Units

The temporomandibular Joint disorders (TMD or ATM) (ver documentación) can’t nowadays be conceived with a simple vision, as if it was an easy problem, located only in the jaw. Many of the patients who consult for this problem need a multidisciplinary approach, where the participation of different specialists of the health complements the approach and the treatment of a complex pathology.

An integrated vision, not a reductionist, that can need the support and the evaluation of different specialists, allows us to offer good results in the treatment of our patients.

We integrate a team of Dentists, Maxillofacial Surgeons and Physiotherapists, that working jointly we have managed to offer good results in the treatment of the TMD of our patients to way and long term.
Having a hospitable environment, allows us to collaborate closely with other specialists directly or indirectly related with this pathology (ORL, Neurologists, Psychologists, Psychiatrists or Specialists in Clinic of the Pain).

The skills of minimally invasive surgery of the TMD (infiltrations, arthrocentesis and arthroscopy (ver vídeo)) allow the resolution of an important number of dysfunctions of the temporomandibular joint. The Physical therapy and the Osteopathy (ver documentación) play a fundamental role as therapeutic complement. Nowadays, it is being investigated by regenerative therapies of the joint injuries through plasma rich in factors of growth or mother cells and it seems that the preliminary results are promising in some cases of ostechondral injuries.

The bruxism (grinding or tightening of the teeth) represents the most frequent cause of temporomandibular dysfunction. The treatment of this parafunction consists of investigating and treating its cause, as well as re-educating the patient by means of skills that diminish this bad habit. The use of day and/or night discharge splints tries to relax the masticatory musculature and avoids the collateral damages that take place in the teeth (wear, mobility or breaks) and finally in the temporomandibular joint (osteoarthritis).

Some patients present dental malocclusion problems. Many of these problems are previous results of dental treatments, made frequently some time ago, but associated with a surcharge (for example: stress), provoke pain in the temporomandibular joint. An occlusal analysis by the Dentist with the Tesckan® technology, can allow us to know the existing degree of occlusal alteration and correct it.

In other occasions, the occlusal alteration cannot be solved by an occlusal adjustment and in case of a dentoesical malocclusion; the evaluation of the same one will allow our team of Maxillofacial Surgery and Orthodontics to evaluate the most suitable treatment. Many cases will be able to be treated as a conservative way with advanced orthodontics or with a minimally invasive surgery and others will be necessary a more complex treatment, with the achievement of an Orthognathic Surgery (spatial repositioning surgery for the jaws).

Nowadays, the Orthognathic Surgery is conceived as a jaw surgery, which has been valued by a team of work, where the orthodontist, the maxillofacial surgeon and a specialized laboratory technician. Thanks to the virtual planning tools (software systems for 3D surgery) a major precision is offered in the surgery and also a few better results.

Often, our patients present associated with the dentofacial deformity a problem of sleep apnoea. The evaluation combines with other specialists of the sleep in an interdisciplinary ambience (UNIT OF THE SLEEP), allows evaluating if the patient is a candidate for a surgery of advancement and rotation of the jaws that improves the airline (retromaxilar obstructive apnoea) (ver vídeo).

The Hilo therapy (therapy with cold at constant temperature) allows us to obtain better Postoperative, with less distension and pain in the complex surgery of the jaws.

ENDOSCOPIC APPROACH IN THE MAXILOFACIAL AREA- MINIMALLY INVASIVE SURGERY

Endoscopy in disorders of the salivary glands

It should be remembered that “stones” (lithiasis) can be formed in different parts of the body, for example the gallbladder, urinary tract and also, salivary glands.
SALIVAL GLAND ENDOSCOPY is especially indicated for obstructive disorders of the salivary glands, especially in cases of “stones”.

Recently, MINIENDOSCOPES have been developed with a diameter between 0.8 -1.6 mm, which incorporates a small video camera with a light at the end of the endoscope.

These advances have led to the development of MINIMALLY INVASIVE modalities for the diagnosis and treatment of diseases related to the major salivary glands. Minimally invasive treatment allows us to apply the concept of organ preservation and its function. This technological advance has represented a paradigm shift in the treatment of disorders of the salivary glands, allowing us to avoid more aggressive surgeries that were previously carried out, such as the complete removal of the affected salivary gland.

In our Institute we have these MINIENDOSCOPES that can be used both for the diagnosis and for the treatment in diseases of the salivary glands.

Our EXPERIENCE in SALIVAL GLANDS ENDOSCOPY allows us, in a single intervention, the diagnosis and treatment under direct visualization of stenosis of ducts, mucous plugs and calcifications.

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ENDOSCOPY in the sinusitis of dental cause

In some patients, sinusitis of dental origin may develop. These sinusitis are especially difficult to diagnose and treat, since they cover the area of knowledge of 3 very different specialties such as Dentistry, Otolaryngology and Maxillofacial Surgery.

They are especially difficult sinusitis in their treatment, and the difficulty in the communication between specialists makes an accurate diagnosis even more difficult and its adequate treatment.

We have in our MAXILOFACIAL ENDOSCOPY unit a wide experience in the complete resolution of odontogenic sinusitis rebellious to previous treatments.

The objective is to restore the function of the Nasosinusal respiratory mucosa. This is achieved thanks to an INVASIVE MINIMAL ENDOSCOPIC SURGERY, which is performed through the natural orifices of the nostrils and intraoral. This intervention allows the patient to, without external scars, restore paranasal sinus function and to resolve the chronic dental infection IN A SINGLE INTERVENTION.

The facial nerve is the main responsible for the voluntary mobility of the face. Its affectation has a functional, communicative and social repercussion, with negative impact on the quality of life and the emotional well-being. There are multiple causes of Facial Paralysis, but the most frequent indications of reconstructive or restorative surgery are Bell’s palsy not recovered (or partially recovered), the sequelae of tumor surgeries located in the parotid gland or the angle (Acoustic or Facial Nerve Neurinoma), injuries caused by other surgical procedures or traumatic brain injury.

In a patient with facial paralysis, it is very important to indicate the most appropriate treatment, depending on the age, the degree of muscle atrophy, the time elapsed since the beginning of the paralysis and the patient’s expectations.

The reparative techniques are called DYNAMICS when they are directed to recover the nerve function, and therefore muscular. For this, it is important to differentiate the time of establishment of the Paralysis.

In acute Facial Palsy, with pathology shorter than 3 weeks, a primary repair of the nerve injury will be evaluated. These surgeries may require a nerve graft, usually of the Greater Atrial Nerve or Sural Nerve (both sensory).

Intermediate Facial Palsy lasts less than 2 years. In these cases, the nerve is usually intact, but there has been no correct functional recovery. The musculature is not atrophied, therefore, if we give a nervous impulse, we can return the muscular functionality. To do this, we can perform a Cross Facial Nerve Graft, a technique known as “Cross-face”, where we select a branch of the Facial Nerve from the healthy side, connect it to a nervous graft (usually from the leg) and tunnel this branch until connecting with the branch of the Facial Nerve injured or not functioning, thus providing this impetus.

In chronic Facial Paralysis, being an injury of more than 2 years of evolution, the muscles are atrophied, with denervation and muscular degeneration, which hinders nerve conduction. One of the techniques most used in dynamic rehabilitation in these cases is Transposition of the Temporal Muscle, especially in elderly patients. For younger patients, a Microvascularized Gracilis Graft is the best option. For this technique, it is usual to perform a first surgical time with Facial Nerve cross graft, and at 8 months, a second time with the muscular contribution once the nerve impulse is established.

Surgeries called STATIC can be used in combination with the above. They are indicated for patients with chronic facial paralysis, temporary in recovery phase, as well as those patients who do not want complex surgeries but who request an improvement in the appearance and the quality of life.

In the Upper Tertiary Facial (forehead and eyelids) we can correct frontal ptosis (eyebrow drop) and palpebral ptosis (eyelid droop) with a Frontal Lifting, Upper Blepharoplasty, Upper Eyestrain or Tarsorrhaphy.

In the Middle Third Facial, we can perform a static suspension of the nasogenian sulcus and the buccal commissure by means of a strip of Fascia Lata (from the lower extremity) tunnelled to the deep temporal fascia (on the scalp). We can perform Nasoplasty with Fascia Lata in those patients who present coaptation of the nasal valve that causes respiratory distress, especially nocturnal, which allows respiratory improvement from the first 24 hours postintervention.

In the lower third, we will perform surgeries to symmetry the lower lip, such as resection of the lower lip depressor on the healthy side through a sublabial mucosal incision or a commissuroplasty. We can improve in the neck the platismoal synkinesias, which result in unsightly vertical bands by involuntary contractions with decrease of the buccal commissure and lower lip. When this is refractory to Botulinum Toxin, platismectomy offers good results.

STATIC SUSPENSION is an alternative for patients who do not want surgical intervention, or that complements the previous options. They are the Tension Threads, which are placed by subcutaneous needles to offer flaccid skin tightening resulting from Facial Paralysis, which can be placed under local anesthesia being a minimally invasive procedure. They can be placed for frontal-eyebrow suspension, malar, nasogenian groove, commissure and mandibular angle; is the so-called nonsurgical Lifting. We inform patients in the Facial Palsy Unit of all the available options, individualizing treatments according to the patient, to increase social, emotional and affective well-being, as well as to improve the quality of life.

The use of dental implants is a treatment extensively used and effective for the substitution of the lost teeth. In general, they offer good results; nevertheless they are not exempt from complications. The most frequent long-term complication is the peri-implant disease.

The peri-implant diseases are inflammatory changes of the tissues that surround the implant. Two entities are described:

• Mucositis: reversible inflammatory process that limits itself to the mucous membrane that surrounds the implant
• Periamplantitis: progressive inflammatory process that, in addition to the mucous, affects the bone that surrounds the implant

The peri-implant diseases must be diagnosed and treated, because its progression can affect in a considerable way to the support of the implant and cause, finally, its loss.

It is well –known that a deficient oral hygiene, the consumption of tobacco, the diabetes badly controlled and to present precedents with the periodontal disease, increase the risk of suffering peri-implant diseases.

The main point/objective of the treatment is to reverse the inflammatory process and to establish a favourable environment to maintain the implants in a state of health.

In the mucositis, the bacterial plaque is eliminated, there are used antiseptics and the factors that could favor the appearance of the disease are corrected. With a good treatment, the mucositis process is reverse and its prognosis is favourable.

In the periamplantitis the treatment depends on the grade and type of the bone loss. In addition to the elimination of the initial bacterial plaque and the use of antiseptics, it is needed a specific surgical treatment to the morphology of the bone defect. The surgical treatment focuses on:

• Regenerative therapy: after the decontamination of the exposed surface of the implant, one proceeds to the regeneration of the defect for the formation of the new bone
• Resective therapy: when it is not possible to regenerate, the surface of the implant is decontaminated and the gum is treated to leave exposed the part of the implant that does not have bone support, so that its cleaning and maintenance is totally accessible

When the bone loss is advanced, the implant must to be removed.

It is vital to maintain a correct oral hygiene, as well as to perform the controls and maintance established by the professional to assure a good health of the implants and to detect any change early.

The osteopathy is a manual medicine especially effective in the origin PAIN of skeletal muscle. But also the manual treatment of the skeletal muscle system produces progress in the nervous, vascular or immune system, extending the effect to origin alterations not muscle skeletal.

The osteopath observes the position in statics and in movement with the aim of recognizing shaken movement patterns and being able to identify the disabled structure or malfunction that causes the clinic of the patient. The osteopathic treatment will consist of MANUAL THERAPY AND RULES OF THERAPEUTIC EXERCISE.

WHAT DO WE TREAT?

1. HEADACHE AND JAW: it is a complex field due to the big variety of types and possible causes. This type of pain can be a symptom of serious pathologies in which the manual treatment is not indicated by what the work of the osteopath is to make a correct exploration and to identify when our treatment is more stated and effective.The headache and jaw that better answers to our treatment is the one that origin in skeletal muscle:
   • PAIN OF CERVICAL ORIGN
   • PAIN OF TEMPOROMANDIBULAR ORIGIN (articulate)
   • PAIN OF MUSCULAR ORIGIN (muscles of the masticating and of the face) and of tensional origin
   • We also treat the MIGRAINE TYPE PAIN (vasomotor)

   It is very frequent that the headache and jaw is accompanied or caused by instability syndromes. If an accurate diagnosis is done, the osteopathic manual treatment is very effective for the vertigo or the instability.

   • VERTIGO (benign paroxysmal postural vertigo and Menière)
   • INSTABILITY or PSEUDO VERTIGO of cervical origin
2. SPINAL PAIN: Pains provoked by degenerative and inflammatory alterations in capsule, ligaments, muscles of the column and nervous roots (especially cervical and lumbar). The spinal pain that better answer to the manual therapy are:
   • DISCOPATHIES that not present signs of irradiation (protrusions, ruptures)
   • RADICULOPATHIES (without motor or sensory impairment)
   • Unspecific LUMBAR AND CERVICAL PAIN
   • Light SPONDYLOLISTHESIS (grade I)
   • ILIO-LUMBAR PAIN
3. PERIPHERAL PAINS: of traumatic, rheumatic or degenerative origin in the peripheral joints. Excepting the clearly traumatic cases, the osteopath treatment focuses on valuing the affected extremity relative to the set to evaluate shaken patterns that influence the pathological load of the joint and its injury. The pains that better answer to the manual therapy are:
   • TENDINOPATHIES
   • LIGAMENTOUS OR MENISCAL INJURIES
   • SUBACROMIAL SYNDROME
   • CARPAL TUNNEL

TREATMENTS:

As an anesthesiologist specialized in pain I treat both acute and chronic pain cases. Regard to acute pain, the management of acute or post-operative pain origin can be optimized. In chronic pain approach I evaluate patients who once diagnosed and treated do not achieve an improvement of pain and/or drug treatment is not tolerated.

Areas of knowledge:

• Cervico-facial pathology: musculoskeletal origin (myofascial syndrome, cervical facet syndrome), or neuropathic (Arnold’s neuralgia).
• Orofacial pain
• Headaches (tension, migraine, trigeminal-authonomic).
• Joint pathology (shoulder, hip, knee)
• Thoraco-lumbar pain; musculoskeletal origin (facet syndrome, lumbar discopathy, sacroiliac pathology, radicular pain, post-laminectomy syndrome, superficial and deep myofascial musculature syndrome (lumbar, iliac psoas, pyramidal)
• Neuropathic pain; complex regional pain syndrome, diabetic neuropathy, toxic, pharmacological, post-operative.
• Mixed pain

A full assessment of the reason for consultation is carried out on the first visit and reviewed; pathological history, current disease (pain characteristics), physical examination and evaluation of complementary scans. This can lead to diagnostic guidance and treatment according to the patient’s diseases and individual conditions.

This treatment can be either medical (pharmacological orally and/or topically) or interventionist. Interventional techniques are guided by anatomical references, ultrasound and radioscopy.

Interventional treatments:

• Myofascial syndrome; infiltration of local anesthetic, botulinum toxin
• Axial and peripheral infiltrations (local anesthetic, corticoids, hyaluronic acid, platelet-rich plasma) according to scientific evidence.
• Infiltration of peripheral nerves and/or interfascial planes with local anesthetic and/or corticosteroid.
• Use of Thermal Radiofrequency or Pulsed Radiofrequency

Chronic pain often provokes thoughts, feelings, and behaviors in people who suffer from it that increase suffering and create an additional problem. In addition, these phenomena often influence the experience of pain itself, making it even more difficult. For this reason, psychological treatments have been playing an increasingly relevant role in the management of chronic pain in recent decades. The psychological interventions in chronic pain that have been shown in clinical trials to reduce emotional distress and improve the quality of life of patients are characterized by the learning of techniques and training in skills that require a very active role on the part of the patient in comparison with other types of treatments.
Among the psychological treatments, cognitive-behavioral therapies, acceptance therapies and mindfulness therapies are the ones that have been offering the best results in the clinical trials that have been carried out to date in different types of chronic pain. MINDFULNESS-BASED COGNITIVE THERAPY (MBCT) is a group treatment program that combines cognitive behavioral therapy and mindfulness-based treatments in an intensive training format. All this makes it a treatment with great potential in the field of chronic pain.
The MBCT program at the Bara-Gaseni clinic is specifically addressed to people with orofacial pain problems of various causes.
Before the start of the program, during an individual 40-minute session, a psychological evaluation and the suitability of the patient for the program are carried out (it is possible that two sessions are needed for some patients). If it is assessed that the MBCT program may be beneficial for the patient, an orientation towards the treatment program will be carried out. On the other hand, if the MBCT program is not suitable for a patient, and it is assessed that there may be other mental health interventions that may be therapeutic, recommendations will be given in this regard.
The MBCT program consists of 8 weekly group sessions lasting about two hours each. In addition to the work that will be done during the sessions, exercises should be done at home every day for approximate one hour. For all these reasons, it is a treatment that during its 8 weeks duration requires intense work and commitment to be able to verify if it is beneficial for each patient.