterior right and left temporalis, low activity of both masseters muscles. The sternocleidomastoid muscles show activity during mandibular closing, which is NOT physiologically correct (the sternocleidomastoid muscle is not a masticatory muscle). Important activity from the digastrics muscles in closing movement, which is NOT physiologically correct.

15

His masticatory muscles were electronically deprogrammed with TENS (Transcutaneal Electronic Neural Stimula­tion). A jaw tracker then registered a neurophysiologic position from where an intraoral appliance was constructed and tested with SEMG (Surface Electromyography.) For this record we used the neurophysiologic technique.

16-comparativa-frontal-1-dio

Patient’s frontal comparative images: initial and four months after DIO (Intra Oral Device) wear. Notice the important improvement of head and shoulder posture.

17-a-comparativa-perfil-diio

Patient’s right profile comparative images: initial and four months after DIO (Intra Oral Device) wear. Notice the important improvement of head and shoulder posture.

17-b-comparativa-perfil-2-diio

Patient’s left profile comparative images: initial and four months after DIO (Intra Oral Device) wear. Notice the important improvement of head and shoulder posture.

19

Patient’s lateral radiograph with the device in neurophysiological position. Notice the space between the posterior arc of the atlas and the occipital base that didn´t exist before.

20

Patient’s frontal comparative radiograph: before the treatment and with the DIO (Intra Oral Device), the patient manages now to have a straight posture of the head.

21

Patient’s lateral and cervical spine comparative radiograph: before the treatment and with the DIO. Notice the space between the posterior arc of the Atlas and the occipital base that did not exist before.

22

Patient’s comparative laminographies: initial in habitual occlusion where we can observe the retro position of the mandibular heads and with the intraoral device with retrodiscal decompression.

23-comparativa-frontal-3-dio

Patient’s frontal comparative images: initial, four months and nine months after DIO wear. The patient had a physiological posture recovery.

24-comparativa-perfil-3-diio

Patient’s right profile comparative images: initial, four months and nine months after DIO wear. The patient had a physiological posture recovery.

25-comparativa-perfil-2-diio-3

Patient’s left profile comparative images: initial, four months and nine months after DIO wear. The patient had a physiological posture recovery.

artigo

Spasmodic Torticollis: The Dental Connection. Anthony b. Sims, D.D.S.; Brendan C> Stack, D>D>S> ;MS.;Gary Demererjian, D.D.S.

 

26

 

The patient also sent videos where he shows his initial incapacity to rotate the head and also comparative videos where he could do that again. The videos are not in the post to preserve patient’s identity.