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Difference between revisions of "4° Clinical case: Temporomandibular disorders"
4° Clinical case: Temporomandibular disorders (view source)
Revision as of 18:54, 30 July 2023
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=== Anamnesis === | === Anamnesis === | ||
[[File:Clicker 00.jpg|thumb|''' | [[File:Clicker 00.jpg|thumb|'''Figure 2:''' Oral situation of the patient affected by TMDs showing the anterior cross bite]] | ||
As usual, we call our patient with a fancy name and precisely 'Clicker' because the patient had been suffering from temporomandibular joint (TMJ) clicks for years. Clicker presented to our neuropathology department complaining of severe orofacial pain and reporting a chronic right TMJ joint removal. She arrived after having already been diagnosed as DTMs always following the RDC protocol and treated with a biteplane to manage the nocturnal teeth grinding only. She, a 40-year-old patient who reported orofacial pain with joint noises such as clicks and crashes on both sides of the face and difficulty in chewing. | As usual, we call our patient with a fancy name and precisely 'Clicker' because the patient had been suffering from temporomandibular joint (TMJ) clicks for years. Clicker presented to our neuropathology department complaining of severe orofacial pain and reporting a chronic right TMJ joint removal. She arrived after having already been diagnosed as DTMs always following the RDC protocol and treated with a biteplane to manage the nocturnal teeth grinding only. She, a 40-year-old patient who reported orofacial pain with joint noises such as clicks and crashes on both sides of the face and difficulty in chewing. | ||
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A first clinical occlusal examination shows a functional occlusal class III with sliding in protrusion in reaching the maximum intercuspidation. On palpation, the masseters, temporals, and external pterygoids on both sides were tender. No balance and gait disturbances, no vertigo, no tinnitus but as our routine we immediately performed trigeminal electrophysiological tests in order to avoid any structural involvement of the trigeminal Central Nevous System (<sub>t</sub>NCS). As already explained in the chapter concerning the 'Balancer' patient with Meningioma in which the interference EMG examination performed by the dental colleagues did not give indications of organic pathology of the tNCS in our Diagnostic Center we only perform Evoked Potentials and the battery of trigmeinal reflexes. In this chapter, taking into account the clinical situation, we have bypassed the purely dental context as, after an initial objective examination, the malocclusive disorder is striking but not certain (figure 2). | A first clinical occlusal examination shows a functional occlusal class III with sliding in protrusion in reaching the maximum intercuspidation. On palpation, the masseters, temporals, and external pterygoids on both sides were tender. No balance and gait disturbances, no vertigo, no tinnitus but as our routine we immediately performed trigeminal electrophysiological tests in order to avoid any structural involvement of the trigeminal Central Nevous System (<sub>t</sub>NCS). As already explained in the chapter concerning the 'Balancer' patient with Meningioma in which the interference EMG examination performed by the dental colleagues did not give indications of organic pathology of the tNCS in our Diagnostic Center we only perform Evoked Potentials and the battery of trigmeinal reflexes. In this chapter, taking into account the clinical situation, we have bypassed the purely dental context as, after an initial objective examination, the malocclusive disorder is striking but not certain (figure 2). | ||
[[File:Clicker 01.jpg|thumb|alt=|left|615x615px| | [[File:Clicker 01.jpg|thumb|alt=|left|615x615px|'''Figure 3:''' Neurognathological Functional electrophysiological tests]] | ||
==== Trigeminal electrophysiology ==== | ==== Trigeminal electrophysiology ==== | ||
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===== Silent period of the masticator muscles ===== | ===== Silent period of the masticator muscles ===== | ||
[[File:Clicker 3.jpg|thumb|''' | [[File:Clicker 3.jpg|thumb|'''Figure 4:''' Silent period of masticatory muscles and representation of areas of interest marked with arrows.|alt=|500x500px]] | ||
Figure 4 shows the neuromuscular responses of the silent period to chin percussion through a triggered neurological hammer when the patient was asked to clench her teeth maximally. If from a neurological point of view it is not possible to highlight elements referable to organic alterations of the <sub>t</sub>CNS, some electrophysiological characteristics, however, are to be referred to a functional disorder of the system. In the upper trace, a decrease in the motor neuron reactivation phase can be seen immediately following the silent period. The possible neurophysiological mechanism capable of determining a similar decrease in facilitatory activities on the mandibular silent period can be ascribed to a change in the spindle motor drive induced by the input of muscle proprioceptors and nociceptors. The neuronal network of this process would take place through a loop formed by: muscle nociceptive afferents, the subnucleus caudalis of the V, inhibitory interneurons on static motor neurons and, as a last link, the modulation of the sensitivity of the neuromuscular spindles..<ref>Ro J.Y.,Capra N.F.: Physiological evidence for caudal brainstem projections of jaw muscle spindle afferents.Exp.Brain Res 1999;128: 425-434</ref> <ref>Capra N.F.,Ro J.Y.: Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles. Pain 2000; 86: 151-162.</ref><ref>Appelberg B.,Hulliger M.,Johansson H.Sojka P.: Actions on g-motoneurones elicited by electrical stimulation of group III muscle afferent fibers in the hind limb of the cat.J Physiol. 1983;335: 275-292.</ref><ref>Macefield G.,Hagbarth E,Gorman R, Gandevia SC,, Burke D.: Decline in spindle support to a-motoneurones during sustained voluntary contractions.J.Physiol 1991;440:497-512.</ref><ref>Mense S.,Skeppar P.: Discharge behavior of feline gamma-motoneurones following induction of an artificial myositis.Pain 1991; 46: 201-210.</ref><ref>Pedersen J, Ljubisavljevic M, Bergenheim M.,Johansson H.: Alterations in information trasmission in ensembles of primary muscle spindle afferents after muscle fatigue in heteronymous muscle.Neuroscience 1998;84: 953-959.</ref> Also in this context the inhibitory component most likely prevails over the excitatory one and this could be ascribed to a malocclusion as we will see later. In particular, it can be noted the overlapping of the jaw jerk behavior, previously tested, in a path rectification condition. The arrow indicates the jaw jerk on all traces and the decrease in amplitude can be observed for the right masseter while it is relatively symmetrical on the temporal muscles.<br /> | Figure 4 shows the neuromuscular responses of the silent period to chin percussion through a triggered neurological hammer when the patient was asked to clench her teeth maximally. If from a neurological point of view it is not possible to highlight elements referable to organic alterations of the <sub>t</sub>CNS, some electrophysiological characteristics, however, are to be referred to a functional disorder of the system. In the upper trace, a decrease in the motor neuron reactivation phase can be seen immediately following the silent period. The possible neurophysiological mechanism capable of determining a similar decrease in facilitatory activities on the mandibular silent period can be ascribed to a change in the spindle motor drive induced by the input of muscle proprioceptors and nociceptors. The neuronal network of this process would take place through a loop formed by: muscle nociceptive afferents, the subnucleus caudalis of the V, inhibitory interneurons on static motor neurons and, as a last link, the modulation of the sensitivity of the neuromuscular spindles..<ref>Ro J.Y.,Capra N.F.: Physiological evidence for caudal brainstem projections of jaw muscle spindle afferents.Exp.Brain Res 1999;128: 425-434</ref> <ref>Capra N.F.,Ro J.Y.: Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles. Pain 2000; 86: 151-162.</ref><ref>Appelberg B.,Hulliger M.,Johansson H.Sojka P.: Actions on g-motoneurones elicited by electrical stimulation of group III muscle afferent fibers in the hind limb of the cat.J Physiol. 1983;335: 275-292.</ref><ref>Macefield G.,Hagbarth E,Gorman R, Gandevia SC,, Burke D.: Decline in spindle support to a-motoneurones during sustained voluntary contractions.J.Physiol 1991;440:497-512.</ref><ref>Mense S.,Skeppar P.: Discharge behavior of feline gamma-motoneurones following induction of an artificial myositis.Pain 1991; 46: 201-210.</ref><ref>Pedersen J, Ljubisavljevic M, Bergenheim M.,Johansson H.: Alterations in information trasmission in ensembles of primary muscle spindle afferents after muscle fatigue in heteronymous muscle.Neuroscience 1998;84: 953-959.</ref> Also in this context the inhibitory component most likely prevails over the excitatory one and this could be ascribed to a malocclusion as we will see later. In particular, it can be noted the overlapping of the jaw jerk behavior, previously tested, in a path rectification condition. The arrow indicates the jaw jerk on all traces and the decrease in amplitude can be observed for the right masseter while it is relatively symmetrical on the temporal muscles.<br /> | ||