CARLA
LEARN ABOUT THE CASE OF CARLA REIS
CLINICAL CASE OF TEMPOROMANDIBULAR DISORDER
SUMMARY OF PATIENT HISTORY
Current disease history – she has felt TMJ clicks since she was a young girl. About 7 years ago, she started pain in both TMJs. She used a brace but feels better without it. Refers to difficulty in eating, and to progressive decrease in mouth opening. Pain has been more intense and is aggravated when chewing.
MAIN COMPLAINTS
> TMJ clicks
> Difficulty in chewing
> Progressively limited mouth opening
> Right TMJ pain 8/10 VAS
> Left TMJ pain 5/10 VAS
SUMMARY OF THE OBJECTIVE EXAMINATION
> Objective Examination – Maximum mouth opening 26 mm without deviation
> Right TMJ: G2 Synovitis (pain on mouth opening) with suspected anterior disc displacement without reduction
> Left TMJ: suspected anterior displacement of the disc with reduction
> Grade 2 muscle contracture
DIAGNOSIS
RIGHT TMJ:
> ANTERIOR DISPLACEMENT OF THE DISC WITH REDUCTION WITH ARTICULAR SPILL
LEFT TMJ:
> ANTERIOR DISPLACEMENT OF THE DISC WITH REDUCTION
> GRADE 2 MUSCLE CONTRACTURE
TREATMENT
> RIGHT TMJ ARTHROSCOPY - LEVEL 2
> LYSIS AND WASHING ARTHROCENTESIS WITH LEFT TMJ VISCOSUPPLEMENTATION
> BOTOX PROTOCOL
> STOMATOGNATHIC SYSTEM REHABILITATION
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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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"THE CRACKLING IS GONE AND NOW I HAVE A QUALITY LIFE I NEVER HAD BEFORE"
Carla Reis
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