Tics are defined in the DSM-IV manual of the American Psychiatric Association as being sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. We report on the treatment of a patient with tic symptom, a cleft lip on the left side and skeletal anterior cross bite. Clinical record: The patient, a girl with a cleft lip on the left side, was referred to us at the age of 5 months by Department of Plastic and Reconstructive Surgery, Iwate Medical University School of Medicine, for the purpose of performing preoperative orthodontics.
Our plastic surgery department performed the cheiloplasty at the age of 6 months. This was followed, at the age of 6 years, by work on the rhinoplasty and secondary cheiloplasty. From the age of 3 years and 6 months, due to poor upper jaw development and as a result of examination of skeletal anterior cross bite, work was commenced as the maxillary protraction, the upper dental arch expansion, and improvement of the rotated central incisors on the upper jaw.
The patient continued to visit the hospital without problems until the age of 7 years and 10 months.
At her next half-yearly visit, at the age of 8 years and 4 months, the patient was observed to have symptoms of blinking, facial twitching, coughing, and strange vocalizations. Her mother had considered these symptoms to be nose-related and taken her daughter to an otorhinolaryngologist, but the examination there produced no improvement and she was thinking of going to another hospital. The authors suspected Tourette's syndrome and introduced the patient to a child psychologist. Tourette's syndrome was diagnosed on the basis of the vocal tic and effectiveness of haloperidol. A year later, the multiple tics had continued with changes of place, type and frequency with no apparent regularity of pattern in either transformation or frequency. Minor incidents, increases of anxiety etc. were thought to precipitate change in and expression of the symptoms, but the patient was extremely cooperative with the orthodontic treatment.
Discussion: Pediatric patients suspected of having a genetic predisposition towards tics may be liable to develop symptoms in response to triggers experienced in the home or school. In this case, the orthodontic treatment did not become a source of stress and the patient's psychological state was observed to be good. It is supposed that the condition was probably precipitated by a latent feeling of inferiority or stress experienced at school or in the children's home. Close coordination with a medical specialist is essential in the case of tics. It is important for the orthodontist to provide not only occlusion-related treatment but also psychological support.