Harry J.M. von Piekartz, Mariano Rocabado, Mark A. Jones Floor is a 27-year-old unemployed single woman who lives alone in Hamburg, Germany. She studied economics and earned a bachelor’s degree 4 years ago; however, she has never been able to find work, largely related to her ongoing problems. She has one older sister who lives in the United States. Her parents have been divorced for 8 years, and she maintains a good relationship with both of them. Floor lives in her own apartment. Financially, she is partly supported by her mother and partly by an inheritance from her grandparents. Floor enjoys running, biking and swimming but has had to give these up due to her ongoing problems. She also enjoys listening to music, which for her serves as a form of relaxation. Floor presented with a combination of head-region and lower-quarter complaints. Floor’s main complaints were unilateral right tinnitus and bilateral headache (right more than left), as well as a pressure and a feeling of altered position in her tongue as though her ‘tongue is being pulled out’ (Fig. 19.1). She reported no decrease in the strength or coordination of her jaw when chewing and talking and no change in her taste. Floor described that she would regularly experience two different occlusions (jaw alignments). During eating, talking and chewing, she felt that what she called her ‘bad occlusion’ (later determined to be a retracted mandible) would increase and influence these orofacial functions, in addition to her other symptoms. In particular, it increased the headache and the tinnitus and also the weird ‘pressure’ feeling of her tongue. She described her other occlusion as her ‘relaxed occlusion’ that appeared when she was relaxed, mostly in the supine-lying position (later determined to be a cross-bite and overbite position). A cross-bite is an abnormal relation of one or more teeth of one arch to the opposing tooth or teeth of the other arch, caused by deviation of tooth position or abnormal jaw position. An overbite is a malocclusion of the teeth in which the front upper incisor and canine teeth project over the lower (also called vertical overlap). Floor described her relaxed occlusion as follows; ‘my jaw position is changed when lying down because my spine is more relaxed’. Floor’s previous experience with dentists and orofacial surgeons provided her with a level of understanding to describe these as different occlusions. Floor reported that her orofacial symptoms (headache, tinnitus, tongue pressure feeling and her bad occlusion feeling) all occurred together and increased during the day after just 10 minutes of talking or eating. The headache and tinnitus were worst, increasing up to a score of 7–8/10 on the visual analogue scale (VAS). She then had to stop the activities and rest or lie down. She also reported that sitting for longer than 60 minutes, either at the computer or watching TV, aggravated the headache and tinnitus. More physical activities, like running, biking and swimming, also increased all these symptoms, and consequently, she had stopped these physical activities about 6 years ago. These same orofacial symptoms were all eased after 20 minutes of lying down or sleeping overnight and were also improved by manipulating the skin by squeezing her mandible, generally when she was lying supine in her ‘relaxed occlusion’ position. This was problematic, as her skin would then become red and start to bleed. This experience occurred at least three times per week. Floor understood the harm of this, which then made her angry but also ashamed. She reported she no longer liked to look at her own face and even avoided the mirror. Floor further described a dull, deep low back pain (Fig. 19.2) that would often radiate into the right groin and deep anterior right hip. The right hip also felt stiff to movement in all directions. An anterior dull right knee pain also occurred in combination with the lumbar and hip-area pains. These lower-quarter complaints shared some relationship with the orofacial symptoms in that they would all generally only occur during the day. The lower back, hip and knee symptoms were mostly aggravated by standing and walking for longer than 20 minutes or 10 minutes of attempted jogging. When she stopped these activities, all three area pains decreased and were gone within 15 minutes, quicker if she would lie down. Any prolonged sitting left her feeling stiff through the lower spine and right hip for 5–10 minutes, which reduced with standing or walking, although this then provoked the lower-quarter pains. Floor also reported that the lumbar and hip pains became worse than usual (more easily aggravated) for 2 days premenstrual. Screening for other lumbar, sacroiliac joint, hip and knee potential aggravating factors revealed no problems with specific low back movements in different directions (except sustained flexion when sitting), turning in bed, stairs (except if already standing too long) and hip or knee movements (including crossing legs, squatting and kneeling). Floor did not report any areas of numbness or pins and needles or any weakness, potential cervical arterial dysfunction or any symptoms associated with spinal cord or cauda equina. When asked about her understanding of her orofacial symptoms, Floor felt strongly that all those symptoms were directly related to her dental occlusion, as were her lower-quarter symptoms. Initial discussion around the influences her problems had on her life and how she coped elicited a clear theme of altered self-concept and social withdrawal. Floor volunteered feeling unattractive and embarrassed by her facial appearance. She disliked it because of the increased facial asymmetry. She did not like meeting other people in groups and consequently had significantly reduced her socializing. Whenever possible, she would present the left side of her face to others, which she described as the ‘less ugly’ side. She declared that she ‘does not feel like a pretty young woman’, and this, is in her opinion, was one reason why she had difficulties finding a partner. She was convinced that nobody was interested in a woman with these problems. Floor’s general health was reported as being good. She had no systemic medical conditions, no visceral problems and no unexplained weight loss. Her blood tests had been negative, and she reported no allergies, otitis media, sinusitis or eye diseases. She had never had any trauma to her face, neck or lower quadrant and there was no history of cancer in her life or in her family. Her urogenital functions had always been normal, and she had no balance or walking disturbances suggestive of spinal cord involvement. Sleeping had never been a problem, and she reported sleeping 7–8 hours a night without complaints. She was not currently on any medications. From the age of 20–22, she took antidepressants (amitriptyline 50 mg per day) and paracetamol (50 mg) as needed according to her complaints. Neither of those provided any real help. At the age of 11 years, Floor was prescribed an interocclusal splint for her overbite of more than 6 mm. After a few months she developed ‘tinnitus’ in her right ear, and her nasal respiration decreased such that she had to breathe more through her mouth. It was around that time that her mother first noticed Floor’s increasing facial asymmetry. The orthodontics treatment continued until Floor was 17 years old. Although the orthodontist was ‘satisfied’ with the result, Floor and her mother completely disagreed, as by then she was suffering from constant tinnitus and regular headaches. Floor decided to consult a plastic surgeon, who reconstructed her nose and chin when she was 21 years old. Following this, the respiration did not improve, and her headaches increased. The weird ‘pressure’ feeling of her tongue started and slowly increased over a period of 5 years after the surgery. She saw different doctors, dentists and physical therapists for her complaints, but they could do nothing for her. Floor’s lumbar, hip and knee pains spontaneously started at the age of 22 years without any clear local predisposing factor and gradually worsened to their present level. She decided to consult an orthopaedic doctor and another physical therapist, and both diagnosed spinal scoliosis, which they explained could be responsible for her low back, hip and knee pains. She received manual therapy for her low back and exercises for her posture over a period of 6 months. Although these interventions would reduce her back, hip and knee pains, the relief would only last up to 2–3 days, and there was no improvement in her face complaints. At the age of 23 years, a specialist temporomandibular joint (TMJ) surgeon diagnosed an extreme frontal dysgnathia (i.e. open-bite, where the front teeth, both upper and lower, are forced outward to such an extent that the teeth of the upper and the lower jaw do not touch each other, even when the mouth is closed) and a mandibular retrognathia (retracted mandible), with a left convex face scoliosis (an extreme maxillary rotation and mandible shift toward the right side). Between the ages of 23–25 years, Floor received preoperative orthodontic treatment to correct the asymmetry of the teeth arch and chin augmentation (surgical reconstruction of the chin by bone implant, providing a better balance to the facial features, in this case Floor’s facial scoliosis). After 8 months, this was followed by a surgical bimaxillary osteotomy and a septo-rhinoplasty (surgical reconfiguration of nasal septum) to improve her nasal respiration. Following this surgery, Floor felt that her face symptoms (tinnitus, headache) and facial asymmetry were significantly improved. Also, her breathing pattern and her thoracic scoliosis were much better, and she felt ‘free in her spine and her hips’, with reduced lower-quarter pains as well. Fourteen days after the bimaxillary osteotomy, two rubber bands were placed on the molars on her left and right maxilla and mandible to support correct mandibular movement. After 12 days, she opened her mouth a little bit too much, and due to the high external forces, the mandible retracted again. She immediately felt this repositioning of the mandible, and shortly after this her familiar face and lower-quarter symptoms returned. When consulting the maxillofacial surgeon and the orthodontist, she felt ignored, as they said there was nothing further they could do because there was no overt change to the surgical reconstructions. Slowly, her complaints all returned and worsened, especially the headaches, tinnitus and nasal breathing restriction. During the last 2 years, she had consulted three specialist maxillofacial surgeons and two specialist orthodontists. Neither the surgeons nor the orthodontists believed her story of the relaxed ‘cross-bite’. This relaxed ‘cross-bite’ in supine lying is also the position where the orthodontist wanted to correct her occlusion, first with a Michigan splint and then after 6 months with braces. Floor did not believe this was the solution, and they were unable to reach agreement. Eventually, she found a surgeon who would operate again with the aim of correcting her bite and restoring her normal nasal respiration. This initially required removing the screws in her mandible (Fig. 19.3) followed by preoperative orthodontics for a minimum of 1 year to reprogram the occlusion (retrain her neuromuscular system to the preferred occlusion). Floor’s goals for the second bimaxillary surgery were, firstly, a solution for her breathing problem and orofacial symptoms, especially the tinnitus and the ‘weird’ tongue feeling, and, secondly, to regain the symmetry of her face that was achieved after the first surgery. At present, her pre-surgical orthodontic treatment was planned in 3 or 4 months, although whether she proceeded or not depended on her financial status. She would have to sell her apartment to pay for these pre-orthodontic treatments and the planned bimaxillary reconstruction. In the meantime, she had decided to consult a specialist orofacial musculoskeletal physiotherapist (first author) who had been recommended to her by her local dentist. Floor had a normal birth, normal progression of developmental milestones and normal childhood health, with no otitis media and no long-term sinusitis. She had never had problems before the initial orthodontic treatment. Her puberty commenced early (around 10 years), and her body subsequently underwent a quicker growth spurt than her maxillofacial skeleton. This was determined on the basis that her deciduous teeth had more caries because the mandible was shorter and abnormally retracted. According to the orthodontist, it was not hereditary, and the cause of her rapid growth was unknown. At first sight, a clear facial asymmetry (scoliosis) can be seen. The right side seems to be smaller, with the following abnormalities: During execution of a small active upper cervical extension movement (20 degrees), the head is seen to deviate toward the left, and the changed nostril (passage) can be seen (Fig. 19.4B). In supine lying, a clear chin and nose bridge deviation is evident toward the left, and an asymmetry in the nose bridge (left flatter than right) is noted. The head is orientated in a small lateral flexion position toward the left. An open-bite and a cross-bite toward the left can be observed, as described previously (Fig. 19.4C). A clear protrusion and laterotrusion position of the mandible toward the left is also evident, and if Floor corrects this to maximal intercuspidation (i.e. correction of the mandibular laterotrusion and protrusion so that upper teeth and lower teeth contact), she feels local discomfort, with an increase in the tinnitus and headache. There is no attrition (i.e. wear and tear of the teeth by parafunctional activities) observed (Fig. 19.4C). Floor was asked to inspire slowly as the therapist applied gentle pressure to block one nostril at a time. Inspiration through the left nostril (right trill blocked) was executed with a lower pitch and for longer duration (6 seconds) than the right side (left trill blocked), which produced a much higher pitch over a shorter duration (2.5 seconds), accompanied with a ‘right ear pressure’ (6/10 on the VAS) and right temporal pressure (4/10). Floor had a flexion posture of the upper cervical spine. When asked to look up and correct the postural deviation, she experienced a heavy feeling in her neck and had difficulty holding it. The craniocervical angle, measured using a CRAFTA digital clinometric program version 1.06 (www.physioedu.com), was clearly reduced (45 degrees; normal = 51 degrees). Posterior observation revealed a position of minimal head rotation to the right, lateral flexion to the left, elevation of the left shoulder and increased pelvic height on the left (Fig. 19.5). Floor’s centre of gravity (COG) was measured with a multifunctional force measuring plate (Zebris Medical GmbH, Germany). Relative to Floor’s base of support, the COG assessment revealed a posterior (41 mm) and right shift (2.6 mm) which was accompanied by other changes in body-mass positioning (e.g. right foot pressure was 59% of her body weight, compared with 41% on the left). This was performed in the upright posture position of the mandible (UPPM), which is an active corrected upright position without teeth contact (von Piekartz, 2007). There were no resting symptoms except tinnitus 2/10 on the VAS. Because the laterotrusion toward the left reproduced the most musculoskeletal signs and symptoms, it was assessed and expressed in a ‘movement diagram’ (Hengeveld and Banks, 2014) (Fig. 19.6). Passive laterotrusion to the left provoked head pain and a pressure feeling in the right ear (2/10 on the VAS) at 4 mm. Tinnitus started at 6 mm. The ‘limit’ of the movement was determined at the onset of resistance (R2) and was stopped at 6 mm because the headache increased to 5/10, the pressure in the ear to 3/10 and the tinnitus to 7/10. In this case, the passive movement was not limited by a true R2 (i.e. no further passive movement available due to resistance) or P2 (i.e. passive movement stopped at patient’s request due to pain); rather, the therapist elected to stop the movement due to the increase in symptoms and his judgement regarding the ‘nature’ of the problem – in this case, the irritability of the presentation and his decision not to let the symptoms increase any further. Passive neurodynamic assessment challenging the cranioneural sensitivity of the mandibular nerve was undertaken by performing left laterotrusion in upper cervical flexion and lateroflexion toward the left (Geerse and von Piekartz, 2015; von Piekartz, 2007). There was no clear difference when compared with laterotrusion performed without this upper cervical pre-positioning.
Orofacial, Nasal Respiratory and Lower-Quarter Symptoms in a Complex Presentation With Dental Malocclusion and Facial Scoliosis
Subjective Examination
Personal Profile
Orofacial and Head-Region Symptoms
Spine, Hip and Knee-Area Symptoms
Patient Perspectives
General Health Screening
History
Past History
Physical Examination
Clinical Observation
Face
Intraoral (Assessed in Supine Lying, Floor’s Relaxed Habitual Occlusion Position)
Nasal Respiration
Spine
Centre of Gravity
TMJ Assessment
TMJ Active Movement Assessment (Performed with the Mandible Passively Corrected to the UPPM)
TMJ Passive Physiological Movement Assessment
TMJ Accessory Movement Assessment
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Orofacial, Nasal Respiratory and Lower-Quarter Symptoms in a Complex Presentation With Dental Malocclusion and Facial Scoliosis
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Fig. 19.1 Body chart of Floor’s head-region symptoms.
Fig. 19.2 Body chart of Floor’s spine, hip and knee-area symptoms.
Fig. 19.3 Three-dimensional tomography taken 2 weeks after Floor’s first bimaxillary osteotomy surgery at age 23. Note the surgery has created a forced protraction of the mandible, resulting in a ‘head-bite’ (direct contact of the incisors) and a bilateral open-bite (no teeth contact during habitual occlusion – in this case, the last three molars of the maxilla and mandible on the right).
Fig. 19.4 (A) Frontal view illustrating the form of Floor’s face (see case text for key features to note). (B) Cranial ventral view from supine position taken at a 30-degree angle from the horizontal line of the face. Note the deviation of the nose bridge in relation to the mandible. (C) Floor’s habitual occlusion. Note the head-bite of the incisors and clear left laterotrusion of the mandible resulting in a cross-bite. Also note the possible open-bite left and right in the (pre)molar region and at the front.
Fig. 19.5 Dorsal view of Floor’s standing posture. Note the lateroflexion and rotation asymmetry of the head and neck and elevation of the left shoulder and pelvis.
Fig. 19.6 Movement diagram illustrating the response to passive laterotrusion movement of the mandible toward the left. The AB line represents the average maximal range of passive laterotrusion movement (12 mm). The AC line represents the quality, nature or intensity of the factors being plotted (in this case, resistance, headache, ear pressure and tinnitus). R1 is the first resistance felt by the examiner during the passive movement. R2, in this case, is where movement was limited when the examiner reached a Grade IV – estimated to be 25% of the available resistance (6 mm). In this case, a decision was made not to perform a stronger movement because the headache increased to VAS 5/10, pressure in the ear to VAS 3/10 and the tinnitus to VAS 7/10. Note each symptom (headache, ear pressure, tinnitus) has a point through the passive movement where that symptom is first provoked (P1) and a level of intensity when the movement test is stopped (P’). Also note that all three increase somewhat proportionally to the increase in resistance, supporting the symptoms that are associated with the laterotrusion movement and also associated with the resistance to this movement.
