Eigild Møller

Oromandibular dystonia involving the lateral pterygoid muscles: four cases with different complexity.

The report describes oromandibular dystonia (OMD) in four women with involuntary activity of the lateral pterygoid muscles (LP), causing incapacitating protrusive and lateral jaw movements and displacements, and treatment with botulinum toxin type A (BTX). For initial survey and treatment control, OMD was analyzed with several, independent, and standardized methods. OMD severity and functional difficulties were evaluated subjectively and scored from videotapes. Jaw movements were assessed graphically with a magnetic tracking system, and electromyographical activity (EMG) of LP was recorded with needle electrodes using an intraoral approach, whereas activity of masseter muscles was recorded with surface electrodes. EMG‐guided BTX injections (25–40 units Botox per muscle) into the muscles were performed with cannula electrodes. Compared with reference values for LP, OMD was associated with a markedly increased level of spontaneous activity, but almost normal level of maximum voluntary activity. The central pattern generator for mastication seemed to override the dystonic activity, as all patients were able to chew despite some distortion. BTX reduced both the spontaneous and the maximum activity for 3–9 months. Concomitantly, a marked reduction of the OMD severity, mandibular movements and functional disturbances were also present with the best effect in localized OMD with late onset.

Action of some pericranial muscles during provoked attacks of common migraine

Abstract In this electromyographic study the activity in the temporal, masseter, sternocleidomastoid and nuchal muscles was recorded bilaterally in 2 males and 2 females during attacks of common migraine precipitated with specific beverages. Muscle activity continuously picked up with bipolar surface electrodes was supplemented by pain ratings at regular intervals, and registrations of similar duration were obtained with the patients free of headache. Recordings were divided into sections of 10 min, and during the last 2 min of each section the average level and the peak of the mean voltage were assessed with intervals of 5 sec. The average of these measurements in per cent of maximal activity was used to characterize the activity in a section. The time course of muscle activity varied between patients and muscles. In general, the migraine attack was characterized by a rise of activity from control level shortly before the patients experienced maximal pain, and location of the hyperactivity corresponded reasonably well with the spatial distribution of pain and tenderness. In two patients activity was sufficiently strong to account for a substantial part of their pain.

Electromyography of pericranial muscles during treatment of spontaneous common migraine attacks

Abstract In 7 patients given a standard treatment during spontaneous attacks of common migraine, activity in the temporal and sternocleidomastoid muscles was studied for 140 min. Pain and nausea ratings were taken with 20 min intervals. Baseline recordings were obtained from all patients during a period without headache and from 8 dental students without a history of migraine. During the attack of migraine, activity in the anterior temporal muscles significantly exceeded the patients own baseline recordings and all muscles were activated more strongly than in the control sample. The increase in per cent of maximal muscle activity was insufficient to account for ischemic pain. Following treatment the activity of the temporal and sternocleidomastoid muscles decreased in 5 patients at the same time as the pain and nausea to the level of the controls. It is suggested that the moderate increase of activity on admission was a residual from stronger contractions earlier in the attack. In addition to cessation of the attack, placement in supine position and intake of diazepam may have contributed to the decline of muscle activity.

Three-Dimensional Magnetic Resonance Image of the Mandible and Masticatory Muscles in a Case of Juvenile Chronic Arthritis Treated With the Herbst Appliance

The present report documents, in a case of juvenile chronic arthritis (JCA) with mandibular retrognathia, three-dimensional (3D) changes in the mandible and the relationship between the mandible and the masticatory muscles resulting from treatment with the Herbst appliance after cessation of growth. Magnetic resonance scanning of the whole head was carried out before and after treatment. The mandible, the masseter, and the medial and lateral pterygoid muscles were segmented bilaterally and reconstructed in 3D for both stages. Superimposition of the datasets was carried out according to anatomical structures in the brain (cranial base). Mandibular superimposition was performed according to the mandibular symphysis and the lower mandibular border. The mandible moved forward and downward relative to the anterior cranial base. In addition, bone apposition was observed at the superior and posterior surfaces of both mandibular condyles and at the roof of the glenoid fossa. The masticatory muscles remained relatively stable in position in relation to the anterior cranial base. To our knowledge, such information in JCA patients has not previously been published in the literature. Using magnetic resonance imaging (MRI), it was possible to gain improved insight into the 3D morphology including soft tissues without the overlap of the surrounding tissues observed in the conventional radiographs. Accordingly, it is suggested that 3D magnetic resonance analysis is a more useful method for the follow-up of the JCA patients than radiographic techniques.

Onabotulinumtoxin A Treatment of Drooling in Children with Cerebral Palsy: A Prospective, Longitudinal Open-Label Study

The aim of this prospective open-label study was to treat disabling drooling in children with cerebral palsy (CP) with onabotulinumtoxin A (A/Ona, Botox®) into submandibular and parotid glands and find the lowest effective dosage and least invasive method. A/Ona was injected in 14 children, Mean age 9 years, SD 3 years, under ultrasonic guidance in six successive Series, with at least six months between injections. Doses and gland involvement increased from Series A to F (units (U) per submandibular/parotid gland: A, 10/0; B, 15/0; C, 20/0; D, 20/20; E, 30/20; and F, 30/30). The effect was assessed 2, 4, 8, 12, and 20 weeks after A/Ona (drooling problems (VAS), impact (0–7), treatment effect (0–5), unstimulated whole saliva (UWS) flow and composition)) and analyzed by two-way ANOVA. The effect was unchanged–moderate in A to moderate–marked in F. Changes in all parameters were significant in E and F, but with swallowing problems ≤5 weeks in 3 of 28 treatments. F had largest VAS and UWS reduction (64% and 49%). We recommend: Start with dose D A/Ona (both submandibular and parotid glands and a total of 80 U) and increase to E and eventually F (total 120 U) without sufficient response.

What Clinical Strategies are Applied for Botulinum Toxin Injection in the Oromandibular Region

Botulinum neurotoxin (BoNT) inhibits the release of acetylcholine from cholinergic nerve terminals in muscles or salivary glands. With reduced activation, the muscle activity or secretion decreases. Indications for medical, non‐cosmetic use of BoNT in the orofacial area include among others oromandibular dystonia, painful masseter hypertrophy, Freys syndrome, and severe drooling. The chapter covers anamnestic characteristics of these conditions as well as clinical, electromyographic (EMG) and laboratory findings, treatment methods with guided injections, and outcome from systematic treatment controls and follow‐up examinations.