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Dysfunction of temporomandibular joints (TMJs)

has various etiologies,1-4 including occlusion, stress,

muscular hyperactivity and the nonsymmetric posi-

tioning of the condyles in the mandibular fossae.5-9

Some investigators have cited the cause as an associa-

tion between occlusal interference and dysfunc-

tion,7-12 whereas others disagree because they have

not found scientific evidence that could confirm such

correlation.13-16

Signs and symptoms of temporomandibular disorders

(TM Ds) vary. H owever, the mo st common ly cited

symptoms and signs are sore masticatory muscles, limi-tation of mandibular movements, TMJ clicking,5-9,17-19

headache, and ear symptoms like tinnitis, fullness, verti-

go, deafness, and o talgia.9,20-31

More than 5 decades ago, ear symptoms were relat-

ed to occlusal factors.8,32-34 Although there is anatom-

ic proximity and similar embryologic origin of the jaw,

TMJ, and the structures of the middle ear, no studies

have linked the occurrence of auditory loss, tinnitus,

auricular fullness, or earache with TMDs. Such factors

as spasms in the masticatory musculature28 that reflect

on the tympanium tensor muscles and on the tensor

neli, alterations in the function of the auditory tube, 35

interference in the petrotympanic fissure,26 and tensionin the anterior malleolar ligament through spheno-

mandibular ligament36 are pointed out as possible caus-

es for the ear symptoms.

To make an accurate diagnosis and to prepare a

treatment plan, a detailed clinical examination and his-

tory must be carried out and must include the use of

the study of casts set on a semiadjustable articulator to

permit the analysis of static and dynamic occlusion.

Depending on the conditions presented by the patient,

various forms of treatment for TMD s may be indicated,

such as interocclusal splints,37,38 physiotherapeutic

resources, psychological therapy,39 therapeutic prosthe-

ses,40 and myofunctional therapy.41

This clinical report describes the treatment of a

patient to determine whether the occlusal alterations

existing in the patients dentures were causing the signs

and symptoms of TMD and ear symptoms.

CLINICAL REPORT

A 27-year-old man with complaints of TMD was

evaluated for treatment. Evaluation procedures were

general with specific clinical dental examinations of the

occlusal area, radiographs of the TMJs, and otorhyno-

laryngologic and audiologic examination before, dur-

ing, and after the treatment with therapeutic removable

partial dentures. The otorhynolaryngologic diagnosis

was based o n the examination of ear, no se, oropharynx,nasopharynx, and larynx.

Audiologic evaluation was composed of pure tone

audiometry to evaluate the hearing threshold and

impedance audiometry to verify middle ear conditions.

In pure tone audiometry, the test sound is generated by

an audiometer. The pure tone is presented to the

patients test ear by air conduction (through a mon oau-

ral ear phone) at frequencies of 125, 250, 500, 1000,

2000 , 4000, and 8 000 H z. A clearly audible tone is

presented first. As soon as the patient hears the tone, he

signals to the tester by raising his finger. The tester

reduces the tone to an intensity so small that it will be

inaudible to the patient and then successively increasesin 5-dB steps until the patient again responds. This is

his threshold.

For estimation of a handicap, if the hearing thresh-

old level of the patient is greater than 25 dB, an

audiogram indicates impairment.42 The impedance of

middle ear can be determined by an acoustic bridge

inserted into the external auditory canal that gener-

ates a pure tone reflected from the eardrum. Adjust-

ments are made so that the reflected sound is bal-

anced within the bridge. A distinctive pattern of

change in impedance with change in pressure differ-

entiates conditions, such as the middle ear being

normal, pathologically negative pressure, fluid in the

middle ear, or disrupted ossicular chain.

Treatment

For treatment, therapeutic removable partial den-

tures were made with acceptable physical and function-

al requirements. After the confirmation of the first

diagnosis, definitive removable partial dentures were

made by using the therapeutic removable partial den-

tures as a guide for the oral rehabilitation. The initial

examination verified that the dentures used by the

Ear symptomatology and occlusal factors: A clinical report

Andra Cndido dos Reis, DDS, a Takami H i rono H ot ta, D D S, M S,b Rosngela Rodrigues Ferreira-Jern ym o, BS,c Cludia M aria de Fel c io, M S, PhD, d and Ricardo Faria Ribeiro, D D S, PhD eScho ol o f D ent is try o f Rib e i ro Preto, U nivers i ty o f So Paulo , Ribe i ro Preto, Sao Paulo , Braz i l

aGraduate Student .b Doctoral Student ; and Professor of Occ lus ion, Univers i ty of Franca,

So Paulo.c Sp e e c h T h e ra p i st , U n i v e r si t y H o s p i t al o f Sc h o o l o f M e d i c i n e o f

Ribei ro Preto, Univers i ty of So Paulo.d Speech Therapi s t and Professor of Speech Patholo gy.eProfessor, D epartmen t of Prosthes is and D ental M ater ia ls.J Prosthe t D ent 200 0 ;83 ;21-4 .

JAN U ARY 2 0 0 0 TH E JO U RN AL O F PRO STH ETIC D EN TISTRY 2 1

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In addition to the return of the functional and

esthetic activities after the therapeutic removable partial

dentures (RPDs) were used for 1 week, pain in the

masticatory muscles and sternocleidomastoid muscle

decreased significantly. The patients condition, which

has been followed up for 2 years, remained stable after

the definitive RPDs were delivered. The subjective

symptomatology judgments made by the patient are

presented in Table III.

DISCUSSION

The patients history and signs and symptoms that

reported the appearance of the symptoms after the

patient did not provide a stable occlusion or a harmo-

nious maxillary relationship (Figs. 1 and 2). After

occlusal reconstruction, there was better accommoda-

tion of the articular structures in the glenoid fossa.

Otologic alterations were not found in the clinical

otorhynolaryngologic evaluation or audiologic exami-

nation . H owever, after occlusal rehabilitation, TM J

clicking, tinnitus, and otalgia were eliminated and a

slight improvement in the pure tone threshold of both

ears occurred. Thus, only the fullness remained. Results

of the audiometric test for the right and left ears, in the

initial, intermediate, and final phases of the treatment

are presented in Tables I and II, respectively.

TH E JO U RN A L O F PRO STH ETI C D EN TI STRY C N D I D O D O S REI S ET A L

2 2 V O LU M E 8 3 N U M BER 1

Fig. 1. Trans c ran ia l r ad iog raph be fo re o ra l r ehab i l i t a t i on ,r ight s ide.

Fig. 2. Transc rania l rad iograph b efore ora l rehabi l i ta t ion , le f ts ide.

Table I . Resul ts o f the audio m etr ic test in the 3 evaluat ionphases, r ight ear

Intensity in decibels (dB)

Frequency/ First I nterm ediate FinalH z phase phase phase Var iation

2 5 0 3 0 2 5 1 5 1 5 d B5 0 0 2 5 1 5 0 5 2 0 d B1 0 0 0 1 0 0 5 0 5 5 d B2 0 0 0 1 5 1 5 1 0 5 d B4 0 0 0 1 0 0 5 1 0 0 d B6 0 0 0 2 0 2 0 0 5 1 5 d B8 0 0 0 0 5 1 5 0 5 0 d B

Average 8 .75 d B

The minu s s ign i nd i ca tes imp rovement i n the hear ing th resho ld .

Table I I . Resul ts o f the audio m etr ic test in the 3 evaluat ionph ases, lef t ear

Intensity in d ecibels (dB)

Frequency/ First I nterm ediate FinalH z phase phase phase Var iation

2 5 0 2 0 1 0 1 1 1 0 d B5 0 0 2 0 0 5 0 5 1 5 d B1 0 0 0 1 5 1 0 0 5 1 0 d B2 0 0 0 2 0 1 0 1 0 1 0 d B4 0 0 0 1 5 1 0 1 0 1 0 d B6 0 0 0 2 0 1 0 1 5 5 d B8 0 0 0 2 0 0 5 1 5 5 d B

Average 9 .28 d B

The minu s sign i nd i c a tes imp rovement i n the hear ing th resho ld .

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placement of RPDs led to the investigation of whether

the etiologic factor was occlusal or otologic. Examina-

tions and adaptation of therapeutic RPDs were used.

Muscular hyperactivity has frequently been att ributed to

occlusal problems.43 Occlusal interference, absence or

decrease of posterior occlusal support, and lack of ante-

rior guidance for mand ibular movements also have been

considered to be etiologic factors for TMDs.1,10,44

H owever, t his is controversial, because several autho rs

claim the absence of scientific evidence.13,15,16

In this clinical report, the occlusal factors observed

during t he diagnostic phase were regarded as one of the

probable causes of dysfunction, which included muscu-

lar hyperactivity. Fabrication of the therapeutic RPDs

provided for the reestablishment o f the functions of the

stomatognathic system: recovery of the vertical dimen-

sion and of the planned occlusion. It is believed that a

better positioning of the condyle was provided in the

glenoid fossa and the clinical signs and the mandibular

functions improved significantly (Figs. 3 and 4).

Stress can affect muscular hyperactivity. When this

was explained, the patient became more confident in

the treatment and in the professional who was treating

him, which reduced his anxiety level. It was then sus-

pected that occlusal and emotional factors and muscu-

lar hyperactivity were responsible for the patients clin-

ical signs. Treatment resulted in remission of symptoms

(tinnitus, otalgia, subjective hearing loss, and fullness)

that could have been caused by occlusal factors.18,45

Malocclusion can produce hypertonus of the mastica-

tor y muscles and, as a consequence, impede the proper

function of the auditory tube35,46 or produce internal

disarrangement of the TMJ interfering in the spheno-

mandibular ligament36 or the discomaleolar liga-

ment,27 which cou ld lead t o m iddle ear symptoms.

Despite the symptoms, the otologic and audiometric

findings seen du ring the first evaluation were no rmal, as

has been observed by other authors.23,25,47-49 In addi-

tion, the improvement of the tone threshold may have

been a consequence of symptom remission.23 These

results confirm the first diagnostic hypothesis that

occlusal and emotional factors were responsible for the

signs and symptoms of the TMD, including the audito-

ry symptoms. The final diagnosis was confirmed

through the clinical follow-up and comparative analysis.

SU MMARY

In this clinical report , it was concluded that the o to-

C N D I D O D O S REI S ET A L TH E JO U RN A L O F PRO STH ETI C D EN TI STRY

JAN U ARY 2 0 0 0 2 3

Fig. 3. Transc rania l rad iograph af ter ora l rehabi l i ta t ion, r ights ide.

Fig. 4. Transc rania l rad iograph af ter ora l rehabi l i ta t ion, le f ts ide.

Table I I I . Sym ptom s in th e f i rst phase, in termedi ate phasew i th t he t em po ra ry r em ov ab le p a r ti a l den tu res and f i na lphase w i t h t he d e f i n i t i ve r em ov ab le p a r ti a l den tu res

Sym ptom s First phase I nterm ediate phase Final phase

Tin n i tu s + + + 0 0TM J c l i c k i n g + + 0 0Fu l l n ess + + + +O talgi a (ri gh t si d e) + + + 0 0M u scu lar p ain + + + 0 0H ead ach e + + + 0 0

0 , Absence o f pa in ; + , s l i gh t pa in ; ++ , med ium pa in ; +++, s t rong pa in .

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logic symptoms for this patient were related to occlusal

factors. In addition, phonoaudiologic and otorhino-

laringologic examination were of great importance for

the differential diagnosis of TMD. Therapeutic RPDs

were effective in reestablishing the occlusion and

served as a guide for the definitive occlusal rehabilita-

tion, which eliminated the painful signs and symptoms.

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