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Abstract— The discomallear ligament is described as a temporomandibular joint, as well as the existence of the
fibrous connection that anatomically and functionally discomallear ligament and its possible influence on the
relates the malleus bone in the middle ear to the otologic symptoms caused by temporomandibular
posteromedial portion of the joint capsule through the disorders.
petrotympanic fissure. It is a structure that presents Keywords— Temporomandibular joint, Malleus, Middle
important clinical aspects, since it may be related to ear, Temporomandibular joint disorders.
otologic symptoms in temporomandibular joint
dysfunctions. The objective of the present study was to I. INTRODUCTION
perform a systematic review of the presence of the The stomatognathic system is closely related
discomallear ligament, its possible influences on otologic anatomically and ontologically to the region surrounding
symptoms and correlation with temporomandibular the middle ear structures (RAMÍREZ ARISTEGUIETA,
dysfunction. The analyzed sources of the literature review BALLESTEROS ACUÑA, & SANDOVAL ORTIZ,
were searched in PubMed, Scielo, Web of Science, Lilacs, 2009)(RODRÍGUEZ VÁZQUEZ, J, MERÍDA
Google Scholar and Ebsco databases through a VELASCO, J, & JIMÉNEZ COLLADO, 1993). The
combination of keywords. An analysis of anatomical discomallear ligament is one of the fibrous connections
specimens was performed through the inspection of 277 that relates the malleus to the posteromedial portion of the
adult skulls and 9 infant skulls, in order to verify the temporomandibular joint capsule (PINTO, 1962), is also
presence of foramina in the petrotympanic fissure on both described as a triangular-shaped band of connective tissue
sides. A computed tomography image was included in this whose base is continuous with the posterior region of the
study and showed a hypodense circular structure joint capsule and disc, which is directed to the middle ear
suggestive of foramen and possible passage of this through the petrotympanic fissure (COLEMAN, 1970).
ligament towards the disc of the temporomandibular Little mentioned in the anatomy books
joint. The evaluation of the anatomical parts showed that (MORGAN, 1982)(BOCHENEK & REICHER,
the adult skulls analyzed, about 90% had a foramen on 1997)(STANDRING, 2005)(ALVES & DEANA, 2010),
both sides, 1.44% on the right side only, 4.33% on the left the discomallear ligament was first referred to in 1954
side only and 3.61% did not present foramen in any of the (REES, 1954), but its detailed description was performed
sides. About the children's skulls, 33.3% had a foramen in 1962 and is also described and demonstrated by several
on both sides, 33.3% on the right side and 33.3% had no other authors (PINTO, 1962). It is a structure that
foramen on either side. In results, the methods evaluated penetrates the caudal end of Meckel's cartilage
and the studies analyzed show the anatomical corresponding to an embryological remnant of the lateral
relationship between the tympanic cavity and pterygoid muscle (CHEYNET, GUYOT, RICHARD,
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
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LAYOUN, & GOLA, 2003). However, other researchers 2.2 Anatomical Pieces Evaluation
stated that Meckel's cartilage has no influence on the This stage was based on a careful evaluation of
development of the temporomandibular joint and also that skulls belonging to the Department of Biological
during the embryonic stage there is no evidence that the Sciences, Anatomy Discipline of School of Dentistry of
lateral pterygoid muscle attaches to the malleus Bauru- University of São Paulo (FOB-USP). The
(FURSTMAN, 1963)(YUODELIS, 1966). inspection of the pieces was done with the naked eye and
The discomallear ligament is a structure that with the aid of a hand magnifier with lighting 75 mm in
presents important clinical aspects (ALVES & DEANA, diameter and increase of 6 times, of the brand Western
2010). Some authors state that dysfunctions in the 3455. It consisted in identifying the presence or absence
temporomandibular joint (TMD) cause alteration of the of foramina in the region of the petrotympanic fissure on
discomallear ligament, causing a displacement of the the left and right sides of 277 (two hundred and seventy -
malleus, resulting in some symptoms such as tinnitus and seven) adult skulls and 9 (nine) children skulls.
deafness (PINTO, 1962)(IOANNIDES & HOOGLAND,
1983). Although the risks of otological symptoms are 2.3 Data source
greater in individuals presenting with disorders such as This literature review contains information
pain during the opening and closing of the mouth or available in the databases PubMed, Scielo, Web of
palpation of the temporomandibular joint (PASCOAL, Science, Lilacs, Google Scholar and Ebsco, using the
2001)(LAM, LAWRENCE, & TENENBAUM, 2001). following keywords: discomallear ligament /
The origin and possible relations between these structures discomalleolar ligament, temporomandibular disorders,
are not fully understood (FELICIO, FARIA, & DA temporomandibular dysfunction, and petrotympanic
SILVA, 2004). This structure can usually be observed in fissure. This led to the initiation of a search strategy and
dissected anatomical pieces. However, it is also possible articles published between 2006 and 2016 were included,
to visualize it in concomitant computed tomography in using a keyword search to obtain information about the
sagittal sections. In the images, furthermore to discomallear ligament (figures 1-6).
discomallear ligament, structures related to
temporomandibular joint are also observed within the 2.4 Data extraction
petrotympanic fissure. In Cone Beam CT images, the After analyzing and reviewing the researched
petrotympanic fissure resembles a small lumen that scientific articles, ten relevant studies related to the
extends in the direction of the epitympanic recess in the objectives of the study were found. Several studies
upper portion of the tympanic cavity, where inferiorly the resulting from the research were read with the objective
malleus bone is located. Studies demonstrate the of identifying relevant information on the subject in
visualization in tomographic images and anatomical question.
pieces that discomallear ligament connects to the head
and anterior region of the malleus bone, disposed from
the posterior and superior portion of the mandibular fossa,
located in the temporal bone (ARAI & SATO, 2012).
Thus, the aim of the present study was to perform a
systematic review of the presence of the discomallear
ligament, its possible influences on otologic symptoms
and correlation with temporomandibular dysfunction .
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
https://dx.doi.org/10.22161/ijaers.6.6.6 ISSN: 2349-6495(P) | 2456-1908(O)
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
https://dx.doi.org/10.22161/ijaers.6.6.6 ISSN: 2349-6495(P) | 2456-1908(O)
Fig.4: LILACS Keywords combination. Papers extracted from the Google Scholar
database:
Papers extracted from the LILACS database: 1- A direct anatomical study of the morphology and
1- Classifications of tunnel-like structure of human functionality of disco-malleolar and anterior malleolar
petrotympanic fissure by cone beam CT (SATO et al., ligaments (ARISTEGUIETA; ACUNA; ORTIZ, 2009).
2008). 2- Anatomical study of the human discomallear
ligament using cone beam computed tomography imaging
and morphological observations (ARAI; SATO, 2011).
3- A study of the discomalleolar ligament in the adult
human (ROWICKI; ZAKRZEWSKA, 2006).
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
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Fig.8: Presence of foramen in the petrotympanic fissure Fig.9: Presence of foramen in the petrotympanic
on the right side, demonstrated by the red arrow. fissure on the left side, demonstrated by the red arrow.
Literature review
After analyzing the combination of the keywords
used for this literature review, a table with a brief
summary of each of the extracted papers was obtained
(table 3).
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
https://dx.doi.org/10.22161/ijaers.6.6.6 ISSN: 2349-6495(P) | 2456-1908(O)
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
https://dx.doi.org/10.22161/ijaers.6.6.6 ISSN: 2349-6495(P) | 2456-1908(O)
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
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Kitsoulis et al. Examination of the 464 university students. Overall incidence of Signs and symptoms
(2011) relation between signs Mouth opening signs and symptoms of of TMD are more
and symptoms of measured with Vernier TMD were 73.3%, common and severe
temporomandibular calipers. Anamnestic higher in women (p- in women. The
dysfunction (TMD) questionnaire applied value 0.0001 <0.05). severity of TMD
and mouth opening, to stratify them into Hearing symptoms were correlated with the
gender, joint and four groups based on associated with TMD degree of mouth
auditory symptoms and the severity of TMD. severity (p-value 0.0001 opening and the
hearing loss. Hearing symptoms and <0.05) as well as number of auditory
a recorded audiogram maximu m mouth symptoms. The
for each subject as opening (p-value 0.004 absence or presence
well. <0.05). Audiometry of mild TMD was
showed that moderate associated with
and severe TMD was normal audiograms,
associated with hearing while moderate and
loss of medium and low severe TMD were
tones, respectively (p- related to hearing
value 0.0001 <0.05). loss in low and low
TMJ pain (p value tones, respectively.
0.0001 <0.05), TMJ Bruxism, joint
ankylosis (p-value ankylosis, joint pain
0.0001 <0.05), bruxism and ear itching were
(p-value 0.0001 <0.05) more common in
and ear itching (p-value TMD than patients
0.0001 <0.05) were also without TMD.
statistically different
between TMD and non-
TMD.
Sencimen et To investigate the The malleus, incus, In 12 cases two The overstretched of
al. (2008) anatomical topography petrotympanic fissure ligaments connected to the condyle together
and the relation (PTF), chorda tympani, the anterior part of the with the ligaments
between the ligaments, anterior malleolar malleus. Of this same between the inner
malleus and ligament (AML), portion, another ear ossicles and the
temporomandibular discomallear ligament ligament that went to TMJ may be the
joint and to determine (DML), PTF was seen in 3 reason for
the role of these malleomandibular cases. In all of cases, the unexplained
ligaments in the ligament, DML joined the otological problems.
movement of the sphenomandibular retrodiscal tissues. In
malleus. ligament and disc joint the other 3 cases, the
were explored in 15 medial and lateral parts
skulls. Tensile and of the ligament were
tensile tests performed attached to the
to clarify the role of retrodiscal tissue after
these structures in the passage through
movement of the PTF.The thickness of
malleus. the ligaments differed
among the specimens.
When the tension was
applied to the DML, no
malleolar movement
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
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TOLLER, 1995)(RODRÍGUEZ VÁZQUEZ et al., capsulitis or even rupture of the ossicle joint
1998)(Dai, Cheng, Wood, & Gan, 2007)(SENCIMEN et (LOUGHNER et al., 1989). In contrast, other authors say
al., 2008). that the ligament has no role in otological manifestations
Individuals with temporomandibular dysfunction may (CHEYNET et al., 2003)(ALVES & DEANA, 2010),
frequently exhibit otological symptoms. The dissonance because it does not contain sufficient force to mobilize the
of the stomatognathic system, such as muscular pain, bones of the middle ear once it is firmly adhered to
TMJ pain, cervical pain, tooth sensitivity, joint noise and, petrotympanic fissure (ALVES & DEANA, 2010).
in general, functional difficulties, were significantly
associated with otologic symptoms in cases of V. CONCLUSION
temporomandibular disorders (FELICIO et al., 2004) For this purpose, that the methods evaluated and the
(KITSOULIS, MARINI, ILIOU, GALANI, & ZIMPIS, studies analyzed show the anatomical relationship
2011)(ÇAKUR & YAŞA, 2016). between the tympanic cavity and the temporomandibular
The discomallear ligament presents mobility as it joint, as well as the existence of the discomallear ligament
passes through petrotympanic fissure, caused by stretches and its possible influence on the otologic symptoms
in the TMJ disc during movements of the mandible caused by temporomandibular disorders.
(COULY & HUREAU, 1976)(CESARIANI et al., .
1991)(SATO, ARAI, IMURA, KAWAI, & YOSUE, REFERENCES
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1998). Some authors state that malleus mobility was tomography imaging and morphological observations.
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With Temporomandibular Joint Dysfunction. J Oral
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International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-6, Issue-6, June- 2019]
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