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I was invited by Dr. Sushil Koirala, Founder and Coordinator – MiCD Global Academy, Chief- Editor of MiCD Clinical Journal, as one of many globally renowned clinicians, academicians and researchers to answer 15 exclusive interview question for their clinical e-journal sharing my experience, clinical and research findings on the subjective of “TMDs – Confusion & Consensus: Expert’s Advice“. The following is the sixth of 15 responses to their questions.
6. How do you take the relations between TMDs and stomatognathic adaptation capacity? And, is it true that in certain instances a patient will adapt well to internal derangement of the TMJ? If so, how does a clinician predict whether successful adaptation will occur?
Adaptation is a compensating mechanism which allows the system to continue to function and perform when the anatomical condition ceases to operate in an ideal manner. Occlusal engrams and muscular engrams are a learned process which is acquired; memorization of the sequence of muscle actions are made in the cortex. It’s the memory trace or physical change made on the central nervous system of the human body that results in repetitive stimulus that allows the masticatory system to adapt and compensate.
It is known that a majority of clinicians who provide restorative/prosthetic, orthodontic and or TMD services to their patients are not able to determine an optimal inter-occlusal jaw relationship for diagnosis let alone effective and stable occlusal treatments. In fact, underlying (voluntary) muscle engrams and postural compensations often exist causing the bite registrations to be skewed.
A technique I use to record an accurate and precise six- dimensional inter-occlusal record implements low frequency J5 dental TENS combined with computerized mandibular scanning (CMS – Myotronics K7). I have discovered and realized from experience removing unwanted muscle engrams is critical. Implementing dental TENS helps remove the unseen muscle hyper tensions and produces an isotonic (involuntary) mandibular path of closure that can be clinically observed and recorded with the K7 kineseograph. If one desires less strain and jaw alignment problems in their occlusion it is important to identify the involuntary path of mandibular closure that is unique to the patient and their TM joint condition. This will assure a more accurate recording of the inter occlusal bite registration.
Clinician’s world-wide recognized that antero-posterior, frontal/lateral, vertical, pitch, yaw and roll relationships between the upper and lower arches are crucial when trying to establish an even terminal contact with balanced occlusal forces. With our technique we are able to eliminate the common second molar high spot (occlusal grinding syndrome) that commonly occurs in a majority of restorative dental practices. Most dentists observe this phenomenon but simply accept it without further questioning. Every clinician around the world knows this often occurs when providing complete arch dentistry. When delivering a splint and or an arch of restorations and the patient closes their teeth together, all the occlusal marks should show evenly, bilaterally and balanced. Every dentist world-wide has seen the occlusal paper markings routinely register in the second molar region. This should not occur, but it often does. One must question the soundness and validity of their occlusal teachings if this occurs in the occlusal-minded dental practice.
In my practice, when treating TMD cases when there is a need to alter the interocclusal relationship, what I often see is the occlusal articulating paper marks evenly distributed around the dental arch when the patients bring their jaws together on their new orthotic. I don’t get high second molar premature contacts when delivering a complete arch of restorations or when asking the patient to close their teeth together on my inter occlusal appliance (GNM orthotic). I routinely see occlusal contact marks that are balanced and my patients report that their bites feel normal and comfortable. They feel the difference immediately and surprised that they are able to chew comfortably with their new orthotic. Straining muscles respond immediately to proper functional occlusion. Dentist who come to our courses see and know what we teach is real and makes the most sense.
When the adaptive capacity of the muscles of the jaws, head and neck exceed beyond their physiologic limits, loss in proper condylar/disc relationships will occur (discs become displaced). Abnormal alignments in the cervical/head relationships muscles will strain, skew and torque and the imbalanced occlusal forces will cause further harm and pains to the masticatory system. Patients will complain of having sore and tender teeth, pain in their face, pain on the side of the heads, pains in the back of their head and neck and other pains that contribute to a decrease in quality of life. When dentists do not understand the reasons for these unseen vertical dimensional losses, they often blame the problems on the patient’s stress levels (emotional upsets) or other psycho-social problems.
The dentist may unknowingly misunderstand these patient concerns as issues the patient is supposed to get used to, but in reality, the human body doesn’t get use to these abnormal strains but rather these unseen forces begin to deteriorate the body (creating body weakness) and emotional distress. When dentists do not quickly resolve these problems, they become undesirable. These patients are identified and listed as the time wasters or whiners and complainers of our profession. In my practice I recognize these patients often have a legitimate concern. It is reasonable to acknowledge that there are conservative remedies and methods that can address these kind of musculoskeletal occlusal/ TMD problems.
To avoid the perpetuation of these problems, it is prudent for all clinicians to recognize and understand what physiologic healthy musculature looks like and what do pathologic muscle conditions look like. Using scientific methodologies to “objectively” measure and record the patient’s muscle conditions helps us identify what is healthy muscles from hyperactive muscle activity or even chronic fatigued muscle conditions. Without seeing measured muscle activity EMG recordings most dentists will never comprehend these statements.
Our diagnosis goes beyond the subjective opinions formed from identifying tender muscles during a manual muscle palpation assessment. Dentists are not trained to identify chronic fatigued muscle and jaw conditions from abnormal hyper muscle conditions. Dentists know that palpating the muscles manually are not definitive enough to identify these bio-physiologic conditions. Even if they recognized the TMD patient has muscle fatigue, what are they going to do about it in order to get their patients muscles to physiologic health state? Without health functioning balanced muscle tonus the patient’s occlusion will continue to be under abnormal forces causing a lot of frustration to all those involved. This is not clinically desirable.
It is prudent for the clinician to recognize that not all patients adapt or tolerate to occlusal imbalances. Some patients are more particular about their bites then other patients. Muscles will strain, twist and torque the underlying bones when the occlusal relationship is off. This is when the dentist should measure and find the patient’s optimal physiologic mandibular position or trajectory (the opening and closing path) relative to the patient’s habitual trajectory and centric occlusion (CO). This is a very important key to understanding dental occlusion. The clinician should not assume the patient’s habitual jaw opening and closing path is “normal” – the habitual voluntary closing path of the mandible may not always be coincident with the involuntary deprogrammed muscle jaw closing path (optimized isotonic trajectory). Likewise, the centric occlusion or adapted centric may not always be the most optimal position. When restoring a group of worn-down teeth, the patient should not be having muscle strains. If there exists any muscles tensions, pains or tender muscles the dental occlusion often represents mal aligned jaws and or mal aligned dental occlusion.
When the condyles shape and form show signs of degeneration and the condylar positioning within the glenoid fossa compressed posteriorly and superiorly, these are clinical indications that the opening and closing path of the mandible (teeth/occlusion) with the associated muscles are posteriorly positioned relative to a more optimal trajectory. It also indicates the posterior occlusal dimension is vertically deficient (over-closed). Mandibular opening and closing deviations and occlusal deflections will occur when the patient’s occlusion is no longer balanced. When these abnormal structural and functional distortions are no longer tolerable and pain begins to occur within the musculature the patient will be motivated to seek answers from their doctors to find a remedy to their headaches, neck tension and jaw pains.
Patients will adapt to various levels of teeth wear, mal aligned jaw relationships and joint derangements. They will try to accommodate to the straining muscles that often occur in the shoulders, lower back as well as jaws resulting in restricted movements and body pains. Not until the muscles produce pains that exceed their pain tolerance threshold (the patient can no longer accommodate), this is when the TMD patient becomes desperate and begins to seek answers from healthcare providers to resolve their problem. 80% of simple to moderate TMD problems can be resolved by just about any occlusal philosophy or technique. Certainly, a certain level of resolution will occur. If they can find a simple remedy, they are happy. If they can’t, frustration, anxiety and depressions will ensue when the dental and medical community are not able to adequately address the deeper hidden underlying issues of occlusion and TMD. The remaining 10-20% desperate more complex TMD patient will begin to seek those dentists who are qualified and able to treat these more complex occlusal/TMD problems. TMD is mainly an musculo-occlusal problem. When one combines both the gnathic and neuromuscular principles together and applies these principles properly is when the paining TMD patient’s needs are met.
I have seen patients go from dentist to dentist, TMJ expert to TMJ expert, surgery to surgery, etc., searching for an answer when various methods and approaches have failed them. Because most dentists do not know how to locate, quantify or measure the TMD patients mandibular to maxillary physiologic jaw relationships accurately, subjective educated guesses and assumptions continue even with the use of occlusal digital technologies. The hyper detailed sensitized TMD patients who presents with cervical problems, TMD primary issues, Class II division pain problems and or anterior open bite pain problems seem to be the type of cases that challenge a majority of TMD and occlusal philosophies. It is these types of cases (10-20% challenging cases) that GNM occlusal approach proves its protocols against other approaches to resolve the challenging cases that would ordinately be referred from doctor to doctor in the cycle of pain. Clinicians who have been trained in these concepts recognize and understand these scientific protocols work and are more effective occlusally.
The GNM objective is to establish healthy occlusion on a mandibular closure path that is free of muscle strain (engrams) that pulls the mandible posterior or frontal/laterally off an isotonic path of closure. All dentists should realize that TMD/occlusal problems with pain should not be perpetuated or ignored in the dental practice. Dentists should realize that paining patients give opportunity to test the soundness of one’s occlusal philosophy and test one’s understanding of muscle health when faced with a patient with TMD problems.
All of these factors can be measured, recorded and objectively quantified when proper GNM occlusal training is received. This is how one can clinically and scientifically predict whether a successful adaptation will occur.
Clayton A. Chan, D.D.S. – Founder/Director
Telephone: (702) 271-2950
Leader in Gneuromuscular