Dystonia is a term that defines a group of diseases characterized by involuntary muscle spasms that generate abnormal movements and postures of a certain part or the whole body. Dystonia is classified as a disease of the nervous system. There are many types of dystonia, and many diseases and conditions can cause dystonia.

Focal dystonia: affects only one region of the body, such as the eyes, neck or hands. Usually, the etiology is unknown. There are hypotheses that suggest that the abnormal movements result from a dysfunction of the nuclei of the base (ganglia of the base).

Cervical dystonia also called spasmodic torticollis represents the most common form of dystonia and is responsible for affecting the muscles that support the neck.

Oral appliances have been manufactured for some years to improve certain dystonias. Oral orthotics can help with movement disorders by decompressing trigeminal nerve endings compressed by the TMJ, thereby reducing aberrant afferent signals to the brain stem, which may be triggering movement disorders.

Fifty-three-year-old female patient presents for consultation with a history of cervical dystonia. She refers involuntary movements.

The patient also reports pain in the neck and lumbar region.

She reports pain in the left shoulder and also pain and stiffness in the neck, especially on the left side.

The clinical record also records cracking in the TMJ temporomandibular joint on the left side and crackling in the TMJ on the right side.

She reports having muscle tremors and involuntary movements.

Difficulty opening the mouth, difficulty swallowing and difficulty chewing.

Right and left profile of the patient.

Usual occlusion of the patient with prostheses on the day of the consultation.

Upper and lower occlusal view of the patient with prostheses on the day of the consultation

Patient without prostheses on the day of the consultation.

Upper and lower occlusal view of the patient without prostheses on the day of the consultation.

Initial panoramic radiograph of the patient before treatment.

Presence of teeth 33, 32, 31, 41. Too many missing teeth.

Generalized horizontal resorption of the alveolar ridges, with the presence of dental calculus.

Pneumatization with alveolar extension of the maxillary sinuses in the region of pre- and molars and anteriors with border atrophy in the bilateral regions of the maxilla.

Radiographs of the lower incisors.

Laminography of the right and left temporomandibular joints in the patient’s open and closed mouth.

Deflection of both right and left mandibular heads is observed.

Flattening the upper anterior surface of joint processes and upper posterior surface of joint processes.

Frontal radiography of the patient before treatment.

There is an important inclination and left turn due to cervical dystonia.

Frontal radiography of the patient before treatment.

There is an important inclination and left turn due to cervical dystonia.

Note the important inclination when comparing the tracing at the points joining fronto-malar sutures, mandibular at the level of the gonion and mastoids.

Lateral and cervical spine radiography of the patient before treatment.

An important inclination is observed due to cervical dystonia.

MRI: Nuclear Magnetic Resonance: sagittal view of the left TMJ in a closed mouth.

Anteroversion of the mandibular condyle

The disc is discreetly displaced anteriorly, with a reduction in open mouth maneuvers. Open mouthed images are not included in this post.

Examination difficult to perform due to the patient’s condition.

MRI: Nuclear Magnetic Resonance: sagittal view of the right TMJ in a closed mouth.

There is an irregularity in the contour of the cortical bone of the mandibular condyle.

The disc is displaced anteriorly with a reduction in open-mouth maneuvers. Open mouthed images are not included in this post.

Examination difficult to perform due to the patient’s condition.

RNM: Ressonância Nuclear Magnética: corte frontal da ATM direita e a ATM esquerda em boca fechada.

Exame de difícil realização devido às condições da paciente.

Dynamic electromyography in habitual occlusion.

There is an important asymmetry between the right and left temporal muscles and also the asymmetry and low activity between the right and left masseters.

The left sternocleidomastoid muscle is in constant activity.

Dynamic electromyography where the patient is asked to turn the head to the right return to the center, turn the left and return to the center.

It is possible to observe the inactivity of the right sternocleidomastoid and the activity of the left sternocleidomastoid that cannot even relax between movements.

Provisional prostheses to build a first orthosis in a physiological neuromuscular position.

The patient had an upper and lower partial denture with only four compromised natural elements.

In this first stage, it was necessary to extract one of the most compromised teeth and build a temporary prosthesis and install the first orthosis.

Imaging studies were initiated to begin planning a lower protocol prosthesis for greater masticatory stability and efficiency and placement of the DIO for dystonia.

Record of the physiological neuromuscular position with the computerized jaw tracker to build the first device on top of the provisional prosthesis.

IN MANY DISTONIC PATIENTS, WE CANNOT USE A  COMPUTED JAW TRACKER BY THE TURNING OF THE HEAD WHICH MAKES THIS REGISTRATION VERY DIFFICULT.

In this patient we were able to make this first record with a pathological free space of 10.7 mm and a retroposition of 1.8 mm.

CT scans for surgical evaluation and planning.

We noticed the mandibular atrophy in the edentulous areas, the bone loss in the remaining elements and the bone availability for the implants in the anterior region.

Due to bone resorption, probably caused by tooth loss, there is not enough bone available for implant placement. We verified the atrophy of the mandibular bone and the proximity to the inferior alveolar dental nerve, preventing the installation of implants in the region posterior to the mental foramen.

CT scans for surgical evaluation and planning.

We noticed the mandibular atrophy in the edentulous areas, the bone loss in the remaining elements and the bone availability for the implants in the anterior region.

Due to bone resorption, probably caused by tooth loss, there is not enough bone available for implant placement. We verified the atrophy of the mandibular bone and the proximity to the inferior alveolar dental nerve, preventing the installation of implants in the region posterior to the mental foramen.

3D reconstruction of the mandible.

In the panoramic radiography, we observed that extractions were performed, flattening of the alveolar ridge in the anterior region and installation of four implants were performed, distributed among the mental foramen for the performance of a lower protocol prosthesis.

The surgery to prepare the reborde and install the four implants was performed by Dr. Guilherme Chwartzmann, the prosthetic planning for the installation of the prostheses in a physiological neuromuscular position was performed by Dr. Luis Daniel Yavich.

New prostheses on implants.

Comparative frontal images of the patient in the first consultation and in one of the treatment controls with the new prostheses installed, but still without the new orthosis.

Record of the physiological neuromuscular position with the computerized jaw tracker to build a new DIO on top of the definitive prosthesis.

IN MANY DISTONIC PATIENTS, WE CANNOT USE A  COMPUTERIZED JAW TRACKER BY THE TURNING OF THE HEAD WHICH MAKES THIS REGISTRATION VERY DIFFICULT.

New prostheses on implants and new orthosis installed.

Lateral and cervical spine radiography of the patient after implant placement

with prostheses and orthosis.

Frontal radiography of the patient during treatment after implantation of implants with prostheses and orthosis.

Frontal radiography of the patient during treatment after implantation of implants with prostheses and orthosis.

Note the important improvement in the inclination when comparing the tracing at the points joining fronto-malar sutures, mandibular at the level of the gonion and mastoids.

It is important to understand in improving the horizontalization of vision so the patient needs to demand less from the cervical spine

Comparative lateral and cervical spine radiographs of the patient after the installation of implants, prostheses and orthosis.

Comparative panoramic radiographs of the patient before and during treatment.

On the initial radiography, we verified remaining dental elements with bone loss and atrophic mandible in the edentulous regions.

In the panoramic radiography during the treatment, we observed that extractions, flattening of the alveolar ridge in the anterior region and installation of four implants were performed, distributed among the mental foramen for the accomplishment of a lower protocol prosthesis.

Comparative frontal radiographs of the patient before and during treatment.

Comparative frontal radiographs of the patient before and during treatment.

Note the important improvement in the inclination when comparing the tracing at the points joining fronto-malar sutures, mandibular at the level of the gonion and mastoids.

It is important to understand in improving the horizontalization of vision so the patient needs to demand less from the cervical spine

Comparative frontal images of the patient at the beginning of the treatment, in a control and with the prostheses and orthosis installed.

Note the important improvement in the verticalization of the head and posture of the shoulders.

There is still a long way to go.

The patient also reports an important improvement in activities such as working at home, writing, reading and watching television.

Patient’s testimony:

After the fall in 2014 and the attempts at treatment, I took the muscle relaxant four times a day and pain medications more often. At the end of 2018, we learned through social media that in Porto Alegre there was a doctor who treated patients with cervical dystonia and in March 2019 I went to the clinic and since then I have been treating Dr. Lidia Yavich who asked for everyone the necessary exams to be able to use an orthosis, but as he needed to give support to use the orthosis and the few remaining teeth were compromised, he did if necessary to extract them and do what was done at Clinica My, implants and the placement of a fixed prothesis.

Today, at one year and nine months, I feel better, the pains and contractures and medications have also decreased, I take today in very low doses, I continue using the orthosis and spend days without using pain medication.