Insightful case study on female patient requiring sedation for TMJ disfunction and other dental issues.
By Dipesh Sitaram DDS, MICCMO, FICCMO, OCF
A 69-year-old female was referred to me for treatment regarding TMJ disfunction. The patient stated the issue started 4-5 years ago when her jaws started to “pop” and became uncomfortably tight. The patient also reports that several of her crowns and bridges “came off." Even after seeking treatment for these problems, her condition did not improve.
Evaluation
Extraoral evaluation reveals symmetrical round face with lips behind the esthetic line with convex facial features. Evaluation showed forward head posture. Palpation of shoulder and neck creates severe pain on both sides with stiffness. Palpation reveals bilateral tenderness (severe): lateral/medial pterygoids, SCM, masseters, and anterior/posterior temporalis. There is generalized tooth wear/attrition and gingival recession along with cervical abfractions possibly due to occlusal loading and sleep bruxism. The mandible tracked forward of the maxilla on visual inspection.
Sagittal jaw motion tracking reveals poor posture of mandible on closure and overall poor velocity of motion.
Patient Stats:
- Height: 5’3"
- Weight: 140
- Meds: Gabapentin, Levothyroxine
- Mallampati Class II
- ASA II
Before images of the patient.
Treatment
Use of an intraoral orthotic directed towards orthopedic realignment of the mandible to the cranium to help stabilize the TM joints and restore them to normal physiological function, while also concomitantly reducing contracted (spastic) craniofacial and cervical musculature.
This will also help develop functional and resting modes within normal physiological parameters. The purpose of the orthopedic appliance is to align the mandible to the craniomaxillary complex optimally in three dimensions thereby relieving muscle, ligament, nerve, and vascular impingement.
Once this case was stable, we proceeded with full mouth reconstruction to establish permanent occlusion in stable form. It was agreed to do surgery with the use of IV sedation due to patient anxiety and extensiveness of dental surgery.
All existing restorations were removed, teeth were prepped for crowns. Patient tolerated treatment well and returned for seating of the restorations.
EMG's showing unstable terminal contact of teeth creating premature imbalance musculature activity.
Gneuromuscular Anatomical Orthotic
Anesthesia notes
Outcome
After final placement of restorations in this physiologic position, the patient has full function with no joint discomfort.
