Testemunho - Carla Reis
 
 
 

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
 
 
 
 
 
 
 
 

BEFORE AND AFTER

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

EVOLUTION OF PAIN IN THE LEFT AND RIGHT TEMPOROMANDIBULAR JOINT

 
 
 
 

EVOLUTION OF MOUTH OPENING

 
 
 
 

“ Os estalidos foram embora e ganhei uma qualidade de vida que eu não tinha. ”

 
Carla Reis
 
 
 
Testemunho - Carla Reis
 
 
 
 
 

Equipa Responsável

 
 
Prof. Doutor David Ângelo
 
 
 
Dr. David Sanz
 
 
 
 
 
 

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