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Sunday, September 26, 2010

Fox Occlusal Plane Angulation Questioned

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

If the occlusal plane is flatter relative to horizontal due to slight upward head tilt what kind of occiput to C1 axis relationship would occur?  How would that effect head movements?

I had a wonderful conversation with a doctor who had serious interest as to my method of establishing the occlusal plane using the Fox plane.  He was analyzing a case I posted on our www.occlusionconnections.com/Blog in the article/blog I posted titled, "What Angle is the Occlusal Plane Relative to Horizon".  He couldn’t quite envision the root angulation and position of my articulated mounted case.

So I decided to post the finished ceph to show the actual root position of the "actual" case.  He was worried that I had atlas/C1 restrictions in my finished case.  The patient has excellent range of motion (side bending, flexion/extension and side bending).  See the actual radiographs confirm that the patient has normalized occipital-C1 space (no restricted).  This Occiput to C-1 is well within normalized limits with an unposed angled occlusal plane as nature intended.  Remember form follows function.  Also note the root angulations, occlusal plane orientation and head postion as they relate to a level horizontal.

One cannot look at models and assume roots are out of line as they relate to an unposed horizontal level head position.  Patient is symptom free with no headaches, no neck aches and no TMD pain problems as previous.  Numerous cases have proven this.

Clinicians need to start get use to seeing what a normal occlusal plane looks like relative to a normalized head posture at horizontal level!

I know many can’t comprehend the angle of this occlusal plane mounting, since flat has been considered normal among some occlusal teachings and philosophies…..A new perspective and understanding of wha is "Physologic" is needed!


Lateral Ceph taken after final restorative was completed at optimized mandibular position.  Note occlusal plane and normalized level head position unposed at time ICAT image (raw) was taken.  Occlusal plane in the mouth is the same occlusal plane angle as articulated cast mounting above.

I know I have a reputation of not knowing anything about Occlusal Planes…what can I say….I just don’t want to reproduce pathology if I have an opportunity to bring the human body toward homeostasis - health!

To discover the latest and most up to date information on GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education CLICK:


© 2008 Occlusion Connections™ All Rights Reserved
http://www.occlusionconnections.com/


Neuromuscular Dentistry

Tuesday, July 20, 2010

Expanding Occlusion Connections-Blog

We're excited to launch the new blog under the Occlusion Connections domain.  To read more posts, CLICK on the NEW Occlusion Connections Blog.  Keep up to date with Dr. Clayton Chan's teachings.

Neuromuscular Dentistry

Tuesday, June 1, 2010

HIP (Hamular Notch Incisive Papilla) MOUNTING: IMPORTANT POINTS TO RECONSIDER

By Clayton A. Chan, DDS

The mandibular and cervical head mechanism PROPRIOCEPTIVELY responds to subtle occluding contacts (distal facing or mesial facing) of the teeth. The occlusal plane and its orientation to the cervical neck and base of the skull also proprioceptively responds to each individual occlusal form and incline plane in total as well as how the occlusal plane is designed in an attempt to seek a balance of forces between the teeth, joints and musculature of the temporalis, masseters and even more so with the suprahyoid/digastricus and the semispinius cervicalis, capitus, trapezius, scalene, levator scapula muscles. Teeth and the occlusal plane do not function independently from the supporting musculature.

Classic HIP mount with fence post and incive pin.

Many technicians still don’t get it, thinking that it doesn’t matter if the doctor Rx/presribes a case for HIP or Fox plane mounting, because they believe they are artists and can customize any occlusal plane to any orientation of the maxillary case with a curve of Spee and make it look esthetic. That may seemly be true superficially, but they fail to realize the clinical outcomes dentist may or may not be aware of. Here are just a few important factors:

1) They fail to recognize that when asked to exccentuate the curve of Spee with the HIP mount that they are just excentuating the negative proprioceptive responses of the mandible to function posteriorly off the neuromuscular trajectory. As the maxillary posterior first and second molar occlusal tables begin to tip posteriorly they begin to act as distalizing forces to the opposing mesially facing lower occlusal tables of the opposing dentition.

2) When building the case to HIP, the lab technicians all admit that the upper posterior crowns are shorter with longer looking lower posterior crowns. This is not just against golden proproptional crown to root ratio principles, but further contributes to abnormal vector of musculo-occlusal forces (abnormal form leads to abnormal function) since the occlusal plane tends to be flatter and does effectively support an isotonic perpendicular closure path of the mandible to support a normalized head posture, thus…

3) A relapse of the closing path will naturally occur over time posterior of an optimized NM trajectory with an accompanying upward head tilt tendency further confirming a level occlusal plane with accompanying relapse of musculo-occlusal signs and symptoms (UNRESOLVED)!

The laboratory technicians all know the truth about the mounting problems and occlusal plane design problems they have with HIP! They admit that it produces odd crown length ratios for years. But may not realize the impact it has on the patients subtle proprioceptive responses to the musculature of the mandible and head and neck posture.

Since they fail to openly admit this to doctors they knowingly and or unknowingly contribute to confusion to the learning dentist, thus confusion in the ranks of our dental profession.

Every doctor has choices and will chose what is best for themselves as well as for their patients. I can only share what I am aware of. Perhaps it may make a difference to some.

Time is a real tester of concepts and principles. It is unrelenting and the TRUTH WILL PREVAIL. You don’t have to take my word for it. Your patients will let you know and the evidence will become obvious in time. It’s a matter of one’s awareness.

For further reading see: Fox Plane and HIP Mounting Considerations Blog

Neuromuscular Dentistry

Tuesday, May 11, 2010

Divine Proportions (Golden Proportions)

By Clayton A. Chan, DDS, MICCMO

Phi is in Art, Nature and Science. It is comprised of null and 1. The Fibonacci sequence, 0, 1, 1, 2, 3, 5, 8, 13….are intrinsically related to the Divine Proportions (1.6.1803…). The divine proportions of a rectangle is 5:8 was found to be the average ratio that was close to the φ and was preferred by most people in regards to its proportions.


Phi simply describes the relationship in perfect proportions of the whole to its parts. It is a relationship so perfect that its parts are to each other as the whole is to its larger part.  The Logarithmic Spiral - Golden Proportions = Divine Proportions

The POWER OF PHI creates harmony and a unique capacity to unite different parts of a whole so that each preserves its own identity, yet blends each into a greater pattern of a single whole. My desire is that Occlusion Connections be a living and dynamic entity to assist the greater pattern of a single whole.

We can only be our best when we align ourselves with the Greater null and 1.

The regenerative principle we have all inherited within our DNA allows us to reflect natures intended design and keeps us on trajectory and at physiologic rest within.

To discover the latest and most up to date information on GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education CLICK:


© 2008 Occlusion Connections All Rights Reserved
http://www.occlusionconnections.com/


Wednesday, May 5, 2010

Skull Orientation, Fox Plane vs. HIP Occlusal Plane Relationships

by Clayton A. Chan, DDS

When considering the “HORIZONTAL GAZE” for each of these skulls one will note that picture “A” skull could have the head tipped slightly more downward to improve a level eye gaze which would increase the occlusal plane angle relative to the horizontal table approaching what I would consider a better more anatomical relationship.

The pictures of the 2 skulls with both physiologic and pathologic head postures will go a long way to clarify the issues of the relevance of the Optimized use of the Fox Plane vs. the HIP mount.

Seeing the bigger picture and correlating these key principles to earths gravitational forces and cervical muscular balance works best and compliments the clinician's cosmetic treatment when a clear and balanced understanding of these foundational occlusal plane concepts are presented in an unbiased manner.

We cover the clinical and laboratory aspects more extensively in our Level 6 Occlusion Connections training.  I hope many of you would consider coming to our OC courses to learn "why and what I do" to help my esthetic/TMD cases.  It is impossible to convey all these great concepts in just a short posting.



To discover the latest and most up to date information on GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education CLICK:


© 2008 Occlusion Connections All Rights Reserved
http://www.occlusionconnections.com/


Tuesday, April 20, 2010

Fox Plane and HIP Plane Mounting Considerations

by Clayton A. Chan,  DDS

The leveling of the maxilla, the managing of the maxilla relative to a proper oriented head and cervical neck, and the concern of a proper occlusal plane are steps toward idealizing the finishing of the restorative case in a phase II treatment.  Leveling of the maxillary plane relates to both function and esthetics.

© 2009 Clayton A. Chan, DDS. All Rights Reserved.

Red dots = HIP reference line. Depending on how the clinician and technician chooses to mount the maxillary cast (classic HIP with fence post and Incisive pin (level) or Modified Fox Plane (angled)) will affect how much tooth reduction is necessary to accommodate the same curve of Spee.

Managing the GAP on an optimized trajectory regardless of cants and roller coaster occlusal planes either on the upper or lower arches using an orthotic based on a HIP or Fox plane technique is of little significance in phase I treatment. All that is basically required to assist in bringing normalacy to the dysfunctional head and neck system is the agreed upon physiologic GAP that is established on a proper trajectory. A lower orthotic placed between two distorted and skewed arches certainly fills in the missing components of occlusion to help relate the upper and lower arches together and with good anatomical occlusion has shown to help in maintaining the neuromuscular myo-trajectory, improving head levelness (from pathologic upward tilt to a physiologic leveled head tilt).

Many clinicians have observed these head re-orienting responses with their patients regardless of Fox Plane or HIP techniques, because the Fox and or HIP does not come into play during the Phase I stabilization phase. It becomes a factor when moving into the Phase II level of esthetic restorative finishing of the case as it relates to crown root ratios and smile lines. If the lab “truthfully and honestly” managed and maintained the classic HIP mounting position from start to finish of the case, the dentist will routinely see shorter upper posterior crowns and longer lower posterior crowns. This is not anatomically correct. This will often cause the labs to cheat the upper crown fabrication, by reorienting the maxillary cast, since the upper posterior preps will not have sufficient occlusal reduction (based on this mount) especially in the second molar regions. Because of this lack of occlusal prep height reduction the lab is forced to remount and alter the cast from the original HIP mount to accommodate the lack of occlusal height reduction. (This is what the labs don’t tell the dentist!) The lower crowns will show, routinely, a longer (higher) crown (crown root ratio) and does not reflect proper golden proportional relationships. We strive for golden proportioned anteriors (tooth width ratios and gingiva to gingiva relationships), yet the posterior uppers and posterior lowers are distorted in crown lengths ratios (a failure of the classic HIP concept!) and not evenly balanced in their upper to lower posterior crown lengths (another failure).

With the Fox plane technique the crown to root ratios in the upper and lower posterior regions are more proportional and reflect a better even distribution of crown to root ratios of both upper and lower posteriors (closer to golden proportions) due to a proper maxillary cast orientation due to a proper occlusal plane set up (see picture above).

Consider the same curve of Spee used in both situation.  Different crown root ratios of upper and lower teeth will result depending on which method is used to mount the maxilla.

 If you choose HIP, make sure you reduce the prep sufficiently so the lab doesn’t have to alter the maxillary mounting occlusally! Don’t be surprised if the lower posterior crowns look longer, the upper posterior crowns shorter and the upper first molar to second bicuspid region looks a bit more toothier.

If the HIP is the method of choice in Phase II restorative, make sure the lab doesn’t alter your mount during the finishing of the case. Over the years they all tend to cheat this step and don’t tell dentist that they altered the mount to accommodate the occlusal plane. The clinician can always confirm the HIP mount by telling the lab that you will be checking the maxillary prepped cast with the finalized porcelain crowns on the prep dies in place at the HIP mount referenced to the table before crowns delivery! Make sure they don’t change or alter the HIP mount if you chose to do so!

The dividing of the crown ratios between the upper and lowers (as seen in the diagram above) will vary depending on the maxillary cast orientation technique. Doctors and technicians have choices! We all need to understand these concepts thoroughly to make the proper choices for our patients.

For more information read Fox Plane Mount, Occlusal Plane

Neuromuscular Dentistry
Neuromuscular Dentistry

Saturday, April 17, 2010

What Angle is the Occlusal Plane Relative to the Horizon?

by Clayton A. Chan, DDS, MICCMO

Nature has amazingly design the masticatory system in such a manner to meet the functional demands in a very physiologic manner.  Our occlusal, cervical, airway and postural system has been pre-determined genetically to function optimally relative to earth’s gravitational forces.  An angled or slanted occlusal plane is natures design when the head is properly supported by balanced muscles.

Because of gravity, the muscles of the structural system as well as the masticatory system allows the human being to function with the head in properly balanced manner to avoid strains and fatigue to the overall postural system. A person 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).  This upward head tilt is the bodies way to accommodate due a mal-aligned bite which tries to defy natures gravitational vertical forces, resulting in a flatter more leveled occlusal plane which does not represent what nature originally intended in its design.

The SN (Sella-Nasion) Plane is noted in the dental literature as a standard objective leveling reference.  What you see in the lateral ceph below is one of one of my patients, male age 47 who presented with former TMD cervical neck problems. Symptoms were resolved with an orthotic. The previous upward head tilt responded positively to the orthotic therapy allowing nature to correct it's head posture including and an improved occlusal plane.  Based on this corrected and more normalized occlusal plane orientation as seen in the below lateral cephalogram I want to transfer this occlusal plane orientation to a flat analyzing table on my articulator to fabricate the upper and lower restorations for FM rehab esthetically and anatomically.

It seems to me that if SN plane is level, symptoms are gone, and patient’s head is now balanced.  Recording this position is the most logical to communicate with the lab to mount the case.

© 2009 Clayton A. Chan, DDS.   All Rights Reserved
to record this maxillary occlusal plane orientation I use the Fox plane as indicated in the blog articles and other publications I have written. It takes the guess work away from the laboratory as long as you implement the process properly like anything. Errors can occur during the following steps:

  1. During the bite registration stage.  If one use computerized mandibular scanning (jaw tracking - eg. scan 4/5 with TENS) and does not have adequate training to accurately interpret and record this kind of neuromuscular bite registration error can occur before the case is even started.
  2. If the EMG interpretation is not correct and one implements erroneous EMG diagnostic protocols (unable to decipher the differences between fatigued EMG patterns vs. normalized EMG patterns or does not monitor the cervical group EMGs believing that these EMG recordings are the same as SCM  EMG recordings one will be greatly mistakened.
  3. Subjective interpretation in these areas of diagnostics will also lead to failed treatment results. 
I believe in using good artistic and scientific clinical judgments to record head levelness like any diagnostic protocol, using the Modified Fox Plane technique as I have formerly indicated is a simple, inexpensive and effective tool every dentist in North America can use.  (By the way, every dental student has been issued a Fox Plane in dental school as a basic learning tool). Note the angle of the occlusal plane.
(These are real time pictures that I routinely take during my clinical work up to document what I actually observed).

© 2009 Clayton A. Chan, DDS. All Rights Reserved
Note how the maxillary recording is simply recorded at level using fast set PV on the bite fork of the Fox Plane and the transferred to a level table. This nicely correlates with the lateral ceph occlusal plane which objectively confirms the mounting and occlusal plane transfer.

© 2009 Clayton A. Chan, DDS. All Rights Reserved

The maxillary cast is simply transferred to the table via the OPI (occlusal plane index) from the Fox Plane recording.  (Read more on Mounting the Maxillary Cast Using the Fox Plane and Occlusal Plane ).

This is the actual photo that some skeptics have tried to alter to disparage the modified Fox Plane technique I have been advocating.  (Important Note: In the background the level counter and bottles sitting on top shows that my patient's head is leveled.  The bottles and level counter top are not slanting and or angled as some scrupulous "instructor/teachers" have tried to convey in their lectures by altering this image in their lectures to distort the truth of my Fox Plane recording).  Level = Level!


In a purposeful attempt to disparage and misconstrue the facts of my published article, a dentist instructor "teacher" of a "cosmetic NM teaching center" used this picture and altered and flipped it in an attempt to discredit my teachings during during his lectures.  What is amazingly wrong with his attempt is that he failed to fully read and comprehend the article that was published in the ICCMO Anthology (Chan, CA: A Review of the Clinical Significance of the Occlusal Plane: Its Variation and Effect on Head Posture: Optimizing the Neuromuscular Trajectory – a Key to Stabilizing the Occlusal-Cervical Posture.  International College of Craniomandibular Orthopedics (ICCMO) Anthology VIII, 2007).  His biased publicized lecture subtitle shown in the below power point slide shows his unscrupulous dishonest disregard for scientific and academic teaching integrity and is in itself a "contradiction".  Additionally, it shows his lack of knowledge and understanding of basics in lateral cephalograms.

This is the altered and flipped picture by this "occlusion teachers" with the accompanying text.

Below is the unscrupulously altered photo by the same dentist (instructor "teacher" of an institute) who purposely altered  my photo again in a second power point slide (by rotating and altering the above photo) and used it without permission in a manner to give a misleading and false impression to the attending listening doctor audience about my occlusal plane teachings and understanding of how I advocate the use of the Fox Plane.  One of my dentist colleagues discovered and reported this poorly mishandled power point slide exposing this doctor/ "teacher's" credibility as an "occlusion instructor" by pointing out in the background the tipped bottles that were positioned on a counter in the background.  The unethical teacher/lecturer purposely rotated the photo to mislead, misguide and convey a false teaching about me and what I believe about head posture, the maxillary occlusal plane orientation and what I consider as horizontal level.


The lecturer/ "occlusion teacher" has exposed his credibility and lack of academic honor.  Such stupidity does not go unnoticed by those who have astute eyes to see beyond what is obvious.  Postural balance is maintained best when the head, neck, shoulders, pelvis and feet are leveled to Earth's horizontal level.  Dentists and the viewing audience clearly recognize what level is and realize that the angled human occlusal plane is simply determined when the dentist can clearly see things from a balanced perspective - not from a distorted biased and altered view). 

The unposed head posture clearly shows the natural angled occlusal plane of the same patient in this lateral cephalogram.


Lateral cephalogram (ICAT) after comprehensive restorative treatment.  Note: unposed natural head position and natural angled occlusal plane.  Images have not be altered or modified.  (You decided ...is the occlusal plane angled or flat?)


© 2009 Clayton A. Chan, DDS. All Rights Reserved

The wax up was done to match the mount using the maxillary transfer table.   Restorations were fabricated to the same mount without alterations to the mount.  (Dr. Chan proudly gives recognition for outstanding ceramic and waxing to Las Vegas Esthetics Lab, Ray Foster and Team).

© 2009 Clayton A. Chan, DDS. All Rights Reserved
I check the crown ratios (they shouldn’t look funny)…reconfirm my AP…check my patient’s subjective responses.  Many dentist and I have discover that when the correct occlusal plane is properly managed, the patient doesn't experience any neck, cervical and shoulder pain problems.  If one uses the classic HIP (hamular notch and incisive papilla) method to manage the case too completion that many are discovering that this can lead to unresolved TMJ/occlusal problems.  If everything seems to line up I go for it!

© 2009 Clayton A. Chan, DDS. All Rights Reserved
I mount my cases and check my cases from the lab to see if they maintained the correct maxillary orientation before delivery (labs are not allowed to cheat or change the mount unless it is wrong). I check my mount. I check the photos, I check and compare what is in the mouth, I check how the angle and slant is…I analyze and re-analyze and confirm with my lateral ceph, check my EMG data (making sure my patients are comfortable and stable), I check my Scan 4/5, scan 2’s, scan 8’s, etc. and decided that this orientation got to be right from the frontal and lateral views….then a re-check the patient and I re-check at the lab bench…. Seems right to me!


© 2009 Clayton A. Chan, DDS. All Rights Reserved
I am happy…that He is happy…. "Don’t lose sight of the Power of the Bite!” I have no regrets about the Fox…because I know it works for me and it works for all the talented clinicians who understand this concept. These pictures are immediately after lower seat, before any adjusting of any crowns….I had the patient come back the next day to TENS and refine the bite.
My patient is very pleased, no neck cervical TMD problems. The bite is awesome.  After gneuromuscular esthetic dentistry the patient no longer reports cervical pain, no shoulder pain, nor any TMD issues.  The patient is stable and very happy.  He is a public speaker and is on streaming internet video weekly and has a great pleasing smile.  You can view him at: http://www.iclv.com/ or spiritflow.net on Sunday mornings and Sunday evenings.

Although, there is some dental literature that tries to indicate that the occlusal plane is parallel to certain boney references as the hamular notch and incisive foramen) they often do not realize that cervical bones from C1 to C7 are not perpendicular, thus misleads and confuses the reader as to which horizontal they are refering to.  Dental literature both in the orthodontic, restorative and prosthetic arena clearly have reported on average an occlusal plane angle of 6-14 degrees when the horizontal gaze is parallel to earth's horizontal level.  Any dental referencing technique that advocates an occlusal plane horizontal to earth's horizontal plane certainly is contributing dental failure and postural/occlusal instability.

A physiologic occlusal plane, determined by balanced cervical neck, shoulder and masticatory muscles of the head is routinely angled by natures design to be perpendicular to a normalized lordotic curvature of the neck from C1 to C7.  This orientation is physiologically sound according to natures proportional design for optimal function of the pharyangeal airway (breathing), optimal head posture for physiologic functioning and positioning of the lower jaw, and proper shoulder posture.  Proper mandibular positioning relative to the cranium does effect and impact body balance, flexion, extension and rotational movements.


Dentists have ignored physiology far too long and have destroyed much with their hands, what nature has spent years growing and developing. A flat occlusal plane relative to horizontal level represents mal-alignment and dysfunction contributing to body fatigue.  Neuromuscular science supports normalize occlusal form.  If clinicians ignore what nature intends they WILL be building fatigue into their cases.  You cannot fool physiologic and anatomical science, especially when it is tested amongst thousands of great clinicians who understand the realities of conservative, ethical and thoughful judicious "gneuromuscular/neuromuscular" treatment for their patients.

As you all know I take a lot of records and this is just a small sampling of what many have been privately emailing me to show what I do. Some may not agree, but I am fine with that. My patient is extremely happy and satisfied.
The occlusal plane should look natural and balanced with the smile (that is how it should appear)…the mount is what tweaks our minds…the lateral ceph objectively confirms the reality, but it may be a need for a paradigm shift in occlusal thinking and re-evaluate whether your occlusal plane mount is too flat or not.  It's worth investigating.

Conclusion:
1) We ultimately desire the cervical neck muscles balanced, thus we observed that the head tilts downward from an upward pathologic TMD position which TMD patients present with (flatter occlusal plane relative to horizontal level), 2) we desire optimal esthetics smiles lines and our patients to be asymptomatic.  We observe on lateral cephalograms that the occlusal plane is angled – no symptoms and 3) we simply desire to reproduce what we actually see in a stable, symptom free system – angled occlusal plane, and not have our lab technicians guess or alter the mounts, thus the Fox plane method we advocate as many recognize as simple and logical is easily transfered via the Fox Plane method indicated at Occlusion Connections.

To read more: The Science of Aligning Body Parts To Improve Function - Part I

© 2009 Clayton A. Chan, DDS. All Rights Reserved.  

Neuromuscular Dentistry
Neuromuscular Dentistry

Thursday, March 25, 2010

10 Occlusal Factors that are often Overlooked in Every Day Dentistry

10 Occlusal Factors that are often Overlooked in Every Day Dentistry

by Clayton A. Chan, DDS
Founder/Director Occlusion Connections - Center of Neuromuscular Dentistry & Orthopedic Advancement

1. Ignoring the status of both left and right temporomandibular joints – condyle/disc relationship within the glenoid fossa. Most within our dental profession do not have a complete grasp of proper condyle/disc relationship, let alone how to optimized the disc if it was in the wrong position (e.g. anteriorly or medially displaced). Clinicians must recognize that occlusion doesn’t start with the status of the TMJ condition, but rather with what is the status of the masticatory muscle system that contributes to the ills of joint degeneration.

2. The status of the masticatory musculature is often overlooked and rarely considered a significant factor when it comes to evaluating the existing occlusal condition of the mouth. Worn dentition, facets, chipping, broken or missing teeth, are indicators that have direct correlation to muscle imbalance problems. How to recognize muscle problems is often ignored and not understood by most clinicians. The fact that even the most astute clinicians do not understand how to resolve cervical neck imbalances, masseter facial pain complaints as well as occipital pain problems at the base of the back of the head is a clear indicator that most may talk about muscle problems, and may even use TENS, etc, but don’t know how to clinically address these problems effectively, shows a significant lack and necessity to learn the proper principles of occlusion.

3. Vertical Dimension of occlusion is often ignored during routine clinical examinations and or overly emphasized when recognized. Most clinicians do not realize how to optimally find the proper vertical position, even if they were faced with a severely overclosed bite. On the flip side, many don’t know how to find the proper vertical dimension of occlusion if they were faced with an anterior open bite case problem. The Physiologic Rest Position CAN be effectively used to establish a reproducible VDO. The challenge is that our dental profession doesn’t understand how to establish physiologic rest as it relates to condyle/disc relationships and correlate it to proper muscle posture in 6 dimensions, thus they don’t believe it is possible to use Physiologic Rest as a determined in establishing a proper vertical dimension.

4. Proper transpalatal width dimension is another misunderstood and or highly unrecognized problem within the dental profession. 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. If muscles are not measured, neither are they properly relaxed prior a diagnosis (establishing a proper maxillary to mandibular cast relationship), how can proper clinical treatment begin for either orthodontic or restorative therapy? How can any clinician proceed to a finalizing phase without proving the final end game and expect a stable neuromuscular result?

5. Establishing Myocentric is one of the most challenging of all. Where is it? What vertical should be used to establish a proper myocentric? And what jaw closure pattern (NM trajectory) should be used to establish a proper myocentric? If a trajectory closure path is not properly identified while at the same time the hidden joint dysfunction is present, then it makes it more difficult for the clinician to remedy the occlusal/muscle/joint problems. Myocentric can be achieved without manual manipulation techniques of the jaw and or having to lay the patient back in a supine position. Gravity, condyle/disc, occlusal and muscle dynamics all play a role in establishing a proper terminal contact position (the bite) even if one is using the K7 or whatever method or bite technique. The bite must be placed in neutral.

6. In the neuromuscular community we shouldn’t have to worry about long myocentric problems. If ones experience has been to observe the patients jaw to shift down and forward during occlusal adjustments after a TENS bite or K7 bite was taken, perhaps a re-evaluation of the techniques learned will help move one forward to appreciate what it means to “optimize” the NM trajectory or optimize the TENS bite. The use of the term Optimized is now being used to give the impression that the bite is being taken correctly, but the fact of the matter is if the clinician has to verbally coach the patient to a particular position (move up….let the jaw float back….more to the left or more to the right, etc. etc. etc.) even if using the K7 Scan 4/5 is a clear indication that the bite is in actuality being forced and may not really be optimized. The clinical application, methods and or techniques presented must be questioned and re-evaluated. At OC the clinicians are discovering that when the bite condyles, disc and muscles are truly optimized on a proper trajectory very little verbal coach needs to be used and one finds that finding the isotonic optimal trajectory takes on a different meaning.

7. Anterior contact and disclusion is a gnathologic concept that must be acknowledged, when you have established an optimal trajectory/closure pattern. To ignore and or dismiss the need to have anterior contact (especially in restorative dentistry) is an admittance of a lack of neuromuscular occlusal understanding, especially if one is seeking optimal occlusal posture and dynamics. Determining the angle of disclusion during protrusive, retrusive as well as the various lateral movements is crucial and significant to any student of occlusion, thus a need to learn GNEUROMUSCLUAR OCCLUSION.

8. The envelop of physiologic function cannot be achieved if the basics to proper VDO, muscles rest, condyle/disc optimization, head and mandibular postural balance is not acknowledged clinically.

9. The angle of the Occlusal Plane is significant and does make a difference as to long term maxillary to mandibular occlusal stability as well as skeletal/structural balance. To ignore what nature has designed as a template and insist that the occlusal plane is to be leveled (flat) relative to horizontal level is a masking of how the stomatognathic system really works. How to determine a proper occlusal plane must be learned and or re-learned in certain cases. Why the occlusal plane is angled is important, because it relates to the anterior teeth and posterior disclusion and functional occlusal dynamics as well as head, neck and shoulder posture.

10. Lastly, occlusal contact management is often under estimated among clinicians today. The power of micro occlusion and its relationship to proprioceptive response as it relates to the central nervous system is tremendous. It does take time, skill and a clear understanding of how the body works. Thank goodness for patient adaptive capacities, but one the adaptive capacity of patients are sick and dysfunctional it now is in the hands of the treating clinicians abilities to try to meet those demands placed on him or her to meet those occlusal challenges in a time, efficient manner. Taking the Psychosomatic route is another means to mask and ignore the real issues of being a physician of the mouth. Taking the route of treating the Somatopsychic takes knowledge, understanding, patience and skill. It can be learned and properly implemented.


Wednesday, February 3, 2010

A Re-evaluation of the Meaning of NMD

"GNEUROMUSCULAR" DENTISTRY - What It Is and What It's Not
by Clayton A. Chan, DDS, MICCMO

by Clayton A. Chan, DDS, MICCMO

 I am posting this to clear up confusion as to what Neuromuscular Dentistry and NM Occlusion is about. Because there are some who profess to be "Neuromuscularly" trained, but in reality have very little understanding and appreciation for the Gnathologic occlusal concepts which are the foundation to neuromuscular dentistry. NMD is not only about scans, EMGS and jaw tracking data, it is about occlusion and it’s relationship to the trigeminal system as it relates to postural system. Let’s not forget that it relates to CLINICAL applications of TMD, restorative/prosthetics and orthodontics. It’s not an academic exercise of knowledge, but rather it should be a display of how the teeth, muscles and joints are functioning (HEALTH not dysfunction) in relationship to the bio-physiology, neurology and their impact to the masticatory system.

 The concept of NMD is not new, neither should it relate to marketing exploits in the name of post graduate dental education. It is a "discipline" in dentistry that requires attention to detail to the core principles that every dental student has learned in their dental training. It is certainly not about an overuse of technological advancements for the learning student to convey to their patients that what they understand about EMGs, jaw tracking and orthotics is to over ride the actual patient responses of ill feeling bites, imbalance of musculature as it relates to restorative reconstruction. LEARNING THE BASICS IN OCCLUSION IS KEY!  The proper application of the GNM principles as taught at OC is key!

When doctors who begin to use these advanced techniques in manners and cannot properly interpret the EMG and jaw tracking data correctly or apply the micro occlusal management principles from a complete clinical perspective, even though in their mind that the data may appear to be normal or correct as per their understanding, it behooves all to assess their training and understanding of scan interpretation, especially when restoring patients through the various phase of reconstruction or restorations (phase I removables, phase I fixed orthotic, phase I porcelain orthotics and or phase II restorative). If the scans appear to be normally low EMGs and the trajectory looks like it is right on trajectory sagittally and frontally and the patient is complaining that they don’t have a bite, then perhaps a reassessment as to one’s understanding of scan interpretation is in order (Level 5 Advanced NM Bite Refinement/K7 Training and Interpretation).  If the EMG and jaw tracking data as per one's understanding shows a balanced occlusion, yet the central nervous system is not calm or neutralized then one's understanding of GNM (gneuromuscular) and or NM (neuromuscular) needs to be reassessed.

 If the patient is having a difficulty with the dentistry provided even if it was performed in the name of GNM or NM and one is not sure what to do….don’t tell the patient that all the scans appear normal and that there is nothing wrong with the dentistry. They are not whiners and complainers for no reason. They have a legitimate concern that needs further investigation, occlusal understanding and another level of skill sets may be required. It is wrong to tell the patient that there is nothing wrong when the Scans appear to be OK to cash this patient to the waste heap of “NM” failures. Let’s reconsider what we have been taught. (Of course the TMD patient must also realize there are no guarantees, when TMD involves multiple layered factors that involved not just structural/anatomical postural issues, but even more the emotional/psychological stressors as well as biochemical issues that often patients rarely want to acknowledge with their dentist).  Learn from those who really practice what they preach. Use your knowledge, skills and good judgment to help your patients and find a resolution to the problem. Be patient, compassionate, respectful of others work and listen to your patients carefully…sometimes they know more than the treating doctors…why because some of them are experienced and have read, learned educated themselves amongst the numerous practitioners they have visited, have been the recipients of many doctors treatments and therapies, yet continue to seek for real answers to real problems.

 As long as Neuromuscular clinicians continue to pretend to hide under the covering of their scans (not really understand OCCLUSION management principles and the importance that microns matter) not fully comprehending the GNM principles what they mean as they relate to CLINICAL TMD pain treatment, restorative occlusal therapy problems and orthodontic/orthopedic issues, then scan interpretation is only a lopsided perspective of what NMD and GNM really advocates.

 Orthopedic Dentistry, Orthopedic Occlusion, GNEUROMUSCULAR Occlusion or Gneuromuscular Dentistry is perhaps an updated means to convey the full package of what NMD originally intended. It shouldn’t convey something less than a complete understanding of both neuromuscular and gnathologics…it is really plain dentistry that requires self discipline.

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Neuromuscular Dentistry - Measuring and Evaluating by Objective Analysis