Orthotic Managment, Clenching and BNS 40 TENS

Clayton A. Chan, DDS Response

QUESTION:Has anyone had experience with their patients using the BNS-40 at home? I just got one to give to a chronic headache pt for home use. The patient is a 49 yr. old female with a 25 year history of headaches, usually 2-3 per week, and she reports she clenches every night. I made her an orthotic and have done 3 adjustment appts. I am considering having her TENS with the BNS-40 every day for two weeks then run more scans and another adjustment for the orthotic. I'm doing this because therapy with the orthotic has given only slight impovement in her condition. Does anyone have alternate methods/protocols they might offer?

Thanks!

JO

RESPONSE:
The chronic paining clencher is one of the more challenging type of cases the clinician will face. Although the use of the BNS-40 Myomonitor TENS is known to be an effective means to relax the masticatory muscles the treating clinician must also recognize that there are other factors involved beyond delivering an orthotic and relaxing muscles. The true clencher will usually show hypertrophy of the masseter muscle extra-orally, a well developed dental arch without depression of the Curve of Spee, and an unfaceted dentition with good anatomic morphology.

The reality is that many patients are a combination bruxer-clenchers. The typical bruxer shows a significant faceting and wear of the dentition, bicuspid drop-off with depression of the Curve of Spec, inadequate arch development with lingual inclination of the lower posterior teeth.

Regardless of whether a patient is a clencher or bruxer there exists an heighten noxious proprioceptive input feeding into the CNS-reticular loop, resulting in a greatly accentuated motor hyperactivity. This means that occlusal therapy must be successfully controlled to reduce the noxious influences which in turn reduces the level of bruxing/clenching in most of our patients. The clencher appears to have a more patterned or engrammed central nervous system component to their noxious occlusal habit. Biofeedback is often a helpful adjunct for the chronic clencher.

Here are a few pointers to consider:

1. Make sure your orthotic is properly designed to accommodate lateral cuspid rise and posterior disclusion.
2. Anterior contact and posterior disclusion is an absolute requirement for these kind of cases (something most NM teachings overlooked).
3. Protrusive contacts must be properly balanced.
4. Retrusive contacts must be balanced, but not eliminated (especially in the supine laying down positions – night time wear).

Bottom line is that proper micro occlusal coronoplasty application must be implemented to get a proper result. The patient must be able to chew and function normally with a properly adjusted orthotic, if not the patient will not be comfortable and wear the appliance. Any interferences during functional jaw movements that remain will trigger unresolved clenching challenges and the patient will not resolve to the next level.
It has been my clinical experience that patients that present as so called “clenchers” will present with:

1. Anterior open bite tendency – They may appear with normal occlusion with seemingly higher Golden Vertical values in the anterior region, but in reality are previous ortho or post surgical cases.
2. Arches appear well developed, but don't let that decieve you.
3. Posterior teeth contact in lateral excursive movements contributing to mandibular jaw torque (culprits to clenching. Relieve posterior interferences, if left the patient will continue to clench).
4. Inadequate disclusion of the posterior teeth during protrusive movements.
5. Maxillary arch can be retrognathic relative to an optimized NM position and trajectory when evaluating with K7 Scan 4/5, an optimized TENs bite and or cephalometrics.

Common Clenching Symptoms Relating to the Bite - Dentist Need to Know
The following headaches can and should be resolved by the dentist:

1. Temporal headaches
2. Masseter facial pain
3. Tenderness and pain at the posterior lower border/corner of the jaw.
4. SCM tenderness
5. Cervical neck pain and tenderness
6. Pain in the occipital region
7. Pain on top of the head
8. Shoulder pain
9. Numbness and tingling in the arms, hands and fingers

Note: No matter how long you TENS and how many Myotrodes you place if you don't fix the bite to proper physiologic parameters, the dentist will be confused and will continue to search for the unobvious.
I believe that clenching problems can be resolved with effective a comprehensive craniomandibular cervical structural approach which goes against what most literature and teachers may say, relinguishing this problem to the CNS emotional psychosomatic stressor department rather than acknowledging the physiologic somatopsychic issue.

We know we can help you!
If you have further questions please don't hestitate to contact me at: clayton@claytonchan.com
Clayton A. Chan, D.D.S.

Neuromuscular Dentistry

Myo-Trajectory and the NM Clinicians Focus

by Clayton A. Chan, DDS - Director of Occlusion Connections

A more optimal trajectory can be observed with computerized mandibular scanning (CMS) and low frequency Myomonitor TENS alone by following an effective bite taking Scan protocol. Understanding how to interpret the scans and what they mean is also very important, before conclusions are made. That is the essence and beauty of understanding NM at the next level. At the next level the trained NM clinician is aware of the elevators and depressor issues, but also realizes that it is not the key focus to optimization of the NM trajectory along an isotonic path/zone or tunnel as it CLINICALLY relates to establishing a bite for TREATMENT. That is the academic exercise of questioning the NM occlusal paradigm to convince oneself whether NMD is correct or not (no problem with questioning). Certainly we desire and want low EMGs, that is one of the clinical objectives.

Note: the above CMS jaw tracking scan shows various sagittal trajectories all of which present with calm low EMG activities (not shown). Reproducibility of mandibular position can be shown in real time when observing the sagittal and frontal cursors (not seen in above scan).
If the clinician tries to focus on the end point (trying to establish neuromuscularly calm muscles first using EMGs as the tool of choice to find the bite, rather than aim for a optimal occlusal bite position using CMS as the first choice to later establish the calm muscles second, the dentist will get frustrated in the NM teachings and lose confidence that NM truly an effective approach. Working extra hard to determine low EMGs, for example, on a paining TMD patient to establish a bite will cause the clinician to realize that calm muscles are not going to happen until a proper positioning (location with an established bite (myocentric) is first established. Muscles don’t want to become isotonically calm when they know there is pathologic form (a wrong bite). We want to get good bites, but if you are using EMGs to observe proprioceptive cranio-mandibular responses, the NM bite taking methods classically taught will lead you down the path of bewilderment and wonder searching for the calm zone of both diagastric/suprahyoids, temporalis anterior, masseter and cervical group calmness with varying degrees of vertical, AP and frontal positioning.

Where does the clinician set the bite when cervical groups are hyperactive? Where to set the bite when temporalis are hyperactive? One may get one area calm, but the other areas may not be calm….if we keep searching and hoping that the EMGs is the key to establishing the best bites, then why doesn’t the NM minded clinician just use EMGs alone to establish the bite and don’t depend on CMS!?

It is obviously clear that CMS is a superior and very important tool to see what is happening spatially with the mandibular position for any and all NM clinicians. It also becomes further clear in Level 5 NM Bite Refinement/Advanced K7 teaches how to properly interpret scan 4/5 and refine the bite taking protocol so the clinicians realize what is significant in implementing the instrumentation tools to do NM dentistry practically and in what order of importance as to TENS, CMS, EMG and ESG.

Neuromuscular Dentistry

Use of the Orthotic

by Clayton A. Chan, D.D.S., M.I.C.C.M.O.

There are several different aspects to consider regarding the use of orthotics.

1) Medico-legal – standard of care is that occlusal therapy be reversible as per ADA statement, removable orthotic appears to fit this criteria better. Especially, to the non NM clinician. It looks more mainstream to the traditional clinician. Much less likely to damage the patient’s own structures when the appliance is removed, whether the patient takes it off or we dentists take it off. Which would make you feel more comfortable if your TMD pain patient ever decided to leave your practice for whatever reason…Leaving your practice with a fixed orthotic in the mouth or with a removable?

2) DOT Occlusal Management – Significantly easier to adjust the bite outside the mouth than in the mouth, especially with paining TMD patients that are not yet committed to phase II treatment.

3) When patient not yet committed to phase II level therapy, removable is less likely to cause a more permanent joint change, because of the capability to remove the appliance when the patient wants to. With fixed the patient has no control of the situation and you own the bite (patient now controls you)! If patient is having difficulties with their bite using fixed on a weekend you have to go in and help, if removable they can take it, see them on Monday. Harder to divorce from a patient who has been in fixed vs. a patient in removable.

4) Removable is safer for the doctor in patient management: The patient can always pull it out of the mouth if the bite is bothering them, with the fixed orthotic the patient can’t do that and will require doctor help and assistance. Haven’t we all had a patient who told us that they could not tolerate their new bite?

5) After 30 day fixed orthotic trial period and patient is not ready to proceed forward with finalizing treatment, what do you do then?

6) Paining TMD patient is not always prepared to move forward with a phase II finalizing mode of treatment after 3 months of orthotic therapy. Most of my TMD pain cases are not ready for phase II for at least 1 year, I don’t want the liability for hygiene issues or any other things that would happen underneath the fixed orthotic.

7) Bite Management is much easier and simpler when setting up the case to transition into Phase II. (Any mandibular shift/change that occurs during the course of treatment is easily transferred without the worries of having to cut off the fixed orthosis to get a lower arch wax up. You don’t have the worries to cut off orthotic, maintain and record the bite for the lab, and then place another fixed orthotic which must be exactly and identical to the same orthotic position you just cut off.

8) Removable orthotic is less hard work vs. fixed orthotic with TMD pain patient. Do you like to adjust bite in a laying down position intra orally or a sitting up position extra orally? Is coronoplasty/ micro occlusion easier intra orally or extra orally?

9) When you need to resurface the orthosis. Which is easier fixed intra orally or removable extra orally?

10) After resurfacing how much energy is required to coronoplasty intra orally or extra orally? Think of the emotional stresses on yourself when dealing with a high proprioceptive paining TMD patient?

Ask yourself several questions:
Why do many prefer the removable orthotic rather than a fixed orthotic?
Is it really easier to manage the TMD paining case with a removable or fixed orthotic?
Why does the dental profession (as a Standard of Care) recommend conservative and reversible therapy especially amongst TMD/occlusal philosophies?

Neuromuscular Dentistry

The Occlusal Plane

Which Occlusal Plane Do You Undestand? Don't Get Confused

by Clayton A. Chan, DDS, MICCMO

Read my scientific article: "A Review of the Clinical Significance of the Occlusal Plane: Its Variation and Effect on Head Posture" - published in the International College of Craniomandibular Orthopedics Anthology, 2007.

"If you don't stand for anything you will fall for anything...."

Establishing the occlusal plane is an important aspect for every clinician and laboratory technician who desires to create beautiful soft smile lines, stable occlusion and supported normalized head and neck posture. Many of the dental goals and objectives for dental health correlate to esthetics as well as the physiologic function of natures dynamic masticatory system. The artistry and design of the smile is often subjective in nature and does not always lend itself to a cookbook receipe of hard fast numbers and values, but often is visualized by the designers and creators of dental occlusion. So it is the same with establishing the occlusal plane.

Reconstruction by Clayton A. Chan, DDS and Mike Milne, CDT & Team Sunrise Dental Laboratory, Las Vegas, NV

Dentistry is both an art as well as a science. Combining the artistry of tooth position, orientation, embrasure spaces (open or closed), occlusal plane position and arch shape development are all examples of the subjective clinical decision making ("non science", yet scientific) that must conform to good principles and universal laws of form and function. Implementing one's judgment, clinical experience in addition to a keen visual eye does not lessen ones position of being objective and clinically sound, especially in the arena of neuromuscular occlusion, orthodontics and restorative/prosthetic care.

There are basic laws in nature and science to support such and so it is the same when establishing the occlusal plane. There is nothing wrong neither is it any less than scientific with using leveling tools (e.g Fox Occlual Plane Analyser, face bows, leveling tables and photos) to help the clinician and technician visualize and capture the maxillary occlusal plane with a normalized head position as long as they are used properly. Subjective is certainly required when it comes to the art of dentistry, yet balanced with the physiologic neuromuscular sciences that can measure muscle function using EMG and CMS technology. I like to use all the scientific tools available in dentistry in addition to applying my artistic mind to create postural form for healthy function.

Note the various occlusal plane references as noted in dental literature.

Depending on boney landmarks alone as references to establish maxillary relationships is almost similar to using jaw joints to reference the mandible/bite. The astute clinician recognizes that neuromuscular and physiologic paradigms reference to healthy muscles not bones which often present with distortions, torques, skews and asymmetries. Repeated studies have shown that relaxed muscles can change the profile and soft tissue architecture over the hamular notch regions. Studies have also shown that relaxed cervical neck musculature with isotonic mandibular muscles will effect head posture and the occlusal plane, thus testing the occlusal plane teaching paradigms as to how these boney landmarks are actually referenced to horizontal level in a physiologic position, not pathologic ("level").

After studing numerous cephalometrics and lateral cervical spine films of patients it is clearly evident that the hamular notch and incisive papilla (HIP) landmarks actually are more closely parallel to the the Ala-Tragus plane, and Campers Plane, NOT parallel to horizontal level as some teach. This is a big misnomer! True HIP of the maxilla in a true physiologic head and cervical relationship actually angles or slants at a 6 to 10 degrees (average) relative to horizontal (see literature references in above article).

Key Point: The lab technicians are challenged when mounting the maxillary casts by artistically guessing because dentists fail to sending the necessary recordings that are essential to reliably fabricate the aesthetic restorative case. They do not rely on stick bites, inaccurate impressions, inadequate photos, distorted models (hamular notches) and wrong fox plane recordings. The artistic eye often comes into play regardless of advocated techniques.

Clinical and laboratory studies have shown when using the boney landmarks of the maxilla to mount the maxillary cast is in fact incorrect and will simulate an unnatural upward head tilt position with the maxillary cast displaying an anterior upward cant 57.6% of the time. That is why most labs ultimately do not complete the restorative cast to these references, but may use it as a guide. Anyone who honestly questions this can check for themselves by mounting the final restorations on the solid mounted maxillary cast to see the type of occlusal plane and what mounting position was actually used.

Labs will say they mount the case to HIP, but will often not dare finish the case to these references because of their experience and realization that this mount will lead to long toothy looking smiles. The technicians realize that the maxilla is not naturally oriented in that manner, thus they make the decision to change the cant of the cast purposely to avoid remakes and an undesirable result for the dentist. The maxillary cast mount should be determined by the dentist, but reality shows that the lab technicians will subjectively and artistically alter the doctors HIP recording to one that is more subtable for finishing the restorative case.

A flat/level HIP mount leads to a pathologic referenced position. A slanted/angled HIP mount is what nature designed physiologically. I advocate the second HIP mount (slanted or angled) which nature intends and is similar to Campers plane or ala tragus plane. This will lead to golden proportions not only in the anterior regions, but also will result in a more idealized crown to root ratio of both the upper to lower posterior molar regions. (Interesting to note that with the classic HIP mount it is often observed that the upper posterior molar crowns will typically look short (staulky) with longer looking lower molar crowns (This is not gold proportions, but results when the maxilla is erroneously mounted to a pathologic relationship). Neuromuscular science supports natures golden proportions and recognizes pathologic distortions! I prefer not to use the fence post and incisive pin as my mounting references to orient the HIP. I use the Fox Plane as indicated in the previous blog titled "Mounting the Maxillary Dental Cast Using the Fox Plane".







Note: A)Pathologic neck posture: Kyphosis resulting in a more flatter occlusal plane. B) Physiologic neck posture: Lordosis resulting in a normalized occlusal plane (angled slant).

If we were to establish boney maxillary cast references such as the hamular notch and incive papilla as some prefer to dogmatically advocate as scientifically objective and mount the maxillary cast to those references the dentist and technician will ultimately be reproducing an undesireable relationship (often resulting in a maxillary cast occlusal plane that appears level and often with the anterior incisal edges vertically upward relative to the posterior teeth). This does not truly represent what nature intended as dental health. Although this idea may appear to be simple to learn and easy to teach this maxillary cast mounting method is in fact one that ignores natures isotonic neutral head position. What we clinicians want to do is replicate healthy relationships of the head, neck and mandible as it relates to the cranum and not pathologic relationship when treating our patients occlusion.

The Fox Plane technique I advocate is a simple means to subjectively analyze and capture what nature intended (an angled HIP mount not flat or level). This is well supported by literature and the orthodontic and prosthetic community. It is a convenient way to capture a proper maxillary recording when the patient is stable and ready to move to the next phase of restorative dentistry. (The classic face bow also works, but is historically more complex and involved and not laboratory friendly). Objective science will always advocate healthy form to support healthy function. The neuromuscular minded clinician needs to learn to use their best judgement skills and understanding and not rely solely on pathologic boney references as their guide. "Nature does not think in mechanical terms". We need to learn from nature, its beauty,design, form and how it functions.

Students in a recent Level 6 course at Occlusion Connections mounted their maxillary casts using the Fox Plane technique. Note the natural angles that resulted and are represented in this series of mountings. This is key to dental aesthetics.

My View and Opinion: Use the Fox Plane technique to reference a physiologic occlusal plane, not depending on maxillary boney references. Capture a correct maxillary slant or angled HIP (Physiologic) keeping the Fox Occlusal Plane Analyzer level and parallel to the ground. Make sure the head is level (see Fox Plane Mount blog for technique). This will allow the clinician to easily capture a proper occlusal plane, not a flat or "level" occlusal plane (pathologic). Frontally the fox plane is perpendicular to the long axis of the face. I am sure the laboratory technician understands these techniques and the esthetic significance better then most clinicians since they actually have first hand experience of mount your dental casts daily!

Not all clinicians have comprehended these simple teachings of the Fox Plane concept and its significance to the head, neck and mandibular physiology. Not all teachers teach from a TMD/orthodontic-orthopedic/restorative perspective. Not all clinicians take cephalograms and cervical neck films to understand and see the relationship of the neck and occlusal plane as it relates to a leveled balanced head position, thus limiting their understanding of the significance of these occlusal plane concepts that are importantly related to head position, mandibular positioning and mandibular trajectory closing paths. Clinicians who have a scientific inquiring mind will have the maturity and desire to pursue these truths with certainty and apply the common sense techniques that naturally become logically apparent. We don't have time to waste when doing clinical dentistry on live patient's using wrong and misleading concepts. We need to take the opportunity and learn proper occlusal concepts that will lead our profession toward bring health to our patients, not for ease and convience of teaching.

"Clinicians and dental laboratory technicians have found it important to DIAGNOSTICALLY identify HIP plane so that the dentist does not restore to a distorted cranial base. Since the patient poplulation with chronic TMD and postural problems obviously has a higher than normal HIP plane variance from normal base plane parameters, it is important that the clinician does not replicate this distorted base. Ergo Hoc Proctor Hoc, if clinicians restore this patient using the HIP reference it will only replicate the anatomic manifestations of the etiologic problems." - Robert Jankelson, Summer 2005 .
Some may laugh, jeer and criticize me for my passion and beliefs of my occlusal plane perspectives as they relate to clinical dentistry, but one day those critics will quiet themselves when our profession begins to further mature to the next level to see that our application of neuromuscular dentistry brings the science as well as the art together. Don't be confused. Change is in the making! Let's be tolerant, thoughtful and respectful of another point of view!

"It's a curious thing that physical courage should be so common in the world and moral courage so rare." - Mark Twain

Neuromuscular Dentistry