Clinical
Before treatment Fig 1
Tourette’s syndrome, which had started five months previously following a seizure. He had glue ear as a child. Brain scan MRI was normal. Henry was under the care of a neurologist.
Symptoms Spontaneous severe swearing and utterances, supraorbital headaches, continuous popping vocal sounds, seizures (had a fit five months previous), up to ı50 tics or involuntary movements in an hour, eye tics (wants to shut his eyes – blepharospasm), head and neck stretching, head banging and punching himself in the head, reduced hearing by 20 per cent and tinnitus in the right ear.
Examination • Posture: head tilt to the right and rotated to the left, left cranial side bend, dropped right shoulder, dropped instep on the left foot, left knee toed out, pelvis up on the left by ı.5 centimetres, enlarged left trapezius.
• Dental: cross bite on the left, significant clicking in the right TMJ.
• Kinesiology: approximately three times stronger in an edge-to-edge bite.
• TMJ palpation: clicking on the left TMJ.
• Jaw vibrational analysis: right side mid-opening and mid-closing click.
• Electromyography: left temporalis constantly firing at rest. When clenching, the left temporalis was firing three times more than the right.
• Matscan (foot scanner) unstable stance with increased sway, unsteady gait, rotating to the left.
• T-Scan (bite scanner): centre of force back and on right molars.
• Questionnaire results: pain and headaches increased with blepharaspasm and exercise. Sight recently deteriorated significantly over six months from long-sighted to severe short-sighted. Has seen eight
Extrusion mechanics Fig 2
specialists for Tourette’s. Patient hears voices in his head saying his name.
• TMJ X-ray: left side (closed) – condyle superiorly and posteriorly displaced. No joint space seen, condylar head flattening with beaking and condylar neck bending. When open, no joint space. Right side – condyle superior displaced and posterior displaced with some joint space.
• Orthotics: patient was wearing foot orthotics, but still the pelvis was up by two centimetres on the left. Head tilt to the right and shoulder dropped on the right. Referred to the podiatrist for new orthotics to ensure pelvis is parallel to the floor.
• Dental findings: significantly micro- dontic with upper cross bite with lower left laterals and canine, Class ı, normal overbite and overjet, narrow airway and large tonsils.
• Masticatory muscle test: all tender, especially the medial and lateral pterygoids and the sternocleidomastoids.
• Range of motion: maximum opening 44mm, left excursion 5mm, right excursion 4mm. Deviation on opening.
• Cervical range of motion: left side bending of head restricted.
• Cranial rhythm: very weak, stronger on the right than left and oscillating.
• MRI: brain – nothing abnormal detected. • TMJ: right side Wilkes Classification IV-V. Anterior non-reducing discs with condyle and eminence degeneration and synovitis. Left side Wilkes Classification III-IV. Anteriomedially dislocated disc with reduction on opening. Mild degenerative changes of the condyle and eminence.
• Orthodontic assessment: full photos, lateral skull and OPG, Bimler tracing
Continued »
TMD splint Fig 5b
Ireland’s Dental magazine 35
Upper Nordstrom appliance Fig 5a
MRI Fig 4
TMD connection Fig 3
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