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.

The temporomandibular joint (TMJ) as a peripheral trigger in the headache. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

1 FRENTEA 36-year-old female patient with a major complaint of headache consults at the clinic, referred by a co-worker who had been treated at the clinic for the same reason.

The patient’s main complaint was a high frequency headache. The patient reports that she has investigated the cause of the pain and even had at the request of the neurologist a nuclear magnetic resonance of the skull that did not accuse any abnormality.

1 PERFILThe patient had already consulted with Neurologist, Otorhinolaryngologist, Orthopedist and with the general practitioner.
The patient also refers back pain.

2 DENTES INICIAISHabitual occlusion of the patient on the day of the consultation.

3 OCLUSAISUpper and lower occlusal views of the patient on the day of the consultation.

Upper and lower incisors show signs of  attrition.

7 PANORAMICAInitial panoramic radiograph of the patient before treatment.

Absence of the second right upper premolar and the lower third molars.

The patient reports that the upper premolar was extracted in adolescence due to lack of space for the eruption of the canine.

The first maxillary molar on the left side and the first lower molar on the left side presented endodontic treatment with extensive restorations and risk of fracture, was informed of the need to extract the third molar retained.

The procedures would only be performed after joint decompression.

8A LAMINOGRAFIALaminography of the temporomandibular joints shows a modification of the axis of growth of the mandibular condyle on the left side caused by a trauma in the early childhood, (green stick fracture).

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

5 C7Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis, rectification of the cervical spine.

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

8b ressonancias sagitaisMRI: sagittal slices of the left TMJ, the closed mouth.

The facet on the upper surface and posterior flattening of the mandibular condyle can be observed.

8Dressonancias sagitais CORTES SUPERIORESNote the important posterior compression of the left condyle.
Primary objective has to be the three-dimensional decompression of the mandibular condyle.

8B CINECIOGRAFIA 1BThe patient’s masticatory muscles were deprogrammed electronically and the resting position was recorded with a computerized kinesiograph.
The patient had a pathological interocclusal free space of 6.3 mm and a mandibular retroposition of 0.5 mm.

9 ORTESEWith the record obtained with the computerized jaw tracker an intraoral device (DIO) was made to achieve the three dimensionally reposition of the mandible.

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

9D PANORAMICA COM ORTESEPanoramic radiograph of the patient during treatment with the DIO (intraoral device).

9C COMPARATIVAS DE TELEPERFIL 1Comparison of lateral radiographs and patient profile: in habitual occlusion before treatment and with the DIO (intraoral device), in a physiological neuromuscular position.

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

10A C7 COMPARATIVASComparison 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.

10B CONTROLE ORTESEControl of intraoral device  (DIO). THESE CONTROLS ARE FREQUENTLY MADE during the first and second phases of the treatment modifying and improving the PHYSIOLOGICAL NEUROMUSCULAR POSITION.

The patient did not report any TMJ-related symptomatology. 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 use a three-dimensional orthodontic, where the teeth are erupted to the new neurophysiological position.

19 ORTO 0Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

20 ORTO 1Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

21 ORTO 2Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

22 ORTO 3Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

23 ORTO 4Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

24 ORTO 5Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

25 ORTO 6During three-dimensional orthodontics the DIO (intraoral device) is recalibrated and changed to maintain the position obtained in FIRST PHASE

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

26 ORTO 7Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

27 ORTO 8Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

29 ORTO 9Sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ pathologies in this specific patient.

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

Preparation to increase the width of the upper incisors respecting the patient’s Neuromuscular Physiological position.

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

Preparation to increase the width of the upper incisors respecting the patient’s Neuromuscular Physiological position.

32 orto finalCompletion of the First and Second Phases in the treatment of TMJ Pathologies. Physiological Neuromuscular Rehabilitation.

In this specific sequence, another possibility was proposed for the patient with an important improvement of aesthetics for the increase of the clinical crowns of the upper incisors, due to the limitation in this case of the composite resins.

The patient alleged: that she did not work on television, that even knowing the aesthetic limitation of the procedure with resins, she was satisfied.

For her the goal of the treatment was the resolution of the PAIN, and that had been reached.

33 OCLUSAIS FINAISUpper and lower occlusal views of the patient after the end of the second phase.

34 PANORAMICA FINALPanoramic radiograph of the patient after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

The extraction of the first maxillary molar and the placement of an implant after bone grafting was necessary. The third left retained molar exodontia was also performed.

35 LAMINOGRAFIA FINALTMJ laminography of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

36 PERFIL FINALLateral radiograph and profile of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

37 C7 FINALLateral radiograph and cervical spine of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

38 FRONTAL FINALFrontal radiography of the patient after the end of the second phase of the treatment through a three-dimensional orthodontic and physiological neuromuscular rehabilitation.

39 FRONTAIS COMPARATIVASComparative frontal radiographs of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

40 C7 COMPARATIVASComparative lateral radiographs and cervical spine of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

41 PERFIL 3 COMPARATIVASComparative lateral radiographs and profile of the patient: before the treatment, during the first phase of the treatment and after the end of the treatment with three-dimensional orthodontics.

43 DENTES COMPARATIVASComparative occlusion of the patient before and after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

44 OCLUSAIS comparativasComparative upper and lower occlusal view of the patient before and after the end of the second phase of the treatment through a three-dimensional orthodontics and physiological neuromuscular rehabilitation.

45 CINECIOGRAFIA final.jpgCineciographic record after completion of the first and second phases of physiological neuromuscular treatment. The neuromuscular trajectories are coincident. We would have liked to have an interocclusal space of 2.5 to 3 mm, we obtained 4.1 mm

46 DEPOIMENTO 1Patient testimony

Dear Lidia,

You know, I really realized how much the treatment I’ve undergone improved my quality of life when I was in the clinic this year (2018) and I looked at my file with the information I had recorded when I started treatment.

To be honest I did not even remember that before the treatment I had pains in the jaw joints !! And how strong they were.

I always had headaches and migraines, besides the pains in the joint of the mandible. I always record it because I remember when I was a child I already felt them. I felt very ill and indisposed when I had crises.

In a certain phase of my life due to the increase in the frequency of pain headache and the constant vomiting I went to many doctors because I thought I was with stomach problem. I thought my headaches and migraines were consequence.

47 DEPOIMENTO 2But based on the examinations I made at the time, my general practice told me that the question of the stomach was actually a consequence of severe headaches and migraines.

So she told me to go to a neurologist for evaluation and treatment. I went to the neurologist, did tests, treatment, tried to avoid the huge list of foods he I was informed as probable triggers of migraine. Everything I did reduced the headaches, but it did not solve the problem that plagued me.

And it was during one of my “crises” of headache that a coworker commented the possibility that I would make an evaluation with a dentist who had treated him when had problems with the TMJ. To be honest, I had no idea what it was, but when if you have pain, every attempt is valid.

47 DEPOIMENTO 3I made the appointment, made available the exams I had already done in the region of the head and remember that in my first conversation with Lidia she commented that the exams indicated that in my infancy I had probably suffered a fall that caused a growth modification of my jaw.

Exactly the side where I had the headaches and the migraine.

I stress that at no time did the treatment for an aesthetic question, but rather seeking, if it is not possible to avoid the pains, but minimizes them.

I spent several years attending the clinic. I remember that my splint in one of the stages of the treatment was a “big monster” (kkk) considering its height.

Gradually throughout the treatment I was noticing the reduction of headaches and of frequency between migraine attacks.

Today, thinking about before and after treatment, I realize how much the treatment,

although prolonged, has improved my quality of life.

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.

 

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

1-itacir-inicial-frontal-copia

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

2-itacir-inicial-lateral-copia

The patient complains of daytime and nighttime clenching.

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

3-dentes

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

4-oclusais

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

5-panoramica-1

Patient’s initial panoramic radiograph before treatment

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

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

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

Endodontically treated 13 and 12 elements.

6-laminografia-1

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

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

7-a-perfil-e-tele

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

7-frontal-1

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

8-c7-e-perfil

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

9-comparativos-emg-basal

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

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

10-dinamico-1

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

10-a-1-corte-ressonancia

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

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

11-jaw-tracker-1

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

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

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

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

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

14-ortese-1

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

16-laminografia-comparativa

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

17-a-perfil-comparativos

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

18-teleradiog-comparativas

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

19-comparativa-frontal

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

20-telefrontais-comparativas

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

21-comparativa-perfil-1

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

22-comparativo-sorriso-1

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

24-radiografia-implante-1

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

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

26-implantes-2

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

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

25-preparo-implante-1

Intraoral device constructed in neurophysiological position with the implants installed.

jaw-tracker-2

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

27-orto-1

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

29-orto-3

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

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

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

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Alignment and recovery of the lower sector with resins.

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

jaw-tracker-3

Control of the neuromuscular trajectory in the rehabilitated patient.

eletro-apos-orto

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

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

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

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

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

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

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

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

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Comparative patient occlusions before and after neurophysiological treatment.

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

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

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

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

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

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

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Main Symptoms:

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

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

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

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

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

 

 

The importance of Mandibular Rest Position by Electronic Deprogramming in the Treatment of Temporomandibular Joint Pathologies, Orthodontic Diagnosis and Oral Rehabilitation. Case report.

1 frontal  Male patient 42 years old arrived to the clinic referring a strong complaint because of  the wear in his upper and  lower arch teeth, frequent breakage of teeth, intense bruxism, shoulder pain and pain in the cervical spine.2 perfil The patient reports an aesthetic problem in his appearance in relation to his frontal  and  profile semblance, and emphasizes that his teeth “are almost over.”3 DENTES In the image of the patient’s habitual occlusion we can observe the intense wear of the upper and lower teeth, especially the anterior sector.

The patient had consulted a colleague to replace an adhesive fixed prosthesis. This colleague,  Dr. Joao Souza  was then attending the TMJ  Pathologies Megarresidency program in our clinic in Porto Alegre.

Dr. Joao Souza while looking at the profile, occlusion and wear condition of the teeth, suggested a consultation in our clinic for an evaluation of both the TMJ and also  the non-surgical possibilities within the neurophysiological philosophy.

The patient had already a scheduled orthognathic surgery, but still considered interesting to make another assessment of his clinic case.4 OCLUSAL Analizing the occlusal view we can better see the high degree of wear and tear of the anterior upper and lower teeth.5 PANORAMICA INICIAL We can observe in the panoramic radiograph the absence of the dental elements 17, 15, 26, 28, 37, 36 and 45.

The elements 38 and 47 are endodontically  treated.6 LAMINOGRAFIA Patient’s TMJ laminography in habitual occlusion: we can observe the inferior and posterior positioning of the articular process on the left side, in the articular fossa, when the jaw is in maximal intercuspal position.

In the maximum opening position we can observe the flattening of the anterior surface of the right articular process. We can also observe the anterior angulation of the articular process, on the left side, with the flattening of its posterior and upper anterior surface.7 PERFIL E ROSTO Lateral radiograph in conjunction with the profile image of the patient before the treatment. This images highlight the aesthetic problem that afflicts the patient.8 FRONTAL INICIAL Patient’s frontal radiograph before treatment.9 C7 INICIAL Patient’s lateral radiograph and cervical spine before treatment.10 ELETROMIOGRAFIA INICIAL ANTES DO DEM Electromyographic record before electronic deprogramming in the first consultation: slightly elevated activity of the left masseter muscle  and both digastrics muscles at rest.

All these masticatory muscles lowered their values after the electronic deprogramming.11 ELETROMIOGRAFIA INICIAL APÓS DEM In this record we can see a decrease in the activity of masticatory muscles at rest after the electronic deprogramming.12 ELETROMIOGRAFIA INICIAIS COMPARATIVASComparative electromyographic records before and after electronic deprogramming of the patient first consultation.7 PERFIL E ROSTOAfter the mandibular electronic deprogramming, it was verified the pathological increase of the interocclusal free space. This information, along all the auxiliary diagnostic tests, allowed us to propose a non-surgical neurophysiological treatment for the patient.

First we needed to locate the jaw in balance with the muscles with a DIO (intraoral device) built in neurophysiological position.

Subsequently we needed to perform a three-dimensional orthodontics to maintain the neurophysiological position in conjunction with a neurophysiological rehabilitation while maintaining the muscle equilibrium  initially obtained. For this it is essential to measure and control the patient in each and all of these phases.

In this patient specific clinic case  the recovery of the free interocclusal space would provide very good aesthetic and functional result!

IT IS NOT IN ALL CASES that surgery can be avoided (EACH CASE IS A CASE) and even similar cases require a personalized assessment and a unique study.

The patient was informed of all treatment stages and analyzing all the alternatives the patient accepted our clinical proposal.

An MRI, (Magnetic Resonance Imaging) to analyze the disk and ligaments  condition of the TMJ, (temporomandibular joint) was requested. The MRI revealed that the discs and ligaments were in good health.

13 a It was used neural transcutaneous electrical stimulation (TENS) in the mandibular division of the trigeminal nerve (V) to relax the masticatory muscles and record the rest position of the jaw.

The patient had a pathological free space of 8 mm and a retrusion of 3.8 mm.

This three-dimensional mandibular rest position had been recorded in the form of an occlusal bite registration, which was later used to construct a DIO (intraoral device).13 Registration for the recalibration of the DIO (intraoral device) during the first phase of the neurophysiological treatment.14 ORTESE RECALIBRADA The DIO (intraoral device) is a removable mandibular device which in this case must be used during the day and night by the patient, including in the meals. This oral appliance is tested electromyographically and magnetographically to support this neurophysiological position.15 PERFIS COMPARATIVOSPatient profile images in habitual occlusion and in neurophysiological occlusion with the DIO (intraoral device) in mouth. 16 FRONTAL COMPARATIVOSPatient frontal images in habitual occlusion and in neurophysiological occlusion with the DIO (intraoral device) in mouth.19 PANORAMICA PREPARO PARA IMPLANTES 1Patient’s panoramic radiograph shows the orthodontic preparation for the installation of dental implants.19b PANORAMICA IMPLANTES 1Patient’s panoramic radiograph after the placement of first dental implants.20 ORTO 1After the placement of the dental implants I began the orthodontic movement for reconstruction of the anterior teeth with composite resin.21 REABILITAÇÃO E ORTO E IMPLANTESAfter the anterior movement of the anterior teeth the braces were temporarily removed to allow the reconstruction of the teeth with composite resin.

This rehabilitation was performed by Dr. Joao Souza following all the neurophysiological protocols.22 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTESAfter the reconstruction with composite resin of the anterior sector, the orthodontic appliance was reinstalled and a new DIO (intraoral device) was constructed in neurophysiological position.

The adhesive prosthesis of the lower right sector was removed and an implant was installed.15b RADIOGRAFIAS LATERAIS COMPARATIVASPatient’s comparative lateral radiographs in habitual occlusion before treatment and in neurophysiological occlusion during treatment.16 bRADIOGRAFIAS FRONTAL COMPARATIVASPatient’s comparative frontal radiographs in habitual occlusion before treatment and in neurophysiological occlusion during treatment.17 LAMINOGRAFIAS CONTROLEThe TMJ laminography in neurophysiological occlusion shows the inferior and anterior positioning of the articular processes in the articular fossa when the jaw is in maximal intercuspal position.18 LAMINOGRAFIAS COMPARATIVASTMJ comparative laminographies: before and during neurophysiological treatment.24 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 2 Sequence of the orthodontic treatment: preparation for the installation of the lower prosthetic implant.25 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 3 Installation of the provisional element in the lower implant and the brace placement on the same element.26 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 4 Sequence of orthodontic treatment for the active eruption of the posterior sectors.27 ORTESE NOVA REABILITAÇÃO E ORTO E IMPLANTES 5   Sequence of the orthodontic treatment for alignment and leveling of the lower anterior teeth for reconstruction with composite resin.28 ORTO 6 Sequence of the orthodontic treatment for alignment and leveling of the lower anterior teeth for reconstruction with composite resin.30  Finalization of all the phases of the neurophysiological treatment.30b Upper and lower occlusal view in the finalization of the neurophysiological treatment.31 COMP Comparative images of the patient’s occlusion before and after the neurophysiological treatment.31B Comparative images of the patient’s upper and lower occlusal views before and after the neurophysiological treatment.32 panoramicas comparativasComparative panoramic radiographs: before treatment and after the neurophysiological treatment, that included  the first phase, the three-dimensional orthodontics and the neurophysiological rehabilitation.

In the course of the treatment it was decided to install two posterior implants The lower due to an infectious process in the third molar, on the right, and the other implant, superior, on the same side, to better support the joint.33 laminografias comparativasPatient’s TMJ comparative laminographies: before, during and after neurophysiological treatment.34teles comparativasPatient’s lateral comparative radiographs: before, during and after neurophysiological treatment.35 frontais comparativos 22 Patient’s frontal comparative images: before, during and after neurophysiological treatment.36 perfis comparativos 2Patient’s profile comparative images: before, during and after neurophysiological treatment.37 posterThe importance of Mandibular Rest Position by Electronic Deprogramming in the Treatment of Temporomandibular Joint Pathologies, Orthodontic Diagnosis and Oral Rehabilitation. Case report.38 depoimento

I had already decided to have surgery for facial correction due to various problems such as wear of the teeth, bruxism, tingling, physical imbalance, pain and bad appearance.

In a consultation for a small dental procedure with Dr. Joao Souza, I was advised by him to get in contact with Dr. Lidia Yavich for a consultation in order to see if there was any chance, in my case, to avoid surgery and solve the problems I was having.

In the first consultation that I had with Dr. Lidia Yavich I was introduced to a facial and dental correction technique that gave me more security than surgery.

Dr. Lidia stated that THERE WERE CASES WHERE SURGERY WAS ABSOLUTELY NECESSARY, but that in my case there could be another alternative.

So, I started the treatment, and THAT really changed my daily life completely. Today I am very happy with the result achieved and the quality of life provided due to the disappearance of the above-reported symptoms.

I would like to place on record that in addition to the professionalism of the entire team of Clinica MY, especially Dr. Lidia, I had the privilege to make great friendships with special people, that will always be a part of my life. I also want to leave a special thanks to Dr.  Joao Souza, that with his recommendation made all this possible because he always strives for quality and the well-being of his patients.