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Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 38-40

Stabilization occlusal appliance therapy for cervical dystonia

Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

Date of Submission16-Mar-2022
Date of Acceptance17-May-2022
Date of Web Publication07-Oct-2022

Correspondence Address:
Dr. Abdullah Mohammed Alzahem
Deanship of Quality Management, King Saud bin Abdulaziz University for Health Sciences, PO Box 3660 (Mail Code 3139), Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijas.ijas_3_22

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Cervical dystonia (CD) is a neurological movement disorder causing awkward head position, affects very few people with unknown clear etiology, and has no full cure. The patient diagnosed with CD can be managed by botulinum toxin therapy and antidystonic agents. Understanding the biomechanics of skull structure used in jaw alignment and raising the vertical dimension of occlusion (VDO) through occlusal stabilization appliance (OSA) therapy to improve the symptoms of the CD. This case report showed significant improvement of CD symptoms by OSA therapy. Vertical distraction of temporomandibular joints and jaw alignment achieved by OSA with gradual increase in VDO. Stabilization occlusal appliance therapy improved the cervical muscles contraction and the skull cervical collapse in case diagnosed with CD.

Keywords: Cervical dystonia, head position, neurological disorder, stabilization occlusal appliance, vertical dimension of occlusion

How to cite this article:
Alzahem AM. Stabilization occlusal appliance therapy for cervical dystonia. Imam J Appl Sci 2021;6:38-40

How to cite this URL:
Alzahem AM. Stabilization occlusal appliance therapy for cervical dystonia. Imam J Appl Sci [serial online] 2021 [cited 2023 May 31];6:38-40. Available from:

  Introduction Top

Cervical dystonia (CD) is a neurological movement disorder, known by sustained involuntary contractions of the cervical muscles, causing abnormal head tilt.[1] It has been classified into three types from the opinion of social adaptation and the differences of frustration tolerance. The three types were as follows: type I (over adaptive type), Type II (maladaptive type), and Type III (compatible type).[2] Symptoms start gradually till a point where do not get substantially worse.[3]

The prevalence of CD in eight European countries was 5.7/100,000 persons.[4] The incidence rate in Minnesota, USA, was 1.2/100,000 person-years with a female: male ratio of 3.6:1.[5] The incidence of diagnosed CD among Cucasian individuals in California is similar to previous estimates in more ethnically homogeneous populations of largely European descent. The incidence in other races, including Hispanic, Asian, and African, appears to be significantly lower. The incidence is also higher in women than in men.[6]

The first treatment option for CD is botulinum toxin therapy (BTT). Other treatment options include oral agents (anticholinergics, benzodiazepines, baclofen, dopaminergic, antidopaminergics, and anticonvulsants) and deep brain stimulation surgery.[7] One of the promising treatment options is appliance therapy with occlusal stabilization appliance (OSA), which acts as a sensory trick.[8] Cervical sensorimotor control is impaired in patients with CD, which can be trained; this might be a potential treatment option for management.[9] The FDA (US agency for the control and regulation of medical prescription drugs and procedures) approves a clinical trial involving the use of a dental appliance for the treatment of Tourette's syndrome (neurological movement disorder), and its identifier (NCT number): NCT02067819.

Very limited number of published research discussed the use of the OSA in the management of CD, and to the best of my knowledge, no published research discussed the effect of raising the vertical dimension of occlusion (VDO) by the OSA to manage the CD. The aim of this study is to report a case of CD treated with OSA using different VDO.

  Case Report Top

A 41-year-old female diagnosed 7 years ago with CD presented to the orofacial pain clinic in the dental center, complaining of tilted head for several years with moderate neck pain treated previously by BTT (Botox®) and pregabalin (Lyrica®) with nonsignificant improvement. The patient has a history of jaw joint sound, discomfort while walking, poor sleep quality, trimer, and neck pain on pain killers.

The patient was evaluated on the first visit, and panoramic X-ray with impressions for teeth was made. The standard extraoral and intraoral examination is done according to DC/TMD international form.[10] On the second visit, OSA for mandible fabricated with 2-mm thickness posterior contacts. The patient was advised to use the OSA for the mandible during daytime except during eating and teeth brushing. The patient follow-up visits are scheduled after 2 weeks, 4 weeks, and every 6 weeks for eight follow-up visits in addition to the initial two visits. The thickness of the OSA posterior contacts for the mandible increased gradually to 6 mm on multiple follow-up visits. Occlusal contacts were checked every visit, and necessary adjustments in the appliance were done to maintain balance bite. Home care instructions on how to use and clean the appliance given to the patient written.

Clinical examination before the appliance therapy shows head tilt to right 40° measured by goniometry with chin pulled toward the right shoulder. Right shoulder higher than left. Left temporomandibular joint (TMJ) click upon mouth opening. Cheek-bite keratosis was noted on both cheeks. Horizontal Incisal Overlap (03 mm), Vertical Incisal Overlap (02 mm), Midline shift to left (01 mm). Straight mouth opening. The maximum mouth opening without pain and unassisted (37 mm), but the assisted mouth opening range (45 mm). The right lateral excursion was 8 mm, the left lateral excursion was 9 mm, and the protrusive movement of the mandible was 6 mm. There is no joint sound during the examination or locking. Sternocleidomastoid muscles were tender, but TMJs were not painful with palpation. Panoramic X-ray showed forwarded condyles on both TMJs. The patient was diagnosed by group of neurologists with CD treated with BTT, and appliance therapy was suggested. After the patient started using the OSA with 02-mm thick posterior contacts, she started to have significant improvement in neck tilt within a month; after that, the improvement stopped till the thickness of the appliance increased. Every 6 weeks, additional self-cure acrylic is added to the posterior segment of the appliance to raise the bite gradually. The patient was able to feel the improvement in head tilt with raising the bite and reported improvement 6 months after start using the appliance, where the head tilt decreased by 25°.

  Discussion Top

The aim of this case report was to look at the effect of raising the bite by OSA for CD patients. Symptoms of CD include muscles contraction, pain, discomfort while walking, sleep quality, and trimer. TMJ health status may be affected by muscles contractions. Using the OSA should help muscle relaxation and TMJ distraction.

Correcting the head position by the OSA therapy explained by previous study reported the effect of increasing the VDO on the strength of cervical flexors and deltoids. Isometric strength of the cervical flexors and deltoids increases significantly from habitual occlusion as the VDO is increased.[11] Increasing the thickness of the appliance to raise the bite affected the cervical muscles positively and corrected head tilt that improved neck pain. This thick appliance caused TMJ distraction, which reduces compression on the superior and inferior stratum fibers, blood vessels and nerves, and stretches muscles and tendons around the joint. Rapid suppression of CD symptoms can often be achieved within minutes using TMJ vertical distraction.[12] Vertical distraction of TMJs and jaw alignment achieved by OSA with gradual increase in thickness to increase the VDO. Stabilization occlusal appliance therapy improved the cervical muscles contraction and the skull cervical collapse.

Future randomized clinical trial study suggested to investigate the effectiveness of OSA with gradual increase of the VDO. In addition, explore the implication of OSA therapy to different neuromuscular disorders in the head-and-neck region.

  Conclusion Top

Thick OSA increases the vertical demission of occlusion and improves the symptoms of CD. OSA thickness increased gradually and needs continuous follow-up every 6 weeks for occlusal adjustment to avoid premature contacts. Stabilization occlusal appliance therapy improved the cervical muscles contraction and the skull cervical collapse in case diagnosed with CD.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


The author would like to thank Professor Saleh Aloraibi from Physiotherapy for his invaluable advice and suggestions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Albanese A, Bhatia K, Bressman SB, Delong MR, Fahn S, Fung VS, et al. Phenomenology and classification of dystonia: A consensus update. Mov Disord 2013;28:863-73.  Back to cited text no. 1
Kashiwase H, Kato M. The classification of idiopathic spasmodic torticollis: Three types based on social adaptation and frustration tolerance. Psychiatry Clin Neurosci 1997;51:363-8.  Back to cited text no. 2
Hafez F, Islam MZ, Nessa J, Shahidullah MS, Sobhan S, Begum S. A case of cervical dystonia with non responsive to usual noninvasive treatment. J Shaheed Suhrawardy Med Coll 2014;6:44-6.  Back to cited text no. 3
Potemkowski A, Sławek J, Stankiewicz J, Fabian A. Epidemiological analysis of primary dystonia in Szczecin and Gdańsk regions. Neurol Neurochir Pol 2003;37 Suppl 5:231-9.  Back to cited text no. 4
Claypool DW, Duane DD, Ilstrup DM, Melton LJ 3rd. Epidemiology and outcome of cervical dystonia (spasmodic torticollis) in Rochester, Minnesota. Mov Disord 1995;10:608-14.  Back to cited text no. 5
Marras C, Van den Eeden SK, Fross RD, Benedict-Albers KS, Klingman J, Leimpeter AD, et al. Minimum incidence of primary cervical dystonia in a multiethnic health care population. Neurology 2007;69:676-80.  Back to cited text no. 6
Dressler D, Altenmueller E, Bhidayasiri R, Bohlega S, Chana P, Chung TM, et al. Strategies for treatment of dystonia. J Neural Transm (Vienna) 2016;123:251-8.  Back to cited text no. 7
Navrotchi C, Badea ME. The influence of occlusal stabilization appliances on cervical dystonia symptoms. Clujul Med 2017;90:438-44.  Back to cited text no. 8
De Pauw J, Mercelis R, Hallemans A, Michiels S, Truijen S, Cras P, et al. Cervical sensorimotor control in idiopathic cervical dystonia: A cross-sectional study. Brain Behav 2017;7:e00735.  Back to cited text no. 9
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache 2014;28:6-27.  Back to cited text no. 10
Chakfa AM, Mehta NR, Forgione AG, Al-Badawi EA, Lobo SL, Zawawi KH. The effect of stepwise increases in vertical dimension of occlusion on isometric strength of cervical flexors and deltoid muscles in nonsymptomatic females. Cranio 2002;20:264-73.  Back to cited text no. 11
Sims AB, Clark VP, Cooper MS. Suppression of movement disorders by jaw realignment. Pain Med 2012;13:731-2.  Back to cited text no. 12


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