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.

 

TMJ Pathologies Treatment: Patient with Severe Headaches and Temporomandibular Joint Pain with Significant Contour Irregularities in the Mandibular Condyle and Mouth Opening Limitation.

In several publications of this page I have presented patients of different ages, different gender and different pathologies of the temporomandibular joints.

This is the second case report about a patient with prosthetic protocols built on implants.

I call once again the importance of  the attention in the diagnosis of temporomandibular joints pathologies and mandibular position as a key part of any procedure in dentistry.

1 FOTO INIC FRONTAL

Female patient 54 years old arrived to the clinic for consultation with severe headache complaints, pain in the temporomandibular joints, pain in the cervical spine, sore shoulders, ear pain, feeling of clogged ears and crepitation in both temporomandibular joints.

2 FOTO INICIAL PERFIL

The patient was referred by her dentist who performed the treatment of implants and prosthetics, rehabilitating the patient, but without being able to relieve the pain that afflicted her.

2A MARCAÇÃO DA DOR

Part of the questionnaire completed by the patient.

The patient reports daily pain.

FUNCTIONS THAT AGGRAVATE HER PAIN:

Mastication

Opening the mouth

Laughing

Yawning

The patient also refers back pain and numbness and tingling in the arms and fingers.

Refers that she wakes up with body aches.

3 DENTES INIC PROT FRONTAL

Patient habitual occlusion on the day of consultation.

The patient had fixed prostheses supported on implants on the lower jaw and a removable upper protocol supported on implants on the maxilla.

4 OCLUSAIS INICIAL PROTPatient’s superior and inferior oclusal view of the prostheses supported on implants on the day of consultation.

5 DENTE INICIAL SEM PROT

Image of the oral cavity of the patient without the upper prosthesis.

6 OCLUSAIS INIC SEM PROT

Patient’s superior and inferior oclusal view without the superior prostheses.

7 PANORAMICA INICIAL

Patient’s initial panoramic radiograph before treatment with the prosthesis in the habitual occlusion before treatment.

Presence of 4 metallic implants in the maxilla 2 on the right side and 2 on the left side; and 5 implants in the anterior mandible region.

8 LAMINOGRAFIA INCIAL

Patient’s TMJ right and left laminography, closed and open mouth: posterior positioning of the articular processes in the joint cavities when the jaw is in maximum intercuspation position.

9 TELE PERFIL INICIAL

Patient’s lateral radiograph with prosthesis in habitual occlusion.

10 C7 INICIAL

Patient’s lateral radiograph and cervical spine with prosthesis in habitual occlusion before treatment.

Alterations of the cervical spine, loss of physiological lordosis and loss of intervertebral spaces especially between the vertebrae C4, C5 and C6.cefalometria 2013 ingles

Ricketts cephalometric analysis before treatment with prostheses in habitual occlusion.

FACTORES CEF ANTESSS

Values of point A convexity and lower facial height before treatment.

11 FRONTAL INICIAL

Frontal radiograph of the patient with the prosthesis in habitual occlusion.

12 RNM DIREITA INICIAL

MRI, sagittal slice of the right TMJ closed mouth: there is an irregularity of contour with reduction of the superior aspect of the mandibular condyle, the condyle is ante versioned. There is a small anterior osteophyte.

The articular disc is displaced anteriorly, WITHOUT REDUCTION when the mouth opens.

Presence of subcortical bone cysts in the anterior superior aspect of the mandibular condyle.

13 RNM  ESQ  INICIAL

MRI, sagittal slice of the left TMJ closed mouth: there is a substantial irregularity of contour of the upper portion of the mandibular condyle, with the formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

13A RNM  ESQ  INICIAL

MRI, another sagittal slice of the left TMJ closed mouth: there is an important  irregularity of contour of the superior aspect of the mandibular condyle and a formation of an anterior osteophyte.

There is a rectification of the articular eminence.

The disc has reduced dimensions lying anteriorly displaced WITHOUT REDUCTION when the mouth opens.

Can be seen an important hipossinal compatible with avascular necrosis.

16A  ESQ boca fechada 2013 T2

MRI in T2 clearly shows the joint effusion.

The differential diagnosis of TMJ effusion has a broad spectrum as the effusions in other joints in other parts of the skeleton.

MRI (magnetic resonance imaging) can give us a lot of information, not just the disc position.

14  RNM FRONTAIS INICIAIS DIR E ESQ-Recuperado

MRI, frontal section of the right and left TMJ, closed mouth. Upper lesion in the right mandibular condyle, as described in the same sagittal slice of the same condyle as subcortical bone cysts.

In the slice of the mandibular head on the left side can be seen an important hipossinal compatible with avascular necrosis.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. It can be caused by various conditions, such as bone or joint damage, pressure inside the bone and other medical conditions.

The condyle affected by avascular necrosis has low signal on T1-weighted images as a result of edematous changes in trabecular bone.

14 SERIE DE RESS DIR FECHADA 2013

Sagittal sections of the right TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

14 SERIE DE RESS DIR ABERTA 2013

MRI,sagittal sections of the right TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

15  SERIE DE RESS ESQ FECH 2013

MRI, sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the images I find most relevant, but also this series are registered.

15 SERIE DE RESS ESQ ABERTA 2013

MRI,sagittal sections of the left TMJ, open mouth before the treatment. There is a limitation on opening of the mandibular condyle.

16 series ESQ boca fechada 2013 T2

MRI, T2 sagittal sections of the left TMJ, closed mouth before the treatment.

There were previously posted to highlight the image I find most relevant, but also this series are registered.

Serial in T2 clearly showing the joint effusion.

Tests were done on the patient to investigate systemic inflammatory disease, which were all negative.

It was also investigated chlamydia trachomatis infections, mycoplasma pneumoniae infections and beta hemolytic streptococcus infections , results in this case were also negative.

It was also investigated the functioning of the thyroid.

17 REGISTRO CINECIOGRAFICO INICIAL

The masticatory muscles of the patient were electronically deprogrammed and DIO (intraoral device) was constructed in neurophysiological position. In other publications computerized kinesiographic methods were mentioned.

In occlusion most often the healthy or pathological condition of the inter-oclusal space is not objectively considered. In this case the free space of the pathological patient is almost 7 mm and a retro position 0 8 mm.

18 DIO SOBRE A PROTESES

With this data and ALWAYS WITH THE INFORMATION OF IMAGES, we built a DIO (intraoral device) to keep the three-dimensionally recorded position.

This device must be tested electromyographically to objectively measure the patient.

19 CONTROLE DA ORTESE

It is essential to control the DIO (intra oral device) as the patient is treated and the mandible is repositioned.

In this case the control still shows us the need for recalibration of the DIO (intraoral device)

19 PANORAMICA COMPARATIVA

Comparative panoramic radiographs: before treatment and after neurophysiological treatment.

20 FRONTAIS COMPARATIVAS

Patient’s frontal radiographs comparison: with the prosthesis in habitual occlusion and the DIO intraoral device built on the prosthesis.

20 LAMINOGRAFIA COMPARATIVAS

Right and left temporomandibular joints laminographies, closed and open mouth comparison: with the prosthesis in habitual occlusion and with the DIO intraoral device built on the prosthesis.

cefalometria 2014 CORTADA ingles

Ricketts cephalometric analysis after treatment with the DIO constructed on the prostheses in neurophysiological occlusion.

FACTORES CEF APOSSS

Values of point A convexity and lower facial height after treatment.

21 PERFIS COMPARATIVOS

Patient’s lateral radiographs comparison: with the prosthesis in habitual occlusion and with the DIO built on the prosthesis in neurophysiological position.

The DIO (intra oral device) is used to support, align and correct deformities in order to improve the functions of the jaw, temporomandibular joints and the muscles that move both. This device should be checked and recalibrated as the records indicate the need for modification.

21A PERFIS COMPARATIVOS

Comparison of aesthetic Ricketts plane in lateral radiograph with prosthesis in habitual occlusion and the DIO constructed on the prosthesis in neurophysiological position.

21 RNM COMPARATIVAS ESQ SAGITAL

Comparison of T1-weighted images: before treatment and after treatment: we can see the improvement in medullary signal.

26 comparativas ESQ boca fechada 2013 e 2014T2

Comparison of T2-weighted images: before and after treatment. It is clear in the first image the inflammatory signal and in the other image the improvement of the intramedullary signal and the remission of posterior effusion.

22 RNM Comparativas direita sagital

Comparison of T1-weighted images: before treatment and after treatment, we can see the improvement in medullary signal and improvement of the cortical bone.

23 RNM Comparativas direita FRONTAL

Frontal T1-weighted images comparison, before and after treatment treatment: we can see the improvement of the upper lesion on the right mandibular condyle.

24 RNM Comparativas ESQUERDA FRONTAL

Frontal T1-weighted images comparison, before and after treatment: we can see the improvement in medullary signal and improvement of the cortical bone of the left mandibular condyle.

25 SERIE DE RESS DIR ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the right TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

25 A SERIE DE RESS ESQ ABERTA 2013 e 2014 COMPARATIVAS

Comparative sagittal sections of the left TMJ open mouth, before and after treatment.

Notice the mandibular condyles WITHOUT LIMITATION IN OPENING  in relation to the limitation that had before treatment.

COMPARATIVAS FRONTAIS POSTURAIS

Patient’s postural frontal comparative images before and after treatment.

COMPARATIVAS POSTURAIS PERFIL

Patient’s  postural profile comparative images  before and after treatment.

27 CEF COMPARATIVAS ingles

Ricketts cephalometric analysis before and after neurophysiological treatment.

COMPARAÇAO DOS FATORES

Skeletal problems in Ricketts cephalometric analysis before and after treatment.

28 DEPOIMENTO

“Headache (already when waking up in the morning), tiredness sensation at the cheekbones, strong tensing at the shoulders and neck, “clicks” at the temporomandibular joint, ear pain… consequently I also felt irritation, indisposition, stress etc.

All of that is something I had to live with for a long time. The investigations made on me always resulted in palliative measures that mitigated the problem for a short time.

I passed through implants and placement of prostheses which even without having (those measurements) the aim of healing this malaise I still had the hope that it would: but the relief only worked for a short period of time. Finally, by indication of my dentist, I arrived at Clinic MY starting then the TMJ treatment. Shortly after the start of the treatment the symptoms started to fade.

I am very thankful for the professionalism and dedication that I found there. Today, feeling better, I go back there for periodic evaluations and also to have the opportunity of thanking  once more.”

Osteonecrosis of the Mandibular Head: recovery of condylar bone marrow alteration

I had been showing clinical cases in the page lidiayavich.com  and in several groups. Some of them with rehabilitation and with tridimensional orthodontics, always after treating the TMJ.

In this post I’m not going to show all the sequence of the patient. I have  the intention to show the improvement of the signal of the MEDULLAR OF THE CONDYLE that had presented osteonecrosis.

Anamnesis and clinical inspection are a fundamental part in the  diagnosis of the patient that presents TMJ pathology.

Images are primordial when we study any sinovial joint, unfortunately I see patients with valuable information in their images that were told that those are just occasional findings.

MRI (magnetic resonance imaging) can give a lot of information and not only the disk position information. Logically is necessary to know what to do with that information.

Osteonecrosis of the mandibular head corresponds to a death of the osseous tissue, also called avascular necrosis.

 Alteration in the bone marrow of the mandibular condyle is a possible cause of TMJ pain.

01

MRI: T 1 closed sagittal rightTMJ before treatment.

Avascular necrosis in the acute phase can be diagnosed only through MRI imaging or biopsy.

The differential diagnosis of altered signal intensity in the mandibular condyle starts with an awareness of its normal signal characteristics.

This condyle has also a severe irregularity on the superior pole, with loss of substance, but in this post I want to analyze the bone marrow signal. Of course, in a diagnosis we need to consider all the information.

-1

MRI: T1 closed sagittal rightTMJ before treatment.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced, which may be caused by several conditions, like joint or bone injury, pressure inside the bone, medical conditions, among others.

A condyle affected by avascular necrosis displays low signal intensity on T1 weighted images as a result of edematous changes in the cancellous bone.

2

MRI: T2 closed sagital rightTMJ before treatment.

The differential diagnosis of effusions in the TMJ has a broad-spectrum as of joint effusions in other skeletal regions.

A MRI (magnetic resonance imaging) can give a lot of information and not only the disk position. In this case THE PATIENT HAS NO DISK.

2AA

The same sagittal slice of the condyle in T1 and T2. Image A shows osteonecrosis of the head of the mandible and image C shows the articular effusion.

The patient complained from severe pain in the TMJ, headache, and pain on the back of the neck.

The patient had a major trauma history in the jaw in adolescence. She had rheumatic fever in childhood.

 We referred her to a rheumatologist, and in that moment she did not present positive results for inflammatory systemic disease.

Her muscles were electronically deprogrammed and a DIO (Intraoral Device) was constructed in a neurophysiological position. In other publications we mentioned the computarized kinesiographic used methods.

2A

Comparing T1  images: A (before the treatment) and B (after the treatment): we can see the improvement and recovery of the the medullar signal. Improvement of the superior cortical of the mandibular head. 

The differential diagnosis and the systemic condition of the patient must be taken in account for the prognosis of the case.

2B Comparing T2  images: C (before the treatment) and D (after the treatment).It is clear in the first one (C) the inflammatory signal and in the other (D) the remission of the effusion.

Sem Título-1

Comparing T1 images (A and B) we can see the improvement and recovery of the  medullar signal and the superior cortical of the mandibular head. In T2 weightened images (C and D) it  is clear (in C) the inflammatory signal and in the other (in D) the remission of the effusion.

Sem Título-6

One year after the second image, a new control was solicited, and the results were even better.

In this case  I decided  NOT TO GO forward to a second phase.  Diagnosis is essential for each case.  Dentistry need to understand like Medicine do, that we have limitations and if a patient needs to live with an orthotic  it is not the end of the world.

We have patients that are going to live with insulin all their life, or with other medicines that are saving their lives or just improving their life quality.
Therefore, diagnosis is essential and for that all the tools that can help to get there are welcome.