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Structural Misalignment: Postural Changes Related toTemporomandibular Joint Pathology
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39. Stack B, Sims A. The relationship between posture and equilibrium and the auriculotemporal
nerve in patients with disturbed gait and balance.
Cranio. 2009;27(4):248–60. https://doi.org/10.1179/
crn.2009.036.
40. Wiest DM, Candotti CT, Sedrez JA, Pivotto LR, da
Costa LMR, Loss JF. Severidade da disfunção temporomandibular e sua relação com a postura corporal.
Fisioterapia E Pesquisa. 2019;26(2):178–84. https://
doi.org/10.1590/1809- 2950/18037026022019.
41. Xiao CQ, Wan YD, Li YQ, Yan ZB, Cheng QY,
Fan PD, Huang Y, Wang XY, Xiong X. Do tem-
poromandibular disorder patients with joint pain
exhibit forward head posture? A cephalometric
study. Pain Res Manag. 2023;2023:7363412. https://
doi.org/10.1155/2023/7363412. PMID: 36776487;
PMCID: PMC9911253.
42. 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-
TMJ Pathology Treatment
LidiaYavich
1 Introduction
Four clinical cases are presented and the cases are to
emphasize their respective nuances and encourage
reporting and publication of complex TMD cases.
Images and bioinstrumentation measurements are
presented as well as highlights from the clinical histories. One case is presented in its two complete
phases, and the other three clinical cases aim to
point out the improvements that can be achieved.
As mentioned previously, TMJ can be affected
by local and systemic pathologies, trauma, infections, autoimmune diseases, and occlusal problems among other etiologies. All these etiological
factors can act separately or in concert, making
the clinical case more difcult to resolve and
modifying expectations of the patient and practitioner for resolution.
2 Case 1
2.1 TMJ Pathologies inChildren
andTeenagers:
TheOverlooked Diagnosis
The importance of this case report is that structural improvements were achieved in the rst
phase of treatment. Can treatment sometimes
L. Yavich (*)
SBPAT, The Brazilian Society for Diagnosis and
Treatment of Temporomandibular Joint Pathologies,
Attending, Clinica My, Porto Allege, RS, Brazil
improve the TMJ pathological situation, or prevent it from worsening? This case report draws
attention to TMJ pathologies in children and
teenagers where the TMJ may be compromised.
2.2 Case Report
A 14-year-old female patient presented to the
clinic complaining 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
origin of the clicking noise (Fig.1). The patient’s
occlusion suggests a simple case. It is expected to
be very easy to evaluate and diagnose the need
for a superior expansion to accommodate and
advance the mandible and afterward to treat the
vertical deciency (Figs.2 and 3). With this lami-
nography, one can see the retro-position of the
left closed-mouth TMJ (highlighted in red), the
change in the growth axis direction on this same
side, and the loss of joint space on both sides.
These images do not show the articular disc condition or the ligaments which can only be seen in
an MRI.The panoramic radiograph for the temporomandibular joints cannot be compared to a
CT scan of the temporomandibular joints and is a
basic examination for the TMJ.
When evaluating a functional failure, one
must consider all the etiologic factors involved in
the dysfunction. The patient reports a trauma
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
B. C. Stack Jr. et al. (eds.), Craniofacial Pain, https://doi.org/10.1007/978-3-031-57563-1_13
217
218
Fig. 1 Intraoral records of the patient’s habitual occlusion
L. Yavi ch
Fig. 2 Patient’s initial panoramic radiograph
when she was a child, “I hit my neck, near my
chin, playing on the bedside table.” A change in
the direction of the growth axis does not happen
physiologically. It is very common for patients
not to remember these childhood traumas.
Besides the rectication of the cervical spine,
there is the start of an inversion of the physiological curvature from C4 (Fig.4). Cephalometry is a
very important part of the diagnosis and treatment of cases, both in orthodontics and facial
orthopedics; however, it is not an exam to show
the pathology of temporomandibular joints. An
MRI of the temporomandibular joints was
ordered (Figs.5 and 6).
The two slices, (1) external and (2) medial,
show irregularity of the bone cortex and anterior
articular disc dislocation. Even though CT is the
method par excellence for observing bone erosions, studies comparing bone erosion scores
and quantitative measures of erosions in RA
joints on CT and MR images demonstrate very
high intramodality and intermodality agree-
TMJ Pathology Treatment
a
b
219
Fig. 3 Laminography of the temporomandibular joints in the closed and open mouth (a). (b) The same images with
color highlights
Fig. 4 Patient’s initial lateral and cervical spine (left) radiograph with a cephalometric tracing (right), all before
treatment
ment. Medial slice (1) shows superior attening,
an anterior marginal osteophyte, and articular
disc dislocation. External slice (2) also shows
superior attening and anterior articular disc
dislocation. This is the TMJ of a 14-year-old
girl!
Systemic diseases, traumas, infections, damage to growth centers, and muscle balance disruption can profoundly inuence the craniofacial
complex during this critical growth phase. There
was no crepitus, nor pain in the TMJ was present,
only a click.
220
ab
ab
Fig. 5 MRI: two slices of the left TMJ closed mouth before treatment
L. Yavi ch
Fig. 6 MRI two slices of the right TMJ closed mouth before treatment
If one cannot improve this situation because
of the sequelae of different etiologies, the next
step is to analyze if one can prevent it from worsening and improve the patient’s life quality. The
patient should be informed about the difculties
and limitations of their cases.
For a dynamic record of SEMG (Fig.7), the
patient is asked to open her mouth, clench, and
swallow. In this record, one can observe that the
patient cannot maintain strength in clenching,
even though she was instructed to clench her
teeth and not to open for the duration of the
ca
ab
cd
TMJ Pathology Treatment
b
Fig. 7 Initial dynamic electromyography (a) in habitual occlusion (b) and jaw tracker data (c)
221
Fig. 8 Comparison of the SEMG records of the patient, (a, b) in habitual occlusion and (c, d) with orthotic in place
exam. Her masticatory muscles were electronically deprogrammed with a dental TENS unit,
and a bite record in neuromuscular physiological position was registered using a jaw tracker.
The information obtained from the images and
the individualized objectives for each clinical
case should always be considered in the bite
registration. Bioinstrumentation is a useful tool
but is only a part of the decision on bite
registration.
tial MRI.We can notice an improvement in the
cervical spine physiological curve and an
increase in the intervertebral spaces (Fig.10). In
all these images, Figs.11, 12, 13, 14, 15 and 16,
we can observe the improvement in the relationship between the mandible head and the articular disc and the positive remodeling of the
cortical bone.
In this specic case, the questions that have to
be asked are the following:
The patient had a pathological free space of
4.3mm and a retro-position of 2.1mm. With this
data, an orthotic can be fabricated. This device is
electromyographically tested to represent the
ideal muscle position. With dynamic electromyography (Fig.8), and with the orthotic in a neuro-
• Was there a pathologic condition of the
patient’s TMJ? If so, which structures were
affected?
• Is it possible to heal or improve the damaged
structures?
muscular physiological position, the patient can
maintain the strength of the bite. In fact, she
increased the strength of the masseters and balanced both digastric muscles.
These images showing the joint decompression (Fig. 9) do not reveal the position of the
articular disc nor the improvement of the irregularities on the cortical bone observed in the ini-
The goal is to bring these structures as close to
a healthy function as possible. Is this always possible? When it is possible, the structures must be
improved. Differential diagnosis allows us a differential prognosis: favorable or not. Not all
arthropathies will have the same result as this
case.
222
ab
L. Yavi ch
a
b
Fig. 9 (a) Laminography of the temporomandibular joints in the closed and open mouth with the orthotic constructed
in neuromuscular physiological position; (b) the same image with color highlights
Fig. 10 Patient’s lateral and cervical spine comparison: (a) in habitual occlusion and (b) with the orthotic constructed
in neuromuscular physiological occlusion
ab
ab
TMJ Pathology Treatment
Fig. 11 Comparative MRI images of the left TMJ sagittal external slice, closed mouth position, (a) before treatment
and (b) after the rst phase of the treatment
223
Fig. 12 Comparative MRI images of the left TMJ, sagittal medial slice, closed mouth position, (a) before treatment
and (b) after the rst phase of the treatment
224
ab
ab
Fig. 13 Comparative MRI images of the left TMJ, sagittal internal slice, closed mouth position, (a) before treatment
and (b) after the rst phase of the treatment
L. Yavi ch
Fig. 14 Comparative MRI images of the right TMJ, sagittal external slice, closed mouth position, (a) before treatment
and (b) after the rst phase of the treatment
ab
ab
TMJ Pathology Treatment
Fig. 15 Comparative MRI images of the right TMJ, sagittal medial slice, closed mouth position, (a) before treatment
and (b) after the rst phase of the treatment
225
Fig. 16 Comparative MRI images of the right TMJ, sagittal internal slice, closed mouth position, (a) before treatment
and (b) after the rst phase of the treatment