Home | About OC | Continuing Education | Course Schedule | Registration | Accommodations | About Dr. Chan | Study Club | Doctor Education | Patient Education | Vision | Research Group | Science | Orthodontics | Laboratory | Dr. Chan’s Articles | GNM Dentistry | Contact Us
Caucasian female age 53
Chief Concern: TMJ facial pain with existing orthotic on lower arch. She keeps breaking NM neuromuscular orthotics. She has had 4 previous orthotics over the past 3 years. Each one failing with holes worn through each of them She experiences pain mainly in right jaw joint and occasional left temporomandibular joint. In general, she is healthy. Has had right side hip replacement surgery. Left hip replacement surgery is scheduled in the future.
- Crepitus mainly on right, some left
- Pain in the jaw radiating to the ear on the right.
- Saw MD thinking it was ear infection, but was reported to be “within normal limits” (WNL).
- Pain on right shoulders
Examination and Diagnostic Work Up:
ICAT imaging was recorded with existing orthotic at the following positions:
- With orthotic at rest
- With orthotic at CO
- With orthotic at Max open
Initial postural (extra oral) and intra oral photos recorded. Comprehensive examination included muscle palpation, subjective assessment, narrative skeletal examination, psychosocial assessment, periodontal, K7 kineseographic (CMS, EMG and ESG) pre low frequency TENS assessment of existing habitual resting modes and mandibular function. Impressions of upper and lowers arches were recorded for diagnostic cast evaluation.
Discussed treatment options and GNM approach.
Low frequency Myomonitor TENS was implemented to break up proprioceptive temporomandibular joint and masticatory muscle engrams 60 minutes prior to implementing objective kineseograph K7 recording of patients mandibular to maxillary jaw relationship. Once an optimized mandibular to maxillary inter occlusal relationship was objectively determined and recorded orthotic fabrication was prescribed to those specific physiologic 6 dimensional recordings.
K7 Kineseographic Objective Assessment was completed which included the following tests (resting and functional mandibular modes):
- Resting EMGs prior to ULF TENS (repeated) – Scan 9
- Functional clench EMG comparing habitual occlusion vs. cotton rolls) repeated – Scan 11
- First tooth contact EMG and timing balance (repeated) – Scan 12
- Jaw tracking habitual open/close, velocity – Scan 2
- Jaw tracking habitual resting for vertical freeway space – Scan 3
- Jaw tracking swallow test for aberrant tongue patterns – Scan 6
- Jaw tracking habitual functional chew patterns – Scan 8
- Jaw tracking habitual mandibular range of motion – Scan 13
- Jaw tracking combined with electrosonography (ESG) joint sound analysis – Scan 15
- Low frequency Myomonitor TENS 60 minutes to deprogram muscle tension
- Resting EMGs after TENS – Scan 10
- Jaw tracking combined with simultaneneous ULF TENS to record Optimal myotrajectory – Scan 4/5
- Record objectively mandibular to maxillary physiologic jaw relationship
Diagnostic Classifications of CMD:
- I. Masticatory Muscle Disorders (Muscle Pain) – muscle spasm activity
- II. Disc Interference Disorders (Internal Derangement) – early and late derangements
- III. Inflammatory Disorders of the Joint – inflammatory arthritis degenerative
- V. Mandibular Hypermobilities – subluxation (hypertranslation) assessment of internal derangement, spontaneous dislocation of condyle
- VIII. Abnormal Jaw Closure – posterior, vertical and frontal lateral closure patterns
Functional recruitment surface electromyography (sEMG) were used to test patients functional muscle recruitment ability before (without orthotic vs. wet cotton rolls as controls vs. with GNM orthotic) to compare functional health of the patient.
Detailed micro occlusal adjustments following GNM protocols were implemented to make sure the lower removable orthotic was comfortable and functional. Patient worn new orthotic 24/7.
Electrosonographic Assessment (Functional TM Joint Sound Analysis):
Crepitation and grating sounds were present on opening and closing. ESG indicates high frequency low to medium amplitude signature sound patterns were present on the right TMJ repeatedly at 0.0 – 13.7 mm opening with recipricol closing sounds.
ESG filtered at 0-300 Hz indicating presence of degenerative joint disease on both left and right tempormandibular joints.
K7 Jaw Tracking Before Treatment
Pre-existing K7 computerized mandibular scanning (CMS) indicated the patient’s mandibular opening and closing path was habitually functioning 4.4 mm posterior to the more optimized closing path (myo-trajectory) with pre-existing “non reducing disc” on the right temporomandibular joint.
DIAGNOSTIC AND TREATMENT TIMING:
Phase I Mandibular Stabilization of Temporomandibular Joints – Lower GNM orthotic was worn 24/7 without wearing holes in it. Patient wore orthotic 4 months and 11 months.
Patient no long experiences grating right joints or clicking popping joints. Disc are reduced allowing patient to have full mandibular movement without restrictions or discomfort.
Phase 2 Finalizing Ortho/Orthopedic Stabilization – 4 years 7 months non surgical osseous regenerative orthopedics to regrow and develop deficient posterior and anterior vertical dimensions of her teeth. This allowed a re-establishing of the lower arch of anterior and posterior teeth to be set at an increased vertical height to decompress and support the adequate joint space (condyle and disc) that were previously over compressed (minimal joint space with flattened and beaking condyles).
The GNM orthotic is used as the orthopedic matrix to accomplish and guide the tooth movement to the physiologic position based on K7 Myotronics jaw tracking (CMS) combined with J5 Myomonitor TENS (involuntary pulse stimulus) to assure an isotonic mandibular path was obtained.
Myotronics K7 computerized mandibular scanning (Jaw tracking sensor array) combined with J5 Myomonitor low frequency TENS was used to measure objectively the patients pre-existing mandibular position before treatment as well as after treatment. This K7 objective measurement was used in conjunction with the GNM orthotic to determine specificially whether the isotronic path of mandibular closure was properly and correctly orthopedically corrected along the isotonic TENs path of mandibular closure.
K7 Jaw Tracking After Treatment
After orthopedic verticalization treatment K7 recording displays stable resting vertical, antero-posterior (AP) and frontal/lateral relationship. A 0.04 mm antero-posterior discrepancy is recorded indicating a significant decrease compared to the 4.4 mm before AP mandibular shift. The patients previous “non reducing disc” problem was also corrected during GNM orthopedic treatment now to reducing disc with normal mandibular function bilaterally. K7’s jaw tracking (scan 4/5) shows an isotonic functional mandibular path of closure has been achieve with effective verticalizing orthopedic treatment mechanics using the GNM orthotic as the orthopedic matrix and treatment guide (K7 with J5 involuntary TENS and scan 4/5 confirms this fact).
Note: No restorative crowns, equilibration (grinding of teeth) were implemented during phase 2 completion treatment. Conservative non surgical approach was implemented following sound gnathic and principled neuromuscular protocols. Combining these principles with sound orthodontic and orthopedic verticalization understanding and skills to osteogenetically verticalize this patients lower occlusal plane to a corrected orthopedic position along an objectively determined myo-trajectory (mandibular closing path) assures long term stability without the aid of “retainers”. GNM protocols and principles when correctly practices allows the teeth, muscles and jaw joints to retain themselves in a homeostatic comfortable and stable position.
Diagnosis is key, conservative, no surgery, removable, no tooth grinding, no restorative crowns. A non invasive logical and committed approach to quality healthy care. Patient was dedicated. Saw the value in this orthopedic GNM approach. No pain medications were prescribed or required. The patient is a believer in GNM dentistry.