CASE SUMMARY: Treatment of Bilateral TMJ disorder
What was causing her pain? There were no typical indicators:
• Periapical radiographs showed no decay, abscess, or bone loss.
• Panoramic Radiograph within normal limits.
• Transcranial Radiograph shows the normal anatomy of condyle heads and Glenoid fossae.
As a Prosthodontist, I have experience with complex dental problems, and with my TMJ specialization, I am able to diagnosis and treat difficult temporomandibular disorders. As a Prosthodontist, I have experience planning multistage treatments and can coordinate with a patient’s general dentist and other dental specialists.
I performed a full clinical examination, which included the following findings:
- MRI images were taken on close and maximum opening and showed bilateral anterior displaced articulating discs with reduction.
- Anne had a limited mandibular opening of 21 mm without pain and 28 mm with pain. With mandibular manipulation 40 mm with a slight increase of pain.
- Bilateral opening clicks noted at 21-25 mm.
- Lateral mandibular movement, left 9 mm and right 10 mm with some discomfort, but no TMJ noises.
- Protrusion 6 mm, but no TMJ noises.
- The muscle of mastication was sore to palpation. Both left and right lateral and medial Pterigoids were particularly painful to the touch, bilateral moderate capsulitis noted.
- Clinical examination corroborated MRI findings of bilateral articulating disc anterior displacement with reduction. Bilateral opening and closing clicks with mandibular manipulation, Maximum Opening (MO) 40 mm.
- An occlusal study noted that she had posterior bilateral interferences on lateral movement on 2/31 and 15/18. Centric relation was unstable by the lack or unstable tooth contact on 1st molars and premolars. Anterior guidance was missing bilateral cuspid rise.
My diagnoses for Anne were:
- Bilateral displaced discs with reduction
- Deficient mutually protected occlusion: Occlusal interferences, missing canine and anterior guidance.
• Impression taken and also delivered same-day maxillary full-coverage anterior reposition orthotic device (acetate + clear self polymerization acrylic) on a position where both articulating discs were reduced with only anterior contact for 1 week, used 24 hours a day. She was instructed to remove the device for eating / oral hygiene and given a prescription of 400mg
ibuprofen every 6 hours as needed for pain.
• Added posterior occlusal contacts on a flat plane to the same orthotic device, and Anne was still pain-free.
• Re-evaluation and adjusted as needed and she used this orthotic device for 1 more week.
• Step back to tentative centric relation and capture the same position with a centric relation orthotic device that had anterior and lateral protections. Anne was still pain-free and had all mandibular movement with a max opening of 39 mm, protrusion 7 mm, and lateral movement of right 10 mm and left 11 mm.
• Anne was maintained with same centric relation orthotic device for 2 more months with 24-hour use. She was seen weekly and we adjusted to a final centric relation position.
• Study casts were mounted again on a Denar articulator with facebow and protrusion and lateral records for occlusal evaluation.
• Anne was sent to an orthodontist to correct malocclusion. Mounted case on articulator provided to an orthodontist for an evaluation.
• Orthodontist treatment was done in 7 months and finished with a final minimal occlusal adjustment in our office. Thankfully we had a stable occlusion on centric with adequate anterior guidance.
• Lastly, a thermo-polymerization acrylic maxillary centric relation appliance was provided for night use.
We followed-up with Anne every 6 months for 2 years. She moved out of town for college and according to her father, she has been stable since completing our treatment.
This case had the following challenges:
1. Bilaterally affected joints.
2. Recapture both discs in centric relation and maintain them stable there.
3. History of being already treated by other colleagues.
4. She was the daughter of a friend!
If you have comments or questions about how I treated Anne from this Bilateral TMJ disorder, please email my office at email@example.com
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