What a clinician needs to see and understand to harmonize occlusion in the TMD patient.
The six dimensions or six degrees of mandibular freedom are:
Vertical relates to the opening and closing dimensional changes of mandibular positioning relative to CO/MIP along the vertical or y-axis.
Antero-posterior (AP) relates to the sagittal positioning of the mandibular body, ramus and both condyles relative to habitual CO along the horizontal x-axis.
Frontal/lateral relates to the mandibular movement laterally left and right when looking at the patient from the front view relative to the midsagittal plane.
Pitch refers to the rotational movements of the mandible about the lateral or z-axis.
Yaw refers to the rotational movements of the mandible about the vertical y-axis.
Roll refers to the rotational movements of the mandible about the horizontal x-axis.
Does the clinician adjust the bite/occlusion to the habitual trajectory ignoring the unseen spastic musculature (and assume the paining TMD patient’s subjective comments are reliable)? or does the clinician adjust the bite/occlusion along an isotonic mandibular path of closure keeping in mind the six dimensions of mandibular freedom (deprogrammed hyper muscle activities) so the mandible with all the teeth can close evenly and precisely with even balanced force along a physiologic myo-trajectory in the 6 dimensions? Vertical, AP, frontal/lateral, pitch, yaw and roll.
Vertical dimension does not only relate to the anterior teeth of the mandible, but dentists must recognize there is also a posterior left vertical dimension of the mandible and a right posterior vertical dimension of the mandible. The pitch, yaw and roll of the left posterior quadrant often is vertically different than the pitch, yaw and roll of the right posterior quadrants, especially when the TMD patient presents with joint/condylar/disc derangement as well as masticatory muscle dysfunctions (example: tight straining muscles on the left side of the jaw will be different in muscle tonus than the right side of the jaw, thus when the patient is asked to close or bite/occlude their teeth together, the clinician should ASK themselves if the TMD patient is accurately registering the first tooth contact prematurity properly when asymmetric muscle tension and strains exist? I think not. Thus, the importance to first deprogram the hypertonic muscle activity and bring the musculature toward a neutral isotonic state when establishing or attempting to adjust any occlusion.
Just because a dentist can adjust an occlusion and have the digital occlusal readings appear balanced and the articulating paper marks could appear even in tensity, does not mean the patient is closing properly on a physiologic isotonic path of closure to satisfy all six dimensions of mandibular freedom. It is easy to make an occlusion look even and balanced, but the marks can also be balanced to the wrong (less than optimal) mandibular position (disc may not be reduced, muscles may not optimally recruit when the vertical dimensions is adjusted to an over-closed position).
The objective of stability is to have the TMD pain patient pain free and comfortable with the ability to close to a terminal contact position at the correct vertical position, to support optimal condylar/disc relationships, along an isotonic mandibular path of closure (myo-trajectory) both AP and frontal/laterally without inducing strains to the teeth, musculature and joints in the pitch, yaw and roll domains up from a stable physiologic rest position. Occlusal contact forces should be even in intensity to meet all six-dimensions that allow freedom of entry and exit to the terminal contact position that is free of all afferent and efferent noxious stimuli. These six-dimensions can be objectively measured and determined NOT having to rely on the unseen hypertonic voluntary muscle activities of TMD cases
A dentists outside of this forum group asked me about the following: He stated….
Dear Clayton
Good morning
The more I ask questions and get your reply, I have found that you have similar views / and the approach that I am working in this part of the world. I being a clinician who respects Self Awareness and Natural Harmony, I trust on the component called ” Occlusal Awareness ” and use it in my practice. I focus on COMFORT, rather than the numbers.
I totally agree with you
““Even the size of the digital wafer effects the lips and surrounding musculature as one opens the mouth to accommodate the width of the digital wafer. When the obilcularis oris, buccinators and lip musculature have to accommodate around the digital wafer the mandible will naturally posteriorize, thus altering their occlusal relationship”. I believe biting with lip closing ( no foreign materials in between lips ) and biting with something in between the lip is different.”
As your interview reply is very comprehensive, if possible I would like to request you to elaborated little more on the effect of thickness of wafer of digital occlusal scanners. Because one of the author wrote it has not much effect in finishing of occlusion.
Regards
SXXXX
My Response:
Anytime you put something between the teeth the mandible will react and compensate positionally changing its jaw relationship. Even the size of the digital wafer effects the lips and surrounding musculature as one opens the mouth to accommodate the width of the digital wafer. When the obilcularis oris, buccinators and lip musculature have to accommodate around the digital wafer the mandible will naturally posteriorize, thus altering their occlusal relationship. The digital wafer will accurately record occluding high spots, but is only as accurate as to the compensated position of the mandible with its condyle/disc and surrounding musculature – think six dimensionally. When a sensor is bitten down on, many sensels are excited simultaneously and the combination of their responses produces the final response of the whole sensor. The system ultimately provides an indication of relative force, either the total digital level or the percentage of the total digital level. There are different levels of sensitivity adjustments to adapt its use to different patients. Once again, regardless of how sensitive or accurate the activation of these sensels, it is the clinical assumption that the patient with the unseen spastic hyper muscles that will be “accurately” occluding into the wafer. I don’t believe that occluding on a digitized wafer will actually record the correct and proper 6 dimensional closing contact position of a complete lower arch of teeth since there are posturing muscles and disc conditions that effect that closing position when occluding.
Some patients will habitually occlude more in the second molar regions during closure, while others may occluding in the bicuspid or anterior regions, but none of these closing patterns assures the clinician whether the patient is optimally closing on the isotonic mandibular path (myo-trajectory). If one doesn’t identify or determine the optimal physiologic closing path of the mandible that is free of muscle tension and disc derangement problems in 6 dimensions, the patient will give close into the digital wafer giving a bite force readings that would indicate certain premature contacts are occurring in certain spots or areas of that wafer, but in reality the actually prematurities are occurring in another location when the patient is TENSed to identify the involuntary closing path of the mandible.
As I indicated in my responses, most clinicians do not distinguish between habitual (voluntary) muscle closing paths vs physiologic (involuntary TENS) muscle closing paths…. They are different, thus the premature occluding contacts will show up different than what the digital wafer will identify. What occluding marks will the astute clinician rely on when deciding to adjust the occlusal surface of particular teeth? Does one rely on the “accurate” and precise digital wafer recordings that were driven by tight straining muscles that created that occluding relationship? Or does one learn how TENS produces an involuntary mandibular movement that will identify other occluding prematurities without the torquing, skewing and straining muscle influences.
One’s understanding of how the mandible and muscles close into a terminal contact (occluding) position does matter and effects the finishing of the occlusion. It also effects the end result of how the muscles respond to that occlusal finish.
If one doesn’t measure these muscular, position and occluding contact muscle responses in all dimensions, one will never know and just assume digital wafers are the end all tool to balance occlusion. It is not.
In our office we have T-scans and OccluSense. I am familiar with them and what they do. I don’t use or depend on them to finish my TMD pain patient cases who have had previously seen DTR doctors with T scan adjustments, and all the various occlusal equilibrating methods used on them. T scan and OccluSense are good at one level, but there is another level of awareness of occlusion that I am trying to convey to the profession that goes beyond the obvious.
Predictable occlusion can measure, locate an optimal jaw position, quantify the quality of muscle calmness and determine the most optimal functional mandibular position. Measurements can quantify the level of mandibular to maxillary positional health. Whether the mandible is functioning on an isotonic path of closure or whether it is closing on a pathologic path of closure that strains the muscles and joints can make a significant clinical difference in dental health. TM joint sounds can be measured and quantified as to what level of joint problems exist.
I believe my answers in these writings have given you a glimpse into my world of dental occlusion and TMD. There is so much more. Dentistry encompasses many facets and disciplines. Occlusion is nothing less than a continuation of growth and development issues from early childhood to adult stages in life. Bio-physiologic principles of occlusion are the same no matter what discipline of dentistry you focus on. From pediatric (early growth), operative preventative care, orthodontic development, cosmetic/restorative comprehensive full mouth, endodontic biologic care, fixed/removable prosthetic implant care to myofascial/TMD care are all parts of this occlusion continuum. Dental occlusion and TMD are part of nature’s process in the life of a dental patient. Dental health requires masticatory muscle and joint stability with precise balanced occlusion functioning along an optimal myo-trajectory. Unstable occlusion leads to unstable muscles and unstable joints. All treatments and methods will FAIL without a clear understanding of the principles and precise application of the GNM concepts in establishing homeostasis (STABILITY) of the BITE. For further insights and information about Occlusion Connections Masterclass training programs visit our website: https://occlusionconnections.com
Educate, educate and educate yourselves. Learn, learn and learn from those dental leaders and experts you have confidence in who know, understand and practice dental occlusion.
Learn from those teachers who practice what they teach in regards to TMD.
Gain the necessary detailed skills, techniques, methods and protocols they offer, especially from those who are still alive, available to teach, demonstrate and can show how they do it.
Don’t be fearful to ask the simple questions that concern you.
Connect with those leader/teachers who can tell you the truths and insights about TMD, so TMD and occlusion are no longer a mystery to you.
Pursue to find those answers you know exists in this world.
Avoid your fears of thinking you are not good enough. Realize your Heavenly Father only wants YOU to be the best here on earth.
When occlusion problems arise and exists in your dental practice and you begin to realize there has to be better way, seek council from those who you know have answers.
Ask yourself why things are happening the way they do in your dental practice? Are you happy with the results you are clinically getting?
Tap into the source of honest enlightening information that makes sense to you. You will learn to know how, where and why things are happening in your practice in good time.
Follow your inward voice with a good conscience. Let your inner voice guide you.
Your teachers will appear when your mind is open and your heart is ready.
Act on those inner intuitions. Don’t be idle or passive, because if you are, you will miss an opportunity along this journey.
Connect with those doctors who have experience, understanding, training and passion in GNM.
Learn from those doctors who have attended Occlusion Connections complete curriculum.
Learn from those who can give good informed answers about GNM, TMD and occlusion.
Introduce yourself to GNM and Occlusion Connections by going to the website.
Find ways to attend courses and learn gneuromuscular (GNM) in a complete way at Occlusion Connections.
Your answers are not that far from you. The solutions to your challenges are closer than you realize.
Educated guesses, subjective feelings and speculation do not produce effective, reliable, lasting results. Controversy is mainly due to a lack of global consensus as to what is TMD. Addressing the source of the problems rather than just treating the symptoms is crucial if one desires to reach maximal dental improvement (MDI). There are three areas that are overlooked by most dentist when treating and researching TMD/TMJ (Myofascial Pain Dysfunction): 1) Structural imbalance, 2) Bio-chemical/nutritional imbalance, and 3) Emotional/psychological imbalance.
I believe TMD is result of our dental professions failure to understand, educate, learn, diagnose and effectively treat the underlying developmental (etiologic) issues of upper respiratory collapse and its impact on the maxillo-mandibular dental arches. Failure to recognize poor tongue repose and how it interferes with posterior tooth eruption (deep bites) or (creates an open bite with a steep mandibular plane angle) leads to narrow arch development and changes to tooth angulation (lingual tipping of posterior teeth). Malocclusion leads to mandibular lateral and posterior displacement and a decrease in physiologic intra oral volume for the tongue. Airway obstruction by the dorsum of the tongue against the posterior pharyngeal walls leads to snoring, obstructive sleep and dysphagia. Airway obstruction also leads to chronic mouth breathing. All of these factors lead to COR pulmonale as well as craniomandibular dysfunctions (which to many are called TMD (temporomandibular dysfunctions).
Within the dental profession, there are two prominent philosophies and perspectives that attempt to address TMD. The bio-physiologic neuromuscular (structural/functional) perspective and the bio-psychosocial perspective (Orofacial). Two different paths of focus with two different clinical outcomes result when entering the world of TMD. Some TMD experts believe in objectively measuring and quantifying their patient’s physiologic responses when diagnosing and treating, while another group of orofacial pain experts believe that measuring instrumentation is not relevant or important in their diagnostic and treatment process of “managing pain.” One group recognizes the teeth/occlusion plays a role in TMD while the other believes the teeth/occlusion play a lesser role in orofacial pain.
This approach focuses not only on the subjective patient complaints, but also on objective assessment of the musculoskeletal occlusal signs and symptoms of TMD research (etiology). Measuring technology and instrumentation are used as part of research and include: 1) computerized mandibular tracking, 2) surface electromyography and 3) electrosonography of the TMJ. These devices have been found to be extremely useful in aiding the clinician to arrive at a diagnosis for conservative treatment based on objective physiologic measured data.
The U.S. Food and Drug Administration (FDA) approved the sale of these electro-diagnostic devices for the purposes of measuring bio-physiologic activity that directly relates to the TMD. The medical necessity of their use for each patient is documented by the treating dentist. Certainly, this scientific, methodical and non-invasive approach to documentation of medical necessity is a fundamental criterion to eliminate controversies. The use of objective quantifiable diagnostic procedures should be implemented to quantify and qualify a patient’s dysfunction if reasonable and scientific consensus is to be established. This approach certainly adds essential, accurate information and credibility in the effective diagnostic and treatment process especially for patients with trauma episodes to the head and cervical regions.
Bio-Psychosocial Perspective
The National Institute of Dental and Craniofacial Research (NIDCR) ignores that TMD may have not only a muscular component to this disease/dysfunction, but that it also may have an occlusal component. This over-site which only exemplifies this perspectives intent, to diminish the bio-physiologic factors of the stomatognathic system and posture of the upper quarter of the bodies systems only adds to its purposefully created controversy and perpetuated use of legalized pharmaceutical therapeutics in an attempt to “manage” the underlying pains and dysfunctions. A non interest in scientific measuring protocols continues to be promoted internationally with more of a focus on academic analysis and reliance on academic designed co-horted studies that keeps the dental and medical professionals circling in a maze of mystery as to how best to “manage” TMJ/TMD and orofacial pain problems. An emphasis to credentialing those with a “specialty” status who have espouse this approach seems to enhance a circular path of analysis with no consensus to how best to resolve the underlying issues. This perspective continues to be advocated by a small group of academics who prefer not to recognize objective measurements as a reasonable and logical progression in scientific investigation as to the patient’s muscle or occlusal complaints. To be the “specialists” of orofacial pain seems to be a significant focus.
It suggests that medicine is the solution to TMD problems.
It suggests that TMD often resolves itself and is self-healing.
It emphasizes that TMD is a self-limiting disease and occlusal (bite) changes are to be avoided.
It does not acknowledge that TMD is a major component in the scope of dental practice nor does it recognize that the dentist has a major role in dealing with muscles, joints and teeth as it pertains to temporomandibular joint disorder and all the associated signs and symptoms that relate to the trigeminal system.
Taking a “wait and see” approach to disease based on unfounded, conflicting opinions lacks responsibility to the public. A support for pain medications that can lead to dependency and drug abuse in dealing with chronic pain rather than a philosophy of support toward prevention is irresponsible. To improperly suggest that occlusion is not even remotely related to TMD when it has been well demonstrated that loss of posterior occlusal support and parafunction have a role, even if an indirect one, is fatuous. If the latter is an unfair criticism, why then would such an approach support the use of flat splints presumably to avoid parafunction?
Where are the clinicians/doctors today who understand the importance of muscle physiology and dental occlusion? Where are those clinicians who are conducting clinical research based on objective measured criteria, recognizing its impact on dental occlusion, body structural alignment, its impact on the central nervous system and relevance to the trigeminal nerve (dental ) system? Where are those clinicians who truly have the desire to be the “Physicians of the Trigeminals System” helping their patients and also are willing to conduct scientific investigations, rather than perpetuate pharmaceutical drugs to mask the pains of their patients and do the much-needed work in dentistry? Who is best qualified to address the TMD/occlusal problems? The TMD pain patients will ultimately decide who is qualified to treat their problems – Credential academic “specialists” or treating clinicians who value objective measurements and understand the occlusal issues?
To date there is no clear method that has been agreed upon regarding what is TMD – temporomandibular joint dysfunction and its associated craniomandibular and neuro-muscular occlusal issues). Because of these controversies, I decided to take the bio-physiologic approach and do my own clinical research and measure each and every one of my TMD pain patients for the past 25 years.
To all my colleagues within our profession who are serious about acknowledging that TMD problems exist and want to fully research how to best treat and avoid the controversies, I would suggest using computerized K7x technology to define, objectively measure, quantify and record the quality and level of dysfunctions of your patients who have TMD/orofacial pain.
Measure, research and gather the following data:
Speed of Mandibular Opening/Closing Before TENS in Sagittal/Frontal/Velocity Mode.
Freeway Space Before TENS using CMS to document 3 dimensional movements of the mandible (in real time) from physiologic rest to C.O. BEFORE TENsing.
Freeway Space After TENS using CMS to document three-dimensional movement (relative to time) of the mandible from physiologic rest to C.O. After TENsing.
Bite Registration in Sweep, Sagittal/Frontal Mode to document the physiologic trajectory of closure (Myo-pulse) and habitual movement of the mandible from rest to C.O.
Swallow Patterns in Sagittal/Frontal Mode to document mandibular movement during swallowing to identify tongue thrust.
Speed of Mandibular Opening/Closing in Velocity Frontal Mode to document the speed of mandible during opening and closing AFTER pulsing.
Chewing Patterns in Sagittal/Frontal Mode to document Dimensional movements of the mandible during chewing.
EMG Resting Levels Before TENS in EMG Raw Mode to document EMG muscle activity with the patient at rest Before TENSing.
EMG Resting Levels After TENS in EMG Raw Mode to document EMG muscle activity with the patient at rest After TENsing.
EMG Clench Test in EMG Processed Mode to document the amount of muscle activity during clenching.
First Tooth Contact in EMG Processed Mode to document the firing order of the muscles to determine first contact.
Mandibular Range of Motion to document patients range of motion.
Joint Sound Tracings with Corresponding CMS Tracings to document bilateral joint sounds simultaneously with jaw tracing (vertical and velocity).
Research has been promised by those in academia and organized dentistry for years, yet patients around the world are still suffering daily. They can no longer wait. My patient’s lives are at stake and they are looking for clinical answers and solutions to their TMD/orofacial pain dilemmas. I as well as many of my colleagues are familiar with these debilitating conditions all around the world. We have discovered affective; objective means to treat these TMD patients with results. At the present, many researchers and orofacial pain doctors have not shown a willingness to work together with the clinicians who actually contend with these problems using a scientific objectively measured approach.
Some within our profession are willing to measure and record the bio-physiologic evidence of their patients to discover what they didn’t know, while others rather chose the easier and convenient route to ignore the truths and facts about these matters.
I repeat: Occlusion is the foundation for advanced dentistry. Conservative and reversable therapies are standards by which our Occlusion Connections (OC) GNM teachings advocate. Stabilizing the masticatory system is a basic and fundamental principle that every dental professional should acknowledge as well as implement into his or her dental practice regardless of what treatment methods are rendered. Stabilization does not mean to cut and prepare more tooth structure while teeth are in “temporaries” or provisional restorations trying to find that physiologic jaw position before finalizing one’s restorative dentistry. I am a firm believer that the stabilization process begins before one decides to cut enamel and dentin and placing provisional restorations for new crowns or bridges. Stabilization does not mean to continue guessing which high spots to grind or guessing one’s mandibular position using occlusal equilibration techniques in a supine position. Stabilization does not assume that just because a patient may have an even balanced bite/occlusion when tapping their teeth together that everything is acceptable and comfortable. Note: Just because a restorative or orthodontically minded dentist can create and even bite/occlusion, does not mean the patient’s mandible and jaw joints are stable and in a correct physiologically functioning position. Full arch splints whether maxillary or mandibular or anterior discluding appliances does not necessarily mean the TM joints and muscles are brought to a physiologically stable position or relationship. Stable means to be pain free (comfortable), free of abnormal muscle tensions (strains) and jaw joint dysfunctions (grating, clicks and pops) that displace the mandible to a strained opening and closing path of closure. Think six-dimensionally!
Doing full mouth rehabilitation to an altered jaw position on patients may have good intentions, but can have devastating consequences to patients who have unrecognized joint derangements or underlying masticatory problems. When the treating dentists does not first align, test and prove the new established jaw relationship so the masticatory system is free of pain and muscle tenderness (establishing homeostasis), regret, unhappiness and blame after seating the restorations can be avoided.
Homeostasis (physiologic stability) is a key and important bio-physiologic concept that is difficult to understand for most dentists today since they do not objectively measure muscle conditions prior to rendering occlusal treatment. Without objectively measuring and recording muscle health (resting modes and functional modes), jaw joint functional health and considering mandibular posture in the six-dimensional domains, it is difficult to grasp the details of what it requires to establish “stable” occlusion. Hyper EMG muscle activity or super low EMG muscle activity are indicative of instability effecting the occlusion. Dentist will experience occlusal challenges and frustrations at follow-up adjustment visits when the condyles/discs that present with dysfunction and/or muscle strains are ignored.
How many follow-up occlusal adjustments are necessary to satisfy a complaining patient’s headaches, neckaches, facial pain or tooth sensitivity problems after the new restorations have been placed? Does the clinician need to grind teeth or restorations down to accommodate the existing bite to make the occlusion even? Or should the dentist consider adding up a little vertical height in the posterior regions of the bite when they finally realized the clicking/popping joints are compressed in superior and posteriorly in the glenoid fossa? Or do the dentists just ignore and refer the case to another office?
When the clinician begins to discern, detect and begin to recognize the numerous musculoskeletal occlusal intra oral and extra oral signs and symptoms of their patient’s, their diagnostic awareness and treatment planning will evolve toward a more conservative and less hurried perspective. I have learned never to assume the patient is going to relax their muscles to a proper vertical or antero-posterior position when their underlying muscles are straining, skewing and twisting the mandibular-cranial relationship. These unrecognized muscle strains and compressed joint problems lead dentists to clinical occlusal frustrations with the many occlusal follow up adjustment visits. Why? Because the patient was not pain free and comfortable first (stable).
One of the often used phrases my good mentor and teacher, Dr. Robert Jankelson, use to tell many of his students was, “Keep the hand-piece in the holster”. Dentistry should be 90% thinking and 10% doing. But in today’s world of dentistry, we observe just the opposite. Why? Because the type of training and philosophies we have received from dental schools and post graduate continuing education and the strong marketing of products by dental manufactures to influence the way dentist think to do their dentistry.
As diagnosticians and good investigators of the stomatognathic system we must first consider the complete dynamic postural masticatory system, to assess in what manner does the mandible/TM Joints relate to the maxilla/cranium physiologically – Vertical, Sagittal, Frontal, Pitch, Yaw, Roll.
Secondly, relax the masticatory muscles (break up the proprioceptive engrams) to establish a base line (homeostasis/foundation) to properly relate the upper and lower arches accurately. Reduce the muscle tensions between the mandible and cranium that skew, strain and torque the teeth, supporting periodontium and temporomandibular joints toward a pathologic occlusal position.
Thirdly, decompress the temporomandibular joints. Remove any disc displacement issues by supporting the temporomandibular joints and muscles with a removable lower orthosis in order for the lower jaw is able to function along a proper myo-trajectory free of any afferent and efferent noxious stimuli that would limit entry and exit to a physiologic terminal contact position prior to any restorative or orthodontic treatment!
I believe a patient who presents with occlusal signs and symptoms, pain, masticatory dysfunctions and joint derangement should begin a Phase One: Diagnostic stabilization process first. Phase Two, is usually required following Phase One “Diagnostic Orthotic Therapy” for the final solution. The orthotic device is used for both diagnosis as well as therapy. At the end of the successful completion of Phase One stabilization therapy, a consultation appointment would be set up for the patient to discuss the various treatment options and procedures for Phase Two (Treatment Phase): 1) Crown and/ or bridge restorations, 2) Orthodontia, 3) Combination of crown and/ or bridge restorations and orthodontia and or 4) A semi-permanent orthotic. Any treatment requiring full arch restorative crown treatment must be properly managed to the six-dimensional stable position during bite transferring protocols from the operatory to the lab and back to the patients mouth in a specific and detailed manner to prevent clinical mishaps. Any follow up occlusal adjustments must be done in a sitting up position (not laying down, supine position) when micro-occlusal adjustments are implemented to meet the needs of the patient’s central nervous system (CNS).
A patient is stable when they are pain free and off all medications for at least 3 months. Three months begins when the patient is pain free – no tender muscles are exhibited on palpation.
As we know most dentists in our profession have not learned how to measure the physiology or functional status of their patient’s jaws. It was early on in my dental journey that I recognized there were many unanswered questions that teachers and leaders in the dental profession were not adequately addressing regarding dental occlusion. In fact, they were avoiding the more complex restorative issues that impacted my patients who were having TMD pain, muscle dysfunction and joint derangement problems.
Because of my curiosity and interest to find better clinical answers, I saw the importance of using objective measuring technologies. Quantifying and accurately measuring particular bio-physiologic parameters of my patient’s dental health like a researcher and scientist brought interest and intrigue to my practice that was formerly not realized. The quality of muscle rest, the functional ability for muscles to recruit when clenching, the balance of muscle response when teeth come together, mandibular positioning and location relative to a habitual centric occlusion, speed at which the mandible and the two condyles/disc system can open and close to an established terminal contact, any aberrant tongue swallowing patterns using computerized jaw tracking and joint sound recordings would add to the diagnostic clinical understanding. I wanted to know whether the TM joints were functioning in an unhealthy (pathologic) manner or functioning in a normal manner (quiet, no aberrant signature sound patterns). These are just some of the many aspects of TMD that I discovered through my studies and research using technology.
I soon realized that quantified data (functional and dynamic) brought a new view point to the comprehensive examination process. It gave me a better understanding of the inner workings of the masticatory and temporomandibular joint system that I formerly didn’t realize. It was the added K7 technology and dental TENS that allowed me to distinguish pathologic conditions from normal healthy physiologic conditions, especially if I wanted to really understand what TMD was about and whether the occlusion (bite) treatment provided to my patient was positively helping or was it negatively inducing TMD/occlusal problems. I wanted to know the long-term effects.
I chose certain measuring technologies to help me discover better detailed answers rather than continue following the classical dogmas and assume the opinionated teachings I learned from others.
Questions I asked were: Why do cusps fracture? Why do veneers break or come off? Why were my patients complaining of unresolving headaches, facial pains, jaw joint clicking and popping, ringing in the ears, ear congestion feelings, or having tender muscles on the side of their heads after seeing many specialists? Or why was I seeing receding gum lines, bone loss and tooth wear facets, tooth mobility even after restorative or orthodontic treatment? Why were patients who have seen numerous healthcare professionals, dentists, TMJ experts, orthodontists, and even after having extensive restorative treatment, still having problems?
Many of these patients who came to my office were wondering why they still had occipital tension, shoulder pains even after seeing many physical therapists, chiropractors, acupuncture, oral surgeons and other attempted treatments for their TMJ/TMDs. Many had worn numerous intra-oral appliances day-time and night-time splints that were not working for them. They reported clenching and unresolved grinding/bruxing of their teeth? These dental problems were not getting better, but in fact, were being ignored and excused by many professionals blaming the patient to have psychiatric stressors or emotional upsets that caused them to whine and complain about these mysterious problems. Medications were not working for them. Why did my patients grind their teeth or brux even though they had airway evaluations and sleep studies that indicated otherwise, yet the patient found no resolution to their underlying issues?
I use the J5 dental TENS and the K7x Occlusal Evaluation system by Myotronics. The K7x system includes computerized mandibular scanning (CMS – Jaw tracking), electromyography (EMG), electrosonography (ESG). These technologies are FDA approved and ADA recognized. They are proven safe and effective aids in the diagnosis and treatment of TMD when used properly. As an analytical and curious clinical dentist, I was interested in learning how the masticatory system worked and functioned from a bio-physiologic perspective – beyond the mechanical. An important note: Instrumentation does not diagnose, neither does it find the bite/occlusal relationship, but it definitely adds and aids in helping the clinician arrive at a proper cranio-mandibular disorders classification as well as aids the dentists in acquiring the proper occlusal relationship for diagnosis and treatment planning.It’s the dentists that needs to be trained and acquire the proper skills and understanding in the use of these instruments and interpretation of the measured data.
The following are general features I consider clinically important when choosing available electro-diagnostic and treatment technologies to do my research and clinical dentistry:
I use technologies that could help me find a more reliable and stable jaw relationship/occlusion, to establish a physiologically stable position for the teeth, muscles and jaw joints. (Not all bio-electronic technologies do this).
I want technology that accurately records (millimeters) my patient’s physiologic responses without digitally manipulating the raw data. (Some technologies modified and electronically manipulate the raw data to make it look clean and impressive on the computer screen).
I want jaw tracking technology that precisely and accurately records the occlusal relationships without occlusal interferences (millimeters) .
I want technology to record muscle activity status as it really is without data manipulation when the patient relaxes their jaw and when they clench (microvolts).
I want technology that records jaw joint sounds, position, location, duration and frequency patterns in real time (hertz).
I also want technology that documents and records cervical head posture – flexion/extension, lateral flexion and head rotations (millimeters).
TRANSCUTANEOUS ELECTRO-NEURAL STIMULATION (Ultra low frequency Dental TENS)
I use Dental TENS to specifically break up proprioceptive muscle engrams (spastic muscle memory). This goes beyond the idea of just “relaxing muscles”. Dental TENS produces an “involuntary” mandibular path of closure response which is key to why dental TENS is valuable for all those clinicians doing restorative or orthodontic occlusal therapy. Note: Dental TENS is not a recording device. I specifically use Myotronics K7x kineseograph to help me identify an optimal mandibular position using J5 Dental TENS muscle stimulus. Not all TENS units are the same.
An ultra-low frequency dental TENS (ULF TENS) unit should deliver a “simultaneous” and “bilateral” pulse. I have discovered through years of experience the J5 Dental TENS is more effective and accurate for physiologic bite registration. Tracking the low frequency TENS pulse patterns using computerized mandibular scanning (K7x) can verify these patterns accurately. (This is an important reason which most expert teachers miss and overlook). The ULF TENS should be a 3-electrode lead system rather than just two electrodes – This is important to relax not only the masticatory muscles, but also the cervical neck region. I find that this is a critical diagnostic and treatment tool (device) for establishing an optimal mandibular position for all TMD/restorative patients with problems. Note: the cervical neck region is a critical part of the mandibular masticatory system that should also be relaxed for optimal posture before a bite registration is recorded. The J5 Dental TENS I use is able to effectively stimulate both the mandible and trapezius musculature simultaneously. The amplitude balance (left and right) controls the level of muscle stimulation. Dental TENS can be observed with the simultaneous use of the K7x jaw track technology.
At our Occlusion Connections teaching center, we use Myotronics J5 Dental TENS and BNS-40 TENS units because of their capability in delivering a “simultaneous synchronous pulse bilaterally” unlike competing manufacturers that produce an alternating stimulus to the mandible. The Dental TENS units we use at OC are the patented 3-electrode lead system. Many within the neuromuscular arena do not realize the importance of these factor which aid in establishing muscle rest of both the masticatory and cervical neck region simultaneously. A frequency that has shown to be most effective by most muscle physiologist is a frequency below 2.0 Hz with a biphasic wave form stimulus between 150-500 milliseconds. The J5 Dental TENS has this specific set frequency that stimulates every 1.5 seconds which makes it bio-physiologic and effective to use in the dental setting. (Note: I specifically do not use medical TENS since these kinds of devices are not designed for dental use).
Many TENS units are approved as a medical TENS device. But not all have FDA approval specifically for “Dental Use” nor are they all designed to function as a dental TENS device. Only Myotronics 4 channel J5 Dental TENS is approved for its intended use for: 1) treatment of TMD, 2) muscle relaxation and 3) physiologic bite registration. Other TENS devices do not meet these criteria. These are just some key reasons why I use these particular technologies in my practice.
I use and advocate the NEW K7x. It is the 11th generation jaw tracking system developed by Myotronics over the last 51 years. The state-of-the-art K7x sensors provide a more stable and more accurate measurement to accurately record the dimensions and dynamics of the patient’s bite (occlusion), jaw movements in three dimensions as well as the posture/tilt of the head.
The following should be considered in optimizing the use of neuromuscular instrumentation when using it to take a bite registration.
1) LEVEL OF ACCURACY – The K7x technology is set at a default gain of 1 mm when taking a bite registration. Competing technology display a default of 2-5 mm gain. Myotronics K7 active cursor on the monitor screen is shown to be stable and precise when no movement of their sensing device is still on the counter top. This is important in regards to the level of accuracy when the clinician takes and records the bite registration. Having instrumentation that has the capability to take accurate bite registrations is one of the key reasons why I use this instrumentation. The technology should be able to synchronize EMGs with jaw tracking simultaneously and display it in real time on the same display rather than having to flip from window to window.
2) COMPREHENSIVE SENSORY ALIGNMENT FEATURE is critical to properly align each scan before data collection. Graphic representation of how to adjust the sensor is needed so the data is consistent and not compromised.
3) ELECTRICAL NOISE IMMUNITY – The K7x picks up virtually no system noise giving the clinician a true representation of the patient’s movements. Data can be compromised because of excessive noise caused by poor systems design and inexpensive components used. The K7x has a 50/60 Hz notch filter and proprietary technology for maximum rejection of the EMI interference in the dental office.
4) IMMUNITY TO MOVEMENT OF OBJECTS – The jaw tracking signal should not be susceptible/ “contaminated” by any movement of metal or non-metal objects (rings, watches, towel clips, dental instruments, etc.) that might not normally come within four feet of the patient nor by minor to moderate head motion.
5) MAXIMUM DEFLECTION of the cursors should not exceed 1 mm. When the doctor’s hands are placed near the patient’s mouth and between the SENSOR ARRAY there should not be any deflective movement of the cursor. The K7x has this capability. Any motion of the operator around the system should not diminish the signaling.
Fine versus thick sweep lines are displayed while the patient is at habitual CO. No noise should be produced when performing a no movement test in both the vertical, A/P and lateral dimensions. Velocity tracings on opening and closing cycles yield visually readable lines on the monitor to discern smooth versus sporadic movements of the jaw.
6) SENSITIVITY TESTING – There should not be any distortions of tracings when moving the hand within three feet of any sensor array. The K7x by Myotronics is extremely stable when comparing similar technologies based on personal experience and research. When performing the sensitivity test it has been observed that any hand movement with objects or no objects produced stable, consistent, readable data on the monitor with no distortion. This is again significant when taking a bite registration and collecting accurate data.
SURFACE ELECTROMYOGRAPHY (Surface EMG)
It is important to be aware, when investing in neuromuscular electro-diagnostic instrumentation, that low noise distortion in the wires and software is an integral factor in the quality and accuracy of data collection. Line noise, external room interferences and sensor array distortion can influence data collection. This can produce flawed and inaccurate data and could lead to flawed data interpretation. Dentists who purchase this type of equipment should make sure that the data collected is noise-free, clear and easy to interpret with precision. (Remember this is scientific research level technology that is used in the clinical setting).
1) SIMULTANEOUS EMG bite registration capability – this modality is a critical component to visualizing muscle activity in real time while using jaw tracking. This feature is automated with the K7x technology, making this technology unique and desirable.
2) ELECTRICAL NOISE IMMUNITY – A necessity for consistent accurate data collection in order to discern between good data and environmental noise. Some technology on the market today picks up 60 Hz noise along with the patient EMG activity. This is unacceptable in a parameter where value lies in its accuracy.
3) EMG FUNCTIONAL CLENCH TEST – Real-time integration EMG capability is a must feature for easy discernable comparative tests and evaluation of muscle balance and muscle recruitment. The monitor display should have the ability to analyze the entire clench without converting from raw data to processed data. (Important clinical feature for reconstruction/ TMD cases). This feature is a must when evaluating technology for clinical use.
4) EMG MONITORING MODE – This feature should be available to provide the clinician real-time bio-feedback to the patient and clinician.
5) OCCLUSAL PREMATURITIES IDENTIFICATION – A feature that is important to produce diagnostic data for clinical application for EMG balance and first tooth contact timing within 20-micron accuracy – It records and displays clinically relevant information beyond just interesting occlusal graphics.
6) SPECTRAL ANALYSIS on EMG to determine muscle fatigue is a unique feature available with K7x technology. EMG leads today are required to comply with FDA directives requiring “protected pins” on patient connected lead wires. Rather than a “quick” fix” of gluing leads into the pre-amplifier, Myotronics technology has a history of complying with these stringent directives in spite of the costly changes in manufacturing costs. The K7x model has the new, safety connectors incorporated in the basic design. When purchasing these kinds of instruments make sure the technology complies with FDA directives for dental patient safety and compliance.
ELECTROSONOGRAPHY (ESG)
1) BALANCED SOUND TRANSDUCER DIAPHRAGMS should be able to record clear, undistorted joint vibrations.
2) UNOBSTRUCTED TRANSDUCERS – Transducers should be placed directly over the skin rather than a dome of solid silicon between the transducer and the skin which would reduce the ability to pick up soft sounds in the joint. It is imperative that this technology has the capacity to distinguish low frequency noise from high frequency noise, a significant feature in distinguishing joint noise diagnostically and accurately.
3) UNLIMITED FILTERING CAPABILITIES – The Myotronics Sonography has the capability to filter out loud joint sounds (clicks, pops, etc.) that might be masking the high frequency of degenerative joint disease sounds. This gives the doctor a better picture of what is going on in the joint during function. Electro-sonographic technology should have the ability to read an entire range of joint sound vibrations. Recording of both the low frequency joint vibrations as well as the high frequency joint vibrations at the same time should be available. This will eliminate having to retake data, save time and avoids loss of good data. The Myotronics electro-sonographic features have met these clinical concerns and challenges for my dental practice.
Using ESG transducers are easy for me and team to use when gathering important jaw joint sound data and helps me arrive at a diagnostic craniomandibular classification of disc interference (Internal derangement) disorder accurately. In my clinical practice when treating TMD cases, guessing and assuming things about jaw joints is not acceptable.
BITE REGISTRATION APPLICATION – The Ultimate Evolution of K7x Jaw Tracking and EMG Technology
We have chosen specifically the K7x since it is designed for clinical bite registration of TMD, fixed and removable prosthetic, orthodontics and diagnostic bite recordings. It was designed by clinical dentists for clinical ease and precision of optimal bite registration. The technology I use has the unique features of combining simultaneous three-dimensional real-time sweep and sagittal/frontal display of mandibular position with real-time graphic display of eight channel EMG for precise identification of the mandibular rest position and optimal myo-trajectory to determine a bite registration.
Any technology of this caliber should come complete with an automated bite recording capability for treatment that is automated to display a myo-trajectory (an involuntary mandibular closing path) with dental TENS.
1) PRECISE MARKING OF THE OCCLUSAL BITE POSITION – Necessary for easy-to-use Myocentric Targeting with graphic software that should allow precise placement of the occlusal bite position to within 0.1 mm precision prior to final bite registration. (I can’t over-state the importance of this key feature for accuracy and precision).
2) RECORDING BITE REGISTRATION WHILE MONITORING EMGs – A visual display and data analysis of real-time EMG to ensure masticatory muscles status of the temporalis, masseter, digastric/suprahyoid and cervical group are key in distinguishing various types of neuromuscular problems.
3) SIMULTANEOUS JAW TRACKING AND EMG CAPABILITY to enable the doctor to guide the mandible to an optimum myocentric bite position while viewing the real-time EMG activity to insure optimally condylar/disc relationship and optimized musculature should not be overlooked.
4) FIRST TOOTH CONTACT EMG MONITORING MODE – Finishing the bite/ or adjusting the bite is critical for any restorative dentist. Today’s technology should have EMG monitoring modes to guide the doctor to balanced occlusal contact force as well as musculature in both function and resting modes when implementing coronoplasty and or occlusal equilibrating techniques. The K7x is the only technology that displays first tooth contact with simultaneous EMG to assist in identifying where to adjust the bite in micron levels.
SENSOR ARRAY
Myotronics sensor array weight is 6 oz only. It is attached via Velcro straps around the head to avoid direct contact to the mandible.
1) WEIGHT OF THE SENSOR ARRAY is significant in that it can affect posture, patient comfort and impede muscle relaxation. The K7x sensor array passes the OC test of light weight compared to other heavier sensor arrays on the market. Heavier weighted sensor array devices can be extremely uncomfortable for a TMD paining patient and is not conducive to patient relaxation and bite optimization.
2) LOW INHERENT NOISE allows for a more accurate easier to discern diagnostic data. Noise can be interpreted as patient information leading to an incorrect reading and diagnosis.
ADA and FDA APPROVAL
The American Dental Association’s Council on Scientific Affairs has awarded surface electromyography (SEMG), computer mandibular scanning (CMS), and (ESG) Electrosonography its “Seal of Acceptance”, as diagnostic aids in the management of temporomandibular and occlusal disorders. The U.S Food and Drug Administration has granted 510K status to each of these mentioned devices for use in the diagnosis and management of musculoskeletal occlusal disorders.
These are just some of the key reasons why I have use Myotronics K7x Occlusal Evaluation System.
Note of Disclosure: I have no proprietary, financial or other personal interest of any nature or kind in advocating Myotronics K7x, product or services that are discussed or presented in these writings.
DIGITAL OCCLUSAL TECHNOLOGIES
I am familiar with various digital occlusal systems. They have been found to be helpful to some clinicians. I believe from experience that the thickness or thinness of these digital occlusal wafers effects the way a patient occludes and positions their mandible. From experience one realizes when biting down on various density of foods or materials the mandible reacts accordingly, altering the six-dimensional jaw position. The dentist must recognize that manufacturers of these devices have different parameters of what they consider accurate and precise when displaying and recording bite force and timing information.
The question I believe every occlusally-minded dentist should ask when considering to invest into these types of devices is: 1) How accurate do you believe a patient’s occlusion (bite) should be? 100 microns accurate? 60 microns accurate? 40 microns or 20 microns or less? The thickness of these wafers matters and does affects how the occluded data is registered in the six-dimensions of occlusion. 2) A key question to ask is: What mandibular position (location) is the digital occlusal technology measuring when equilibrating or adjusting the patient’s occlusion? Think of the six mandibular dimensions of occlusion. Regardless of what occlusal technique or technologies used I have learned that no electronic technologies adjust the occlusion. The doctors knowledge, understanding, skill and judgement does the occlusal adjustments based in information he/she understands.
I have the OccluSense which is a 60-micron thin digitized wafer. Other manufacturers offer a 100-micron wafer. Both accurately record to the level that they are intended for their use. It is unclear as to what level of filtering settings is best when trying to interpret the accuracy of the displayed premature occlusal contacts with these technologies.
The OccluSense wafer does record at a 60-micron level showing red articulating paper markings that are also transferred onto the occlusal surfaces like traditional articulating paper along with occlusal force data displayed on an iPad. The 60 micron red digital marking paper wafer does transfer marks all over occlusal surfaces making it a real challenge for any dentist to figure out what red mark they should adjust/grind away and which one they should not touch. There is no calibrated ruler to determine what level of bite force pressure is clinically relevant, so sliding the vertical filtering is but a clinical guess and best subjective judgement based on the clinicians understanding and awareness about occlusal details. Perhaps some dentist may not be aware of the significance of these occlusal details.
Any dentist who is not really trained in coronoplasty or micro adjustments will most likely just start grinding down inadvertently whatever high spots they think are the problematic spots based on what they think they are seeing on the OccluSense iPad recordings. This can be a real problem for both the doctor and patient when the bite may appear even and balanced, but to the patient their bite may not feel comfortable. This has been proven to be a real dilemma for many patients who have experience this type of occlusal equilibrating adjustments.
The dentists must learn and acquire the skills to adjust occlusion correctly. Technologies only can give information, but they cannot diagnose, treat nor adjust your patients. The doctor must learn how to properly interpret what the data means from these technologies and the doctors must learn how to adjust the bite in the correct mandibular position to avoid further TMD and occlusal problems regardless of technologies used.
A brief summary of my office treatment protocol that I follow for all TMD patients is listed below:
TMJ CONSULT: This visit will be about 1-2 hours long. The patient meets the doctor to discuss their problem. The doctor presents a general assessment based on his observations, approach, experience and philosophy to his treatment method with options.
COMPREHENSIVE EXAMINATION: A complete history of the problem, medical/dental history, physical assessment, psychosocial cursory evaluation, pharmacological assessment, thorough review of all previous doctors and health care providers seen, recommendations and treatment outcomes, head and neck examination – including muscle palpation and postural, occlusal evaluation, TMJ evaluation – electrosonography (joint sound recordings), periodontal examination, thorough review of all radiographs (FMX, panoramic, tomography, cephalometric, submental vertex, lateral cervical spine, AP coronal trauma series), recording of pre-existing dental conditions. Additionally, an evaluation of the patient’s physiologic resting and functional body responses that go beyond subjective complaints. A further discussion and interaction with the doctor about treatment options.
NEUROMUSCULAR ANALYSIS: This involves the recording of jaw movements at rest, in function, before and after dental TENS using Myotronics K7 (Kineseographic Occlusal Evaluation System). Data is gathered from EMG recordings and coordinated with CMS (computerized mandibular scanning – jaw tracking) recordings using these specific measuring instruments. An “optimized-bite” registration is recorded accurately to determine an optimal physiologic resting position that is unique to each patient. This physiologic rest position (not the habitual rest position) is recorded and verified with objective data to establish proper vertical, antero-posterior and frontal/lateral relationships.
The following is a brief outline of the recordings that are gathered:
Electromyographic (EMG) Analysis with low frequency TENS – K7 Scan 9, 10, 11, 12.
Sonographic Analysis/ Range of Motion Analysis – K7 Scan 15, 16.
Computerized CMS with simultaneous low frequency TENS (Optimized-Bite) registration to determine a six-dimensional “physiologic” jaw position – K7 Scan 4/5.
PHASE I GNM THERAPY (GNM Orthosis Therapy with Dental TENS and K7): This visit comprises the delivery of the gneuromuscular (GNM) orthotic appliance. The GNM orthotic is designed specifically to exact jaw recordings that were accomplished at the previous visit. The K7 computer diagnostics and dental TENS are also implemented when refining the appliance to the patient’s physiologic resting and functioning musculature (~ 3+ hours’ time is typically required for most of my complex cases when implementing micro-occlusal adjustment protocols in a detailed manner).
Very little doubt is left as to the accuracy, precision and what this GNM protocol accomplishes for each of my TMD patients. I am able to stabilize the jaw and muscles to their optimal physiologic rest position which is confirmed by measurable diagnostic recorded data in real-time. This data is then used to confirm and locate a proper lower jaw to upper cranial relationship.
FOLLOW UP VISITS are implemented to monitored and access the progress of each case using J5 low frequency dental TENS as well as other micro-occlusal adjustment techniques as per the patient’s specific needs.
Dental appliances to correct the mal relationships of dental occlusion are widely accepted as therapeutic. They are a conservative non-invasive first step in the diagnosis and treatment of occlusal therapy (Zhang FY, Wang XG, Dong J, Zhang JF, Lu YL. , 2013). Not all intra oral appliances (splints) are the same or equivalent in their effectiveness. A splint is defined as “a rigid or flexible appliance for the fixation of displaced or movable parts”. “Splints” are technically used to protect the teeth and or immobilize the jaw. It may be custom formed to fit over the teeth, but are not intended to precisely re-position one’s jaw relationship.
An orthosis is a custom-fabricated or custom-fitted device or support designed to align, correct, treat muscles, joints or skeletal parts which are weak, ineffective to prevent neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity. An orthosis fits over the teeth to realign the jaw and associated structures to a functional and orthopedic position. An orthosis when properly adjusted should eliminate masticatory dysfunctions and enhance functional health and stability. A key point: the orthosis I design and fabricate for my patients is based on a bite registration that is precisely measured within tenths of millimeters using the K7 kineseograph combined with the simultaneous use of the J5 low frequency dental TENS (Myotronics, Kent, WA). Based on objectively recorded data, I am able to identify my patients specific physiologic jaw position to then design the lower anatomical orthosis based on accurate measurements. This orthosis is able to support a mandibular position that allows optimal physiologic resting modes as well as optimal function once the orthotic is properly adjusted using micro-occlusal GNM protocols. I do not guess or assume my patient’s mandibular position when treating my patients with a lower anatomical orthosis. My orthosis implements all the gnathic and neuromuscular occlusal principles to address the simple to more complex problems that involved cervical dysfunctions, TMJ primary problems, retrognathic and prognathic problems as well as anterior open bite problems. My occlusal philosophy suggests that an occlusal appliance should be able to address these problems effectively and therapeutically. One appliance is all I need for my patients that addresses their day time and night time needs.
Treatment of common myogenic oriented orofacial pain in dentistry using occlusal orthotics has been shown to be effective in reducing masticatory muscle discomfort and dysfunction. Dental literature recognizes that occlusal interferences diminish normal musculoskeletal movement and are harmful. Diagnosis of these problems using precise technology can aid the dentist in correcting these structural problems confirmed with objective occlusal analysis. Dentists have the responsibility in assessing and diagnosing the structural component of each patient’s musculoskeletal occlusal system. Precise occlusal adjustments and management of the orthosis implemented in restorative dentistry, orthodontics, and orthognathic surgery can assist in reducing temporomandibular dysfunction (TMD) headaches pain and dysfunction if done correctly. Understanding neuromuscular stress reduction protocols are key in orthotic appliance design and occlusal management in order to help the biomechanical efficiency, chewing ability and, reduction of the numerous signs and symptoms of TMD patients.
As an advancing advocate and leader in TMD and occlusal treatment, I suggest all clinicians to begin measuring their TMD patients jaw relationships when a more accurate and physiologic mandibular to maxillary jaw relationship is desired. Computerized digital occlusal analysis provides objective data of occlusal contacts and muscle force to accurately assess diagnosis and treatment, as monitored with computerized jaw tracking and electromyography (EMG).
Physiologic occlusion is an understanding of how the mandible relates to the maxilla and even more importantly how the mandible is affecting head posture and all the associated structures that relates to the coming together of the teeth, muscles and joints. Resting and functional status of muscle health and physiology of the dental patient are routinely overlooked in the diagnostic work-up and comprehensive examination. Treating to the existing habitual occlusion or MIP is often assumed to be “stable” enough for most dentists when doing restorative or prosthetic dentistry as long as the patient is not complaining of pain, headaches, facial tension or jaw joint clicking/popping. Reporting any jaw joint pain or tenderness intra or extra-meatally should cause a clinician to pause definitive treatment until one determines the underlying cause of these masticatory dysfunctions, joint derangements and pain problems. Just because teeth are free of cavities or obvious periodontal disease does not mean that everything is OK musculature wise. When evaluating a patient’s overall dental health, one must also consider the overall physiologic position of the condyles and disc as well as the mandible because the determined structural jaw relationship will impact the restorative or prosthetic treatment outcomes.
Sometimes maxillary teeth are retro-inclined lingually (Class II, division 2) due to tooth size discrepancies. Maxillary incisors that are retrusive in position are often due to narrowing of the arch or missing upper bicuspid from previous extraction orthodontic treatment. The narrowing of the arch will cause the mandible to function in a posterior (forced adapted) position relative to a more anterior physiologic orthopedic muscle rested position relative to the adapted MIP/habitual position. Facial profiles commonly show a dished in appearance with the upper lip depressed when the maxillary incisors are retracted posteriorly.
Patient’s accommodative capacity over the years can adapt to their existing MIP to a certain degree even though vertical growth patterns of the first molars from early childhood where unknowingly stunted vertically. Vertical growth potential of the lower arch of teeth are often blocked by abnormal tongue habits and upper airway nose breathing obstruction. The tongue abnormally functions over the growing 6-year molars while the nose and airway are restricted from excessive mucous in the nose due to allergies and inflammation. These intra oral growth restrictions are all part of an accommodating response to abnormal growth patterns ( e.g., lower one third of the face is diminished in growth but adapted).
The lower one-third of a child’s face can develop toward a retrusive profile, thus setting the stage in the adult stages of life with a narrow dental arch, over-close bites, deep curve of Spee and forward head posture. Certainly, tooth wear patterns will appear in the lower incisal edges with bicuspids exhibiting wear facets on the buccal and mesial surfaces as the mandible wants to function anteriorly. The neck of condyles over time are forced to accommodate to this over-closed vertical position of the jaws exhibiting anterior bends in the neck of the condyles (abnormal), due to masseter muscle over-use (hyperactivity) with accompany mandibular gonial angle bone deposition. Over time the patient could complain of temporal headaches, occipital tension, facial pain and tenderness, teeth sensitivities, loose mobile teeth and abnormal toothaches to name a few. Most dentists would then report these clinical problems as having unknow etiologies. Why?
Receding gums in the anterior or posterior regions depending on the abnormal occlusal forces involved, with accompanied clicking/popping jaw joints during opening and closing of the mouth and fracturing cusps are all part of the cycle of unstable occlusion trying to adapt. Is this “Normal”? Is this physiologically stable occlusion? Are these musculoskeletal occlusal sign and symptoms being ignored within our profession assuming that MIP is a stable treatment position to our routine daily dentistry? We are often led to believe that these problems are just the normal evolution of aging, thus dentistry and restorative procedures continue to build about these pathologic adapted MIP relationships.
In general, we know teeth dominate, muscles and temporomandibular joints will accommodate as long as pain, masticatory dysfunctions and joint derangements do not appear. When pain, masticatory dysfunction and joint derangement present themselves (patients complaining of their pain problems) one must realize that the present intercuspal relationship is no longer sufficient, adequate or healthy to maintain long-term stability. These observed problems in fact are pathologic, impairing and leads to various stages of masticatory dysfunction.
How keen is a dentist’s clinical awareness and understanding about these matters of TMD and dental occlusion? Today’s dentists must begin to think both gnathicly and neuromuscularly (GNM). This is how I “think” and I view my cases as a GNM minded clinician. Today, dentists need to get proper training to update themselves and grasp and implement these principles optimally. Knowing this will avoid patient harm and dental occlusal failures.
