ANA
LEARN ABOUT THE CASE OF ANA ALBERTO
CLINICAL CASE OF TEMPOROMANDIBULAR DISORDER
SUMMARY OF PATIENT HISTORY
Current disease history - about 20 years ago with TMJ clicks. She placed implants in 2017 and due to having had her mouth open for long periods of time, she says this resulted in a jaw dislocation. On that day she felt a lot of pain combined with limited mouth opening. Since then, it hasn’t clicked. Over the past few months, she has experienced difficulty in eating and progressively has the feeling that her mouth opens less. She used a brace without improvement. She underwent arthrocentesis with another doctor on the left TMJ on 7 February 2018, without improvement. She says she lost a lot of quality of life, and feels 7/10 pain (VAS) in the left TMJ. She claims to feel pain in the right TMJ that is actually non-existent and comes from the left TMJ.
MAIN COMPLAINTS
> Left TMJ pain 7/10 VAS
> Progressive limitation of mouth opening
> Difficulty in chewing
> Her teeth do not fit well
SUMMARY OF THE OBJECTIVE EXAMINATION
> Maximum mouth opening of 29 mm with deviation without correction to the left
> Left TMJ - left synovitis with clicking in the translation movement
> Right TMJ - mild synovitis, with displacement with reduction
> Grade 2 muscle contracture
DIAGNOSIS
RIGHT TMJ:
> ANTERIOR DISC DISPLACEMENT WITH REDUCTION,
LEFT TMJ:
> ANTERIOR DISC DISPLACEMENT WITH NO REDUCTION, DISC DRILLING + TMJ OSTEOARTHROSIS
> GRADE 2 MUSCLE CONTRACTURE
TREATMENT
> LEFT TMJ OPEN SURGERY - DISCECTOMY AND REGENERATION
> RIGHT TMJ ARTHROSCOPY - LEVEL 2
> BOTOX PROTOCOL
> STOMATOGNATHIC SYSTEM REHABILITATION
BEFORE AND AFTER
EVOLUTION OF PAIN IN THE LEFT AND RIGHT TEMPOROMANDIBULAR JOINT
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EVOLUTION OF MOUTH OPENING
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“ AFTER SURGERY, I HAVE A NEW AND PAIN-FREE LIFE. ”
Ana Alberto
TEAM IN CHARGE
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