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.

A 55-year-old female patient attends the consultation for suffering from cervical dystonia to the left, she reports pain in her shoulders with preponderance of the left shoulder, and the patient also reports pain in her neck.

Patient report:

Good morning Dr. Lidia.

As requested, I write my health history:

I fell around the age of five, with a violent slamming on my mouth;

The only disease I had was chickenpox, when I was 9 years old;

I have genetic hemochromatosis.

I had three normal deliveries with analgesia;

I wore braces when I was 14 years old because of the protruding canines;

Extraction of the 4 wisdom teeth at the age of 21, they were lying down;

Last year I used braces to uncross the bite;

As for dystonia: I started noticing it about 7 years ago. Initially the head pulled very little and slowly, it really started to get worse after a couple of years.

I consulted several neurologists, all of whom recommended Botox.

I made four application attempts, with no result.

I do Pilates with a physiotherapist.

Also, I don’t remember anything else that might be relevant.

A hug:

The patient reports crackling in both temporomandibular joints.

She reports strange sounds in her right ear.

In her search for treatments she consulted neurologists, acupuncturists, physiotherapists and osteopaths.

Habitual occlusion of the patient on the day of her first appointment.

Upper and lower occlusal view of the patient.

Note the incisal wear of the lower incisors.

Initial electromyographic record with the patient in habitual occlusion.

Very low activity at maximum intercuspation, the masseters and anterior temporalis they cannot generate work.

Very high activity of the right sternocleidomastoid (remember that the patient has dystonia to the left). The sternocleidomastoid should show no activity at maximum intercuspation.

High activity of both digastrics. Nor should they activate in maximum intercuspation.

Initial panoramic radiograph of the patient at the beginning of treatment.

Even though this is not a radiograph for evaluating the temporomandibular joints, the facet of the left condyle can be seen.

Patient’s lateral and cervical spine radiograph before treatment.
Note the torsion of the neck, which does not allow a lateral radiograph in position.

An MRI slice of the patient’s usual occlusion prior to treatment. Note the posterior erosion of both mandible heads, superior facets in both mandibular heads and significant retrodiscal compression in the left TMJ.

Modification of the mandibular condyle growth axis.

Computed tomography of the patient before treatment. Multiplanar reconstruction.


Left TMJ, posterior erosion, superior facet, in the sagittal section.


In the frontal cut, loss of the external lateral space.


Modification of the mandibular condyle growth axis.

Computed tomography of the patient before treatment. Multiplanar reconstruction.


Right TMJ retroposition of the mandibular head.


Modification of the mandibular condyle growth axis.

Occlusion of the patient with the DIO installed.


IN MANY DYSTONIC PATIENTS, WE CANNOT USE A COMPUTERIZED KINECIOGRAPH BY HEAD ROTATING WHICH MAKES THIS RECORD VERY DIFFICULT.


In this patient we were able to use the cineciograph after a long time and several orthoses.


The orthosis appears too high, but the patient has an adequate lip seal

Comparison of values in the skeletal problems of the patient with cervical dystonia in habitual occlusion and with the device placed in the mouth.


With the orthosis in place and the value of the lower facial height is within the norm and the convexity of point A has improved.


In habitual occlusion, the lower facial height is well below the norm.

Electromyographic record with the DIO (intraoral device) installed.

An improvement in the activity of the masseters and anterior temporalis is observed.

Series of comparative frontal images during treatment.

Comparative frontal images of the patient at the first visit and during treatment.

Comparative back images of the patient at the first visit and during treatment.

Comparative left profile images of the patient at the first visit and during treatment.

Comparative right profile images of the patient at the first visit and during treatment.

Comparative lateral and cervical spine radiographs of the patient before in habitual occlusion and during treatment with the device in place.

Computed tomography of the patient in the control of the treatment. Multiplanar reconstruction.


Left TMJ, positive posterior erosion remodeling, improvement in retrodiscal and upper facet compression.

Computed tomography of the patient in the control of the treatment. Multiplanar reconstruction.


Right TMJ, positive posterior erosion remodeling, improvement in retrodiscal and upper facet compression.

Comparative electromyographic recordings in habitual occlusion and with the DIO (intraoral device) installed.

PATIENT TESTIMONY:

I started noticing the symptoms of dystonia in 2010. Initially a slight tremor that evolved into involuntary head movements, pulling to the left side.


I immediately started doing Pilates with a physiotherapist. This, I believe, was fundamental for not having a great postural deterioration.


There were several consultations with orthopedists, neurologists, a psychologist, three or four attempts of botox applications, without any improvement.

In mid-2017, I “discovered” Dr Lidia through the dystonia group on social media. I got in touch and for the first time I felt that someone really took this disease seriously and with interest.


After imaging exams she found that an orthosis could be indicated for my case.


She was always very clear that there was no guarantee of any improvement or cure, but with her knowledge, study and dedication, I have shown significant improvement.


With the frequent use of the orthosis, I am now able to hold my head without having to hold it in my hands. Also with guidance and indication from Dr Lidia, in addition to pilates, which I never stopped, I follow up with an osteopath, also essential for releasing and stretching the muscles.