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Neuromuscular TMJ Dentistry Case History
Patient DescriptionFemale, age 57, school teacher
Principal ComplaintsWoman in her 50's, was referred to me by her oral surgeon for an evaluation. Her chief complaint was severe left facial pain of eight months duration and, recently, right facial pain. When asked to point to the area of pain, she pointed to the left mandibular angle.
Medical HistoryOne year ago, while the patient was eating a corn chip, her jaw popped very loudly and the pain started. The jaw was still clicking and rubbing.
She had previously suffered from migraines continuously for years which stopped suddenly in 1989 after back alignment and wisdom tooth extractions. For the past year, she had regular headaches and other TMJ symptoms.
Her history is significant for hypothyroidism, vertigo, allergic rhinitis, osteoporosis, osteoarthritis, scoliosis, carpal tunnel syndrome, 6 screws in her lower back for a slipped disc that was pinching a nerve to her leg, and acid reflux.
Oral ConditionAll teeth were present and WNL, with some bone loss on lower second molars. Lower molars were lingually inclined and upper molars had a mesial tilt.
The patient had braces on three occasions; in 1967, the upper only; in 1980, upper and lower; in 1993, upper and lower. Her mouth was slightly retrognathic and exhibited loss of vertical dimension.
Her radiographs showed normal joint anatomy, however the condyles were posteriorly displaced when the mouth was in closed position.
SymptomatologyCrepitation was present in TM joints, left TMJ had opening and closing click. Maximum opening was 45 mm. Lateral excursion was 7 mm right and 10 mm left.
Jaw pain on left side was constant. Her headaches lasted all day, they usually started upon awakening, sometimes later. Her neck pain was also constant.
She had ear pain on both sides, worse on the left. She was experiencing sharp pricks of pain all over her body, especially her right knee, causing her to stumble. Other symptoms were; vertigo, facial pain in sinus area, poor sleep, chronic fatigue, eye twitching, postnasal drainage, and memory problems.
MedicationsLexapro, Sprinolac, Forteo, Synthroid, Flonase, Allegra, Certuss, Nexium.
Treatment RecordAt her second diagnostic visit (three days after the first one), she was fitted with temporary occlusal guards to open the vertical dimension.
She returned 3 weeks later for placement of the Gelb MORA (mandibular oral repositioning appliance) and commented that most of her symptoms had improved. She left feeling very optimistic.
At her next appointment, four weeks later, the orthotic was adjusted, the premolar prematurities were removed, clasps tightened, and lingual bulk was removed to help her speech. The patient tested kinesiologically strong with a deltoid press while wearing the appliance, indicating that the jaw was in its correct position.
She was anxious to report that she no longer suffered from headaches and she was sleeping better and had more energy. Also earaches were gone, as was jaw pain, neck pain and facial sinus pain. Stabbing, pinching pains had stopped and her stumbling was better.
She felt less anxious and stressed out. Her eyes stopped twitching and postnasal drainage was less. One month later her maximum opening was 50 mm, her lateral excursions right and left were 12 mm, all back to normal.
The patient has been seen monthly to maintain orthotic at current level by relining the occlusion to maintain the correct Gelb 4/7 jaw position.
She no longer needs to take her medication for vertigo, no longer takes the Certuss and Flonase, occasionally takes the Allegra as needed.
She went on a short vacation and her appliance cracked, immediately the headaches started again and she had to start Nexium for the acid reflux, which recurred but went away again as soon as her appliance was repaired and her normal molar occlusion was restored.
The patient now feels like she is back to normal and ready to start Phase II treatment to expand and align her upper and lower jaws and open her vertical dimension so that she doesn't have to wear an orthotic the rest of her life.
It is interesting to note that after 8 months of treatment, she brought her 88 year old mother in, who also suffered from TMJ disorder, and has also seen much improvement since treatment began.
This case shows how dependent the patient is on the appliance keeping her jaw in the correct position 24/7. In Phase II, we will work toward adjusting her occlusion to permanently maintain the correct position without an appliance.
Risto E. Hurme, D.D.S.
Craniofacial Pain and TMJ Disorders
1017 Shook Avenue
San Antonio, TX 78212