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Congenital Muscular Torticollis: Rehabilitation with a

Customized Appliance

Krishna D. Prasad, BDS, MDS, Chethan Hegde, BDS, MDS, Namrata Shah, BDS, MDS, Manoj Shetty, BDS, MDS

ABSTRACT
The word torticollis is derived from two Latin words: tortus, meaning ‘‘twisted,’’ and collum, which means ‘‘neck.’’ Among
the musculoskeletal anomalies, congenital muscular torticollis is the third most common, with an incidence of 0.4% to
1.9%. This case report describes the multidisciplinary management of congenital muscular torticollis in an 18-year-old
female patient. (J Prosthet Orthot. 2013;25:89Y92.)
KEY INDEXING TERMS: congenital muscular torticollis, torticollis rehabilitation, cervical dystonia

C
ongenital muscular torticollis (CMT) is a musculoskeletal experienced since her childhood. A detailed history of the pa-
condition observed at birth or early infancy resulting tient revealed that the defect had been noticed since 1 year of
from unilateral fibrosis and shortening of the sternoclei- age. There were no events of abnormal obstetric presentation
domastoid muscle (SCM). Congenital muscular torticollis is during birth, episodes of any gross trauma, infections, previous
the third most frequently occurring musculoskeletal condition head and neck surgery, or associated neck pain. As part of the
in infants, with a reported incidence of 0.4% to 1.9%.1 In de- rehabilitation process, the patient had undergone physical
veloping countries such as India, delay is commonly observed therapy including active neck-stretching exercises at the age
in seeking treatment of disorders such as CMT because of lack of 3 years, with unsatisfactory results.
of awareness about the disorder per se and the available treat- Physical examination revealed that the patient was mod-
ment options. The most common observation is the limitation erately built, with disproportion noted in the cervical region
of all neck movements and the typical positioning of the neck caused by the shortened neck and a raised shoulder on the
in lateral flexion to the ipsilateral side and rotation to the right side (Figure 1). Although gait seemed unaffected, the
contralateral side, causing the chin to point toward the con- patient had a posture with a forward lean toward the right side.
tralateral shoulder.2 When diagnosed and treated before 1 year The head was tilted toward the right side and the chin was
of age, CMT resolves almost spontaneously in most cases. If raised to the unaffected side. The SCM on the affected side was
the condition is managed after 5 years of age, the form and short, firm, fibrous, and nontender with reduced range of
effectiveness of treatment are controversial.1 cervical movement. Facial asymmetry was also noticed with
recessed eyebrow and zygoma on the affected side. No ab-
normalities were noticed with her mandibular movements
CASE REPORT and temporomandibular joint functions. Intraoral examination
An 18-year-old female patient reported to the Department showed a slight shift in the lower dental midline to the right
of Prosthodontics, A.B. Shetty Memorial Institute of Dental with Angles class I malocclusion. Based on the history and
Sciences, Mangalore, with a complaint of tilting of her head to clinical findings, a diagnosis of CMT was given, and postural
the right side. There was difficulty in her neck movements and torticollis and spasmodic torticollis were considered as alter-
she expressed concern about the unusual appearance she had nate diagnoses. Because torticollis is known to be a symptom
of several pathologic conditions, an ophthalmological, otorhi-
nolaryngological, and neurological evaluation was conducted
and did not reveal any abnormalities.
KRISHNA D. PRASAD, BDS, MDS, CHETHAN HEGDE, BDS, MDS, The objective of treatment was to improve the range of
NAMRATA SHAH, BDS, MDS, and MANOJ SHETTY, BDS, MDS, are motion of the neck. To achieve this objective, a multidisciplinary
affiliated with the Department of Prosthodontics, A.B. Shetty Me- approach was planned, which comprised a unipolar surgical
morial Institute of Dental Sciences, Karnataka, India. release of the right SCM, which would then be stabilized using
Current affiliation for Namrata Shah, BDS, MDS, is the Department of a custom-made functional neck-stabilizing appliance along
Prosthodontics, Peoples’ College of Dental Sciences, Bhopal, Madhya with physical exercise.
Pradesh India.
Disclosure: The authors declare no conflict of interest.
Copyright * 2013 American Academy of Orthotists and Prosthetists. SURGERY
Correspondence to: Namrata Shah, BDS, MDS, Department of Prostho- The surgical procedure was an inferior open tenotomy of
dontics, A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, the right SCM. A single transverse incision was made along
Mangalore -575018, Karnataka, India; email: drnamrata@live.in the skin folds of the neck about 1 cm above the clavicle. The

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Copyright © 2013 American Academy of Orthotists and Prosthetists. Unauthorized reproduction of this article is prohibited.
Prasad et al. Journal of Prosthetics and Orthotics

Figure 1. Pretreatment photograph.

clavicular head of the SCM was released, followed by the sur-


rounding fibrosed cervical fascia.

FABRICATION OF STABILIZATION APPLIANCE Figure 3. Patient wearing the appliance.


A week before the surgery, an irreversible hydrocolloid im-
pression (Zhermack Neocolloid Impression Material, Italy) was strap was engaged under the left armpit. On the posterior
made of the affected side of the neck and reinforced with type II aspect, another strap attached to the waist belt. The shoulder
gypsum product (Kalabhai Dental Plaster, Kaldent, Kalabhai, brace was thus stabilized by three straps attached to a waist
India) after placing a wet gauze for retention of the plaster to belt. The smaller mandibular brace extended on the right side
the alginate (Figure 2A). A working model was poured in type III from the occipital protuberance posteriorly to the chin ante-
gypsum product (Kalabhai Dental Stone, Kalstone, Kalabhai, riorly. It was supported by a strap that engaged the left side
India). A wax pattern was carved and the fabrication of of the head circumferentially below the chin. The two braces
a custom-made functional neck-stabilizing brace was accom- were attached to each other using two screw assemblies. The
plished using heat polymerizing acrylic resin (Figure 2B). The posterior assembly extended from the angle of the mandible to
appliance was made of two bracesVa shoulder brace and a man- the clavicle (1.5 in., long which could be unwound to a length
dibular brace. The shoulder brace was large, extending from of 4 in.). The anterior assembly extended from the mandibu-
the right clavicular region anteriorly to the right scapula pos- lar brace at a point 2 cm behind the chin of to a point on the
teriorly. Provisions for attachment of two straps were made shoulder brace midway between the clavicle and sternum (1 in.
anteriorly. The lateral strap attached to a waist belt. The medial long and could be unwound to a length of 5 in.; Figure 3).

Figure 2. (A) Impression procedure for appliance fabrication. (B) Wax pattern of the appliance.

90 Volume 25 & Number 2 & 2013

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Journal of Prosthetics and Orthotics Congenital Muscular Torticollis

Figure 4. Posttreatment follow-up (4 months).

The basic design was to apply traction through controlled success rate of more than 95% is observed when the treatment
separation of the two braces by unwinding the screw. For the is initiated before the first year of life.1 Manual stretching of the
first postsurgical week, the appliance was passive and was used neck in flexion/extension, lateral bending, and rotation are
as a stabilization splint to maintain the released muscle posi- recommended as active physical exercises.2 Moreover, non-
tion and prevent scar tissue formation. The patient was asked surgical intervention alone after the age of 1 year is rarely
to wear the appliance for the whole day, except for sleeping successful.1
hours. The appliance was used as an active appliance subse- There have been conflicting reports on the value of surgery
quently for a period of 3 weeks. A regimen of unwinding half in an adult patient because of increased risk of complications.
a screw by the patient herself once after every 2 days was Lee et al.4 and Minamitani et al.5 concluded that late release
followed for 3 weeks. of SCM could yield acceptable results. Ippolito and Tudisco6
stated that neck movement could be improved with late sur-
PHYSICAL EXERCISE gery. In contrast, Coventry and Harris7 suggested that surgery
Along with the prosthodontic management, active physical has no benefit after 12 years of age, whereas Ling8 further
exercise was also followed. To attain relaxation, all movements lowers the upper limit of surgical intervention to the age of
of the cervical spine were performed in a slow, relaxed, passive 5 years. The use of botulinum toxin has been reviewed in re-
manner by the physiotherapist. This was followed by sustained calcitrant cases of CMT and has been suggested as a good al-
passive stretching of the affected SCM. The head was bent ternative.5 However, the presence of contracture and fibrosis
progressively in side flexion to the left, held there for some would necessitate surgery, whereas botulinum would be of
time, and then rotated gradually to the right. The patient showed little value in the case discussed here.
gradual improvement in her neck position and mobility. The postoperative immobilization protocol for CMT is also
By the fourth week, the patient had shown immense im- controversial. Various methods used include traction, cast,
provement in the neck rotations and flexion; thus, it was de- halo, vest, and collar; their primary role is to maintain the re-
cided to ask the patient to discontinue with the appliance and leased muscle position.1 Cervical collars, although comfortable
instead use a cervical collar for a period of 3 months for the to wear, with better compliance, have a limitation in that they
stabilization of the new position. After 4 months of follow-up, can only provide stabilization and negligible traction. The other
a remarkable improvement was noticed in the patient’s ability methods are not individualized to the patient’s needs and of-
to perform various neck movements and in the flexibility of ten are not satisfactory. Although it provides good traction, the
the SCM (Figure 4). head halter usually requires an extended hospital stay.1
The appliance discussed here is based on our successful
management of a similar condition reported earlier.3 The ad-
vantages in addition to functioning as a stabilization appliance
DISCUSSION include providing active traction. The traction can be con-
Congenital muscular torticollis is a contraction, often spas- trolled, adjusted, and measured through the screw assemblies.
modic in nature, of the muscles of the neck, chiefly those The direction of traction is predetermined through careful
supplied by the spinal accessory nerve.3 Complete resolution placement and alignment of the screw assemblies. The device
of CMT is seen either spontaneously within months after birth also provides continuous traction for the period of its wear,
or after the early initiation of conservative measures.4 A excluding nighttimes. This minimizes hospital stay and the

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Copyright © 2013 American Academy of Orthotists and Prosthetists. Unauthorized reproduction of this article is prohibited.
Prasad et al. Journal of Prosthetics and Orthotics

need for frequent visits for physical therapy and bedside trac- REFERENCES
tion. Patient compliance has also been found to be satisfactory. 1. Sudesh P, Bali K, Mootha AK, Dhillon MS. Results of bipolar release
in the treatment of congenital muscular torticolis in patients older
than 10 years of age. J Child Orthop 2010;4:227Y232.
CONCLUSION 2. Do TT. Congenital muscular torticollis: current concepts and
The case reported here demonstrates that our indigenously review of treatment. Curr Opin Pediatr 2006;18:26Y29.
designed customizable appliance could cost-effectively yet ef-
3. Shetty M, Hegde C, Burman J, et al. Muscular torticollisVfunctional
ficiently rehabilitate an 18-year-old female patient with CMT. A
and esthetic rehabilitation with an indigenously designed neck
coordinated team effort enabled us to bring about remarkable
stabilizing appliance. J Indian Prosthodontic Soc 2008;8:52Y54.
improvement in her neck functions, although we could not
resolve the facial asymmetry. The apparent drawback with the 4. Lee EH, Kang YK, Bose K. Surgical correction of muscular torticollis
appliance is its bulk and weight. Modified designs with lighter in the older child. J Pediatr Orthop 1986;6:585Y589.
and stronger materials can be used in the future to overcome 5. Minamitani K, Inoue A, Okuno T. Results of surgical treatment
this drawback. of muscular torticollis for patients greater than 6 years of age. J
Pediatr Orthop 1990;10:754Y759.
6. Ippolito E, Tudisco C. Idiopathic muscular torticollis in adults:
results of open sternocleidomastoid tenotomy. Arch Orthop Trauma
ACKNOWLEDGMENT
Surg 1986;105:49Y54.
We would like to thank the following for their support and coopera-
tion: Prof (Dr) B. Rajendra Prasad, principal, A.B. Shetty Memorial 7. Coventry MB, Harris LE. Congenital muscular torticollis in
Institute of Dental Sciences; Prof (Dr) Murli Mohan, professor, De- infancy: some observation regarding treatment. J Bone Joint
partment of Oral and Maxillofacial Surgery, A.B. Shetty Memorial Surg Am 1959;41:815Y822.
Institute of Dental Sciences; and Dr Padamaraj Hegde, A.B. Shetty
Memorial Institute of Dental Sciences. We also acknowledge Dr. 8. Ling CM. The influence of age on the results of open sternomastoid
Giridhar Naidu S., Reader, Department of Oral Medicine and Radi- tenotomy in muscular torticollis. Clin Orthop Relat Res 1976;
ology, Peoples’ Dental Academy for support and guidance. 116:142Y148.

92 Volume 25 & Number 2 & 2013

Copyright © 2013 American Academy of Orthotists and Prosthetists. Unauthorized reproduction of this article is prohibited.

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