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