Facing Forward Issue 4 - The Case of the Half-chewed Hockey Puck

Share the knowledge

Sometimes it is the unexpected event that leads to the most interesting answers.

Patient KB was a healthy sport-minded 6 year-old.

In Canada that means ice hockey above all else. He had an Angle Class 1 occlusion with potential mild crowding of the maxillary incisors Fig 2. Otherwise his only dental problem was severe grinding of his teeth at night, something he had done for several years. There was extensive flattening of the cusps of the posterior teeth as a result.

The birth history was relevant. There had been prolonged labour and a difficult birth with severe compression of the occiput. This can lead to displacement of the temporal bones with lateral displacement of the squamous portions of these bones. This in turn results in the ears being flared, in this case on both sides. There was no history of other possible cranial difficulties or problems with suckling or swallowing, poor sleeping patterns, constant crying, restlessness, airway difficulties etc.

PatientKBdentition — Fig. 2 Patient has an Angle Class 1 occlusion with mild lack of space for maxillary incisors.

At 4 years of age he started to play organized hockey. At this age, falling on ice is normal but the kids are well padded, they wear helmets and everyone, including the kids, take falls as part of the game. They do not have far to fall but what is not well protected is landing on their tail bones. The shock to the pelvis is transmitted up the spine to the occipital condyles. As a result, jamming of these condyles may develop. This is transmitted to the whole occiput and the temporal bones with a resulting loss of cranial mobility at an age when growth of the cranium is still very active. The three parts of the occiput do not fuse until about 6-7 years of age.

The unusual turn of events was that as a probable result of the loss of cranial flexibility he took to chewing things during the day. This included his baseball mitt and even his hockey puck Fig 3. Even more odd was that when watching TV he took to chewing buttons off his clothing then stuffing them down behind the couch in the small boy hope that no one would notice.

Fig. 3 Patient KB’s odd behaviour included incessant chewing of items easily accessible by a 6 year old boy. The chewed items pictured above include the leather covering of a baseball glove and a hockey puck. Note the significant chunks the patient had chewed from the 2.5cm thick puck of dense rubber.

The first step was referral to an osteopath. She reported an extremely rigid head but otherwise he had a well-balanced body, with good general mobility. After several visits for osteopathic treatment there was much greater mobility of the cranium but the bruxing continued.

I then placed a simple ALF appliance Fig 4 partly to gain extra space for the unerupted maxillary incisors but mostly to help mobilize the maxillae and cranium. Adjustments were at 6 week intervals. Care was taken to keep the level of force within his physiological tolerance, as assessed by the osteopath. The bruxing stopped spontaneously after 3 months. Active orthodontic treatment was given for a total of 7 months then the ALF appliance was left in place until the permanent incisors had erupted.

Further developments of the dentition was satisfactory.

Ten years later the family had moved away but his mother reported he had no further problems either from a dental or general health aspect. He was still a keen hockey player but now with contact hockey, a much more violent affair especially to the teeth. No guarantees given for his future dental welfare, just a short prayer to the patron saint of hockey players and the suggestion that he have a sports mouth guard fitted as soon as possible.

The point of the story is that the biological imperative occasionally finds strange ways to express itself. There is good evidence that in biological terms cranial vitality takes precedence even over an adequate airway. To maintain that vitality the body will enlist whatever tools are available to keep the bony cranium moving, in this case the masticatory muscles. It is a reasonable assumption that the birth trauma was a major predisposing factor. The shocks from the repeated falls in hockey were the immediate trigger, a conclusion supported by my osteopathic colleague.

Transient episodes of bruxing are common in children as they lose their deciduous molars but in this case the bruxing at night had persisted for several years. It was not present prior to starting to play hockey. An important point was the advantage of having the osteopathic diagnosis and appropriate adjunctive treatment, something I was happy to have as part of the treatment plan since it helped to avoid recurrence of the bruxing.

Gavin

Share the knowledge

Facing Forward Issue 4 – The Case of the Half-chewed Hockey Puck

Leave a Reply Cancel reply

Professional Profile