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

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

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

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

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

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

The patient also reports bruxism and nighttime clenching.

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

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

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

Summary report written by the patient

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

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

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

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

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

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

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

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

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

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

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

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

7 PANORAMICA INICIALInitial panoramic radiograph of the patient before treatment.

8 LAMINOGRAFIA INCIAL

TMJ laminography in habitual occlusion and in open mouth.

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

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

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

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

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

12 eletromiog dinamica inicial

Dynamic electromyographic record of the patient in habitual occlusion.

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

13 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

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

14 cortes sagitais da ATM ESQUERDA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

15 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

16 cortes sagitais da ATM DIREITA FECHADA ANTES DO TRAT

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

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

Important retrodiscal compression.

17 RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

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

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

20 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

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

21 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – left  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22 TOMOGRAFIA

Tomographic examination of temporo-mandibular joints.

Multiplanar reconstruction – right  TMJ in habitual occlusion before treatment.

Important posteriorisation of the mandible head.

22a REGISTRO CINECIOGRAFICO INICIAL

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

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

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

The stomatognathic musculature is no exception.

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

The patient has a pathological free space of 7.7 mm.

The patient also had a 0.6 mm mandibular retroposition.

23 oclusao DIO

Occlusion of the patient with the DIO (intraoral device)

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

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

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

24 COMPARATIVAS FRONTAIS POSTURAIS

Comparative frontal postural images.

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

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

25 eletromiog dinamica com DIO

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

26 CONTROLE DA ORTESE

28 RNM Comparativas esquerda 1 sagital

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

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

29 RNM Comparativas esquerda 2 sagital

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

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

30 RNM Comparativas esquerda 2 sagital

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

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

31 RNM Comparativas esquerda 2 sagital

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

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

32 RNM Comparativas direia 2 sagital

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

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

33 RNM Comparativas direia 2 sagital

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

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

34 RNM Comparativas direia 2 sagital

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

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

35 RNM Comparativas direia 2 sagital

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

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

36 RNM Comparativas esquerda frontal

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

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

37 RNM Comparativas direita frontal

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

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

38 panoramicas comparativas

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

39 laminografias comparativas

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

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

40 frontais comparativas

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

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

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

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

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

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

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

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

47 DEPOIMENTO 3

Patient’s statement:

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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