Case report of 2-year-old child with congenital torticollis and crossbite treated with functional orthopedics of the jaws

1. Introduction

Satisfactory chewing is achieved by a bilateral alternating pattern, absence of occlusal interferences or premature contacts, stability, good functioning of the temporomandibular muscles (TMJ), neuromuscular maturation and symmetry of the maxilla, since skeletal asymmetries at the base of the skull can make correct chewing difficult [1, 2].

At approximately 6 years of age, the construction of the base of the face has practically been completed. The symmetrical development of the skull bones is essential so that the mandible can perform lateral-protrusive movements bilaterally. The maxilla is anatomically connected to the frontal, ethmoid and sphenoid bones; concomitantly, the mandible, through the condyle, articulates with the mandibular fossa inserted into the temporal bones. Any change in the bones at the base of the skull can impact mandibular positioning [2-4].

It is known that a greater number of dental contacts when carrying out chewing movements leads to more effective chewing [4]. Any situation that alters the development of the skull base, such as congenital torticollis, for example, needs to be investigated in a timely manner and directed to specific professionals; physiotherapists.

Congenital torticollis is characterized by shortening of the sternocleidomastoid muscle (SCM), limiting movement of the neck, which is quite evident at birth or after birth. Hypomobility of the neck promotes cervical flexion on the affected side and cervical rotation on the opposite side, leaving the baby predisposed to developing flattening of the occipital bone. If the tension pattern is maintained, the flattening may progress to positional plagiocephaly [3, 5-7]. Positional plagiocephaly can anteriorize the position of the mandibular fossa and condyle on this side, leading the baby to develop a tilt of the jaw on the opposite side, with early approximation between the dental arches on this side, predisposing to the development of unilateral crossbite [6, 7].

The baby may have difficulty sucking both breasts or hurt one breast; The vacuum of the tongue may be compromised due to the change in position of the jaw, making suction ineffective, which may make chewing difficult in the future [1, 6, 8].

For correct chewing development, the vertical dimensions on both sides must be symmetrical. It is recommended that if there are different vertical dimensions, the chewing function will occur more frequently where this vertical dimension is smaller, as the mandible will need to unclude less, generating less energy expenditure in the chewing process [9]. If the altered function remains, over time it may lead to discrepancies in maxillomandibular development and future facial asymmetries [9, 10].

The present work aims to remove both dental interferences that cause anterior and posterior crossbite, as well as those that prevent latero-protrusive movements from being well executed (right/left side) [9], [10], through symmetrization of the maxilla and occlusal adjustments.

2. Methodology

Clinical case report of a two-year-old female patient, with unilateral crossbite on the right (anterior/posterio) (Fig. 1), diagnosed with congenital torticollis, difficulty breastfeeding and difficulty performing alternating lateral movements. The treatment was divided into three stages: the first stage consisted of occlusal adjustment without the eruption of the deciduous second molars. The second stage began with the complete eruption of all primary teeth and was completed after 7 months. The third step was performed after removing the device.

Fig. 1Patient with unilateral right anterior/posterior crossbite

Fig. 21st stage: Occlusal adjustment by grid and addition of resin. In A, Grid was performed on the palatal surface of teeth 51/52/53; palatal cusp of tooth 54 and buccal surface of teeth 81/82/83/84. In B, addition of resin was carried out on the lingual cusp of tooth 84 and Inclined Plane on the buccal surface of tooth 52

1st Stage: Occlusal adjustment by adding resin to the posterior teeth with Planas Direct Tracks. Occlusal adjustments were performed on the right unilateral anterior side and the posterior crossbite side. Grid was performed on the palatal surface of teeth 51/52/53; palatal cusp of tooth 54 and buccal surface of teeth 81/82/83/84. The addition of resin was carried out on the lingual cusp of tooth 84 and Inclined Plane on the buccal surface of tooth 52. Flat Direct Tracks were placed only on primary teeth that presented dental interference (Fig. 2).

2nd Stage: Symmetrization of the maxilla. To detect maxillary asymmetry, the Orthogrille ®instrument was used (Fig. 3).

Fig. 3Orthogrille image®

The Orthogrille^® was positioned on the cut plaster model. A dotted line was drawn in the region of the palatal raphe to the most distal point of the incisive papilla and around the lingual surface of the second molars (Fig. 4). The Othogrille was used to measure the symmetry of the maxilla and an intra-arch sagittal asymmetry was detected, where the left hemi-maxilla was more mesialized than the right.

Fig. 4A dotted line was drawn in the region of the palatal raphe to the most distal point of the incisive papilla and around the lingual surface of the second molars

An encapsulated device based on devices by Maurício [13] and Deshayes [2] was installed with the purpose of distalizing sector 63-65 of the left hemi-maxilla and repositioning the mandible (Fig. 5). This device is a functional orthopedic device as it promotes changes in posture and therapeutic posture through adjustments to the device’s acrylic to enable mandibular movement.

The treatment to correct asymmetry lasted 7 months, with device activations every 15 days (Fig. 6).

Fig. 5Image of the encapsulated device based on devices from Maurício [ 13] and Deshayes [2]

Fig. 6Hemi-maxilla with corrected distalized sector 63-65

3rd Step: Occlusal Adjustment by grid (Fig. 7). After symmetrization of the maxilla, occlusal adjustment was performed using a grid on the mesial surface of teeth 53/63 and on the distal surface of teeth 73/83, enabling the mandible to perform ideal chewing.

Fig. 73rd stage: Occlusal adjustment by grid. The criteria for occlusal adjustments by grid were based on mandibular dynamics (opening/closing, right and left laterality and protrusion movements). The grid was performed on the mesial side of teeth 53/63 and on the distal side of teeth 73/83

3. Results

Fig. 8 presents the three completed steps. In Fig. 8(a) we can observe the anterior/posterior crossbite on the right side and in Fig. 8(b) the correction of this anteroposterior crossbite with occlusal adjustment by grid on the palatal surface of teeth 51/52/53, palatal cusp of tooth 54, and buccal surface of teeth 81/82/83/84 and addition of resin with Planas Direct Tracks on the lingual surface of the buccal cusp of tooth 84 and buccal surface of tooth 52. In Fig. 8(c), encapsulated device based on devices by Maurício [13] and Deshayes [2] it was installed with the purpose of distalizing sector 63-65 of the left hemi-maxilla and repositioning the mandible. In Fig. 8(d), after 7 months, there was correction of the distalization of sector 63-65 and the execution of lateroprotrusive movements after occlusal adjustment by g rad and the mesial surface of teeth 53/63 and the distal surface of teeth 73/83.

Fig. 8The three completed steps

a) Anterior/posterior crossbite on the right side

b) Correction of anteroposterior crossbite with occlusal adjustment using a grid on the palatal surface of teeth 51/52/53, palatal cusp of tooth 54 and buccal surface of teeth 81/82/83/84, and addition of resin with Planas Direct Tracks on the lingual surface of the buccal cusp of tooth 84 and Inclined Plane on tooth 52

c) Installation of the encapsulated device with the purpose of distalizing sector 63-65 of the left hemi-maxilla and repositioning the mandible

d) After 7 months, the distalization of sector 63-65 was corrected and lateroprotrusive movements were performed after occlusal adjustment by grid of the mesial surface of teeth 53/63 and the distal surface of teeth 73/83

4. Discussion

The treatment was carried out in a timely manner as a crossbite will have repercussions on the development and growth of the stomatognathic system [4].

Changes in the bones at the base of the skull can alter mandibular positioning [2]. The dental interference that caused the corrected crossbite, followed by the symmetrization of the maxilla and the occlusal adjustment may impact harmonious mandibular movements.

5. Conclusions

Functional Jaw Orthopedics restores bilateral and alternate mandibular movements, so that the patient can perform ideal chewing. Dental interference occurs due to the underdevelopment of the stomatognathic system, facilitating the installation of the crossbite. The crossbite was corrected, the maxilla was symmetrized with the distalization of sector 63-65 and the removal of dental interference made it possible to perform lateroprotrusive movements (right/left side).