Relating GNM Occlusal Diagnostic Protocols and Treatment to the Diagnostic Cranio-mandibular Classification

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Relating GNM Occlusal Treatment to the Diagnostic Cranio-mandibular Classification

Clayton A. Chan, DDS

Abstract: 
Dentists who are involved in the diagnosis and treatment of TMD should implement a protocol that is comprehensive, yet systematic in nature to bring about a healthy, pain free masticatory system when maximum dental improvement (MDI) is desired.

Read more on protocols and guidelines:

Not all dental splints or orthotic appliances will solve all TMD problems. Establishing long-term occlusal stability requires the dentist to be dedicated to the occlusal principles and a complete understanding of the five foundational neuromuscular occlusal principles along with a clear comprehension of these four common neuromuscular TMD challenges that dentist face.   All dentists who have been trained in both the gnathic and neuromuscular (GNM teachings) recognize the seriousness and importance of applying these key concept in practice will require dedication, discipline and skills when effective results are desired.

A regimented diagnostic protocol is at the core of any treatment philosophy when addressing cervical dysfunctions, TMJ primary problems, retrognathic mandibular problems (Class II division 2) and anterior open bite tendency problems.  These 4 categories make up the majority of neuromuscular TMD occlusal challenges that few dentist fully comprehend in clinical practice.  The clinician must determine if the occlusion is ideal and whether the occlusal discrepancy is caused by underlying problems of the joints, muscles, teeth or the cervical neck region.

Many times, an occlusal appliance becomes such an integral part of the therapy yet most clinicians do not recognize what is missing in their occlusal management regimen while neglecting to recognize the category to which the neuromuscular TMD problem actually exits.

Many in the profession believe that there is not one “magic” appliance that will solve all problems. The use of various types of anterior deprogrammers, splints, jigs, MORA and orthotics are clearly used for various purposes that relates to a specific conditions, yet the overall principles by which the masticatory system works is neither fully understood by dentists who also have a varying views and philosophies represented by the many and varied designed intra oral appliances are used in attempt to treat the variety of problems that challenge the dentists.  The dental profession in general fail to address the underlying masticatory, gnathic, neuromuscular and cervical issues, thus making TMD and occlusion more complex than it really should.

Today diagnosis and classification of every temporomandibular joint disorder, as well as problems affecting the masticatory musculature, is confused by a temporomandibular joints emphasis and focus rather than a focus on balancing all the associated components of the masticatory system including the head, neck, teeth and temporomandibular joints.  Most TMD and occlusal classifications are established based mainly on TM joint problems rather than based on a bio-physiologic functional muscle perspective which focuses on the quality of muscle health, quality of mandibular movement, quality of joint function and healthy mandibular posture relative to its terminal contact positioning of the teeth.  Patient symptoms, conditions and joint derangement problems have made up the majority of various cranio-mandibular philosophies and classifications, yet provide very little aid in achieving maximum dental improvement to one’s quality of functional health.

Diagnostic Cranio-mandibular Classification Revisited
The most commonly used occlusal classification in dentistry, the Angle’s classification,5 fails to observe the relationship of the teeth to the TMJs or consider the health, position, or condition of the TMJ. By contrast, the diagnostic craniomanidibular classification that the OC GNM trained dentists focuses on are:

  1. Masticatory Muscle Disorders (Muscle Pain)
  2. Disc Interference Disorders (Internal Derangements)
  3. Inflammatory Disorders of the Joint
  4. Chronic Mandibular Hypomobility
  5. Mandibular Hypermobilities
  6. Growth Disorders of the Jaws
  7. Traumatic Injuries
  8. Abnormal Jaw Closure Patterns

Too often, the temporomandibular joints are made the focus for a particular diagnosis and the use of a particular appliance, rather than understanding what is the physiologic starting relationship between the maxillary to mandibular to re-establish a physiologic balance in mandibular functional treatment is often missing.

Choosing a particular mode of therapy and or use of an intra oral appliance should always follow a complete understanding of how the masticatory system operates to improve both the gnathic as well as neuromuscular systems quality of function.

The goal of every occlusal treatment is to create a healthy, pain-free, stable masticatory system which includes health muscles, stable TM joints and stable functional occlusion.

There are ten foundational keys for achieving long-term gneuromuscular (GNM) occlusal stability.

  1. Homeostasis of the TMJ’s
  2. “Physiologic” (terminal contact) position
  3. Anatomically correct occlusal plane
  4. Non entrapping anterior contacts.
  5. Cuspid rise supports posterior disclusion
  6. Unrestrictive contacts in lateral excursive
  7. Protrusive and retrusive balance
  8. Vertical dimension of occlusion
  9. Optimal myo-trajectory
  10. Proper transpalatal width

GNM I: Homeostasis of the temporomandibular joints is a fundamental medical principle. Continued compression of the temporomandibular joint (condyle/disc in fossa – a delicate entity) via abnormal occlusal/biting force relationships and hyperactive musculature contribute to a progressive degradation of internal derangements and TMD disorders.  Homeostasis is achieved when abnormal compressive forces on the joint system are eliminated and supported by a physiologic healthy occlusal contacts which nature intends to design in support of  healthy TM joints with optimal function. The TM joints overtime can be in active slow progressive degradation because of mal aligned teeth, abnormal tooth wear, breakage and or missing teeth. The temporomandibular (TM) joints are not designed to be “load bearing” joints. Rather the teeth and dental arches are designed to support the lower part of the face (via the mandible) and upper maxilla without abnormal compressive forces.  Elicited pain on opening against pressure, closing against pressure and or protruding the mandible against pressure is indicative of intra capsular disorders. The goal is to re-establish muscle homeostasis, re-establish physiologic a mandibular to maxillary position thus allow abnormal TMJ forces to continue the degrading progression of the TMJ deformation.

  • Objective Assessment method: Technological advances using conventional computed tomography images, cone-beam computed tomography (CBCT),  MRI magnetic resonance imaging, electrosonography (ESG) and computerized mandibular scanning (CMS) are indispensable objective measurable aids in identifying various internal derangements and TMJ health before, during and after treatment.

GNM II: “Physiologic” (occlusal, terminal contact) position. Maximum intercuspation between the upper and lower teeth must be in harmony with an “isotonic” mandibular closing path (myo-trajectory). This is different than the assumed habitual or accommodated closing trajectory (teeth closing into their habitual maximum intercuspal position). This position is NOT established at physiologic rest position. Physiologically positioned occlusal contacts may be different than the adapted habitual accommodated occlusal contact position when TMD symptoms are present.  A physiologic position can only be detected and determined with involuntary Myomonitor TENS (transcutaneous electroneural stimulation). Low frequency TENS overcomes engrammed habitual muscle memory of spastic activity that skew, torque and strain the abnormal occlusal contacts coming from the strained surrounding bones of the maxilla, mandible and TM joints. Low frequency TENS is a simple, non-invasive means to break up muscle engrams. Technological advances using computerized mandibular scanning (jaw tracking) is an aid in identifying the quality of terminal contact (whether normal, guarded or poor) as well as the quality of the terminal contact position whether muscle balanced or not. A physiologic (healthy) terminal contact is determined from an isotonic rested mandibular position.

Treatment can be reversible with a GNM orthotic (to help condylar disc problems). In many patients, definitive occlusal therapy can be considered once the patient is pain free and medication free (a minimal of 3 months consistently without incident) as the primary treatment modality when implementing one or more options:

  1. Micro occlusal correction – Used if grinding on the sagittal plane is less than 0.2 mm along the myo-trajectory to accommodate closure to centric occlusion (CO).
  2. Orthodontic/orthopedics – Used when natural dentition is present (with minimal restorative dentistry), levelling and aligning of dentition is needed to correct deficient vertical dimensions in both anterior and posterior regions of the mouth. Careful and precise occlusal management is implemented when transitioning the teeth to the new occlusal position while simultaneously maintaining supportive healthy condylar disc relationships, musculature and temporomandibular joint relationships to optimal physiologic parameters.
  3. Restorative dentistry – Used when orthodontics is not indicated and previous extensive crowns, bridges and restorative implants have been implemented and or required.
  4. Orthognathic surgery – rarely implement but considered when coronoid hyperplasia exists, previous failed joint surgeries have not produced the desired result, and severe maxillary and or mandibular orthognathic facial underdevelopment exists.

The goal is to do the least amount of dentistry, using a conservative approach to preserve the dentition, restore physiologic functional masticatory health, improve quality of dental health and satisfy the 10 principles for a stable occlusion.

  • Objective Assessment method: Low frequency Myomonitor TENS combined with jaw tracking (CMS) to compare involuntary mandibular movement vs. habitual voluntary mandibular movement and closure patterns to a terminal contact position (sagittal, frontal/lateral and velocity).  Involuntary jaw closure patterns must be coincident with voluntary closure patterns (before and after TENS) to establish homeostasis and optimal quality mandibular function at any stage of occlusal treatment.

GNM III: Anatomically correct occlusal plane. Head posture effects the occlusal plane angle. The occlusal plane angle should be anatomically oriented (angled downward from the sagittal view, not flat) to supports proper head and neck posture. The occlusal plane orientation is reflection of one’s head posture and cervical/neck condition.  An occlusal plane that is level to horizontal level indicates an upward head tilt resulting in the cervical alignment to shift toward kyphosis.  An occlusal plane that is angled 6-14 degrees (normalized) is indicative of a more normalized head posture and lordotic curvature of the cervical region.  A patient with a forward neck posture will accommodate to maintain the flow of oxygen into his/her body.  This forward neck and head posture tendency is indicative of an upward head tilt with a resulting flatter occlusal plane.  The upward head tilt contributes to TMD and accommodative pathologic issues (e.g., shoulder pain, neck pain, temporal headaches).  An upward head tilt is the bodies way to accommodate to a mal-aligned bite (mandible will functioning posterior to an isotonic myo-trajectory) which contributes to abnormal vector of forces to the surrounding musculature and increased wear on the dentition and TM joints.

  • Objective assessment method: Cervical spine imaging (sagittal view), CBCT imaging  (unposed sagittal view), cephalogram – sagittal (unposed head position) imaging, photograhic lateral views with patient standing up.

GNM IV: Non entrapping anterior contacts. Anterior tooth contacts should be light, but not entrapping the physiologic closure path of the mandible.  Occlusal contacting force should be even and bilaterally balanced along an isotonic closing path (myo-trajectory). Computerized mandibular scanning (jaw tracking) combined with low frequency TENS is used to objectively measure and identifying the accurate path of mandibular closure along that isotonic myo-trajectory and to assure the mandibular jaw track pattern is arriving at a terminal contact position free of interferences.  Anterior closure contacts should not induce an increased premature muscle activity responses beyond a balance synchronized EMG response.

  • Objective assessment method: Computerized mandibular scanning (CMS – jaw tracking) with and without low frequency TENS used to objectively quantify and measure involuntary jaw closure patterns.  relative to voluntary mandibular jaw closure patterns.  Involuntary vs voluntary closure patterns (before and after TENS) can establish level of homeostasis and quality mandibular freedom/function when closing to a terminal contact position.

GNM V: Cuspid rise supports posterior disclusion.  Cuspid rise should occurring during lateral sliding movements of the mandible allowing the posterior teeth to separate immediately.

  • Objective assessment method: Computerized mandibular jaw tracking scans are used as aid in quantifying the angle of disclusion pattern whether too steep, to flat or normalized.

GNM VI: Unrestrictive contacts in lateral excursive.  Lateral excursive movements should not be restricted by posterior occlusal premature contacts. Proper curve of Wilson/Monson (transversely) must exist to support quality functional (chewing, swallowing) movements free of any interferences.

  • Objective assessment method: Quality of terminal contact functional chew can be quantified and determined using computerized mandibular scanning (CMS – jaw tracking) as an aid in verifying the quality of the functional chew cycle, the shape and form of the chew cycle pattern and quality of the terminal contact position at the end of the chew cycle (whether normal, guarded or poor).

GNM VII: Protrusive and retrusive balance. Protrusive and retrusive contacts must be balanced to prevent abnormal muscular torques and strains.

  • Objective assessment method: Computerized mandibular jaw tracking recorded data is used as aid in quantifying the protrusive angle of disclusion pattern whether too steep (Class II division 2), to flat (Class III) or normal (Class I).

GNM VIII: Vertical dimension of occlusion. Vertical dimension of occlusion (VDO) can be reproducibly determined up from the physiologic rest position. Vertical dimension is best determined when homeostasis of the musculature has been established along an isotonic mandibular trajectory. Note: anterior VDO is different from posterior VDO depending on condition of muscles and joints (left and right side).

  • Objective assessment method: Technological advances using computerized mandibular scanning (jaw tracking) combined with low frequency TENS is used as aid in identifying accurate vertical dimensions of occlusion, quality of resting mandibular positions relative to terminal contact (CO) position.

GNM IX: Optimal myo-trajectory. All patients who experience myofascial pain, joint derangements and masticatory dysfunction close posterior to their isotonic myo-trajectory. A physiologically normalized joint position (regardless of joint condition, intra capsular or extra capsular) can be determined when an optimal myo-trajectory has been established without manual manipulation.  Establishing a physiologic diagnostic treatment position is a fundamentally key to any accurate and effective diagnosis prior to treatment.  A terminal healthy contact position of the teeth is achieved when they can occlude in maximum intercuspal relationship with the discs reduced (not entrapped nor displaced during functional maximum opening and closing movements).

  • Objective assessment method: Technological advances using computerized mandibular scanning (jaw tracking) combined with low frequency TENS are aids in identifying accurately the quality of terminal contact (normal, guarded or poor), the isotonicity of the myo-trajectory of the mandibles closing path to terminal contact (whether posterior to, anterior to or coincident with an optimized myo-trajectory).  Involuntary vs. voluntary closure patterns (before and after TENS) can establish level of homeostasis and quality mandibular freedom/function when closing to a terminal contact position.

GNM X: Proper transpalatal width and normalized tongue swallowing patterns is crucial to long term occlusal and neuromuscular stability. Any restriction to normal tongue swallowing patterns is contributory to abnormal tongue swallowing dynamics, airway obstruction and neuromuscular dental collapse.  Without a clear understanding of muscle health as it relates to proper mouth breathing and tongue postural dynamics the so called “neutral zone” cannot be established nor optimally maintained. Dental relapse will ensue when abnormal muscle activity and abnormal tongue swallowing habits are not normalized to physiologic parameters.

  • Objective assessment method: Computerized mandibular scanning (jaw tracking) tests are used to assess normal swallow patterns from anterior tongue thrust and or lateral tongue thrust patterns with and without water assist. Before and after objective measurements are used to determine if treatment goals have been clinically achieved.

Treatment Considerations:
Initial treatment may vary from simple (short-term) orthotic therapy to help decrease various musculoskeletal occlusal problems to complex orthotic therapy (long term) to assist in managing inflammatory disorders in the joint, disc problems, abnormal mandibular closure pattern problems (vertical, posterior, frontal/lateral).  Orthotic therapy for others may require a longer period of treatment time if patients are more sensitive, have experienced chronic pain problems or invasive joint surgery problems.  Anti-inflammatory medications can be implemented when indicated to avoid more invasive surgical correction.

  • Subjective assessment method: Use of the Subjective Summary form comprised of a list of symptoms is used to rank and scale (0-5, left and right side) each symptom whether improvement has been achieved.  This assessment tool is used at each appointment visit during the course of treatment.

When a craniomandibular diagnostic classification has been established, the goal of initial treatment is directed toward aligning the masticatory system (including teeth muscles and joints) toward homeostasis. The GNM orthosis is worn as a means to assist in reprogramming spastic musculature, re-establish mal aligned dental arches, improve abnormal postures of the head and neck and remove able forces to the TM joints. Once homeostasis and a pain free status of comfort has been achieved a reduction in the use of orthotic wear time can be implemented (controlled weaning off) as an attempt to determine whether the patient can function comfortably back to their previous occlusal position.  If it has been determined that symptoms re-occur it can be determined that this physiologic relationship is therapeutically effective and at patients discretion can proceed toward a more definitive therapy.

Orthopedic Alignment:
The GNM orthotic is an orthopedic device designed to orthopedically re-align

the mandible to the cranium, stabilizing the temporomandibular joints and restoring them to normal physiological function while concomitantly reducing contracted (spastic) craniofacial and cervical musculature while developing functional and resting modes within normal physiological parameters.

Tests are required for the placement of an orthotic that is custom designed and constructed using data derived from jaw tracking (range of motion), low frequency TENS (to diminish pathologic muscle engrams) and EMG recorded data. The purpose of this orthopedic appliance is to align the mandible to the craniomaxillary complex optimally in three dimensions thereby relieving muscle, ligament, nerve and vascular impingement.  It serves to maintain the stomatognathic musculature at the optimal resting length from origin to insertion thus decreasing pain and improving function.

Objective measurements of the muscles at rest as well as functional modes of mandibular function must be analyzed in determining whether the patient’s masticatory system and cervical postural system has met the criteria of healthy. This assessment should be determined prior to moving forward with any definitive therapy.  Failure to establish healthy mandibular ranges of motion, normalized joint function, quality terminal contact velocity at mandibular terminal closure maybe the result of muscle splinting that prevents optimal function of the joints, musculature and occlusion.

If the disc cannot be adequately reduced (optimized within the joint compartment) one cannot say the maximum dental improvement (MDI) has been achieved. If the problem is limited to muscle splinting, a properly design orthotic must be re-evaluated and implemented to establish an optimal mandibular function and quality of resting muscle tonus. If the orthotic eliminates the muscle hyperactivity, allows the condyle/disc to optimally function, with occlusal interferences eliminated to prevent muscle splinting a positive outcome can be predicted. Failure to achieve relief of the masticatory system including the associated cervical regions may indicate the presence of a TMJ derangement, pain and masticatory dysfunctions disorders have not be adequately resolved.

Diagnostic Protocol
At the center of the GNM occlusal approach is a regimented diagnostic protocol that arrives at a craniomandibular classification based on objective measurements to arrive at a particular mode of treatment due to masticatory dysfunctions and impairments observed and reported.

Musculoskeletal occlusal dysfunctions can manifest in any or all parts of the human body system. It is the clinician’s job to determine whether the occlusion is optimally functioning or whether the masticatory system is impaired (dysfunctional) causing problems to the joints, muscles, and teeth. An objective analysis of the entire masticatory system is the only way to determine this. Such analysis should include the following assessment:

  1. Masticatory Muscle Disorders (muscle pain) – Muscle pain and muscle splinting can result in decreased mandibular range of motion. Protective muscle splinting, muscle spasm activity, and or muscle inflammation (myocitis) must be considered. Computerized mandibular scanning (jaw tracking) measures and verifies objectively patient’s incisal opening sagittal tracing patterns is used as aids in identify whether masticatory muscle disorders is involved.
  2. Disc Interference Disorders (Internal Derangements) – Reciprocal clicks on opening and closing can be early, mid or late derangement problems. Dislocated disc or severely restricted mandibular opening problems can be confirmed with electrosonographic (ESG) recordings that objectively measures high and low frequency as well as amplitude TM joint signature patterns. Location of these derangements can be quantified.
  3. Inflammatory Disorders of the Joint – Joint pain is exhibited on palpation with teeth separated and with wide opening. Synovitis/capsulitis, retro-discitis, inflammatory arthritis (degenerative arthritis or traumatic arthritis) must be considered. Tomographic and or CBCT imaging is used to document and confirm patient’s ability to open wide and record any radiographic loss of boney contours and sclerosis of glenoid fossa.
  4. Chronic Mandibular Hypomobility – Decreased mandibular opening and may have decreased lateral excursions. Pain or no pain and range of motion will help confirm whether contracture of elevator muscles, capsular fibrosis (following trauma), ankyloses (following trauma, and or any skeletal abnormalities exist.  Computerized mandibular scanning (jaw tracking) measures and verifies objectively patient’s lateral tracing patterns.
  5. Mandibular Hypermobilities – Excessive movement of the mandible. Subluxation, spontaneous dislocation of condyle, or chronic (recurrent) dislocation of condyles with normal function or with internal derangement can be identified with capsular ligament tears, whether condyle moves passed the midpoint of the articular eminence or if 2 clicks on opening and 2 clicks on closing are present. Tomographic and or CBCT imaging is used to document and confirm. Electrosonographic recordings objectively locates and measures high and low frequency and amplitude TM joint signature patterns.
  6. Growth Disorders of the Jaws – Skeletal mal-relationships such as: Vertical maxillary deficiency, vertical maxillary excess, apertongnathia, asymmetries, Class I, II, III, acquired changes in the joint structure, and or unilateral capsular hyperplasia must also be considered.  Computerized mandibular scanning (jaw tracking) measures and verifies objectively patient’s tongue swallowing movement patterns whether normal or aberrant.
  7. Traumatic Injuries – Fractures of the jaws and/ or teeth can include maxillary or mandibular fractures and or bleeding within the joint from trauma. These kind of problems should be treated with impressions and a soft bite guard to fit over the lower teeth. This will aid in decreasing continued trauma to the intra-capsular structures as a result of swallowing. A referral to qualified oral surgeon maybe indicated.
  8. Abnormal Jaw Closure – Mandible closing posterior to and or lateral to the myo-trajectory may also include posterior closure patterns, vertical deficiency closure patterns and lateral closure abnormalities. (Without objectively measuring instrumentation these mandibular closing patterns are often highly overlooked and rarely considered in the dental profession). Computerized mandibular scanning (jaw tracking) combined with low frequency TENS measures and verifies objectively abnormal closure patterns. Subjective visual assessment is not accurate enough to see these problems at this level and standard of care.

Discussion
As stated previously, the first goal of occlusal treatment is to establish what level of TMJ/TMD disorder exists since these problems can range from easy, simple, moderate, difficult to complex. The clinician must determine which patient will benefit from orthotic therapy and which patient would not. They also must determine whether they have the skills, time and training to service the patient’s particular concerns and needs appropriately.

If orthotic therapy is successful, the patient and clinician may begin to consider what other types of dentistry will be required afterwards to fulfill the requirements of maintaining the stable occlusion beyond the removable orthotic. To simplify this discussion, treatment may be divided into two phases.

Phase 1 Treatment: GNM Anatomical Orthotic 
Most occlusal splints have one primary function: to alter an occlusion to create an environment that will alter the condyles disc relationship in some manner.

The goal of GNM orthotic treatment is to establish a measured optimal physiologic mandibular to maxillary jaw relationship where the patient is able to optimally function (chew, speak and sleep) with one appliance that supports, stabilizes discs and strengthens the masticatory system 24/7.  There is no need to choose between various appliances if an optimal relationship is objectively measured, determined and correctly managed occlusally.  Establishing proper condylar disc function, healthy muscular function, optimal occlusal function and cervical balance is a reasonable treatment goal for dental health (being free of masticatory dysfunctions, physical and bodily impairments and restrictions).

Phase 2 Treatment
A second phase of treatment may be implemented if and when the patient acknowledges that a definitive phase is in his/her best interest in reaching their objectives and treatment goals.

Phase 2 may involve orthodontic/orthopedics, restorative/biomimetic dentistry, or a combination of these methods in order to maintain a physiologic stable relationship.  Orthognathic surgery is rarely considered but is possible if conditions require such.

These treatment options are specifically designed to transition a pathologic dysfunctional impaired condition (now stabilized) to a finalized physiologic healthy condition without the need of a removable orthotic. Once optimal mandibular function and optimal resting and optimal muscle functional parameters have been verified using:

  • Computerized jaw tracking (CMS) to measure mandibular function,
  • Electromyography (EMG) to measure muscle resting quality, functional muscle recruiting ability and balance and
  • Electrosonography (ESG) to measure quality of joint quietness and velocity of movement
  • Confirmed with radiographic imaging,
  • Diagnostic models related in their physiologic anatomical correct position
  • Supported with intra oral and extra oral photographs.

Appropriate treatment can be planned and implemented based on these healthy physiologic parameters. The occlusal end point is to establish the previously described ten requirements of stability, using the most conservative approach possible.

Conclusion
Solving complex TMD and occlusal problems can be tremendously rewarding. The key to successful treatment based on foundational process of objective analysis in both the diagnosis and treatment phases. Focusing on a comprehensive diagnostic work up and implementing strategic occlusal management protocols in both phase I and phase II stages of treatment based on time-tested gnathic and neuromuscular (GNM) principles and protocols is the key to treatment success.

______________________

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