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.