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 8^th cranial nerve. Hearing loss with age (presbycusis) is an example. Eight cranial nerve tumors may also lead to such hearing loss.

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.

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.

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.

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

Patient’s initial panoramic radiograph

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.

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.

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.

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

Retrognathic profile and rectification of the cervical spine.

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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

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

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

Structural and functional changes.

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but  OTHERS CANNOT.

Even a decompressed joint, takes time to recover

Some structural lesions can be recovered, but OTHERS CANNOT.

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

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

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.

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.

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.

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.

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.

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.

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

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

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.

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.

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

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

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.

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.

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

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.

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

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.

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.

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 Study and Investigation Page. One year of publication

Dear friends,

At December 2014 I started the Project TMJ Study and Investigation Page. At first, all its content was offered in three languages: Portuguese, English and Spanish. Due to the analysis of the webpage access statistics, at March 2015 I decided to offer the content solely in Portuguese and English.

Nowadays, the medicine based on evidence is hierarchically stratified from top to bottom where in the base of the pyramid we find the clinic cases, which are rarely seen as evidence. The TMJ Study and Investigation Page had, in its conception, the purpose of posting the clinic cases, which were carefully published with the documentation related to each of the patients treated at Clínica MY with pain complaints, dysfunction and TMJ pathology.

The proposition was of presenting these clinic cases and concepts in order share them, offering free access to the content along images, surface electromyographies, computerized kinesiography, scanned before and after the therapeutic process. Cases of tridimentional orthodontics and neurophisiologic reabilitation of the second phase of treatment, after the TMJ treatment, were also included.

The TMJ Study and Investigation Page is completing, in this month of December, one year since it started, and I want to celebrate its anniversary with you. With this project, we have a place in the Internet that presents a line of work known as neurophysiologic dentistry, which takes into account the whole body system. It is an area that also operates regarding the posture and the mandibular functioning. In order to do that, the physiologic dentistry aims to establish, in the patient, a position that is based on a harmonious relation between the muscles, the teeth, and the temporolandibular joints.

In the publication of the end of this year I have chosen the most significant images of the whole year of publications, with their direct links to each one of the originals publications.

Joint Decompression in a Neurophysiological Mandibular Rest Position Promotes a Positive Remodeling in a Degenerative Process of a Teenager Temporomandibular Joint

Anatomy is the platform on which physiology functions

Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy.

Articular discs recapture with mandibular neurophysiological repositioning

Cervical Dystonia or Spasmodic Torticollis: Positive evolution after Neurophysiological Treatment

Recapture of articular disc displacement with reduction. Recapture or not recapture that is the question.

Inter relation of Craniomandibular disorders and vertebral spine. Case report

Tridimensional Orthodontics in the Second Phase of TMJ Pathologies

Neurophysiological Combined Orthodontics and Rehabilitation: patient with degenerative conditions in several body joints

TMJ Pathologies Treatment: first and second phase (tridimensional orthodontics) in a hypermobile joint patient with low signal in the head of the mandible bone marrow. Case report.

Articular Disc Recapture: patient with significant mandibular heads asymmetry and unilateral reducible luxation. Case report

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

TMJ ( temporomandibular joint) Pathologies: Patient with severe pain in the region of the face, neck and temporomandibular joint. First and second phase.

Patient with Ankylosing Spondylitis and non inflammatory TMJ pathology

Mandible Condyle Fracture Consolidation by Neurophysiological Alignment of the Segments, Four Months after Unsuccessful Surgery. Case report

The importance of Mandibular Rest Position by Electronic Deprogramming in the Treatment of Temporomandibular Joint Pathologies, Orthodontic Diagnosis and Oral Rehabilitation. Case report.

TMJ Pathologies in Children and Teenagers the Overlooked Diagnosis

Training in Diagnosis and Treatment of TMJ Pathologies

The Postural Position of the Mandible and its Complexity in the Maxillomandibular Tridimensional Relation: first and second phase in a patient with severe symptoms with subtle information on the images.

e images.

The Tridimensional Neurophysiological Position of the Mandible in Implant Prosthesis Protocol

I want to thank my family that is always at my side in each one of the projects, I also want to thank my friends, that from Brazil and from many places of the world, supported and support this project. Last, but not least, I want to thank my colleagues and patients that often write, encouraging and thanking the existence of this virtual place.

By closing, in this moment, the annual analysis and the perspective for the year that follows, I therefore thank the readers of all places in the world that follow the TMJ Study and Investigation Page. It is a privilege to count with your visits.

With the best votes for 2016, and wishing for a year of peace, health, love and happiness for all.

Dr. Lidia Yavich

 

Inter relation of Craniomandibular disorders and vertebral spine. Case report

Understanding the complex inter relation of Craniomandibular disorders require a wide comprehension not only on anatomy and physiology of head and neck, but also of the vertebral spine.

The cervical spine is the flexible link between the head and the trunk.

The patient consults in the clinic with strong complaints of: Ache in the top of the head, frontal ache, pain in the back of the head, scalp ache, pain in the eyebrow zone, ache behind the eyes, shoulder ache.

Cervical pain, numbness and tingling in the hands and fingers. Pain in both TMJ (temporomandibular joints)

Dizziness, blocked ears sensation.

Ringing ears

Constant difficult to open the mouth

Difficult for mastication

Bruxism.

When she was 4 years old she had a car accident and was thrown out of the vehicle.

SHE RELATES INTENSE HEADACHE SINCE INFANCY.

The patient relates that when she was fourteen years old she had “maxillary cists” and many teeth where extracted

She began to break frontal teeth when she was twenty years old. Prostheses where constructed but the sensation was that anything fixed.

She continued with headache.

Surface electromyography, dynamic record in habitual occlusion. In this protocol we ask to the patient to open the mouth, to close, bite strong and swallow. In this electromyographic record we measure 8 muscles: Right and left anterior temporalis, right and left masseters, right and left superior trapezius and right and left digastrics. We observe very low activity of the superficial temporalis right and left and an almost absence of activity in both masseters. Both digastrics show activity when the patient is biting, what is not physiologic because the digastrics are muscles that work in mouth opening and NOT in mouth closing.

In the radiographic exam we observe the absence of dental elements 16, 15,22,26,27,38,36,46 and 47. Other dental permanent elements are present

The panoramic radiograph shows the asymmetry of the corps and the ramus of the mandible

TMJ laminography of the patient before treatment in habitual occlusion and opening. Asymmetry of the articular cavities. Important asymmetry of the mandibular heads.

Significant flattening of the anterior surface of the articular process in the left side. Anterior angulation of the articular process of the right side and flattening of the posterior and anterior surfaces.

Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy http://www.craniomaxillary.com

The cervical spine is the flexible link between the head and the trunk.

The cervical spine gives sustainability to the cranium and guarantees the movement. Any dysfunction of this balance can provoke pain.

REMEMBER WHEN PATIENT WAS FOUR YEARS OLD SHE HAD A CAR ACCIDENT AND WAS THROWN OUT OF THE VEHICLE.

An often overlooked result of sudden hyperextension or hyperflexion of the cervical muscles is the trauma to the intra-articular structures of the temporomandibular joint. The damage is caused by force acting on connecting structures of different mass and weight. The difference in velocity between cranium and mandible which is in a muscle ligamentous sling during hyperflexion or hyperextension can cause stretching, tearing or overt detachment of the posterior and lateral ligaments of the temporomandibular joint. This factor, in itself, can cause anterior and medial displacement of the articular disc.

Loss of the physiologic cervical lordoses of the patient, inter-vertebral spaces diminishing, increase of the space between the posterior arc of the atlas and the occipital

Frontal radiograph of the patient in habitual occlusion. ROCABADO (1984) refers that the ideal position for the head in space depends on three planes: bipupilar plane, otic plane and occlusal transverse plane. These three planes keep a horizontal and parallel relation that assures postural stability for the cranium. Is evident that this premises are not present in this patient.

One of the slices of the MRI in closed mouth shows a small disc with and anterior displacement on the right side. In the open slice of the RNM (not included in this post) the disc is not recaptured on the right side.

Significant flattening of the anterior surface of the articular process in the left side.

Anterior angulation of the articular process of the right side and flattening of the posterior and anterior surfaces. Structural modifications of the mandibular condylar process as one of the sequels of traumatism in infancy www.craniomaxillary.com

Her masticatory muscles were electronically deprogrammed with an electronic mandibular deprogrammer.

A jaw tracker then registered a neurophysiologic position from where an intraoral appliance was constructed and tested with SEMG (Surface Electromyography)

We consider not only the jaw tracker information after the electronic deprogramming but fundamentally the information of the MRI for the decision of the bite record for the tridimensional construction of the intraoral device.  For this we use the neurophysiologic technique of Dr. Learreta.

The patient presents a pathological free way space of 9,2 mm and a mandibular retro position of 5,2 mm.

With this data we construct an intraoral device tested electromiographically to support the new neurophysiological occlusion

Dynamic Surface electromyography record wearing the DIO (Intra Oral Device) constructed in neurophysiologic position. In this protocol we ask to the patient to open the mouth, to close, to bite strong and swallow WITH THE DEVICE IN THE MOUTH

In this electromyographic record we measure 8 muscles: Right and left anterior temporalis, right and left masseters, right and left superior trapezius and right and left digastrics. We observe the activity in both superficial temporalis and in both masseters and the reduction of the digastrics activity when the patient is biting.

Even is not an ideal record when we compare with the initial record in habitual occlusion shows the progress of the treatment, in the first record the patient could not activate her masseters. This shows a strong tool in the control of the treatment.

Patient´s comparative laminographies: initial in habitual occlusion where we can observe the retro position of the mandibular heads and with the intraoral device in neurophysiological position with a tridimensional decompression of the retrodiscal space.

Patient’s electromyographic records comparison (A) in habitual occlusion and (B) with the device in neurophysiological position.

Patient’s frontal postural image in habitual occlusion and with the device in neurophysiological position. Tridimensional recovery of the vertical dimension. Improvement of the head and shoulder posture.

As the occlusal vertical dimension is amended IN BALANCE WITH MASTICATORY MUSCLES AND TEMPOROMANDIBULAR JOINTS, a significant change in the cervical posture happens that need to be evaluated and follow by trained professionals in this area

Patient’s postural lateral imagesin habitual occlusion and with the device in neurophysiological position. Tridimensional recovery of the vertical dimension. Improvement of the head and shoulder posture.

Postural lateral images and lateral radiographs and cervical spine in habitual occlusion comparison with the device in neurophysiological position. IMPROVEMENT OF THE CERVICAL SPINE.
 As the occlusal vertical dimension is amended in balance with masticatory muscles and temporomandibular joints, a significant change in the cervical posture happens that need to be evaluated and follow by trained professionals in this area.

I searched for the Clinicamy to calm down my pain. The headache began since childhood. Nothing was ever found, a lot of exams, medications and no results.

Approximately with 14 or 15 years old I had cists in the mouth and loose some teeth. Before that, with 4 years old I had a car accident and I was thrown out of the vehicle.

Probably then everything began. Because I grinded my teeth ( I didn´t perceive that) I began to lose other teeth.

Pain increased, pressure in the neck and head, spine, and knees. Misalignment of the spine with dehydration of the vertebral discs, arthrosis signals in C4-C5, C5-C6, e C6-C7. I was recommended by my dentist Dr João de Souza to search an alternative for my pain, at that time he was wearing a DIO for the treatment of a TMJ dysfunction with Dr. Lidia Yavich.

In that time he didn´t treat TMJ Pathologies, today he studied how to treat cases like mine.

That was the salvation for my pain. The treatment propitiated a better quality of life.

In this moment when muscles, temporomandibular joints and occlusion are in balance, the patient will initiate a neurophysiological rehabilitation treatment with implants and prostheses.