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Features and Treatment of Skeletal Class III

Malocclusion with Severe Lateral Mandibular


Shift and Asymmetric Vertical Dimension
Etsuko Kondo, DDS, DDSc1
Aim: To highlight the effectiveness of orthodontic treatment and bilateral equalization of the
vertical occlusal dimension, along with the correction of asymmetric cervical and masticatory muscle activities in patients with Class III malocclusion with lateral deviation of the
mandible and severely asymmetric condyle and ramus. Methods: Two normally growing
and one nongrowing Japanese patients with severe lateral deviation of the mandible, asymmetric vertical occlusal dimension, and severely asymmetric temporomandibular joints are
discussed. In addition to orthodontic treatment, all patients received physiotherapy of the
cervical muscles and gum-chewing training for elimination of the masticatory muscular
imbalance. Patients also had postural training during treatment. All patients were treated
with a bite plate to equalize the bilateral posterior vertical dimension, followed by full multibracketed treatment to establish a stable form of occlusion and to improve facial esthetics.
Results: This interdisciplinary treatment approach resulted in normalization of stomatognathic function, elimination of temporomandibular joint dysfunction symptoms, and
improvement of facial appearance and posture. In growing patients, the significant
response of the fossa, condyle, and ramus on the affected side during and after occlusal
correction contributed to the improvement of cervical muscle activity. In contrast, less
improvement was observed in the growing patient who did not receive physiotherapy of
the neck muscles, postural training, or masticatory habit training during the posttreatment
period. The nongrowing patient showed little morphologic improvement of the cervical
spine, condyle, and fossa during treatment and after retention, even with physiotherapy of
the neck muscles and attention to posture and masticatory habits. Conclusion: Based on
these results, early occlusal improvement, combined with physiotherapy to achieve muscular balance of the neck and masticatory muscles, was found to be effective. It is important
to assess the morphology and function of the neck muscles and cervical spine prior to
occlusal therapy in patients with an asymmetric vertical dimension, lateral deviation of the
mandible, and asymmetric temporomandibular joint structures. Therapy should correlate
orthopedic and surgical patient management as needed. World J Orthod 2004;5:924.

orphologic abnormality of the neck muscles,


particularly the sternocleidomastoid (SCM) and
upper trapezius muscles, and asymmetric activities
of the masseter, temporalis, and other masticatory
muscles are often found in patients with occlusal
abnormality with lateral deviation of the mandible,

severely asymmetric posterior vertical occlusal


dimension, and marked morphologic abnormality of
the condyle and ramus.1,2 Characteristics common
to these patients include narrowing or loss of the
atlanto-occipital joint space and morphologic abnormality of the cervical spine, such as C2-C3 fusion.2
Another characteristic is dysfunction of the atlantooccipital and atlantoaxial joints, with the dens protruding 6 mm or more above the McGregor line3 into
the cranial base, causing the cranium to tilt to the
side with SCM muscle contraction and rotate to the
side with upper trapezius contraction. The result is
limited upper neck movement, particularly head

1Private

Practice of Orthodontics, Tokyo, Japan.

CORRESPONDENCE
Dr Etsuko Kondo, 2-3-4 Tamagawadenenchofu, Setagaya-ku,
Tokyo, Japan 158-0085. E-mail: kortho@tkd.att.ne.jp

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Diagnosis

rotation. Various modalities, such as physiotherapy


of the neck muscles and gum-chewing training for
elimination of masticatory muscle imbalance, should
be employed, along with tooth positioner wear for
harmonization of occlusion and muscle activity. The
patient is instructed to pay due attention to posture
and gait during daily activities and to do exercises
for postural balance. As a result, morphologic abnormality of the cervical spine and muscles can be
improved, with downward movement of the dens,
resulting in a normal head posture and smooth head
rotation. Masticatory muscle activities became symmetric, accompanied by marked morphofunctional
improvement of the neck muscles, cervical spine,
temporomandibular joints (TMJ). In contrast, less
improvement has been observed in growing patients
with a strongly contracted upper trapezius muscle,
without physiotherapy of the neck muscles or attention to posture and unilateral masticatory habits
after treatment. Asymmetry of the neck muscles
increased over time, leading to the recurrence of
morphologic abnormality of the cervical spine,
condyle, and ramus. The distance from the apex of
the dens to the McGregor line increased again to 6
mm or more, accompanied by increased limitation of
head rotation and progression of morphologic abnormality of the ramus, with occasional TMJ symptoms.
Thus, occlusal correction combined with physiotherapy of the neck muscles and attention to posture
and masticatory habits significantly contributed to
the morphologic improvement of the condyles and
ramus, and reduced the postretention incidence of
TMJ symptoms. Growing patients who received
occlusal correction and physiotherapy of the neck
before completion of the permanent dentition benefited far more from the treatment than did nongrowing patients. Three Japanese patients, two growing
and one nongrowing, are presented to illustrate the
differences in treatment outcome.

Facial photographs (Fig 1a) showed that the profile


was concave with a short upper lip, a favorable
nasolabial angle at 100 degrees, and a prominent
chin. The mandible deviated to the left as the head
tilted to the right side, with SCM muscle contraction,
and rotated to the left, with upper trapezius muscle
contraction, creating poor head posture and facial
asymmetry. The range of active head movement was
limited slightly on the right.
Intraoral photographs (Fig 1b) and dental casts
(Fig 1d) showed that the patient was in the early permanent dentition stage. The molars and canine on
both sides were full Class III with a mandibular lateral deviation of 7.0 mm to the left and significant
lack of posterior vertical occlusal height on the left,
unilateral masticatory habit side. Clicking was noted
at 33.0 mm on wide opening in the right joint, with a
mandibular shift to the left.
The panoral radiograph (Fig 1c) showed a round
condyle and a short ramus on the mandibular left
side, with lower posterior vertical dimension and a
contracted upper trapezius muscle. All permanent
teeth were present.
The lateral cephalogram at pretreatment (Fig 2b)
showed that the cervical spine was a lordosis type,
with narrow intervertebral space between C2, C3,
and C4, causing a protrusion of 5.0 mm on the superior edge of dens above the McGregor line. This
caused the restriction of the atlantoaxial joint, resulting in poor head posture. The apices of the maxillary
anterior and posterior teeth were in close proximity
to the nasal floor, suggesting a severe lack of maxillary vertical alveolar height in the anterior and posterior regions. The skeletal Class III malocclusion was
due to a retruded maxilla and a prognathic mandible
(SNA, 75.0 degrees; SNB, 83.0 degrees; ANB, 8.0
degrees). The maxillary and mandibular incisors had
a favorable inclination (U1 to SN, 107.0 degrees; L1
to DC-L1i line, 85.0 degrees). The functional occlusal
plane to AB plane angle was 70.0 degrees, with a
resulting Wits appraisal of 14.0 mm (Fig 3).
The anteroposterior (AP) cephalogram at pretreatment (Fig 2a) showed the cranium and the dens of
C2 tilted to the right side. The affected left ramus
was shorter, resulting in facial asymmetry. This
caused the occlusal plane to tip in a direction opposite to the tilt of the cranium.
The axial cephalogram (see Fig 2a) showed that
the contraction of the upper left trapezius muscle
induced hypertrophy of the temporal and occipital
bone. This may have caused a narrowing of the intervertebral spaces between C2, C3, and C4, with
excessive protrusion of 5.0 mm of the apex of dens

CASE 1
This growing patient was a Japanese female, 9 years
11 months of age, with a skeletal Class III malocclusion, with severe lateral deviation of mandible to the
left and severely asymmetric posterior vertical
dimension between right and left sides. She had
poor head posture due to mild contraction of the
right SCM and left upper trapezius muscles. She also
had a left unilateral masticatory habit. The primary
complaints were anterior crossbite and temporomandibular dysfunction (TMD) in the left joint. The
patient received physiotherapy twice a month during
treatment, and was observed for 7 years 8 months.
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VOLUME 5, NUMBER 1, 2004

Pretreatment (9yY11M)

Kondo

Posttreatment (12Y 7M)

5 years 6 months posttreatment (18Y 1 M)

Fig 1 Case 1. Comparison of (a) facial photographs, (b) intraoral photographs, (c) panoramic radiographs, and (d)
dental cast photographs from pretreatment to 5 years 6 months posttreatment.

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WORLD JOURNAL OF ORTHODONTICS

Kondo

Pretreatment (9yY11M)

Posttreatment (12Y 7M)

5 years 6 months posttreatment (18Y 1 M)

Fig 2 Case 1. Comparison of (a) AP and (b) lateral cephalograms and (c) EMG findings from pretreatment to 5
years 6 months posttreatment.

above the McGregor line, resulting in dysfunction of


the atlantoaxial joint. There was limited head rotation and asymmetric masticatory muscle activity and
condylar movement, causing asymmetric growth of
the condyle, ramus, and other joint structures in this
growing patient.
The joint radiographs (see WJO web edition, at
www.quintpub.com) showed a difference in size and
shape between right and left condyle and ramus,
with a more round condyle and short ramus on the
left side. The left condyle was located slightly more
posteriorly in the fossa.

Electromyographically (Fig 2c), the left temporalis


muscle showed hyperactivity in rest position after 30
minutes of myopulsing, causing asymmetric masticatory muscle activities between the right and left
sides.
These findings implicated the imbalance of neck
muscle activity, and the unilateral masticatory habit
greatly affected the formation of the left joint area
and enhanced mandibular dysfunction. This resulted
in underdevelopment of the mandible on the left
side, characterized by morphologic abnormalities of
the ramus and condyle, causing asymmetric growth
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Fig 3 Case 1. Tracings of cephalograms and composite tracings from pretreatment to 5 years 6 months posttreatment (on S-N at sella, ANS-PNS at anterior nasal spine, Go-Me at gonion).

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of the mandible and asymmetric vertical dimension


between the right and left sides, causing severe
mandibular lateral deviation to the left.

Intraoral photographs and dental casts (see Figs


2b and 2d) showed the stable and functional occlusion. The equalized bilateral posterior vertical dimension was established with nonextraction and maintained during 5 years 6 months posttreatment. The
overjet and overbite were normal at 3.0 mm. The
panoral radiograph and joint radiographs at 5 years
6 months posttreatment (see Figs 1c and 2c)
showed that all roots were parallel, with no abnormality. The malformed condyle and ramus on the left
side were markedly improved. Both condyles were in
comparable positions in the articular fossae, both on
occlusion and on wide opening of 42.0 mm, indicating that normal jaw function had been attained by 5
years 4 months posttreatment. There has been no
recurrence of clicking or other TMD sequelae after 5
years 4 months posttreatment.
The lateral cephalogram at 5 years 6 months
posttreatment (see Fig 2b) showed a normal cervical
spine, lordosis type, with widened intervertebral
spaces between C2, C3, and C4, resulting in reduction of the apex of the dens to the McGregor line
from 5.0 mm to a normal 2.0 mm. As a result, normal atlantoaxial joint movement, and other cervical
joint movements and active head movements, were
maintained for more than 5 years.
The composite tracing (see Fig 3) showed a favorable maxillary and mandibular response. The ANB
angle increased from 8.0 degrees to 1.5 degrees.
The maxillary and mandibular incisors had a favorable inclination, with an increased maxillary alveolar
vertical height of 4 mm. The functional occlusal
plane moved down posteriorly 12 degrees. The tooth
axis of maxillary and mandibular posterior teeth and
the AB plane were perpendicular to the functional
occlusal plane. The upper lip height increased 5.0
mm and the nasolabial angle was 100 degrees, creating an attractive and harmonious lip profile.
The composite tracing superimposed on the
mandibular area at gonion (see Fig 3) showed
increased ramus and alveolar height of the posterior
area on the affected side. The left side was larger
than the right (nonaffected) side. The resulting
ramus and posterior vertical height became almost
equal at 5 years 6 months posttreatment, creating a
symmetric face.
The AP cephalograms at 5 years 6 months posttreatment (see Fig 2a) confirmed that the tilt of the
cranium and occlusal plane were eliminated. Both
rami were almost the same height, creating a symmetric frontal view.
The electromyocardiogram (EMG) record at 5
years posttreatment (see Fig 2c) showed symmetric
masticatory muscle activity. Optimal masticatory
muscle activity had been attained, creating a well-

Treatment
If the case were to be treated by four premolar
extraction, the mandibular incisors would be lingually inclined and the nasolabial angle would be
increased, resulting in a dished face with a prominent chin and a narrow tongue space, causing possible airway problems.
The decision was made to treat the case by
nonextraction using the Alexander technique, with a
bite-opening plate and Class III elastics, to eliminate
the asymmetric vertical dimension between the right
and left sides. The patient concurrently received
physiotherapy for neck and masticatory muscles,
with vigorous gum chewing. The patient was
instructed to pay attention to posture during daily
activities.

Course of treatment
Orthodontic treatment was started (at 10 years of
age) with a bite-opening plate in the mandibular arch
and an Alexander appliance in the maxillary arch.
Physiotherapy of the neck muscles was instituted.
Two months after the start of treatment (10 years
2 months of age), the anterior crossbite was almost
eliminated and TMD symptoms had disappeared.
The Alexander appliance was then placed in the
mandibular arch and vertical elastics were used in
the posterior area.
Thirty-one months after the start of treatment (12
years 7 months of age), the AP skeletal and occlusal
disharmonies had been corrected, with an equalized
vertical dimension. A dramatic occlusal improvement had been obtained and was maintained during
the 5 years 6 months posttreatment retention
period. Tongue and masticatory muscle myotherapy
continued to the present, and a retainer and a tooth
positioner were used for 2 years posttreatment.

Treatment results
The facial photographs at 5 years 6 months posttreatment (see Fig 1a) showed favorable improvement of
the head and cervical posture. The SCM and upper
trapezius muscles were restored to symmetry and the
left unilateral masticatory habit was eliminated. The
active head movement was normalized in all directions.
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Kondo

balanced face. The skeletal Class III case, with


severe lateral deviation and deficient posterior vertical occlusal dimension, was successfully treated and
maintained more than 5 years posttreatment.

6.0 mm of the superior edge of dens above the


McGregor line. This caused the restriction of the
atlanto-occipital and atlantoaxial joints, resulting in
poor head posture. The apices of both the maxillary
and mandibular posterior teeth were in close proximity to the nasal floor and the lower border of the
mandible, respectively, suggesting a severe lack of
alveolar height in both the anterior and posterior
regions. A prognathic mandible existed (SNA, 81.0
degrees; SNB, 85.0 degrees; ANB, 4.0 degrees).
The mandibular plane angle was low (SN-GoMe,
28.0 degrees). The mandibular incisors were
procumbent, with a short vertical position (L1 to DCL1i, 84.0 degrees; L1 to GoMe, 105 degrees). The
functional occlusal plane to AB plane angle was 73
degrees with a Wits appraisal of 13.0 mm (Fig 6).
The AP cephalogram (Fig 5a) showed the cranium
and the dens of C2 severely tipped to the right. The
affected left ramus was shorter, resulting in facial
asymmetry. This caused the occlusal plane to tip in
a direction opposite to the tilt of the cranium.
The axial cephalogram (Fig 5c) showed the effects
of strong contraction of the upper trapezius on the
left, which induced severe hypertrophy of the temporal and occipital bones on the same side. It may also
have caused a narrowing intervertebral space
between C2 and C3. The straightening of the cervical spine has led to excessive protrusion into the cranial base of 6.0 mm of the apex of dens above the
McGregor line, causing dysfunction of the atlantooccipital and atlantoaxial joints and limited head
rotation. The resulting asymmetric masticatory muscle activity and condylar movement produced asymmetric growth of the condyle, ramus, and other joint
structures in this growing patient. Electromyographically (Fig 5d), both of the left temporalis and masseter muscles were hypertonic.
These findings indicated that the imbalance of
neck muscle activity and the unilateral masticatory
habit were affecting the formation of the left joint
area, inducing mandibular dysfunction. This resulted
in underdevelopment of the mandible on the left
side, characterized by morphologic abnormalities of
ramus and condyles, causing asymmetric growth of
the mandible and asymmetric vertical dimensions
between the right and left sides, producing severe
mandibular left lateral deviation.

CASE 2
This growing Japanese female, 10 years 11 months
of age, had a Class III malocclusion with severe lateral deviation of the mandible to the left, severe
asymmetric vertical occlusal dimensions between
the right and left sides, and severely deformed
condyle and ramus on the left. She had poor head
posture, due to contraction of the left upper trapezius and right SCM muscles. She also had a left unilateral masticatory habit. The patients primary complaints were lateral deviation of the mandible and
TMD in the left joint. The patient received physiotherapy for the neck muscles during orthodontic treatment, but she did not receive physiotherapy posttreatment. The patient was observed for 8 years 11
months posttreatment.

Diagnosis
The facial photographs (Fig 4a) showed that the original profile was concave, with a short upper lip. The
mandible deviated to the left, as the head tilted to
the right side with SCM muscle contraction. The
head rotated to the left with upper trapezius muscle
contraction, and a shortened left masseter muscle,
creating markedly poor head posture and facial
asymmetry. The range of active head movement was
limited on the right side.
Intraorally (Fig 4b), the patient was in the early
transitional dentition stage and had a Class III molar
relationship on the right. The mandible deviated 8.0
mm to the left on occlusion and the maxillary arch
was constricted. The dental cast (Fig 4d) showed a
severely asymmetric vertical occlusal dimension
between the right and left sides, with a reduced vertical dimension on the left, unilateral masticatory
habit side. Clicking was noted at 28.0 mm of wide
opening in the right joint, with a mandibular shift to
the left.
The panoral radiograph (Fig 4c) showed a short,
thick ramus and a malformed condyle on the left,
deviated side during chewing. All permanent teeth
were present.
The lateral cephalogram at pretreatment (Fig 5b)
showed a straight cervical spine, with narrow intervertebral spaces between C2 and C3 and between
the occipital bone and C1, causing a protrusion of

Treatment
If the case was to be treated by four premolar extraction, the profile would be a dished face with a prominent chin and narrow tongue space, causing problems for the airway and disturbing nasal breathing.
15

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Pretreatment (10yY11M)

Posttreatment (14Y 6M)

5 years 4 months posttreatment (19Y 10 M)

Fig 4 Case 2. Comparison of (a) facial photographs, (b) intraoral photographs, (c) panoramic radiographs, and (d)
dental cast photographs from pretreatment to 5 years 4 months posttreatment.

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VOLUME 5, NUMBER 1, 2004

Pretreatment (10yY11M)

Kondo

Posttreatment (14Y 6M)

5 years 4 months posttreatment (19Y 10 M)

Fig 5 Case 2. Comparison of (a) AP cephalograms, (b) lateral cephalograms, (c) axial cephalograms, and (d) EMG
findings from pretreatment to 5 years 4 months posttreatment.

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Fig 6 Case 2. Tracings of cephalograms and composite tracings from pretreatment to 5 years 4 months posttreatment (on S-N at sella, ANS-PNS at anterior nasal spine, Go-Me at gonion).

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Thus, a decision was made to treat the case by


nonextraction, using a full bracket system with a
palatal expansion lingual arch and bite-opening
plate to eliminate the asymmetric vertical dimension
between the right and left sides. Treatment included
muscle training by constant, vigorous gum chewing
and instructions to pay due attention to posture during daily activities.

The panoral radiograph at 5 years 4 months posttreatment (see Fig 4c) showed that roots of both maxillary and mandibular posterior teeth on the right side
were almost parallel, but the left posterior teeth were
mesially inclined because of the existing unilateral
masticatory habit and the contracted upper trapezius
muscle. However, the severely deformed condyle and
ramus on the left side were markedly improved and
almost symmetric between right and left sides at the
end of posttreatment. The recurrence of the asymmetric condyle and ramus were observed at 5 years
4 months posttreatment, however.
Posttreatment, the lateral cephalogram (see Fig
5b) showed that the cervical spine changed from a
straight type to normal lordosis type, with widened
intervertebral space and space between the occipital bone and C1, resulting in a reduction of the apex
of dens to the McGregor line from 6.0 mm to 4.0
mm at the end of active treatment. However, the
patient experienced a renarrowing of the space
between the occipital bone and C1 (normal space,
4.0 mm to 9.0 mm), resulting in the apex of the dens
to the McGregor line increasing again to 6.0 mm.
This was accompanied by increased limitation of
head rotation and progression of morphologic abnormality of the ramus and condyle on the left side.
Occasional TMJ symptoms were experienced during
the 5 years 4 months posttreatment period.
The composite tracing (Fig 6) showed that a favorable maxillar y and mandibular response was
obtained. As a result, the ANB angle increased from
4.0 degrees to 2.5 degrees. The maxillary and
mandibular incisors had a favorable inclination, with
increased maxillary alveolar vertical height of 4.0
mm. The functional occlusal plane moved down posteriorly 7.0 degrees, so that both tooth axes of maxillary and mandibular posterior teeth and the AB
plane were perpendicular to the functional occlusal
plane, resulting in a stable occlusion, which was
maintained for more than 5 years posttreatment.
The composite tracing on the mandibular plane at
gonion (see Fig 6) shows the increase in ramus and
alveolar height of the posterior area on the left,
affected side was larger than on the non-affected
side during active treatment. However, during 5
years 4 months posttreatment, the increase of
ramus height on the non-affected side (right) was
larger than the affected side (left). This caused
recurrence of the short ramus and reduced neck
condyle on the left.
The AP cephalogram at 5 years 4 months posttreatment (see Fig 5a) showed a much shorter facial height
and shorter ramus on the left. The occlusal plane tilt in
a direction opposite to the tilt of the cranium became
worse in the 5 years 4 months posttreatment period.

Course of treatment
Orthodontic treatment was started, when the patient
was 11 years of age, with full appliances and a bite
plate. Physiotherapy of the neck muscles was
started. At 6 months after the start of treatment (11
years 6 months of age), the maxillary arch was
expanded and the anterior crossbite and the left
mandibular deviation were almost eliminated.
Migraine, dizziness, tinnitus, and TMD symptoms
disappeared.
At 42 months after the start of treatment (14
years 6 months of age), a stable occlusion, with an
equalized vertical dimension, had been established.
The retention period was 5 years 4 months. Tongue
and masticatory muscle myotherapy has been continued to the present. A retainer and a tooth positioner were used for 2 years.

Treatment results
The posttreatment facial photographs (see Fig 4a)
showed favorable improvement of the facial profile
and head posture. However, imbalance of cervical
and masticatory functions recurred during posttreatment due to little morphologic improvement of the
strongly contracted upper trapezius muscle, which
remained even with physiotherapy of the neck muscles. The patient did not receive physiotherapy of the
neck muscles after treatment. The left unilateral
masticatory habit and limited active head movement
remained.
Intraoral photographs and the dental cast (see
Figs 4b and 4d) showed a well-seated posterior
occlusion and matched midline. A Class I canine and
molar relationship, normal overjet, and an overbite
of 3.0 mm were established at the end of active
treatment. However, the asymmetric posterior vertical dimension was not improved, even at 5 years 4
months posttreatment, and there was recurrence of
the mandibular deviation of 3.0 mm to the left
because of the remaining imbalance of cervical and
masticatory function, with a unilateral masticatory
habit.
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The axial cephalogram (see Fig 5c) revealed a


marked difference in shape between left and right
sides in both the occipital and temporal bones,
which became worse due to the strongly contracted
left upper trapezius during the 5 years 4 months
posttreatment period.
The joint radiographs at 5 years 4 months posttreatment (see web edition) showed that the differences in size and shape of the right and left
condyles still remained. Both condyles were in comparable positions in the fossae, both on occlusion
and on wide opening at 42.0 mm, indicating that
normal jaw function remained at 5 years 4 months
posttreatment. Occasional clicking was noted on
opening in the right joint, and there was a recurrence of trismus pain during the 5 years 4 months
after treatment. Electromyographically, at 5 years 4
months posttreatment, the left temporalis muscle
remained hypertonic.
This growing patient had difficult problems,
including a strongly contracted upper left trapezius
muscle and a unilateral masticatory habit. The correction of all these problems was difficult and could
not be done by orthodontic treatment only, with no
physiotherapy of the cervical spine and muscles and
no patient cooperation.

view. The range of active head movement was limited to the right side.
Intraoral photographs and the dental cast (Figs
7b and 7d) showed the molars in Class I with an
unmatched midline, deviated to the left by 3.0 mm,
a posterior crossbite, an asymmetric posterior vertical dimension, and reduced vertical dimension on
the left. The maximum opening was 32.0 mm. Clicking occurred early in the left joint on opening, with
increased mandibular shifting to the left.
The lateral cephalogram at pretreatment (Fig 8b)
showed the cervical spine was a straight type, with
narrow intervertebral space, with fusion of occipital
bone and C1 and fusion of C2 and C3, causing a
6.0-mm protrusion of the superior edge of dens
above the McGregor line. These caused the restriction of the atlanto-occipital and atlantoaxial joints,
causing a poor head posture and a tilted and
rotated cranium. There was a strong antegonial
notch with a shorter ramus on the left side, suggesting hyperactivity of the left masseter muscle.
The cephalometric analysis (Fig 9) revealed a
favorable jaw relationship (SNA, 78.0 degrees; SNB,
72.0 degrees; ANB, 6.0 degrees) and favorable inclination of the maxillary incisors and the mandibular
incisors (U1 SN, 92.5 degrees; L1 to DC-L1i line,
83.0 degrees).
The AP cephalogram (Fig 8a) showed the cranium
and dens of C2 severely tilted to the right, and a
much shorter facial height and ramus on the left,
causing the occlusal plane to tip in a direction opposite to the tilt of the cranium, resulting in severe
facial asymmetry.
The panoral (Fig 7c) and joint radiographs (see
WJO web edition, at www.quintpub.com) showed a
trophic condyle, shallow fossa, and a severely thin,
short ramus on the left, with masseter muscle
hyperactivity. The left joint space was larger in habitual occlusion than the right joint. Deformity of the
left condyle and disc apparently diminished the selfseating capacity, making the disc susceptible to
anterior displacement and causing left TMJ symptoms. Electromyographically (Fig 8d), the left masseter and both temporalis muscles showed hyperelectric activities in rest position.
The axial cephalogram (Fig 8d, center) showed
that a contracted right SCM muscle induced cranial
rotation and hypertrophy of the temporal bone on
the right side. This may have caused a straight cervical spine and pushed the dens of the axis up into
the cranial face, causing excessive protrusion (6.0
mm) of the dens of apex above the McGregor line,
fusion of occipital bone and C1, fusion of C2 and
C3, and dysfunction of the atlanto-occipital and
atlantoaxial joints. As a result, there was limited

CASE 3
This adult female patient was 34 years 9 months of
age, with a Class I malocclusion, mandibular deviation to the left, and a severely malformed condyle,
ramus, and fossa on the same side. She had poor
head posture due to the morphologic abnormality of
the cervical spine (fusion of occipital bone and C1,
and fusion of C2 and C3) and contraction of the
right SCM and hyperactivity of both the masseter
and temporalis muscles on the left. The patient had
been orthodontically treated for Class III malocclusion, by four first premolars extraction, at 14 years
of age. She suffered constantly from stiff shoulders,
tinnitus, and migraine, and complained of occasional TMD symptoms of the left joint. The patient
was observed for 6 years 3 months.

Diagnosis
The facial photographs (Fig 7a) showed the
mandible severely deviated to the left as the head
tilted to the right with right SCM muscle contraction.
She had asymmetric masseter muscles, with a
shortened left masseter muscle, creating severe
facial asymmetry and poor head posture on frontal
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Pretreatment (34Y 7M)

Kondo

Posttreatment (36Y 9M)

4 years 2 months posttreatment (40Y 1 M)

Fig 7 Case 3. Comparison of (a) facial photographs, (b) intraoral photographs, (c) panoramic radiographs, and (d)
dental cast photographs from pretreatment to 4 years 2 months posttreatment.

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Pretreatment (9yY11M)

Posttreatment (12Y 7M)

5 years 6 months posttreatment (18Y 1 M)

Fig 8 Case 3. Comparison of (a) AP cephalograms, (b) lateral cephalograms, and (c) EMG findings and axial
cephalogram from pretreatment to 4 years 2 months posttreatment.

head rotation, asymmetric masticatory muscle activity, and abnormal condylar movement, causing a
trophic condyle and a severely thin, short ramus on
the left.

After 2 weeks of splint wear (34 years 7 months


of age), the TMD symptoms disappeared. Placement
of a palatal expander and a full edgewise appliance
was then done (34 years 9 months of age). The
palatal expander was worn for 6 months.
At 14 months after the start of treatment (35 years
9 months of age), the appliance was removed. A stable occlusion was established. A tooth positioner and
retainer were used for 2 years posttreatment.
The postretention period was 4 years 2 months.
The occlusion remained stable and there were fewer
TMD complaints, but occasional clicking remained.

Treatment
Treatment was aimed at functional improvement of
the cervical and masticatory muscles through physiotherapy, correction of the jaw relationship by maxillary expansion, and unloading of the joints through
occlusal improvement, using full appliances and a
palatal expander.
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Fig 9

Kondo

Tracings of pretreatment and 7 years 2 months posttreatment cephalograms.

Treatment results

This adult patient showed little morphologic


improvement of the cervical spine, ramus, condyle,
and fossa, both during and after retention, even with
physiotherapy of the neck muscles and attention to
posture and masticatory habits. As a result, occasional clicking persisted with the left joint and TMD
symptoms recurred twice a year during the 4 years 2
months posttreatment period. These were resolved
spontaneously, though mild tinnitus, dizziness, and
migraine remained.

The facial photographs (see Fig 7a) showed that the


tilted head and occlusal plane were not adequately
improved, even 4 years 2 months posttreatment. As
a result, the head movement showed limited flexion
and rotation to the right.
Intraoral photographs and the dental cast (Figs
7b and 7d) showed a stable occlusion; this was
maintained for 4 years posttreatment. However, the
posteriorly asymmetric vertical dimension remained.
The posttreatment lateral cephalogram (Fig 8b)
showed a straight type of cervical spine, with fusion
of occipital bone and C1 and fusion of C2 and C3
remaining. The apex of the dens still remained at
6.0 mm protrusion to the McGregor line.
The AP cephalogram (Fig 8a) demonstrated neither poor head posture nor differences in ramus
length and facial height between the right and left
sides or the occlusal plane tilt. The tilted dens could
not be improved during treatment or posttreatment.
The panoral (Fig 7c) and joint radiographs (see
web edition) showed a slight increase in size of the
left condyle both during and after treatment,
though the severely malformed condyle and ramus
on the left side still remained. Electromyographically (Fig 8d), 4 years 2 months posttreatment, the
lef t masseter and right temporalis muscles
remained severely hypertonic with abnormal electric activities, indicating masticatory function could
not improved.

DISCUSSION AND CONCLUSION


The cervical spine and muscles serve to stabilize
head position and play an important role in the complex movement of the head. They also assist the masticatory muscles in smooth mandibular movement.
The axis of the second vertebrae with the dens constitutes the atlantoaxial joint and is involved in upper
neck movement. In these patients, the cranium was
tilted to the SCM muscle contraction side and was
rotated to the upper trapezius muscle contraction
side. The contracted SCM and/or contracted upper
trapezius muscles induced hypertrophy of the temporal and occipital bones on the affected side. This may
also cause fusion or morphologic abnormality of the
C2-C3 joint, straightening the cervical spine and
pushing the dens of the axis up into the cranial base.
These changes trigger dysfunction of the atlantooccipital and atlantoaxial joints and disturbance of
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tion to head and body posture, unilateral masticatory


habit, and strong contraction of the upper trapezius.
The distance from the dens to the McGregor line
increased to 6.0 mm. The patient continued to experience limited head rotation and hypertonicity of the
masseter and temporalis muscles, further increasing
the morphologic abnormality of the condyle and
ramus on the hypertonic side. Physiotherapy of the
cervical area, combined with occlusal treatment at an
early stage of growth and development, helped normalize the dens-to-cranium relationship, function of
the atlanto-occipital and atlantoaxial joints, head rotation, and masticatory muscle activity. This, in turn,
helped improve the morphology of the condyle and
ramus. The TMJ undergoes major changes in morphology from the mixed dentition period to the completion
of the permanent dentition. Occlusal treatment and
correction of morphologic abnormality of the cervical
spine and muscles at an early stage of growth and
development can be expected to allow the patient to
obtain symmetric masticatory muscle activity and
smooth mandibular movement. This will contribute
greatly to healthy development and functional recovery
of the TMJ and the maxillofacial skeleton as a whole.
In complex cases with occlusal abnormality, lateral
deviation of the mandible, and asymmetric vertical
dimension between right and left sides, combined
with morphologic abnormality of the cervical spine and
muscles, it is important for the orthodontist to collaborate with an orthopedic surgeon in early comprehensive treatment and management of the problems prior
to completion of the permanent dentition.

head rotation, which in turn produces marked asymmetry of masticatory muscle activity, with hyperactivity and hypertonicity, as the head tilts away from the
side of the unilateral masticatory habit. Morphologic
abnormality of the condyle and ramus develop on the
hypertonic side. This may be due to excessive compressive loading by the closing muscles, which acts
to deflect the mandible and deforms the mandibular
notch and condyle, as reported by Soma.4 Asymmetric masticatory muscle activity can also induce asymmetric mandibular movement and growth in growing
children. The marked dysplasia of the condyle and
ramus observed in the adult patient can be attributed to the contraction of the right SCM muscle,
causing hyperactive masseter muscles, morphologic
abnormality of the cervical spine present from childhood, causing dysfunction of the mandible, as well as
the atlanto-occipital and atlantoaxial joints, and limitation of head rotation. Thus, movement of the left
condyle remained restricted for many years, leading
to underdevelopment of the condyle and ramus on
that side. This, in turn, aggravated morphologic
abnormality of the cervical spine and abnormal activities of the neck and masticatory muscles, accentuating the tilt and rotation of the cranium. The contracted masseter muscle remained hypertonic,
producing severe facial asymmetry and poor head
posture and worsening the morphologic abnormality
of the condyle and ramus. Graber5 stressed that the
articular process thickens as the force of the temporalis increases. These observations support the
hypothesis that contraction of the SCM and upper
trapezius muscles may induce mandibular dysfunction, resulting in underdevelopment of the mandible
on the affected side.
In case 1, movement of the left condyle was disturbed, with contraction of the right SCM and the left
upper trapezius muscles, adversely affecting the
condylar growth. The physiotherapy of the neck muscles helped eliminate the morphologic abnormality of
the cervical spine, limitation of rotational head movement, and asymmetric masticatory muscle activity.
The occlusal treatment was also effective in unloading the joint and achieving a stable occlusion conducive to smooth jaw movement. As a result, the
range of motion of the af fected condyle was
restored, allowing more symmetric mandibular movement. The morphology of the condyle and ramus was
also improved to near symmetry before completion
of the permanent dentition, and excellent symmetry
was achieved during the remaining growth.
In case 2, movement of the left condyle was disturbed, with strong contraction of the left upper
trapezius and right SCM muscle, adversely affecting
condylar growth. The morphologic abnormality of the
cervical region was aggravated due to a lack of atten-

ACKNOWLEDGMENTS
It gives us great pleasure to be able to publish these cases though
the kindness and editing of Professor T. M.Graber. The author
wants to thank the team members who made this report possible:
Shiho Arai, Michiyo Sasaki, Junko Noda, Sumie Suzuki, Toshitsugu
Sakuma.

REFERENCES
1.

2.

3.

4.
5.

Kondo E, Aoba TJ. Case report of malocclusion with abnormal


head posture and TMJ symptoms. Am J Orthod Dentofacial
Orthop 1999;116:481493.
Kondo E, Nakahara R, Ono M, et al. Cervical spine problems
in patients with temporomandibular disorder symptoms: An
investigation of the orthodontic treatment effects for growing
and nongrowing patients. World J Orthod 2002;3:295312
McGregor M. The significance of certain measurements of
the skull in the diagnosis of basilar impression. Br J Radiol
1948;21:171181.
Soma K. Distribution of occlusal stress on mandible, dentition and teeth. J Stomatol Soc Jpn 1993;60:19.
Graber TM. Orthodontics: Principles and Practice (ed 3).
Philadelphia: WB Saunders, 1997:129179.

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WEB ONLY
Pretreatment (9yY11M)

Posttreatment (12Y 7M)

5 years 6 months posttreatment (18Y 1 M)

Fig 2
Posttreatment (14Y 6M)

5 years 4 months posttreatment (19Y 10 M)

Fig 5
Pretreatment (9yY11M)

Posttreatment (12Y 7M)

5 years 6 months posttreatment (18Y 1 M)

Fig 8

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