The Anatomical Removable Orthosis
The lower anatomical orthosis I advocate is a specialized dental appliance that is orthopedically designed to match the physiologic function of the patient’s jaw and head posture. (Read more….). It is scientifically determined using computerized jaw tracking technology, low frequency TENS and EMG data technology is used to determine and confirm the bite registration which is key to establishing an “Optimized” jaw relationship. Patient’s who experience, jaw pain, headaches, neck aches, facial pain and or has an over-closed bite can benefit from this therapy.
This anatomical appliances main objective is to orthopedically relign the mandible to the cranium to bring support, balance and allow true physiologic rest to the musculature.
Dentist Responsibilities to Making the Orthosis Treatment Effective
In today’s arena of TMJ treatment arena there are many types of splints and appliances (upper splints, lower splints, anterior deprogramers, flat plane splints, MORA’s, discluders, soft splints, lower splints, pivot appliances, etc.) that dentist have attempted to use for their paining patients as a means to try to help remedy the various muscular and jaw joints symptoms. Many of these appliances have produced varying results – some effective, others ineffective.
It has become common knowledge among patients that not all splints including orthotics work. Why is this?
Dentist often assume that opening one’s bite to some vertical dimension is supposedly suppose to help the patient. Although, this may seemingly be a good thing in an attempt separate the teeth from coming together and also allowing the musculature and TM Joints to relax at a better relationship the vertical dimension of these appliances is opened by some educated guess often by the dentist and never really “physiologically” relaxed and measured objectively with low frequency TENS and or determined with physiologic measuring technology.
It is the dentists responsibility to identify the correct mandibular to maxillary jaw relationship (the vertical, antero-posterior, frontal/lateral, pitch, yaw and roll). If a correct jaw relationship is physiologically determined (not just established to a habitual accommodated jaw position) and also properly adjusted, why would any dentist need to use multiple appliances (day time wear, night time wear) to resolve TMD/craniofacial pain? Nature didn’t give us day time set of teeth to wear and for night, a night time wearing set of teeth. One good and properly adjusted orthotic appliance should suffice to meet both the gnathologic as well as neuromuscular requiements to reduce the spastic muscle tension.
It is the dentist responsibility to make sure the orthosis or any appliance that is being implemented is properly adjusted so that the orthosis feels comfortable and does not feeling like an irritating foreign object in the mouth. It’s the design of the orthotic and how the occlusal biting surfaces are adjusted that makes the difference.
The patient should know within 24 hours whether the orthosis/appliances is properly adjusted or not, whether it feels comfortable or not. The patient should not feel like they have feeling like they have to tolerate an appliance that does not feel right when the bite their teeth together. The orthosis should be properly adjusted so the patient can chew and eat food with the orthosis. It should not cause teeth to be sensitive, if it does, ask your dentist to check the bite and make the proper adjustments. The orthosis should not cause more TMJ and muscular pain. If it does ask your dentist to identify, mark and adjust the occlusal premature interferences that are triggering the imbalanced muscle responses.
One good thing about a removable orthosis – If it doesnt’ feel right you can always take it out and let your dentist know that something is wrong. Be patient with your dentist so they can troubleshoot the biting occluding problem so you can get the resolution you are seeking.
© 2009 Clayton A. Chan, DDS. All Rights Reserved.
The Leader in Neuromuscular and Gneuromuscular Dentistry
by Clayton A. Chan, D.D.S., M.I.C.C.M.O
Four main categories or types of neuromuscular dysfunction problems within the TMJ pain arena. It is these 4 types of cases that have challenged a majority of neuromuscular minded clinicians. Each of these types requires specific occlusal protocols to be understood and followed when implementing orthotic therapy. It is clear from numerous TMJ pain patients complaints that TMJ treating dentist across the board have often failed in this area because of their lack of understanding the dynamics of the proprioceptive occlusal responses feedback mechanism to the masticatory and CNS system. Specific design requirements as well as micro occlusal management skills and protocols must be followed if a lower orthotic is to re-establish physiologic health and optimal function in a timely manner. Myofacial pain related to TMD should not be a hit an miss phenomenon, but will continue as long as the dentist do not discipline themselves in the art and science of neuromuscular occlusion.
Today’s TMJ treating clinician often overlook and fails to recognized that each of these 4 conditions require specific occlusal management protocols to be followed and implemented if effective and positive outcomes are to be expected. Not all TMJ, TMD (temporomandibular joint dysfunction, MPD (myofacial pain dysfunction) or CMD (craniomandibular dysfunction), although in this clinicians perspective, should be treated in the same manner (cooking cutter protocols) although the lower anatomical orthotic has been found to be very effective and useful when implemented properly.
1) Cervical Dysfunction TMJ Disorders
2) TMJ Primary Disorders
3) Class II, Division 2 TMJ Disorders
4) Anterior Open Bite TMJ Disorders
The significance to optimal treatment planning is based on sound stabilization techniques and occlusal management of the mandibular orthosis. A thorough understanding of each type of dysfunction requires a specific feature that meets the requirement of physiologic function. Knowing these features will assist the clinician to better comprehend how best to manage and transition the case to a finalization stage of treatment.
Symptoms That Accompany These Problems
- Unresolving neck and shoulder aches in the upper trapezius region
- Unresolved occipital pain
- Unresolving temporal pain (unilaterally or bilaterally)
- Unresolving facial masseter pain and tenderness (unilaterally or bilaterally)
- Pain behind the eyes (retro, sub and supra orbital)
- Unresolved pain at the lower posterior border of the mandible (unilaterally or bilaterally)
- Unresolved pain in the SCM and Scalene muscles
- Unresolved pain in the digastric/suprahyoid muscles
These are the common unresolved sights of pain due to “Mandibular Torque” that will persist as long as mandible to cranial relationship is strained. Imbalanced bite/occluding forces are present even if the centric bite appears to be even and balanced. Functional movements are often overlooked and not understood by most TMJ experts, because of their lack of occlusal-muscular awareness as to how the physiology works. Many have attempted to use adjunctive therapies to band-aid these unrelenting pain problems when the clinician does not understand the occlusal issues at play, yet some within the TMJ bio-psychosocial community continue to perpetuate their philosophy to the masses and do not believe that occlusion relates to TMD. Even many within the NM dental community still have not been adequately trained to recognize these issues even at a basic level and will continue to pass these problems off as untreatable and part of the so called “TMJ syndrome”. Discipline on the part of the treating clinician is required.
Note: This author, treating clinician, teacher and researcher differs to believe what TMJ traditionalist have been advocating for years. 90% of TMJ is related to muscles and abnormal occlusal function. Leaving the patient helpless and paralyzed by promoting a pharmocologic psychosocial philosophy of TMJ is a dis-service to the TMJ paining community and negates the 45 years of science and technological advances that has brought a great understanding of what TMJ/TMD is really about.
To properly treatment plan these problems requires the clinician to understand what to look for during the clinical examination process as well as to recognize the hidden indicators of postural, mandibular and joint dysfunction. How to objectively evaluate the patient’s complaint by implement proper bite registration protocols using low frequency TENS and computerized mandibular scanning technology will better assist the dentist in identify the excessive vertical dimensions as well as the proper neuromuscular trajectory required to stabilize the TM joint and muscular systems. Implementing this knowledge and occlusal management techniques will lay the foundation toward sound comprehensive treatment planning.
For more information and Training see:
Initial Treatment for TMJ – Patient Understanding
OC Work up Protocol for the TMD Dysfunctional Patient - Patient Understanding
Treatment Planning Level 3 - Training for Dentist
Discovering GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education
Three approaches or a combination thereof, may be recommended as initial therapy:
1. Occlusal correction, equilibration or coronoplasty (reshaping teeth to remove interferences that cause abnormal jaw displacement) are various approaches that the dental profession offers among those clinicians who have been trained in these techniques. The terms occlusal correction, equilibration and coronoplasty are carefully chosen terms that refer to differing occlusal philosophies and clinical beliefs as to what method and protocols are to be implemented.
Caution to the consumer patient: Be vary careful and to have any dentist adjust or grind on your teeth, especially a complete arch, because it can induce irreversible jaw positioning problems, specifically for those patient who may have underlying condyle/disc problems, joint derrangement problems and or masticatory pain problems. Equilibrating or adjusting one’s bite is a big deal and the teeth must be adjusted to a physiologic position, if not, symptoms as mentioned in this site will occur!
2. Construct an orthotic to orthopedically align the lower jaw to the cranium in three dimensions providing there is a bite over closure. If symptoms subside after wearing the appliance for three months pain free and off medications, crowns may be recommended to maintain the orthopedic position established by the orthotic. Orthodontia may be recommended to avoid crowns. Possibly a combination of orthodontia and crowns will be recommended if needed. When posterior (back) teeth are missing, dentures and /or partials may be recommended.
This is the most conservative and proven method to establish joint, muscle and postural stability. It is reversible and the standard of care, especially for any patient experiencing TMJ/TMD problems.
The orthopedic orthotic is not designed for long term use. If the symptoms reoccur after the orthotic is removed, a second phase of treatment may be necessary to complete the treatments with one of the following methods at the orthopedic position:
- Crown and/or bridge restorations
- Combination of crown and/ or bridge restorations and orthodontia
- A semi-permanent orthotic
When the most posterior teeth (back molars) are missing or all teeth are missing removable partial dentures, provisional flipper(s) or implant surgery to place missing teeth (bicuspids/molars) maybe required to assist in jaw stabilization.
3. Surgery is the last and least recommended when irreversible damage has occurred in the joints and is beyond natures healing capacity. Vary rare is temporomandibular joint surgery recommended or even indicated. Complete joint replacement is rarely indicated and should be avoided unless previous failing condyle and fossa replacements have previous failed. Do not take joint surgery lightly!
Establishing an optimal physiologic mandibular position first with a removable appliance/orthotic, using sound neuromuscular principles without manipulation is recommended, especially when all methods and TMJ approaches have failed.
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by Clayton A. Chan, D.D.S., M.I.C.C.M.O
Equilibration (Occlusal Equilibration)
Equilibration is a technique used to gain an even bite in a habitual or centric related position. Teeth, fillings or crown restorations are typically adjusted by the dentist. These type of occlusal adjustments are done with a high or low speed handpiece (“drill”) to remove any bite contacts that are prematurily contacting during jaw closure. The equilibration technique does not necessarily consider cusp to fossa relationships, but rather its focus is to develop an even bite in an accommodated habitual position. It is prudent to recognize the musculoskeletal occlusal signs and symptoms prior to having this procedure performed by your dentist. The vertical health of the jaw, the antero-posterior health of the mandible as well as the lateral health of the mandible and joints are not necessarily considered by all dentist as key factors when relating the support and overall physiologic health of the cranio-mandibular cervical posture, especially when perform this take away procedure among most dentists.
Your Bite Is Important – Don’t let any dentist take it from you.
“Equilibration is a valid occlusal procedure only when used with normalized temporomandibular joints and when masticatory muscles are in a state of normal tonus at their resting lengths except during periods of function. Equilibration should only be performed at the end of stage II finishing procedures, i.e., when the restorative or orthodontic treatment is completed. To do equilibration procedures prior to this is inappropriate since this adapts the occlusion to temporomandibular joint pathology or dysfunction.”
Brendan C. Stack, DDS, MS
Grummons, D.: Orthodontics for the TMJ/TMD Patient, Wright and Co. Publishers, Scottsdale, AZ.,1994
WHEN TO GRIND and WHEN EQUILIBRATION IS ACCEPTABLE
- When the patient is not experiencing any masticatory pain or discomfort. (This means, no tender muscles of the temples, facial muscles, lower jaw muscles and shoulder muscles, prior to any dental procedure).
- When there exists a solid stable habitual bite and routine single tooth dentistry is performed and the dentist needs to adjust the new filling or crown only into position.
- When there is no clicking or popping of the jaw joints prior to any dental procedures. (Patient’s and dentist should be aware of this)!
- When there is sufficient vertical height and dimension of tooth structure available.
- When there is sufficient enamel to adjust.
- When a single tooth is hitting or contacting prematurely and is sensitive or having tooth pain.
- When it has been recognized that jaw joint degeneration does not exist. (No clicking sounds, grating sounds (crepitus) exists).
WHEN NOT TO GRIND or EQUILIBRATE the TEETH
- When the patient reports or experiences tender masticatory muscles or pain.
- When there is jaw joint pain (Intra capsular or extra capsular)
- When there is existing jaw joint degeneration (Tomographic, MRI or cone beam imaging can confirm).
- When there is clicking and popping sounds (crepitus) during opening and closing of the jaw (this indicates that the jaw/occlusion is not stable).
- If there is a previous history of jaw’s locking opened or closed. (This usually is an indication that there is a condylar disc problem).
- If the person has had an extensive amount of restorative dentistry performed, adjusting or equlibrating the bite will often lead to further occlusal problems (unless the dentist is extremely skilled and understand the consequences and treatment outcomes.
- When there is lack of posterior vertical dimension of occlusion.
- When there exists airway obstruction and breathing problems.
Most equilibrations (tooth grinding) procedures are performed in a laying or supine position. This is not natural. Gravity plays a significant role in how the mandible moves and functions. Muscles of the jaw always seeks a neutral position or relationship and want to be supported by a comfortable bite when sitting up in an upright position. Be very cautious to have any dentist adjust or change your bite unless a consultation and examination is performed and a thorough diagnosis and treatment plan calls to do so. Equilibrating a bite to establish a balanced bite is very note worthy and noble, but it is imperative that the dentist must have hand skills, a thorough knowledge of muscle physiology, cervical neck and head posture understanding as well as comprehend the dynamics and condition of the patients temporomandibular joints prior to performing equilibration techniques. Remember it is a take away process (irreversible procedure). Removing unwanted occlusal inteferences must be done in a manner that satisfies the physiology of the musculature of the mandible to the cranium and musculature of the cervical/ neck and head region.
Typically, removing tooth structure to establish an even bite should be a rare and uncommon procedure within the dental profession since most patients who come for dental care often have an uneven accommodated bite with clicking and popping joints, grating joints, chronic unresolved shoulder aches, facial pain, jaw joint pain, headaches, neck aches, ear congestion or fullness in the ears feelings amongst a list of musculoskeletal occlusal problems. If equilibration is performed properly on patients who do not present with an over closed bite (deep bite, or retruded bites) the equilibration process can be very helpful. If the patient has existing TMJ problems or has an imbalanced atlas (C1, C2), imbalanced occiput and/ or imbalance pelvis (sacrum/iliac) equilibration procedures should not be causually done, especially on natural dentition or restored mouths that have insufficient vertical dimension of occlusion.
Patients with deficient vertical and worn dentition should consider having dental procedures that add back to the loss of vertical dimension (to restore the lost height of teeth) rather than further removing more tooth structure that can reduce the vertical height of your posterior teeth and cause one to loose a physiologic opening and closing path of the jaw (neuromuscular trajectory).
Classical equililibration techniques when done in a supine (laying down) position, even with the most skilled hands, can result in:
- The patient feeling that their front teeth are hitting stronger or more firm than the back posterior teeth.
- Pressure on the upper front teeth.
- Increased temporal headaches and neck aches.
- Tooth mobility
- Increased tooth sensitivity.
- Increased ear congestion feelings (stuffy ears).
- Ringing in the ears
Follow up visits may be required to adjust out those occlusal prematurities that are determined to be hitting on the upper lingual surfaces or lower labial surfaces of the anterior teeth while the patient is sitting up. Although these techniques have been around for as long as dentistry has been around, it is at best an subjective means to balance the teeth with no measurable accounting as to what it is doing to the surrounding musculature. If the patient has a high level of accommodatative capacity (tolerance) the equilibration process may help improve the bite and occlusal balance. If the patient has a very narrow accommodation (tolerance) to these changes as seemingly small as they may be, they can contribute to devistating challenges, that are not easily or inexpensively remedied.
All patients must be aware that the most dentist who are performing the classic equilibration procedure to give you and even “balanced bite” do not measure or quantify before hand how much tooth structure they are planning to grind away, except by eye balling the process. Remember, this is your teeth and your bite that you are use to feeling, swallow, use daily and chew your food. Your comfort and stability of your occlusion is crucial to your well-being. One single micro change or alteration to the way the teeth come together even if the equilibration was done on a single tooth surface can cause a cascading domino effect on your bite that will be difficult for any person and trained dentist to return to your bite back to the original condition, if not impossible.
Check with your dentist and inquiry if equilibration is really approprioate and necessary for your particular situation.
© 2009 Clayton A. Chan, DDS. All Rights Reserved.
The Leader in Neuromuscular and Gneuromuscular Dentistry