Posteriorization of the Mandibular Condyle, Compression of the Retrodiscal Tissue and Anteriorization of the Articular Disc as a cause of Neurologic Pain. Recovery of the Physiological Relationship of the Head of the Mandible with the Articular Disc. Series of clinical cases.

In this page we present some of the physiological neuromuscular foundations for the treatment of temporomandibular joint pathologies, it was also presented the importance of differential diagnosis and also the use of bioinstrumentation as surface electromyography and computerized kinesiography.

Images of patients related to their symptoms were also presented. Several etiological factors such as trauma in early childhood, especially green stick fracture, recapture of the intra-articular discs in reducible displacements, and interrelation between craniomandibular disorders and the vertebral column.

When we talk about the treatment of TMJ pathologies we have to understand that there are different approaches. The proposal for a palliative treatment is the symptomatic treatment, that is, a treatment that seeks to block the symptoms. It is given through the administration of drugs, such as analgesics, anti-inflammatory and myo relaxing drugs. The restorative approach is the treatment that seeks when possible to correct or heal what is damaged. To know what is wrong, a differential diagnosis is necessary. This diagnosis must always be made prior to the treatment proposal.

1 FOTO INIC FRONTALA 19-year-old female patient presents at the clinic with complaints of constant headache, neck pain and swelling in the face, back of the head pain and migraines.

According to the anamnesis filled out by the patient herself, in the initial consultation she reports clicks in the jaw, dizziness, ear pain and low back pain.

The patient also reports bruxism and nighttime clenching.

2 FOTO INICIAL PERFILThe patient also refers to retro-ocular pain on the right side, pain in both shoulders, and pain in the TMJ (right temporomandibular joint).

The patient reports cracks in the TMJ on the right side, sensation of ear covering, strange sounds and non-specific facial pain.

The patient claims difficulty in opening the mouth and difficulty in chewing.

Summary report written by the patient

In the middle of the year 2014, I had a routine consultation at a dentist to clean my teeth and I reported cracking and pain in the jaw, she did not pay attention, she said it was normal and it would soon pass.

Since then I started with severe headaches, dizziness, ear pain, back pain, my feet (more in  my heel), pain in my eye as well, and in days of painful crises, my right eye would hardly open and the right side of the my face all swollen (mumps type).

After this worsening we looked for an TMJ specialist who gave me an acrylic plate, thin and only for my upper teeth.

I used the splint for six months and after that all the symptoms worsened.

We looked for another specialist, who made the same acrylic plate for the upper teeth, but in a very different size, it was a thick plate.

In the beginning it helped, after six months, all the symptoms started to appear stronger.

We consulted a new specialist, who made a new type of appliance, with the wires and the blue acrylic on the side (I took it to show to you), it was what had helped me the most, using it for 24 hours, improved pain, even dizziness , but after a year of use everything returned and with all the pain still stronger, however during that one year of treatment, despite the improvements I could not make any kind of physical effort even not strong  my jaw swelled (gym, climbing stairs, picking up weight …)

In March 2017, a year and four months of use of the appliance, the professional said it was time to start “weaning”, start leaving the device and use only to sleep because I should already be good, I commented that it had gotten worse and she insisted that it was the time to be well…

It was then that we looked for another specialist, this one said that the plate in use was not suitable for the problem and made a new plate of acrylic that judged the correct one for the presented problem, was thin and of acrylic, equal to the first one I already used, only for the upper teeth, I immediately told to my mother and to him that this plate would not solve, since I had already used identical plate in previous treatment, he insisted saying yes, that was the correct one.

With the use of the device I also did  hot compresses and shocks of physiotherapy and also needles, which helped a lot in the neck muscles that hurt a lot, but this device from the beginning did not help, the headaches that felt every day were even worse, I’ve had more dizziness.

3 DENTES INIC PROT FRONTALHabitual occlusion of the patient on the day of the consultation.

6 OCLUSAIS INIC SEM PROTUpper and lower occlusal views of the patient on the day of the consultation.

7 PANORAMICA INICIALInitial panoramic radiograph of the patient before treatment.

8 LAMINOGRAFIA INCIAL

TMJ laminography in habitual occlusion and in open mouth.

The laminography of the temporomandibular joints shows a modification of the axis of growth of the mandibular condyles caused by a trauma in the early childhood, (green stick fracture).

Important retro position of the jaw mandibular heads especially on the left side causing an important retrodiscal compression.

9 TELE PERFIL INICIALLateral radiograph of the patient in habitual occlusion before treatment.

10 C7 INICIALLateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis, rectification of the cervical spine.

11 FRONTAL INICIALFrontal radiography of the patient in habitual occlusion before treatment.

12 eletromiog dinamica inicial

Dynamic electromyographic record of the patient in habitual occlusion.

It is important to understand that surface electromyography is an additional tool in diagnosis, and not the only determinant, is a very interesting tool to be able to control the evolution in our own patient during the course of treatment.

13 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the left TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

The magnetic nuclear resonance of the patient in habitual occlusion demonstrates the anterior dislocation of both articular discs, retroposition of the mandibular heads and modification of the axis of growth caused by traumatism in the early childhood (Structural modifications of the mandibular condylar process as one of the sequels of traumatism. in infancy). Dislocation is reducible (open mouth resonance not included in this post).

14 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the left TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

15 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the right TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

16 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

 MRI: sagittal T1 slices of the right TMJ closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular heads are in retroposition.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

17 RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

MRI: T1 frontal slices of right and left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right and left temporomandibular joint evidences a severe loss of joint space.

20 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Right and left sagittal slices in habitual occlusion prior to treatment.

21 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – left  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – right  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22a REGISTRO CINECIOGRAFICO INICIAL

When our proposal is a restorative treatment, we have a FIRST PHASE where the goal when possible is to heal the joint. Sometimes we can only improve it or prevent it from getting worse. Knowing what we can treat and what we cannot treat and the limitations of each individual case is very important.

To correctly evaluate the maxillomandibular relationship we should begin to consider the physiological position of mandibular rest.

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 electronically deprogrammed and a new resting neuromuscular physiological position was recorded.

The patient has a pathological free space of 7.7 mm.

The patient also had a 0.6 mm mandibular retroposition.

23 oclusao DIO

Occlusion of the patient with the DIO (intraoral device)

With the record obtained with the jaw tracker an intraoral device (DIO) was made to three dimensionally reposition the mandible.

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

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

24 COMPARATIVAS FRONTAIS POSTURAIS

Comparative frontal postural images.

The patient was derived along with TMJ pathology treatment for a physiotherapy team in the city where she resides. Along with mandibular repositioning the conditioning of all postural chains is necessary.

Each patient needs a specific derivation according to the particular case.

25 eletromiog dinamica com DIO

Dynamic electromyographic record of the patient with the DIO (intraoral device) in physiological neuromuscular occlusion.

26 CONTROLE DA ORTESE

28 RNM Comparativas esquerda 1 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

29 RNM Comparativas esquerda 2 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

30 RNM Comparativas esquerda 2 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

31 RNM Comparativas esquerda 2 sagital

MRI: Comparison of left sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

32 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

33 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

34 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

35 RNM Comparativas direia 2 sagital

MRI: Comparison of right sagittal cut T1, closed mouth, before physiological neuromuscular treatment, and the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

36 RNM Comparativas esquerda frontal

RNM: Comparison of FRONTAL SLICE  T1, left TMJ, closed mouth, before the physiological neuromuscular treatment, and the same left TMJ, FRONTAL SLICE T1, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

37 RNM Comparativas direita frontal

RNM: Comparison of FRONTAL SLICE  T1, right TMJ, closed mouth, before the physiological neuromuscular treatment, and the same right TMJ, FRONTAL SLICE T1, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

38 panoramicas comparativas

Comparative panoramic radiographs of the patient before starting the treatment and at the beginning of the second phase of the treatment. At this time the removal of the third molars included can also be done.

39 laminografias comparativas

Comparative laminographies of the patient before starting the treatment and at the beginning of the second phase of the treatment. The joint decompression can be observed.

Laminographs and or COMPUTERIZED TOMOGRAPHS, even showing decompression DO NOT SHOW the position of the articular disc. The position of the articular disc and the presence or not of osseous edema of the mandibular condyle can only be evaluated with nuclear magnetic resonance. The result or not of the recovery of the Physiological Relationship of the Jaw Head to the Articular Disc can be evaluated by comparing the MRI after the first phase and the comparison with the initial MRI.

40 frontais comparativas

Comparative frontal radiographs of the patient before starting the treatment and at the beginning of the second phase of the treatment.

When the first phase is completed, we verify if the subsequent control images correspond to our goals set in the initial diagnosis. We know that there are cases where we can improve the case, and others where we can prevent it from worsening, and others where we can only treat the pain.

The patient did not report any symptoms from the temporomandibular joint. The comparative MRI showed the recovery of the physiological relation of the head of the mandible with the articular disc.

The electromyographic and kinesiographic records objectively showed improvement of the neuromuscular function.

In the case of positive results from the first phase we can start a second phase of treatment to remove the device that is used permanently during the first phase of the treatment. For this we can perform a three-dimensional orthodontic, a physiological neuromuscular rehabilitation or the combination of both. Always maintaining the mandibular location in balance with the muscular planes, temporomandibular joint and dental planes.

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

In this case we will move to a three-dimensional orthodontic, where the teeth are erupted to the new physiological neuromuscular position.

A three-dimensional orthodontics needs to maintain the three-dimensional position of the mandible in balance with its bone and muscle planes achieved in the FIRST PHASE, and whenever possible maintain the Physiological Relationship of the Jaw Head with the Articular Disc.
It is fundamental to understand, that this passage has to be made keeping the DIO (intraoral device, together with the different devices to be used for the dental eruption)

47 DEPOIMENTO 3

Patient’s statement:

After long three years of failure looking for a treatment for my problem in my city, I found Dr. Lidia in a simple Google search.

I went to her and with a proposal completely different from the others, we started the new treatment immediately.

I was in an advanced stage, where I had  headache all day, pain in the ear, swollen eye (often unable to open), right side of the swollen face too (like a mumps), pain in the neck, pain in my back and also on foot.

I had no quality of life, because I was in pain all the time. When I started the treatment in the first two days I did not feel any more headaches. With the monthly follow up, adjusting as my body asked, I no longer felt any pain in anything and I returned to a normal life.

Today I am in the middle of the second phase, super anxious to go to the end and every month that passes I feel better and better.

Recapturing the Articular Disc or Repositioning the Mandibular Condyle? What about Rethinking the Concept as the Recovery of the Physiological Relationship of the Head of the Mandible with the Articular Disc. Patients with a long history of pain. Case series. First Section.

Recapture the articular disc, repositioning the mandibular condyle?

What about rethinking the concept as the recovery of the physiological relationship of the mandible head with the articular disc ,WHEN IT IS POSSIBLE.

And when is it not possible? What is the differential diagnosis? WHAT CAN WE OFFER TO OUR PATIENTS?

What type of orthotic or intraoral device to use? What is the purpose of an orthotic  in a TMJ Pathology treatment? Repositioning the jaw, recapturing the articular discs? Is this always possible? DEPEND ON THE DIFFERENTIAL DIAGNOSIS!

Does it have changes in the articular structures of the temporomandibular joint?

Does it have distortions in the horizontal, vertical and transverse posture of the craniomandibular complex?

How are the bones?

How’s the cartilage?

How’s the articular disk?

How are the muscles in this system?

How is the cervical spine in relation to the whole system?

How is the relation of the vertebral column with the other parts of the system?

The teeth, the two temporomandibular joints and the postural musculature are parts of the same bone, the mandible. They are deeply interrelated and interdependent in growth, form, and function. An abnormality in one, profoundly affects the others.

1 frente

A 30-year-old female patient presents at the clinic with a history of headache, pain in the forehead, pain and stiffness in the nape of the neck, left eyebrow pain, pain behind the right eye, and pain in the right shoulder. The patient reports TMJ pain (temporomandibular joint) on the right side.

The patient reports bilateral crackling, non-specific facial pain, and muscle tremor, difficulty opening the mouth, difficulty in chewing and mandibular locking.

Summary report written by the patient:

I do not remember a sudden drop where there might have been some kind of injury.
At 6 years of age I was a gymnast. I always had falls, front, back and head. But there were protections on the floor.

Near 8 years old, I extract a molar from the lower left side. I think that from this I have always forced more chewing on the right side.

At approximately 13/14 years of age, I remember starting the cracks on the right side. On this side I had a cross bite and a deciduous canine that “bit” behind the lower tooth.

At this stage, the crackling became more frequent, causing a bit of difficulty to fully open the mouth.  When trying to open the mouth without the snap, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

In 2004 I had the first “lockup”. I remember being in winter and cold. I tried to do the “game” of the jaw and I could not open the mouth. Then I forced myself to open my mouth and I felt a strong crack, followed by pain in the ear / nose. The impression was that it had displaced some bone / nerve.

From this episode, whenever I force more the region, the locking happens. Ex: when I eat meats, candy, peanuts. Things that I need to force when chewing.

In 2008 I put orthodontic appliance to make the corrections. In the treatment, I made a process of spacing the teeth, with a device in the roof of the mouth to open the arch. I kept my teeth apart for a while.

After finishing the treatment, corrected the teeth, the clicks returned lighter. Approximately 1 year later, the locking returned as well. I started with headaches and cervical pain. I felt slight tingling in the head.

In 2015 I started to hear some kind of “sand” on the left side. Then I got pregnant and in this period began the crackling also on the left side. In February 2017 I had the first “lock” on the left side.

Now when I feel the locking, I try to relax the muscles well, leaving the jaw loose for a few minutes. Sometimes it returns to normal anyway, other times I have to force it with the opening of the mouth, causing a strong crack.

2 foto inicial perfil

Current information:

When I close my mouth, I feel my jaw line back slightly, to “marry” the bite. To keep my mouth “loose” and comfortable, I have to snap both sides, and let the jaw loose.

When I try to open my mouth without the snaps, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

Crashes usually occur:

– Yawning;

– In the morning (awake with the jaw locked);

– Eating meats.

2 tomo

CT: Part of the initial study of the patient sent before the consultation requested by another professional.

Anamnesis and clinical examination are a key part in the diagnosis of patients with TMJ pathology.

Computed tomography is an excellent image, but when we treat a synovial joint in a patient with TMJ pathologies, CT does NOT PROVIDE THE INFORMATION OF THE SOFT TISSUES.

Magnetic Nuclear Resonance (NMR) can give a lot of information and not just the position of the disk. It is essential to have the knowledge to KNOW WHAT TO DO WITH THIS INFORMATION.

We cannot treat a patient with mandible head necrosis or with medullary edema or arthrosis or rheumatoid arthritis or lupus in the same way that we treat another patient with only a wrong position of the jaw.

The temporomandibular joints of all these patients need to be decompressed, but that is only part of the problem.

3 dentes inicHabitual occlusion of the patient on the day of the consultation.

4 oclusaisUpper and lower occlusal views of the patient prior to treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

5 panoramica

Initial panoramic radiograph of the patient before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

6 laminografia

The laminography of the temporomandibular joints shows a modification of the growth axis of the mandibular condyles in both the left and right caused by a traumatism in the early childhood, (fracture in green stick).

Retro position of both mandibular heads in the articular fossae.

TMJ laminography in habitual occlusion and open mouth.

cicatriz do queixoThree-dimensional asymmetries in the head of the condyle may have been caused by different etiologies and cause morphofunctional pathologies.

Changes in the orientation of the mandible head occur in patients who have suffered blows in the chin region, either anteroposterior, vertical or lateral. We can observe in these cases a deformation of the head of the mandible in the form of curvature, with an anterior concavity, which in some cases may be so important which produces a compression of the retrodiscal region, causing severe symptoms.

7 frontal

Frontal radiography of the patient in habitual occlusion before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

8 teleperfil

Lateral radiograph of the patient in habitual occlusion before treatment.

9 c 7Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis and rectification of the cervical spine.

16 rnm inicial 1

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

17 rnm inicial 2

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

19 rnm inicial4

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

20 rnm dir inicial5

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

21 rnm inicial 6

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

22 frontal rnm inicial 7MRI: frontal slices of the right and the left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right and left temporomandibular joint evidences a severe loss of joint space.

24 atm aberta24a eletromiografia dinãmica habitual rolos de algodão

Dynamic electromyography record of the patient in habitual occlusion and with cotton rolls on the right side (second column), left side (third column) and both right and left sides (fourth column).

Note the improvement in recruitment of motor units in the fourth column.

25 registro cineciografico inicial

Patient’s initial record for the construction of the DIO ( intraoral device)

To correctly evaluate the Maxilomandibular relationship we should begin to consider the physiological rest mandible position.

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

The stomatognathic musculature is no exception.

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

The patient has in this first record a pathological free space of 6,4 mm. 

The patient also presented a 0.4 mm  of mandibular retro position.

26 recalibraÇÃo da orteseRecalibration of the physiological neuromuscular position of the DIO (intraoral device)

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

28 ortoseOcclusion of the patient with the DIO (intraoral device)

With the record obtained with the jaw tracker an intraoral device (DIO) was made to reposition the mandible three-dimensionally.

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

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

29 controle da orteseAnother cinecigraphic record to control the DIO (intraoral device) in a physiological neuromuscular position as the device is changed or recalibrated.

The patient did not report any more symptomatology. The electromyography and kinesiography records objectively showed improvement of the neuromuscular function.

I asked for the second MRI (nuclear magnetic resonance) to objectively evaluate the physiological relationship between the mandibular condyles and the articular disc.

35 rnm comparativas 1RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

35b rnm comparativas 1RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

36 rnm comparativas 2RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

38 rnm comparativas 4RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

39 rnm comparativas 5

RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

40 rnm comparativas 6RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

41 rnm comparativas7RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

42 rnm comparativas 8RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ,  closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

43 frontal rnm comparativas 8

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

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

44 frontal rnm comparativas 8

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

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

45 imagens

The patient did not report any more symptomatology. The comparative MRI showed the recovery of the physiological relationship of the mandible head with the articular disc.

The electromyographic and kinesiographic records objectively showed improvement of the neuromuscular function.

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

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

46 depoimento 1Patient Testimony:

My first memory of locking joints was at age 15 or so.

I looked for orthodontic specialists; I made the necessary “adjustments”, but the locking and the pain still continued.

I looked for Dr. Lidia now at the age of 30, since other experts told me that only surgery would be possible in my case. And yet, without knowing exactly whether we would succeed.

After starting the first phase of treatment with the device, the pain ceased and never again I had the jaw locking that so frighten me.

47 depoimento 2

I adapted very easily to the treatment, I was and I am being much disciplined with the use of the device.

Now, as Dr. Lidia explained to me, with the discs already in the right place, we will pass for the second phase, for withdrawal of the device.

Today I’m having a routine without worry that I can “lock” at any time.

I’m very grateful to Dr. Lidia.

TMJ Study and Investigation Page. Three years of publication.

Dear friends,

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

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

Three years of publication

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

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

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

FINAL

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

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

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

I want to celebrate these three years with you.

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

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

MARCUS LAZARI frontal E SAGITAL

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

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

3 ANOS DE PUBLICAÇÕES 2

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

Thank you!

Lidia Yavich

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

33 FINAL

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

24

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

27 CEF COMPARATIVAS ingles

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

FRONTAL COMPARATIVAS ESQUERDA 2016

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

10 abre e fecha inicial

FINALE FINALE

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

ITACIR COMBINADA

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

1 FOTOS FRENTE

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

HELLA

TMJ Study and Investigation Page. One year of publication

INITIAL

2

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

Thank you!

Lidia Yavich

TMJ 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 headache for 30 years. Neuromuscular Physiological Rehabilitation. First and second phase. Case Report.

1 FOTOS FRENTE

A 54- year old female patient arrives to the clinic for consultation, referred by her rheumatologist with complaints of daily headache since her 23 years of age. The patient associates the beginning of the headache with the installation of a definitive crown on the right upper central incisor. When she was 12 years old the suffered a traumatism that provoked the fracture of the tooth. The patient also reports bruxism.

2 FOTOS PERFIL 2

The patient reports that in consultation with a neurologist, a nuclear magnetic resonance of the skull was requested, in which a change in white matter was detected.

At the same time the patient consults with a cardiologist. A FOP (Patent Oval Form) is detected, with no need for a surgical approach.

2A

After years and years of consultations and treatments for daily headaches, the patient also has a diagnosis of fibromyalgia.

The patient makes use of marevan, 5mg daily as indicated by the Cardiologist.

Sandomigran 1 time per day per Neurologist indication.

Nexium 40 mg once daily indication of Gastroenterologist.

Marevan works in the prevention of venous thromboembolism, systemic embolism in patients with prosthetic heart valves or atrial fibrillation, stroke, acute myocardial infarction and recurrence of myocardial infarction. Oral anticoagulants are also indicated in the prevention of systemic embolism in patients with cardiac valve disease.

Sandomigran, pizotifen is an antaminic characterized by its polyvalent inhibitory effect on biogenic amines, such as serotonin, histamine and tryptamine. It is suitable for the prophylactic treatment of migraine, reducing the frequency of seizures. Pizotifen also has appetite-stimulating properties and is mildly antidepressant.

Nexium: Expected action of medication, disappearance of symptoms of heartburn, epigastric pain and acid regurgitation. Healing of peptic ulcers.

3 dentes

Habitual occlusion of the patient on the day of the consultation. Note the persistence of a lower deciduous tooth on the left side.

4 OCLUSAIS

Upper and lower occlusal views of the patient on the day of the consultation. Note the persistence of a lower deciduous tooth on the left side.

Presence of bilateral torus mandibularis.

The lower incisors show signs of wear.

5 PANORAMICA 1

Absence of dental elements 18, 28, 38 and 48. Maintenance of element  75  in the dental arch. The element 11 is endodontically treated. Presence of fixed prosthesis with intracanal pin in element 11.

6 LAMINOGRAFIA INICIAL

The laminography of the temporomandibular joints shows a modification of the growth axis of both mandibular condyles caused by a trauma in the early childhood, (greenstick fracture).

7 TELEPERFIL

Lateral radiograph of the patient in habitual occlusion before treatment.

8 FRONTAL

Frontal radiography of the patient in habitual occlusion before treatment.

9 C7

Lateral and cervical radiograph of the patient in habitual occlusion prior to treatment. Note the loss of space between the cervical vertebrae, especially between C5 and C6, where osteophytes are also observed.

10

MRI: Sagittal slice of the left TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Facet on the superior surface and posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

Notice the posterior compression in this slice.

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

11

MRI: another sagittal slice of the left TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

12

MRI: Sagittal slice of the right TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Facet on the superior surface and posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

13

MRI: another sagittal slice of the right TMJ in the closed mouth, we can observe the anteversion of the mandibular condyle. Posterior flattening of the mandibular condyle. The articular disc is displaced anteriorly, with reduction in open-mouth maneuvers. (Open mouth images not included in the post).

Notice the posterior compression in this slice.

In the magnetic resonance image of the temporomandibular joints it is fundamental to read the structure of the disc  besides the position of the disc.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

14

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

Notice the posterior compression in this slice.

An articular disk as in this specific case, thin, without a real structure capable of maintaining a good function, the primary objective has to be the tridimensional decompression of the mandibular condyle. This particular articular disc has no structure to fulfill the function for which it is intended.

17 registro inicial para o DIO

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

An intraoral device (DIO) was made to for three- dimensional mandible repositioning.

The patient presented a pathological free interocclusal space of 4,4 mm, a mandibular retroposition of 1, 6 mm, also a right deviation of 1 mm.

20 OCLUSAO DIO

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

21 Registro cinesiográfico para controlar o DIO em posição neurofisiológica

Control of the intraoral device registration (DIO). These controls are frequently performed during the first phase of the treatment, also monitored by surface electromyography. On average this first phase lasts one year. Modifying and improving PHYSIOLOGICAL NEUROMUSCULAR POSITION.

22 RC1

MRI: comparative sagittal sections of the left TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

23RC2

MRI: another comparative sagittal sections of the left TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

25 B RC5

MRI: comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

25 ARC4

MRI: another comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

24RC3

MRI: another comparative sagittal sections of the right TMJ closed before and after the Neuromuscular Physiological treatment.
Notice the three-dimensional joint decompression. Primordial objective in this specific case.

After the completion of the first phase of the treatment of TMJ pathologies and the patient WITHOUT HEADACHE, we began the second phase of TMJ pathology treatment.

In this specific case: three-dimensional orthodontics together with the rehabilitation of the necessary dental pieces and aesthetic improvement of the patient’s anterior teeth.

25 PANORAMICA ANTES DA ORTO

At this point I had to make a decision regarding the permanence of the deciduous tooth, firm and without mobility.

I did not think I should extract it for the placement of the implant, but to maintain it.

I clarified to the patient that during orthodontics we could lose it. I understood that this would have a compromise in the patient’s occlusion, but this fact did not concerned me, with the TMJ being decompressed and the patient functioning well, both electromyographically and in the computerized kinesiograph tests.

25 ORTO 1

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

26 ORTO 2

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

27 ORTO 3

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

28 ORTO 4

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

29 reconst do dente desiduo

Direct composite resin reconstruction of  the 75 and 37 elements maintaining patient’s  Neuromuscular Physiological position.

30 ORTO 6

Sequence of three-dimensional orthodontics in the second phase of TMJ pathologies treatment in this specific patient. Direct composite resin reconstruction of  the 75 and 37 elements maintaining patient’s  Neuromuscular Physiological position.

31 ORTO 8

Sequence of three-dimensional orthodontics in the second phase of TMJ pathologies treatment in this specific patient. Preparation for the reconstruction of elements 33, 32, 31, 41, 42 and 43 maintaining the patient’s Neuromuscular Physiological position.

32 ORTO 9

Direct composite resin reconstruction of  33,32,31,41,42 and 43 elements maintaining the patient’s Neuromuscular Physiological position, with three-dimensional orthodontics.

33 lentes de contato

After the resolution of the strong headache (reason why the patient consulted the clinic) and the finalization of the tridimensional orthodontics, it was decided to make laminated facets from canine to canine for aesthetic reasons.

34 Finalizaçaoo da primeira e segunda fase

Completion of the First and Second Phases in the treatment of TMJ Pathologies. Physiological Neuromuscular Rehabilitation.

36 LPANORAMICA FINAL

Patient’s panoramic radiograph after the end of the treatment in the Neuromuscular Physiological Dentistry.

37 LAMINOGRAFIA FINAL

Patient’s temporomandibular joints laminography  in physiological neuromuscular occlusion after treatment completion.

38 FRONTAL final

Patient’s frontal radiograph  in physiological neuromuscular occlusion after treatment completion.

39 LATERAIS COMPARATIVAS

Patient’s comparative lateral radiographs  before and after treatment. The first  in habitual occlusion and the second in physiological neuromuscular occlusion.

45 DEPOIMENTO 1

At age 11, I had a fall and broke the upper incisor tooth. At the time, I sought a dentist and he said that I should wait for the adult stage to make the porcelain definitive crown.

In 1986, when I was 23, I went to another dentist to make the crown. After the root canal treatment, the crown was placed.

In that moment I felt that there was an elevation that touched the lower tooth. The next day I woke up with an endless headache. Day by day the pain intensified.

I returned to the dentist and reported the fact, he said that in time it would settle. For 25 years I investigated the reason for my headache with several doctors.

In 2006 a rheumatologist asked me for an MRI of the skull, changes were identified in the gray matter. During this period, I was admitted to HMV for an investigation, and the diagnosis was SAF, topiramate 50 mg was introduced as a preventive of migraine and anticoagulant.These drugs were used from 2006 to 2011.

45 DEPOIMENTO 2

In 2007, I underwent systemic chemotherapy with METOTREXATE for 1 year. In 2011 another pain site showed up, this time in the hip, so I underwent corticoid in the vein for 6 months.

I decided to abandon the treatment, because it was no use. I looked for a respected neurologist who switched all my medication for an anti-allergy for headache prevention and an antiplatelet.

The diagnosis was leukoencephalopathy in a small degree. I also gave up treatment, because it did not work, either.

This neurologist referred me to another rheumatologist who examined me and identified a problem in my TMJ and a bursitis in the hip.

The same rheumatologist sent me to Dr. Lidia Yavich and to an orthopedist. In a short time I did not feel the same headache when I woke up. After all this, I continue to do MRI, and the changes have stabilized.

45 DEPOIMENTO 3

 

I sought an opinion from a second neurologist, and he thinks that all the changes I have are due to the intensity of the headache that I felt daily.

He did not agree with any diagnosis made so far.

I also believe that, because after the treatment with Dr. Lidia, I regained my quality of life.

The medication I use today: antiplatelet due to the existing changes and because I have a patent foramen ovale.

I thanks also to Dr. Luis Daniel for the conjunct treatment restoring function and aesthetics.

 

Child with Otalgia (earache) and Conductive Hearing Loss: when measuring makes the difference. Normalization of hearing thresholds. First and second phase. Case report.

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment.

The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY  TEMPOROMANDIBULAR DISORDERS  is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

There are two general types of hearing loss, conductive and sensorineural.

Conductive hearing loss results from disruption in the passage of sound from the external ear to the oval window.

Anatomically, this pathway includes the ear canal, tympanic membrane, and ossicles. Such loss may be due to cerumen impaction, tympanic membrane perforation, otitis media, osteosclerosis , intraaural muscle dysfunction, or displacement of the ossicles by the malleolar ligament.

Sensorineural hearing loss results from otology abnormalities beyond the oval window. Such abnormalities may affect the sensory cells of the cochlea or the neural fibers of the 8th cranial nerve. Hearing loss with age (presbycusis) is an example. Eight cranial nerve tumors may also lead to such hearing loss.

1

Male patient, eleven years old,  arrived to the clinic for consultation referring headache, pain on the  back of the head, shoulder pain, neck pain, hand numbness and tingling  in hands and LIMITATION OF MOUTH OPENING.

1A

The patient reports pain in the left ear and sensation of ear blockage especially on the left side. He also has tinnitus in both ears and DECREASE OF HEARING IN BOTH EARS.

Any hearing loss reported by the patient, must be evidenced by an audiometry.

2

Patient’s medical history: is relevant to this case the antecedent trauma on the chin at early childhood. It is also important to consider his recurrent infections of  ear and throat and that when he was eight months old he had a severe pneumonia that required hospitalization.

3

Images of the patient’s habitual occlusion. Upper and lower oclusal view. Patient’s photos:  frontal, profile and smiling on the day of consultation.

4

Patient’s initial panoramic radiograph

5

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

In the maximum opening position, we can observe the anterior angulation of the left articular processes.

6

Patient’s habitual image occlusion before treatment, in the consultation day.We may observe here an important overbite.

It is evident the lack of space for the correct positioning of the  left maxillary canine.

7

Superior and lower oclusal view of the patient before treatment. It is evident the lack of space for the correct positioning of the left maxillary canine.

8

Patient’s lateral radiograph together with the profile image before treatment.

Retrognathic profile and rectification of the cervical spine.

9 res fechada

MRI T1: Sagittal slice, left and right TMJ closed mouth before treatment.

We can observe anterior facets on the right and left mandibular heads.

In the right TMJ the disk is slightly anteriorly dislocated. The anterior dislocation is more evident on the left TMJ, with the head of the mandible backed on the retrodiscal  zone.

10 res aberta

MRI T1: Sagittal slice, left and right TMJ open mouth before treatment.

We can observe anterior facets on both mandibular heads.

Both mandibular condyles cannot translate, reducing mouth opening.

12 cineciog 1

Initial kinesiographic record: 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 of the record. Limited mouth opening as the patient can open only 32.9 mm.

11 ELET INICIAL

Surface electromyography of the patient in habitual occlusion in which are measured:

Anterior right and left temporalis

Right and left masseter

Right and left digastrics

Right and left superior trapezius

Activation of the digastrics in closure, these muscles should only must be in activity along the opening movement

During the examination there was an activation of the right and left upper trapezius even when the patient was instructed to lower his shoulders.He had activated both trapezius throughout the examination.

13

The patient reports pain in the left ear and sensation of ear blockage, especially on the left side. He also has tinnitus and DECREASE OF HEARING IN BOTH EARS.

ANY HEARING LOSS REPORTED BY THE PATIENT MUST BE EVIDENCED BY AN AUDIOMETRY.

15 AUDIOMETRIA INICIAL

An audiogram is produced by using a relative measure of the patient hearing as compared with an established “normal “value. It is a graphic representation of auditory threshold responses that are obtained from testing a patient’s hearing with pure-tone stimuli. The parameters of the audiogram are frequency, as measured in cycles per second (HZ) and intensity, as measured in dB­­­­.

The first audiometry of the patient revealed a mild hearing loss in the left ear and a moderate hearing loss in his right ear.

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Hearing loss is classified as mild, in which the ear is unable to detect sounds below 40 decibels which makes it  difficult to understand human speech.

In moderate loss, the sounds below 70 decibels are not heard.

17

We recorded the mandibular rest position after electronic deprogramming, together with the information of the MRI (magnetic resonance imaging) to orient our decisions of the bite registration, for the three-dimensional construction of the DIO (intraoral device).

The patient has a pathological free space of 8.6 mm and 8 mm of mandibular retro position.

The degree of compression determinates de reaction of the patient.

The retrusion of the mandible, whether it is iatrogenically induced, or a result of malocclusion, often results in otalgia due to excessive compression of the neurovascular retrodiscal tissues. The patient’s impression is ear pain.

18

I informed the parents of the patient, that at this stage, I was only worried about the health of the patient, and focused on  improving the functions, the symptoms and controlling the conductive hearing loss.

Hearing loss resulting from Eustachian tube dysfunction, initiated by craniomandibular disorders is usually subjective.

For this reason there is a need for an objective control by audiometry.

 I explained that I would not make any orthodontic intervention at this stage to include in the arcade the canine that was misaligned and out of space. I told them  that I would take care of it later and in this case I would not have the need to extract teeth.

19

The installed device is controlled through surface electromyography to evaluate the function.

20 AUDIOMETRIA 2

Patient’s second audiometry  shows normal thresholds in the left ear and a mild hearing loss in his right ear.

21 AUDIOMETRIA 1 e  2

Comparing the first and second audiometry of the patient during treatment.

Thresholds normalization of the right ear and thresholds improvement of the left ear.

23

Structural lesions may produce functional changes which in turn increases the structural changes.

24

Structural and functional changes.

25

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but  OTHERS CANNOT.

25A

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but OTHERS CANNOT.

26

It takes time to stabilize the muscles during treatment, different patients, different ages and different pathologies.

27 AUDIOMETRIA 3

Patient’s third audiometry shows NORMAL thresholds in the left ear and NORMAL thresholds in his right ear.

28 AUDIOMETRIA 1 e  2 e 3

Comparing the first, second and third audiometry of the patient during treatment.
Thresholds normalization in the right and left ear.

At this time with the normalization of the conductive hearing loss, the remission of symptoms and improvement of the images from the exams, we began the second phase through a three-dimensional orthodontics.

29 SERIES DE ORTO 1

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

30 SERIES DE ORTO 2

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

30 A PERFIL E RAD LATERAL ORTO

Patient’s lateral radiograph together with the profile image during treatment.

Aesthetic and not retrognathic profile as at the beginning of treatment.

There was not a recovery of the physiological lordosis, but there surely was an improvement of the cervical spine.

31 SERIES DE ORTO 3

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

32  SERIES DE ORTO4

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

33 RETIRADA DO DIO

Removal of the DIO (intra oral device) at the current stage of the three-dimensional orthodontics.

34 SERIES DE ORTO4

Images without the DIO (intraoral device) and completion of the treatment of the three-dimensional orthodontic in neurophysiological occlusion.

OCLUSAIS FINAIS

Comparative images of the upper and lower oclusal views from the patient before and after completion of the first and the second phase of the neurophysiologic treatment.

35 AUDIOMETRIA 4

The fourth audiometry of the patient after completion of the two phases of treatment maintains the normal thresholds in both the left ear and the right ear.

SERIES DE ORTO

Part of the sequence of the three-dimensional orthodontics in the second stage of the treatment of TMJ disorders in this particular patient.

panoramicas comparativas

Comparative panoramic radiographs: before treatment and after completion of the three-dimensional orthodontics.

CEF COMPARATIVOS

Comparative of lateral radiographs of the patient: at the beginning of the treatment in habitual occlusion, after the  completion of the three-dimensional orthodontic in neurophysiological occlusion and six years after the completion of treatment control.

37 CINESIO comparativoS

Patient’s kinesiographic records comparison: before and after treatment.

The mouth opening  of the patient improved from 32.9 mm to 38.9 mm and it also reached an excellent speed regarding  mouth opening and closing.

37 eletro comparativo

Patient’s electromyography records comparison: before, during and after treatment.

39 jaw trackwe  comparativoa

Patient’s kinesiographic records after electronically mandibular deprogramming comparison: before treatment the habitual trajectory is not coincident with the neuromuscular trajectory.

After treatment the habitual trajectory is tridimensional coincident with the neuromuscular trajectory.

40 todas as audiometrias

Comparing the first, second, third and forth  audiometry of the patient.
Thresholds normalization of right and left ear.

FINALE FINALE

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment. The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY  TEMPOROMANDIBULAR DISORDERS  is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

42 DEPOIMENTO 1

When the patient ended all the treatment, and being still a teenager, he left the following testament:

My dentist referred me to the orthodontist because I had a crooked canine. So, after a panoramic radiograph she suspected that I could have a TMJ problem. Then she referred me to Porto Alegre to do a MRI, and from that exam it was found something that indicated a TMJ problem. So then I started the tratment with Dr. Lidia Yavich, that also investigated the tinnitus and my hearing problem.

When I was little I felt and hit the chin but my parents didn’t know that it could affect my TMJ.

I suffered a lot from an earache and sore throat. I had even scheduled an ear surgery but after six months of treatment it was no longer necessary to do it. Today I am doing well. I have a good hearing and I don’t have any more the tinnitus and the throat pain. I am happy with this treatment, thanks to God and to Dra. Lidia Yavich.

42 DEPOIMENTO

Here follows the testimony of the same patient seven years after the completion of the treatment:

Today, more than seven years after the end of the TMJ treatment with Dr. Lidia, and thanks to the God-given gifts to her, I haven’t been suffering any more with the earaches nor with the throat pain or the hearing loss. I had had, before the treatment, the indication to make an ear operation since I was loosing my hearing and that was not necessary with the TMJ treatment because during the treatment I was monitorated by exams that had proven that my hearing improved. Today I live a normal life, without having problems with those things from the past. I thanks the treatment done by Dr. Lidia which has healed me and improved my life.

 

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.”

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