Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5184_Библиотеки_им_академика_М_И_Перельмана.pdf
194
L. Yavich
Fig. 8 Image showing an illustration of the heads of the mandibles (windows) and plain lms of a patient where the
structures bear no resemblance to the healthy physical structure of the illustration
Fig. 9 Whole-body postural photos: front, back, right, and left prole and front smiling
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
Fig. 10 Photographic records of a frontal view, right and left lateral views in maximum intercuspation (above), and
superior and inferior occlusal views
195
the panoramic view but in the plain lms. In previous examples of Figs. 6 and 7, the structural
deformities already appeared in the panoramic
view. This is not describing cephalometric analysis but rather pointing out the lack of parallelism
of the frontal planes in the frontal radiograph.
The head is balanced over the cervical spine
and is in equilibrium with the bi-pupillary and
occlusal planes. An important third plane is the
transverse mandibular, which must be parallel to
the nasal, auricle, and pupillary planes.
When the head loses its optimal gravitational
relationship with respect to the surface of the
earth, the patient’s balance is disturbed, which
can cause vertigo, nausea, and frequent myalgias
in postural muscles. The neuromuscular system
is in a state of constant activity in order to keep
those planes in an optimal physiological relationship with each other both while sitting and
standing.
A healthy cervical spine should not be straight
as seen in Fig. 12b, but concaved posteriorly,
described as cervical lordosis. A change in head
posture can be devastating to the neuromuscular
system. Notice an important loss of space
between the fth and sixth cervical vertebrae and
also osteophytes in the same vertebrae.
Symptomatically, the cervical region overlaps
with the craniofacial region. The superior cervical nerves, discs, facets, and muscles are a potential source of referred pain, and the second and
third cervical nerves innervate the angle of the
mandible, lower region of the TMJ, and parts of
the ear, mastoid, and nape of the neck. Any irritation or dysfunction of these nerves can be associated with cervicofacial pain.
In this patient, there was an anterior displacement of the joint disc in closed mouth
with recapture in open mouth in both temporomandibular joints. MRI of the cervical spine
showed the reduction of the intervertebral discs
between C6 and C7 where a disc-osteophytic
complex is observed, normally associated with
a bulging (protrusion) of the intervertebral disc
in the cervical spine. With the loss of intervertebral space and the retro-positioned condyles
on the plain lms together with the clinical
data, it is strongly suspected that an anterior
displacement of the articular disc as well as
protrusions in the cervical spine, both conrmed by MRI (Fig. 13), are related. This is
why it is fundamental to look at all our patient’s
data as a puzzle to be solved. It seems logical
to look at the patient as a whole.
196
L. Yavich
a
b
Fig. 11 (a) Panoramic and (b) TMJ plain lms of the patient with condyle color highlights
4.5 Structural Misalignment
Related toTemporomandibular
Joint Pathology
condyle retro-position. The patient showed an
“ideal occlusion” without relapses from the orthodontic treatment, which was nished 5 years
previously (Fig. 14). She exhibited no interferA 17-year-old patient who had already been
treated orthodontically returned to the clinic
complaining of headache, ear pain, shoulder
pain, and bilateral joint clicks. She had pain in
her TMJs and a stronger ache when retrodiscal
palpation was performed, an indication of
ence in jaw protrusion nor lateral translation. A
surface electromyography was performed to
measure the right and left anterior temporalis
muscle and right and left masseter muscle activ-
ity in maximum intercuspation and clenching.
The masseter muscles, the most powerful of the
cd
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
197
ab
Fig. 12 Frontal and lateral radiographs including C7. (a) Notice that planes are not parallel to the horizon. (b) Arrows
highlight the loss of space between the fth and sixth cervical vertebrae and also osteophytes in the same vertebrae
ab
ef
Fig. 13 Top, TMJ MRI. (a and d) Original color and (b, c) colored to make the dislocated articular disc easier to visual-
ize. Bottom, (e) cervical spine MRI, and (f) cervical spine X-ray
198
Fig. 14 Patient’s habitual occlusion; frontal, right, and left lateral photograph (above); and upper and lower occlusal
view
L. Yavich
Fig. 15 Electromyographic record of the patient in habitual occlusion
stomatognathic system, were unable to contract
during clenching (Fig.15). Masseter muscles are
unable to contract, and the patient had an ideal
occlusion. The initial reaction was to think that
there was a malfunction with the electromyograph or that there was some error in the placement of the electrodes. Plain lms and a TMJ
MRI were requested.
Laminography in habitual occlusion, the
retro-position of the mandibular heads, especially
on the left side (Fig.16) (red arrow), was clearly
visible. This retro-position provokes a signicant
retrodiscal compression. A modication of the
growth axis (greenstick fracture) bilaterally
caused by a trauma in infancy is also visible. The
MRI shows an anterior disc displacement in the
right and left TMJs with reduction (Fig. 17)
(open-mouth MRI not included). The patient’s
masticatory muscles were electronically deprogrammed to check the differences between the
neuromuscular and dental trajectories. The closing path is that which is taken during the dis-
db
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
Fig. 16 Patient’s laminography in open and closed mouth in habitual occlusion
ac
Fig. 17 (a, b) Patient’s MRI in habitual occlusion in closed mouth. (c, d) Same image with color highlight
199
placement of the mandible when it passes from
its position of rest (MRP) to the position of usual
occlusion. This trajectory is the result of the various muscular contraction vectors. These vectors
determine a line of mandibular displacement,
which brings the mandible into contact with its
antagonist (maxilla).
The neuromuscular trajectory (Fig. 18)
measured after deprogramming with transcutaneous electrical neural stimulation (TENS)
does not match the usual trajectory, having a
discrepancy in the sagittal, frontal, and vertical
directions. The patient’s habitual dental path is
posterior to the neuromuscular pathway. The
graphic makes perfect sense coinciding with
the images and the clinical tests. The patient
presented a pathological freeway space of
6.2 mm and a retromandibular position of
2.5mm. The ultimate goal in orthodontic and
facial orthopedic treatments is to treat all three
components of the stomatognathic system and
create an environment for the synergistic function of the teeth, temporomandibular joints,
and neuromuscular system.
200
L. Yavich
Fig. 18 Jaw tracker data after electronic deprogramming
5 Summary
A static image of beautiful occlusion does not
speak of muscular harmony, does not show if
there is coordination between the systems, and
does not show if the patient has either local or
remote pain. Occlusion needs a denition where
all systems are represented. The stomatognathic
system is linked primarily with the trigeminal
nerve and the cervical spine and consequently
with the whole body. If one does not understand
that teeth are the ending point of this joint, that
the temporomandibular joint can be affected by
systemic and local pathologies, and that muscles
move the mandible, treatment failure may not be
understood, especially in cases where TMJ
pathologies are present.
Understanding the complex interrelationship
of craniomandibular disorders requires a broad
understanding, not only of the anatomy and phys-
iology of the head and neck, but also of the spine.
Nociceptive reexes originating from the temporomandibular joint lead to adaptive postural
responses (craniomandibular, head and neck,
trunk, and limbs). These will be addressed in the
following chapter: Structural Misalignment:
Postural Changes Related to Temporomandibular
Joint Pathology.
Suggested Readings
1. Abbas AK, Lichtman AH, Pillai S. Basic immunology: functions and disorders of the immune system.
6th ed; 2019.
2. Stevens A, Lowe JS.Pathology. Mosby; 2000.
3. Moses AJ.Controversy in temporomandibular disorders: clinicians’ guide to critical thinking. Futa Book
Publishers; 1997.
4. Arabshahi B, Baskin KM, Cron RQ.Reactive arthritis
of the temporomandibular joints and cervical spine in
a child. Pediatr Rheumatol Online J. 2007;5:4. https://
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
201
doi.org/10.1186/1546- 0096- 5- 4. PMID: 17550629;
PMCID: PMC1869027.
5. Bag AK, Gaddikeri S, Singhal A, Hardin S, Tran
BD, Medina JA, Curé JK. Imaging of the temporomandibular joint: an update. World J Radiol.
2014;6(8):567–82. https://doi.org/10.4329/
wjr.v6.i8.567. PMID: 25170394; PMCID:
PMC4147437.
6. Basmajian JV, De Luca Carlo J. Muscles alive: their
functions revealed by electromyography. Williams &
Wilkins; 1985.
7. Bayar N, Kara SA, Keles I, Koç MC, Altinok D,
Orkun S. Temporomandibular joint involvement in
rheumatoid arthritis: a radiological and clinical study.
Cranio. 2002;20(2):105–10. https://doi.org/10.1080/0
8869634.2002.11746198.
8. Cedströmer AL, Andlin-Sobocki A, Abbu N,
Hedenberg-Magnusson B, Dahlström L, Berntson
L.Condylar alterations and facial growth in children
with juvenile idiopathic arthritis. J Orofac Orthop.
2020;81(3):163–71.
020- 00216- 8. Epub 2020 Feb 20. PMID: 32077980;
PMCID: PMC7186245.
9. Cevidanes LH, Alhadidi A, Paniagua B, Styner M,
Ludlow J, Mol A, Turvey T, Proft WR, Rossouw
PE. Three-dimensional quantication of mandibular asymmetry through cone-beam computerized
tomography. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2011;111(6):757–70. https://doi.
org/10.1016/j.tripleo.2011.02.002. Epub 2011 Apr
16. PMID: 21497527; PMCID: PMC3095695.
10. Conti AC, Oltramari PV, Navarro Rde L, de Almeida
MR. Examination of temporomandibular disorders
in the orthodontic patient: a clinical guide. J Appl
Oral Sci. 2007;15(1):77–82. https://doi.org/10.1590/
s1678- 77572007000100016. PMID: 19089105;
PMCID: PMC4327217.
11. Costen JB.A syndrome of ear sinus symptoms dependent upon disturbed functions of TMJ. Ann Otol.
1934;43(1):1–15.
12. Costen JB.Neuralgias and ear symptoms associated
with disturbed function of the TMJ.JAMA J Am Med
Assoc. 1936;107:252–4.
13. Cram JR, Kasman GS.Introduction to surface electromyography. Gaithersburg: Aspen Publishers; 1998.
p.408.
14. Wilson-Pauwels L, Akesson EJ, Stewart PA, Spacey
SD.Cranial nerves in health and disease. BC Decker
Inc.; 2002.
15. Simmons HC, American Academy of Craniofacial
Pain. Craniofacial pain: a handbook for assessment,
diagnosis and management. 3rd ed. Chroma,
Incorporated; 2009.
16. Rozencweig D, Gerdolle D, Delgoffe C, Stricker
M.Imagerie de l'ATM: aide au diagnostic des troubles
cranio-mandibulaires. Editora Cahiers de prothèses
éditions; 1995.
17. Defabianis P. Post-traumatic TMJ internal derangement: impact on facial growth (ndings in a pediatric
age group). J Clin Pediatr Dent. 2003;27(4):297–303.
https://doi.org/10.1007/s00056-
https://doi.org/10.17796/jcpd.27.4.2782236161
p3p467.
18. Defabianis P. TMJ fractures in children and adolescents: treatment guidelines. J Clin Pediatr Dent.
2003;27(3):191–9.
19. Ortu E, Pietropaoli D, Adib F, Masci C, Giannoni M,
Monaco A.Electromyographic evaluation in children
orthodontically treated for skeletal class II malocclusion: comparison of two treatment techniques.
CRANIO®. 2017;37:129. https://doi.org/10.1080/08
869634.2017.1393916.
20. Emshoff R, Brandlmaier I, Bösch R, Gerhard S,
Rudisch A, Bertram S. Validation of the clinical
diagnostic criteria for temporomandibular disorders
for the diagnostic subgroup—disc derangement with
reduction. J Oral Rehabil. 2002;29(12):1139–45.
https://doi.org/10.1046/j.1365- 2842.2002.00980.x.
21. Antonio MV, Gil JG. Enfermedades reumaticas
extrarticulares. Masson; 1998.
22. Ferreira CL, Da Silva MA, de Felício CM.Orofacial
myofunctional disorder in subjects with temporomandibular disorder. Cranio. 2009;27(4):268–74. https://
doi.org/10.1179/crn.2009.038.
23. Gary Demerjian G, Barkhordarian A, Chiappelli
F. Temporomandibular joint and airway disorders
a translational perspective. Springer International
Publishing AG, part of Springer Nature; 2018.
24. de Souza Pinto GN, Grossmann E, Iwaki Filho
L, Groppo FC, Poluha RL, Muntean SA, Iwaki
LC.Correlation between joint effusion and morphology of the articular disc within the temporomandibular joint as viewed in the sagittal plane in patients with
chronic disc displacement with reduction: a retrospective analytical study from magnetic resonance imaging. CRANIO®. 2019;39:119. https://doi.org/10.108
0/08869634.2019.1582166.
25. Helenius LM, Hallikainen D, Helenius I, Meurman
JH, Könönen M, Leirisalo-Repo M, Lindqvist
C.Clinical and radiographic ndings of the temporomandibular joint in patients with various rheumatic
diseases. A case-control study. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2005;99(4):455–63.
https://doi.org/10.1016/j.tripleo.2004.06.079.
26. Ide Y, Nakazawa K.Anatomical atlas of the temporomandibular joint. Quintessence Publishing Co., Ltd;
2001.
27. Isberg A, Widmalm SE, Ivarsson R. Clinical, radiographic, and electromyographic study of patients
with internal derangement of the temporomandibular
joint. Am J Orthod. 1985;88(6):453–60. https://doi.
org/10.1016/s0002- 9416(85)80044- 0.
28. Jankelson B.Three-dimensional orthodontic diagnosis and treatment. A neuromuscular approach. J Clin
Orthod. 1984;18(9):627–36.
29. Jankelson Robert R. Sensitivity/specicity: straw
men, red herrings, and dental politics. Cranio.
2013;31(3):156–8. https://doi.org/10.1179/
crn.2013.023.
30. Jaunet E, Le Guern A, Le Tacon P, Thery-Dumeix C,
Deshayes MJ. Uncovering and treating asymmetry
202
L. Yavich
before 6 years in our daily clinical practice: option
or obligation? Orthodontics or orthopedics? Int
Orthod. 2013;11(1):35–59. https://doi.org/10.1016/j.
ortho.2012.12.013. Epub 2013 Feb 1.
31. Guimarães JP, Ferreira LA. Atlas de diagnóstico por
imaginologia das desordens temporomandibulares.
Ed. UFJF; 2012.
32. McNamara JA Jr., SD Kapila KY VanRiper.
Temporomandibular disorders and orofacial pain:
separating controversy from consensus. (2009)
33. Kim C-W, Han M-C.Cortes anatómicos: correlacionados con RM y TC.Espanha: Doyma; 1990.
34. Kuroda S, Tanimoto K, Izawa T, Fujihara S,
Koolstra JH, Tanaka E. Biomechanical and biochemical characteristics of the mandibular condylar
cartilage. Osteoarthr Cartil. 2009;17(11):1408–15.
https://doi.org/10.1016/j.joca.2009.04.025. Epub
2009 May 18.
35. Learreta JA, Barrientos EE.Temporomandibular joint
method to study the morphology and relationship of
the hard structures. Cranio. 2010;28(4):223–31.
36. Learreta JA, Yavich LG. Of healthy and pathologic
images of temporomandibular joint. São Paulo: Artes
Médicas; 2008.
37. Learreta JA, Yavich LG. Structural modications
of the mandibular condylar process as one of the
sequels of traumatism in infancy. J Cranio Maxill Dis.
2014;3:85–8.
38. Lopes SL, Costa AL, Cruz AD, Li LM, de Almeida
SM. Clinical and MRI investigation of temporomandibular joint in major depressed patients.
Dentomaxillofac Radiol. 2012;41(4):316–22. https://
doi.org/10.1259/dmfr/27328352. PMID: 22517997;
PMCID: PMC3729006.
39. Piancino MG, Tepedino M, Cavarra F, Bramanti E,
Laganà G, Chimenti C, Cirillo S.Condylar long axis
and articular eminence in MRI in patients with temporomandibular disorders. CRANIO®. 2018;38:342.
https://doi.org/10.1080/08869634.2018.1532647.
40. Masi M, Lederman HM, Yamashita HK, de Arruda
Aidar LA. Temporomandibular joint evaluation
with magnetic resonance imaging in children with
functional unilateral posterior crossbite, treated
with rapid maxillary expansion. Am J Orthod
Dentofacial Orthop. 2009;136(2):207–17. https://doi.
org/10.1016/j.ajodo.2007.10.048.
41. Melchior MO, Mazzetto MO, Magri LV. Relation
of painful TMD with the speech function: what
are the possible characteristics of mandibular
movements and the main symptoms reported?
Codas. 2019;31(2):e20180161. https://doi.
org/10.1590/2317- 1782/20182018161.
42. Michelotti A, Iodice G. The role of orthodontics
in temporomandibular disorders. J Oral Rehabil.
2010;37(6):411–29.
2842.2010.02087.x. Epub 2010 Apr 9.
43. Maulén-Yáñez M, Meeder-Bella W, Videla-Jiménez
PJ, González-Arriagada WA. Assessment of association between muscular diagnosis in temporomandibular disorders with mandibular kinematics.
https://doi.org/10.1111/j.1365- -
CRANIO®. 2018;37:365. https://doi.org/10.1080/08
869634.2018.1465513.
44. Monaco A, Cattaneo R, Marci MC, Marzo G, Gatto R,
Giannoni M. Neuromuscular diagnosis in orthodontics: effects of TENS on maxillo-mandibular relationship. Eur J Paediatr Dent. 2007;8(3):143–8.
45. Moncada G, Cortés D, Millas R, Marholz
C. Relationship between disk position and degenerative bone changes in temporomandibular joints
of young subjects with TMD. An MRI study. J
Clin Pediatr Dent. 2014;38(3):269–76. https://doi.
org/10.17796/jcpd.38.3.w43m8474433n7ur2.
46. Jankelson RR. Neuromuscular dental diagnosis and
treatment hardcover. Ishiyaku Euroamerica; 1990.
47. Skármeta NP, Araneda L, Araya C.Destructive psoriatic arthritis of the temporomandibular joint: a clinical
case, an overview of the pathophysiology and its differential diagnoses. CRANIO®. 2018;38(3):201–7.
48. Piancino MG, Cannavale R, Dalmasso P, Tonni I,
Filipello F, Perillo L, Cattalini M, Meini A.Condylar
asymmetry in patients with juvenile idiopathic arthritis: could it be a sign of a possible temporomandibular joints involvement? Semin Arthritis Rheum.
2015;45(2):208–13. https://doi.org/10.1016/j.semar-
thrit.2015.04.012. Epub 2015 May 2.
49. Pollack B. Cases of note: Michigan jury awards
$850,000in ortho case: a tempest in a teapot. J Mich
Dent Assoc. 1988;70(11–12):540–2.
50. Saldanha AD, Hilgenberg PB, Pinto LM, Conti
PC. Are temporomandibular disorders and tinnitus
associated? Cranio. 2012;30(3):166–71. https://doi.
org/10.1179/crn.2012.026.
51. Schmitter M, Kress B, Rammelsberg
P.Temporomandibular joint pathosis in patients with
myofascial pain: a comparative analysis of magnetic
resonance imaging and a clinical examination based
on a specic set of criteria. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2004;97(3):318–24.
https://doi.org/10.1016/j.tripleo.2003.10.009.
52. Shankland WE 2nd. Anterior throat pain syndromes: causes for undiagnosed craniofacial pain.
Cranio. 2010;28(1):50–9. https://doi.org/10.1179/
crn.2010.007.
53. Sims A, Stack B. Tourette’s syndrome: a pilot study
for the discontinuance of a movement disorder.
Cranio. 2009;27(1):11–8. https://doi.org/10.1179/
crn.2009.003.
54. Sims AB, Stack BC, Demerjian GG. Spasmodic
torticollis: the dental connection. Cranio.
2012;30(3):188–93. https://doi.org/10.1179/
crn.2012.029.
55. Cortes D, et al. Association between disk position
and degenerative bone changes of the temporomandibular joints: an imaging study in subjects with
TMD.CRANIO. 2011;29(2):117.
56. Sano T, Yajima A, Otonari-Yamamoto M, Wakoh M,
Katakura A.Interpretation of images and discrepancy
between osteoarthritic ndings and symptomatology in temporomandibular joint. Jpn Dent Sci Rev.
2008;44(1):83–9.
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
203
57. Varol A, Sencimen M, Gulses A, Altug HA, Dumlu A,
Kurt B.Diagnostic importance of MRI and CT scans
for synovial osteochondromatosis of the temporomandibular joint. Cranio. 2011;29(4):313–7. https://
doi.org/10.1179/crn.2011.046.
58. Voudouris JC, Kuftinec MM. Improved clinical use
of twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in
treatment and long-term retention: growth relativity.
Am J Orthod Dentofac Orthop. 2000;117(3):247–66.
https://doi.org/10.1016/s0889- 5406(00)70231- 9.
59. Wang MQ, He JJ, Chen CS, Widmalm SE.A preliminary anatomical study on the association of condylar
and occlusal asymmetry. Cranio. 2011;29(2):111–6.
https://doi.org/10.1179/crn.2011.019.
60. Warhekar AM, Wanjari PV, Phulambrikar
T.Unilateral trid mandibular condyle: a case report.
Cranio. 2011;29(1):80–4. https://doi.org/10.1179/
crn.2011.011.
61. Yajima A, Sano T, Otonari-Yamamoto M, Otonari T,
Ohkubo M, Harada T, Wakoh M.MR evidence of characteristics in symptomatic osteoarthritis of the temporomandibular joint: increased signal intensity ratio
on proton density-weighted images of bone marrow
in the mandibular condyle. Cranio. 2007;25(4):250–6.
https://doi.org/10.1179/crn.2007.038.
62. Yavich LG.Alterações na orientação do côndilo mandibular devido a traumatismos na primeira infância.
JBA. 2001;1(4):270–9.
63. Yavich LG. Eletromiograa de superfície no diagnóstico e controle do tratamento das disfunções temporomandibulares. JBA. 2001;1(3):193–8.
64. Yavich LG. Paciente com disfunção temporomandibular apresentando assimetria condilar e micro
nódulos no terço anterior das pregas vocais. JBA.
2002;2(5):12–9.
65. Yavich LG. Princípios neuromusculares na
Odontologia, trajetória de fechamento habitual coincidente com a trajetória de fechamento neuromuscular. JBA. 2002;2(6):101–11.
66. Yitschaky O, Yitschaky M, Zadik Y. Case report
on trial: do you, doctor, swear to tell the truth, the
whole truth and nothing but the truth? J Med Case
Rep. 2011;5:179.
5- 179. PMID: 21569508; PMCID: PMC3113995.
https://doi.org/10.1186/1752- 1947-