TMJ Pathologies Treatment: Patient with Severe Headaches and Temporomandibular Joint Pain with Significant Contour Irregularities in the Mandibular Condyle and Mouth Opening Limitation.

In several publications of this page I have presented patients of different ages, different gender and different pathologies of the temporomandibular joints.

This is the second case report about a patient with prosthetic protocols built on implants.

I call once again the importance of  the attention in the diagnosis of temporomandibular joints pathologies and mandibular position as a key part of any procedure in dentistry.

1 FOTO INIC FRONTAL

Female patient 54 years old arrived to the clinic for consultation with severe headache complaints, pain in the temporomandibular joints, pain in the cervical spine, sore shoulders, ear pain, feeling of clogged ears and crepitation in both temporomandibular joints.

2 FOTO INICIAL PERFIL

The patient was referred by her dentist who performed the treatment of implants and prosthetics, rehabilitating the patient, but without being able to relieve the pain that afflicted her.

2A MARCAÇÃO DA DOR

Part of the questionnaire completed by the patient.

The patient reports daily pain.

FUNCTIONS THAT AGGRAVATE HER PAIN:

Mastication

Opening the mouth

Laughing

Yawning

The patient also refers back pain and numbness and tingling in the arms and fingers.

Refers that she wakes up with body aches.

3 DENTES INIC PROT FRONTAL

Patient habitual occlusion on the day of consultation.

The patient had fixed prostheses supported on implants on the lower jaw and a removable upper protocol supported on implants on the maxilla.

4 OCLUSAIS INICIAL PROTPatient’s superior and inferior oclusal view of the prostheses supported on implants on the day of consultation.

5 DENTE INICIAL SEM PROT

Image of the oral cavity of the patient without the upper prosthesis.

6 OCLUSAIS INIC SEM PROT

Patient’s superior and inferior oclusal view without the superior prostheses.

7 PANORAMICA INICIAL

Patient’s initial panoramic radiograph before treatment with the prosthesis in the habitual occlusion before treatment.

Presence of 4 metallic implants in the maxilla 2 on the right side and 2 on the left side; and 5 implants in the anterior mandible region.

8 LAMINOGRAFIA INCIAL

Patient’s TMJ right and left laminography, closed and open mouth: posterior positioning of the articular processes in the joint cavities when the jaw is in maximum intercuspation position.

9 TELE PERFIL INICIAL

Patient’s lateral radiograph with prosthesis in habitual occlusion.

10 C7 INICIAL

Patient’s lateral radiograph and cervical spine with prosthesis in habitual occlusion before treatment.

Alterations of the cervical spine, loss of physiological lordosis and loss of intervertebral spaces especially between the vertebrae C4, C5 and C6.cefalometria 2013 ingles

Ricketts cephalometric analysis before treatment with prostheses in habitual occlusion.

FACTORES CEF ANTESSS

Values of point A convexity and lower facial height before treatment.

11 FRONTAL INICIAL

Frontal radiograph of the patient with the prosthesis in habitual occlusion.

12 RNM DIREITA INICIAL

MRI, sagittal slice of the right TMJ closed mouth: there is an irregularity of contour with reduction of the superior aspect of the mandibular condyle, the condyle is ante versioned. There is a small anterior osteophyte.

The articular disc is displaced anteriorly, WITHOUT REDUCTION when the mouth opens.

Presence of subcortical bone cysts in the anterior superior aspect of the mandibular condyle.

13 RNM  ESQ  INICIAL

MRI, sagittal slice of the left TMJ closed mouth: there is a substantial irregularity of contour of the upper portion of the mandibular condyle, with the formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

13A RNM  ESQ  INICIAL

MRI, another sagittal slice of the left TMJ closed mouth: there is an important  irregularity of contour of the superior aspect of the mandibular condyle and a formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

16A  ESQ boca fechada 2013 T2

MRI in T2 clearly shows the joint effusion.

The differential diagnosis of TMJ effusion has a broad spectrum as the effusions in other joints in other parts of the skeleton.

MRI (magnetic resonance imaging) can give us a lot of information, not just the disc position.

14  RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

MRI, frontal section of the right and left TMJ, closed mouth. Upper lesion in the right mandibular condyle, as described in the same sagittal slice of the same condyle as subcortical bone cysts.

In the slice of the mandibular head on the left side can be seen an important hipossinal compatible with avascular necrosis.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. It can be caused by various conditions, such as bone or joint damage, pressure inside the bone and other medical conditions.

The condyle affected by avascular necrosis has low signal on T1-weighted images as a result of edematous changes in trabecular bone.

14 SERIE DE RESS DIR FECHADA 2013

Sagittal sections of the right TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

14 SERIE DE RESS DIR ABERTA 2013

MRI,sagittal sections of the right TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

15  SERIE DE RESS ESQ FECH 2013

MRI, sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

15 SERIE DE RESS ESQ ABERTA 2013

MRI,sagittal sections of the left TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

16 series ESQ boca fechada 2013 T2

MRI, T2 sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the image I find most relevant, but also this series are registered.

Serial in T2 clearly showing the joint effusion.

Tests were done on the patient to investigate systemic inflammatory disease, which were all negative.

It was also investigated chlamydia trachomatis infections, mycoplasma pneumoniae infections and beta hemolytic streptococcus infections , results in this case were also negative.

It was also investigated the functioning of the thyroid.

17 REGISTRO CINECIOGRAFICO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and 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 free space of the pathological patient is almost 7 mm and a retro position 0 8 mm.

18 DIO SOBRE A PROTESES

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

This device must be tested electromyographically to objectively measure the patient.

19 CONTROLE DA ORTESE

It is essential to control the DIO (intra oral device) as the patient is treated and the mandible is repositioned.

In this case the control still shows us the need for recalibration of the DIO (intraoral device)

19 PANORAMICA COMPARATIVA

Comparative panoramic radiographs: before treatment and after neurophysiological treatment.

20 FRONTAIS COMPARATIVAS

Patient’s frontal radiographs comparison: with the prosthesis in habitual occlusion and the DIO intraoral device built on the prosthesis.

20 LAMINOGRAFIA COMPARATIVAS

Right and left temporomandibular joints laminographies, closed and open mouth comparison: with the prosthesis in habitual occlusion and with the DIO intraoral device built on the prosthesis.

cefalometria 2014 CORTADA ingles

Ricketts cephalometric analysis after treatment with the DIO constructed on the prostheses in neurophysiological occlusion.

FACTORES CEF APOSSS

Values of point A convexity and lower facial height after treatment.

21 PERFIS COMPARATIVOS

Patient’s lateral radiographs comparison: with the prosthesis in habitual occlusion and with the DIO built on the prosthesis in neurophysiological position.

The DIO (intra oral device) is used to support, align and correct deformities in order to improve the functions of the jaw, temporomandibular joints and the muscles that move both. This device should be checked and recalibrated as the records indicate the need for modification.

21A PERFIS COMPARATIVOS

Comparison of aesthetic Ricketts plane in lateral radiograph with prosthesis in habitual occlusion and the DIO constructed on the prosthesis in neurophysiological position.

21 RNM COMPARATIVAS ESQ SAGITAL

Comparison of T1-weighted images: before treatment and after treatment: we can see the improvement in medullary signal.

26 comparativas ESQ boca fechada 2013 e 2014T2

Comparison of T2-weighted images: before and after treatment. It is clear in the first image the inflammatory signal and in the other image the improvement of the intramedullary signal and the remission of posterior effusion.

22 RNM Comparativas direita sagital

Comparison of T1-weighted images: before treatment and after treatment, we can see the improvement in medullary signal and improvement of the cortical bone.

23 RNM Comparativas direita FRONTAL

Frontal T1-weighted images comparison, before and after treatment treatment: we can see the improvement of the upper lesion on the right mandibular condyle.

24 RNM Comparativas ESQUERDA FRONTAL

Frontal T1-weighted images comparison, before and after treatment: we can see the improvement in medullary signal and improvement of the cortical bone of the left mandibular condyle.

25 SERIE DE RESS DIR ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the right TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

25 A SERIE DE RESS ESQ ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the left TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

COMPARATIVAS FRONTAIS POSTURAIS

Patient’s postural frontal comparative images before and after treatment.

COMPARATIVAS POSTURAIS PERFIL

Patient’s  postural profile comparative images  before and after treatment.

27 CEF COMPARATIVAS ingles

Ricketts cephalometric analysis before and after neurophysiological treatment.

COMPARAÇAO DOS FATORES

Skeletal problems in Ricketts cephalometric analysis before and after treatment.

28 DEPOIMENTO

“Headache (already when waking up in the morning), tiredness sensation at the cheekbones, strong tensing at the shoulders and neck, “clicks” at the temporomandibular joint, ear pain… consequently I also felt irritation, indisposition, stress etc.

All of that is something I had to live with for a long time. The investigations made on me always resulted in palliative measures that mitigated the problem for a short time.

I passed through implants and placement of prostheses which even without having (those measurements) the aim of healing this malaise I still had the hope that it would: but the relief only worked for a short period of time. Finally, by indication of my dentist, I arrived at Clinic MY starting then the TMJ treatment. Shortly after the start of the treatment the symptoms started to fade.

I am very thankful for the professionalism and dedication that I found there. Today, feeling better, I go back there for periodic evaluations and also to have the opportunity of thanking  once more.”

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.