CLINICAL CASE OF TEMPOROMANDIBULAR DISFUNCTION
Summary of the Patient's History
The patient began experiencing popping sounds in the temporomandibular joints (TMJ) over 5 years ago. This was the first sign he detected. Following this, he experienced bilateral pain and episodes of a locked jaw. He decided to seek help from the rheumatology department of a hospital, where the colleague quickly realized he might be facing a case of temporomandibular dysfunction and referred him to the Portuguese Institute of the Face.
The patient reports having to turn his head to open his mouth.
MAIN COMPLAINTS
> Douleur aux ATM (douleur de 8/10 à l'ATM droite et douleur de 6/10 à l'ATM gauche)
> Crépitements
> Limitation de l'ouverture de la bouche
> Céphalées
> Articulation bloquée
> Tension des muscles mastication
> Tension des muscles cervicaux
SUMMARY OF THE OBJECTIVE EXAM
> Arthralgia, popping, and crepitus of the right TMJ
> Popping of the left TMJ
> Maximum oral opening of 31mm, without deviations
DIAGNOSTIC
RIGHT ATM
> Displacement of the disc with reduction, Osteoarthritis, and Arthralgia (confirmed by MRI and CT)
> Without myalgias or headaches.
RIGHT ATM
> Disc detachment without reduction, Osteoarthritis, and Arthralgia (confirmed by MRI and CT)
> Without myalgias or headaches.
PLAN
> Arthroscopy of the right and left TMJ N2, with disc repositioning + infiltration of Ropivacaine + Super PRP
> Physical therapy protocol from the Portuguese Institute of the Face
EVOLUTION
"AMO pre-op 31 mm >> 6M post-op >> AMO 44 mm
ATM pain pre-op 7/10 >> 6M post-op >> 0/10
Left ATM pain pre-op 7/10 >> 6M post-op >> 0/10"
BEFORE AND AFTER
"I can now open my mouth normally."
João Monteiro
RESPONSIBLE TEAM
