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.

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

The work that is been presented in this publication won the third place in the clinical table presentation in the congress of the IAO (International Association for Orthodontics) April 2012, entitled – TMJ Pathologies in Children and Teenagers, the Overlooked Diagnosis.

At the same congress I presented a more extensive conference on the mentioned subject.

I presented this paper at a congress that bring together orthodontists and orthopedists from around the world. The intention was to make them aware about TMJ pathologies in children and teenagers even in cases apparently simples that we can see in our clinics, where the TMJ can be compromised.The evaluation of the TMJ and the diagnosis of its pathologies should be an inseparable part of our procedures, not only in orthodontics and orthopedics but in all areas of dentistry.

I had presented in this page several cases with the first and second phases completed.

In this publication I WILL PRESENT ONLY THE FIRS PHASEas it was presented in the clinical table and in the lecture.

Nowadays the patient is already in an advanced stage of the second phase.

THE IMPORTANT SUBJECT  IN THIS PUBLICATION IS THE STRUCTURAL IMPROVEMENTS ACHIEVED IN THIS FIRST PHASE.

1 Female patient, 14 years of age comes to consultation with complaints of pain in the lower teeth, shoulder pain and TMJ clicking on the left side.

Aesthetic correction is an important issue  for the patient, but she and her mother were also  concerned with the  pain in the lower teeth and the noise generated by the click. 

2 dentes The occlusion of the patient suggests a case without major difficulty, a simple case.

In this case could be very easy to evaluate and diagnose the need for superior expansion for the accommodation and advancement of the mandible, and afterwards the vertical deficiency.3 oclusais Often when we analyze a case for orthodontic correction, we can list the possible etiological factors that led the patient to this situation.

When evaluating a functional failure we must take into account ALL THE ETIOLOGIC FACTORS INVOLVED IN THIS DYSFUNCTION.4 panoramica Patient’s initial panoramic radiograph before treatment.5 lateral cervical Patient’s initial lateral and cervical spine radiograph before treatment.

Besides the rectification of the cervical spine we can notice the start of an inversion of the physiological curvature from C4.6 frontalPatient’s initial frontal radiograph before treatment.7 cefalometria Cephalometry is a very important part in the diagnosis and correction of clinical cases, both in orthodontics as in orthopedics, BUT it is not an exam to show pathology of temporomandibular joints.8 laminografiaThe laminography of the temporomandibular joints in closed and open mouth is considered as the panoramic radiograph for the temporomandibular joints.

It cannot be compared to a CT scan of the temporomandibular joints, but it is a basic examination for the first information on TMJ.8 laminografia corIn this same image with color highlight, we can appreciate the retroposition of the left TMJ, the change in the growth axis of this same side and the loss of joint space on both sides.

The patient reports a traumatism when she was child “I hit the neck, near to the chin, playing on the bedside table”.9 ampliação laminografiaLaminography image magnification with highlight color, closed mouth, right and left side.10 ampliação laminografiaThis image magnification from the temporomandibular joints in closed mouth; right and left sides, DOES NOT SHOW THE ARTICULAR DISC CONDITION NOR THE LIGAMENTS.12 ressonancia When the patient comes for consultation with some sort of dysfunction, the professional treatment should be directed to the restoration of normal function, when possible.

To know what normal function is, we must understand that ANATOMY IS THE PLATFORM WHERE PHYSIOLOGY PERFORMS.

13 ressonancia It is necessary to know the functional anatomy of any part of our body to understand the physiopathology of any part of our body.

14 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

MRI: patient’s left TMJ closed mouth before treatment:

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

15 ressonancia

MRI: patient’s left TMJ closed mouth before treatment;

Other slice of the same MRI:

MRI: patient’s left TMJ closed mouth before treatment:

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

16 ressonancia

MRI: patient’s left TMJ closed mouth before treatment:

Other slice of the same MRI:

MRI: patient’s left TMJ closed mouth before treatment:

Mild irregularity of the bone cortical.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

17 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

MRI: patient’s right TMJ closed mouth before treatment.

Superior flattening, anterior marginal osteofhyte.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

20 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

Other slice of the same MRI:

MRI: patient’s right TMJ closed mouth before treatment.

Superior flattening, anterior marginal osteofhyte.

Anterior dislocation of the articular disc.

REMEMBER: THIS IS THE TMJ of a 14-year-old teenager.

She had no crepitation NOR PAIN IN the TMJ, only a click.

I have often read different views of colleagues expressing that the image information knowledge would not change anything, since it would not alter the procedures to be followed in the treatment.

21

When the patient comes to our clinic with some sort of dysfunction the treatment should be directed to the restoration of normal function.

How could this professional succeed if he  doesn not understand what is a normal function.

Remember ANATOMY IS THE PLATFORM WHERE PHYSIOLOGY PERFORMS.

When a patient like this, presents damage in the cortical bone and also in the articular disc and its ligaments, the question should be: CAN I IMPROVE THIS SITUATION?

If the answer is positive, it is important to document it in an objective way, in order to inform the colleagues that are always eager to learn and are not afraid to change paradigms. IF WE CAN NOT IMPROVE THIS SITUATION because of the sequels of different etiologies, we need to analise if we can improve our patient’s life quality and we also must inform the patient about the difficulties and limitations of each case.

22 Remember that systemic diseases, traumatism, infections, damage to the site of growth, muscle balance disruption, can have a profound influence on the craniofacial complex during this critical growth phase.23 eletromiografia inicial Initial dynamic electromyography record in habitual occlusion. We ask to the patient to open the mouth, clench strong and swallow. In this record we can observe that the patient cannot maintain the strength in clenching, even that she was instructed to close the mouth and not to open before we ask her to do that.24 registro magnetografico Her masticatory muscles where electronically deprogrammed and a bite record  in neurophysiological position was registered using a jaw tracker.

Remember that the information obtained from the images and that the  individualized objectives for each clinical case should always be taken into account in the bite registration.

The patient had a pathological free space of 4.3 mm and a retro position of 2.1 mm

This record is three-dimensional.

25 DIOWith this data we can construct a DIO (intraoral device). This device must be tested electromiographically to represent the ideal position of the muscles.26 eletromiografia DIO Dynamic electromyography record with the intraoral device in neurophysiological position. In this record we can see that the patient can maintain the strength of the bite, and that she increased the strenght of the masseters  and balanced  both digastric.27 ELETROS COMPARATIVAS Comparison of the SEMG records of the patient, the first in habitual occlusion and the second with the intraoral device in neurophysiological position.28 perfil comparativas Standing posture (orthostatic position) right side, sagittal plane:

Trunk antepulsion position improved;

Improvement of the shoulder anterior rotation;

It seems that the shoulder blades are flat, more neutral;

In the first photograph, in habitual occlusion, it can be observed a rectification of  the physiological curvature in the cervical spine. On the second photograph we can see an improvement of the physiological curvature.

The head position is more balanced, closer to the proper alignment of the center of gravity where the neck flexors seem to be less contracted.

30 c7 comparativasPatient’s lateral and cervical spine comparison: in habitual occlusion and in neurophysiological occlusion.

Improvement  of the cervical spine physiological curve.

Increase of the  intervertebral spaces.31 comparativas do perfil Patient’s lateral radiographs with the profile comparison: in habitual occlusion and in neurophysiological occlusion.

Recovery of the lower facial height.32 lamino comparativas TMJ laminographies comparison: in habitual occlusion and in neurophysiological occlusion. Observe the decompression of the  temporomandibular joints.33 lamino comparativas COR In the same image with color highlight, we can better observe the decompression of the temporomandibular joints and compare it with the laminography in habitual occlusion.34 lamino comparativas COR AMPLIADAS Comparative images of TMJ laminographies magnification: in habitual occlusion and neurophysiological occlusion. Right and left TMJ, closed mouth.35 lamino comparativas COR AMPLIADAS PROVISORIASLaminography image magnification with highlight color, closed mouth. Right  and left TMJ in neurophysiological position.

This image, EVEN THAT IT IS SHOWING THE JOINT DECOMPRESSION, DOES NOT PROVE THE ARTICULAR DISC RECAPTURE, NOR PROVES THE IMPROVEMENT OF THE IRREGULARITIES ON THE CORTICAL BONE OBSERVED IN THE INITIAL PATIENT’S MRI.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

14 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

36 RNM AFTER TREATMENT

Comparative MRI images, left TMJ closed mouth, after the first phase of the treatment

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

15 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

39 RNM AFTER TREATMENT 2

Comparative MRI images, left TMJ closed mouth, after the first phase of the treatment.

Comparative MRI images after the first phase of the treatment

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

16 ressonancia

MRI: patient’s left TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

40 RNM AFTER TREATMENT

Comparative MRI images, left TMJ closed mouth, after the first phase of the treatment.

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

17 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

42 RNM AFTER TREATMENT

Comparative MRI images, right TMJ closed mouth, after the first phase of the treatment.

Comparative MRI images after the first phase of the treatment.Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

LET’S REMEMBER THE IMAGES OF THE INITIAL MRI

20 ressonancia

MRI: patient’s right TMJ closed mouth before treatment.

Comparative MRI images after the first phase of the treatment.

44 RNM AFTER TREATMENT

Comparative MRI images, right TMJ closed mouth, after the first phase of the treatment.

Observe the good relation between the mandible head and the articular disc.

Observe the positive remodeling of the cortical bone.

Nowadays the patient is already in an advanced stage of the second phase.

In this image we have a third MRI that was not presented at the IAO Congress.

The structures continue to improve.

46 3 RIGHT TMJ

Right TMJ closed mouth sagittal slices comparison: initial, after the first phase of treatment and in the control of the second phase still not completed.

 In this image we have a third MRI that was not presented at the IAO Congress.

47 LEFT TMJ

Left TMJ closed mouth sagittal slices comparison: initial, after the first phase of treatment and in the control of the second phase still not completed.

The structures continue to improve.

The evaluation of the TMJ and the diagnosis of its pathologies should be an inseparable part of our procedures, not only in orthodontics and orthopedics but in all areas of dentistry.

We need to know:

Has the TMJ  a pathologic condition?

If positive, which structures are damaged?

How this condition can influence the joint  function and  the future of the patien’s joint?

Do I have the possibilty to give to the patient the condition to heal the damaged structures or to improve them?

The target is to bring this structures the closer we can to a healthy function, when possible.

Is this always possible? OF COURSE NOT, but when  it is possible, the structures must be repaired.

Logically, differential diagnosis allow us a prognosis: favorable or not. favorable.

NOT ALL THE ARTHROPATHIES WILL HAVE THE RESULT WE HAD IN THIS CASE, BUT PROGNOSIS IS ALSO A PIECE IN THE INITIAL DIAGNOSIS that must include all the systems involved.

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.

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

1

Female patient 31 years old comes to consultation reporting severe headache, severe pain in the temporal, especially on the left side, pain on the left ear and pressure on the left eye.

She also states strong neck pain, dizziness, and reports that she feels a burning sensation on the cheek and also pain.

2

She also reports allergic rhinitis and sinusitis, for which she had already made several treatments. But the rhinitis or the sinusitis where never acompannied by the pain she was reporting. This was something new.

She reports having bruxism.

3 OCLUSAO INICIAL

The patient states that she used removable and also fixed orthodontics appliances from her 15 years old until her 18 years old.

She refers to a traumatism in the anterior sector in which the incisor fractured the incisal edge when she was a child.(see publication Structural Modifications of the Mandibular Condylar Process as one of the sequels of traumatism in infancy)4 OCLUSAIS

We can see the wear on the upper and lower incisors.

Regarding the beginning of the pain, the patient reported that she frequently felt fatigue in her facial muscles; she was a teacher and talked a lot during the classes.

But then she felt just fatigue, she never had the pain she was feeling now.

The episode that the patient reported as triggering the pain was when she broke a tooth when she was chewing.4 retrato

Patient testimony

When I broke my tooth while chewing, I went to an emergency clinic where they made a curative and headed me for a root canal.

When the root canal was finished, I left the dental office with A LOT OF PAIN.

But it was not toothache; it was a lot of pain in the face, especially in the masseter muscle.

 Days after  I started to feel an hallucinating pain in the neck, pain in the left ear and headache;

At the time I was derived to a professional who did occlusal adjustments and installed a splint.

I threw away the splint, since I complained that the device did not ease the pain but increased the pain I was feeling.

From that moment I started to consult a lot of professionals.

When she ended the latter sentence, the patient looked into my eyes and while crying she asked: Dr, do you believe in the things I´m telling you?

I said YES, and I answered, I BELIEVE IN YOUR REPORT.

The patient increased her crying and told me that many of the professionals she visited said that she had nothing and the pain was a thing of her head. Just stress!

4A PANORAMICA INICIAL

The panoramic radiograph of the patient shows the root canals endodontically treated (maxillary first molar on the left, 26). This is the tooth that the patient reported having fractured and treated)

We can see that the third molar on the left (48) is angled and impacted on the distal of the second lower molar on the right.

4B LAMINOGRAFIA INICIAL

In the temporomandibular joint laminography of the patient, we can see an anterior angulation of the articular processes. We can also observe a flattening of the upper and posterior surface of both articular processes; it is more significant on the right side.

4C RADIOGRAFIA LATERAL INICIAL

Patient’s lateral radiograph before treatment4D LARGO DE PERNASAt a certain moment a scanning of the lower limbs was asked to the patient, as a difference in length of the lower limbs was suspected. It revealed to be just a muscle shortening, since structurally her lower limbs presented the same measure.5 abre e fecha 1

Computerized kinesiology analyzes the graphic movements that the jaw performs in the three directions of space. The patient has an opening of 30 mm which is already considered a limitation.

The patient does not have good speed in opening and  closing the mouth. This can be an indicator of muscle disorders, intra-articular injuries or discrepancies between the teeth and the muscles.

6 BASAL ANTES E APOS O DEM

In this basal electromyography the masticatory muscles are in hyperactivity, after electronic deprogramming the muscles down their values.

An electromyography with a lower value, after the electronic relaxation, for a particular muscle, is more important than the absolute value before being pulsed.

7 MORDE FORTE ABRE ENGOLE

In this dynamic electromyography, the patient clench hard twice, opens her mouth, closes her mouth and swallows. Masseter muscles, which are the most potent muscles of the stomatognathic system generate very little activity in maximum occlusion.

The anterior temporalis are recruiting more motor units than the masseters, which is not physiological in a system that works in a balanced manner.

8 HABITUAL E ROLOS

In this dynamic electromyography (A) the patient bites into habitual maximum intercuspation, (B) the patient bites with cotton rolls on the right and the  left between her occlusal surfaces, the activity improves considerably.

Every modification of the joint position leads to muscle length change, and consequently it change its strength.The muscles that are shortened or lengthened by approximately 20% exhibit the so-called mechanical failure and a decreased intrinsic potency (Macintosh, Valencia et al., 1986).9 ressonancias iniciais

MRI of the patient: we can see an anterior angulation of the articular processes, flattening of the upper and posterior surface of both articular processes, information that we already have in the laminography.

The joint articular discs are very thinned which structurally implies an articular disc that can not always fulfill the function for which an articular disk is designed. It is imperative to promote joint decompression.

Remember the electromyography improvement that we had with the placement of cotton rolls between the occlusal surfaces.

11A TOMA DE MORDIDA

The masticatory muscles of the patient were deprogrammed electronically and the rest position was registered with a computerized jaw tracker.

This record was very difficult to achieve.  It was very difficult to deprogram the patient.  Even so a very thin DIO (intraoral device) was constructed in neurophysiological position  to promote the jaw reposition that was in a slight posterior position.

We left an inter-occlusal free space of 1 mm which  normally is very little (remember that the jaw tracker enables this type of measurement)

In the screen we may read a comment  that says (this is the record that I managed to take). I wanted to register this in the original record, as many times we don´t get a good record in the first time and this was the case. Logically records will modify as the system improves.11B RECALIn this other record where we are recalibrating the patient’s device , we can see the coincidence of the habitual trajectory with the neuromuscular trajectory. The patient is now deprogramming better so we could build  a better intra-oral device.

12 ABRE FECHA ORTESE

In this kinesiographic record with the DIO (intraoral device) in neurophysiological position, we can see the improvement of the trajectory in mandibular opening, closing and speed. Remember that the patient did not have a good speed in mandibular opening and closing, and she had a more vertical opening trajectory.

13 ABRE FECHA comparativas

Kinesiographic comparative records of opening, closing and speed: in habitual position before treatment and with the DIO (intraoral device).

13A TOMA DE MORDIDA E RECAL

Comparative rest position records: before treatment and recalibrating the DIO (intraoral device). In the recalibration record we can observe the coincidence of the habitual trajectory with the neuromuscular trajectory.

14 PANORAMICA ANTES DA ORTO

The first phase was carried out ( treatment of the TMJ)  with the controls and recalibrations required to enhance the mandibular position, in this case together with physical therapy to balance the postural chains.

At the request of the panoramic radiograph before moving on to the second phase of this case (three-dimensional orthodontics) it can be observed the third right lower molar eruption. This molar was impacted in the distal of the second right  lower molar. (31-year-old patient).

At this step it was only released the acrylic of the DIO in the region of the third impacted molar, returning the vertical dimension of the patient and allowing the eruption of the third molar.

15 PANORAMICAS COMPARATIVAS

Comparison of pre-treatment panoramic radiograph and after the first phase with the DIO (intraoral device) installed in neurophysiological position.

At this point a three-dimensional orthodontics is initiated to remove the DIO.

This orthodontic treatment as was explained in previous publications (see the publication Tridimensional Orthodontics in the Second Phase  of TMJ pathologies) must maintain the mandibular location  in balance with the muscular planes, with the temporomandibular joints and the dental plans, obtained in the first phase.

For this we have tools such as surface electromyography and electronic jaw deprogramming, that helps us to control how the system is functioning.

Few sequences will be shown until the full withdrawal of the DIO (intraoral device)

16 orto 0 1

Active eruption of lateral segments, already in a more advanced stage. The teeth are filling the space formerly occupied by the DIO.18 PANORAMICA CONTROLE  ORTO

Patient´s panoramic x-ray: control of the active eruption. It corresponds to the sequence shown in the previous image.

19 orto 0 1B

Three-dimensional orthodontics treatment continuation: Image with and without the device, the lateral sectors have already erupted.20 orto 2Three-dimensional orthodontics treatment continuation.21 oclusao final

The alignment of the upper and lower incisors sector was achieved just as the restoration with resin of the fractured part of the incisor.

Conclusion of the three-dimensional orthodontics after TMJ treatment.22 OCLUSAIS FINALConclusion of the three-dimensional orthodontics after TMJ treatment.22A eletromiografia final 22APatient’s dynamic electromyographic record after treatment.22B eletromiografia COMPARATIVAPatient’s SEMG records: before and after treatment. We can analyze the balance and functioning of the masseter, which did not happen in the initial registration.23 ABRE FECHA APOS O TRATAMENTO 2Kineciographic record: opening, closing and speed after treatment conclusion.23 B abertura e fechamento comparativasKinesiographic comparative records of opening, closing and speed: in habitual position before treatment, with the DIO (intraoral device) and after treatment conclusion.24 LAMINOGRAFIAfinal LPatient’s laminography in neurophysiological occlusion after treatment conclusion.25 LAMINOGRAFIAS COMPARATIVAS

Patient’s comparative laminographies: in habitual occlusion before treatment and neurophysiological occlusion after treatment conclusion.

It should be understood that the chosen mandibular position is the one where the joints are decompressed and muscles are able to recruit more motor units, for that we use electronic mandibular deprogramming. Registration also depends on the information obtained in the images.25B res. comparativasMRI (magnetic resonance imaging) comparative images of the patient: in habitual occlusion before treatment and in neurophysiological occlusion in the conclusion of treatment.

It should be understood that the chosen mandibular position is the one where the joints are decompressed and muscles are able to recruit more motor units, for that we use electronic mandibular deprogramming.

Registration ALSO DEPENDS on the information obtained in the images. MRI also provides information that should be taken into account when we decide the mandibular position, enhancing the data provided by the computerized jaw tracker: which and the type of disc, disk positioning, whether or not recapture among other data.

26 panoramica final LPatient’s panoramic radiography after conclusion of the second phase, in this case the three-dimensional orthodontics.26B panoramica COMPARATIVAS

Patient’s comparative panoramic radiographs: 1 before treatment, 2 during the first phase, 3 during the three-dimensional orthodontics, 4 after conclusion of the three-dimensional orthodontics.

27 fase frontalPatient’s comparative frontal image before and after treatment.28 fase perfilPatient’s comparative profile image before and after treatment.29Patient testimony

Dear Doctor,

I clearly remember when everything began.

First I used to feel a huge fatigue in the muscles of the face and mouth. I was very stressed then, I was teaching and I used to speak a lot.

Then I broke a tooth. And (ouch!) what to do? I looked for an emergency doctor and he made me a curative. He advised me to go to a dentist and I had to make a root canal there. I left the clinic in pain.(an incredible, allucinating headache,and ear pain)

I began to loos weight… I felt a malaise, a lack ou courage. My face muscle, the masseter seemed to be making weightlifting. Felt as strong and stout, but it hurt so much! It looked as if I had 200 Kg on my face and my neck seemed not to be part of my body. What an unbearable pain! I felt a general rejection, a lack of will of living.) My whole body started to ache. Even fibromyalgia some would say I had, others said I had one leg which was smaller that the other other would say… To sum up, I was a time bomb of all the problems professionals said I had… (I felt like that…)

From there I visited a lot of professionals.

Michigan splint, intensive physiotherapy, chiropractic terapy , shiatsu, do-in… So desperate I was! I even searched for an afro-brazilian religious priest (mãe de santo)….. But nothing relief me from my pain.

I was then that I went to see a very SPECIAL person in my CRAZY life! Dr. Lidia!!

It got better… but NOOOO the strife started to increase!!! Exams, resonances, what an affliction!

From that day five years had passed until my life got back in track… Back to normal with or without pain. But actually it came back on track WITHOUT ANY PAIN!!!

But for that a lot of water had flowed under the bridge!

The result was that after many appointments at the clinic, I remember the attendance on a Sunday of World Cup when Brazil was Champion and that compassionate soul (hahaha) helped me.

So much pain! So much despair! Even so that doctor had so much will and patience to cure me!

It was a hard path. But… We made it and we found that one of my wisdom teeth were totally ignorant (they had no wisdom at all) and it decided to sprout after my thirties.

I used to say that my teeth were like two soccer fan crowds that did not fit, as Palmeiras e Corintians (something like Chelsea and Manchester). They were in ethernal fight!

But after the storm…. My problems started to be solved.

Today I have a big smile thanks to Dr. t Lidia, hahaha. I pray everyday to her.

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.

1

Female patient 22 years old comes to the clinic with a strong headache principally on the top, pain on both temporalis, pain on the back of the head and on the shoulders.

Difficulty in chewing hard food, crepitations on both temporomandibular joints.

She reports bruxism since childhood.

Patient´s testimony

Since I was very little my parents reported that I had bruxism at night

1B

Patient with joint hipermobility. Patients with ligament hipermobilty present more risk to develop articular pathology.

2 DENTES Initial occlusion of the patient before treatment.3 OCLUSALSuperior and inferior occlusal view of the patient before treatment.

Wear in the upper and lower anterior sector
3b dinamico habitual

Surface electromyography, dynamic record in habitual occlusion. We ask to the patient to open the mouth, to close the mouth, to bite strong and to swallow. In this patient’s electromyography record we observe little activity in the masseters and anterior temporalis. We can also observe asymmetry between the right and left temporalis. It is obvious that the masseters have a loss of activity in the middle of the maximal occlusion.

4 PANORAMICA Patient’s initial panoramic radiograph before treatment.5LAMINOGRAFIA INICIAL

TMJ laminography of the patient before treatment in habitual occlusion and opening. Asymmetry of the mandibular heads. Superior and posterior position of the articular process of the right side in the joint cavity, provoking a retrodiscal compression.

We observe asymmetry between the left and right mandibular heads.

Alteration of the axis of the right mandibular condyle.

Patient´s testimony:

When I was 5 years old, while I was playing in the  pre school class interval  I had a traumatism.

A seesaw hit my chin when I was playing with another girl. They put ice on my chin to reduce the swelling. There was no much pain or apparent fracture.

I did not perform medical tests.

I remember another traumatism I had when I was 13 years old, I slipped on the sidewalk and felt hitting my chin on the ground, I FRACTURED THE UPPER INCISORS,  (they have resin)

Sometimes I wake up and I feel that I´m biting and moving my mandible.

If I don´t use the bruxism splint to sleep I brake the resin of my teeth.

The splint protects the resin, BUT DOESN´T ALLIVIATE THE PAIN.

The website of the Clinica MY  www.clinicamy.com.br  has the links for both articles. . Alterações na Orientação do Côndilo Mandibular Devido a Traumatismos na Primeira Infância (Portuguese). Clinic case presented in the 4th edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

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

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2, July/December de 2014.

6 RNM INICIAL MRI: left TMJ closed mouth  lateral slice. 7 RNM INICIAL MRI: left TMJ closed mouth  slice. MILD IRREGULARITY OF THE CORTICAL BONE OF THE MANDIBULAR HEAD.

When we analyze a MRI we have to take into account a lot of information beside disk position

8 RNM INICIAL

MRI :left TMJ closed mouth . Medial slice. Low signal in the head of the mandible bone marrow. The patient had a history of tonsillitis and otitis repetition.

When we requested for an ASO the exam showed high values, for which because of that she was medicated.

9 RNM INICIAL  MRI :right TMJ closed mouth medial  slice.
10 RNM INICIAL

MRI: right TMJ closed mouth  slice. Superior facet of the mandible head. Mild dislocation of the articular disc and retro position of the condyle.

11 rad. lateral Lateral radiograph and patient’s profile12 cervicalThe lateral radiograph including the cervical spine shows it´s rectification (loss of the physiological lordosis). Mild curvature inversion at C4.

13 Registro jaw tracker-3

Patient’s masticatory muscles were electronically deprogrammed and a bite in a neurophysiological position was registered using a jaw tracker.For the bite registration record we always use the information of the images obtained and the planned goals for each individual case.

The patient presented a free way pathological space of 6 mm and a retro-position of 2,8mm

A DIO (Intraoral Device)  was constructed in a neurophysiological position.

The website of the Clinica MY www.clinicamy.com.br  has the link for the article Neuromuscular Principles in Dentistry, Habitual Trajectory coincident with the Neuromuscular Trajectory.

Princípios Neuromusculares na Odontologia, Trajetória de Fechamento Habitual Coincidente com a Trajetória de Fechamento Neuromuscular (Portuguese) Brazilian Journal of TMJ, occlusion and Orofacial Pain, April/ June 2002.

14 dinamico com dio  Patient’s electromyography record with the DIO ( intraoral device) constructed in neurophysiological position). Observe the excellent muscle activity with the device.

15 registro eletromiografico comparativo  Patient’s electromyography records comparison: the first in habitual occlusion and the second with the intraoral device in neurophysiological position.  In the lower record the masseters present excellent activity with the device, even more if we compare the initial record where  the masseters lose  activity in the middle of the maximal occlusion.

Some MRI selected slices : before treatment and after de FIRST PHASE.

We need to be aware of the planned goals for this patient with joint hypermobility and a sequel of traumatism in infancy where we can see low signal in the head of the mandible bone marrow.

  • Better tridimensional placement of the mandibular condyle.
  • Closing dental trajectory coincident with the muscular closing trajectory.
  • Temporomandibular joints decompression.

 Image 1: improvement of the left condyle upper pole cortical bone in this lateral slice.

 Image 2: improvement of the left condyle superior pole cortical bone, bone marrow  signal improvement, positive remodeling of the condylar posterior surface.

Image 3: Improvement of the bone marrow signal and positive remodeling of the condylar posterior surface.

Image 4 : Positive remodeling of the superior pole and posterior surface of the head of the mandible.

16 A panoramica INICIO 2 FASEWe began assembling the upper and lower braces for a tridimensional orthodontics, maintaining the DIO (intraoral device)

A tridimensional orthodontics needs to maintain the tridimensional mandible position in balance with its osseous and muscular planes obtained in the FIRST PHASE, and always when possible it has the purpose to maintain the temporomandibular joint in a harmonious relation with the mandibular fossa as well as the disk in a correct position.

16B LATERAL INICIO 2 FASEPatient’s lateral radiograph and cervical spine  in the beginning of the 2 PHASE.17 comparativas coluna 1  Comparative lateral radiograph an cervical spine of the patient: before the FIRST PHASE and in the beginning of  the SECOND PHASE

In this image there is no recovery of the lordosis but yes, an improvement of the mild curvature inversion at C4.

18 orto 1

Tridimensional orthodontics sequence in the second phase of TMJ pathologies treatment, in this specific patient.

REMEMBER THAT NOT EVERY CASE WILL ALLOW YOU TO ADVANCE TO A SECOND PHASE.

19 orto 2 20 orto 3  Active eruption in the tridimensional orthodontics.21 orto 4   Active eruption in the tridimensional orthodontics.22 orto 5  Continuation of the tridimensional orthodontics with sequence of intraoral devices23 orto 6  New DIO (intraoral device) for the continuation of the tridimensional orthodontics.24 orto 7 25 orto 8 26 orto 9 27 orto 10 27B paciente retirando el dispositivo  Removal of the DIO ( intraoral device)28 orto 11 Image without the intraoral device.29 finaliz trat orto Tridimensional orthodontics treatment finalization in neurophysiological occlusion.30 comparação oclusao inical e final  Patient’s occlusion image in neurphysiological occlusion after treatment finalization. Comparison with the initial occlusion image.31 ELETRO FINAL  Patient’s electromyography records comparison: the first in habitual occlusion before the FIRST PHASE and the second AFTER THE TRIDIMENSIONAL ORTHODONTICS TREATMENT FINALIZATION. The masseters present excellent activity comparing with the initial record where the masseters lose activity in the middle of the maximal occlusion. Also the masseters present better potency than the temporalis.32 final CERVICO COMPARATIVAS  Patient’s lateral and cervical spine comparative radiograph: before the FIRST PHASE and in the TRIDIMENSIONAL ORTHODONTICS FINALIZATION.

Notice the cervical lordosis improvement.

33 lamino comparativas  Patient’s comparative laminography: initial in habitual occlusion where we can observe the retro position of the mandible heads, and the tridimensional orthodontics finalization laminography.

34 PANO FINAL (1) Patient’s panoramic control radiograph after the TRIDIMENSIONAL ORTHODONTICS finalization.35 RNM FINAL Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.36 RNM FINAL  Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.37 RNM FINAL  Left TMJ, closed mouth before treatment and left TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.38 RNM FINALRight TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.39 RNM FINAL  Right TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.40 RNM FINAL

Right TMJ, closed mouth before treatment and right TMJ, closed mouth 4 YEARS AFTER THE TRIDIMENSIONAL ORTHODONTICS FINALIZATION.

DEPOIMENTOTMJ 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.

FINAL

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

The former publication worked on  the neurophysiological approach of the first and second phase in the treatment of TMJ pathologies. The patient of the last publication, entitled “Tridimensional Orthodontics in the Second Phase of TMJ Pathologies” has her complete dentition in mouth and a good periodontal health, condition that permited us by a tridimensional orthodontics to restore and balance the system after the First Phase, with the REMOVAL OF THE INTRAORAL DEVICE.

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.

In this publication we will report a case where a good quality of life was returned to the patient and we could offer a neurophysiological rehabilitation combined with a tridimensional orthodontics, always keeping the mandibular localization in equilibrium with the muscular planes, temporomandibular joint and dental planes, achieved in the first Phase.

1 HELENA DE MATTOS Female patient 54 years old came to the consultation with strong pain in the superior part of the head, in both temporalis, in the back of the head and in the cervical spine.

1B HELENA DE MATTOS

The pain was so strong that SHE REFERRED THE WILL to extract all the teeth, believing that they were the origin of the pain. She reported a lot of pain in the face, and strong twinges in the ears.

1C

The patient marked the pain areas in the head and neck, but she referred pain in several joints of the body.

Patient’s testimony

Long time ago I began to feel ear pain. I consulted   many otorhinolaringologist that told me I didn´t had anything wrong in my ear. Then I consulted  a neurologist that medicated me with carbamezepine and told me that I had a GLOSSOFHARYNGEAL NEURALGIA.

I felt very uncomfortable with the medication. I experienced dizziness and lack of concentration.

I consulted  Dr. Valdai Souza, a physician , who removed the medication, improved my general health and checking my TMJ referred me to Clinica My.

2 DENTES The patient presented a very deteriorated aesthetics, BUT THE MOTIVE OF HER CONSULTATION WAS PAIN IN THE TEMPOROMANDIBULAR JOINT, PAIN IN THE FACE, STRONG HEADACHE AND PAIN IN THE EAR.

The patient had tried too many dentistry treatments; even so she continued grinding and breaking teeth. She had lost teeth. She had prostheses installed, but the patient gave up to search a better aesthetics because  the pain in the joint and  headache didn´t allow her a normal life.

3 DENTES Patient’s  occlusal view is marked by the wear of the anterior teeth, both superior and inferior

She had consulted  several specialists until she was derived by her physician to Clinica My.

4 PANORAMICA

In the radiographic exam we observe the absence of the 18,16,28,28,36, 46 4 48 dental elements.

The 15, 14, 22, 24, 26, 35,44 e 45 elements are endodontically treated.

Fixed prosthesis with support in the 16/15 elements. Presence of unitary fixed with metallic intracanal pin in the 14, 22, 26, 35, 34 e 45 dental elements.

Extensive restoration in the 13, 24 e44 dental elements.

Restorative material in the 11, 21, 23, 27, 32 and 47 elements.

Maxillary and mandibular bone loss more pronounced in the edentulous areas.

Elongation of the left styloid process.

5 LAMINOGRAFIA

Patient’s laminography in habitual occlusion shows de retro position of the mandibular condyles and a sequel of traumatism in infancy (left side). We can observe in this image the alteration of the axis of the mandibular condyle. The website of the Clinica MY  www.clinicamy.com.br  has the links for both articles. . Alterações na Orientação do Côndilo Mandibular Devido a Traumatismos na Primeira Infância (portuguese). Clinic case presented in the 4th edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

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

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2,  July/December de 2014.

5B LAMINOGRAFIA Alterations in the Orientation of the Mandibular Condyle Because of Traumatism in Infancy

Clinic case presented in the number 4 edition of the Brazilian Journal of TMJ, occlusion and Orofacial Pain, October/ December 2001.

5C LAMINOGRAFIA Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy.

Article published in the Journal of Cranio-Maxillary Diseases, volume 3, issue 2,  July/December de 2014.

5D ressonancia boca fechada

One of the slices of the MRI showing the asymmetry of the mandibular heads and the alteration of the condyle axis in the left side.

The articular discs are anteriorly dislocated with reduction in the slices of the MRI in open mouth (not included in this publication). The principal objective in this case is the TMJ decompression and the tridimensional balance of the masticatory muscles. The structural asymmetries provoked by traumatism cannot be modified. But yes we can balance the muscles!

Patient’s testimony

My mother told me that when I was very little I felt from a tree and hit my head.

6 TELE PERFIL

The profile radiograph shows the patient’s occlusion collapse. In a simple view we could attribute this collapse to the teeth loss, BUT IS NOT SO SIMPLE. The patient presents also a dimensional loss provoked by the alteration of de axis of the mandibular condyle.

This dimensional loss is many times observed in patients with all THE DENTAL ELEMENTS IN MOUTH, but they also present an alteration of the mandibular condylar axis, because of traumatism in infancy or others etiologic conditions that affected one or both mandibular heads.

7 C7

The lateral radiograph including the cervical spine shows the vertebral misalignment, the degenerative condition, the loss of space between the vertebrae.

Patient’s testimony:

I had a car accident, a truck crossed in front of my vehicle, I hit  my face on the car’s front glass  and I needed an intervention  in my face.

7B C7 2

Osteophytes especially in C4, C5 and C6. The patient also has the cervical MRI showing  vertebral discs protrusions.  

7D FRONTAL 8 A DENTES ORTOSE

Her muscles were electronically deprogrammed and a DIO (Intraoral Device) or ortese was constructed in a neurophysiological position. In other publications we mentioned the kinesiographic methods wich were used.

8 B eletromiografia em oc. habitual

Surface electromyography in habitual occlusion shows an important asymmetry between the right and left temporalis muscles, also asymmetries between right and left masseters.

8C fotos comparativas frontais

Aesthetic modifications with the intraoral device in neurophysiological position in mouth.

10B PANORAMICA implantes 1

The installation of two implants on the inferior left side were planned and also two implants on the superior right side where the patient had an old prosthesis. All these procedures were ALWAYS WITH THE DIO (intraoral device) constructed in neurophysiological position in mouth 24 hours in a day.

10C panoramicas comparativas

Comparative panoramic radiographs: initial panoramic radiograph before the treatment and the panoramic radiograph with the implants installed, always with the DIO, Intraoral Device in neurophysiological position.

9 dentes cavidades

The cavity preparation had only a provisional aesthetic goal that permitted us to begin the anterior sector orthodontics movement. That will be posted later.

10 dentes prov e inicio da ortodontia

The teeth were rehabilitated PROVISIONALLY WITH RESINES to improve patient´s aesthetics and self-esteem. The patient had no symptomatology, that condition permitted us to work in the recuperation of her stomatognathic system health and aesthetics.

Orthodontics movement wearing THE INTRAORAL DEVICE WAS INITIATED.  The first objective was the molar uprighting on the inferior right side in order to recuperate the  space to install the implant.

11 preparo ortodontico setor anterior

The second objective continuing the neurophysiological rehabilitation combined with the tridimensional orthodontics was the vestibularization of the superior anterior sector to aloud the proper anatomical reconstruction of the teeth.

12 preparo protese-1

Some of the teeth presented pulp degeneration, needing endodontic and a reinforcement of the dental nuclei with metallic pins.

13 cimentação de coroas provisorias Implant on the place of the 46, after space recuperation14 cimentação definitiva dos provisórios 15 cimentação coroas definitivas

In this view, without the DIO (Intraoral Device), with the metal-ceramic crowns already cemented, we can see the wear of the inferior anterior sector, which needs to be rehabilitated with resins.

16 terminado

In this case, the initial planning was to maintain the intraoral device after rehabilitation, because the dimensional loss was very large. The patient presented bone loss and degenerative conditions in several body joints: A PROSTHESES IN HER HIP, AN IMPORTAT MISALIGNEMENT OF THE CERVICAL SPINE WITH OSTEOPHYTES AND LOSS OF THE SPACE BETWEEN VERTEBRAE.

The 35 element had a 10 years fractured old pin with important overload (remember that this was the last tooth in mouth in the left inferior sector before the implants installation) .

The extraction of this element was decided.The patient  is WITHOUT PAIN, AND WITH THE SPACE PRESERVED BY THE DIO, will decide later the implant installation.

16B oclusal final 17 laminografia final

Laminography showing the tridimensional decompression of the mandibular heads.

18 laminografias comparativas

Laminography comparison before and after the neurophysiological rehabilitation combined with the tridimensional orthodontics.

19 PANORAMICA final

Panoramic radiograph with the finalization of the rehabilitation and the space of the 35 element preserved for the future implant.

20 panoramicas comparativas

Panoramic radiographs comparison: intial panoramic before treatment, panoramic during the treatment and panoramic after the neurophysiological rehabilitation combined with the tridimensional orthodontics.

21 comparativas frontais

Frontal radiographs comparison before and after the neurophysiological rehabilitation combined with the tridimensional orthodontics.

23

Intraoral photographs before and after treatment.

21 comparativas laterais

Patient’s lateral and cervical spine radiographs comparison before and after the neurophysiological rehabilitation combined with the tridimensional orthodontics. Remember that one of the reasons to maintain the intraoral device was because the degenerative conditions of the cervical spine and in other joints.

22 postura comparativa

Patient’s postural and aesthetics modifications before treatment and after the neurophysiological rehabilitation

dEPOIMENTO 1

I arrived in the clinic with a strong  pain in the face, headache and pain in my ear. I wanted to extract all my teeth because of the pain and twinges in the ear.

In a quiet environment I felt the buzz on my left ear and the pain rose to the head. Sometimes I spent the night walking to be able to endure…

I began to treat the TMJ (temporomandibular joint) pathology. And I got a relief of my pain.

After two years I initiated the rehabilitation. In the middle of the rehabilitation I had a pelvis surgery; the physicians needed to install a hip prosthesis.

I had also a tumor in my kidney and the physicians needed to remove it.

Without pain and with aesthetic improvement Dr. Lidia and Dr. Luis Daniel explained to me that they couldn´t totally remove the device, because the dimensional loss  was too large and also because of my degenerative active condition, which meant loss of stability not only in the TMJ, but also in other joints.

dEPOIMENTO 2

Nowadays I wear a small intraoral device.This device  will be changed for one aesthetics DIO, instead of the transparent  one.

My life quality improved 100 percent, I sleep very  well and I even  don´t feel the buzz any more, neither the twinges.

THE AESTHETICS ACHIEVEMENT ALSO IMPROVED MY SELF-ESTEEM, even if that was not the motive for my treatment. The reason was to alleviate my pain. NOW  WITHOUT PAIN, EVEN THE AESTHETICS IS IMPORTANT.

A big hug and my gratitude to my Drs. for my life quality change !

FINAL

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

1A

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.

1

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.

2

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.

3

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.

4

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.

5

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.

6

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.

7

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)

8

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.

9 10

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.

11

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.

12

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

13

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.

14

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.

15

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.

16

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.

17

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.

18

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

19

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

20

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.

21

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

22

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

23

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.

24

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.

25

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.

26