Damon technique for orthodontic treatment of a patient with temporomandibular joint dysfunction

Abstract

The Damon system is an effective, less-invasive treatment that provides orthodontic dentists with an adequate biomechanical process, offering a reduction in treatment time; patients with temporomandibular dysfunction present even greater complexity in their clinical picture, relying on clinical and radiographic differential diagnoses to facilitate a good prognosis. The objective was to apply the orthodontic treatment (Damon technique) to stabilize patients with temporomandibular dysfunction. The patient with premature loss of the first lower molars (36 and 46) experienced pathological alterations in the temporomandibular joints (TMJs) (bilaterally). The diagnosis was reached using the clinical history of temporomandibular joint disorders (diagnostic criteria) axis II: moderate pain (VAS) in muscles, moderate stress (Hamilton 51/60), lateral and panoramic cephalic radiographs, magnetic resonance imaging of bilateral TMJ, cephalometry, photographs, and models. Treatment with the Damon system is recommended to recover optimal functional occlusion in a short period, followed by referral for oral rehabilitation as an adjunct to the treatment plan. The verticalization of the second molars, maximum optimal intercuspidation, appropriate overbite and overjet, and pain control in the TMJ were evaluated. Stabilization of the disc condyle complex by eliminating interference and premature points of contact providing cervical/cranio/mandibular balance.

Introduction

Temporomandibular parafunctions must be differentiated in an adequate way in a patient's diagnosis, before any dental treatment, if orthodontics is planned. It is important to consider that the previous extractions in the patients complicate the clinical picture even further.[1] Alteration of the components of the cervical–mandibular complex in the skull results in a disorder with obvious signs that include noises in the joint, such as clicks or crackles, pain in the suprahyoid muscles on palpation or during chewing, limitation of mandibular movements, alterations of opening and closing the oral cavity, involuntary contraction of the chewing muscles, headache, periodontal pain, diffuse facial pain, otalgia, and tinnitus.[2,3] Additional signs include degenerative changes, such as osteoarthritis and rheumatoid arthritis, which are frequent complications of improper management of patients with temporomandibular joint (TMJ) dysfunction. Damon (2016) recommends applying the system in which its biomechanical principle avoids extractions and protects against rhizolysis, which is indicated in patients with root dwarfism; this is a passive system, and there is no attachment that presses the arc against the slot at any time during treatment.[4,5] The orthodontist applies the biological force at the right time, and the impact produced has a positive effect, creating efficient dental movement. The objective was to apply the orthodontic treatment (Damon system) to stabilize the patient with temporomandibular dysfunction.

Case History

A 37-year-old man presented himself for consultation at the dental care center (Centro de Atencion Odontologica Universidad de Las Americas) for primary care according to the Consensus-Based Clinic Case Reporting (CARE) protocol. Joint discomfort was present with posterior pain in the neck, occasionally in the occipital and temporal regions [Figure 1a-c]; TMJ examination revealed the presence of joint noises in opening and closing. Finally, the diagnosis was as follows: disc dislocation with reduction, bilateral clicks in maximum aperture, joint hypermobility [Figure 2], moderate pain the visual analogue scale (VAS) in muscles according to the research diagnostic criteria for temporomandibulares disorders axis II questionnaire, moderate stress (Hamilton 51/60), premature points of contact, interferences in literalities, and protrusive and retrusive signs [Figures 3 and 4]. In addition, pieces 26, 16, 47, and 37 showed facets of wear on incisal edges and canines [Figure 5a and b]. Moreover, loss of space due to the inclination of the second molars was observed, and rotations in lower premolars were noted as lost teeth 36 and 46 [Table 1]. Orthodontic treatment with the Damon system was proposed, and informed consent was signed by the patient, indicating that he was aware of the risks [Figures 6 and 7].

Figure 1.

(a) Front Photo. (b) Right Profile. (c) Left Profile

Figure 2.

Initial xr_Panoramic

Figure 3.

Initial xr_ Lateral Cephalic

Figure 4.

Magnetic Resonance

Figure 5.

(a) Rigth Initital Intraoral. (b) Left Initial Introral

Table 1.

Plan

Bolton analysis (3 to 3)	Aforementioned dates
Summation of the lower teeth (3 to 3)	36 mm
Summation of the upper teeth (3 to 3)	50 mm
Range 3: 36/50 × 100	72%
Norm: 77.2% maxillary problem
Ideal max.	47
Discrepancy	3
Available maxillary space	103
Necessary maxillary space	103
Maxillary space required	0
Available mandibular space	74
Necessary mandibular space	62
Mandibular space required	12

Figure 6.

Maxilar Initial

Figure 7.

Mandibular Initial

Upper arcade cementing of self-ligating brackets in the Damon system was placed as initial arches: superior arch 0.16 NiTi/lower arch 0.14 NiTi brand Damon. They were collocated with an upper arc 14 × 25 NiTi/lower arc 0.16 NiTi following the Damon series. Open spikes compressed between 47/35 and 37, 35 is placed to avoid the inclination of teeth 47 and 37 due to the loss of teeth 46 and 36 used arches combined by superior 18 × 25/inferior 17 × 25 brand Damon was placed in the upper arcade of a mooring in the previous block. Arcs were augmented with superior 18 × 25 steel with mooring in block/17 × 25 lower arch steel with mooring in the anterior block from canine to canine and a chain between teeth 34 and 44. Torque overexpression was observed in the lateral incisors, so the investment was made in the cementation of brackets in teeth 12/22, with the goal of minimizing torque and controlling overexpression. In the lower arcade, the initial cementation carried out in premolar tooth 45 did not completely reverse the distal turn, so the bracket was relocated. In the lower arcade, the arches placed were upper arch 14 × 25 NiTi Damon/lower arch 0.16 NiTi Damon and upper arch 14 × 25 NiTi/lower arch 14 × 25 NiTi Damon. The upper 14 × 25 arch was maintained with internal metal ligation of teeth 13 to 23. In the inferior arches, the 14 × 25 NiTi arch was maintained with internal consolidation between teeth 33 and 43 plus chains between teeth 33/34 and 43/44. Damage was determined in the closing gate of bracket 31/32. It can be observed that teeth do not reach the expected alignment; subsequently, the bracket was changed, and the same arches were placed. The second lower premolars were still very distant from the first lower premolars, and a plan was made to continue advancing the series of arches with displacement and verticalization of the second molars. To achieve this, a superior/lower 18 × 25 NiTi arch was placed, with a spring of open spikes compressed in teeth 27, 17, 37, and 47 and premolars 35, 25, 15, and 45. The upper arch was consolidated internally with a 19 × 25 Brider arch with a crimpable hook for use with elastics. In the lower arcade, a change was made by an 18 × 25 steel arch with the consolidation of teeth 44 to 34 and a chain was placed between teeth 34 and 35 and between teeth 44 and 45. In the upper arch, the 19 × 25 Brider arch was maintained with internal consolidation, and in the lower arch, in the same way, the 18 × 25 steel arch with a spring of open spikes was compressed between the second molar and second premolar to recover the space for the first lower molars. A gate was released in the bracket on tooth 45, and there was a pushing force on the overbite or the premolar, creating a mesial turn, which is why a 0.14 NiTi arc was implemented to correct the rotation of tooth 45. The upper arcade was maintained. The upper arcade had no changes, and the arches were retained; the lower arc increased from 0.14 to 0.16, and panoramic radiography was requested so that parallelism could be assessed [Figure 8a and b].

Figure 8.

(a) Treatment rigth. (b) Treatment left

The control X-rays showed a lack of parallelism in the roots of canines that were relocated by brackets with an upper arch 19 × 25 Brider/inferior 14 × 25 NiTi. The upper arch 19 × 25 Brider consolidated from canine to canine was maintained, and in the lower arch, there was bracket loss in tooth 35. Therefore, a button was placed near the arc, consolidated, or near teeth 44 to 34 and a chain was placed between teeth 34 and 35 and between teeth 44 and 45. The upper arch was maintained, and the lower arch was changed to a 16 × 22 steel one. The chain was placed on teeth 34 to 35 for mesialization of the missing millimeters [Figure 9a and b]. The patient returned with closed spaces, and the button on tooth 35 was missing [Figures 10 and 11]. Delta elastics were used for interdigitation, removal of appliances, and containment placement [Figures 12 and 13].

Figure 9.

Final front treatment. (b) Final left treatment

Figure 10.

Final x-rx Panoramic

Figure 11.

Final x-rx Cephalic

Figure 12.

Maxilar Final

Figure 13.

Mandibular Final.

The spaces between teeth 46 and 36 are immediately replaced after the removal of the brackets with the placement of dental implants (Zimmer Tapered Screw-Vent, 4.1 x10 mm), waiting 21 days of osseointegration as indicated by the manufacturer, rehabilitating in this period completing with 2 crowns cement screwed in the form of premolar. The space that was recovered was not enough for the use of a molar.

Discussion

The extraction of the first lower molars during childhood as an involuntary course of action to save the masticatory function in this patient evidently triggered downstream events, which is in accordance with what was reported.[6] These occurrences, when maintained for a long period, were complicated and left sequelae in the neighboring and antagonistic teeth; wear on the upper–lower incisor edges was compatible with bruxism.[7,8] The differential diagnosis of TMD in the present study allowed us to collect a wide range of clinical manifestations (signs and symptoms) that, when compared with the rest of the population, coincide especially with muscle hypertonicity in the masseter, temporal, internal, and external pterygoids and with myalgia and obvious contractures[9,10]; this point is relevant, and because the treated patient's features were within these parafunctions, these factors were important when performing physical and clinical examinations to achieve an accurate diagnosis, thus allowing specialized care.[11,12] Traditionally, these disorders have been overlooked because they are considered only of interest to dental surgeons.[13] Within the process with the Damon system, an overexpression of the torque of the upper lateral incisors was observed, and torque control with an inversion in the direction of the bracket was required. Since the system is self-ligating, it does not use elastic bands.[14]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.