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.
Male 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.

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.

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.
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.
Superior 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.
Patient’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.
Patient 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.
Patient’s frontal radiograph in habitual occlusion before treatment.
Lateral radiograph in conjunction with the profile image of the patient before treatment.
Patient’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.
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.

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.

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.

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.
MRI 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.

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

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.
Kinesiographic 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.

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.

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.
In 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.
Sequence 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.
Sequence of the three-dimensional orthodontics in this specific clinical case.
Sequence 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.
The upper incisors were rehabilitated with resins to recover the aesthetics and functionality of the patient.
Patient’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.
The 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
The patient’s occlusion after neurophysiological treatment. First and second phase finished.
Patient’s comparative occlusion images before and after the neurophysiological treatment.
Upper and lower oclusal view of the patient after the neurophysiological treatment.
Patient’s comparative images of the upper and lower oclusal view before and after the neurophysiological treatment.
Patient’s panoramic radiograph after the first and second phase of the neurophysiological treatment.
Comparative panoramic radiographs: before treatment, during treatment and after completion of the three-dimensional orthodontics and neurophysiological rehabilitation.
Patient’s laminography after the first and second phase of the neurophysiological treatment.
Patient’s comparative lateral radiographs, before and after the neurophysiological treatment.
Patient’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.
Comparative frontal images of the patient: before and after the neurophysiological treatment.

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

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.
