Treatment of TMJ Pathologies: Patient with headache and excessive clenching. Physiological Neuromuscular Rehabilitation. First and second phase. Case Report.

1 frontal inicial rosto

A 32-year-old male patient presents at the clinic with complaints of constant headaches, pain in the jaw and daily pressure on the teeth.
The patient also reports pain in the temporomandibular joints and pain to open the mouth.

2 lateral inicial rosto

The patient also reports bilateral clicks and the sensation of clogged ears.
It also states in its clinical history difficulty in chewing and opening the mouth and inability to control teeth tightening.
The patient reported that he sought various dentists and treatments and that he had previously used “miorelaxant” splints that did not alleviate the referred symptoms.

3 OCLUSÃO 1

Habitual occlusion of the patient on the day of the consultation.
The patient had a deep bite and significant wear on the upper and lower incisors.

4 OCLUSAIS

Upper and lower occlusal views of the patient prior to treatment. Wear on lower and upper incisors.

5 PANORAMICA INICIALInitial panoramic radiograph of the patient before treatment.

Absence of teeth 18, 28, 38, 48.

Horizontal resorption of alveolar ridges.

6 P6 INICIAL

Patient TMJ laminography in habitual occlusion before treatment.

The laminography of the temporomandibular joint shows retroposition of the articular processes in the articular cavities when the mandible is in position of maximum intercuspation
In the mandibular aperture, the presence of osteophytes was observed in both condyles.Flattening of the superior anterior surface of the articular processes and superior posterior of the right articular process.

7 TELE PERFIL INICIAL

Lateral radiograph and patient profile in habitual occlusion before treatment. Rectification of the cervical spine.

8 C7 INICIAL

Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Rectification of the cervical spine.

9 FRONTAL INICIAL

Frontal radiography of the patient in habitual occlusion before treatment.

10 ress1

MRI: sagittal slices of the left closed TMJ before treatment. The mandibular head is in retro position. The joint disc is slightly dislocated.
The articular disc has a reduction in open-mouth maneuvers. Open mouth images not included in this post.

11 ress3

MRI: sagittal slices of the left closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

12 b ress

MRI: sagittal slices of the right closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

13 ress4

MRI: sagittal slices of the right closed TMJ before treatment. The mandibular head is in retro position. The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.
Open mouth images not included in this post.

13 cineciog 1

Patient’s initial cineciographic record
Three-dimensional view of the mandibular movement.
The record shows opening and closing and speed when making these moves. The patient shows an opening of more than 50 mm
Note a significant loss of speed in the mandibular closure.

13 eletromiografia inicial

Dynamic electromyographic record in patient’s habitual occlusion before treatment.

Note very little activation of the right and left masseter muscles in maximal intercuspation, indicating to the patient to bite hard without opening his mouth.

The masseter muscles are the most powerful muscles of the stomatognathic system, even more considering a  brachyfacial biotype patient as in this case.

13 REGISTRO

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 a pathological free space of 8,2 mm, already discounting the two physiological mm of a healthy free space.

The patient also presented a 2 mm mandibular retro position

13C PRIMEIRA ORTESE LUIS

With 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.

13A FRONTAL DIO

Frontal radiography of the patient with the DIO (intraoral device) constructed in a physiological neuromuscular position.

13B LATERAL COM DIO

Lateral and cervical radiograph of the patient with the DIO (intraoral device) constructed in a physiological neuromuscular position.

The second MRI is requested after one year on average of the first phase treatment, also during the second phase of the treatment, the patient is monitored, and the device recalibrated or changed according to the controlled data throughout this step.

14 ress comp 1

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc.

15 ress comp 2

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

16 ress comp 3

MRI: comparative sagittal sections of the left TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

17 ress comp DIR

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

18 ress comp DIR

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

19 ress comp DIR

MRI: comparative sagittal sections of the right TMJ, closed mouth, before and after the Neuromuscular Physiological treatment.
Three-dimensional joint decompression is noted. Primordial objective in this specific case.
Note the best relation between the mandibular head and the articular disc and the positive remodeling of the mandibular head.

20 PRIMEIRA ORTESE DA 2 FASE

The patient did not report any more symptomatology related to the TMJ. Bioinstrumentation also objectively showed an improvement in neuromuscular function.

We 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 orthodontics, where the teeth are erupted to the new neurophysiological position.

21 ORTO 1

In the second phase, in this case the three-dimensional orthodontics,the patient is monitored and deprogrammed electronically, and often the device is recalibrated or changed, to maintain the position obtained in the first phase.

Part of the sequence of the second phase (in this specific clinical case).

22 ORTO 2

Part of the sequence of the second phase (in this specific clinical case).

23 ORTO 3

Part of the sequence of the second phase (in this specific clinical case).

24 ORTO 4

Part of the sequence of the second phase (in this specific clinical case).

25 ORTO 5

Part of the sequence of the second phase (in this specific clinical case).

26 orto 6

Part of the sequence of the second phase (in this specific clinical case).

27 orto 7

Part of the sequence of the second phase (in this specific clinical case).

28 ORTO 8

Finalization of the second phase.

29 OCLUSAIS FINAIS

Patient’s upper and lower occlusal view after the finalization of the second phase.

43 oclusoes comparativas

Comparative occlusion of the patient before and after the end of the second phase of the treatment using a three-dimensional orthodontics.

The non-coincidence of the median dental lines may be noted.
The patient’s fundamental alignment is muscle alignment that does not always coincide with tooth alignment. In this case the muscular alignment is respected.

44 oclusoes comparativas

Patient’s comparative superior and inferior occlusal view, before and after, the end of the second phase of the treatment by a three-dimensional orthodontics.

eletromiografia final

Electromyographic record of the patient in physiological neuromuscular position after the completion of three-dimensional orthodontics.

Note the higher recruitment of motor units in the masseter muscles that previously showed little activity.

30 FRONTAL FINAL

Frontal radiography of the patient after the end of the second phase of the treatment.
Patient in physiological neuromuscular occlusion.

31 TELEPERFIL FINAL

Lateral radiograph and patient profile after completion of the second phase of treatment.
Patient in physiological neuromuscular occlusion.

32 C7 FINAL

Lateral and cervical radiography of the patient after the end of the second phase of the treatment.
Patient in physiological neuromuscular occlusion.

33 PANORAMICA FINAL

Panoramic radiograph of the patient after the end of the second phase of the treatment with three-dimensional orthodontics.

34 LAMINOGRAFIA FINAL

Patient TMJ laminography after the completion of three-dimensional orthodontics.
Patient in physiological neuromuscular occlusion.

35 comparativas panoramicas

Comparative panoramic radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

36 comparativas laminografias

Patient comparative TMJ laminography: before treatment and after completion with three-dimensional orthodontics.

40 COMPARAÇÃO TELE PERFIL

Comparative lateral and profile radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

Take into account that the result corresponds more to a three-dimensional recovery of the vertical dimension and not simply to an anteroposterior modification.
Even a retroposition of the mandibular head is the product of a three-dimensional alteration.

41 COMPARAÇÃO FRONTAIS

Comparative frontal radiographs of the patient: before treatment and after finishing with three-dimensional orthodontics.

42 C7 COMPARATIVAS

Comparative patient lateral and cervical radiographs: before treatment and after completion with three-dimensional orthodontics.

46 DEPOIMENTO 1

At the end of 2012, I attended the Life and Health program on RBS TV and saw a report with Dr. Luis Daniel Yavich Mattos, on the treatment of problems related to TMJ.

Living with constant headaches, jaw pain and daily pressure on the teeth,

I decided to bet on the treatment and I do not regret it.

Since I was 18 years old, I had been suffering from pain in the TMJ region, and what

bothered me was a pressure that made me want to grind my teeth even

day, which I have always identified as bruxism.

I had already sought out various dentists and treatments, with the use of the famous splints to sleep. The diagnosis was always the same: emotional stress was the cause of my teeth and constant pains, although the pains started only after I have extracted my first wisdom.

47 DEPOIMENTO 2

I used to use the plates to sleep during the 24 hours of the day, so the will of biting and grinding teeth. The use of the splints  prevented wear, but the pressure I felt to bite and grind my teeth caused me TMJ fatigue and headaches.

And when I had no more hope emerged, the possibility of doing the treatment with Dr. Luis Daniel and Dr. Lidia Yavich, when I was 32 years old.

With Dr. Luis Daniel they were approximately 1 year and 2 months  using a very high plate, 24 hours a day, including to make meals, which I only took to do the oral hygiene.

The device was called the “big monster,” because of the height. In the end, no longer  pain and without the will of grinding and biting my teeth.

I went on to the second stage of treatment, now with Dr. Lidia Yavich.

48 DEPOIMENTO 3

With Dr. Lidia were approximately 3 years, in which I used fixed dental appliance, with brackets, steel wires, etc., in order to be able to stop using the board 24 hours a day, and improve the aesthetics of my dental arch.

As the treatment progressed, the device was diminished and new splints were used in order of erupting my teeth respecting the TMJ position.

At the end of the treatment, I now use one sleeping device and another one for aesthetic reasons.

I no longer have the willingness to bite and grind teeth, or pain in the TMJ or headaches. I can yawn without worrying about hurting my jaw.

Finally, it was an individualized, artisanal treatment that required time and dedication, and brought excellent results, which is why I am eternally grateful to Dr. Luis Daniel and to Dr. Lidia.

 

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.

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

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

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

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

It is vital the early detection of this deficiency.

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

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

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

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

1

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

1A

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

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

2

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

3

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

4

Patient’s initial panoramic radiograph

5

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

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

6

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

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

7

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

8

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

Retrognathic profile and rectification of the cervical spine.

9 res fechada

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

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

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

10 res aberta

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

We can observe anterior facets on both mandibular heads.

Both mandibular condyles cannot translate, reducing mouth opening.

12 cineciog 1

Initial kinesiographic record: loss of speed when the patient opens and closes his mouth. There is no coincidence between the opening and closing trajectories in the sagittal view of the record. Limited mouth opening as the patient can open only 32.9 mm.

11 ELET INICIAL

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

Anterior right and left temporalis

Right and left masseter

Right and left digastrics

Right and left superior trapezius

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

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

13

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

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

15 AUDIOMETRIA INICIAL

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

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

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

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

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

17

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

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

The degree of compression determinates de reaction of the patient.

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

18

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

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

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

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

19

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

20 AUDIOMETRIA 2

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

21 AUDIOMETRIA 1 e  2

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

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

23

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

24

Structural and functional changes.

25

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but  OTHERS CANNOT.

25A

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but OTHERS CANNOT.

26

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

27 AUDIOMETRIA 3

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

28 AUDIOMETRIA 1 e  2 e 3

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

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

29 SERIES DE ORTO 1

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

30 SERIES DE ORTO 2

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

30 A PERFIL E RAD LATERAL ORTO

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

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

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

31 SERIES DE ORTO 3

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

32  SERIES DE ORTO4

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

33 RETIRADA DO DIO

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

34 SERIES DE ORTO4

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

OCLUSAIS FINAIS

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

35 AUDIOMETRIA 4

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

SERIES DE ORTO

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

panoramicas comparativas

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

CEF COMPARATIVOS

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

37 CINESIO comparativoS

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

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

37 eletro comparativo

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

39 jaw trackwe  comparativoa

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

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

40 todas as audiometrias

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

FINALE FINALE

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

It is vital the early detection of this deficiency.

42 DEPOIMENTO 1

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

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

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

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

42 DEPOIMENTO

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

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

 

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.

 

I often observe the debate on etiology and therapeutics, especially in TMJ dysfunction discussions groups, which are integrated by patients and professionals. These groups are active not only in Brazil but in several countries and communities from around the world.

I hope this space will add, strengthen or clarify those discussions.

The professional who treats patients with TMJ pathology has to take into account, at the moment of studying the clinical case, the patient’s particularities and the anatomical structures that are involved and provoking pain and affliction to our patient.

Even if the professional is scrupulous, evolutions can be different from patient to patient. That is why the professional has to investigate carefully which are the structures that can improve or even heal and which are the ones that cannot improve or still which ones we do not know if can be improved in the process of treatment.

Recognizing what we do not know is perhaps more important than recognizing  what we do know: and the communication of this understanding to the patient is essential.

When we start a treatment we must be certain of the structures we can meliorate, or even prevent of getting worse  and we also must know which structures  we DO NOT HAVE THE CONDITION TO MELIORATE and we certainly must communicate that to the patient. Within this framework, the most important thing is to investigate if  we can improve the quality of life of the patient.

1 FOTO FRONTAL

Female patient with 45 years old arrives to the clinic for consultation suffering from headache every day, also suffering from neck pain and pain in the back of the neck, pain in both temporomandibular joints and severe pain on the shoulders.

Pain is more intense on the left side.

2 FOTO PERFIL - Copia

The patient reports a sensation of plugged ears and hearing decrease which was confirmed by an audiometry that refers normal hearing at  4KHZ and a severe sensorineural hearing loss at 6 KHZ and moderate at 8 KHz in the right ear.

The left ear has normal hearing thresholds.

The patient presents a buzzing in the left ear, and peculiar noises.

3 DENTES INICIAIS - Copia

Patient’s habitual occlusion in the consultation day. Note patient’s overbite.

The patient reports that she wakes up with pain in the teeth, because of clenching.

4 OCLUSAIS INICIAIS - Copia

Patient’s upper and lower oclusal view before treatment. Note the wear of the lower anterior teeth. The patient states that have made maxillary anterior teeth reconstruction with resin due to attrition caused by bruxism.

5 PANORAMICA INICIAL - Copia

Patient’s panoramic radiograph before treatment. Absence of teeth 18,28,48.

Tooth 38 in a horizontal position, impacted

Reabsorption of the alveolar ridges.

6 LAMINOGRAFIA INICIAL - Copia

Radiographic image of the right and left temporomandibular joints in closed and open mouth. Flattening of the anterior superior and posterior superior surface of the left articular process.

7 TELEPERFIL

Patient’s lateral radiograph in habitual occlusion before treatment. Rectification of the cervical spine.

8 FRONTAL

Patient’s frontal radiograph in habitual occlusion before treatment.

9 C7

Patient’s lateral radiograph and cervical spine in habitual occlusion before treatment. Rectification of the cervical spine.

10 abre e fecha inicial

Patient’s computerized kinesiographic record before treatment. Patient without mouth opening restriction. Decreased closing speed, typical graph of an incisal guide that interferes with the closing trajectory.

11 RNM INICIAL DIREITA FECH

Sagittal slices of the right closed TMJ. The mandible heads presents irregularities and cortical and subcortical sclerosis. Degenerative process.

The right articular disc shows small size, change in signal intensity and degenerative morphostructural aspect. It is anteriorly displaced.

11B RNM INICIAL aberta dir

Sagittal slices of the right open TMJ. The articular disc shows small size, is anteriorly displaced WITHOUT REDUCTION WHEN THE MOUTH OPENS.

12 RNM INICIAL DIR FECH

Another sagittal internal slice of the right closed TMJ showing cortical bone irregularities. Degenerative aspect.

The articular disc shows small size, change in signal intensity and degenerative morphostructural aspect. It is anteriorly displaced, WITHOUT REDUCTION WHEN THE MOUTH OPENS.

12B RNM INICIAL aberta dir

Another sagittal slice of the right open TMJ. The articular disc shows small size, is anteriorly displaced WITHOUT REDUCTION WHEN THE MOUTH OPENS.

13 RNM INICIAL esquerda FEC

Sagittal slices of the left closed TMJ. Mild contours irregularity with rectification of the superior aspect of the mandibular condyle. The articular disc presents reduced dimensions.Alteration in orientation of the mandibular condilar axis because of traumatism in infancy. The disc is anteriorly displaced, WITH REDUCTION WHEN THE MOUTH OPENS.

14B RNM INICIAL esquerda aberta

Sagittal slice of the left open TMJ. THE DISC REDUCES WHEN THE MOUTH OPENS.

15 frontais iniciais

Frontal slice of the right and left temporomandibular joints, closed mouth. Note the cortical discontinuity on the right side already registered in the sagittal sections of the same side. The left side shows a medial disc deviation.

16 REGISTRO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and a DIO (intraoral device) was constructed in neurophysiological position. In other publications computerized kinesiographic methods were mentioned.

In occlusion most often the healthy or pathological condition of the inter-oclusal space is not objectively considered. In this case the pathological free space of the patient is almost 7, 4 mm

16A ortese inicial so frontal

With this data and ALWAYS WITH THE INFORMATION OF THE IMAGES OBTAINED WITH THE MRI, we built a DIO (intraoral device) to keep the three-dimensionally recorded position.

One year after the beginning of neurophysiological treatment, the patient had to interrupt the treatment to undergo a spine surgery.

The patient returned 10 months after the interval, recovered from the intervention. The patient was  then again documented to assess any changes that might have happened during the interruption and the spine surgery.

17 FOTO frontal reinicio de tratamento 1

Patient’s postural comparative frontal images: before treatment and restarting therapeutic after the spine surgery.

18 FOTO PERFIL reinicio de tratamento 2

Patient’s postural profil comparative images: before treatment and restarting therapeutic after the spine surgery.

19 ORTESE REINICIO DE TRATAMENTO

The masticatory muscles of the patient were AGAIN electronically deprogrammed and NEW DIO (intraoral device) was built in neurophysiological position.

20 PANORAMICA COM ORTESE

Patient’s panoramic radiograph with the DIO (intraoral device) built in neurophysiological position.

21 LAMINOGRAFIA COM ORTESE

Patient’s right and left temporomandibular joints laminography  in closed and open mouth  with the DIO built in neurophysiological position.

22 TELEPERFIL COM ORTESE

Patient’s lateral radiograph with the DIO built in neurophysiological position.

23 C7 COM ORTESE

Patient’s lateral and cervical spine radiograph with the DIO built in neurophysiological position.

PATIENT’S ANALYSIS AT THIS STAGE OF THE TREATMENT.

Patient with degenerative processes not only in the temporomandibular  joints but also in the cervical spine and lumbar spine which led her to surgery.

Inability to recapture of the right TMJ disk. Whereby this was an objective that was not taken into account.

Remission of symptoms and improvement of  life quality.

Physiological mandibular posture, recovery of free space interocclusal through the DIO (Intraoral device).

In this particular case even WITHOUT DISC RECAPTURE (CONDITION THAT WAS EXPLAINED IN THE DIAGNOSIS)  the patient can pass into the second phase, always taking into account that we should protect the joint during the night and during physical activity.

Each case is unique and the decision to move to a second phase also needs an individualized study.

It was decided to begin the SECOND PHASE of treatment to remove the DIO (intraoral device), keeping the neurophysiological occlusion.

26 orto 1

For this we used a three-dimensional orthodontics, where the teeth are erupted in order to reach the new neurophysiological position.

27 orto 2

In the second phase, in this case the three-dimensional orthodontic the patient is monitored and electronically deprogrammed. The device is often  recalibrated or replaced, to maintain the position obtained in the first phase.

28 orto 3

In the second phase, in this case the three-dimensional orthodontic the patient is monitored and electronically deprogrammed. The device is often recalibrated or replaced, to maintain the position obtained in the first phase.

In this sequence the patient is still with the DIO (intraoral device)  in the mouth.

29 retirada da ortese

Removal of the DIO (intra oral device)

30 orto final

Completion of the second phase of the neurophysiological treatment in this case with a three-dimensional orthodontics. 

The second phase is here understood as the three- dimensional orthodontics, restorative, prosthetic procedures in accordance with each clinical case in order to remove the DIO, while maintaining the neurophysiological position obtained in the first phase.

31 oclusais finais

Patient’s upper and lower oclusal views after completion of the three-dimensional orthodontics.

32 LAMINOGRAFIA final

Patient’s right and left temporomandibular joints laminography in closed and open mouth  in neurophysiological position after finalization of the treatment.

33 panoramica  final

Patient’s panoramic radiograph in neurophysiological occlusion in the completion of treatment. The tooth 38 that was in a horizontal and impacted position was extracted since the patient had no more symptoms of joint pain.

34 TELEPERFIL final

Patient’s lateral radiograph in neurophysiological occlusion in the completion of the second phase of neurophysiological treatment.

NOVA RESSONANCIAS FINAIS

Temporomandibular joints MRI after de finalization of the second phase.

We must remember that this is a patient with degenerative processes and impossibility of recapture of the right TMJ disc, the left disk is so damaged that it does not fulfill its function.

The patient no longer has symptoms.

The final MRI shows no worsening of the situation and in the frontal slice it shows a better three-dimensional location of the mandibular condyle and cortical improvement.

36 B radiog laterais comparativas menor

Patient’s lateral comparative radiographs: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

35 registro COMPARATIVOS

Comparative records of mandibular rest position at the beginning of the treatment to build the DIO (intraoral device), and at the end of the second phase of the treatment (tridimensional orthodontics) to build a DIO (intraoral device) for night use.

Notice that in the beginning of the treatment the patient had a pathological interocclusal space of 7.4mm, and in the record at the end of the second phase for the nocturne DIO the patient has 3.3mm of free interocclusal space.

We have to take into account that  the free interocclusal space IS A THREE-DIMENSIONAL SPACE, AND WHEN WE HAVE STRUCTURAL DIFFERENCES IN THE JOINTS, THE SPACE IS NOT EQUAL ON THE RIGHT AND THE LEFT SIDE.

35 iimagens comparativas de perfil

Patient’s  comparative profil postural images: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery and treatment interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

36 iimagens comparativas frontais

Patient’s frontal comparative postural images: at the beginning of treatment in habitual occlusion, during treatment after the spine surgery and treatment interruption with the DIO (intraoral device) in neurophysiological occlusion and after completion of the three-dimensional orthodontics in neurophysiological occlusion.

37 DEPOIMENTO

I had made several appointments with specialists, such as otorhinolaryngologist, dentists and maxilo-facial surgeons. However, all of them were without success and that is when I looked for Dr. Lidia to whom I reported the following symptoms.

I used to wake up every day with a lot of pain on the left side, both in the head and neck and I used to feel a rigidity on the neck and shoulder. In that time I used to take painkillers every single day in the morning. I also used to suffer of a serious problem of bruxism and because of that I wore out my front teeth, both the upper and lower teeth, and I had to restore them. I used to feel a lot of pain from the tremendous pressure that I used to make between the lower and upper part of my mouth. Another symptom was the high sensitivity on the teeth when I drank cold liquids. I felt as my ears were always blocked in such a way that my hearing decreased. I also used to hear a noise, especially on the left side, which sounded like a continuous whistle.

38 DEPOIMENTO

I also told the doctor that when I was a child I was hit with a brick, in the middle of a child’s play.

After reporting all that she asked me to make many exams and many of them were made in the MY Clinic and finally she told me that I had a problem in the TMJ. I started a treatment with her in 2011. I started to use an acrylic splint on my lower teeth day and night, all the time, taking it of only for its hygiene.

The pain that I used to feel so much decreased and in short time I did not feel it any more. Doctor Lidia had to adjust the orthotic monthly, making exams in her clinic until it reached the optimal height. On the next year from when I started the treatment I had to interrupt it for 8 or 10 months because I had to make a column surgery but I returned to the treatment as soon as I was well enough. I kept on treatment for one more year and after that I started the second part of the treatment with braces.

39 DEPOIMENTO

At the time that the treatment ended I did not need to use any more braces nor the full time orthotic. Today I need to use the orthotic only when I do physical activities and to sleep. I never again felt the horrible pain that I used to feel. I also never felt again the sensation of having blocked ears and happily the noise reduced. Today I am very happy that I do not have to take daily painkillers and that I do not have any pain. I am very grateful to doctor Lidia because she discovered and solved my problem.

evento setembro2

For the interested coleagues in this training: the course starts at the September 1st.
Please write to the email for more informations:  lidiayavich@gmail   ou  lidiayavich@clinicamy.com.br
+55 5130612237    +55 5133322124       This course will be given in Portuguese

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

 

 

TMJ Study and Investigation Page. One year of publication

Dear friends,

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

Nowadays, the medicine based on evidence is hierarchically stratified from top to bottom where in the base of the pyramid we find the clinic cases, which are rarely seen as evidence. The TMJ Study and Investigation Page had, in its conception, the purpose of posting the clinic cases, which were carefully published with the documentation related to each of the patients treated at Clínica MY with pain complaints, dysfunction and TMJ pathology.

INITIAL

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

site em portugues nova ingles

The TMJ Study and Investigation Page is completing, in this month of December, one year since it started, and I want to celebrate its anniversary with you. With this project, we have a place in the Internet that presents a line of work known as neurophysiologic dentistry, which takes into account the whole body system. It is an area that also operates regarding the posture and the mandibular functioning. In order to do that, the physiologic dentistry aims to establish, in the patient, a position that is based on a harmonious relation between the muscles, the teeth, and the temporolandibular joints.

site em ingles novaIn the publication of the end of this year I have chosen the most significant images of the whole year of publications, with their direct links to each one of the originals publications.

31

Joint Decompression in a Neurophysiological Mandibular Rest Position Promotes a Positive Remodeling in a Degenerative Process of a Teenager Temporomandibular Joint

english 1-1

Anatomy is the platform on which physiology functions

Sem Título-1

Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy.

26

Articular discs recapture with mandibular neurophysiological repositioning

26

Cervical Dystonia or Spasmodic Torticollis: Positive evolution after Neurophysiological Treatment

2

Recapture of articular disc displacement with reduction. Recapture or not recapture that is the question.

17 COLUNA E PERFIL COMP

Inter relation of Craniomandibular disorders and vertebral spine. Case report

24

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

FINAL

Neurophysiological Combined Orthodontics and Rehabilitation: patient with degenerative conditions in several body joints

FINAL

TMJ Pathologies Treatment: first and second phase (tridimensional orthodontics) in a hypermobile joint patient with low signal in the head of the mandible bone marrow. Case report.

33

Articular Disc Recapture: patient with significant mandibular heads asymmetry and unilateral reducible luxation. Case report

Sem Título-1

Osteonecrosis of the Mandibular Head: recovery of condylar bone marrow alteration

6 BASAL ANTES E APOS O DEM

TMJ ( temporomandibular joint) Pathologies: Patient with severe pain in the region of the face, neck and temporomandibular joint. First and second phase.

18 comparativas

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

15 3D comparativas

Mandible Condyle Fracture Consolidation by Neurophysiological Alignment of the Segments, Four Months after Unsuccessful Surgery. Case report

37 poster

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

41 RNM AFTER TREATMENT cor

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

evento 4

Training in Diagnosis and Treatment of TMJ Pathologies

31

The Postural Position of the Mandible and its Complexity in the Maxillomandibular Tridimensional Relation: first and second phase in a patient with severe symptoms with subtle information on the images.

e images.

26B LATERAIS COMPARATIVAS LINHA

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

I want to thank my family that is always at my side in each one of the projects, I also want to thank my friends, that from Brazil and from many places of the world, supported and support this project. Last, but not least, I want to thank my colleagues and patients that often write, encouraging and thanking the existence of this virtual place.

By closing, in this moment, the annual analysis and the perspective for the year that follows, I therefore thank the readers of all places in the world that follow the TMJ Study and Investigation Page. It is a privilege to count with your visits.

With the best votes for 2016, and wishing for a year of peace, health, love and happiness for all.

Dr. Lidia Yavich

 

The Postural Position of the Mandible and its Complexity in the Maxillomandibular Tridimensional Relation: first and second phase in a patient with severe symptoms with subtle information on the images.

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.

Only recently, dentistry began to think about the jaw and its association with the skull as a three-dimensional relationship, instead of considering it an isolated structure and evaluated in two dimensions as has been done traditionally.

To properly evaluate the maxillomandibular relationship we should start considering the physiological rest position.

Physiological rest is a concept, applicable to the rest of the body muscles

The stomathognatic muscles and not the exception

1 FRONTAL Male patient arrived to the clinic for consultation referring a strong pain behind the eyes, nonspecific facial pain, popping in the right temporomandibular joint and crackling on the same side.2 FRONTAL The patient reports tingling and numbness in the cervical spine, tingling sensation in his right shoulder. He also reports pain and stiffness in the back of the neck, shoulder pain and muscular tremor.

The patient had completed an orthodontic treatment and after the removal of the orthodontic device he began to feel the reported symptoms .3 PERFIL Due to the strong symptoms the patient consulted several professionals: clinical dentist, physiotherapist, general practitioner and a orthopedist for the  shoulder pain.

The orthodontist who treated him referred the patient to me, to see if I could help him.

4 MARCAÇÃO DA DOR

Section of the clinical record where the patient marks the pain points

 

Marking the pain points: headache, back of the neck stiffness, pain in the top of the head and in the forehead. Pain behind the eyes and in the back of the neck, popps, nonspecific facial pain, crepitus, dizziness and muscle tremor.

5 DENTESPatient’s habitual occlusion before treatment.

6 OCLUSALPatient’s occlusal superior and inferior view before treatment.

7 PANORAMICA INICIALPatient’s initial panoramic radiograph before treatment.

8 LAMINOGRAFIA INICIALPatient’s TMJ right and left laminography, closed and open mouth before treatment.

9 TELEPERFILPatient’s lateral radiograph before treatment.

10 FRONTALPatient’s frontal radiograph before treatment.

11 C7Patient’s lateral radiograph and cervical spine before treatment.

12 ELETROMIOGRAFIA INICIAL

Patient’s electromyography record in habitual occlusion before treatment.

In this dynamic record we registered the anterior right and left temporal muscles, the right and left masseter muscles, the right and left digastric muscles and the right and left upper trapezius muscles.

For this record we ask to the patient to open the mouth, close the mouth, clench strong and swallow.

Notice the asymmetry between the right masseter muscle and the left masseter muscle at maximal intercuspal sustained position. The digastric muscles during swallowing are activated before the masseter muscles which should not happen in a functional swallowing.

13 F CINECIO INICIAL

Patient’s initial kinesiographic record shows a significant loss of speed when the patient opens and closes the mouth. There is no coincidence between the neuromuscular trajectories in the sagittal view of the record.

The patient has hypermobile joints and has no limitation in opening the mouth.

13 A RES. ESQ 1 INICIAL MRI: sagittal slice left TMJ closed mouth. This image does not show significant alterations.

13 B RES. ESQ 2 INICIAL MRI: sagittal slice left TMJ closed mouth, this more medial slice shows the compression and the retroposition of the mandibular condyle. We can observe a facet on the top of the mandibular head.

REMEMBER THAT we are looking at a two-dimensional image and we have to understand that the COMPRESSION IS TRIDIMENSIONAL.

13 C RES. DIR 1 INICIAL  MRI: sagittal slice right TMJ closed mouth, this medial slice shows the compression and the retroposition of the mandibular condyle. We can observe a facet on the top of the mandibular head.

REMEMBER THAT we are looking at a two-dimensional image and we have to understand that the COMPRESSION IS TRIDIMENSIONAL.

13 D RES. DIR 2 INICIAL MRI: sagittal slice right TMJ closed mouth, in this medial slice is even more evident the compression and the retroposition of the mandibular condyle. We can observe a facet on the top of the mandibular head.

REMEMBER THAT we are looking at a two-dimensional image and we have to understand that the COMPRESSION IS TRIDIMENSIONAL.

13 E RESFRONTAIS INICIAIS

MRI: frontal slice from the right and left TMJ, closed mouth in habitual occlusion before treatment.

The right TMJ frontal slice makes clear a loss of joint space especially on the lateral pole.region  In both frontal images we can notice the reduction of the joint space.

13G REGISTRO NEUROFISIOLOGICOTo 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 and not the exception

The masticatory muscles of the patient were deprogrammed electronically and a new neurophysiological rest position was recorded.

14 ORTESE INICIAL With this data we constructed a DIO (intraoral device), to keep the three-dimensionally recorded position. This device must be tested electromyographically to objectively measure the patient.

Of course checking the patient’s symptoms is important, but the surface electromyography objectively shows if the muscular function improved, worst or did not change.

15 ELETROMIOGRAFIA COM O DIO Patient’s electromyographic record with the DIO (intraoral device), in neurophysiological position.

Note the symmetry of the masseter muscles. The digastric muscles DON’T ACTIVATE before the masseter muscles during swallowing. This implies that the patient closes the teeth and swallows and not the contrary as the first record in habitual occlusion.

16 CINCECIO COM DIO Patient’s kinesiographic record with the DIO (intraoral device): there has been an improvement in speed and COINCIDENCE in the trajectories when he opens and closes the mouth.17 FRONTAIS COMPARATIVAS Patient’s frontal radiographs comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

18 LAMINOGRAFIAS COMPARATIVAS Patient’s TMJ right and left closed and open mouth laminography comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

19 TELERADIOGRAFIAS COMPARATIVASPatient’s lateral radiographs comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

In the middle of the treatment I referred the patient to a physical terapist for a postural reprogramming.

With the jaw in a neurophysiological position the physiotherapist colleague worked on the rest of the muscular chains. The patient also presented an incipient discopathy at the level of C3 and C6.

20 PANORAMICAS COMPARATIVASPatient’s panoramic radiograph comparison: before treatment and during the neurophysiological treatment.20 A cinesiografias COMPARATIVAS Kinesiographic records comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

Note the improvement of the speed and the COINCIDENCE in the opening and closing trajectories.

20 A ELETROMIOGRAFIAS COMPARATIVAS Electromyography records comparison: in habitual occlusion before treatment and with the DIO (intraoral device), in neurophysiological position.

Note the symmetry of the masseter muscles, the digastric muscles DON’T ACTIVATE before the masseter muscles during swallowing. This implies that the patient closes the teeth and swallows and not the contrary as the first record in habitual occlusion before treatment.

21 ORTO The patient did not complained from pain and the other symptoms he had in the beginning of the treatment.The electromyography and kinesiographic records objectively showed the muscular function improvement.

We decided to start the SECOND PHASE of the treatment.

For this we used a three-dimensional orthodontics, where the teeth are erupted towards the new neurophysiological position. This procedure  will allow us, following the technical steps to remove the DIO.

22 ORTO 2  In the  second phase, in this case the three-dimentional orthodontics  the patient is monitored and electronically deprogrammed and many times the device is recalibrate to maintain the position obtained in the first phase.

23 ORTO Sequence of the second phase (in this specific clinical case).

24 ORTO Sequence of the second phase (in this specific clinical case).

25 ORTO Sequence of the second phase (in this specific clinical case).

26 ORTO Sequence of the second phase (in this specific clinical case).

27 ORTO Sequence of the second phase (in this specific clinical case).

28 ORTO2 Sequence of the second phase (in this specific clinical case).

29 ORTO

Second phase completed!

39 panoramica finalPatient’s panoramic radiograph after the finalization of the three-dimensional orthodontics.

30 ress comparativa frontal dir 1 MRI: Comparison of the frontal section of the RIGHT TMJ closed mouth  before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint, especially in the lateral pole.

30 ress comparativa frontal dir 1 flecha

MRI: Comparison of the frontal section of the RIGHT TMJ closed mouth  before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint, especially in the lateral pole. Note the arrows.

31 ress comparativa frontal esq 1 MRI: Comparison of the frontal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.31 ress comparativa frontal esq flecha 1MRI: Comparison of the frontal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint. Note the arrows.32 ressonancia comparativa 1 MRI: Comparison of the sagittal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.33 ressonancia comparativa 2

MRI: Comparison of the sagittal section of the LEFT TMJ closed mouth, before neurophysiological treatment, and the same  LEFT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.

34 ressonancia comparativadir 1 int

MRI: Comparison of the sagittal section of the RIGHT  TMJ closed mouth, before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.

Improvement in the relationship between the mandibular condyle and the articular disk.

35 ressonancia comparativadir 2int MRI: Comparison of the sagittal section of the RIGHT TMJ closed mouth, before neurophysiological treatment, and the same  RIGHT TMJ closed mouth  after the COMPLETION OF THE SECOND PHASE with the three-dimensional orthodontics.

Note the decompression of the temporomandibular joint.

Improvement in the relationship between the mandibular condyle and the articular disk.36 eletromiografia final Patient’s electromyography record in neurophysiological occlusion AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.

Note the symmetry of the masseter muscles.

The digastric muscles DO NOT ACTIVATE before the masseter muscles during swallowing. This implies that the patient closes the teeth and swallows and not the contrary as the first record in habitual occlusion before treatment..

This means that the objectives achieved in the FIRST PHASE with the DIO in neurophysiological position were held after the finalization of the THREE DIMENSIONAL ORTHODONTICS.

37 eletromiografia comparativas Patient’s electromyography records comparison:

Before the treatment in habitual occlusion.

With the DIO (intraoral device), in neurophysiological position, during the FIRST PHASE of the treatment.

 AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.38 laterais comparativas

Patient’s lateral radiograph comparison:

Before the treatment in habitual occlusion.

With the DIO (intraoral device), in neurophysiological position, during the FIRST PHASE of the treatment.

 AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.

38 laterais comparativas 1

 Maxillomandibular values comparison: 

Before the treatment in habitual occlusion.

With the DIO (intraoral device), in neurophysiological position, during the FIRST PHASE of the treatment.

 AFTER THE FINALIZATION OF THE THREE DIMENSIONAL ORTHODONTICS.

41 OCLUSAO FINALIn a recent revision after two years of completion of the SECOND PHASE with the three dimensional, I registered the habitual patient’s occlusion.

The patient continues free of symptoms.

In the postural mandible position and its complex three-dimensional relationship with the maxilla little details are essentials, especially in a hypermobile joint patient.

It is not a case of deep bite, not a case where simply moving the incisive guide anteriorly could solve the problem.

In the  images the three-dimensional compression in this patient looks SUBTLE, but no less devastating.

Each case is different and every human being is a unique individual.

patient testimony

 In the first evaluation, Dr. Lidia was very helpful explaining to me all the method of the treatment and what was necessary to achieve the expected results.

 Along the way, I had neither more headaches nor joint pain, I was pain free.

Everyone in the team was very devoted to my treatment, and I had in the end an excellent result.

Today I am very grateful to Dr. Lidia and her team for all the attention.

Big huge to everyone from clinica my.

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

Female patient, 40 years old comes to consultation referred by her rheumatologist WITH STRONG PAIN IN the TMJ (temporomandibular joint), TWINGES IN THE HEAD AND MOUTH OPENING LIMITATION.

The patient had a diagnosis of seronegative spondyloarthropathy until then nonspecific.Later diagnosed as Ankylosing Spondylitis

Seronegative spondyloarthropathies refers to a group of diseases that share common characteristics, including the occurrence of inflammation in the spine, peripheral joints and in various peri-articular tissues, in particular entheses.

Seronegative spondyloarthropathies laboratory outstanding feature is the absence of rheumatoid factor and auto antibodies. They have strong association with human leukocyte antigen HLA-B27.

1  The patient reports clicking on the right TMJ, difficulty to open the mouth, difficulty and paint in chewing. She also reports bruxism.2She reports feeling headache, neck pain, pain in the right eyebrow, pain behind the eyes, pain in the right shoulder. She also reports pain in both temporomandibular joints which is stronger  in the right joint.

Points where the patient reports pain

The patient marks on the record the most important points of pain.3  In the first consultation, during the anamnesis the patient reported that she had initiated a treatment for the bruxism problem, and that at one point with the device change she  began to feel a very strong pain and her mouth locked.

4The occlusal view shows the superior anterior sector wear and the anterior lower sector wear.5Patient’s panoramic radiograph.6The joints radiographic image shows the superior and posterior positioning of the articular process on the left side in the joint cavity when the jaw is in maximal intercuspal position.

In the maximum opening position, there is flattening of the posterior and anterior surface of the left mandibular condyle process and a flattening of the superior and anterior surface of the right mandibular condyle process. The right side also presents an alteration of the growth axis of the mandibular condyle.

6BPatient’s lateral and profile radiograph before treatment.7Patient’s lateral radiograph and cervical spine before treatment.7BPatient’s frontal radiograph in habitual occlusion before treatment.8 abre e fecha inicOpening and closing computerized kinesiographic record, the patient can open only 32 mm feeling strong pain, which shows an important limitation.

The patient also has a deflection of 2.7 mm to the right.8 B COMP abre e fecha inic Note in the skull graph, the left condyle moves more than the right condyle where the deviation is.

9The surface electromyography exam evaluates the superior anterior temporal right and left, the right and left masseter, the right and left digastrics and the right and left upper trapezius.

In this electromyography record the patient could not generate a good activity when we asked to bite hard (keeping the teeth in maximum intercuspation) and clench.

At the beginning of the record when we asked the patient to open the mouth it is important to note the different activity between right and left digastrics.

The left digastric activates double than the right digastric.

9

Image enlargement showing the difference in translation of the mandibular condyles. Patient in maximum mouth opening.

It is important to be able to understand and connect all the information, the surface electromyography and the computerized kinesiograph. These data still does NOT PROVIDE A DIAGNOSIS, However they are tools to help us in the diagnosis.

I asked the patient for an MRI-(magnetic resonance imaging) of the temporomandibular joints.

When the patient filled out the clinical record for the MRI she reported that she did a tattoo a month before, that prevented the realization of the MRI until completing the time of three months after the realization of the tattoo.

Remember that the resonator is a large magnet and tattoos have pigments which may contain metal and could heat up and cause burns.

We kept the patient with a temporary splint until we had the MRI information, as explained in previous posts; WE MUST NOT TREAT A PATIENT WITHOUT  A DEFINED DIAGNOSIS.

We could easily assume that as the patient had a systemic nonspecific inflammatory arthritis attacking various joints of her body also the TMJ could be involved.

It is fundamental to rethink something which SOMETIMES could be ONLY A CONJECTURE, even if the patient is a carrier of an inflammatory autoimmune disease.

In the systemic part it is the rheumatologist who will decide the therapy.

Our part is to promote a non-compressive position of the TMJ where the masticatory muscles may perform without loading the joint, and where the patient can fulfill all the functions of the stomatognathic system.

9APatient’s inflamed elbow after synovectomy with the disease still not controlled

9A  MRI: sagittal sections selected. Left TMJ closed mouth: articular disc anteriorly displaced. Change in the growth axis of the mandibular condyle.

Left TMJ open mouth: limitation in mouth opening.

The images here are in T1, all images analyzed including T2 and STIR DOES NOT SHOW inflammatory signs.

It is relevant to remember that in the first consultation, during the anamnesis the patient reported that she had initiated a treatment for the bruxism problem, and that at one point with the device change she began to feel a very strong pain and the mouth locked.

The patient remembers that the device change aimed to align the median line of the upper incisors to the median line of the lower incisors.

This has to be a warning to all of us in dentistry which were taught to carry out all our treatments without knowing the condition of the TMJ.  

9B  MRI: sagittal sections selected. Right TMJ closed mouth: articular disc anteriorly displaced. Change in the growth axis of the mandibular condyle.

Right TMJ open mouth: limitation in mouth opening.

After conducting the analysis of the MRI images, studying all the slices and all required parameters (not included in the post), we can proceed to carry out a neurophysiologic record.
10The masticatory muscles of the patient were electronically deprogrammed and the rest position was recorded with a computerized kinesiograph.

This record has been difficult to achieve. The patient was limited and in great pain. A very low DIO was made, leaving an interocclusal free space of one mm which would normally be too little.

11DIO (intraoral device constructed in neurophysiologic position)11A  Patient’s frontal image on the same day, before and after installing the intraoral device in neurophysiologic position.

11B  Patient’s lateral image on the same Day, before and after installing the intraoral device in neurophysiologic position.

11cPatient’s electromyography record in neurophysiologic occlusion wearing the device (DIO), even the muscles activation is low the difference with the initial record is remarkable.11DComparative EMG records: the upper in habitual occlusion and lower in neurophysiological occlusion with the DIO (intraoral device).12 abre e fecha com DIO  Patient’s kinesiographic record with the DIO (intraoral device) constructed in neurophysiological position.Improvement in mouth opening. 13 recalibração  DIO recalibration to improve the patient’s neurophysiological position. The condition of the patient now allows best records because the significant decrease in pain.14Control of the intraoral device, habitual and neuromuscular trajectory are coincident.15 REGISTROS DE AB COMPARATIVOSPatient’s comparative kinesiographic records before and during treatment. Improvement of the patient mandibular opening.16 abre e fecha inicNote on the skull graphic, both condyles right and left move symmetrically.16 A abre e fecha inicImage enlargement showing both condyles right and left moving symmetrically. Patient in maximum mouth opening.17 comparativosPatient’s kinesiographic records comparison with the skull 3D model before and after treatment.

17B comparativosSkull models in 3 D, graphic animation from patient’s kinesiographic record before and after treatment comparison. Patient in maximum mouth opening.

17A 2008MRI: Right TMJ, closed and open mouth before and after treatment. Articular disc in habitual position,(the disc was dislocated before treatment) Resolution of the opening limitation.

17B 2008MRI: Leftt TMJ, closed and open mouth before and after treatment. Articular disc in habitual position. Resolution of the opening limitation.

18 comparativasMRI: TMJ sagittal comparative images, open and closed mouth before and after treatment.

19 bThe patient without pain, decided to continue with the DIO and not perform the phase 2 to eliminate de DIO, with a tridimensional orthodontics. She decided only to restore the teeth that were worn. Restorations made by Dr. Luis Daniel Yavich Mattos.

20

When I was 39 years old I was diagnosed by my rheumatologist with arthritis.

All major joints of my left side were suddenly and without warning, very swollen, such as knee and elbow, preventing me from performing my simplier movements such as standing and stretching my arm.

I had swelling, redness and intense pain. Then I started to feel pain in the TMJ. I ended up in the clinic of an orthodontist and facial orthopedist  who told me that I had ‘bruxism’ and that I needed to use a device to place the tongue in the right position.

I wore the appliance for a month or two, my TMJ locked, I could not open my mouth and I felt an absurd pain in my entire head, I no longer knew what hurted more, if it were the joints of the body or my head and mouth.

My rheumatologist, apprehensive that I could have arthritis also in the TMJ immediately referred me to Dr. Lidia Yavich, who received me in the office and managed to relieve my pain completely .

I HAVE TO STRESS THAT, THERE WAS NO MEDICATION THAT COULD CEASE THE PAIN that I felt in the TMJ and in the cervical spine, NOTHING!

After the imaging studies performed by indication of Dr. Lidia, we came to the conclusion that I was not suffering from arthritis in both TMJ, but from a dislocation  of my right condyle  after using for a short time a mistaken device to place my bite and tongue in the ” RIGHT POSITION”

That treatment did not considered important assumptions as the asymmetry of my condyles, or their position, or the disc status in relation to the condyles, causing much suffering.

It took me a long time to understand what was happening to me in my TMJ; I suffered from absurd pain in the head in the middle of a very difficult treatment for arthritis. I was disfigured, terrified and unsure after using the first device with the previous professional because he did not know how to end the pain and even seemed, not to know what was actually happening with me.

I had panic to imagine that I had arthritis in my TMJ, but only after the MRI and the Dr. Lidia interpretation it was possible to exclude the possibility of rheumatic disease in the TMJ in that moment, and from then on to make an efficient treatment.

In a few weeks Dr. Lidia not only took out ALL THE PAIN of the TMJ, but also led me to a treatment that repositioned my disc and  stopped the pain, even being a carrier of a severe autoimmune disease.

I have been using the DIO for seven years without any pain, I have full understanding of the meaning of bruxism in my case and correct approach to the problem, including the options that I could have for a more permanent solution instead the use of the DIO.

I am very grateful to my rheumatologist  today for indicating me a treatment that saved me, because I certainly would have gone crazy with those TMJ pains.

I am very grateful to Dr. Lidia who took me from the rock bottom in which I found myself, ignorant from all  that was happening in a joint so unknown from most of us:.the TMJ.

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

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In the former publications of this study page some of the neurophysiological fundaments of the TMJ pathologies treatment were presented, the importance of the differential diagnosis and also the utilization of bioinstrumentation like surface electromyography and jaw tracker were also introduced.

Patients images relating their symptomatology were also shown, some of the diverse etiological factors as traumatisms in infancy, especially green stick fracture, intra articular discs recapture in reducible dislocations, interrelation between Craniomandibular disorders and vertebral spine, as well as a case of cervical dystonia and its relation with TMJ that can also be read in this page. From December 2014 there were seven publications.

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When we talk about TMJ pathologies treatment we need to understand that there are different approaches. The proposal of a Palliative treatment is the Symptomatic treatment, which tries to block the symptoms. For that means, it uses analgesics administration, anti- inflammatory drugs and muscle relaxants.

The restorative approach is the treatment that aims, when possible to correct or to heal what is damaged. Recognition of what is wrong (differential diagnosis) must precede the question of how to fix it. To know what is wrong, it is necessary a differential diagnosis. This diagnosis must always be elaborated before we reach a treatment proposal.

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When our proposal is a restorative treatment, we have a FIRST PHASE where the objective is to heal the joint when it is possible. Sometimes we can only improve the joint condition or to avoid its deterioration.

To know what we can treat and what we cannot deal with, and the limitations of every individual case.

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When we finished the first phase, we compare if the control images of the case corresponds with the goals we intended to achieve in our initial diagnosis. We know that there are cases that can meliorate, others that we can avoid its aggravation, and still others that we can only can relieve the pain. If the case has positive results of the first phase we can initiate a second phase of the treatment in order to remove the device that is used in a permanent way during the first phase of the treatment.

For this we can perform a tridimensional orthodontics, a neurophysiological rehabilitation or the combination of both.

Always remember of keeping the mandibular localization in equilibrium with the muscular planes, temporomandibular joint and dental planes.

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I will relate what happened at the current week with a teenager patient that had finished the first phase, in a case of  neurophysiologic decompression of the temporomandibular joint and where she was still wearing the DIO (intraoral device)

The patient had remission of her symptomatology (ear pain irradiated from the TMJ since childhood), and now she was preparing herself  to initiate the second phase with a tridimensional orthodontics. I wasn´t satisfied with her breathing so again I asked for an evaluation to meliorate her breathing and consequently her tongue position.

The professional that made this evaluation affirmed that the patient presented an open bite and that she needed to consult a buco maxillary surgeon to “close her bite” by surgery.

The anguish that was provoked on the patient and that consequently also affected me, resulted in my indignation on her conclusive opinion referring the patient to a surgical consultation without firs entering first in contact with the professional responsible for the treatment (me in this case)

In any way I demand complicity of any professional, since I consider ethics beyond everything. As much as respect for the patient.

This event encouraged me to publish a case on tridimentional orthodontics in the second phase of TMJ pathologies

Before the SECOND PHASE, let´s begin with the FIRST PHASE.

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Female patient, 17 years old consults in the clinic complaining of headache, ear pain, shoulder pain and bilateral clicks.

In the clinical inspection she had strong ache when retrodiscal palpation was performed.

The patient showed an “ideal occlusion” and in the clinical tests she did not exhibits any kind of interferences neither in protrusion nor in lateral translation.

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Patient’s initial laminography in habitual occlusion before treatment

Patient’s initial laminography in habitual occlusion,  retro position of the mandibular heads, especially on the left side provoking an important retrodiscal compression.

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Patient’s MRI in habitual occlusion, both anterior reducible disc luxation, retro- position of the mandible heads and modification of the growth axis provoked by a traumatism in infancy (Structural modification of the mandibular condylar process as one of the sequels of traumatism in infancy). The luxation is reducible (MRI in open mouth not included in this post)

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Patient’s initial electromyography record (4 channels) in habitual occlusion

In this record we measure both right and left anterior temporalis, and right and left masseters. Notice that the masseters that are the most potent muscles of the masticatory system cannot generate activity.

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A static image doesn’t speak of muscular harmony, doesn’t show if there is coordination between the systems and does not show if the patient has local or distant pain.

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Patient’s masticatory muscles were electronically deprogrammed. A bite was registered in a neurophysiological position with a jaw tracker.

The patient presents a pathological free way space of 6,2 mm and a retro mandibular position of 2,5 mm.

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With this data we construct an intraoral device (DIO) tested electromiographically to support the neurophysiological occlusion.

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Patient’s comparative laminographies

Patient’s initial laminography in habitual occlusion, retro position of the mandibular heads, especially on the left side provoking an important retrodiscal compression. The new laminography with the intraoral device in neurophysiological position shows the tridimensional decompression of the retrodiscal zone.

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Comparison of the two electromyography records the first in habitual occlusion and the second with the intraoral device in neurophysiologic position. The masseters present excellent activity with the DIO, compare the first initial record where these muscles couldn’t activate.

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Comparison of one of the slices of the MRI. Left closed TMJ before the treatment in habitual occlusion and in a neurophysiological occlusion with the DIO.

Disc in physiological position and tridimensional decompression of the mandibular head.

Correlation with the electromyography records in habitual occlusion and in neurophysiological occlusion with the DIO.

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Comparison of one of the slices of the MRI. Right closed TMJ before the treatment in habitual occlusion and in a neurophysiological occlusion with the DIO.

Disc in physiological position and tridimensional decompression of the mandibular head.

Correlation with the electromyography records in habitual occlusion and in neurophysiological occlusion with the DIO.

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Lateral radiograph of the patient for the initiation of the tridimensional orthodontics treatment. The patient is with the DIO (intraoral device constructed in neurophysiological position)

Patient’s masticatory muscles were electronically deprogrammed for the bite registration and the construction of the intraoral device.

Not all case can pass to a second phase, orthodontics, prosthodontics or rehabilitation.

There are patients with active autoimmune disease, where is not possible to eliminate de intraoral device, because these patient’s  anatomical structures ( temporomandibular joints, cervical spine…) are affected by the disease, what makes this structures unstable pillars, because of the active inflammatory process.

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Neuromuscular diagnosis in orthodontics: effects of TENS on maxillo-mandibular relationship.

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Atlas of Maxillary Orthopedics: diagnosis Thomas Irmtrud and Jonas Rakosi. Electronic rest mandibular registration in three spatial planes.

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Starting the 2 phase of the treatment in this case with a tridimensional orthodontics. The device will be removed keeping the muscular planes in equilibrium with the osseous and dental plans.  INITIATING THE ACTIVE ERUPTION.

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Image with and WITHOUT the intraoral device. The space between arches IS THE SPACE THAT WE NEED TO RESTORE (this space is filled with the DIO). The DIO operated as a tridimensional boot sole. IN THE SECOND PHASE THE ACTIVE ERUPTION OF THE TEETH will fulfill the objective

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Continuing the treatment in the tridimensional orthodontics. Image with and without the device. Posterior sector already erupted.

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Molar and pre-molar sector already erupted. Alignment of the lower incisors and finalization of the tridimensional orthodontics in the second phase of TMJ Pathologies.

The ultimate goal in an orthodontic treatment is to treat all three components of the stomatognathic system and create an environment for synergistic function of the teeth, temporomandibular joints and neuromuscular system.

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A tridimensional orthodontic needs to maintain the tridimensional position of the mandible in balance with its osseous and muscular planes obtained in the first phase, and whenever possible it needs to keep the temporomandibular joint in an harmonic relation with the mandibular fossa as well with the articular disc in correct position.

gRUMMONS

The patient’s clinical history, clinical inspection, technology, bioinstrumentation and images, helped us to improve TMJ pathologies diagnosis and treatment.

When we arrive to a SECOND PHASE, many professionals and patients don´t know that the active eruption has been used from MANY, MANY years ago. Dr. Duane Grummons book edited in 1994 is only one of the several examples. Logically a TRIDIMENSIONAL ORTHODONTICS in the patient with TMJ Pathology needs a differential diagnosis and a restorative treatment in the FIRST PHASE.

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If we don´t understand that teeth are the ending point of a joint…

If we don´t understand that this joint can be affected by systemic

and local pathologies…

If we don´t understand that it is the muscles that move the mandible

and propitiate the rest position…

If we don´t understand that structural differences determine tridimentional adaptations…

We may not understand treatments failure, in the cases where the patients present TMJ pathologies.

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