Recapturing the Articular Disc or Repositioning the Mandibular Condyle? What about Rethinking the Concept as the Recovery of the Physiological Relationship of the Head of the Mandible with the Articular Disc. Patients with a long history of pain. Case series. First Section.

Recapture the articular disc, repositioning the mandibular condyle?

What about rethinking the concept as the recovery of the physiological relationship of the mandible head with the articular disc ,WHEN IT IS POSSIBLE.

And when is it not possible? What is the differential diagnosis? WHAT CAN WE OFFER TO OUR PATIENTS?

What type of orthotic or intraoral device to use? What is the purpose of an orthotic  in a TMJ Pathology treatment? Repositioning the jaw, recapturing the articular discs? Is this always possible? DEPEND ON THE DIFFERENTIAL DIAGNOSIS!

Does it have changes in the articular structures of the temporomandibular joint?

Does it have distortions in the horizontal, vertical and transverse posture of the craniomandibular complex?

How are the bones?

How’s the cartilage?

How’s the articular disk?

How are the muscles in this system?

How is the cervical spine in relation to the whole system?

How is the relation of the vertebral column with the other parts of the system?

The teeth, the two temporomandibular joints and the postural musculature are parts of the same bone, the mandible. They are deeply interrelated and interdependent in growth, form, and function. An abnormality in one, profoundly affects the others.

1 frente

A 30-year-old female patient presents at the clinic with a history of headache, pain in the forehead, pain and stiffness in the nape of the neck, left eyebrow pain, pain behind the right eye, and pain in the right shoulder. The patient reports TMJ pain (temporomandibular joint) on the right side.

The patient reports bilateral crackling, non-specific facial pain, and muscle tremor, difficulty opening the mouth, difficulty in chewing and mandibular locking.

Summary report written by the patient:

I do not remember a sudden drop where there might have been some kind of injury.
At 6 years of age I was a gymnast. I always had falls, front, back and head. But there were protections on the floor.

Near 8 years old, I extract a molar from the lower left side. I think that from this I have always forced more chewing on the right side.

At approximately 13/14 years of age, I remember starting the cracks on the right side. On this side I had a cross bite and a deciduous canine that “bit” behind the lower tooth.

At this stage, the crackling became more frequent, causing a bit of difficulty to fully open the mouth.  When trying to open the mouth without the snap, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

In 2004 I had the first “lockup”. I remember being in winter and cold. I tried to do the “game” of the jaw and I could not open the mouth. Then I forced myself to open my mouth and I felt a strong crack, followed by pain in the ear / nose. The impression was that it had displaced some bone / nerve.

From this episode, whenever I force more the region, the locking happens. Ex: when I eat meats, candy, peanuts. Things that I need to force when chewing.

In 2008 I put orthodontic appliance to make the corrections. In the treatment, I made a process of spacing the teeth, with a device in the roof of the mouth to open the arch. I kept my teeth apart for a while.

After finishing the treatment, corrected the teeth, the clicks returned lighter. Approximately 1 year later, the locking returned as well. I started with headaches and cervical pain. I felt slight tingling in the head.

In 2015 I started to hear some kind of “sand” on the left side. Then I got pregnant and in this period began the crackling also on the left side. In February 2017 I had the first “lock” on the left side.

Now when I feel the locking, I try to relax the muscles well, leaving the jaw loose for a few minutes. Sometimes it returns to normal anyway, other times I have to force it with the opening of the mouth, causing a strong crack.

2 foto inicial perfil

Current information:

When I close my mouth, I feel my jaw line back slightly, to “marry” the bite. To keep my mouth “loose” and comfortable, I have to snap both sides, and let the jaw loose.

When I try to open my mouth without the snaps, the opening becomes smaller than after the click. That is, if I do not play with the jaw, the mouth does not open completely.

Crashes usually occur:

– Yawning;

– In the morning (awake with the jaw locked);

– Eating meats.

2 tomo

CT: Part of the initial study of the patient sent before the consultation requested by another professional.

Anamnesis and clinical examination are a key part in the diagnosis of patients with TMJ pathology.

Computed tomography is an excellent image, but when we treat a synovial joint in a patient with TMJ pathologies, CT does NOT PROVIDE THE INFORMATION OF THE SOFT TISSUES.

Magnetic Nuclear Resonance (NMR) can give a lot of information and not just the position of the disk. It is essential to have the knowledge to KNOW WHAT TO DO WITH THIS INFORMATION.

We cannot treat a patient with mandible head necrosis or with medullary edema or arthrosis or rheumatoid arthritis or lupus in the same way that we treat another patient with only a wrong position of the jaw.

The temporomandibular joints of all these patients need to be decompressed, but that is only part of the problem.

3 dentes inicHabitual occlusion of the patient on the day of the consultation.

4 oclusaisUpper and lower occlusal views of the patient prior to treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

5 panoramica

Initial panoramic radiograph of the patient before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

6 laminografia

The laminography of the temporomandibular joints shows a modification of the growth axis of the mandibular condyles in both the left and right caused by a traumatism in the early childhood, (fracture in green stick).

Retro position of both mandibular heads in the articular fossae.

TMJ laminography in habitual occlusion and open mouth.

cicatriz do queixoThree-dimensional asymmetries in the head of the condyle may have been caused by different etiologies and cause morphofunctional pathologies.

Changes in the orientation of the mandible head occur in patients who have suffered blows in the chin region, either anteroposterior, vertical or lateral. We can observe in these cases a deformation of the head of the mandible in the form of curvature, with an anterior concavity, which in some cases may be so important which produces a compression of the retrodiscal region, causing severe symptoms.

7 frontal

Frontal radiography of the patient in habitual occlusion before treatment.

Orthodontic treatment contention wire is observed between the right and left lower canines.

8 teleperfil

Lateral radiograph of the patient in habitual occlusion before treatment.

9 c 7Lateral and cervical radiograph of the patient in habitual occlusion before treatment. Note the loss of cervical lordosis and rectification of the cervical spine.

16 rnm inicial 1

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

17 rnm inicial 2

MRI: sagittal slices of the left TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

19 rnm inicial4

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

20 rnm dir inicial5

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

21 rnm inicial 6

MRI: sagittal slices of the right TMJ in the closed mouth before treatment. There is an anteroversion of the mandibular condyle. The mandibular head is in retro position.

The articular disc is displaced anteriorly, with reduction in maneuvers in open mouth.

Important retrodiscal compression.

22 frontal rnm inicial 7MRI: frontal slices of the right and the left temporomandibular joints, closed mouth in habitual occlusion before treatment.

The frontal slice of the right and left temporomandibular joint evidences a severe loss of joint space.

24 atm aberta24a eletromiografia dinãmica habitual rolos de algodão

Dynamic electromyography record of the patient in habitual occlusion and with cotton rolls on the right side (second column), left side (third column) and both right and left sides (fourth column).

Note the improvement in recruitment of motor units in the fourth column.

25 registro cineciografico inicial

Patient’s initial record for the construction of the DIO ( intraoral device)

To correctly evaluate the Maxilomandibular relationship we should begin to consider the physiological rest mandible position.

Physiological rest is a concept applicable to all the muscles of the body.

The stomatognathic musculature is no exception.

The patient’s masticatory muscles were deprogrammed electronically and a new physiological neuromuscular position at rest was recorded.

The patient has in this first record a pathological free space of 6,4 mm. 

The patient also presented a 0.4 mm  of mandibular retro position.

26 recalibraÇÃo da orteseRecalibration of the physiological neuromuscular position of the DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

28 ortoseOcclusion of the patient with the DIO (intraoral device)

With the record obtained with the jaw tracker an intraoral device (DIO) was made to reposition the mandible three-dimensionally.

The PHYSIOLOGICAL NEUROMUSCULAR position was recorded in the form of an occlusal bite record, which was later used to make a DIO (intraoral device)

In the first phase the intraoral devices are recalibrated and / or changed according to each specific case as the jaw, muscles and TMJ improve.

29 controle da orteseAnother cinecigraphic record to control the DIO (intraoral device) in a physiological neuromuscular position as the device is changed or recalibrated.

The patient did not report any more symptomatology. The electromyography and kinesiography records objectively showed improvement of the neuromuscular function.

I asked for the second MRI (nuclear magnetic resonance) to objectively evaluate the physiological relationship between the mandibular condyles and the articular disc.

35 rnm comparativas 1RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

35b rnm comparativas 1RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

36 rnm comparativas 2RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

38 rnm comparativas 4RNM: Comparison of the sagittal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

39 rnm comparativas 5

RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

40 rnm comparativas 6RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

41 rnm comparativas7RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

42 rnm comparativas 8RNM: Comparison of the sagittal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ,  closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological relation of the head of the mandible with the articular disc.

43 frontal rnm comparativas 8

RNM: Comparison of the frontal slice of the left TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same left TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

44 frontal rnm comparativas 8

RNM: Comparison of the frontal slice of the rigt TMJ, closed mouth, before the physiological neuromuscular treatment, and of the same right TMJ, closed mouth, after the FIRST PHASE of the treatment.

Recovery of the physiological refrontallation of the head of the mandible with the articular disc.

45 imagens

The patient did not report any more symptomatology. The comparative MRI showed the recovery of the physiological relationship of the mandible head with the articular disc.

The electromyographic and kinesiographic records objectively showed improvement of the neuromuscular function.

It was decided to start the SECOND PHASE of the treatment to remove the DIO (intraoral device), maintaining the neuromuscular physiological occlusion.

For this we use a three-dimensional orthodontic, where the teeth are erupted to the new physiological neuromuscular position.

46 depoimento 1Patient Testimony:

My first memory of locking joints was at age 15 or so.

I looked for orthodontic specialists; I made the necessary “adjustments”, but the locking and the pain still continued.

I looked for Dr. Lidia now at the age of 30, since other experts told me that only surgery would be possible in my case. And yet, without knowing exactly whether we would succeed.

After starting the first phase of treatment with the device, the pain ceased and never again I had the jaw locking that so frighten me.

47 depoimento 2

I adapted very easily to the treatment, I was and I am being much disciplined with the use of the device.

Now, as Dr. Lidia explained to me, with the discs already in the right place, we will pass for the second phase, for withdrawal of the device.

Today I’m having a routine without worry that I can “lock” at any time.

I’m very grateful to Dr. Lidia.

Child with Otalgia (earache) and Conductive Hearing Loss: when measuring makes the difference. Normalization of hearing thresholds. First and second phase. Case report.

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment.

The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY  TEMPOROMANDIBULAR DISORDERS  is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

There are two general types of hearing loss, conductive and sensorineural.

Conductive hearing loss results from disruption in the passage of sound from the external ear to the oval window.

Anatomically, this pathway includes the ear canal, tympanic membrane, and ossicles. Such loss may be due to cerumen impaction, tympanic membrane perforation, otitis media, osteosclerosis , intraaural muscle dysfunction, or displacement of the ossicles by the malleolar ligament.

Sensorineural hearing loss results from otology abnormalities beyond the oval window. Such abnormalities may affect the sensory cells of the cochlea or the neural fibers of the 8th cranial nerve. Hearing loss with age (presbycusis) is an example. Eight cranial nerve tumors may also lead to such hearing loss.

1

Male patient, eleven years old,  arrived to the clinic for consultation referring headache, pain on the  back of the head, shoulder pain, neck pain, hand numbness and tingling  in hands and LIMITATION OF MOUTH OPENING.

1A

The patient reports pain in the left ear and sensation of ear blockage especially on the left side. He also has tinnitus in both ears and DECREASE OF HEARING IN BOTH EARS.

Any hearing loss reported by the patient, must be evidenced by an audiometry.

2

Patient’s medical history: is relevant to this case the antecedent trauma on the chin at early childhood. It is also important to consider his recurrent infections of  ear and throat and that when he was eight months old he had a severe pneumonia that required hospitalization.

3

Images of the patient’s habitual occlusion. Upper and lower oclusal view. Patient’s photos:  frontal, profile and smiling on the day of consultation.

4

Patient’s initial panoramic radiograph

5

Patient temporomandibular joint laminography before treatment: we can observe the superior and posterior position of the left condylar process in the articular cavity when the jaw is in the position of  maximum intercuspidation.

In the maximum opening position, we can observe the anterior angulation of the left articular processes.

6

Patient’s habitual image occlusion before treatment, in the consultation day.We may observe here an important overbite.

It is evident the lack of space for the correct positioning of the  left maxillary canine.

7

Superior and lower oclusal view of the patient before treatment. It is evident the lack of space for the correct positioning of the left maxillary canine.

8

Patient’s lateral radiograph together with the profile image before treatment.

Retrognathic profile and rectification of the cervical spine.

9 res fechada

MRI T1: Sagittal slice, left and right TMJ closed mouth before treatment.

We can observe anterior facets on the right and left mandibular heads.

In the right TMJ the disk is slightly anteriorly dislocated. The anterior dislocation is more evident on the left TMJ, with the head of the mandible backed on the retrodiscal  zone.

10 res aberta

MRI T1: Sagittal slice, left and right TMJ open mouth before treatment.

We can observe anterior facets on both mandibular heads.

Both mandibular condyles cannot translate, reducing mouth opening.

12 cineciog 1

Initial kinesiographic record: loss of speed when the patient opens and closes his mouth. There is no coincidence between the opening and closing trajectories in the sagittal view of the record. Limited mouth opening as the patient can open only 32.9 mm.

11 ELET INICIAL

Surface electromyography of the patient in habitual occlusion in which are measured:

Anterior right and left temporalis

Right and left masseter

Right and left digastrics

Right and left superior trapezius

Activation of the digastrics in closure, these muscles should only must be in activity along the opening movement

During the examination there was an activation of the right and left upper trapezius even when the patient was instructed to lower his shoulders.He had activated both trapezius throughout the examination.

13

The patient reports pain in the left ear and sensation of ear blockage, especially on the left side. He also has tinnitus and DECREASE OF HEARING IN BOTH EARS.

ANY HEARING LOSS REPORTED BY THE PATIENT MUST BE EVIDENCED BY AN AUDIOMETRY.

15 AUDIOMETRIA INICIAL

An audiogram is produced by using a relative measure of the patient hearing as compared with an established “normal “value. It is a graphic representation of auditory threshold responses that are obtained from testing a patient’s hearing with pure-tone stimuli. The parameters of the audiogram are frequency, as measured in cycles per second (HZ) and intensity, as measured in dB­­­­.

The first audiometry of the patient revealed a mild hearing loss in the left ear and a moderate hearing loss in his right ear.

Symptoms of mild hearing loss occurring in childhood often go unnoticed. It is vital the early detection of this deficiency.

Hearing loss is classified as mild, in which the ear is unable to detect sounds below 40 decibels which makes it  difficult to understand human speech.

In moderate loss, the sounds below 70 decibels are not heard.

17

We recorded the mandibular rest position after electronic deprogramming, together with the information of the MRI (magnetic resonance imaging) to orient our decisions of the bite registration, for the three-dimensional construction of the DIO (intraoral device).

The patient has a pathological free space of 8.6 mm and 8 mm of mandibular retro position.

The degree of compression determinates de reaction of the patient.

The retrusion of the mandible, whether it is iatrogenically induced, or a result of malocclusion, often results in otalgia due to excessive compression of the neurovascular retrodiscal tissues. The patient’s impression is ear pain.

18

I informed the parents of the patient, that at this stage, I was only worried about the health of the patient, and focused on  improving the functions, the symptoms and controlling the conductive hearing loss.

Hearing loss resulting from Eustachian tube dysfunction, initiated by craniomandibular disorders is usually subjective.

For this reason there is a need for an objective control by audiometry.

 I explained that I would not make any orthodontic intervention at this stage to include in the arcade the canine that was misaligned and out of space. I told them  that I would take care of it later and in this case I would not have the need to extract teeth.

19

The installed device is controlled through surface electromyography to evaluate the function.

20 AUDIOMETRIA 2

Patient’s second audiometry  shows normal thresholds in the left ear and a mild hearing loss in his right ear.

21 AUDIOMETRIA 1 e  2

Comparing the first and second audiometry of the patient during treatment.

Thresholds normalization of the right ear and thresholds improvement of the left ear.

23

Structural lesions may produce functional changes which in turn increases the structural changes.

24

Structural and functional changes.

25

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but  OTHERS CANNOT.

25A

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but OTHERS CANNOT.

26

It takes time to stabilize the muscles during treatment, different patients, different ages and different pathologies.

27 AUDIOMETRIA 3

Patient’s third audiometry shows NORMAL thresholds in the left ear and NORMAL thresholds in his right ear.

28 AUDIOMETRIA 1 e  2 e 3

Comparing the first, second and third audiometry of the patient during treatment.
Thresholds normalization in the right and left ear.

At this time with the normalization of the conductive hearing loss, the remission of symptoms and improvement of the images from the exams, we began the second phase through a three-dimensional orthodontics.

29 SERIES DE ORTO 1

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

30 SERIES DE ORTO 2

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

30 A PERFIL E RAD LATERAL ORTO

Patient’s lateral radiograph together with the profile image during treatment.

Aesthetic and not retrognathic profile as at the beginning of treatment.

There was not a recovery of the physiological lordosis, but there surely was an improvement of the cervical spine.

31 SERIES DE ORTO 3

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

32  SERIES DE ORTO4

Sequence of the three-dimensional orthodontic in the second stage of treatment of TMJ disorders in this particular patient. REMEMBER THAT NOT EVERY CASE WILL ALLOW THE IMPLEMENTATION OF A SECOND STAGE.

33 RETIRADA DO DIO

Removal of the DIO (intra oral device) at the current stage of the three-dimensional orthodontics.

34 SERIES DE ORTO4

Images without the DIO (intraoral device) and completion of the treatment of the three-dimensional orthodontic in neurophysiological occlusion.

OCLUSAIS FINAIS

Comparative images of the upper and lower oclusal views from the patient before and after completion of the first and the second phase of the neurophysiologic treatment.

35 AUDIOMETRIA 4

The fourth audiometry of the patient after completion of the two phases of treatment maintains the normal thresholds in both the left ear and the right ear.

SERIES DE ORTO

Part of the sequence of the three-dimensional orthodontics in the second stage of the treatment of TMJ disorders in this particular patient.

panoramicas comparativas

Comparative panoramic radiographs: before treatment and after completion of the three-dimensional orthodontics.

CEF COMPARATIVOS

Comparative of lateral radiographs of the patient: at the beginning of the treatment in habitual occlusion, after the  completion of the three-dimensional orthodontic in neurophysiological occlusion and six years after the completion of treatment control.

37 CINESIO comparativoS

Patient’s kinesiographic records comparison: before and after treatment.

The mouth opening  of the patient improved from 32.9 mm to 38.9 mm and it also reached an excellent speed regarding  mouth opening and closing.

37 eletro comparativo

Patient’s electromyography records comparison: before, during and after treatment.

39 jaw trackwe  comparativoa

Patient’s kinesiographic records after electronically mandibular deprogramming comparison: before treatment the habitual trajectory is not coincident with the neuromuscular trajectory.

After treatment the habitual trajectory is tridimensional coincident with the neuromuscular trajectory.

40 todas as audiometrias

Comparing the first, second, third and forth  audiometry of the patient.
Thresholds normalization of right and left ear.

FINALE FINALE

Various physical and psychological activities of children and adolescents may be affected due to hearing impairment. The conductive hearing loss resulting from Eustachian tube dysfunction INITIATED BY  TEMPOROMANDIBULAR DISORDERS  is OFTEN NOT CONSIDERED.

It is vital the early detection of this deficiency.

42 DEPOIMENTO 1

When the patient ended all the treatment, and being still a teenager, he left the following testament:

My dentist referred me to the orthodontist because I had a crooked canine. So, after a panoramic radiograph she suspected that I could have a TMJ problem. Then she referred me to Porto Alegre to do a MRI, and from that exam it was found something that indicated a TMJ problem. So then I started the tratment with Dr. Lidia Yavich, that also investigated the tinnitus and my hearing problem.

When I was little I felt and hit the chin but my parents didn’t know that it could affect my TMJ.

I suffered a lot from an earache and sore throat. I had even scheduled an ear surgery but after six months of treatment it was no longer necessary to do it. Today I am doing well. I have a good hearing and I don’t have any more the tinnitus and the throat pain. I am happy with this treatment, thanks to God and to Dra. Lidia Yavich.

42 DEPOIMENTO

Here follows the testimony of the same patient seven years after the completion of the treatment:

Today, more than seven years after the end of the TMJ treatment with Dr. Lidia, and thanks to the God-given gifts to her, I haven’t been suffering any more with the earaches nor with the throat pain or the hearing loss. I had had, before the treatment, the indication to make an ear operation since I was loosing my hearing and that was not necessary with the TMJ treatment because during the treatment I was monitorated by exams that had proven that my hearing improved. Today I live a normal life, without having problems with those things from the past. I thanks the treatment done by Dr. Lidia which has healed me and improved my life.