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
236
ab
L. Yavi ch
a b
Fig. 30 Patient’s comparative images of the upper and lower occlusal views before (a) and (b) after completion of the
rst- and the second-phase treatment
Fig. 31 Comparative
panoramic radiographs:
(a) before treatment and
(b) after completion of
the three-dimensional
orthodontics
a
b
TMJ Pathology Treatment
237
ab c
Fig. 32 Comparative lateral radiographs of the patient: (a) at the beginning of the treatment in habitual occlusion, (b)
after the completion of the three-dimensional orthodontic, and (c) 6years after treatment conclusion
ab
Fig. 33 Patient’s kinesiographic records’ comparison: before and after the two phases of orthodontic treatment
238
L. Yavi ch
a
b
c
Fig. 34 Patient’s electromyography comparison: (a) before, (b) during the rst phase with the orthotic, and (c) after
the completion of the orthodontic treatment
ab
TMJ Pathology Treatment
Fig. 35 Patient’s kinesiographic records’ comparison after electronically mandibular deprogramming (a) before treat-
ment and (b) after treatment
239
Fig. 36 Threshold tonal audiometry 6years after the completion of the two phases of TMJ treatment
240
L. Yavi ch
4 Case 3
4.1 Mandible Condyle Fracture
Consolidation by
Neuromuscular
andPhysiological Alignment
oftheSegments, 4Months
After Unsuccessful Surgery
A 57-year-old male patient was referred by his
dentist. His principal complaints were lack of
strength when chewing, difculty in opening the
mouth, cervical pain, pain in the TMJs, and ringing in the left ear. History revealed that the patient
fell in the bathroom 4months before the consultation, hitting his jaw and fracturing his mandible. He was subsequently submitted to surgery
for a fracture of the symphysis and the left mandibular condyle (Fig.37). Upon physical examination, there were no obvious ndings, a
panoramic radiograph was ordered, and a nonunion of the left condyle was observed.
In the patient’s panoramic radiograph, one can
see asymmetric mandibular condyles and a radiopaque image compatible with an osteosynthesis
wire in the lower region of condylar on the left
side with bone fragment displacement (Fig.38).
In the region of the chin on the right, a horizontal
radiopaque image compatible with an osteosynthesis device for repair of the fracture of the anterior symphysis can be seen. Dental abnormalities
included missing dentition and a posterior open
bite on the left side (Fig.39).
A CT was ordered (Figs.40 and 41). The surface electromyographic record before electronic
deprogramming showed the right and left masseter muscles, the right trapezius muscle, and the
right digastric muscle with elevated activity at
rest. The activity of most of these muscles
lowered after electronic deprogramming
(Fig.42). Based on the case history and its clinical and radiographic features, this case was diagnosed as a nonunion fracture of the left mandibular
condyle.
Nonunion is a complication in mandibular
fractures. The causative factors include delay in
treatment, infection, inadequate immobilization,
and improper internal xation. Furthermore, a
concomitant infection may be present. Other suspected contributory factors included a failure to
receive antibiotics, delay in treatment, teeth in
the fracture line, alcohol and drug abuse, inexperience of the surgeon, and lack of patient compliance. Generally, treatment of nonunion consists
of standard techniques of debridement, antibiotic
therapy, and further immobilization. We referred
Fig. 37 Patient’s panoramic radiograph on the day of consultation showing a nonunion of the left condyle (arrow)
TMJ Pathology Treatment
Fig. 38 Magnication of the left mandibular condyle on
the panoramic radiograph demonstrating attempted wire
synthesis
the patient back to the surgeon where a new surgical procedure was proposed. The patient
refused to undergo another surgical procedure.
Considering the patient’s refusal of revision
surgery, a conservative approach was then proposed. The patient was informed about possible
limitations due to his age. Ultralow-frequency
and low-amplitude transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax
the masticatory muscles to record the rest position of the mandible. The mandibular rest position was recorded after electronic deprogramming,
together with the information from the MRI to
orient bite registration, and a three-dimensional
orthotic was fabricated (Fig.43). The patient had
241
a pathological free space of 6.4mm and 4.3mm
of mandibular retro-position. This tridimensional
mandible rest position was recorded in the form
of a bite occlusal registration, which was later
used to construct an orthotic (Fig. 44). This
removable mandibular appliance must be worn
during the day and night. This intraoral appliance
tested by electromyography and kinesiographically supports the neuromuscular physiological
position. The patient was asked to wear the intraoral appliance full-time and to remove it only for
cleaning. The dynamic evaluations improved,
and the patient felt no more pain or chewing difculty. During the treatment, new orthotics in
neuromuscular physiological position were constructed (Fig.45).
A second panoramic radiograph was taken
after 3months. The new panoramic radiograph
(Fig.46b) showed an improvement in the condyle position. Finally, 4months after the second
panoramic radiograph, a third image (Fig.46c)
was ordered where union of the fracture was
demonstrated. These images show (a) the day of
the rst consultation with the habitual occlusion; (b) 3months later with the rst orthotic;
and (c) 7months after the rst consultation with
a new orthotic; an improvement of condyle
position and the bone union can clearly be seen.
It is important to note the changes not only in
the images but also in the occlusion with the
orthotics as the muscles adjust to a more physiological position. A new CT was ordered
(Fig. 47) and clearly showed the union of the
fracture without subjecting the patient to a second surgery and without using any maxillomandibular xation (MMF).
Fractures of the mandibular condyle are one
of the most commonly occurring mandibular
fractures. Management of these fractures has
always been a controversial issue. One of the
complications of mandibular condyle fracture is
nonunion. Fractures, where the muscles tend to
draw fragments together, are more favorable than
those fractures where the muscles tend to draw
fragments apart. The distraction of fracture
fragments is observed in many mandibular condyle fractures. The most observed type is the displacement of the condyle head to the anteromedial
242
Fig. 39 Patient’s habitual occlusion on the day of consultation
Fig. 40 CT sagittal slices conrming the nonunion of the mandibular condyle fracture 4months after surgery
L. Yavi ch
Fig. 41 3D reconstruction showing nonunion of the mandibular condyle fracture 4months after surgery
side because of lateral pterygoid muscle action.
The ability to place the mandible in a spatial relationship by measuring the masticatory muscles at
their resting length can be an important auxiliary
tool to assist in the rehabilitation of condylar
fractures.
TMJ Pathology Treatment
a
b
243
Fig. 42 Comparative rest electromyography (a) before and (b) after electronic deprogramming
Fig. 43 Graphic record of the mandible tridimensional position after electronic deprogramming
244
Fig. 44 First orthotic constructed in a neuromuscular and physiological position
Fig. 45 Second orthotic constructed in a neuromuscular and physiological position
ab c
L. Yavi ch
ab c
Fig. 46 Comparative images of the rst (a), second (b), and third (c) left condyle on the section of the panoramic
radiographs
TMJ Pathology Treatment
Fig. 47 CT sagittal slices conrming the union of the mandibular condyle fracture following treatment
245
5 Case 4
5.1 Patient withAutoimmune
Disease andaCompressive
Noninammatory TMJ
Pathology
A 40-year-old female patient, with a diagnosis of
seronegative spondyloarthropathy, later diagnosed as ankylosing spondylitis, came to the
clinic referred to by her rheumatologist. The
patient was complaining of intense pain of the
TMJ, dysesthesias of the head, and mouth opening limitation. Seronegative spondyloarthropathies refer to a group of diseases that share
common characteristics including the occurrence
of inammation in the spine, peripheral joints,
and, in various peri-articular tissues, entheses
(where tendons and ligaments insert onto bones).
The outstanding feature of seronegative spondyloarthropathies is the absence of rheumatoid factor and autoantibodies in the laboratory tests.
Seronegative spondyloarthropathies have a
strong association with human leukocyte antigen
HLA-B27. The patient reported that she had been
diagnosed at age 39 with arthritis when all her
major joints, such as the knee and elbow, on the
left side suddenly became inamed. Swelling,
redness, and intense pain prevented her from performing simple movements such as standing and
extending her arm.
When she started to feel pain in the TMJ, she
consulted an orthodontist and facial orthopedist
who informed her that she had “bruxism” and
that she needed to use a device to place her tongue
in the correct position. She wore the appliance for
a month, and then her TMJ locked. She could not
open her mouth and felt an extreme pain in her
entire head. At this point, she no longer knew
what hurt more, the joints of the body or her head
and mouth. She stressed that there was no medication that could ease the pain she felt in the TMJ
and in the cervical spine. Her rheumatologist was
apprehensive that she could have arthritis in the
TMJ and immediately referred her.
She reported clicking on the right TMJ, difculty opening the mouth, difculty and pain with
chewing, and bruxism. She also felt strong headaches, neck pain, pain in the right eyebrow, pain
behind the eyes, pain in the right shoulder, and
pain in both temporomandibular joints, stronger
in the right joint (Figs. 48 and 49). In the rst
consultation, the patient reported that she had initiated treatment for bruxism and that upon her
orthotic being changed, she began to feel a very
intense pain and her mouth locked.
The radiographic image of the joint (Figs.50
and 51) shows the superior and posterior positioning of the articular process on the left side
(highlighted in red) in the joint cavity when the
jaw is in maximal intercuspation. In the maximum opening position, there is a attening of the
posterior and anterior surface of the left mandibular condyle process (highlighted in red) and a
attening of the superior and anterior surface of
the right mandibular condyle process (highlighted in blue). The right side also presents an
alteration of the growth axis of the mandibular
condyle.
Opening and closing computerized kinesiographic records show that the patient can open
only 32mm, which is a signicant limitation.
The skull model image shows the difference in
the translation of the mandibular condyles