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Difference between revisions of "4° Clinical case: Temporomandibular disorders"
4° Clinical case: Temporomandibular disorders (view source)
Revision as of 08:53, 9 August 2023
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===== Jaw jerk in rest position ===== | ===== Jaw jerk in rest position ===== | ||
The jaw jerk, keeping the mandible in a position of centric occlusion, performed to verify the contribution of the periodontal receptors together with the muscle and tendon proprioceptors, was obviously facilitated by the dental contact but the asymmetry in amplitude (<math>2R-3R= 0, 1 | The jaw jerk, keeping the mandible in a position of centric occlusion, performed to verify the contribution of the periodontal receptors together with the muscle and tendon proprioceptors, was obviously facilitated by the dental contact but the asymmetry in amplitude (<math>2R-3R= 0, 1 | ||
</math>mV; <math>2L-3L= 1</math> mV) increased. This result agrees with what was stated in a study by Yoshino T et al.<ref>Yoshino T.Kokubyo Gakkai Zasshi. Effects of lateral mandibular deviation on masseter muscle activity. 1996 Mar;63(1):70-87. doi: 10.5357/koubyou.63.70.PMID: 8725358 </ref> in which the mandibular position was deviated by 0.5, 1.0, 1.5, 2.0 and 3.0 mm to the right and left from a reference position corresponding to the rest position. Jaw jerk amplitude on the mediotrusive side increased primarily in proportion to mandibular deviation. The study concludes by suggesting that jaw jerk may aid the clinical examination of minor mandibular deviations. The conclusion of this 1st trigeminal electrophysiological step was to ascertain the organic integrity of the <sub>t</sub>CNS through the symmetry and synchronics of the <sub>b</sub>Root-MEPs,<ref name=":1" /> and consider it as an 'Organic Symmetry',<ref>G Frisardi, G Chessa, A Lumbau, S Okkesim, B Akdemir, S Kara, F.Frisardi. The Reliability of the Bilateral Trigeminal Roots-motor Evoked Potentials as an Organic Normalization Factor: Symmetry or Not Symmetry. Dentistry S2 8, 2161-1122</ref> i.e. normalizer of the masticatory neurophysiological process while the asymmetries of the jaw jerk a functional disorder due to an unbalanced peripheral input or an inhibitory process on the trigeminal motoneurons of the nociceptive type. In essence, the conclusion of a mandibular spatial disorder would seem more indicative, which we will ascertain later when the Neuro Evoked Centric Relationship is performed to verify the physiological spatial position. | </math>mV; <math>2L-3L= 1</math> mV) increased. This result agrees with what was stated in a study by Yoshino T et al.<ref>Yoshino T.Kokubyo Gakkai Zasshi. Effects of lateral mandibular deviation on masseter muscle activity. 1996 Mar;63(1):70-87. doi: 10.5357/koubyou.63.70.PMID: 8725358 </ref> in which the mandibular position was deviated by 0.5, 1.0, 1.5, 2.0 and 3.0 mm to the right and left from a reference position corresponding to the rest position. Jaw jerk amplitude on the mediotrusive side increased primarily in proportion to mandibular deviation. The study concludes by suggesting that jaw jerk may aid the clinical examination of minor mandibular deviations. The conclusion of this 1st trigeminal electrophysiological step was to ascertain the organic integrity of the <sub>t</sub>CNS through the symmetry and synchronics of the <sub>b</sub>Root-MEPs,<ref name=":1" /> and consider it as an 'Organic Symmetry',<ref>G Frisardi, G Chessa, A Lumbau, S Okkesim, B Akdemir, S Kara, F.Frisardi. The Reliability of the Bilateral Trigeminal Roots-motor Evoked Potentials as an Organic Normalization Factor: Symmetry or Not Symmetry. Dentistry S2 8, [tel:2161-1122 2161-1122]</ref> i.e. normalizer of the masticatory neurophysiological process while the asymmetries of the jaw jerk a functional disorder due to an unbalanced peripheral input or an inhibitory process on the trigeminal motoneurons of the nociceptive type. In essence, the conclusion of a mandibular spatial disorder would seem more indicative, which we will ascertain later when the Neuro Evoked Centric Relationship is performed to verify the physiological spatial position. | ||
===== Silent period of the masticator muscles ===== | ===== Silent period of the masticator muscles ===== | ||
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Sebastian Silva Ulloa, Ana Lucía Cordero Ordóñez, Vinicio Egidio Barzallo Sardi }}Therefore, it is essential to operate in synergy with the trigeminal neuromotor content in order to have an 'Observable' more indicative of the masticatory reality and in this case of the real spatial position that the jaw wants to reach beyond the dental interference. To achieve this target we have developed a method of simultaneous Transcranial Electrical Stimulation of the trigeminal roots which evokes a direct response of all the masticatory muscles which we call <sub>b</sub>Root-MEPs as previously mentioned which has an indication of the 'state' integrity of the <sub>t</sub>CNS and at the same time it determines an elevation of the mandible from the rest position to the Occlusal Centric. This Centric has been named by us Functional Neuro Evoked Centric. (Figure 5) | Sebastian Silva Ulloa, Ana Lucía Cordero Ordóñez, Vinicio Egidio Barzallo Sardi }}Therefore, it is essential to operate in synergy with the trigeminal neuromotor content in order to have an 'Observable' more indicative of the masticatory reality and in this case of the real spatial position that the jaw wants to reach beyond the dental interference. To achieve this target we have developed a method of simultaneous Transcranial Electrical Stimulation of the trigeminal roots which evokes a direct response of all the masticatory muscles which we call <sub>b</sub>Root-MEPs as previously mentioned which has an indication of the 'state' integrity of the <sub>t</sub>CNS and at the same time it determines an elevation of the mandible from the rest position to the Occlusal Centric. This Centric has been named by us Functional Neuro Evoked Centric. (Figure 5) | ||
<center> | <center> | ||
<gallery widths=" | <gallery widths="250" heights="200" perrow="3" slideshow""=""> | ||
File:Clicker 00.jpg|'''Figure 5a:''' Presumably pathological usual occlusal position, with anterior crossbite and wear of the central incisors | File:Clicker 00.jpg|'''Figure 5a:''' Presumably pathological usual occlusal position, with anterior crossbite and wear of the central incisors | ||
File:Barberini21.jpg|'''Figure 5b:''' Positioning of the recording electrodes on the masseters on both sides and of the electrodes to evoke the direct response from the trigeminal roots | File:Barberini21.jpg|'''Figure 5b:''' Positioning of the recording electrodes on the masseters on both sides and of the electrodes to evoke the direct response from the trigeminal roots | ||
File:Barberini2.jpg|'''Figure 5c:''' Result of mandibular elevation from resting position to Centric Neuro Evoked Functional via bRoot-MEPs | File:Barberini2.jpg|'''Figure 5c:''' Result of mandibular elevation from resting position to Centric Neuro Evoked Functional via bRoot-MEPs | ||
</gallery> | </gallery> | ||
</center> | </center> | ||
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=== Functional Neuro Gnathological rehabilitation === | === Functional Neuro Gnathological rehabilitation === | ||
Regarding the treatment of patients with TMDs there are still many strategic-conceptual conflicts such as, for example, the use of TENS<ref>Didier HA, Cappellari AM, Gaffuri F, Curone M, Tullo V, Didier AH, Giannì AB, Bussone G. Predictive role of '''gnathological''' techniques for the '''treatment''' of persistent idiopathic facial pain (PIFP). Neurol Sci. 2020 Nov;41(11):3315-3319. doi: 10.1007/s10072-020-04456-9. Epub 2020 May 21.PMID: 32440980</ref> which the RDC protocol has considered clinically invalid as much as from a neurophysiological point of view TENS is not an appropriate method for not being able to evoke a response from all masticatory muscles but only the superficial ones. In this limitation lies the spatial error of the mandibular position which would be in a more anterior position due exclusively to the motor response of the masseter muscle (a topic which will be dealt with in the section 'Crisis of the Paradigm'). | Regarding the treatment of patients with TMDs there are still many strategic-conceptual conflicts such as, for example, the use of TENS<ref>Didier HA, Cappellari AM, Gaffuri F, Curone M, Tullo V, Didier AH, Giannì AB, Bussone G. Predictive role of '''gnathological''' techniques for the '''treatment''' of persistent idiopathic facial pain (PIFP). Neurol Sci. 2020 Nov;41(11):[tel:3315-3319 3315-3319]. doi: 10.1007/s10072-020-04456-9. Epub 2020 May 21.PMID: 32440980</ref> which the RDC protocol has considered clinically invalid as much as from a neurophysiological point of view TENS is not an appropriate method for not being able to evoke a response from all masticatory muscles but only the superficial ones. In this limitation lies the spatial error of the mandibular position which would be in a more anterior position due exclusively to the motor response of the masseter muscle (a topic which will be dealt with in the section 'Crisis of the Paradigm'). | ||
For this reason we bypass the manufacture of a bite plane to arrive directly at the definitive neurognathological prosthetic rehabilitation. In this specific case it was a Functional Neuro Evoked Centric rehabilitation of the anterior incisors and the four lower molars, two per side. The realization, however, followed some particularly obligatory pre-ordered steps which represent the best way to achieve real neuro-occlusal stability, as we will see in detail below. (figure 6) | For this reason we bypass the manufacture of a bite plane to arrive directly at the definitive neurognathological prosthetic rehabilitation. In this specific case it was a Functional Neuro Evoked Centric rehabilitation of the anterior incisors and the four lower molars, two per side. The realization, however, followed some particularly obligatory pre-ordered steps which represent the best way to achieve real neuro-occlusal stability, as we will see in detail below. (figure 6) | ||